Member Handbook. The Contractor shall develop a member handbook for its members. The Contractor’s member handbook shall be submitted annually for OMPP’s review. The member handbook shall include the Contractor’s contact information and Internet website address and describe the terms and nature of services offered by the Contractor, including the following information required under 42 CFR 438.10(f), which enumerates certain required information. The member handbook may be offered in an electronic format as long as the Contractor complies with 42 CFR 438.10(c)(6). The Hoosier Healthwise MCE Policies and Procedures Manual outlines the member handbook requirements. The Hoosier Healthwise member handbook shall include the following: Contractor’s contact information (address, telephone number, TDD number, website address); The amount, duration and scope of services and benefits available under the Contract in sufficient details to ensure that participants are informed of the services to which they are entitled, including, but not limited to the differences between the benefit options; The procedures for obtaining benefits, including authorization requirements; Contractor’s office hours and days, including the availability of a 24-hour Nurse Call Line; Any restrictions on the member’s freedom of choice among network providers, as well as the extent to which members may obtain benefits, including family planning services, from out-of-network providers; The extent to which, and how, after-hours and emergency coverage are provided, as well as other information required under 42 CFR 438.10(f), such as what constitutes an emergency; The post-stabilization care services rules set forth in 42 CFR 422.113(c); The extent to which, and how, urgent care services are provided; Applicable policy on referrals for specialty care and other benefits not provided by the member’s PMP, if any; Information about the availability of pharmacy services and how to access pharmacy services; Member rights and protections, as enumerated in 42 CFR 438.100, which relates to enrollee rights. See Section 4.8 for further detail regarding member rights and protections; Responsibilities of members; Special benefit provisions (for example, co-payments, deductibles, limits or rejections of claims) that may apply to services obtained outside the Contractor’s network; Procedures for obtaining out-of-network services; Standards and expectations to receive preventive health services; Policy on referrals to specialty care; Procedures for notifying members affected by termination or change in any benefits, services or service delivery sites; Procedures for appealing decisions adversely affecting members’ coverage, benefits or relationship with the Contractor; Procedures for changing PMPs; Standards and procedures for changing MCEs, and circumstances under which this is possible, including, but not limited to providing contact information and instructions for how to contact the enrollment broker to transfer MCEs due to one of the “for cause” reasons described in 42 CFR 438.56(d)(2)(iv), including, but not limited to, the following: Receiving poor quality of care; Failure to provide covered services; Failure of the Contractor to comply with established standards of medical care administration; Lack of access to providers experienced in dealing with the member’s health care needs; Significant language or cultural barriers; Corrective action levied against the Contractor by the office; Limited access to a primary care clinic or other health services within reasonable proximity to a member’s residence; A determination that another MCE’s formulary is more consistent with a new member’s existing health care needs; Lack of access to medically necessary services covered under the Contractor’s contract with the State; A service is not covered by the Contractor for moral or religious objections, as described in Section 6.3.3; Related services are required to be performed at the same time and not all related services are available within the Contractor’s network, and the member’s provider determines that receiving the services separately will subject the member to unnecessary risk; The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls with another MCE; or Other circumstances determined by the office or its designee to constitute poor quality of health care coverage. The process for submitting disenrollment requests. This information shall include the following: Hoosier Healthwise members may change MCEs after the first ninety (90) calendar days of enrollment only for cause; Members are required to exhaust the MCE’s internal grievance and appeals process before requesting an MCE change ; Members may submit requests to change MCEs to the Enrollment Broker verbally or in writing, after exhausting the MCE’s internal grievance and appeals process; and The MCE shall provide the Enrollment Broker’s contact information and explain that the member must contact the Enrollment Broker with questions about the process. This information shall include how to obtain the Enrollment Broker’s standardized form for requesting an MCE change. The process by which an American Indian/ Alaska Native member may elect to opt-out of managed care pursuant to 42 USC § 1396u–2(a)(2)(C) and transfer to fee-for-service benefits through the State; Procedures for making complaints and recommending changes in policies and services; Grievance, appeal and fair hearing procedures as required at 42 CFR 438.10(g)(2)(xi), including the following: 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 member can use to file a grievance or appeal by phone; The fact that, if requested by the member and under certain circumstances: (1) benefits will continue if the member files an appeal or requests a State fair hearing within the specified timeframes; and (2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member. For a State hearing describe (i) the right to a hearing, (ii) the method for obtaining a hearing, and (iii) the rules that govern representation at the hearing. Information about advance directives; How to report a change in income, change in family size, etc.; Information about the availability of the prior claims payment program for certain members and how to access the program administrator; Information on alternative methods or formats of communication for visually and hearing-impaired and non-English speaking members and how members can access those methods or formats; Information on how to contact the Enrollment Broker; Statement that Contractor will provide information on the structure and operation of the health plan; and In accordance with 42 CFR 438.10(f)(3), that upon request of the member, information on the Contractor’s provider incentive plans will be provided.
Appears in 12 contracts
Samples: Professional Services, Professional Services, Professional Services
Member Handbook. The Contractor shall develop a member handbook for its members. The Contractor’s member handbook shall be submitted annually for OMPP’s review. The member handbook shall include the Contractor’s contact information and Internet website address and describe the terms and nature of services offered by the Contractor, including the following information required under 42 CFR 438.10(f), which enumerates certain required information. The member handbook may be offered in an electronic format as long as the Contractor complies with 42 CFR 438.10(c)(6). The Hoosier Healthwise MCE Policies and Procedures Manual outlines the member handbook requirements. The Hoosier Healthwise member handbook shall include the following: ▪ Contractor’s contact information (address, telephone number, TDD number, website address); ▪ The amount, duration and scope of services and benefits available under the Contract in sufficient details to ensure that participants are informed of the services to which they are entitled, including, but not limited to the differences between the benefit options; ▪ The procedures for obtaining benefits, including authorization requirements; ▪ Contractor’s office hours and days, including the availability of a 24-hour Nurse Call Line; ▪ Any restrictions on the member’s freedom of choice among network providers, as well as the extent to which members may obtain benefits, including family planning services, from out-of-network providers; ▪ The extent to which, and how, after-hours and emergency coverage are provided, as well as other information required under 42 CFR 438.10(f), such as what constitutes an emergency; ▪ The post-stabilization care services rules set forth in 42 CFR 422.113(c); ▪ The extent to which, and how, urgent care services are provided; ▪ Applicable policy on referrals for specialty care and other benefits not provided by the member’s PMP, if any; ▪ Information about the availability of pharmacy services and how to access pharmacy services; ▪ Member rights and protections, as enumerated in 42 CFR 438.100, which relates to enrollee rights. See Section 4.8 for further detail regarding member rights and protections; ▪ Responsibilities of members; ▪ Special benefit provisions (for example, co-payments, deductibles, limits or rejections of claims) that may apply to services obtained outside the Contractor’s network; ▪ Procedures for obtaining out-of-network services; ▪ Standards and expectations to receive preventive health services; ▪ Policy on referrals to specialty care; ▪ Procedures for notifying members affected by termination or change in any benefits, services or service delivery sites; ▪ Procedures for appealing decisions adversely affecting members’ coverage, benefits or relationship with the Contractor; ▪ Procedures for changing PMPs; ▪ Standards and procedures for changing MCEs, and circumstances under which this is possible, including, but not limited to providing contact information and instructions for how to contact the enrollment broker to transfer MCEs due to one of the “for cause” reasons described in 42 CFR 438.56(d)(2)(iv), including, but not limited to, the following: • Receiving poor quality of care; • Failure to provide covered services; • Failure of the Contractor to comply with established standards of medical care administration; • Lack of access to providers experienced in dealing with the member’s health care needs; • Significant language or cultural barriers; • Corrective action levied against the Contractor by the office; • Limited access to a primary care clinic or other health services within reasonable proximity to a member’s residence; • A determination that another MCE’s formulary is more consistent with a new member’s existing health care needs; • Lack of access to medically necessary services covered under the Contractor’s contract with the State; • A service is not covered by the Contractor for moral or religious objections, as described in Section 6.3.3; • Related services are required to be performed at the same time and not all related services are available within the Contractor’s network, and the member’s provider determines that receiving the services separately will subject the member to unnecessary risk; • The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls with another MCE; or • Other circumstances determined by the office or its designee to constitute poor quality of health care coverage. ▪ The process for submitting disenrollment requests. This information shall include the following: • Hoosier Healthwise members may change MCEs after the first ninety (90) calendar days of enrollment only for cause; • Members are required to exhaust the MCE’s internal grievance and appeals process before requesting an MCE change ; • Members may submit requests to change MCEs to the Enrollment Broker verbally or in writing, after exhausting the MCE’s internal grievance and appeals process; and • The MCE shall provide the Enrollment Broker’s contact information and explain that the member must contact the Enrollment Broker with questions about the process. This information shall include how to obtain the Enrollment Broker’s standardized form for requesting an MCE change. ▪ The process by which an American Indian/ Alaska Native member may elect to opt-out of managed care pursuant to 42 USC § 1396u–2(a)(2)(C) and transfer to fee-for-service benefits through the State; ▪ Procedures for making complaints and recommending changes in policies and services; ▪ Grievance, appeal and fair hearing procedures as required at 42 CFR 438.10(g)(2)(xi), including the following: • 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 member can use to file a grievance or appeal by phone; • The fact that, if requested by the member and under certain circumstances: (1) benefits will continue if the member files an appeal or requests a State fair hearing within the specified timeframes; and (2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member. ▪ For a State hearing describe (i) the right to a hearing, (ii) the method for obtaining a hearing, and (iii) the rules that govern representation at the hearing. ▪ Information about advance directives; ▪ How to report a change in income, change in family size, etc.; ▪ Information about the availability of the prior claims payment program for certain members and how to access the program administrator; ▪ Information on alternative methods or formats of communication for visually and hearing-impaired and non-English speaking members and how members can access those methods or formats; ▪ Information on how to contact the Enrollment Broker; ▪ Statement that Contractor will provide information on the structure and operation of the health plan; and ▪ In accordance with 42 CFR 438.10(f)(3), that upon request of the member, information on the Contractor’s provider incentive plans will be provided.
Appears in 6 contracts
Samples: Professional Services, Professional Services, Contract
Member Handbook. The Contractor shall develop a member handbook for its members. The Contractor’s member Member handbook shall be submitted annually for OMPP’s reviewprior approved by HCA and be in a format that is easily understood. The member Member handbook shall include the Contractor’s contact information and Internet website address and describe a table of contents, HCA approved definitions for the terms specified in 42 C.F.R. § 438.10(c)(4)(i) and nature defined in the Agreement or as referenced in Section 3.2 of services offered by the ContractorManaged Care Policy Manual, and at a minimum comply with the following: The CONTRACTOR’s demographic information, including the following toll-free telephone number for Member services and hours of operation; Information on how to obtain services such as after-hours and Emergency Services, including the 911 telephone system or its equivalent and the triage/nurse advice line; Member rights and responsibilities, pursuant to 42 C.F.R. §100 and Section 4.15.4 of this Agreement, including any restrictions on the Member’s freedom of choice among Contract Providers; Information pertaining to coordination of care by and with PCPs (within the CONTRACTOR’s MCO) and information required under 42 CFR 438.10(f), which enumerates certain required information. The member handbook may be offered in an electronic format as long as the Contractor complies with 42 CFR 438.10(c)(6). The Hoosier Healthwise MCE Policies and Procedures Manual outlines the member handbook requirements. The Hoosier Healthwise member handbook shall include the following: Contractor’s contact information pertaining to transition of care (address, telephone number, TDD number, website addressbetween MCOs); How to obtain care in emergency and urgent conditions and that prior authorization is not required for Emergency Services, including what constitutes an Emergency Medical Condition and Emergency Services, and the Member’s right to use any hospital or other setting for emergency care; The amount, duration duration, and scope of services all benefits, services, and benefits available under the Contract goods included in and excluded from coverage in sufficient details detail to ensure that participants are informed of Members understand the services benefits to which they are entitled. Include a separate section and/or addendum that describes the provisions and limitations (including amount, includingduration, but scope, and cost-sharing) of the ABP, the qualifications and conditions for ABP exemptions, the benefit and cost-sharing differences for an ABP Exempt Member, and the process by which a Member can self-identify as potentially an ABP Exempt Member and voluntarily opt-out of the ABP; Information on accessing Behavioral Health or other specialty services, including a discussion of the Member’s rights to self-refer to Contract and Non-Contract family planning Providers, a female Member’s right to self-refer to a women’s health specialist within the CONTRACTOR’s network, and that Members may self-refer for Behavioral Health services and are not limited required to visit their PCP first; Limitations to the differences between receipt of care from Non-Contract Providers; A list of services for which prior authorization or a referral is required and the benefit optionsmethod of obtaining both; The procedures for obtaining benefits, including authorization requirementsInformation on Utilization Management; Contractor’s office hours and days, including the availability of a 24-hour Nurse Call Line; Any restrictions on the member’s freedom of choice among network providers, as well as the extent to which members may obtain benefits, including family planning services, from out-of-network providers; The extent to which, and how, after-hours and emergency coverage are provided, as well as other information required under 42 CFR 438.10(f), such as what constitutes an emergency; The post-stabilization care services rules set forth in 42 CFR 422.113(c); The extent to which, and how, urgent care services are provided; Applicable A policy on referrals for specialty care and other benefits not provided furnished by the memberMember’s PMP, if anyPCP; Information about the availability of pharmacy services and on how to access pharmacy services; Member rights Information regarding Grievances, Appeals, and protections, as enumerated Fair Hearing procedures and time frames including all pertinent information provided in 42 CFR 438.100C.F.R § 438.400 through § 438.424; Information on the Member’s right to terminate enrollment and the process for voluntarily disenrolling from the CONTRACTOR’s MCO; Information on the MCO switch process; Information on how Members change their demographic information; Information regarding Advance Directives as described in 42 C.F.R. part 489, subpart I and in accordance with 42 C.F.R. § 422.128 and the Mental Health Care Treatment Decisions Act, NMSA 1978, 24- 7B-1 et seq. and Section 4.5.6 of this Agreement; Information regarding how to obtain a second opinion; Information on cost sharing, if any; How to obtain information, upon request, determined by HCA as essential during the Member’s initial contact with the CONTRACTOR, which relates may include a request for information regarding the CONTRACTOR’s structure, operation, and physician’s or senior staff’s incentive plans; Value Added Services and how the Member may access those benefits; Information regarding the birthing option program; Language that clearly explains that a Native American Member may self-refer to enrollee rights. See Section 4.8 an I/T/U for further detail regarding member rights and protections; Responsibilities of members; Special benefit provisions (for example, co-payments, deductibles, limits or rejections of claims) that may apply to services obtained outside the Contractor’s network; Procedures for obtaining out-of-network services; Standards Information on how to report fraud, waste and expectations to receive preventive health servicesAbuse; Policy Information on referrals to specialty careMember’s privacy rights; Procedures Information on the circumstance/situations under which a Member may be billed for notifying members affected by termination or change in any benefits, services or service delivery sitesassessed charges or fees; Procedures specifically that a Provider may not bill a Member or assess charges or fees except: (i) if a Member self-refers to a specialist or other Contract Provider without following the CONTRACTOR’s procedures (e.g., without obtaining prior authorization) and the CONTRACTOR denies payment to the Provider, the Provider may bill the Member; (ii) if a Provider fails to follow the CONTRACTOR’s procedures, which results in nonpayment, the Provider may not bill the Member; and (iii) if a Provider bills the Member for appealing decisions adversely affecting members’ coveragenon-Covered Services or for self-referrals, benefits or relationship with the ContractorProposer shall inform the Member and obtain prior agreement from the Member regarding the cost of the procedure and the payment terms at the time of service; Procedures for changing PMPsInformation on how to access services when out of State; Standards and procedures for changing MCEsInclude information about Care Coordination, including the role of Care Coordinators, and circumstances under which this is possible, including, but not limited to providing contact information and instructions for how to contact a Care Coordinator; Information on the enrollment broker Member rewards program and how a Member accesses the program and earns rewards; Include information on how to transfer MCEs due to one of the “for cause” reasons described in 42 CFR 438.56(d)(2)(iv)access all services, including, including but not limited to, the following: Receiving poor quality of care; Failure to provide covered EPSDT services, dental services, emergency and non-emergency medical transportation services, Behavioral Health services, including Peer Support Services, and LTC services; Failure Include information on how to select/change PCP; Describe how to access language assistance services for individuals with limited English proficiency (LEP) and auxiliary aids and services, including additional information in alternative formats or languages; Include information about the CISC program as required by HCA; Include Health Education and Health Literacy information as specified in Section 4.15.11 of this Agreement; Include how Members can access the Provider directory on the CONTRACTOR’s website and instructions for how Members can request a printed copy of the Contractor Provider directory; Include information explaining to comply with established standards of medical care administration; Lack of access to providers experienced in dealing with the member’s health care needs; Significant language or cultural barriers; Corrective action levied against the Contractor by the office; Limited access to a primary care clinic or other health services within reasonable proximity to a member’s residence; A determination that another MCE’s formulary is more consistent with a new member’s existing health care needs; Lack of access to medically necessary services covered under the Contractor’s contract with the State; A service is not covered by the Contractor for moral or religious objections, as described in Section 6.3.3; Related services are required to be performed at the same time and not all related services are available within the Contractor’s network, and the member’s provider determines that receiving the services separately will subject the member to unnecessary risk; The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls with another MCE; or Other circumstances determined by the office or its designee to constitute poor quality of health care coverage. The process for submitting disenrollment requests. This information shall include the followingMembers: Hoosier Healthwise members may change MCEs after the first ninety (90) calendar days of enrollment only for cause; Members are required to exhaust the MCE’s internal grievance and appeals process before requesting an MCE change ; Members may submit requests to change MCEs to the Enrollment Broker verbally or in writing, after exhausting the MCE’s internal grievance and appeals process; and The MCE shall provide the Enrollment Broker’s contact information and explain that the member must contact the Enrollment Broker with questions about the process. This information shall include how to obtain the Enrollment Broker’s standardized form for requesting an MCE change. The process by which an American Indian/ Alaska Native member may elect to opt-out of managed care pursuant to 42 USC § 1396u–2(a)(2)(C) and transfer to fee-for-service benefits through the State; Procedures for making complaints and recommending changes in policies and services; Grievance, appeal and fair hearing procedures as required at 42 CFR 438.10(g)(2)(xi), including the following: 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 member can use to file a grievance or appeal by phone; The fact that, if requested by the member and under certain circumstances: (1) benefits will continue if the member files an appeal or requests a State fair hearing within the specified timeframes; and (2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member. For a State hearing describe (i) that the right to a hearing, CONTRACTOR has an independent Ombudsman; (ii) how they may contact the method for obtaining a hearing, Ombudsman; and (iii) the rules that govern representation at the hearing. Information about advance directives; How to report a change in income, change in family size, etc.; Information about the availability roles and responsibilities of the prior claims payment program for certain members Ombudsman and how to the Ombudsman may assist the Member; and Include how Members can access the program administrator; Information on alternative methods or formats of communication for visually and hearing-impaired and non-English speaking members and how members can access those methods or formats; Information on how to contact the Enrollment Broker; Statement that Contractor will provide information Formulary on the structure CONTRACTOR’s website and operation instructions for how Members can request a printed copy of the health plan; and In accordance with 42 CFR 438.10(f)(3), that upon request of the member, information on the Contractor’s provider incentive plans will be providedFormulary.
Appears in 3 contracts
Samples: Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement
Member Handbook. The Contractor shall develop a member handbook for its HIP members. The Contractor may choose to develop a separate handbook for the HIP line of business. The Contractor’s member handbook shall be submitted annually for OMPP’s review. The member handbook shall include the Contractor’s contact information and Internet website address and describe the terms and nature of services offered by the Contractor, including the following information required under 42 CFR 438.10(f), which enumerates certain required information. The member handbook may be offered in an electronic format as long as the Contractor complies with 42 CFR 438.10(c)(6). The Hoosier Healthwise HIP MCE Policies and Procedures Manual outlines the member handbook requirements. The Hoosier Healthwise HIP member handbook handbooks shall include the following: Contractor’s contact information (address, telephone number, TDD number, website address); The amount, duration and scope of services and benefits available under the Contract in sufficient details to ensure that participants are informed of the services to which they are entitled, including, but not limited to the differences between the HIP Plus and HIP Basic benefit options; The procedures for obtaining benefits, including authorization requirements; Contractor’s office hours and days, including the availability of a 24-hour Nurse Call Line; Any restrictions on the member’s freedom of choice among network providers, as well as the extent to which members may obtain benefits, including family planning services, from out-of-network providers; The extent to which, and how, after-hours and emergency coverage are provided, as well as other information required under 42 CFR 438.10(f), such as what constitutes an emergency; The post-stabilization care services rules set forth in 42 CFR 422.113(c); The extent to which, and how, urgent care services are provided; Applicable policy on referrals for specialty care and other benefits not provided by the member’s PMP, if any; Information about the availability of pharmacy services and how to access pharmacy services; Member rights and protections, as enumerated in 42 CFR 438.100, which relates to enrollee rights. See Section 4.8 for further detail regarding member rights and protections; Responsibilities of members; Special benefit provisions (for example, co-payments, deductibles, limits or rejections of claims) that may apply to services obtained outside the Contractor’s network; Procedures for obtaining out-of-network services; Standards and expectations to receive preventive health services; Policy on referrals to specialty care; Procedures for notifying members affected by termination or change in any benefits, services or service delivery sites; Procedures for appealing decisions adversely affecting members’ coverage, benefits or relationship with the Contractor; Procedures for changing PMPs; Standards and procedures for changing MCEs, and circumstances under which this is possibleHIP pregnancy policies, including, but not limited to providing contact information and instructions for how to contact the enrollment broker to transfer MCEs due to one a description of the “for cause” reasons described in 42 CFR 438.56(d)(2)(ivHIP Maternity program (MAMA), including, but not limited to, the following: Receiving poor quality of care; Failure to provide covered services; Failure of the Contractor to comply with established standards of medical care administration; Lack of access to providers experienced in dealing with the member’s health care needs; Significant language or cultural barriers; Corrective action levied against the Contractor by the office; Limited access to a primary care clinic or other health services within reasonable proximity to a member’s residence; A determination that another MCE’s formulary is more consistent with a new member’s existing health care needs; Lack of access to medically necessary services covered under the Contractor’s contract with the State; A service is not covered by the Contractor for moral or religious objections, as described in Section 6.3.3; Related services are required to be performed at the same time and not all related services are available within the Contractor’s network, and the member’s provider determines that receiving the services separately will subject the member to unnecessary risk; The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls with another MCE; or Other circumstances determined by the office or its designee to constitute poor quality of health care coverage. The process for submitting disenrollment requests. This information shall include the following: Hoosier Healthwise members may change MCEs after the first ninety (90) calendar days of enrollment only for cause; Members are required to exhaust the MCE’s internal grievance and appeals process before requesting an MCE change ; Members may submit requests to change MCEs to the Enrollment Broker verbally or in writing, after exhausting the MCE’s internal grievance and appeals process; and The MCE shall provide the Enrollment Broker’s contact information and explain that the member must contact the Enrollment Broker with questions about the process. This information shall include how to obtain the Enrollment Broker’s standardized form for requesting an MCE change. The process by which an American Indian/ Alaska Native member may elect to opt-out of managed care pursuant to 42 USC § 1396u–2(a)(2)(C) and transfer to fee-for-service benefits through the State; Procedures for making complaints and recommending changes in policies and services; Grievance, appeal and fair hearing procedures as required at 42 CFR 438.10(g)(2)(xi), including the following: 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 member can use to file a grievance or appeal by phone; The fact that, if requested by the member and under certain circumstances: (1) benefits will continue if the member files an appeal or requests a State fair hearing within the specified timeframes; and (2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member. For a State hearing describe (i) the right to a hearing, (ii) the method for obtaining a hearing, and (iii) the rules that govern representation at the hearing. Information about advance directives; How to report a change in income, change in family size, etc.; Information about the availability of the prior claims payment program for certain members and how to access the program administrator; Information on alternative methods or formats of communication for visually and hearing-impaired and non-English speaking members and how members can access those methods or formats; Information on how to contact the Enrollment Broker; Statement that Contractor will provide information on the structure and operation of the health plan; and In accordance with 42 CFR 438.10(f)(3), that upon request of the member, information on the Contractor’s provider incentive plans will be provided.;
Appears in 2 contracts
Samples: Contract, Contract Amendment
Member Handbook. The Contractor shall develop a member handbook for its members. The Contractor’s member handbook MCP Member Handbook shall be submitted annually for OMPP’s review. clearly labeled as such and shall include:
i. The rights of members including all rights found in OAC rule 5160-26-08.3 and any member handbook shall include the Contractor’s contact information and Internet website address and describe the terms and nature of services offered responsibilities specified by the Contractor, including MCP. With the following information required under 42 CFR 438.10(f), which enumerates certain required information. The member handbook may be offered exception of any prior authorization (PA) requirements the MCP describes in an electronic format as long as the Contractor complies with 42 CFR 438.10(c)(6). The Hoosier Healthwise MCE Policies and Procedures Manual outlines the member handbook requirementshandbook, the MCP cannot establish any member responsibility that would preclude the MCP’s coverage of a Medicaid-covered service.
ii. The Hoosier Healthwise member handbook shall include Information regarding services excluded from MCP coverage and the following: Contractor’s contact information (address, telephone number, TDD number, website address); The amount, duration and scope of services and benefits available under through the Contract MCP and how to obtain them, including at a minimum:
1. All services and benefits requiring PA or referral by the MCP or the member’s PCP;
2. Self-referral services, including Title X services, and women’s routine and preventative health care services provided by a woman’s health specialist as specified in sufficient details OAC rule 5160-26-03;
3. FQHC, RHC, and certified nurse practitioner services specified in OAC rule 5160- 26-03; and
4. Any applicable pharmacy utilization management strategies prior-approved by ODM.
iii. Information regarding available emergency services, the procedures for accessing emergency services and directives as to ensure that participants are informed the appropriate utilization, including:
1. An explanation of the services to which they are entitled, including, but terms “emergency medical condition,” “emergency services,” and “post-stabilization services,” as defined in OAC rule 5160-26-01;
2. A statement that PA is not limited to the differences between the benefit options; The procedures required for obtaining benefits, including authorization requirements; Contractor’s office hours and days, including emergency services;
3. An explanation of the availability of a 24-hour Nurse Call Linethe 911 telephone system or its local equivalent;
4. A statement that members have the right to use any hospital or other appropriate setting for emergency services; Any restrictions on and
5. An explanation of the member’s freedom of choice among network providers, as well as the extent to which members may obtain benefits, including family planning services, from out-of-network providers; The extent to which, and how, after-hours and emergency coverage are provided, as well as other information required under 42 CFR 438.10(f), such as what constitutes an emergency; The post-stabilization care services rules set forth requirements specified in OAC rule 5160-26-03.
iv. The procedure for members to express their recommendations for change to the MCP;
v. Identification of the categories of Medicaid recipients eligible for MCP membership;
vi. Information stating that the MCP’s ID card replaces the member’s monthly Medicaid card, how often the card is issued, and how to use it;
vii. A statement that medically necessary health care services shall be obtained through the providers in the MCP’s provider network with any exceptions that apply such as emergency care;
viii. Information related to the selection of a PCP from the MCP provider directory, how to change PCPs at least monthly, the MCP’s procedures for processing PCP change requests after the initial month of MCP membership, and how the MCP will provide written confirmation to the member of any new PCP selection prior to or on the effective date of the change;
ix. A description of Healthchek services including who is eligible and how to obtain Healthchek services through the MCP;
x. Information on additional services available to members including care management;
xi. A description of the MCP’s policies regarding access to providers outside the service area for non-emergency services and if applicable, access to providers within or outside the service area for non-emergency after hours services;
xii. Information on member-initiated termination options in accordance with OAC rule 5160-26-02.1;
xiii. Information about MCP-initiated terminations;
xiv. An explanation of automatic MCP membership renewal in accordance with OAC rule 5160-26-02;
xv. The procedure for members to file an appeal, a grievance, or state hearing request as specified in OAC rule 5160-26-08.4, the MCP’s mailing address, and a copy of the optional form(s) that members may use to file an appeal or grievance with the MCP. Copies of the form(s) to file an appeal or grievance shall also be made available through the MCP’s member services program;
xvi. The standard and expedited state hearing resolution time frames as outlined in 42 CFR 422.113(c); 431.244;
xvii. The extent to whichmember handbook issuance date;
xviii. A statement that the MCP may not discriminate on the basis of race, color, religion, gender, gender identity, sexual orientation, age, disability, national origin, military status, ancestry, genetic information, health status, or need for health services in the
xix. An explanation of subrogation and how, urgent care services are provided; Applicable policy coordination of benefits;
xx. A clear identification of corporate or parent identity when a trade name or DBA is used for the Medicaid product;
xxi. Information on referrals the procedures for specialty care and other benefits not provided by the member’s PMP, if any; Information about the availability of pharmacy services and how members to access pharmacy services; Member rights and protections, as enumerated in 42 CFR 438.100, which relates to enrollee rights. See Section 4.8 for further detail regarding member rights and protections; Responsibilities of members; Special benefit provisions (for example, co-payments, deductibles, limits or rejections of claims) that may apply to services obtained outside the Contractor’s network; Procedures for obtaining out-of-network services; Standards and expectations to receive preventive behavioral health services; Policy ;
xxii. Information on referrals to specialty care; Procedures for notifying members affected by termination or change in any benefitsthe MCP’s advance directives policies, services or service delivery sites; Procedures for appealing decisions adversely affecting members’ coverage, benefits or relationship with the Contractor; Procedures for changing PMPs; Standards and procedures for changing MCEs, and circumstances under which this is possible, including, but not limited to providing contact information and instructions for how to contact the enrollment broker to transfer MCEs due to one of the “for cause” reasons described in 42 CFR 438.56(d)(2)(iv), including, but not limited to, the following: Receiving poor quality of care; Failure to provide covered services; Failure of the Contractor to comply with established standards of medical care administration; Lack of access to providers experienced in dealing with the member’s health care needs; Significant language or cultural barriers; Corrective action levied against the Contractor by the office; Limited access to a primary care clinic or other health services within reasonable proximity to including a member’s residence; A determination that another MCE’s formulary is more consistent with right to formulate advance directives, a new member’s existing health care needs; Lack description of access to medically necessary services covered under the Contractor’s contract with the State; A service is not covered by the Contractor for moral or religious objections, as described in Section 6.3.3; Related services are required to be performed at the same time and not all related services are available within the Contractor’s networkapplicable state law, and a statement of any limitation regarding the member’s provider determines that receiving the services separately will subject the member to unnecessary risk; The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls with another MCE; or Other circumstances determined by the office or its designee to constitute poor quality implementation of health care coverageadvance directives as a matter of conscience;
xxiii. The process for submitting disenrollment requests. This information shall include the following: Hoosier Healthwise members may change MCEs after the first ninety (90) calendar days of enrollment only for cause; Members are required to exhaust the MCE’s internal grievance and appeals process before requesting an MCE change ; Members may submit requests to change MCEs to the Enrollment Broker verbally or in writing, after exhausting the MCE’s internal grievance and appeals process; and The MCE shall provide the Enrollment Broker’s contact information and explain A statement that the member must MCP provides covered services to members through a provider agreement with ODM, and how members can contact the Enrollment Broker with questions about the processODM;
xxiv. This information shall include how to obtain the Enrollment Broker’s standardized form for requesting an MCE change. The process by which an American Indian/ Alaska Native member may elect to opt-out of managed care pursuant to 42 USC § 1396u–2(a)(2)(C) and transfer to fee-for-service benefits through the State; Procedures for making complaints and recommending changes in policies and services; Grievance, appeal and fair hearing procedures as required at 42 CFR 438.10(g)(2)(xi), including the following: 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 call-in system phone numbers;
xxv. A statement that additional information is available from the member can use to file MCP upon request including, at a grievance or appeal by phone; The fact thatminimum, if requested by the member and under certain circumstances: (1) benefits will continue if the member files an appeal or requests a State fair hearing within the specified timeframes; and (2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member. For a State hearing describe (i) the right to a hearing, (ii) the method for obtaining a hearing, and (iii) the rules that govern representation at the hearing. Information about advance directives; How to report a change in income, change in family size, etc.; Information about the availability of the prior claims payment program for certain members and how to access the program administrator; Information on alternative methods or formats of communication for visually and hearing-impaired and non-English speaking members and how members can access those methods or formats; Information on how to contact the Enrollment Broker; Statement that Contractor will provide information on the structure and operation of the health plan; MCP and In any physician incentive plans the MCP operates;
xxvi. Process for requesting or accessing additional MCP information or services including at a minimum:
1. Oral interpretation or translation services;
2. Written information in the prevalent non-English languages in the MCP’s service
3. Written information in alternative formats.
xxvii. If applicable, detailed information on any member co-payments the MCP has elected to implement in accordance with 42 CFR 438.10(f)(3), that upon request of OAC rule 5160-26-12;
xxviii. How to access the member, information on the ContractorMCP’s provider incentive plans will be provideddirectory; and
xxix. The MCP shall provide access to provider panel information to members via the MCP’s website and printed provider directories.
Appears in 2 contracts
Samples: Provider Agreement, Provider Agreement
Member Handbook. The Contractor shall develop a member handbook for its members. The Contractor’s member handbook MCP Member Handbook shall be submitted annually for OMPP’s review. clearly labeled as such and shall include:
i. The rights of members including all rights found in OAC rule 5160-26-08.3 and any member handbook shall include the Contractor’s contact information and Internet website address and describe the terms and nature of services offered responsibilities specified by the Contractor, including MCP. With the following information required under 42 CFR 438.10(f), which enumerates certain required information. The member handbook may be offered exception of any prior authorization (PA) requirements the MCP describes in an electronic format as long as the Contractor complies with 42 CFR 438.10(c)(6). The Hoosier Healthwise MCE Policies and Procedures Manual outlines the member handbook requirementshandbook, the MCP cannot establish any member responsibility that would preclude the MCP’s coverage of a Medicaid-covered service.
ii. The Hoosier Healthwise member handbook shall include Information regarding services excluded from MCP coverage and the following: Contractor’s contact information (address, telephone number, TDD number, website address); The amount, duration and scope of services and benefits available under through the Contract MCP and how to obtain them, including at a minimum:
1. All services and benefits requiring PA or referral by the MCP or the member’s PCP;
2. Self-referral services, including Title X services, and women’s routine and preventative health care services provided by a woman’s health specialist as specified in sufficient details OAC rule 5160-26-03;
3. FQHC, RHC, and certified nurse practitioner services specified in OAC rule 5160- 26-03; and
4. Any applicable pharmacy utilization management strategies prior-approved by ODM.
iii. Information regarding available emergency services, the procedures for accessing emergency services and directives as to ensure that participants are informed the appropriate utilization, including:
1. An explanation of the services to which they are entitled, including, but terms “emergency medical condition,” “emergency services,” and “post-stabilization services,” as defined in OAC rule 5160-26-01;
2. A statement that PA is not limited to the differences between the benefit options; The procedures required for obtaining benefits, including authorization requirements; Contractor’s office hours and days, including emergency services;
3. An explanation of the availability of a 24-hour Nurse Call Linethe 911 telephone system or its local equivalent;
4. A statement that members have the right to use any hospital or other appropriate setting for emergency services; Any restrictions on and
5. An explanation of the member’s freedom of choice among network providers, as well as the extent to which members may obtain benefits, including family planning services, from out-of-network providers; The extent to which, and how, after-hours and emergency coverage are provided, as well as other information required under 42 CFR 438.10(f), such as what constitutes an emergency; The post-stabilization care services rules set forth requirements specified in OAC rule 5160-26-03.
iv. The procedure for members to express their recommendations for change to the MCP;
v. Identification of the categories of Medicaid recipients eligible for MCP membership;
vi. Information stating that the MCP’s ID card replaces the member’s monthly Medicaid card, how often the card is issued, and how to use it;
vii. A statement that medically necessary health care services shall be obtained through the providers in the MCP’s provider network with any exceptions that apply such as emergency care;
viii. Information related to the selection of a PCP from the MCP provider directory, how to change PCPs at least monthly, the MCP’s procedures for processing PCP change requests after the initial month of MCP membership, and how the MCP will provide written confirmation to the member of any new PCP selection prior to or on the effective date of the change;
ix. A description of Healthchek services including who is eligible and how to obtain Healthchek services through the MCP;
x. Information on additional services available to members including care management;
xi. A description of the MCP’s policies regarding access to providers outside the service area for non-emergency services and if applicable, access to providers within or outside the service area for non-emergency after hours services;
xii. Information on member-initiated termination options in accordance with OAC rule 5160-26-02.1;
xiii. Information about MCP-initiated terminations;
xiv. An explanation of automatic MCP membership renewal in accordance with OAC rule 5160-26-02;
xv. The procedure for members to file an appeal, a grievance, or state hearing request as specified in OAC rule 5160-26-08.4, the MCP’s mailing address, and a copy of the optional form(s) that members may use to file an appeal or grievance with the MCP. Copies of the form(s) to file an appeal or grievance shall also be made available through the MCP’s member services program;
xvi. The standard and expedited state hearing resolution time frames as outlined in 42 CFR 422.113(c); 431.244;
xvii. The extent to whichmember handbook issuance date;
xviii. A statement that the MCP may not discriminate on the basis of race, color, religion, gender, gender identity, sexual orientation, age, disability, national origin, military status, ancestry, genetic information, health status, or need for health services in the
xix. An explanation of subrogation and how, urgent care services are provided; Applicable policy coordination of benefits;
xx. A clear identification of corporate or parent identity when a trade name or DBA is used for the Medicaid product;
xxi. Information on referrals the procedures for specialty care and other benefits not provided by the member’s PMP, if any; Information about the availability of pharmacy services and how members to access pharmacy services; Member rights and protections, as enumerated in 42 CFR 438.100, which relates to enrollee rights. See Section 4.8 for further detail regarding member rights and protections; Responsibilities of members; Special benefit provisions (for example, co-payments, deductibles, limits or rejections of claims) that may apply to services obtained outside the Contractor’s network; Procedures for obtaining out-of-network services; Standards and expectations to receive preventive behavioral health services; Policy ;
xxii. Information on referrals to specialty care; Procedures for notifying members affected by termination or change in any benefitsthe MCP’s advance directives policies, services or service delivery sites; Procedures for appealing decisions adversely affecting members’ coverage, benefits or relationship with the Contractor; Procedures for changing PMPs; Standards and procedures for changing MCEs, and circumstances under which this is possible, including, but not limited to providing contact information and instructions for how to contact the enrollment broker to transfer MCEs due to one of the “for cause” reasons described in 42 CFR 438.56(d)(2)(iv), including, but not limited to, the following: Receiving poor quality of care; Failure to provide covered services; Failure of the Contractor to comply with established standards of medical care administration; Lack of access to providers experienced in dealing with the member’s health care needs; Significant language or cultural barriers; Corrective action levied against the Contractor by the office; Limited access to a primary care clinic or other health services within reasonable proximity to including a member’s residence; A determination that another MCE’s formulary is more consistent with right to formulate advance directives, a new member’s existing health care needs; Lack description of access to medically necessary services covered under the Contractor’s contract with the State; A service is not covered by the Contractor for moral or religious objections, as described in Section 6.3.3; Related services are required to be performed at the same time and not all related services are available within the Contractor’s networkapplicable state law, and a statement of any limitation regarding the member’s provider determines that receiving the services separately will subject the member to unnecessary risk; The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls with another MCE; or Other circumstances determined by the office or its designee to constitute poor quality implementation of health care coverageadvance directives as a matter of conscience;
xxiii. The process for submitting disenrollment requests. This information shall include the following: Hoosier Healthwise members may change MCEs after the first ninety (90) calendar days of enrollment only for cause; Members are required to exhaust the MCE’s internal grievance and appeals process before requesting an MCE change ; Members may submit requests to change MCEs to the Enrollment Broker verbally or in writing, after exhausting the MCE’s internal grievance and appeals process; and The MCE shall provide the Enrollment Broker’s contact information and explain A statement that the member must MCP provides covered services to members through a provider agreement with ODM, an10d how members can contact the Enrollment Broker with questions about the processODM;
xxiv. This information shall include how to obtain the Enrollment Broker’s standardized form for requesting an MCE change. The process by which an American Indian/ Alaska Native member may elect to opt-out of managed care pursuant to 42 USC § 1396u–2(a)(2)(C) and transfer to fee-for-service benefits through the State; Procedures for making complaints and recommending changes in policies and services; Grievance, appeal and fair hearing procedures as required at 42 CFR 438.10(g)(2)(xi), including the following: 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 call-in system phone numbers;
xxv. A statement that additional information is available from the member can use to file MCP upon request including, at a grievance or appeal by phone; The fact thatminimum, if requested by the member and under certain circumstances: (1) benefits will continue if the member files an appeal or requests a State fair hearing within the specified timeframes; and (2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member. For a State hearing describe (i) the right to a hearing, (ii) the method for obtaining a hearing, and (iii) the rules that govern representation at the hearing. Information about advance directives; How to report a change in income, change in family size, etc.; Information about the availability of the prior claims payment program for certain members and how to access the program administrator; Information on alternative methods or formats of communication for visually and hearing-impaired and non-English speaking members and how members can access those methods or formats; Information on how to contact the Enrollment Broker; Statement that Contractor will provide information on the structure and operation of the health plan; MCP and In any physician incentive plans the MCP operates;
xxvi. Process for requesting or accessing additional MCP information or services including at a minimum:
1. Oral interpretation or translation services;
2. Written information in the prevalent non-English languages in the MCP’s service
3. Written information in alternative formats.
xxvii. If applicable, detailed information on any member co-payments the MCP has elected to implement in accordance with 42 CFR 438.10(f)(3), that upon request of OAC rule 5160-26-12;
xxviii. How to access the member, information on the ContractorMCP’s provider incentive plans will be provideddirectory; and
xxix. The MCP shall provide access to provider panel information to members via the MCP’s website and printed provider directories.
Appears in 2 contracts
Samples: Provider Agreement, Provider Agreement
Member Handbook. The Contractor shall develop a member handbook for its members. The Contractor’s member handbook shall be submitted annually for OMPP’s review. The member handbook shall include the Contractor’s contact information and Internet website address and describe the terms and nature of services offered by the Contractor, including the following information required under 42 CFR 438.10(f438.10(f)(6), which enumerates certain required information. The member handbook may be offered in an electronic format as long as the Contractor complies with 42 CFR 438.10(c)(6). The Hoosier Healthwise MCE Policies and Procedures Manual outlines the member handbook requirements. The Hoosier Healthwise member handbook shall include the following: Contractor’s contact information (address, telephone number, TDD number, website address); The amount, duration and scope of services and benefits available under the Contract in sufficient details to ensure that participants are informed of the services to which they are entitled, including, but not limited to the differences between the benefit options; The procedures for obtaining benefits, including authorization requirements; Contractor’s office hours and days, including the availability of a 24-hour Nurse Call Line; Any restrictions on the member’s freedom of choice among network providers, as well as the extent to which members may obtain benefits, including family planning services, from out-of-network providers; The extent to which, and how, after-hours and emergency coverage are provided, as well as other information required under 42 CFR 438.10(f438.10(f)(6)(viii), such as what constitutes an emergency; The post-stabilization care services rules set forth in 42 CFR 422.113(c); The extent to which, and how, urgent care services are provided; Applicable policy on referrals for specialty care and other benefits not provided by the member’s PMP, if any; Information about the availability of pharmacy services and how to access pharmacy services; Member rights and protections, as enumerated in 42 CFR 438.100, which relates to enrollee rights. See Section 4.8 for further detail regarding member rights and protections; Responsibilities of members; Special benefit provisions (for example, co-payments, deductibles, limits or rejections of claims) that may apply to services obtained outside the Contractor’s network; Procedures for obtaining out-of-network services; Standards and expectations to receive preventive health services; Policy on referrals to specialty care; Procedures for notifying members affected by termination or change in any benefits, services or service delivery sites; Procedures for appealing decisions adversely affecting members’ coverage, benefits or relationship with the Contractor; Procedures for changing PMPs; Standards and procedures for changing MCEs, and circumstances under which this is possible, including, but not limited to providing contact information and instructions for how to contact the enrollment broker to transfer MCEs due to one of the “for cause” reasons described in 42 CFR 438.56(d)(2)(iv), including, but not limited to, the following: o Receiving poor quality of care; o Failure to provide covered services; o Failure of the Contractor to comply with established standards of medical care administration; o Lack of access to providers experienced in dealing with the member’s health care needs; o Significant language or cultural barriers; o Corrective action levied against the Contractor by the office; o Limited access to a primary care clinic or other health services within reasonable proximity to a member’s residence; o A determination that another MCE’s formulary is more consistent with a new member’s existing health care needs; o Lack of access to medically necessary services covered under the Contractor’s contract with the State; o A service is not covered by the Contractor for moral or religious objections, as described in Section 6.3.3; o Related services are required to be performed at the same time and not all related services are available within the Contractor’s network, and the member’s provider determines that receiving the services separately will subject the member to unnecessary risk; o The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls with another MCE; or o Other circumstances determined by the office or its designee to constitute poor quality of health care coverage. The process for submitting disenrollment requests. This information shall include the following: o Hoosier Healthwise members may change MCEs after the first ninety (90) calendar days of enrollment only for cause; o Members are required to exhaust the MCE’s internal grievance and appeals process before requesting an MCE change ; o Members may submit requests to change MCEs to the Enrollment Broker verbally or in writing, after exhausting the MCE’s internal grievance and appeals process; and o The MCE shall provide the Enrollment Broker’s contact information and explain that the member must contact the Enrollment Broker with questions about the process. This information shall include how to obtain the Enrollment Broker’s standardized form for requesting an MCE change. The process by which an American Indian/ Alaska Native member may elect to opt-opt- out of managed care pursuant to 42 USC § 1396u–2(a)(2)(C) and transfer to fee-for-for- service benefits through the State; Procedures for making complaints and recommending changes in policies and services; Grievance, appeal and fair hearing procedures as required at 42 CFR 438.10(g)(2)(xi438.10(g)(1), including the following: o The right to file grievances and appeals; o The requirements and timeframes for filing a grievance or appeal; o The availability of assistance in the filing process; o The toll-free numbers that the member can use to file a grievance or appeal by phone; o The fact that, if requested by the member and under certain circumstances: (1) benefits will continue if the member files an appeal or requests a State fair hearing within the specified timeframes; and (2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member. For a State hearing describe (i) the right to a hearing, (ii) the method for obtaining a hearing, and (iii) the rules that govern representation at the hearing. Information about advance directives; How to report a change in income, change in family size, etc.; Information about the availability of the prior claims payment program for certain members and how to access the program administrator; Information on alternative methods or formats of communication for visually and hearing-impaired and non-English speaking members and how members can access those methods or formats; Information on how to contact the Enrollment Broker; Statement that Contractor will provide information on the structure and operation of the health plan; and In accordance with 42 CFR 438.10(f)(3438.6(h), that upon request of the member, information on the Contractor’s provider incentive plans will be provided.
Appears in 1 contract
Samples: Professional Services
Member Handbook. The Contractor shall develop a member handbook for its members. The Contractor’s member handbook shall be submitted annually for OMPP’s review. The member handbook shall include the Contractor’s contact information and Internet website address and describe the terms and nature of services offered by the Contractor, including the following information required under 42 CFR 438.10(f), which enumerates certain required information. The member handbook may be offered in an electronic format as long as the Contractor complies with 42 CFR 438.10(c)(6). The Hoosier Healthwise MCE Policies and Procedures Manual outlines the member handbook requirements. The Hoosier Healthwise member handbook shall include the following: Contractor’s contact information (address, telephone number, TDD number, website address); The amount, duration and scope of services and benefits available under the Contract in sufficient details to ensure that participants are informed of the services to which they are entitled, including, but not limited to the differences between the benefit options; The procedures for obtaining benefits, including authorization requirements; Contractor’s office hours and days, including the availability of a 24-hour -hour Nurse Call Line; Any restrictions on the member’s freedom of choice among network providers, as well as the extent to which members may obtain benefits, including family planning services, from out-of-network providers; The extent to which, and how, after-hours and emergency coverage are provided, as well as other information required under 42 CFR 438.10(f), such as what constitutes an emergency; The post-stabilization care services rules set forth in 42 CFR 422.113(c); The extent to which, and how, urgent care services are provided; Applicable policy on referrals for specialty care and other benefits not provided by the member’s PMP, if any; Information about the availability of pharmacy services and how to access pharmacy services; Member rights and protections, as enumerated in 42 CFR 438.100, which relates to enrollee rights. See Section 4.8 for further detail regarding member rights and protections; Responsibilities of members; Special benefit provisions (for example, co-payments, deductibles, limits or rejections of claims) that may apply to services obtained outside the Contractor’s network; Procedures for obtaining out-of-network services; Standards and expectations to receive preventive health services; Policy on referrals to specialty care; Procedures for notifying members affected by termination or change in any benefits, services or service delivery sites; Procedures for appealing decisions adversely affecting members’ coverage, benefits or relationship with the Contractor; Procedures for changing PMPs; Standards and procedures for changing MCEs, and circumstances under which this is possible, including, but not limited to providing contact information and instructions for how to contact the enrollment broker to transfer MCEs due to one of the “for cause” reasons described in 42 CFR 438.56(d)(2)(iv), including, but not limited to, the following: Receiving poor quality of care; Failure to provide covered services; Failure of the Contractor to comply with established standards of medical care administration; Lack of access to providers experienced in dealing with the member’s health care needs; Significant language or cultural barriers; Corrective action levied against the Contractor by the office; Limited access to a primary care clinic or other health services within reasonable proximity to a member’s residence; A determination that another MCE’s formulary is more consistent with a new member’s existing health care needs; Lack of access to medically necessary services covered under the Contractor’s contract with ith the State; A service is not covered by the Contractor for moral or religious objections, as described in Section 6.3.3; Related services are required to be performed at the same time and not all related services are available within the Contractor’s network, and the member’s provider determines that receiving the services separately will subject the member to unnecessary risk; The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls with another MCE; or Other circumstances determined by the office or its designee to constitute poor quality of health care coverage. The process for submitting disenrollment requests. This information shall include the following: Hoosier Healthwise members may change MCEs after the first ninety (90) calendar days of enrollment only for cause; Members are required to exhaust the MCE’s internal grievance and appeals process before requesting an MCE change ; Members may submit requests to change MCEs to the Enrollment Broker verbally or in writing, after exhausting the MCE’s internal grievance and appeals process; and The MCE shall provide the Enrollment Broker’s contact information and explain that the member must contact the Enrollment Broker with questions about the process. This information shall include how to obtain the Enrollment Broker’s standardized form for requesting an MCE change. The process by which an American Indian/ Alaska Native member may elect to opt-out of managed care pursuant to 42 USC § 1396u–2(a)(2)(C) and transfer to fee-for-service benefits through the State; Procedures for making complaints and recommending changes in policies and services; Grievance, appeal and fair hearing procedures as required at 42 CFR 438.10(g)(2)(xi), including the following: 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 member can use to file a grievance or appeal by phone; The fact that, if requested by the member and under certain circumstances: (1) benefits will continue if the member files an appeal or requests a State fair hearing within the specified timeframes; and (2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member. For a State hearing describe (i) the right to a hearing, (ii) the method for obtaining a hearing, and (iii) the rules that govern representation at the hearing. Information about advance directives; How to report a change in income, change in family size, etc.; Information about the availability of the prior claims payment program for certain members and how to access the program administrator; Information on alternative methods or formats of communication for visually and hearing-impaired and non-English speaking members and how members can access those methods or formats; Information on how to contact the Enrollment Broker; Statement that Contractor will provide information on the structure and operation of the health plan; and In accordance with 42 CFR 438.10(f)(3), that upon request of the member, information on the Contractor’s provider incentive plans will be provided.ninety
Appears in 1 contract
Samples: Contract
Member Handbook. The Contractor shall develop a member handbook for its HIP members. The Contractor may choose to develop a separate handbook for the HIP line of business. The Contractor’s member handbook shall be submitted annually for OMPP’s review. The member handbook shall include the Contractor’s contact information and Internet website address and describe the terms and nature of services offered by the Contractor, including the following information required under 42 CFR 438.10(f438.10(f)(6), which enumerates certain required information. The member handbook may be offered in an electronic format as long as the Contractor complies with 42 CFR 438.10(c)(6). The Hoosier Healthwise HIP MCE Policies and Procedures Manual outlines the member handbook requirements. The Hoosier Healthwise HIP member handbook handbooks shall include the following: Contractor’s contact information (address, telephone number, TDD number, website address); The amount, duration and scope of services and benefits available under the Contract in sufficient details to ensure that participants are informed of the services to which they are entitled, including, but not limited to the differences between the HIP Plus and HIP Basic benefit options; The procedures for obtaining benefits, including authorization requirements; Contractor’s office hours and days, including the availability of a 24-hour Nurse Call Line; Any restrictions on the member’s freedom of choice among network providers, as well as the extent to which members may obtain benefits, including family planning services, from out-of-network providers; The extent to which, and how, after-hours and emergency coverage are provided, as well as other information required under 42 CFR 438.10(f438.10(f)(6)(viii), such as what constitutes an emergency; The post-stabilization care services rules set forth in 42 CFR 422.113(c); The extent to which, and how, urgent care services are provided; Applicable policy on referrals for specialty care and other benefits not provided by the member’s PMP, if any; HIP pregnancy policies, including, but not limited to a description of the HIP Maternity program and the member’s ability to transfer to MAGP during pregnancy, information on how to initiate the transfer, as well as information on requirements for transferring back to HIP following end of pregnancy; HIP cost-sharing policies, including, but not limited to non-payment penalties resulting in lock-out or transfer to HIP Basic, as well as the exceptions to such non- payment penalties, as detailed in Section 4.7.1.2; HIP co-payments for emergency room services, and the ability to receive a waiver by calling the 24-hour Nurse Call Line prior to utilizing a hospital emergency department; Information about the availability of pharmacy services and how to access pharmacy services; Member rights and protections, as enumerated in 42 CFR 438.100, which relates to enrollee rights. See Section 4.8 7.8 for further detail regarding member rights and protections; Responsibilities of members; Special benefit provisions (for example, co-payments, deductibles, limits or rejections of claims) that may apply to services obtained outside the Contractor’s network; Procedures for obtaining out-of-network services; Standards and expectations to receive preventive health services; Policy on referrals to specialty care; Procedures for notifying members affected by termination or change in any benefits, services or service delivery sites; Procedures for appealing decisions adversely affecting members’ coverage, benefits or relationship with the Contractor, including, but not limited to a medically frail determination; Procedures for changing PMPs; Standards and procedures for changing MCEs, and circumstances under which this is possible, including, but not limited to providing contact information and instructions for how to contact the enrollment broker to transfer MCEs due to one of the “for cause” reasons described in 42 CFR 438.56(d)(2)(iv), including, but not limited to, the following: o Receiving poor quality of care; o Failure to provide covered services; o Failure of the Contractor to comply with established standards of medical care administration; o Lack of access to providers experienced in dealing with the member’s health care needs; o Significant language or cultural barriers; o Corrective action levied against the Contractor by the office; o Limited access to a primary care clinic or other health services within reasonable proximity to a member’s residence; o A determination that another MCE’s formulary is more consistent with a new member’s existing health care needs; o Lack of access to medically necessary services covered under the Contractor’s contract with the State; o A service is not covered by the Contractor for moral or religious objections, as described in Section 6.3.39.3.3; o Related services are required to be performed at the same time and not all related services are available within the Contractor’s network, and the member’s provider determines that receiving the services separately will subject the member to unnecessary risk; o The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls with another MCE; or o Other circumstances determined by the office or its designee to constitute poor quality of health care coverage. The process for submitting disenrollment requests. This information shall include the following: Hoosier Healthwise members o HIP member may only change MCEs after the first ninety (90) calendar days of enrollment only for cause, unless the change is requested prior to either (i) making their initial POWER account contribution or fast track prepayment or (ii) being enrolled in HIP Basic or HIP State Plan Basic in accordance with Section 4.6, whichever occurs first; o Members are required to exhaust the MCE’s internal grievance and appeals process before requesting an MCE change due to poor quality of care; o Members may submit requests to change MCEs to the Enrollment Broker verbally or in writing, after exhausting the MCE’s internal grievance and appeals process; and o The MCE shall provide the Enrollment Broker’s contact information and explain that the member must contact the Enrollment Broker with questions about the process. This information shall include how to obtain the Enrollment Broker’s standardized form for requesting an MCE change. The process by which an American Indian/ Alaska Native member may elect to opt-opt- out of managed care pursuant to 42 USC § 1396u–2(a)(2)(C) and transfer to fee-for-for- service benefits through the State; Procedures for making complaints and recommending changes in policies and services; Grievance, appeal and fair hearing procedures as required at 42 CFR 438.10(g)(2)(xi438.10(g)(1), including the following: o The right to file grievances and appeals; o The requirements and timeframes for filing a grievance or appeal; o The availability of assistance in the filing process; o The toll-free numbers that the member can use to file a grievance or appeal by phone; o The fact that, if requested by the member and under certain circumstances: (1) benefits will continue if the member files an appeal or requests a State fair hearing within the specified timeframes; and (2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member. For a State hearing describe (i) the right to a hearing, (ii) the method for obtaining a hearing, and (iii) the rules that govern representation at the hearing. Information about advance directives; How to report a change in income, change in family size, etc.; How to request a medically frail determination during the benefit year; Information about the availability of the prior claims payment program for certain members and how to access the program administrator; Information on alternative methods or formats of communication for visually and hearing-impaired and non-English speaking members and how members can access those methods or formats; Information on how to contact the Enrollment Broker; Statement that Contractor will provide information on the structure and operation of the health plan; and In accordance with 42 CFR 438.10(f)(3438.6(h), that upon request of the member, information on the Contractor’s provider incentive plans will be provided.
Appears in 1 contract
Samples: Professional Services
Member Handbook. The Contractor shall develop a member handbook for its membersmembers and disseminate it as required under 42 CFR 438.10(g)(3)(i)-(iv). The Contractor is required to provide members notice of any significant change, as defined by the State, in the information specified in the member handbook at least 30 days before the intended effective date of the change per 42 CFR 438.10(g)(4).Within five (5) calendar days of a new member’s full enrollment with the Contractor in accordance with Section 4.6, the Contractor shall develop and send the member a Member Handbook. The Contractor’s member handbook shall be submitted annually for OMPPFSSA’s review, and any time changes are made. The member handbook shall include the Contractor’s contact information and Internet website address and describe the terms and nature of services offered by the Contractor, including the following information required under 42 CFR 438.10(f), which enumerates certain required information. The member handbook may be offered in an electronic format as long as the Contractor complies with 42 CFR 438.10(c)(6). The Hoosier Healthwise MCE Policies and Procedures Manual outlines the member handbook requirementsCare Connect
EXHIBIT 1. The Hoosier Healthwise member handbook shall include the following: E SCOPE OF WORK
1. Contractor’s 's contact information (address, telephone number, TDD number, website address); ;
2. The toll-free telephone number for member services, medical management, and any other unit providing services directly to members;
3. The amount, duration and scope of services and benefits available under the Contract in sufficient details to ensure that participants members are informed of the services to which they are entitled, including, but not limited to including service authorization requirements and information about the EPSDT benefit and differences between the benefit options; options ;
4. The procedures for obtaining benefits, including authorization requirements; requirements and/or referrals for specialty care and other benefits not furnished by the member’s primary care provider;
5. Contractor’s office hours and days, including the availability of a 24-hour Hour Nurse Call Line; Any ;
6. Information on accessing transportation including how it is provided for any carved-out benefits per 42 CFR 438.10(g)(2)(i);
7. Standards and expectations for receiving preventive health services;Any restrictions on the member’s freedom of choice among network providers, as well as the extent to which members may obtain benefits, including family planning services, from out-of-network providers; ;
8. How emergency care is provided, that an authorization is not required, and that the enrollee has a right to use any hospital or other setting for emergency care;
9. The extent to which, and how, after-after hours and emergency coverage are provided, as well as other information required under 42 CFR 438.10(f438.10(g)(2)(v), such as what constitutes an emergency; emergency condition or service, the fact that prior authorization is not required for emergency services, and that the enrollee has a right to use any hospital or other setting for emergency care;
10. The post-stabilization care services rules set forth in 42 CFR 422.113(c); The extent to which, and how, urgent care services are provided; Applicable policy on referrals for specialty care and other benefits not provided by the member’s PMP, if any; Information about the availability of pharmacy services and how to access pharmacy services; Member rights and protections, as enumerated in 42 CFR 438.100, which relates to enrollee rights. See Section 4.8 for further detail regarding member rights and protections; Responsibilities of members; Special benefit provisions (for example, co-payments, deductibles, limits or rejections of claims) that may apply to services obtained outside the Contractor’s network; Procedures for obtaining out-of-network services; Standards and expectations to receive preventive health services; Policy on referrals to specialty care; Procedures for notifying members affected by termination or change in any benefits, services or service delivery sites; Procedures for appealing decisions adversely affecting members’ coverage, benefits or relationship with the Contractor; Procedures for changing PMPs; Standards and procedures for changing MCEs, and circumstances under which this is possible, including, but not limited to providing contact information and instructions for how to contact the enrollment broker to transfer MCEs due to one of the “for cause” reasons described in 42 CFR 438.56(d)(2)(iv), including, but not limited to, the following: Receiving poor quality of care; Failure to provide covered services; Failure of the Contractor to comply with established standards of medical care administration; Lack of access to providers experienced in dealing with the member’s health care needs; Significant language or cultural barriers; Corrective action levied against the Contractor by the office; Limited access to a primary care clinic or other health services within reasonable proximity to a member’s residence; A determination that another MCE’s formulary is more consistent with a new member’s existing health care needs; Lack of access to medically necessary services covered under the Contractor’s contract with the State; A service is not covered by the Contractor for moral or religious objections, as described in Section 6.3.3; Related services are required to be performed at the same time and not all related services are available within the Contractor’s network, and the member’s provider determines that receiving the services separately will subject the member to unnecessary risk; The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls with another MCE; or Other circumstances determined by the office or its designee to constitute poor quality of health care coverage. The process for submitting disenrollment requests. This information shall include the following: Hoosier Healthwise members may change MCEs after the first ninety (90) calendar days of enrollment only for cause; Members are required to exhaust the MCE’s internal grievance and appeals process before requesting an MCE change ; Members may submit requests to change MCEs to the Enrollment Broker verbally or in writing, after exhausting the MCE’s internal grievance and appeals process; and The MCE shall provide the Enrollment Broker’s contact information and explain that the member must contact the Enrollment Broker with questions about the process. This information shall include how to obtain the Enrollment Broker’s standardized form for requesting an MCE change. The process by which an American Indian/ Alaska Native member may elect to opt-out of managed care pursuant to 42 USC § 1396u–2(a)(2)(C) and transfer to fee-for-service benefits through the State; Procedures for making complaints and recommending changes in policies and services; Grievance, appeal and fair hearing procedures as required at 42 CFR 438.10(g)(2)(xi), including the following: 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 member can use to file a grievance or appeal by phone; The fact that, if requested by the member and under certain circumstances: (1) benefits will continue if the member files an appeal or requests a State fair hearing within the specified timeframes; and (2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member. For a State hearing describe (i) the right to a hearing, (ii) the method for obtaining a hearing, and (iii) the rules that govern representation at the hearing. Information about advance directives; How to report a change in income, change in family size, etc.; Information about the availability of the prior claims payment program for certain members and how to access the program administrator; Information on alternative methods or formats of communication for visually and hearing-impaired and non-English speaking members and how members can access those methods or formats; Information on how to contact the Enrollment Broker; Statement that Contractor will provide information on the structure and operation of the health plan; and In accordance with 42 CFR 438.10(f)(3), that upon request of the member, information on the Contractor’s provider incentive plans will be provided.;
Appears in 1 contract
Samples: Contract for Providing Risk Based Managed Care Services
