Common use of Enrollee Services Clause in Contracts

Enrollee Services. A. Enrollee Service Representatives (ESRs) The Contractor must employ ESRs trained to answer Enrollee inquiries and concerns from Enrollees and Eligible Beneficiaries, consistent with the requirements of 42 C.F.R. § 422.111(h) and 423.128(d) as well as the following requirements: 1. Be trained to answer Enrollee inquiries and concerns from Enrollees and prospective Enrollees; 2. Be trained in the use of TTY, Video Relay services, remote interpreting services, how to provide accessible PDF materials, and other Alternative Formats; 3. Be capable of speaking directly with, or arranging for an interpreter to speak with, Enrollees in their primary language, including American Sign Language, or through an alternative language device or telephone translation service; 4. Inform callers that interpreter services are free; 5. Be knowledgeable about MassHealth, Medicare, and the terms of the Contract, including the Covered Services listed in Appendix A; 6. Be available to Enrollees to discuss and provide assistance with resolving Enrollee Complaints; 7. Have access to the Contractor’s enrollee database, EOHHS’s Eligibility Verification System (EVS), and an electronic provider directory; 8. Make oral interpretation services available free-of-charge to Enrollees in all non-English languages spoken by Enrollees, including American Sign Language (ASL); 9. Maintain the availability of services, such as TTY services, computer-aided transcription services, telephone handset amplifiers, assistive listening systems, closed caption decoders, videotext displays and qualified interpreters and other services for Deaf and hard of hearing Enrollees; 10. Demonstrate sensitivity to culture, including disability culture and the Independent Living Philosophy; 11. Provide assistance to Enrollees with cognitive impairments; for example, provide written materials in simple, clear language at a reading level of grade 6 and below, and individualized guidance from Enrollee Services Representatives to ensure materials are understood; 12. Provide reasonable accommodations needed to assure effective communication and provide Enrollees with a means to identify their disability to the ICO; 13. Maintain employment standards and requirements (e.g., education, training, and experience) for Enrollee services department staff and provide a sufficient number of staff to meet defined performance objectives; and 14. Ensure that Enrollee Services Representatives make available to Enrollees and Eligible Beneficiaries, upon request, information concerning the following: a. The identity, locations, qualifications, and availability of Providers; b. Enrollees’ rights and responsibilities; c. The procedures available to an Enrollee and Provider(s) to challenge or appeal the failure of the ICO to provide a Covered Service and to appeal any Adverse Actions (denials); d. How to access oral interpretation services and written materials in Prevalent Languages and Alternative Formats; e. Information on all Covered Services and other available services or resources (e.g., State agency services) either directly or through referral or authorization; f. The procedures for an Enrollee to change plans or to opt out of the Demonstration; and g. Additional information that may be required by Enrollees and Eligible Beneficiaries to understand the requirements and benefits of the ICO.

Enrollee Services. A. 2.12.1. Enrollee Service Representatives (ESRs) ). The Contractor must employ ESRs trained to answer Enrollee inquiries and concerns from Enrollees and Eligible Beneficiariespotential Enrollees, consistent with the requirements of 42 C.F.R. §§ 422.111(h) and 423.128(d) as well as the following requirements: 12.12.1.1. Be trained to answer Enrollee inquiries and concerns from Enrollees and prospective Enrolleespotential Enrollees regarding medical, behavioral, and LTSS services provided; 22.12.1.2. Be trained in the use of TTY, Video Relay video relay services, remote interpreting services, how to provide accessible PDF materials, and other Alternative Formatsalternative formats; 32.12.1.3. Be capable of speaking directly with, or arranging for an interpreter to speak with, Enrollees in their primary language, including American Sign LanguageLanguage (ASL), or through an alternative language device or telephone translation service; 42.12.1.4. Inform callers that interpreter services are free; 52.12.1.5. Be knowledgeable about MassHealthMedi-Cal, Medicare, the CFAM- MOU, and the terms of the Contract, including the Covered Services listed in Appendix A; 62.12.1.6. Be available to Enrollees to discuss and provide assistance with resolving Enrollee ComplaintsGrievances and complaints; 7. Have access to the Contractor’s enrollee database, EOHHS’s Eligibility Verification System (EVS), and an electronic provider directory; 82.12.1.7. Make oral interpretation services available free-of-charge to Enrollees in all non-English languages spoken by Enrollees, including American Sign Language (ASL); 92.12.1.8. Maintain the availability of services, such as TTY services, computer-aided transcription services, telephone handset amplifiers, assistive listening systems, closed caption decoders, videotext displays and qualified interpreters and other services for Deaf and hard of hearing Enrollees; 102.12.1.9. Demonstrate sensitivity to culture, including disability culture competent care and the Independent Living Philosophyindependent living philosophy; 112.12.1.10. Provide assistance to Enrollees with cognitive impairments; for example, provide written materials in simple, clear language at a reading level of sixth grade 6 and below, and individualized guidance from Enrollee Services Representatives ESRs to ensure materials are understood; 122.12.1.11. Provide reasonable accommodations needed to assure effective communication and provide Enrollees with a means to identify their disability to the ICOContractor; 132.12.1.12. Maintain employment standards and requirements (e.g., education, training, and experience) for Enrollee services department staff and provide a sufficient number of staff to meet defined performance objectives; and 142.12.1.13. Ensure that Enrollee Services Representatives ESRs make available to Enrollees and Eligible Beneficiariespotential Enrollees, upon request, information concerning the following: a. 2.12.1.13.1. Enrollees’ rights and responsibilities; 2.12.1.13.2. The procedures for an Enrollee to change plans or to opt out of Cal MediConnect; 2.12.1.13.3. How to access oral interpretation services and written materials in Threshold Languages and alternative formats; 2.12.1.13.4. The identity, locations, qualifications, and availability of Network Providers; b. Enrollees’ rights and responsibilities; c. The procedures available to an Enrollee and Provider(s) to challenge or appeal the failure of the ICO to provide a Covered Service and to appeal any Adverse Actions (denials); d. How to access oral interpretation services and written materials in Prevalent Languages and Alternative Formats; e. 2.12.1.13.5. Information on all Covered Services and other available services or resources (e.g., State state agency services) either directly or through referral or authorization; f. 2.12.1.13.6. Be able to direct enrollees to the Denti-Cal program for any fee-for-service dental benefits available from Medi-Cal; 2.12.1.13.7. The procedures for available to an Enrollee and Network Provider(s) to change plans challenge or to opt out Appeal the failure of the DemonstrationContractor to provide a Covered Service and to Appeal any adverse actions (denials); and g. 2.12.1.13.8. Additional information that may be required by Enrollees and Eligible Beneficiaries potential Enrollees to understand the requirements and benefits of the ICOCal MediConnect.

Enrollee Services. A. 2.12.1. Enrollee Service Representatives service representatives (ESRs) ). The Contractor must employ ESRs trained to answer Enrollee inquiries and concerns from Enrollees and Eligible Beneficiariespotential Enrollees, consistent with the requirements of 42 C.F.R. §§ 422.111(h) and 423.128(d) as well as the following requirements: 12.12.1.1. Be trained to answer Enrollee inquiries and concerns from Enrollees and prospective Enrolleespotential Enrollees regarding medical, behavioral, and LTSS services provided; 22.12.1.2. Be trained in the use of TTY, Video Relay video relay services, remote interpreting services, how to provide accessible PDF materials, and other Alternative Formatsalternative formats; 32.12.1.3. Be capable of speaking directly with, or arranging for an interpreter to speak with, Enrollees in their primary language, including American Sign LanguageLanguage (ASL), or through an alternative language device or telephone translation service; 42.12.1.4. Inform callers that interpreter services are free; 52.12.1.5. Be knowledgeable about MassHealthMedi-Cal, Medicare, the CFAM- MOU, and the terms of the Contract, including the Covered Services listed in Appendix A; 62.12.1.6. Be available to Enrollees to discuss and provide assistance with resolving Enrollee ComplaintsGrievances and complaints; 7. Have access to the Contractor’s enrollee database, EOHHS’s Eligibility Verification System (EVS), and an electronic provider directory; 82.12.1.7. Make oral interpretation services available free-of-charge to Enrollees in all non-English languages spoken by Enrollees, including American Sign Language (ASL)ASL and how to access those services; 92.12.1.8. Maintain the availability of services, such as TTY services, computer-aided transcription services, telephone handset amplifiers, assistive listening systems, closed caption decoders, videotext displays and qualified interpreters and other services for Deaf and hard of hearing Enrollees; 102.12.1.9. Demonstrate sensitivity to culture, including disability culture competent care and the Independent Living Philosophyindependent living philosophy; 112.12.1.10. Provide assistance to Enrollees with cognitive impairments; for example, provide written materials in simple, clear language at a reading level of sixth grade 6 and below, and individualized guidance from Enrollee Services Representatives ESRs to ensure materials are understood; 122.12.1.11. Provide reasonable accommodations needed to assure effective communication and provide Enrollees with a means to identify their disability to the ICOContractor; 132.12.1.12. Maintain employment standards and requirements (e.g., education, training, and experience) for Enrollee services department staff and provide a sufficient number of staff to meet defined performance objectives; and 142.12.1.13. Ensure that Enrollee Services Representatives ESRs make available to Enrollees and Eligible Beneficiariespotential Enrollees, upon request, information concerning the following: a. 2.12.1.13.1. Enrollees’ rights and responsibilities; 2.12.1.13.2. The procedures for an Enrollee to change plans or to opt out of Cal MediConnect; 2.12.1.13.3. How to access oral interpretation services and written materials in Threshold Languages and alternative formats; 2.12.1.13.4. The identity, locations, qualifications, and availability of Network Providers; b. Enrollees’ rights and responsibilities; c. The procedures available to an Enrollee and Provider(s) to challenge or appeal the failure of the ICO to provide a Covered Service and to appeal any Adverse Actions (denials); d. How to access oral interpretation services and written materials in Prevalent Languages and Alternative Formats; e. 2.12.1.13.5. Information on all Covered Services and other available services or resources (e.g., State state agency services) either directly or through referral or authorization; f. The procedures 2.12.1.13.6. Be able to direct enrollees to the Denti-Cal program for an Enrollee to change plans or to opt out of the Demonstration; and g. Additional information that may be required by Enrollees and Eligible Beneficiaries to understand the requirements and any fee-for-service dental benefits of the ICO.available from Medi-Cal;

Enrollee Services. A. 2.12.1. Enrollee Service Representatives service representatives (ESRs) ). The Contractor must employ ESRs trained to answer Enrollee inquiries and concerns from Enrollees and Eligible Beneficiariespotential Enrollees, consistent with the requirements of 42 C.F.R. §§ 422.111(h) and 423.128(d) as well as the following requirements: 12.12.1.1. Be trained to answer Enrollee inquiries and concerns from Enrollees and prospective Enrolleespotential Enrollees regarding medical, behavioral, and LTSS services provided; 22.12.1.2. Be trained in the use of TTY, Video Relay video relay services, remote interpreting services, how to provide accessible PDF materials, and other Alternative Formatsalternative formats; 32.12.1.3. Be capable of speaking directly with, or arranging for an interpreter to speak with, Enrollees in their primary language, including American Sign LanguageLanguage (ASL), or through an alternative language device or telephone translation service; 42.12.1.4. Inform callers that interpreter services are free; 52.12.1.5. Be knowledgeable about MassHealthMedi-Cal, Medicare, the CFAM- MOU, and the terms of the Contract, including the Covered Services listed in Appendix A; 62.12.1.6. Be available to Enrollees to discuss and provide assistance with resolving Enrollee ComplaintsGrievances and complaints; 7. Have access to the Contractor’s enrollee database, EOHHS’s Eligibility Verification System (EVS), and an electronic provider directory; 82.12.1.7. Make oral interpretation services available free-of-charge to Enrollees in all non-English languages spoken by Enrollees, including American Sign Language (ASL)ASL and how to access those services; 92.12.1.8. Maintain the availability of services, such as TTY services, computer-aided transcription services, telephone handset amplifiers, assistive listening systems, closed caption decoders, videotext displays and qualified interpreters and other services for Deaf Xxxx and hard of hearing Enrollees; 102.12.1.9. Demonstrate sensitivity to culture, including disability culture competent care and the Independent Living Philosophyindependent living philosophy; 112.12.1.10. Provide assistance to Enrollees with cognitive impairments; for example, provide written materials in simple, clear language at a reading level of sixth grade 6 and below, and individualized guidance from Enrollee Services Representatives ESRs to ensure materials are understood; 122.12.1.11. Provide reasonable accommodations needed to assure effective communication and provide Enrollees with a means to identify their disability to the ICOContractor; 132.12.1.12. Maintain employment standards and requirements (e.g., education, training, and experience) for Enrollee services department staff and provide a sufficient number of staff to meet defined performance objectives; and 142.12.1.13. Ensure that Enrollee Services Representatives ESRs make available to Enrollees and Eligible Beneficiariespotential Enrollees, upon request, information concerning the following: a. 2.12.1.13.1. Enrollees’ rights and responsibilities; 2.12.1.13.2. The procedures for an Enrollee to change plans or to opt out of Cal MediConnect; 2.12.1.13.3. How to access oral interpretation services and written materials in Threshold Languages and alternative formats; 2.12.1.13.4. The identity, locations, qualifications, and availability of Network Providers; b. Enrollees’ rights and responsibilities; c. The procedures available to an Enrollee and Provider(s) to challenge or appeal the failure of the ICO to provide a Covered Service and to appeal any Adverse Actions (denials); d. How to access oral interpretation services and written materials in Prevalent Languages and Alternative Formats; e. 2.12.1.13.5. Information on all Covered Services and other available services or resources (e.g., State state agency services) either directly or through referral or authorization; f. The procedures 2.12.1.13.6. Be able to direct enrollees to the Denti-Cal program for an Enrollee to change plans or to opt out of the Demonstration; and g. Additional information that may be required by Enrollees and Eligible Beneficiaries to understand the requirements and any fee-for-service dental benefits of the ICO.available from Medi-Cal;