Common use of Member Handbook Clause in Contracts

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.

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.

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.

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.;

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.

Member Handbook. The Contractor shall develop a member handbook for its members. The Contractor’s member handbook shall may be submitted annually for OMPP’s reviewoffered in an electronic format as long as the Contractor complies with 42 CFR 438.10(c)(6). The member handbook shall must 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 's contact information (address, telephone number, TDD number, website addressweb site);  • Contractor's office hours and days, including the availability of a twenty-four (24) hour Nurse Call Line; • The amount, duration and scope of services and benefits available under the Contract in sufficient details detail to ensure that participants are informed of the services to which they are entitled, including, but not limited to the differences between the benefit optionsincluding service authorization requirements;  • The procedures for obtaining benefits, including authorization requirements;  Contractor’s office • Standards and expectations for receiving preventive health services; • The extent to which, and how, after-hours and daysEmergency coverage are provided, including EXHIBIT 1 SCOPE OF WORK as well as other information required under 42 CFR 438.10(f) related to Emergency services; • The post-stabilization care services rules set forth in 42 CFR 422.113(c); • Any applicable policies on referrals for specialty care and other benefits; • Information on how to access non-emergency medical transportation, the availability limitation of a 24-hour Nurse Call LineNEMT as well as the member responsibilities for scheduling, using, and cancelling rides;  • 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 • Grievance, appeal and expectations fair hearing procedures as required at 42 CFR 438.10(g)(2)(xi), and described in Section 4.12, including the following: o The right to receive preventive health servicesfile grievances and appeals;  Policy on referrals 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 specialty carefile a grievance or appeal by phone;  Procedures and 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: o The right to a hearing; o The method for notifying members affected by termination or change obtaining a hearing; and o The rules that govern representation at the hearing. • Member rights and protections, as enumerated in any benefits, services or service delivery sites42 CFR 438.100 and as further detailed in Section 4.10 of this Scope of Work;  Procedures for appealing decisions adversely affecting • Responsibilities of 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, 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, to the following:  EXHIBIT 1 SCOPE OF WORK o Receiving poor quality of care;  o Failure of the Contractor to provide covered services;  o 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;  o Significant language or cultural barriers;  o Corrective action levied against the Contractor by the officeFSSA;  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 6.3.37.3.2;  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 Lack of access to providers experienced in dealing with the member’s healthcare needs; o The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls re-enrolls with another Hoosier Care Connect MCE; or  o Other circumstances determined by the office FSSA or its designee to constitute poor quality of health care coverage.  • The process for submitting disenrollment requests. This information shall must include the following:  Hoosier Healthwise members o Members may change MCEs after the first ninety (90) calendar days of enrollment only for when they have just cause;  o Members are required to exhaust the MCE’s internal grievance and appeals process before requesting an MCE change for 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 must 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 , including how to obtain the Enrollment Broker’s standardized form for requesting an MCE change.  EXHIBIT 1 SCOPE OF WORK • Procedures for making complaints, recommending changes in policies and services, and contacting the Member Advocate for assistance; • Information about advance directives as described in Section 4.7.5; • 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 Hoosier Care Connect Enrollment Broker; • Statement that Contractor will provide information on the structure and operation of the health plan; • 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; • The process by which an American Indian/ Alaska Native Indian 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 • The copayment system, schedule, and recommending changes exemptions outlined in policies Section 12; 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 process by which a grievance or appeal;  The availability of assistance in the filing process;  The toll-free numbers that the member can use receive a waiver by calling the 24-hour Nurse Call Line prior to file utilizing 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, etchospital Emergency department.;  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.

Member Handbook. The Contractor shall develop a member handbook for its members. The Contractor’s member handbook shall may be submitted annually for OMPP’s reviewoffered in an electronic format as long as the Contractor complies with 42 CFR 438.10(c)(6). The member handbook shall must 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 's contact information (address, telephone number, TDD number, website addressweb site);   Contractor's office hours and days, including the availability of a twenty-four (24) hour Nurse Call Line;  The amount, duration and scope of services and benefits available under the Contract in sufficient details detail to ensure that participants are informed of the services to which they are entitled, including, but not limited to the differences between the benefit optionsincluding service authorization requirements;   The procedures for obtaining benefits, including authorization requirements;  Contractor’s office  Standards and expectations for receiving preventive health services; EXHIBIT 1 SCOPE OF WORK  The extent to which, and how, after-hours and daysEmergency coverage are provided, including as well as other information required under 42 CFR 438.10(f) related to Emergency services;  The post-stabilization care services rules set forth in 42 CFR 422.113(c);  Any applicable policies on referrals for specialty care and other benefits;  Information on how to access non-emergency medical transportation, the availability limitation of a 24-hour Nurse Call LineNEMT as well as the member responsibilities for scheduling, using, and cancelling rides;   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  Grievance, appeal and expectations fair hearing procedures as required at 42 CFR 438.10(g)(2)(xi), and described in Section 4.12, including the following: o The right to receive preventive health servicesfile grievances and appeals;  Policy on referrals 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 specialty carefile a grievance or appeal by phone;  Procedures and 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: o The right to a hearing; o The method for notifying members affected by termination or change obtaining a hearing; and o The rules that govern representation at the hearing.  Member rights and protections, as enumerated in any benefits, services or service delivery sites42 CFR 438.100 and as further detailed in Section 4.10 of this Scope of Work;  Procedures for appealing decisions adversely affecting  Responsibilities of 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, 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” EXHIBIT 1 SCOPE OF WORK reasons described in 42 CFR 438.56(d)(2)(iv), including, but not limited to, to the following:  o Receiving poor quality of care;  o Failure of the Contractor to provide covered services;  o 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;  o Significant language or cultural barriers;  o Corrective action levied against the Contractor by the officeFSSA;  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 6.3.37.3.2;  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 Lack of access to providers experienced in dealing with the member’s healthcare needs; o The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls re-enrolls with another Hoosier Care Connect MCE; or  o Other circumstances determined by the office FSSA or its designee to constitute poor quality of health care coverage.   The process for submitting disenrollment requests. This information shall must include the following:  Hoosier Healthwise members o Members may change MCEs after the first ninety (90) calendar days of enrollment only for when they have just cause;  o Members are required to exhaust the MCE’s internal grievance and appeals process before requesting an MCE change for 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 must 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 , including how to obtain the Enrollment Broker’s standardized form for requesting an MCE change.  EXHIBIT 1 SCOPE OF WORK  Procedures for making complaints, recommending changes in policies and services, and contacting the Member Advocate for assistance;  Information about advance directives as described in Section 4.7.5;  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 Hoosier Care Connect Enrollment Broker;  Statement that Contractor will provide information on the structure and operation of the health plan;  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;  The process by which an American Indian/ Alaska Native Indian 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 copayment system, schedule, and appealsexemptions outlined in Section 12; and  The requirements and timeframes for filing process by which a grievance or appeal;  The availability of assistance in the filing process;  The toll-free numbers that the member can use receive a waiver by calling the 24-hour Nurse Call Line prior to file utilizing 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, etchospital Emergency department.;  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.

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.

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