Common use of Enrollee Services Clause in Contracts

Enrollee Services. ‌ Insurer shall maintain an enrollee service unit to provide Enrollee-related customer service. The enrollee service unit shall have the ability to answer Enrollee inquiries by telephone, electronic communication, and written communication. The enrollee service unit shall be accessible by a toll-free telephone number during the hours of 7:30 a.m. to 7:30 p.m. Eastern Time, Monday through Friday, except on FHKC-recognized holidays. Insurer shall utilize automatic call distribution equipment and enrollee services representatives staffing sufficient to handle the expected volume of calls. Insurer shall also provide a telecommunication device for the deaf (TTY/TDD) and access to interpreter services. Insurer shall ensure enrollee services representatives are satisfactorily trained and capable of resolving Enrollee and potential Enrollee inquiries in all areas related to Florida Healthy Kids. Insurer’s enrollee services representatives shall be familiar with the basic eligibility requirements for the Florida Healthy Kids Program, but shall refer or transfer individuals with detailed questions or concerns to the Florida KidCare call center. Insurer shall monitor the enrollee services line to ensure Insurer meets certain performance standards and for quality assurance, including recording calls, conducting routine audits, and other monitoring activities. Insurer shall meet the performance guarantees related to enrollee services included in Attachment C. Insurer shall provide a publicly available website with access to Florida Healthy Kids information. The publicly available website shall include: a. The Enrollee handbook, b. A printable provider directory, c. A searchable electronic provider directory, d. A link to FHKC’s Florida Healthy Kids website, and e. Any other information that may be needed by Enrollees or potential Enrollees. Insurer’s publicly available website is subject to FHKC approval. Insurer shall also provide a non-public website with secure access for Enrollees that shall include: a. The ability for Enrollees to print a temporary ID card, b. The ability for Enrollees to request a new ID card, and c. Enrollee educational materials (unless Insurer chooses to make such materials available on the publicly available website). Insurer’s non-public website is subject to FHKC’s approval. 21.1 Escalated Enrollee Issues‌ FHKC sometimes receives Enrollee complaints or concerns directly from Enrollees or forwarded from state agencies, legislative offices, and others. FHKC may forward such issues to Insurer for research and resolution. An escalated Enrollee issue may be designated by FHKC as an urgent escalated Enrollee issue based upon factors such as the Enrollee’s health status. All other escalated Enrollee issues are considered routine escalated Enrollee issues. Insurer shall acknowledge receipt of the escalated Enrollee issue within two (2) hours for urgent escalated Enrollee issues and by close of business for routine escalated Enrollee issues unless a different timeframe is specified by FHKC. Insurer shall provide regular status updates to FHKC on any activities and progress underway, including when further action and progress are temporarily halted. In the event progress is temporarily halted, Insurer shall allow no more than two (2) Business Days or three (3) Calendar Days between updates, whichever is earlier. Insurer shall not wait to be prompted for status updates by FHKC to provide such updates. To the extent reasonable and unless otherwise required by FHKC, Insurer shall resolve routine escalated Enrollee issues within five (5) Business Days and urgent escalated Enrollee issues within two (2) Business Days, unless the Enrollee’s health requires faster resolution. In the event the expected resolution timeframe is not reasonable to resolve the escalated Enrollee issue, Insurer shall inform FHKC in writing and provide an expected timeframe for resolution and the basis for the extended timeframe, subject to FHKC approval. Escalated Enrollee issues are not intended to take the place of or circumvent any aspect of the Grievance or Appeal process. The Parties shall act in good faith in the performance of this provision.

Enrollee Services. ‌ Insurer shall maintain an enrollee service unit to provide Enrolleeenrollee-related customer service. The enrollee service unit shall have the ability to answer Enrollee inquiries by telephone, electronic communication, communication and written communication. The enrollee service unit shall be accessible by a toll-free telephone number during the hours of 7:30 a.m. to 7:30 p.m. Eastern Time, Monday through Friday, except on FHKCstate-recognized holidays. Insurer shall utilize automatic call distribution equipment and enrollee services representatives staffing sufficient to handle the expected volume of calls. Insurer shall also provide a telecommunication device for the deaf (TTY/TDD) and access to interpreter services. Insurer shall ensure enrollee services representatives are satisfactorily trained and capable of resolving Enrollee and potential Enrollee inquiries in all areas related to Florida Healthy Kids. Insurer’s enrollee services representatives shall be familiar with the basic eligibility requirements for the Florida Healthy Kids Program, but shall refer or transfer individuals with detailed questions or concerns to the Florida KidCare call center. Insurer shall monitor the enrollee services line to ensure Insurer meets certain performance standards and for quality assurance, including recording calls, conducting routine audits, audits and other monitoring activities. Insurer shall meet the performance guarantees related to enrollee services included in Attachment C. Insurer shall provide a nurse line staffed by licensed nurses and available to Enrollees twenty- four (24) hours per day, seven (7) days a week. The nurse line shall provide health education and assist Enrollees in determining which place of care (e.g., urgent care center, emergency department, PCP office) is clinically appropriate for the symptoms described. Insurer shall also provide a behavioral health crisis line staffed by licensed professionals and available to Enrollees twenty-four (24) hours per day, seven (7) days a week. The behavioral health crisis line may be provided as part of the nurse line or separately. If the behavioral health crisis line is part of the nurse line, all licensed nurses must be trained appropriately. Insurer shall provide a publicly available website with access to Florida Healthy Kids information. The publicly available website shall include: a. The Enrollee handbook, b. A printable provider directory, c. A searchable electronic provider directory, d. Insurer’s preferred drug list (PDL), e. A link to FHKC’s Florida Healthy Kids website, and e. f. Any other information that may be needed by Enrollees or potential Enrollees. Insurer’s publicly available website is subject to FHKC approval. Insurer shall also provide a non-public website with secure access for Enrollees that Enrollees. The non-public website access shall include: a. The ability for Enrollees to print a temporary ID card, b. The ability for Enrollees to request a new ID card, and, c. Enrollee educational materials (unless Insurer chooses to make such materials available on the publicly publicly-available website), and d. Cost sharing accumulator information i. Insurer shall track the Enrollees’ cost share contributions to assist families in tracking their progress towards the out-of-pocket maximum. Insurer’s non-public website is subject to FHKC’s approval. 21.1 21-1 Escalated Enrollee Issues‌ FHKC sometimes receives Enrollee complaints or concerns directly from Enrollees or forwarded from state agencies, legislative offices, offices and others. FHKC may forward such issues to Insurer for research and resolution. An escalated Enrollee issue may be designated by FHKC as an urgent escalated Enrollee issue based upon factors such as the Enrollee’s health status. All other escalated Enrollee issues are considered routine escalated Enrollee issues. Insurer shall acknowledge receipt of the escalated Enrollee issue within two (2) hours for urgent escalated Enrollee issues and by close of business for routine escalated Enrollee issues unless a different timeframe is specified by FHKC. Insurer shall provide regular status updates to FHKC on any activities and progress underway, including when further action and progress are temporarily halted. In the event progress is temporarily halted, Insurer shall allow no more than two (2) Business Days or three (3) Calendar Days between updates, whichever is earlier. Insurer shall not wait to be prompted for status updates by FHKC to provide such updates. To the extent reasonable and unless otherwise required by FHKC, Insurer shall resolve routine escalated Enrollee issues within five (5) Business Days and urgent escalated Enrollee issues within two (2) Business Days, unless the Enrollee’s health requires faster resolution. In the event the expected resolution timeframe is not reasonable to resolve the escalated Enrollee issue, Insurer shall inform FHKC in writing and provide an expected timeframe for resolution and the basis for the extended timeframe, subject to FHKC approval. Escalated Enrollee issues are not intended to take the place of or circumvent any aspect of the Grievance or Appeal process. The Parties shall act in good faith in the performance of this provision.

Enrollee Services. ‌ Insurer shall maintain an enrollee service unit to provide Enrollee-related customer service. The enrollee service unit shall have the ability to answer Enrollee inquiries by telephone, electronic communication, and written communication. The enrollee service unit shall be accessible by a toll-free telephone number during the hours of 7:30 a.m. to 7:30 p.m. Eastern Time, Monday through Friday, except on FHKC-recognized holidays. Insurer shall utilize automatic call distribution equipment and enrollee services representatives staffing sufficient to handle the expected volume of calls. Insurer shall also provide a telecommunication device for the deaf (TTY/TDD) and access to interpreter services. Insurer shall ensure enrollee services representatives are satisfactorily trained and capable of resolving Enrollee and potential Enrollee inquiries in all areas related to Florida Healthy Kids. Insurer’s enrollee services representatives shall be familiar with the basic eligibility requirements for the Florida Healthy Kids Program, but shall refer or transfer individuals with detailed questions or concerns to the Florida KidCare call center. Insurer shall monitor the enrollee services line to ensure Insurer meets certain performance standards and for quality assurance, including recording calls, conducting routine audits, and other monitoring activities. Insurer shall meet the performance guarantees related to enrollee services included in Attachment C. Insurer shall provide a publicly available website with access to Florida Healthy Kids information. The publicly available website shall include: a. : The Enrollee handbook, b. , A printable provider directory, c. , A searchable electronic provider directory, d. , A link to FHKC’s Florida Healthy Kids website, and e. and Any other information that may be needed by Enrollees or potential Enrollees. Insurer’s publicly available website is subject to FHKC approval. Insurer shall also provide a non-public website with secure access for Enrollees that shall include: a. : The ability for Enrollees to print a temporary ID card, b. , The ability for Enrollees to request a new ID card, and c. and Enrollee educational materials (unless Insurer chooses to make such materials available on the publicly available website). Insurer’s non-public website is subject to FHKC’s approval. 21.1 Escalated Enrollee Issues‌ FHKC sometimes receives Enrollee complaints or concerns directly from Enrollees or forwarded from state agencies, legislative offices, and others. FHKC may forward such issues to Insurer for research and resolution. An escalated Enrollee issue may be designated by FHKC as an urgent escalated Enrollee issue based upon factors such as the Enrollee’s health status. All other escalated Enrollee issues are considered routine escalated Enrollee issues. Insurer shall acknowledge receipt of the escalated Enrollee issue within two (2) hours for urgent escalated Enrollee issues and by close of business for routine escalated Enrollee issues unless a different timeframe is specified by FHKC. Insurer shall provide regular status updates to FHKC on any activities and progress underway, including when further action and progress are temporarily halted. In the event progress is temporarily halted, Insurer shall allow no more than two (2) Business Days or three (3) Calendar Days between updates, whichever is earlier. Insurer shall not wait to be prompted for status updates by FHKC to provide such updates. To the extent reasonable and unless otherwise required by FHKC, Insurer shall resolve routine escalated Enrollee issues within five (5) Business Days and urgent escalated Enrollee issues within two (2) Business Days, unless the Enrollee’s health requires faster resolution. In the event the expected resolution timeframe is not reasonable to resolve the escalated Enrollee issue, Insurer shall inform FHKC in writing and provide an expected timeframe for resolution and the basis for the extended timeframe, subject to FHKC approval. Escalated Enrollee issues are not intended to take the place of or circumvent any aspect of the Grievance or Appeal process. The Parties shall act in good faith in the performance of this provision.