Enrollment and Education Activities. A. Member Enrollment The Contractor shall: 1. Assist EOHHS with activities related to enrollment of Enrollees, as directed by XXXXX, including, but not limited to, activities such as making preliminary assignments of Enrollees to Participating PCPs and reporting such assignments to EOHHS in a form and format specified by EOHHS; 2. Accept for enrollment all Members, as further specified by EOHHS, referred by EOHHS in the order in which they are referred without restriction; and 3. Accept for enrollment in the Contractor’s Plan, all Members identified by EOHHS at any time without regard to income status, physical or mental condition (such as cognitive, intellectual, mobility, psychiatric, and sensory disabilities as further defined by EOHHS), age, gender, sexual orientation, religion, creed, race, color, physical or mental disability, national origin, ancestry, status as a Member, pre-existing conditions, expected health status, or need for health care services. 4. For new Enrollees enrolled pursuant to Section 2.2.A.5, the Contractor shall collaborate with and support EOHHS in ensuring uninterrupted care. Such collaboration and support shall include, but not be limited to, participating in Enrollee outreach; and identifying specific issues and working with EOHHS to resolve those issues. B. Identification Card The Contractor shall provide new Enrollees with an identification card for the Contractor’s plan. The Contractor shall: 1. Mail an identification card to all Enrollees no later than 15 business days after the Enrollee’s Effective Date of Enrollment; 2. Ensure (pursuant to 42 USC 1396u-2(g)) that all identification cards issued by the Contractor to Enrollees include a code or some other means of allowing a hospital and other providers to identify the Enrollee as a MassHealth Member. The Enrollee identification card must also include: a. The name of the Contractor; b. The Enrollee’s name; c. A unique identification number for the Enrollee other than the Enrollee’s social security number; d. The Enrollee’s MassHealth identification number; e. The name and relevant telephone number(s) of the Contractor’s customer service number; and f. The name and customer service number of the Behavioral Health Vendor. C. New Enrollee Information The Contractor shall provide New Enrollees with Enrollee Information that meets the requirements of Section 2.8.C including a Provider directory that meets the requirements of Section 2.5.C and an Enrollee handbook based on a model provided by EOHHS, as further directed by EOHHS, that contains the Enrollee Information specified below. The Contractor must submit such Enrollee Information to be reviewed and approved by EOHHS at least 60 days prior to publication. Such Enrollee Information must be written in a manner, format and language that is easily understood at a reading level of 6.0 and below. The Enrollee Information must be made available in Prevalent Languages and in Alternative Formats free-of- charge, including American Sign Language video clips. The Contractor shall provide the Enrollee Information to each Enrollee within a reasonable time after receiving notice of the Enrollee’s enrollment. The Enrollee Information, shall include, but not be limited to, a description of the following: 1. How to access Contractor’s BH CPs and LTSS CPs, including through self-referral, and information about BH CPs and LTSS CPs; 2. The role of the PCP, the process for selecting and changing the Enrollee’s PCP, and the policies on referrals for specialty care and for other benefits not furnished by the Enrollee’s PCP; 3. The extent to which, and how, after-hours and Emergency Services and Poststabilization Care Services are covered, including: a. What constitutes an Emergency Medical Condition, Emergency Services, and Poststabilization Care Services; b. The fact that prior authorization is not required for Emergency Services; c. How to access the Contractor’s 24-hour Clinical Advice and Support Line; d. The process and procedures for obtaining Emergency Services, including the use of the 911-telephone system; e. The services provided by Emergency Services Programs (ESPs) and how to access them; f. The locations of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services; and g. The fact that the Enrollee has a right to use any hospital or other setting for Emergency Services; 4. The availability of free oral interpretation services from the Contractor in all non- English languages spoken by Enrollees and how to obtain such oral interpretation services; 5. The availability of all written materials that are produced by the Contractor for Enrollees in Prevalent Languages and how to obtain translated materials; 6. The availability of all written materials that are produced by the Contractor for Enrollees in Alternative Formats free-of-charge and how to access written materials in those formats and the availability of free auxiliary aids and services, including at a minimum, services for Enrollees with disabilities; 7. The toll-free Enrollee customer services telephone number and hours of operation, and the telephone number for any other unit providing services directly to Enrollees; 8. The rights and responsibilities of Enrollees, including but not limited to, those Enrollee rights described in Section 2.8.G.5; 9. Information on Grievances and Appeals and Ombudsman processes, and Board of Hearing (BOH) procedures and timeframes, pursuant to Section 2.8.G.1 and 2.8.G.2 including: a. The right to file Grievances and Appeals; b. The requirements and timeframes for filing a Grievance; c. The availability of assistance in the filing process; d. The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone; e. The right to obtain a BOH hearing; f. The method for obtaining a BOH hearing; g. The rules that govern representation at the BOH hearing; h. The right to file a grievance directly with EOHHS, how to do so, and EOHHS contact information; and i. Information about the availability of and access to Ombudsman services; 10. Information on advance directives in accordance with Section 2.8.G.5.v; and 11. Information on how to report suspected fraud or abuse. 12. Information about continuity and transition of care for new Enrollees; 13. Information about how to access MassHealth services including the amount, duration, and scope of available MassHealth services in sufficient detail to ensure that Enrollees understand the benefits to which they are entitled and the procedures for obtaining such benefits, including authorization requirements, any cost sharing, if applicable, and how transportation to such services may be requested. The Contractor shall also inform Enrollees of the availability of assistance through the MassHealth Customer Service Center for help determining where to access such services; 14. Information about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) and Preventative Pediatric Healthcare Screening and Diagnosis (PPHS), as further directed by XXXXX; 15. The services for which MassHealth does not require authorization or referral from the Enrollee’s Primary Care Provider (PCP), for example, family planning services or individual behavioral health outpatient therapy; 16. The extent to which, and how, Enrollees may obtain benefits, including Emergency Services and family planning services, from non-MassHealth providers; 17. How to obtain information about MassHealth providers; 18. Enrollee cost sharing;
Appears in 4 contracts
Samples: Primary Care Accountable Care Organization Contract, Primary Care Accountable Care Organization Contract, Primary Care Accountable Care Organization Contract
Enrollment and Education Activities.
A. Member Enrollment The Contractor shall:shall:
1. Assist EOHHS with activities related to enrollment of Enrollees, as directed by XXXXXEOHHS, including, but not limited to, activities such as making preliminary assignments of Enrollees to Participating PCPs PCCs and reporting such assignments to EOHHS in a form and format specified by EOHHS;EOHHS;
2. Accept for enrollment all Members, as further specified by EOHHS, referred by EOHHS in the order in which they are referred without restriction; and
3. Accept for enrollment in the Contractor’s Plan, all Members identified by EOHHS at any time without regard to income status, physical or mental condition (such as cognitive, intellectual, mobility, psychiatric, and sensory disabilities as further defined by EOHHS), age, gender, sexual orientation, religion, creed, race, color, physical or mental disability, national origin, ancestry, status as a Member, pre-existing conditions, expected health status, or need for health care services.
4. For new Enrollees enrolled pursuant to Section 2.2.A.5, the Contractor shall collaborate with and support EOHHS in ensuring uninterrupted care. Such collaboration and support shall include, but not be limited to, participating in Enrollee outreach; and identifying specific issues and working with EOHHS to resolve those issues.
B. Identification Card Card The Contractor shall provide new Enrollees with an identification card for the Contractor’s plan. The Contractor shall:
1. Mail an identification card to all Enrollees no later than 15 business days after the Enrollee’s Effective Date of Enrollment;
2. Ensure (pursuant to 42 USC 1396u-2(g)) that all identification cards issued by the Contractor to Enrollees include a code or some other means of allowing a hospital and other providers to identify the Enrollee as a MassHealth Member. The Enrollee identification card must also include:
a. The name of the Contractor;
b. The Enrollee’s name;
c. A unique identification number for the Enrollee other than the Enrollee’s social security number;
d. The Enrollee’s MassHealth identification number;
e. The name and relevant telephone number(s) of the Contractor’s customer service number; and
f. The name and customer service number of the Behavioral Health Vendor.
C. New Enrollee Information The Contractor shall provide New Enrollees with Enrollee Information that meets the requirements of Section 2.8.C including a Provider directory that meets the requirements of Section 2.5.C and an Enrollee handbook based on a model provided by EOHHS, as further directed by EOHHS, that contains the Enrollee Information specified below. The Contractor must submit such Enrollee Information to be reviewed and approved by EOHHS at least 60 days prior to publication. Such Enrollee Information must be written in a manner, format and language that is easily understood at a reading level of 6.0 and below. The Enrollee Information must be made available in Prevalent Languages and in Alternative Formats free-of- charge, including American Sign Language video clips. The Contractor shall provide the Enrollee Information to each Enrollee within a reasonable time after receiving notice of the Enrollee’s enrollment. The Enrollee Information, shall include, but not be limited to, a description of the following:
1. How to access Contractor’s BH CPs and LTSS CPs, including through self-referral, and information about BH CPs and LTSS CPs;
2. The role of the PCP, the process for selecting and changing the Enrollee’s PCP, and the policies on referrals for specialty care and for other benefits not furnished by the Enrollee’s PCP;
3. The extent to which, and how, after-hours and Emergency Services and Poststabilization Care Services are covered, including:
a. What constitutes an Emergency Medical Condition, Emergency Services, and Poststabilization Care Services;
b. The fact that prior authorization is not required for Emergency Services;
c. How to access the Contractor’s 24-hour Clinical Advice and Support Line;
d. The process and procedures for obtaining Emergency Services, including the use of the 911-telephone system;
e. The services provided by Emergency Services Programs (ESPs) and how to access them;
f. The locations of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services; and
g. The fact that the Enrollee has a right to use any hospital or other setting for Emergency Services;
4. The availability of free oral interpretation services from the Contractor in all non- English languages spoken by Enrollees and how to obtain such oral interpretation services;
5. The availability of all written materials that are produced by the Contractor for Enrollees in Prevalent Languages and how to obtain translated materials;
6. The availability of all written materials that are produced by the Contractor for Enrollees in Alternative Formats free-of-charge and how to access written materials in those formats and the availability of free auxiliary aids and services, including at a minimum, services for Enrollees with disabilities;
7. The toll-free Enrollee customer services telephone number and hours of operation, and the telephone number for any other unit providing services directly to Enrollees;
8. The rights and responsibilities of Enrollees, including but not limited to, those Enrollee rights described in Section 2.8.G.5;
9. Information on Grievances and Appeals and Ombudsman processes, and Board of Hearing (BOH) procedures and timeframes, pursuant to Section 2.8.G.1 and 2.8.G.2 including:
a. The right to file Grievances and Appeals;
b. The requirements and timeframes for filing a Grievance;
c. The availability of assistance in the filing process;
d. The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone;
e. The right to obtain a BOH hearing;
f. The method for obtaining a BOH hearing;
g. The rules that govern representation at the BOH hearing;
h. The right to file a grievance directly with EOHHS, how to do so, and EOHHS contact information; and
i. Information about the availability of and access to Ombudsman services;
10. Information on advance directives in accordance with Section 2.8.G.5.v; and
11. Information on how to report suspected fraud or abuse.
12. Information about continuity and transition of care for new Enrollees;
13. Information about how to access MassHealth services including the amount, duration, and scope of available MassHealth services in sufficient detail to ensure that Enrollees understand the benefits to which they are entitled and the procedures for obtaining such benefits, including authorization requirements, any cost sharing, if applicable, and how transportation to such services may be requested. The Contractor shall also inform Enrollees of the availability of assistance through the MassHealth Customer Service Center for help determining where to access such services;
14. Information about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) and Preventative Pediatric Healthcare Screening and Diagnosis (PPHS), as further directed by XXXXX;
15. The services for which MassHealth does not require authorization or referral from the Enrollee’s Primary Care Provider (PCP), for example, family planning services or individual behavioral health outpatient therapy;
16. The extent to which, and how, Enrollees may obtain benefits, including Emergency Services and family planning services, from non-MassHealth providers;
17. How to obtain information about MassHealth providers; 18. Enrollee cost sharing;
Appears in 2 contracts
Samples: Contract for Primary Care Accountable Care Organization Services, Contract
Enrollment and Education Activities.
A. Member Enrollment The Contractor shall:
1. Assist EOHHS with activities related to enrollment of Enrollees, as directed by XXXXX, including, but not limited to, activities such as making preliminary assignments of Enrollees to Participating PCPs and reporting such assignments to EOHHS in a form and format specified by EOHHS;EOHHS;
2. Accept for enrollment all Members, as further specified by EOHHS, referred by EOHHS in the order in which they are referred without restriction; and
3. Accept for enrollment in the Contractor’s Plan, all Members identified by EOHHS at any time without regard to income status, physical or mental condition (such as cognitive, intellectual, mobility, psychiatric, and sensory disabilities as further defined by EOHHS), age, gender, sexual orientation, religion, creed, race, color, physical or mental disability, national origin, ancestry, status as a Member, pre-existing conditions, expected health status, or need for health care services.
4. For new Enrollees enrolled pursuant to Section 2.2.A.5, 2.2.A.4 the Contractor shall collaborate with and support EOHHS in ensuring uninterrupted care. Such collaboration and support shall include, but not be limited to, participating in Enrollee outreach; and identifying specific issues and working with EOHHS to resolve those issues.
B. Identification Card The Contractor shall provide new Enrollees with an identification card for the Contractor’s plan. The Contractor shall:
1. Mail an identification card to all Enrollees no later than 15 business days after the Enrollee’s Effective Date of Enrollment;
2. Ensure (pursuant to 42 USC 1396u-2(g)) that all identification cards issued by the Contractor to Enrollees include a code or some other means of allowing a hospital and other providers to identify the Enrollee as a MassHealth Member. The Enrollee identification card must also include:
a. The name of the Contractor;
b. The Enrollee’s name;
c. A unique identification number for the Enrollee other than the Enrollee’s social security number;
d. The Enrollee’s MassHealth identification number;
e. The name and relevant telephone number(s) of the Contractor’s customer service number; and
f. The name and customer service number of the Behavioral Health Vendor.
C. New Enrollee Information The Contractor shall provide New Enrollees with Enrollee Information that meets the requirements of Section 2.8.C 2.9.C including a Provider directory that meets the requirements of Section 2.5.C 2.6.D and an Enrollee handbook based on a model provided by EOHHS, as further directed by EOHHSXXXXX, that contains the Enrollee Information specified below. The Contractor must submit such Enrollee Information to be reviewed and approved by EOHHS at least 60 days prior to publication. Such Enrollee Information must be written in a manner, format and language that is easily understood at a reading level of 6.0 and below. The Enrollee Information must be made available in Prevalent Languages and in Alternative Formats free-of- of-charge, including American Sign Language video clips. The Contractor shall provide the Enrollee Information to each Enrollee within a reasonable time after receiving notice of the Enrollee’s enrollment. The Enrollee Information, shall include, but not be limited to, a description of the following:
1. How to access Contractor’s BH CPs and LTSS CPs, including through self-referral, and information about BH CPs and LTSS CPs;
2. The role of the PCP, the process for selecting and changing the Enrollee’s PCP, and the policies on referrals for specialty care and for other benefits not furnished by the Enrollee’s PCP;
3. The extent to which, and how, after-hours and Emergency Services and Poststabilization Care Services are covered, including:
a. What constitutes an Emergency Medical Condition, Emergency Services, and Poststabilization Care Services;
b. The fact that prior authorization is not required for Emergency Services;
c. How to access the Contractor’s 24-hour Clinical Advice and Support Line;
d. The process and procedures for obtaining Emergency Services, including the use of the 911-telephone system;
e. The services provided by Emergency Services Programs (ESPs) Community Based Health Centers and how to access them;
f. How to access and use the Behavioral Health Help Line, including how the Contractor’s Clinical Advice and Support line will interface with the Behavioral Health Help Line;
g. The locations of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services; and
g. h. The fact that the Enrollee has a right to use any hospital or other setting for Emergency Services;
4. The availability of free oral interpretation services from the Contractor in all non- non-English languages spoken by Enrollees and how to obtain such oral interpretation services;
5. The availability of all written materials that are produced by the Contractor for Enrollees in Prevalent Languages and how to obtain translated materials;materials;
6. The availability of all written materials that are produced by the Contractor for Enrollees in Alternative Formats free-of-charge and how to access written materials in those formats and the availability of free auxiliary aids and services, including at a minimum, services for Enrollees with disabilities;
7. The toll-free Enrollee customer services telephone number and hours of operation, and the telephone number for any other unit providing services directly to Enrollees;
8. The rights and responsibilities of Enrollees, including but not limited to, those Enrollee rights described in Section 2.8.G.52.9.G.7;
9. Information on Grievances and Appeals and Ombudsman processes, and Board of Hearing (BOH) procedures and timeframes, pursuant to Section 2.8.G.1 2.9.G.1 and 2.8.G.2 2.9.G.2 including:
a. The right to file Grievances and Appeals;
b. The requirements and timeframes for filing a Grievance;
c. The availability of assistance in the filing process;
d. The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone;
e. The right to obtain a BOH hearing;
f. The method for obtaining a BOH hearing;
g. The rules that govern representation at the BOH hearing;; and
h. The right to file a grievance directly with EOHHS, how to do so, and EOHHS contact information; and;
i. 10. Information about the availability of and access to Ombudsman services;
1011. Information on advance directives Advance Directives in accordance with Section 2.8.G.5.v; and2.5.C.5.e;
1112. Information on how to report suspected fraud or abuse.;
1213. Information about continuity and transition of care for new Enrollees;
1314. Information about how to access MassHealth services including the amount, duration, and scope of available MassHealth services in sufficient detail to ensure that Enrollees understand the benefits to which they are entitled and the procedures for obtaining such benefits, including authorization requirements, any cost sharing, if applicable, and how transportation to such services may be requested. The Contractor shall also inform Enrollees of the availability of assistance through the MassHealth Customer Service Center for help determining where to access such services;services;
1415. Information about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) and Preventative Pediatric Healthcare Screening and Diagnosis (PPHS), as further directed by XXXXX;
1516. The services for which MassHealth does not require authorization or referral from the Enrollee’s Primary Care Provider (PCP), for example, family planning services or individual behavioral health outpatient therapy;therapy;
1617. The extent to which, and how, Enrollees may obtain benefits, including Emergency Services and family planning services, from non-MassHealth providers;
1718. How to obtain information about MassHealth providers; 18;
19. Enrollee cost sharing;sharing;
20. Any restrictions on freedom of choice among MassHealth providers; and 21. Information about Behavioral Health Services provided through the MassHealth Behavioral Health Vendor.
D. Provider Directory The Contractor shall:
1. Maintain a searchable Provider directory (or directories) of Participating PCPs and other Affiliated Providers as further specified by EOHHS that is made available in Prevalent Languages and Alternative Formats, upon request, and includes, at a minimum, the following information for each such provider:
a. Alphabetical list including any specialty and group affiliation as appropriate;
b. Geographic list of Providers by town;
c. Office address and telephone numbers as well as website URL as appropriate;
d. Office hours for each Provider;
e. Cultural and Linguistic Competence and capabilities, including languages spoken by the Provider or by skilled medical interpreter at site, including ASL, and whether the Provider has completed cultural competence training;
f. Whether or not the Provider’s office or facility has accommodations for people with physical disabilities, including offices, exam rooms, and equipment; and
g. Whether the Provider is accepting new patients.
2. Provide EOHHS with an updated electronic submission of its Provider directory (or directories) upon request, and on a semi-annual basis, if updated, and an electronic submission of changes to the Provider Directory monthly.
3. Provide the Provider directory to its Enrollees as follows:
a. The Contractor shall provide a copy in paper form to Enrollees upon request. The Contractor shall update its paper-version of its Provider directory monthly if the Contractor does not have a mobile-enabled, electronic directory as further specified by EOHHS and quarterly if the Contractor has such mobile-enabled electronic directory as further specified by EOHHS;
b. The Contractor shall include written and oral offers of such Provider directory in its outreach and orientation sessions for New Enrollees; and
c. The Contractor shall include an electronic copy of its Provider directory on the Contractor’s website in a machine-readable file and format. The Contractor shall update its electronic version of its Provider directory no later than 30 calendar days after being made aware of any change in information.
4. The Contractor shall provide to EOHHS, in accordance with Appendix F and as requested by EOHHS, an ad hoc report of all rates paid to a parent organization or a subsidiary in the previous Contract Year;
5. The Contractor shall develop, maintain and update information about Participating PCPs, with areas of special experience, skills, and training including, but not limited to, Providers with expertise in treating: children, adolescents, people with HIV, persons experiencing homelessness, people with disabilities, people with Autism Spectrum Disorder, people who are deaf or hard-of-hearing, people who are blind or visually impaired, and children in the care or custody of DCF or youth affiliated with DYS (either detained or committed. The Contractor shall make available to EOHHS, Members, and Enrollees, such information upon request.
Appears in 2 contracts
Samples: Standard Contract, Standard Contract
Enrollment and Education Activities.
A. Member Enrollment The Contractor shall:shall:
1. Assist EOHHS with activities related to enrollment of Enrollees, as directed by XXXXXEOHHS, including, but not limited to, activities such as making preliminary assignments of Enrollees to Participating PCPs and reporting such assignments to EOHHS in a form and format specified by EOHHS;EOHHS;
2. Accept for enrollment all Members, as further specified by EOHHS, referred by EOHHS in the order in which they are referred without restriction; and
3. Accept for enrollment in the Contractor’s Plan, all Members identified by EOHHS at any time without regard to income status, physical or mental condition (such as cognitive, intellectual, mobility, psychiatric, and sensory disabilities as further defined by EOHHS), age, gender, sexual orientation, religion, creed, race, color, physical or mental disability, national origin, ancestry, status as a Member, pre-existing conditions, expected health status, or need for health care services.
4. For new Enrollees enrolled pursuant to Section 2.2.A.5, the Contractor shall collaborate with and support EOHHS in ensuring uninterrupted care. Such collaboration and support shall include, but not be limited to, participating in Enrollee outreach; and identifying specific issues and working with EOHHS to resolve those issues.
B. Identification Card Card The Contractor shall provide new Enrollees with an identification card for the Contractor’s plan. The Contractor shall:
1. Mail an identification card to all Enrollees no later than 15 business days after the Enrollee’s Effective Date of Enrollment;
2. Ensure (pursuant to 42 USC 1396u-2(g)) that all identification cards issued by the Contractor to Enrollees include a code or some other means of allowing a hospital and other providers to identify the Enrollee as a MassHealth Member. The Enrollee identification card must also include:
a. The name of the Contractor;
b. The Enrollee’s name;
c. A unique identification number for the Enrollee other than the Enrollee’s social security number;
d. The Enrollee’s MassHealth identification number;
e. The name and relevant telephone number(s) of the Contractor’s customer service number; and
f. The name and customer service number of the Behavioral Health Vendor.
C. New Enrollee Information The Contractor shall provide New Enrollees with Enrollee Information that meets the requirements of Section 2.8.C including a Provider directory that meets the requirements of Section 2.5.C and an Enrollee handbook based on a model provided by EOHHS, as further directed by EOHHS, that contains the Enrollee Information specified below. The Contractor must submit such Enrollee Information to be reviewed and approved by EOHHS at least 60 days prior to publication. Such Enrollee Information must be written in a manner, format and language that is easily understood at a reading level of 6.0 and below. The Enrollee Information must be made available in Prevalent Languages and in Alternative Formats free-of- charge, including American Sign Language video clips. The Contractor shall provide the Enrollee Information to each Enrollee within a reasonable time after receiving notice of the Enrollee’s enrollment. The Enrollee Information, shall include, but not be limited to, a description of the following:
1. How to access Contractor’s BH CPs and LTSS CPs, including through self-referral, and information about BH CPs and LTSS CPs;
2. The role of the PCP, the process for selecting and changing the Enrollee’s PCP, and the policies on referrals for specialty care and for other benefits not furnished by the Enrollee’s PCP;
3. The extent to which, and how, after-hours and Emergency Services and Poststabilization Care Services are covered, including:
a. What constitutes an Emergency Medical Condition, Emergency Services, and Poststabilization Care Services;
b. The fact that prior authorization is not required for Emergency Services;
c. How to access the Contractor’s 24-hour Clinical Advice and Support Line;
d. The process and procedures for obtaining Emergency Services, including the use of the 911-telephone system;
e. The services provided by Emergency Services Programs (ESPs) and how to access them;
f. The locations of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services; and
g. The fact that the Enrollee has a right to use any hospital or other setting for Emergency Services;
4. The availability of free oral interpretation services from the Contractor in all non- English languages spoken by Enrollees and how to obtain such oral interpretation services;
5. The availability of all written materials that are produced by the Contractor for Enrollees in Prevalent Languages and how to obtain translated materials;
6. The availability of all written materials that are produced by the Contractor for Enrollees in Alternative Formats free-of-charge and how to access written materials in those formats and the availability of free auxiliary aids and services, including at a minimum, services for Enrollees with disabilities;
7. The toll-free Enrollee customer services telephone number and hours of operation, and the telephone number for any other unit providing services directly to Enrollees;
8. The rights and responsibilities of Enrollees, including but not limited to, those Enrollee rights described in Section 2.8.G.5;
9. Information on Grievances and Appeals and Ombudsman processes, and Board of Hearing (BOH) procedures and timeframes, pursuant to Section 2.8.G.1 and 2.8.G.2 including:
a. The right to file Grievances and Appeals;
b. The requirements and timeframes for filing a Grievance;
c. The availability of assistance in the filing process;
d. The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone;
e. The right to obtain a BOH hearing;
f. The method for obtaining a BOH hearing;
g. The rules that govern representation at the BOH hearing;
h. The right to file a grievance directly with EOHHS, how to do so, and EOHHS contact information; and
i. Information about the availability of and access to Ombudsman services;
10. Information on advance directives in accordance with Section 2.8.G.5.v; and
11. Information on how to report suspected fraud or abuse.
12. Information about continuity and transition of care for new Enrollees;
13. Information about how to access MassHealth services including the amount, duration, and scope of available MassHealth services in sufficient detail to ensure that Enrollees understand the benefits to which they are entitled and the procedures for obtaining such benefits, including authorization requirements, any cost sharing, if applicable, and how transportation to such services may be requested. The Contractor shall also inform Enrollees of the availability of assistance through the MassHealth Customer Service Center for help determining where to access such services;
14. Information about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) and Preventative Pediatric Healthcare Screening and Diagnosis (PPHS), as further directed by XXXXX;
15. The services for which MassHealth does not require authorization or referral from the Enrollee’s Primary Care Provider (PCP), for example, family planning services or individual behavioral health outpatient therapy;
16. The extent to which, and how, Enrollees may obtain benefits, including Emergency Services and family planning services, from non-MassHealth providers;
17. How to obtain information about MassHealth providers; 18. Enrollee cost sharing;
Appears in 1 contract
Samples: Primary Care Accountable Care Organization Contract
Enrollment and Education Activities.
A. Member Enrollment The Contractor shall:
1. Assist EOHHS with activities related to enrollment of Enrollees, as directed by XXXXX, including, but not limited to, activities such as making preliminary assignments of Enrollees to Participating PCPs and reporting such assignments to EOHHS in a form and format specified by EOHHS;EOHHS;
2. Accept for enrollment all Members, as further specified by EOHHS, referred by EOHHS in the order in which they are referred without restriction; and
3. Accept for enrollment in the Contractor’s Plan, all Members identified by EOHHS at any time without regard to income status, physical or mental condition (such as cognitive, intellectual, mobility, psychiatric, and sensory disabilities as further defined by EOHHS), age, gender, sexual orientation, religion, creed, race, color, physical or mental disability, national origin, ancestry, status as a Member, pre-existing conditions, expected health status, or need for health care services.
4. For new Enrollees enrolled pursuant to Section 2.2.A.5, 2.2.A.4 the Contractor shall collaborate with and support EOHHS in ensuring uninterrupted care. Such collaboration and support shall include, but not be limited to, participating in Enrollee outreach; and identifying specific issues and working with EOHHS to resolve those issues.
B. Identification Card The Contractor shall provide new Enrollees with an identification card for the Contractor’s plan. The Contractor shall:
1. Mail an identification card to all Enrollees no later than 15 business days after the Enrollee’s Effective Date of Enrollment;
2. Ensure (pursuant to 42 USC 1396u-2(g)) that all identification cards issued by the Contractor to Enrollees include a code or some other means of allowing a hospital and other providers to identify the Enrollee as a MassHealth Member. The Enrollee identification card must also include:
a. The name of the Contractor;
b. The Enrollee’s name;
c. A unique identification number for the Enrollee other than the Enrollee’s social security number;
d. The Enrollee’s MassHealth identification number;
e. The name and relevant telephone number(s) of the Contractor’s customer service number; and
f. The name and customer service number of the Behavioral Health Vendor.
C. New Enrollee Information The Contractor shall provide New Enrollees with Enrollee Information that meets the requirements of Section 2.8.C 2.9.C including a Provider directory that meets the requirements of Section 2.5.C 2.6.D and an Enrollee handbook based on a model provided by EOHHS, as further directed by EOHHSXXXXX, that contains the Enrollee Information specified below. The Contractor must submit such Enrollee Information to be reviewed and approved by EOHHS at least 60 days prior to publication. Such Enrollee Information must be written in a manner, format and language that is easily understood at a reading level of 6.0 and below. The Enrollee Information must be made available in Prevalent Languages and in Alternative Formats free-of- of-charge, including American Sign Language video clips. The Contractor shall provide the Enrollee Information to each Enrollee within a reasonable time after receiving notice of the Enrollee’s enrollment. The Enrollee Information, shall include, but not be limited to, a description of the following:
1. How to access Contractor’s BH CPs and LTSS CPs, including through self-referral, and information about BH CPs and LTSS CPs;
2. The role of the PCP, the process for selecting and changing the Enrollee’s PCP, and the policies on referrals for specialty care and for other benefits not furnished by the Enrollee’s PCP;
3. The extent to which, and how, after-hours and Emergency Services and Poststabilization Care Services are covered, including:
a. What constitutes an Emergency Medical Condition, Emergency Services, and Poststabilization Care Services;
b. The fact that prior authorization is not required for Emergency Services;
c. How to access the Contractor’s 24-hour Clinical Advice and Support Line;
d. The process and procedures for obtaining Emergency Services, including the use of the 911-telephone system;
e. The services provided by Emergency Services Programs (ESPs) Community Based Health Centers and how to access them;
f. How to access and use the Behavioral Health Help Line, including how the Contractor’s Clinical Advice and Support line will interface with the Behavioral Health Help Line;
g. The locations of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services; and
g. h. The fact that the Enrollee has a right to use any hospital or other setting for Emergency Services;
4. The availability of free oral interpretation services from the Contractor in all non- non-English languages spoken by Enrollees and how to obtain such oral interpretation services;
5. The availability of all written materials that are produced by the Contractor for Enrollees in Prevalent Languages and how to obtain translated materials;materials;
6. The availability of all written materials that are produced by the Contractor for Enrollees in Alternative Formats free-of-charge and how to access written materials in those formats and the availability of free auxiliary aids and services, including at a minimum, services for Enrollees with disabilities;
7. The toll-free Enrollee customer services telephone number and hours of operation, and the telephone number for any other unit providing services directly to Enrollees;
8. The rights and responsibilities of Enrollees, including but not limited to, those Enrollee rights described in Section 2.8.G.52.9.G.7;
9. Information on Grievances and Appeals and Ombudsman processes, and Board of Hearing (BOH) procedures and timeframes, pursuant to Section 2.8.G.1 2.9.G.1 and 2.8.G.2 2.9.G.2 including:
a. The right to file Grievances and Appeals;
b. The requirements and timeframes for filing a Grievance;
c. The availability of assistance in the filing process;
d. The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone;
e. The right to obtain a BOH hearing;
f. The method for obtaining a BOH hearing;
g. The rules that govern representation at the BOH hearing;; and
h. The right to file a grievance directly with EOHHS, how to do so, and EOHHS contact information; and;
i. 10. Information about the availability of and access to Ombudsman services;
1011. Information on advance directives Advance Directives in accordance with Section 2.8.G.5.v; and2.5.C.5.e;
1112. Information on how to report suspected fraud or abuse.
1213. Information about continuity and transition of care for new Enrollees;
1314. Information about how to access MassHealth services including the amount, duration, and scope of available MassHealth services in sufficient detail to ensure that Enrollees understand the benefits to which they are entitled and the procedures for obtaining such benefits, including authorization requirements, any cost sharing, if applicable, and how transportation to such services may be requested. The Contractor shall also inform Enrollees of the availability of assistance through the MassHealth Customer Service Center for help determining where to access such services;services;
1415. Information about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) and Preventative Pediatric Healthcare Screening and Diagnosis (PPHS), as further directed by XXXXXEOHHS;
1516. The services for which MassHealth does not require authorization or referral from the Enrollee’s Primary Care Provider (PCP), for example, family planning services or individual behavioral health outpatient therapy;therapy;
1617. The extent to which, and how, Enrollees may obtain benefits, including Emergency Services and family planning services, from non-MassHealth providers;
1718. How to obtain information about MassHealth providers; 18;
19. Enrollee cost sharing;sharing;
20. Any restrictions on freedom of choice among MassHealth providers; and
21. Information about Behavioral Health Services provided through the MassHealth Behavioral Health Vendor.
D. Provider Directory The Contractor shall:
1. Maintain a searchable Provider directory (or directories) of Participating PCPs and other Affiliated Providers as further specified by EOHHS that is made available in Prevalent Languages and Alternative Formats, upon request, and includes, at a minimum, the following information for each such provider:
a. Alphabetical list including any specialty and group affiliation as appropriate;
b. Geographic list of Providers by town;
c. Office address and telephone numbers as well as website URL as appropriate;
d. Office hours for each Provider;
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