Common use of Handbook Clause in Contracts

Handbook. ‌ 3.12.3.1 For MSC+ and MSHO, a Handbook must be provided, that has been prior approved by the STATE and for MSHO, by CMS. The Member Handbook or Handbook must be made available annually to MSC+ Enrollees no later than January 1 of the Contract Year, or for MSHO as required 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 3.12.3.1(3)(a) through (y).‌‌‌‌ (2) For MSC+, the STATE will provide annually to the MCO a model Handbook as the base document. Prior to distribution to the MCO, the model Handbook will be prior approved by MDH to ensure that MDH’s requirements are included. The MCO will not have to subsequently submit the Handbook to MDH after receiving approval from the STATE. After the MCO has incorporated its specific information, the completed Handbook will be submitted to the STATE for prior approval. (3) For MSHO the Member Handbook and for MSC+ the Handbook must include the following, [42 CFR §438.10(g)]: (a) Definitions consistent with CMS requirements, as listed in the model Handbook;‌ (b) A description of the MCO’s medical and remedial care program, including specific information on Covered Services, including amount, duration and scope of benefits available, limitations, and non-covered services; (c) General descriptions of the coverage for durable medical equipment, including additional equipment and home modifications available to eligible MSHO and MSC+ members through home and community based services, level of coverage available, and 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; (d) A description of the Enrollee’s rights and protections as specified in 42 CFR §438.100; (e) A description of cost-sharing, if applicable; (f) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, §62Q.14; (g) Information about providing coverage for prescriptions that are dispensed as written (DAW); (h) 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;‌ (i) 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 Handbook, the STATE shall consult with tribal governments; (j) A description of how Enrollees may access and obtain services to which they are entitled under Medical Assistance, but that are not provided under this Contract; (k) A description of Medical Necessity for mental health services under Minnesota Statutes, §62Q.53; (l) A description of how transportation is provided; (m) A description of how the Enrollee may access and 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; 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; and 7) how Enrollees may access Home and Community-Based Services.  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; (n) What constitutes an emergency medical condition and emergency services; (o) Any restrictions on the Enrollee’s freedom of choice among network providers; (p) The process of selecting and changing the Enrollee’s Primary Care Provider, if the MCO requires the Enrollee to select a Primary Care Provider; (q) A toll-free telephone number that the Enrollee may call regarding MCO coverage or procedures; (r) 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 that must be exhausted before filing for a State Fair Hearing, and, the availability of an expert medical opinion from an external organization pursuant to section 6.1.48, and the availability of a second opinion at the STATE’s expense during a State Fair Hearing. This includes but is not limited to:‌‌  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.  The right to file Grievances and Appeals.  The requirements and timeframes for filing a Grievance or Appeal.  The availability of assistance in the filing process.  The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone. (s) An explanation that, when an Appeal or State Fair Hearing is requested by the Enrollee,  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  The Enrollee may be required to pay the cost of services furnished while the Appeal is pending, consistent with State policy, if the final decision is not wholly favorable to the Enrollee. (t) Any Appeal rights under state law available to Providers to challenge the failure of the MCO to cover a service; (u) 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; (v) How to exercise an Advance Directive: (w) Information on how to report suspected Fraud or Abuse; (x) 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 11.8; and‌‌ (y) 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 (c)(2)(ii).‌

Handbook. ‌ 3.12.3.1 For MSC+ and MSHO, a Handbook must be provided, that has been prior approved by the STATE and for MSHO, by CMS. The Member Handbook or Handbook must be made available annually to MSC+ Enrollees no later than January 1 of the Contract Year, or for MSHO as required 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 3.12.3.1(3)(a) through (y).‌‌‌‌y). (2) For MSC+, the STATE will provide annually to the MCO a model Handbook as the base document. Prior to distribution to the MCO, the model Handbook will be prior approved by MDH to ensure that MDH’s requirements are included. The MCO will not have to subsequently submit the Handbook to MDH after receiving approval from the STATE. After the MCO has incorporated its specific information, the completed Handbook will be submitted to the STATE for prior approval. (3) For MSHO the Member Handbook and for MSC+ the Handbook must include the following, [42 CFR §438.10(g)]: (a) Definitions consistent with CMS requirements, as listed in the model Handbook;‌Handbook; (b) A description of the MCO’s medical and remedial care program, including specific information on Covered Services, including amount, duration and scope of benefits available, limitations, and non-covered services; (c) General descriptions of the coverage for durable medical equipment, including additional equipment and home modifications available to eligible MSHO and MSC+ members through home and community based services, level of coverage available, and 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; (d) A description of the Enrollee’s rights and protections as specified in 42 CFR §438.100; (e) A description of cost-sharing, if applicable; (f) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, §62Q.14; (g) Information about providing coverage for prescriptions that are dispensed as written (DAW); (h) 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;‌languages; (i) 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 Handbook, the STATE shall consult with tribal governments; (j) A description of how Enrollees may access and obtain services to which they are entitled under Medical Assistance, but that are not provided under this Contract; (k) A description of Medical Necessity for mental health services under Minnesota Statutes, §62Q.53; (l) A description of how transportation is provided; (m) A description of how the Enrollee may access and 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; 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; and 7) how Enrollees may access Home and Community-Based Services.  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; (n) What constitutes an emergency medical condition and emergency services; (o) Any restrictions on the Enrollee’s freedom of choice among network providers; (p) The process of selecting and changing the Enrollee’s Primary Care Provider, if the MCO requires the Enrollee to select a Primary Care Provider; (q) A toll-free telephone number that the Enrollee may call regarding MCO coverage or procedures; (r) A description of all Grievance, Appeal and State Fair Hearing Appeal rights and procedures available to Enrollees, including the MCO’s Grievance and Appeal System procedures that must be exhausted before filing for a State Fair HearingAppeal, and, the availability of an expert medical opinion from an external organization pursuant to section 6.1.486.1.50, and the availability of a second opinion at the STATE’s expense during a State Fair HearingAppeal. This includes but is not limited to:‌‌ to:  For State Fair HearingAppeal: 1) the right to a hearing; 2) the method for obtaining a hearing; and 3) the rules that govern representation at the hearing.  The right to file Grievances and Appeals.  The requirements and timeframes for filing a Grievance or Appeal.  The availability of assistance in the filing process.  The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone. (s) An explanation that, when an Appeal or State Fair Hearing Appeal is requested by the Enrollee,  Benefits will continue if the Enrollee files an Appeal or a request for State Fair Hearing Appeal within the timeframes specified for filing, and requests continuation of benefits within the time allowed; and‌‌‌ and  The Enrollee may be required to pay the cost of services furnished while the Appeal is pending, consistent with State policy, if the final decision is not wholly favorable to the Enrollee. (t) Any Appeal rights under state law available to Providers to challenge the failure of the MCO to cover a service; (u) 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; (v) How to exercise an Advance Directive: (w) Information on how to report suspected Fraud or Abuse; (x) 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 11.8; and‌‌and (y) 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 (c)(2)(ii).‌c)(2)(ii).

Handbook. ‌ 3.12.3.1 For MSC+ and MSHO, a Handbook must be provided, that has been prior approved by the STATE and for MSHO, by CMS. The Member Handbook or Handbook must be made available annually to MSC+ Enrollees no later than January 1 of the Contract Year, or for MSHO as required 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 3.12.3.1(3)(a) through (y).‌‌‌‌y). (2) For MSC+, the STATE will provide annually to the MCO a model Handbook as the base document. Prior to distribution to the MCO, the model Handbook will be prior approved by MDH to ensure that MDH’s requirements are included. The MCO will not have to subsequently submit the Handbook to MDH after receiving approval from the STATE. After the MCO has incorporated its specific information, the completed Handbook will be submitted to the STATE for prior approval. (3) For MSHO the Member Handbook and for MSC+ the Handbook must include the following, [42 CFR §438.10(g)]: (a) Definitions consistent with CMS requirements, as listed in the model Handbook;‌Handbook; (b) A description of the MCO’s medical and remedial care program, including specific information on Covered Services, including amount, duration and scope of benefits available, limitations, and non-covered services; (c) General descriptions of the coverage for durable medical equipment, including additional equipment and home modifications available to eligible MSHO and MSC+ members through home and community based services, level of coverage available, and 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; (d) A description of the Enrollee’s rights and protections as specified in 42 CFR §438.100; (e) A description of cost-sharing, if applicable; (f) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, §62Q.14; (g) Information about providing coverage for prescriptions that are dispensed as written (DAW); (h) 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;‌languages; (i) 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 Handbook, the STATE shall consult with tribal governments; (j) A description of how Enrollees may access and obtain services to which they are entitled under Medical Assistance, but that are not provided under this Contract; (k) A description of Medical Necessity for mental health services under Minnesota Statutes, §62Q.53; (l) A description of how transportation is provided; (m) A description of how the Enrollee may access and 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; 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; and 7) how Enrollees may access Home and Community-Based Services.  • 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; (n) What constitutes an emergency medical condition and emergency services; (o) Any restrictions on the Enrollee’s freedom of choice among network providers; (p) The process of selecting and changing the Enrollee’s Primary Care Provider, if the MCO requires the Enrollee to select a Primary Care Provider; (q) A toll-free telephone number that the Enrollee may call regarding MCO coverage or procedures; (r) A description of all Grievance, Appeal and State Fair Hearing Appeal rights and procedures available to Enrollees, including the MCO’s Grievance and Appeal System procedures that must be exhausted before filing for a State Fair HearingAppeal, and, the availability of an expert medical opinion from an external organization pursuant to section 6.1.486.1.50, and the availability of a second opinion at the STATE’s expense during a State Fair HearingAppeal. This includes but is not limited to:‌‌  to: • For State Fair HearingAppeal: 1) the right to a hearing; 2) the method for obtaining a hearing; and 3) the rules that govern representation at the hearing.  • The right to file Grievances and Appeals.  • The requirements and timeframes for filing a Grievance or Appeal.  • The availability of assistance in the filing process.  • The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone. (s) An explanation that, when an Appeal or State Fair Hearing Appeal is requested by the Enrollee,  • Benefits will continue if the Enrollee files an Appeal or a request for State Fair Hearing Appeal within the timeframes specified for filing, and requests continuation of benefits within the time allowed; and‌‌‌  and • The Enrollee may be required to pay the cost of services furnished while the Appeal is pending, consistent with State policy, if the final decision is not wholly favorable to the Enrollee. (t) Any Appeal rights under state law available to Providers to challenge the failure of the MCO to cover a service; (u) 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; (v) How to exercise an Advance Directive: (w) Information on how to report suspected Fraud or Abuse; (x) 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 11.8; and‌‌and (y) 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 (c)(2)(ii).‌c)(2)(ii).

Handbook. ‌ 3.12.3.1 For MSC+ and MSHO, a Handbook must be provided, that has been prior approved by the STATE and for MSHO, by CMS. The Member Handbook or Handbook must be made available annually to MSC+ Enrollees no later than January 1 of the Contract Year, or for MSHO as required 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 3.12.3.1(3)(a) through (y).‌‌‌‌y). (2) For MSC+, the STATE will provide annually to the MCO a model Handbook as the base document. Prior to distribution to the MCO, the model Handbook will be prior approved by MDH to ensure that MDH’s requirements are included. The MCO will not have to subsequently submit the Handbook to MDH after receiving approval from the STATE. After the MCO has incorporated its specific information, the completed Handbook will be submitted to the STATE for prior approval. (3) For MSHO the Member Handbook and for MSC+ the Handbook must include the following, [42 CFR §438.10(g)]: (a) Definitions consistent with CMS requirements, as listed in the model Handbook;‌ (b) A description of the MCO’s medical and remedial care program, including specific information on Covered Services, including amount, duration and scope of benefits available, limitations, and non-covered services; (c) General descriptions of the coverage for durable medical equipment, including additional equipment and home modifications available to eligible MSHO and MSC+ members through home and community based services, level of coverage available, and 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; (d) A description of the Enrollee’s rights and protections as specified in 42 CFR §438.100; (e) A description of cost-sharing, if applicable; (f) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, §62Q.14; (g) Information about providing coverage for prescriptions that are dispensed as written (DAW); (h) 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;‌languages; (i) 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 Handbook, the STATE shall consult with tribal governments; (j) A description of how Enrollees may access and obtain services to which they are entitled under Medical Assistance, but that are not provided under this Contract; (k) A description of Medical Necessity for mental health services under Minnesota Statutes, §62Q.53; (l) A description of how transportation is provided; (m) A description of how the Enrollee may access and 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; 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; and 7) how Enrollees may access Home and Community-Based Services.  • 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; (n) What constitutes an emergency medical condition and emergency services; (o) Any restrictions on the Enrollee’s freedom of choice among network providers; (p) The process of selecting and changing the Enrollee’s Primary Care Provider, if the MCO requires the Enrollee to select a Primary Care Provider; (q) A toll-free telephone number that the Enrollee may call regarding MCO coverage or procedures; (r) A description of all Grievance, Appeal and State Fair Hearing Appeal rights and procedures available to Enrollees, including the MCO’s Grievance and Appeal System procedures that must be exhausted before filing for a State Fair HearingAppeal, and, the availability of an expert medical opinion from an external organization pursuant to section 6.1.486.1.50, and the availability of a second opinion at the STATE’s expense during a State Fair HearingAppeal. This includes but is not limited to:‌‌  to: • For State Fair HearingAppeal: 1) the right to a hearing; 2) the method for obtaining a hearing; and 3) the rules that govern representation at the hearing.  • The right to file Grievances and Appeals.  • The requirements and timeframes for filing a Grievance or Appeal.  • The availability of assistance in the filing process.  • The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone. (s) An explanation that, when an Appeal or State Fair Hearing Appeal is requested by the Enrollee,  • Benefits will continue if the Enrollee files an Appeal or a request for State Fair Hearing Appeal within the timeframes specified for filing, and requests continuation of benefits within the time allowed; and‌‌‌  and • The Enrollee may be required to pay the cost of services furnished while the Appeal is pending, consistent with State policy, if the final decision is not wholly favorable to the Enrollee. (t) Any Appeal rights under state law available to Providers to challenge the failure of the MCO to cover a service; (u) 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; (v) How to exercise an Advance Directive: (w) Information on how to report suspected Fraud or Abuse; (x) 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 11.8; and‌‌and (y) 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 (c)(2)(ii).‌

Handbook. ‌ 3.12.3.1 3.13.3.1 For MSC+ and MSHOSNBC, a Handbook must be provided, provided that has been prior approved by the STATE and for MSHO, by CMS. The Member Handbook or Handbook must be made available annually to MSC+ Enrollees no later than January 1 of the Contract Year, or for MSHO as required by CMS.STATE: (1) For MSHOSNBC SNP Enrollees, the MCO will cooperate with the MSHO Plan D-SNP Integrated Member Materials Workgroup 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 D-SNP Materials Workgroup workgroup to develop its own Member Handbook, which is then submitted to the STATE and includes information as below in section 3.12.3.1(3)(a3.13.3.2(1) through (y).‌‌‌‌38). For SNBC SNP the complete Handbook must be made available annually to Enrollees as required by CMS. (2) For MSC+non-SNP Enrollees, the STATE will provide annually to the MCO a model Handbook as the base document. Prior to distribution to the MCO, the model Handbook will be prior approved by MDH to ensure that MDH’s requirements are included. The MCO will not have to subsequently submit the Handbook to MDH after receiving approval from the STATE. After the MCO has incorporated its specific information, the completed Handbook will be submitted to the STATE for prior approval. For SNBC non-SNP the complete Handbook must be made available annually to Enrollees no later than January 1. (3) For MSHO the Member Handbook and for MSC+ the 3.13.3.2 The Handbook must include the following, following [42 CFR §438.10(g)]: (a1) Definitions consistent with CMS requirements42 CFR §438.10(c)(4)(i), as listed in the model Handbook;‌ (b2) A statement that Enrollees are accountable to make efforts to maintain their health and inform health care Providers of changes in their health. (3) A description of the MCO’s medical and remedial care program, including specific information on Covered Services, including amount, duration and scope of benefits available, limitations, limitations and non-covered services; (c4) General descriptions of the coverage for durable medical equipment, including additional equipment and home modifications available to eligible MSHO and MSC+ members through home and community based services, level of coverage available, and 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; (d5) A description of the MCO’s policies related to access to Case Management or Care Management services from the MCO; (6) 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; (7) A description of the Enrollee’s rights and protections as specified in 42 CFR §438.100; (e) 8) A description of cost-cost sharing, if applicable; (f9) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, §62Q.14; (g10) Information about providing coverage for prescriptions that are dispensed as written (DAW); (h11) 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;‌languages; (i12) 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 Handbook, the STATE shall consult with tribal governments; (j13) A description of how Enrollees may access and obtain services to which they are entitled under Medical Assistance, but that are not provided under this Contract; (k14) A description of Medical Necessity for mental health services under Minnesota Statutes, §62Q.53; (l15) A description of how transportation is provided; (m16) A description of how the Enrollee may access and 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; and 7) how Enrollees may access Home and Community-Community- Based Services.  Services through the county, and 8) how to obtain accessibility information required under section 6.11. (17) 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.  . (18) 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; (n19) What constitutes an emergency medical condition and emergency services; (o20) Any restrictions on the Enrollee’s freedom of choice among network providers; (p21) The process of selecting and changing the Enrollee’s Primary Care Provider, if the MCO requires the Enrollee to select a Primary Care Provider; (q22) 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; (r23) 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; (24) A description of all Grievance, Appeal and State Fair Hearing Appeal rights and procedures available to Enrollees, including the MCO’s Grievance and Appeal System procedures that must be exhausted before filing for a State Fair HearingAppeal, and, and the availability of an expert medical opinion from an external organization pursuant to section 6.1.488.8.7, and the availability of a second opinion at the STATE’s expense during a State Fair HearingAppeal. This includes includes, but is not limited to:‌‌  to: (25) For State Fair HearingAppeal: 1) the right to a hearing; 2) the method for obtaining a hearing; and 3) the rules that govern representation at the hearing.  The right to file Grievances and Appeals.  The requirements and timeframes for filing a Grievance or Appeal.  The availability of assistance in the filing process.  The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone. (s) An explanation that, when an Appeal or State Fair Hearing is requested by the Enrollee,  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  The Enrollee may be required to pay the cost of services furnished while the Appeal is pending, consistent with State policy, if the final decision is not wholly favorable to the Enrollee. (t) Any Appeal rights under state law available to Providers to challenge the failure of the MCO to cover a service; (u) 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; (v) How to exercise an Advance Directive: (w) Information on how to report suspected Fraud or Abuse; (x) 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 11.8; and‌‌ (y) 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 (c)(2)(ii).‌and

Handbook. ‌ 3.12.3.1 For MSC+ and MSHO, a Handbook must be provided, that has been prior The MCO Enrollee Handbook must follow the Member Handbook Model Guidelines technical specs document posted on the DHS web site for Medicaid. The MCO must follow CMS models and specifications for MSHO. Any deviations from the Enrollee Handbook technical specifications must be approved by the STATE and for MSHO, by CMS. The Member Handbook or Handbook must be made available annually to MSC+ Enrollees no later than January 1 of the Contract Year, or for MSHO as required 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 3.12.3.1(3)(a3.12.3.2(1) through (y).‌‌‌‌25). (2) For MSC+, the STATE will provide annually to the MCO a model Handbook as the base document. Prior to distribution to the MCO, the model Handbook will be prior approved by MDH to ensure that MDH’s requirements are included. The MCO will not have to subsequently submit the Handbook to MDH after receiving approval from the STATE. After the MCO has incorporated its specific information, the completed Handbook will be submitted to the STATE for prior approval. (3) 3.12.3.2 For MSHO the Member Handbook and for MSC+ the Handbook must include the following, [42 CFR §438.10(g)]: (a1) Definitions consistent with CMS requirements, as listed in the model Handbook;‌Handbook;‌‌ (b2) A description of the MCO’s medical and remedial care program, including specific information on Covered Services, including amount, duration and scope of benefits available, limitations, and non-covered services; (c3) General descriptions of the coverage for durable medical equipment, including additional equipment and home modifications available to eligible MSHO and MSC+ members through home and community based services, level of coverage available, and 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; (d4) A description of the Enrollee’s rights and protections as specified in 42 CFR §438.100;438.100;‌ (e5) A description of cost-sharing, if applicable; (f6) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, §62Q.14; (g7) Information about providing coverage for prescriptions that are dispensed as written (DAW); (h) 8) 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;‌ (i9) 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 Handbook, the STATE shall consult with tribal governments; (j10) A description of how Enrollees may access and obtain services to which they are entitled under Medical Assistance, but that are not provided under this Contract;Contract;‌ (k11) A description of Medical Necessity for mental health services under Minnesota Statutes, §62Q.53; (l12) A description of how transportation is provided; (m13) A description of how the Enrollee may access and 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; 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; and 7) how Enrollees may access Home and Community-Based Services.  • 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; (n14) What constitutes an emergency medical condition and emergency services;services;‌ (o15) Any restrictions on the Enrollee’s freedom of choice among network providers; (p16) The process of selecting and changing the Enrollee’s Primary Care Provider, if the MCO requires the Enrollee to select a Primary Care Provider; (q17) A toll-free telephone number that the Enrollee may call regarding MCO coverage or procedures; (r18) A description of all Grievance, Appeal and State Fair Hearing Appeal rights and procedures available to Enrollees, including the MCO’s Grievance and Appeal System procedures that must be exhausted before filing for a State Fair HearingAppeal, and, the availability of an expert medical opinion from an external organization pursuant to section 6.1.486.1.50, and the availability of a second opinion at the STATE’s expense during a State Fair HearingAppeal. This includes but is not limited to:‌‌  to: • For State Fair HearingAppeal: 1) the right to a hearing; 2) the method for obtaining a hearing; and 3) the rules that govern representation at the hearing.  • The right to file Grievances and Appeals.  • The requirements and timeframes for filing a Grievance or Appeal.  • The availability of assistance in the filing process.  • The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone. (s19) An explanation that, when an Appeal or State Fair Hearing Appeal is requested by the Enrollee,  • Benefits will continue if the Enrollee files an Appeal or a request for State Fair Hearing Appeal within the timeframes specified for filing, and requests continuation of benefits within the time allowed; and‌‌‌  and • The Enrollee may be required to pay the cost of services furnished while the Appeal is pending, consistent with State policy, if the final decision is not wholly favorable to the Enrollee. (t20) Any Appeal rights under state law available to Providers to challenge the failure of the MCO to cover a service; (u21) 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; (v22) How to exercise an Advance Directive: (w23) Information on how to report suspected Fraud or Abuse; (x24) 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- stop-loss protection is provided, and a summary of survey results pursuant to section 11.8; and‌‌and (y25) 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 CFR‌ §438.364 (c)(2)(ii).‌c)(2)(ii).