Common use of Enrollment Information to be Presented Clause in Contracts

Enrollment Information to be Presented. The MCO shall present to all new Enrollees the following information within fifteen (15) calendar days of availability of readable enrollment data from the STATE. If an Enrollee becomes ineligible and is disenrolled from the MCO, but eligibility is reestablished within the following three months and the Enrollee’s eligibility is reestablished in the same program and he/she is re-enrolled in the same MCO, the MCO will not be required to send a new member packet, including the EOC or Member Handbook and a provider directory, but must send the Enrollee another MCO member identification card. For MSC+, an Evidence of Coverage (EOC) and for MSHO, a Member Handbook, that has been prior approved by the STATE and for MSHO, by CMS. For MSHO, the MCO will cooperate with the MSHO Plan Member Materials Workgroup to adjust the CMS Medicare model Member Handbook to incorporate STATE requirements. The MCO will use the model developed by the MSHO Plan Member Materials Workgroup to develop its own Member Handbook, which is then submitted to the STATE and includes information as below in section 3.6.6(A)(3)(a) through (s). For MSC+, the STATE will provide annually to the MCO a model EOC or EOC Addendum as the base document. Prior to distribution to the MCO, the model EOC or EOC Addendum will be prior approved by MDH to ensure that MDH’s requirements are included. The MCO will not have to subsequently submit the EOC or EOC Addendum to MDH after receiving approval from the STATE. After the MCO has incorporated its specific information, the completed EOC or EOC Addendum will be submitted to the STATE for prior approval. For MSHO the Member Handbook and for MSC+ the EOC or EOC Addendum must include the following, and must be distributed annually to MSC+ Enrollees no later than January 31, or for MSHO as required by CMS: (a) A description of the MCO’s medical and remedial care program, including specific information on Covered Services, limitations, and non-covered services; (b) A description of the Enrollee’s rights and protections as specified in 42 CFR § 438.100; (c) Cost sharing, if applicable; (d) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, § 62Q.14; (e) Information about providing coverage for prescriptions that are dispensed as written (DAW); (f) A statement informing Enrollees that the MCO shall provide language and accessibility assistance to Enrollees that ensures meaningful access to its programs and services, and how to obtain auxiliary aids and services, including information in alternative formats or languages; (g) A description of how American Indian Enrollees may directly access Indian Health Care Providers and how such Enrollees shall obtain referral services. In prior approving this portion of the EOC or Member Handbook, the STATE shall consult with tribal governments; (h) A description of how Enrollees may access services to which they are entitled under Medical Assistance, but that are not provided under this Contract; (i) A description of Medical Necessity for mental health services under Minnesota Statutes, § 62Q.53; (j) A description of how transportation is provided; (k) A description of how the Enrollee may obtain services, including 1) hours of service; 2) appointment procedures; 3) Service Authorization requirements and procedures; 4) what constitutes Medical Emergency and Post Stabilization care;

Enrollment Information to be Presented. The MCO shall present to all new Enrollees the following information within fifteen (15) calendar days of availability of readable enrollment data from the STATE. If an Enrollee becomes ineligible and is disenrolled from the MCO, but eligibility is reestablished within the following three months and the Enrollee’s eligibility is reestablished in the same program and he/she is re-enrolled in the same MCO, the MCO will not be required to send a new member packet, including the EOC or Member Handbook and a provider directory, but must send the Enrollee another MCO member identification card. For MSC+, an . (A) Evidence of Coverage (EOC) and for MSHO, a Member Handbook, that has been prior approved by the STATE and for MSHO, by CMS. For MSHO, the MCO will cooperate with the MSHO Plan Member Materials Workgroup to adjust the CMS Medicare model Member Handbook to incorporate STATE requirements). The MCO will use the model developed by the MSHO Plan Member Materials Workgroup to develop its own Member Handbook, which is then submitted to the STATE and includes information as below in section 3.6.6(A)(3)(a) through (s). For MSC+, the STATE will provide annually to the MCO a model EOC or EOC Addendum as the base document. Prior to distribution to the MCO, the model EOC or EOC Addendum will be prior approved by MDH to ensure that MDH’s requirements are included. The MCO will not have to subsequently submit the EOC or EOC Addendum to MDH after receiving approval from the STATE. After the MCO has incorporated its specific information, the completed EOC or EOC Addendum will be submitted to the STATE for prior approvalapproval and must be distributed annually to Enrollees no later than January 31. For MSHO the Member Handbook and for MSC+ the The complete EOC or the EOC Addendum must include the following, and must be distributed annually to MSC+ Enrollees no later than January 31, or for MSHO as required by CMS: (a1) A description of the MCO’s medical and remedial care program, including specific information on Covered Services, limitations, and non-covered services; (b2) A description of the Enrollee’s rights and protections as specified in 42 CFR § 438.100; (c3) Cost sharing, if applicable; (d4) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, § 62Q.14; (e5) Information about providing coverage for prescriptions that are dispensed as written (DAW); (f6) A statement informing Enrollees that the MCO shall provide language and accessibility assistance to Enrollees that ensures ensure meaningful access to its programs and services, and how to obtain auxiliary aids and services, including information in alternative formats or languages; (g7) A description of how American Indian Enrollees may directly access Indian Health Care Providers and how such Enrollees shall obtain referral services. In prior approving this portion of the EOC or Member HandbookEOC, the STATE shall consult with tribal governments; (h) 8) A description of how Enrollees may access services to which they are entitled under Medical Assistance, but that are not provided under this Contract; (i9) A description of Medical Necessity for mental health services under Minnesota Statutes, § 62Q.53; (j10) A description of how transportation is provided; (k11) A description of how the Enrollee may obtain services, including including: 1) hours of service; 2) appointment procedures; 3) Service Authorization requirements and procedures; 4) what constitutes Medical Emergency and Post Stabilization care; 5) the process and procedures for obtaining both Medical Emergency and Post Stabilization care, including a 24-hour telephone number for Medical Emergency Services; and 6) procedures for Urgent Care and Out of Network care. (a) The MCO must indicate that Service Authorization is not required for Medical Emergencies and that the Enrollee has a right to use any hospital or other setting for Emergency Care. (b) If the MCO does not allow direct access to specialty care, the MCO must inform Enrollees the circumstances under which a referral may be made to such Providers; (12) A toll-free telephone number that the Enrollee may call regarding MCO coverage or procedures; (13) An explanation of the MCO’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT), known in Minnesota and hereinafter as the Child and Teen Checkups (C&TC) program for Children; (14) A description of all Grievance, Appeal and State Fair Hearing rights and procedures available to Enrollees, including the MCO’s Grievance and Appeal System procedures, the availability of an expert medical opinion from an external organization pursuant to sections 6.1.40, the ability of Grievances, Appeals and State Fair Hearings to run concurrently, and the availability of a second opinion at the MCO’s expense. This includes, but is not limited to: (a) For State Fair Hearing: 1) the right to a hearing; 2) the method for obtaining a hearing; and 3) the rules that govern representation at the hearing. (b) The right to file Grievances and Appeals. (c) The requirements and timeframes for filing a Grievance or Appeal. (d) The availability of assistance in the filing process. (e) The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone. (15) An explanation that, when an Appeal or State Fair Hearing is requested by the Enrollee: (a) Benefits will continue if the Enrollee files an Appeal or a request for State Fair Hearing within the timeframes specified for filing, and requests continuation of benefits within the time allowed; and (b) The Enrollee may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is not wholly favorable to the Enrollee. (16) Any Appeal rights under state law available to Providers to challenge the failure of the MCO to cover a service; (17) A description of the MCO’s obligation to assume financial responsibility and provide reimbursement for Medical Emergency Services, Post-Stabilization Care Services and Out of Service Area Urgent Care; (18) General descriptions of the coverage for durable medical equipment, level of coverage available, criteria and procedures for any Service Authorizations, and also the address and telephone number of an MCO representative whom an Enrollee can contact to obtain (either orally or in writing upon request) specific information about coverage and Service Authorization. The MCO shall provide information that is more specific to a prospective Enrollee upon request; (19) A description of the Enrollee’s right to request information about Physician Incentive Plans from the MCO, including whether the MCO uses a Physician Incentive Plan that affects the use of referral services, the type of incentive arrangements, whether stop-loss protection is provided, and a summary of survey results pursuant to section 17.2 below; and (20) A description of the Enrollee’s right to request the results of an external quality review study; and a description of the MCO’s Quality Assurance System, pursuant to 42 CFR § 438.364.

Enrollment Information to be Presented. The MCO shall present to all new Enrollees the following information within fifteen (15) calendar days of availability of readable enrollment data from the STATE. If an Enrollee becomes ineligible and is disenrolled from the MCO, but eligibility is reestablished within the following three months and the Enrollee’s eligibility is reestablished in the same program and he/she is re-enrolled in the same MCO, the MCO will not be required to send a new member packet, including the EOC or Member Handbook and a provider directory, but must send the Enrollee another MCO member identification card. For MSC+, an . (A) An Evidence of Coverage (EOC) and for MSHO, a Member Handbook, that has been received prior approved approval by the STATE STATE, and for MSHO, by CMS. that includes the following: (1) For MSHOSNBC SNP Enrollees, the MCO will cooperate with the MSHO Plan D-SNP Integrated Member Materials Workgroup work group to adjust the CMS Medicare model Member Handbook EOC to incorporate STATE requirements. The MCO will use the model developed by the MSHO Plan Member D-SNP Materials Workgroup work group to develop its own Member HandbookEOC, which is then submitted to the STATE and includes information as below in section 3.6.6(A)(3)(a3.3.7(A)(3)(a) through (sw). . (2) For MSC+non-SNP Enrollees, the STATE will provide annually to the MCO a model EOC Evidence of Coverage (EOC) or EOC Addendum as the base document. Prior to distribution to the MCO, the model EOC or EOC Addendum will be prior approved by MDH to ensure that MDH’s requirements are included. The MCO will not have to subsequently submit the EOC or EOC Addendum to MDH after receiving approval from the STATE. After the MCO has incorporated its specific information, the completed EOC or EOC Addendum will be submitted to the STATE for prior approval. . (3) For MSHO the Member Handbook both SNBC SNP and for MSC+ non-SNP the EOC or the EOC Addendum must include the following, and either the EOC or the EOC Addendum must be distributed annually to MSC+ Enrollees no later than January 31, 31 or for MSHO as required by CMS: (a) A statement that Enrollees are accountable to make efforts to maintain their health and inform health care Providers of changes in their health. (b) A description of the MCO’s medical and remedial care program, including specific information on Covered Services, limitations, limitations and non-covered services; (bc) A description of the MCO’s policies related to access to Case Management or Care Management services from the MCO; (d) An explanation of the MCO’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT), known in Minnesota and hereinafter as the Child and Teen Checkups (C&TC) program; (e) A description of the Enrollee’s rights and protections as specified in 42 CFR § 438.100; (cf) Cost sharing, if applicable; (dg) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, § 62Q.14; (eh) Information about providing coverage for prescriptions that are dispensed as written (DAW); (fi) A statement informing Enrollees that the MCO shall provide language and accessibility assistance to Enrollees that ensures meaningful access to its programs and services, and how to obtain auxiliary aids and services, including information in alternative formats or languages; (gj) A description of how American Indian Enrollees may directly access Indian Health Care Providers and how such Enrollees shall obtain referral services. In prior approving this portion of the EOC or Member HandbookEOC, the STATE shall consult with tribal governments; (hk) A description of how Enrollees may access services to which they are entitled under Medical Assistance, but that are not provided under this Contract; (il) A description of Medical Necessity for mental health services under Minnesota Statutes, § 62Q.53; (jm) A description of how transportation is provided; (kn) A description of how the Enrollee may obtain services, including including: 1) hours of service; 2) appointment procedures; 3) Service Authorization requirements and procedures; 4) what constitutes Medical Emergency and Post Stabilization care;; 5) the process and procedures for obtaining both Medical Emergency and Post Stabilization care, including a 24-hour telephone number for Medical Emergency Services; 6) procedures for Urgent Care, and Out of Network care; 7) how Enrollees may access Home and Community- Based Services through the county, and 8) how to obtain accessibility information required under section 6.12.

Enrollment Information to be Presented. The MCO shall present to all new Enrollees the following information within fifteen (15) calendar days of availability of readable enrollment data from the STATE. If an Enrollee becomes ineligible and is disenrolled from the MCO, but eligibility is reestablished within the following three months and the Enrollee’s eligibility is reestablished in the same program and he/she is re-enrolled in the same MCO, the MCO will not be required to send a new member packet, including the EOC or Member Handbook and a provider directory, but must send the Enrollee another MCO member identification card. For MSC+, an card.‌ An Evidence of Coverage (EOC) and for MSHO, a Member Handbook, that has been received prior approved approval by the STATE STATE, and for MSHO, by CMS. that includes the following: (1) For MSHOSNBC SNP Enrollees, the MCO will cooperate with the MSHO Plan D-SNP Integrated Member Materials Workgroup work group to adjust the CMS Medicare model Member Handbook EOC to incorporate STATE requirements. The MCO will use the model developed by the MSHO Plan Member D-SNP Materials Workgroup work group to develop its own Member HandbookEOC, which is then submitted to the STATE and includes information as below in section 3.6.6(A)(3)(a3.3.7(A)(3)(a) through (sw). . (2) For MSC+non-SNP Enrollees, the STATE will provide annually to the MCO a model EOC Evidence of Coverage (EOC) or EOC Addendum as the base document. Prior to distribution to the MCO, the model EOC or EOC Addendum will be prior approved by MDH to ensure that MDH’s requirements are included. The MCO will not have to subsequently submit the EOC or EOC Addendum to MDH after receiving approval from the STATE. After the MCO has incorporated its specific information, the completed EOC or EOC Addendum will be submitted to the STATE for prior approval. . (3) For MSHO the Member Handbook both SNBC SNP and for MSC+ non-SNP the EOC or the EOC Addendum must include the following, and either the EOC or the EOC Addendum must be distributed annually to MSC+ Enrollees no later than January 31, 31 or for MSHO as required by CMS: (a) A statement that Enrollees are accountable to make efforts to maintain their health and inform health care Providers of changes in their health.‌ (b) A description of the MCO’s medical and remedial care program, including specific information on Covered Services, limitations, limitations and non-covered services; (bc) A description of the MCO’s policies related to access to Case Management or Care Management services from the MCO; (d) An explanation of the MCO’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT), known in Minnesota and hereinafter as the Child and Teen Checkups (C&TC) program; (e) A description of the Enrollee’s rights and protections as specified in 42 CFR § 438.100; (cf) Cost sharing, if applicable; (dg) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, § 62Q.14; (eh) Information about providing coverage for prescriptions that are dispensed as written (DAW); (fi) A statement informing Enrollees that the MCO shall provide language and accessibility assistance to Enrollees that ensures meaningful access to its programs and services, and how to obtain auxiliary aids and services, including information in alternative formats or languages; (gj) A description of how American Indian Enrollees may directly access Indian Health Care Providers and how such Enrollees shall obtain referral services. In prior approving this portion of the EOC or Member HandbookEOC, the STATE shall consult with tribal governments; (hk) A description of how Enrollees may access services to which they are entitled under Medical Assistance, but that are not provided under this Contract; (il) A description of Medical Necessity for mental health services under Minnesota Statutes, § 62Q.53; (jm) A description of how transportation is provided; (kn) A description of how the Enrollee may obtain services, including including: 1) hours of service; 2) appointment procedures; 3) Service Authorization requirements and procedures; 4) what constitutes Medical Emergency and Post Stabilization care; 5) the process and procedures for obtaining both Medical Emergency and Post Stabilization care, including a 24-hour telephone number for Medical Emergency Services; 6) procedures for Urgent Care, and Out of Network care; 7) how Enrollees may access Home and Community- Based Services through the county, and 8) how to obtain accessibility information required under section 6.13.8. The MCO must indicate that Service Authorization is not required for Medical Emergencies and that the Enrollee has a right to use any hospital or other setting for Emergency Care. If the MCO does not allow direct access to specialty care, the MCO must inform Enrollees the circumstances under which a referral may be made to such Providers; (o) A toll-free telephone number that the Enrollee may call regarding MCO coverage or procedures, and updated information regarding Providers, language spoken and open and closed panels of Providers; (p) The number of the 24-hour telephone nurse line where an RN can be reached for assistance related to urgent medical needs or emergency care; (q) A description of all Grievance, Appeal and State Fair Hearing rights and procedures available to Enrollees, including the MCO’s Grievance and Appeal System procedures, the availability of an expert medical opinion from an external organization pursuant to section 8.8.8, the ability of Grievances, Appeals and State Fair Hearings to run concurrently, and the availability of a second opinion at the MCO’s expense. This includes, but is not limited to: i) For State Fair Hearing: 1) the right to a hearing; 2) the method for obtaining a hearing; and 3) the rules that govern representation at the hearing. ii) The right to file Grievances and Appeals. iii) The requirements and timeframes for filing a Grievance or Appeal. iv) The availability of assistance in the filing process. v) The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone. (r) An explanation that when an Appeal or State Fair Hearing is requested by the Enrollee: (i) Benefits will continue if the Enrollee files an Appeal or a request for State Fair Hearing within the timeframes specified for filing, and requests continuation of benefits within the time allowed; and (ii) The Enrollee may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is not wholly favorable to the Enrollee. (s) Any Appeal rights under state law available to Providers to challenge the failure of the MCO to cover a service; (t) A description of the MCO’s obligation to assume financial responsibility and provide reimbursement for Medical Emergency Services, Post- Stabilization Care Services, and Out of Service Area Urgent Care; (u) General descriptions of the coverage for durable medical equipment, level of coverage available, criteria and procedures for any Service Authorizations, and also the address and telephone number of an MCO representative whom an Enrollee can contact to obtain (either orally or in writing upon request) specific information about coverage and Service Authorization. The MCO shall provide information that is more specific to a prospective Enrollee upon request; (v) A description of the Enrollee’s right to request information about Physician Incentive Plans from the MCO, including whether the MCO uses a Physician Incentive Plan that affects the use of referral services, the type of incentive arrangements, whether stop-loss protection is provided, and a summary of survey results pursuant to section 17.2 below; and (w) A description of the Enrollee’s right to request the results of an external quality review study and a description of the MCO’s Quality Assurance System, pursuant to 42 CFR § 438.364.‌ Pharmacy Directory. For SNBC SNP Enrollees, this directory must be an integrated Medicare and Medicaid pharmacy directory.

Enrollment Information to be Presented. The MCO shall present to all new Enrollees the following information within fifteen (15) calendar days of availability of readable enrollment data from the STATE. If an Enrollee becomes ineligible and is disenrolled from the MCO, but eligibility is reestablished within the following three months and the Enrollee’s eligibility is reestablished in the same program and he/she is re-enrolled in the same MCO, the MCO will not be required to send a new member packet, including the EOC or Member Handbook and a provider directory, but must send the Enrollee another MCO member identification card. For MSC+, an . (A) An Evidence of Coverage (EOC) and for MSHO, a Member Handbook, that has been prior approved by the STATE STATE, and for MSHO, by CMS. . (1) For MSHO, the MCO will cooperate with the MSHO Plan D-SNP Integrated Member Materials Workgroup work group to adjust the CMS Medicare model Member Handbook EOC to incorporate STATE requirements. The MCO will use the model developed by the MSHO Plan Member D-SNP Materials Workgroup work group to develop its own Member HandbookEOC, which is then submitted to the STATE and includes information as below in section 3.6.6(A)(3)(a) through (st). . (2) For MSC+, the STATE will provide annually to the MCO a model EOC or EOC Addendum as the base document. Prior to distribution to the MCO, the model EOC or EOC Addendum will be prior approved by MDH to ensure that MDH’s requirements are included. The MCO will not have to subsequently submit the EOC or EOC Addendum to MDH after receiving approval from the STATE. After the MCO has incorporated its specific information, the completed EOC or EOC Addendum will be submitted to the STATE for prior approval. . (3) For both MSHO the Member Handbook and for MSC+ the EOC or EOC Addendum must include the following, and must be distributed annually to MSC+ Enrollees no later than January 31, or for MSHO as required by CMS: (a) A description of the MCO’s medical and remedial care program, including specific information on Covered Servicesbenefits, limitations, and non-covered servicesexclusions; (b) A description of the Enrollee’s rights and protections as specified in 42 CFR § 438.100; (c) Cost sharing, if applicable; (d) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, § 62Q.14; (e) Information about providing coverage for prescriptions that are dispensed as written (DAW); (f) A statement informing Enrollees that the MCO shall provide language and accessibility assistance to Enrollees that ensures meaningful access to its programs and services, and how to obtain auxiliary aids and services, including information in alternative formats or languages; (g) A description of how American Indian Enrollees may directly access Indian Health Care Providers and how such Enrollees shall obtain referral services. In prior approving this portion of the EOC or Member HandbookEOC, the STATE shall consult with tribal governments; (h) A description of how Enrollees may access services to which they are entitled under Medical Assistance, but that are the MCO does not provided provide under this Contract; (i) A description of Medical Necessity for mental health services under Minnesota Statutes, § 62Q.53; (j) A description of how transportation is provided; (k) A description of how the Enrollee may obtain services, including 1) hours of service; 2) appointment procedures; 3) Service Authorization requirements and procedures; 4) what constitutes Medical Emergency and Post Stabilization care;

Enrollment Information to be Presented. The MCO shall present to all new Enrollees the following information within fifteen (15) calendar days of availability of readable enrollment data from the STATE. If an Enrollee becomes ineligible and is disenrolled from the MCO, but eligibility is reestablished within the following three months and the Enrollee’s eligibility is reestablished in the same program and he/she is re-enrolled in the same MCO, the MCO will not be required to send a new member packet, including the EOC or Member Handbook and a provider directory, but must send the Enrollee another MCO member identification card. . (A) For MSC+, an Evidence of Coverage (EOC) and for MSHO, a Member Handbook, that has been prior approved by the STATE and for MSHO, by CMS. . (1) For MSHO, the MCO will cooperate with the MSHO Plan Member Materials Workgroup to adjust the CMS Medicare model Member Handbook to incorporate STATE requirements. The MCO will use the model developed by the MSHO Plan Member Materials Workgroup to develop its own Member Handbook, which is then submitted to the STATE and includes information as below in section 3.6.6(A)(3)(a) through (s). . (2) For MSC+, the STATE will provide annually to the MCO a model EOC or EOC Addendum as the base document. Prior to distribution to the MCO, the model EOC or EOC Addendum will be prior approved by MDH to ensure that MDH’s requirements are included. The MCO will not have to subsequently submit the EOC or EOC Addendum to MDH after receiving approval from the STATE. After the MCO has incorporated its specific information, the completed EOC or EOC Addendum will be submitted to the STATE for prior approval. . (3) For MSHO the Member Handbook and for MSC+ the EOC or EOC Addendum must include the following, and must be distributed annually to MSC+ Enrollees no later than January 31, or for MSHO as required by CMS: (a) A description of the MCO’s medical and remedial care program, including specific information on Covered Services, limitations, and non-covered services; (b) A description of the Enrollee’s rights and protections as specified in 42 CFR § 438.100; (c) Cost sharing, if applicable; (d) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, § 62Q.14; (e) Information about providing coverage for prescriptions that are dispensed as written (DAW); (f) A statement informing Enrollees that the MCO shall provide language and accessibility assistance to Enrollees that ensures meaningful access to its programs and services, and how to obtain auxiliary aids and services, including information in alternative formats or languages; (g) A description of how American Indian Enrollees may directly access Indian Health Care Providers and how such Enrollees shall obtain referral services. In prior approving this portion of the EOC or Member Handbook, the STATE shall consult with tribal governments; (h) A description of how Enrollees may access services to which they are entitled under Medical Assistance, but that are not provided under this Contract; (i) A description of Medical Necessity for mental health services under Minnesota Statutes, § 62Q.53; (j) A description of how transportation is provided; (k) A description of how the Enrollee may obtain services, including 1) hours of service; 2) appointment procedures; 3) Service Authorization requirements and procedures; 4) what constitutes Medical Emergency and Post Stabilization care;

Enrollment Information to be Presented. The MCO shall present to all new Enrollees the following information within fifteen (15) calendar days of availability of readable enrollment data from the STATE. If an Enrollee becomes ineligible and is disenrolled from the MCO, but eligibility is reestablished within the following three months and the Enrollee’s eligibility is reestablished in the same program and he/she is re-enrolled in the same MCO, the MCO will not be required to send a new member packet, including the EOC or Member Handbook and a provider directory, but must send the Enrollee another MCO member identification card. For MSC+, an An Evidence of Coverage (EOC) and for MSHO, a Member Handbook, that has been received prior approved approval by the STATE STATE, and for MSHO, by CMS. that includes the following: (1) For MSHOSNBC SNP Enrollees, the MCO will cooperate with the MSHO Plan D-SNP Integrated Member Materials Workgroup work group to adjust the CMS Medicare model Member Handbook EOC to incorporate STATE requirements. The MCO will use the model developed by the MSHO Plan Member D-SNP Materials Workgroup work group to develop its own Member HandbookEOC, which is then submitted to the STATE and includes information as below in section 3.6.6(A)(3)(a3.3.7(A)(3)(a) through (sw). . (2) For MSC+non-SNP Enrollees, the STATE will provide annually to the MCO a model EOC Evidence of Coverage (EOC) or EOC Addendum as the base document. Prior to distribution to the MCO, the model EOC or EOC Addendum will be prior approved by MDH to ensure that MDH’s requirements are included. The MCO will not have to subsequently submit the EOC or EOC Addendum to MDH after receiving approval from the STATE. After the MCO has incorporated its specific information, the completed EOC or EOC Addendum will be submitted to the STATE for prior approval. . (3) For MSHO the Member Handbook both SNBC SNP and for MSC+ non-SNP the EOC or the EOC Addendum must include the following, and either the EOC or the EOC Addendum must be distributed annually to MSC+ Enrollees no later than January 31, 31 or for MSHO as required by CMS: (a) A statement that Enrollees are accountable to make efforts to maintain their health and inform health care Providers of changes in their health. (b) A description of the MCO’s medical and remedial care program, including specific information on Covered Services, limitations, limitations and non-covered services; (bc) A description of the MCO’s policies related to access to Case Management or Care Management services from the MCO; (d) An explanation of the MCO’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT), known in Minnesota and hereinafter as the Child and Teen Checkups (C&TC) program; (e) A description of the Enrollee’s rights and protections as specified in 42 CFR § 438.100; (cf) Cost sharing, if applicable; (dg) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, § 62Q.14; (eh) Information about providing coverage for prescriptions that are dispensed as written (DAW); (fi) A statement informing Enrollees that the MCO shall provide language and accessibility assistance to Enrollees that ensures meaningful access to its programs and services, and how to obtain auxiliary aids and services, including information in alternative formats or languages; (gj) A description of how American Indian Enrollees may directly access Indian Health Care Providers and how such Enrollees shall obtain referral services. In prior approving this portion of the EOC or Member HandbookEOC, the STATE shall consult with tribal governments; (hk) A description of how Enrollees may access services to which they are entitled under Medical Assistance, but that are not provided under this Contract; (il) A description of Medical Necessity for mental health services under Minnesota Statutes, § 62Q.53; (jm) A description of how transportation is provided; (kn) A description of how the Enrollee may obtain services, including including: 1) hours of service; 2) appointment procedures; 3) Service Authorization requirements and procedures; 4) what constitutes Medical Emergency and Post Stabilization care;; 5) the process and procedures for obtaining both Medical Emergency and Post Stabilization care, including a 24-hour telephone number for Medical Emergency Services; 6) procedures for Urgent Care, and Out of Network care; 7) how Enrollees may access Home and Community- Based Services through the county, and 8) how to obtain accessibility information required under section 6.12.

Enrollment Information to be Presented. The MCO shall present to all new Enrollees the following information within fifteen (15) calendar days of availability of readable enrollment data from the STATE. If an Enrollee becomes ineligible and is disenrolled from the MCO, but eligibility is reestablished within the following three months and the Enrollee’s eligibility is reestablished in the same program and he/she is re-enrolled in the same MCO, the MCO will not be required to send a new member packet, including the the‌ EOC or Member Handbook and a provider directory, but must send the Enrollee another MCO member identification card. For MSC+, an Evidence of Coverage (EOC) and for MSHO, a Member Handbook, that has been prior approved by the STATE and for MSHO, by CMS. For MSHO, the MCO will cooperate with the MSHO Plan Member Materials Workgroup to adjust the CMS Medicare model Member Handbook to incorporate STATE requirements. The MCO will use the model developed by the MSHO Plan Member Materials Workgroup to develop its own Member Handbook, which is then submitted to the STATE and includes information as below in section 3.6.6(A)(3)(a) through (s). For MSC+, the STATE will provide annually to the MCO a model EOC or EOC Addendum as the base document. Prior to distribution to the MCO, the model EOC or EOC Addendum will be prior approved by MDH to ensure that MDH’s requirements are included. The MCO will not have to subsequently submit the EOC or EOC Addendum to MDH after receiving approval from the STATE. After the MCO has incorporated its specific information, the completed EOC or EOC Addendum will be submitted to the STATE for prior approval. For MSHO the Member Handbook and for MSC+ the EOC or EOC Addendum must include the following, and must be distributed annually to MSC+ Enrollees no later than January 31, or for MSHO as required by CMS: (a) A description of the MCO’s medical and remedial care program, including specific information on Covered Services, limitations, and non-covered services;services;‌ (b) A description of the Enrollee’s rights and protections as specified in 42 CFR § 438.100; (c) Cost sharing, if applicable; (d) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, § 62Q.14; (e) Information about providing coverage for prescriptions that are dispensed as written (DAW); (f) A statement informing Enrollees that the MCO shall provide language and accessibility assistance to Enrollees that ensures meaningful access to its programs and services, and how to obtain auxiliary aids and services, including information in alternative formats or languages; (g) A description of how American Indian Enrollees may directly access Indian Health Care Providers and how such Enrollees shall obtain referral services. In prior approving this portion of the EOC or Member Handbook, the STATE shall consult with tribal governments; (h) A description of how Enrollees may access services to which they are entitled under Medical Assistance, but that are not provided under this Contract; (i) A description of Medical Necessity for mental health services under Minnesota Statutes, § 62Q.53; (j) A description of how transportation is provided; (k) A description of how the Enrollee may obtain services, including 1) hours of service; 2) appointment procedures; 3) Service Authorization requirements and procedures; 4) what constitutes Medical Emergency and Post Stabilization care;