Common use of Member Handbook Clause in Contracts

Member Handbook. (A) After execution of the Contract, and upon request of the Department, the Contractor shall submit its member handbook to the Department for review and approval. The Department shall notify the Contractor in writing of its approval or disapproval within thirty working days after receiving the member handbook. If the Department does not respond within thirty days, the Contractor may deem its member handbook approved by the Department. (B) At minimum, the member handbook shall explain in clear terms the following information: (1) The amount, duration, and scope of benefits provided by the Contractor described in sufficient detail to ensure that Enrollees understand scope of service and the benefits to which they are entitled; (2) Contractor’s procedures for obtaining benefits, including service authorization requirements; (3) The extent to which, and how, enrollees may obtain benefits from Non-Participating Providers; (4) The extent to which, and how, after-hours emergency coverage is provided including: (i) what constitutes an Emergency Medical Condition, Emergency Services, and Post-Stabilization Care Services with reference to the definitions in 42 CFR 438.114(a); (ii) the fact that prior authorization is not required for Emergency Services; (iii) the process and procedures for obtaining Emergency Services including use of the 911 telephone system or its local equivalent; (iv) the location of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Care Services covered under Contract; and (v) the fact that the Enrollee has the right to use any hospital or other setting for emergency care. (5) The Post-Stabilization Care Services rules set forth at 42 CFR 422.113(c); (6) Contractor’s policy on referrals for specialty care and for other benefits not furnished by the Enrollee’s Primary Care Provider; (7) Description of Enrollee cost-sharing requirements, where applicable; (8) How and where to access any benefits that are available under the State plan but are not covered under the Contract, including any cost sharing, and how transportation is provided; (9) A statement that the Contractor does not discriminate against any Enrollee on the basis of race, color, national origin, disability, sex, religion, or age in admission, treatment or participation in its programs, services, and activities; (10) Information on the availability of oral interpretation, including the fact that it is available for any language and that written information is available in prevalent languages, and includes a statement on how to access these services; (11) Information on the availability of written materials in alternative formats and in an appropriate manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency, and a statement on how to access these formats; (12) Names, locations, telephone numbers of, and non-English languages spoken by, current, Participating Providers in the Enrollee’s service area, including identification of Participating Providers that are not accepting new patients. This includes, at a minimum, information on Primary Care Providers, specialists, and hospitals; (13) Any restrictions on the Enrollee’s freedom of choice among Participating Providers; (14) Enrollee rights and protections, as specified in Article 9 of this Contract; (15) Information on Grievance, Appeal, and State fair hearing procedures and timeframes as provided in 42 CFR 438.400 through 42 CFR 438.424, in a Department approved description that shall include the following: (i) the Enrollee’s right to a State fair hearing, how to obtain a hearing, and representation rules at a hearing; (ii) the Enrollee’s right to file Grievances and Appeals; (iii) the requirements and timeframes for filing a Grievance or Appeal; (iv) the availability of assistance in the filing process; (v) the Enrollee’s ability to file a Grievance with the Contractor if the Enrollee has a complaint or concern with regard to a Provider; (vi) the toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone; and (vii) the fact that, when requested by the Enrollee: (a) disputed services will continue if the Enrollee files an Appeal or a request for a State fair hearing within the timeframes specified for filing, and (b) The Enrollee may be required to pay the cost of disputed services furnished while the Appeal is pending, if the final decision is adverse to the Enrollee. (16) Information to adult Enrollees on Advance Directives policies, including a description of applicable State law as set forth in 42 CFR 422.128; (17) A statement that additional information is available upon an Enrollee’s request regarding structure and operation of the Contractor, including information on: (i) the Contractor’s policy for selection of Participating Providers (staff and subcontractors) and what is required of them; and (ii) that information is available on request regarding the Contractor’s Physician Incentive Plan, if any. (18) A description of the circumstances in which the Enrollee may be responsible for payment including when: (i) the Enrollee has given advanced written consent to the Provider to pay for and obtain a service that is not a benefit of the plan; (ii) the Enrollee has given advanced written consent to the Provider to pay for the services and has obtained a services not authorized by the Contractor; (iii) the Enrollee has had an Appeal or State fair hearing decisions adverse to the Enrollee and disputed services were continued during the Appeal or State fair hearing process at the Enrollee’s request; and (iv) the Enrollee has become ineligible for Medicaid for any portion of the time period during which services were provided. (19) Description of Member Services function; and (20) Information that Indian Enrollees may obtain Covered Services at an eligible Indian Health Care Provider.

Member Handbook. (A) After execution of the Contract, and upon request of the DepartmentOn a yearly basis, the Contractor shall submit its member handbook to the Department for review and approvalapproval at least 45 days prior to general distribution. The Department shall notify the Contractor in writing of its approval or disapproval within thirty working days after receiving the member handbookhandbook unless the Department and Contractor agree to another timeframe. If the Department does not respond within thirty daysthe agreed upon time frame, the Contractor may deem its member handbook such materials approved by the Department. (B) At minimum, the member handbook shall explain in clear terms the following information: (1) The amount, duration, and scope of benefits provided by the Contractor described in sufficient detail to ensure that Enrollees understand the scope of service and the benefits to which they are entitled; (2) The Contractor’s procedures for obtaining benefitsCovered Services, including any service authorization requirements; how and under what circumstances out of area services are covered; policy on referrals to specialty care; and procedures for resolving Enrollee issues related to authorization of coverage or payment for services; (3) The extent to which, and how, enrollees may obtain benefits from Non-Participating Providers; (4) The extent to which, and how, after-hours emergency coverage is provided including: (i) what constitutes an Emergency Medical Condition, Emergency Services, and Post-Stabilization Care Services with reference to the definitions in 42 CFR 438.114(a)Services; (ii) the fact that prior authorization is not required for Emergency Services; (iii4) the process and procedures for obtaining Emergency Services including use of the 911 telephone system or its local equivalent; (iv) the location of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Care Services covered under Contract; and (v) the fact that the Enrollee has the right to use any hospital or other setting for emergency care. (5) The Post-Stabilization Care Services rules set forth at 42 CFR 422.113(c); (6) Contractor’s policy on referrals for specialty care and for other benefits not furnished by the Enrollee’s Primary Care Provider; (7) Description A description of Enrollee cost-sharing requirements, where applicable; (8) How and where to access any benefits that are available under the State plan but are not covered under the Contract, including any cost sharing, and how transportation is provided5) Toll free Member Services telephone number; (96) A statement that description of the Contractor does not discriminate against any Enrollee on the basis of race, color, national origin, disability, sex, religion, or age in admission, treatment or participation in its programs, services, and activitiesMember Services function; (10) Information on the availability of oral interpretation, including the fact that it is available for any language and that written information is available in prevalent languages, and includes a statement on how to access these services; (117) Information on the availability of written materials in alternative formats and in an appropriate manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency, and a statement on how to access these formats; (12) Names, locations, telephone numbers of, and non-English languages spoken by, current, Participating Providers in the Enrollee’s service area, including identification of Participating Providers that are not accepting new patients. This includes, at a minimum, information on Primary Care Providers, specialists, and hospitals; (13) Any restrictions on the Enrollee’s freedom of choice among Participating Providers; (14) Enrollee rights and protections, as specified in Article 9 of this Contract; (15) Information on Grievance, Appeal, and State fair hearing procedures and timeframes as provided in 42 CFR 438.400 through 42 CFR 438.424, in a Department approved description that shall include the following: (i) the Enrollee’s right to a State fair hearing, how to obtain a hearing, and representation rules at a hearing; (ii) the Enrollee’s right to file Grievances and Appeals; (iii) the requirements and timeframes for filing a Grievance or Appeal; (iv) the availability of assistance in the filing process; (v) the Enrollee’s ability to file a Grievance with the Contractor if the Enrollee has a complaint or concern with regard to a Provider; (vi) the toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone; and (vii) the fact that, when requested by the Enrollee: (a) disputed services will continue if 8) How the Enrollee files an Appeal may file a Complaint, Grievance, or a request for a State fair hearing within the timeframes specified for filing, and (b) The Enrollee may be required to pay the cost of disputed services furnished while the Appeal is pending, if the final decision is adverse to the EnrolleeAppeal. (16C) Information The Contractor shall notify the Department when it makes changes to adult Enrollees on Advance Directives policies, including a description of applicable State law as set forth in 42 CFR 422.128; (17) A statement that additional information is available upon an Enrollee’s request regarding structure and operation the member handbook at least 90 days prior to the changes taking effect. If the Department deems the changes being made to the member handbook to be “significant” the Contractor shall give each enrollee written notice of the Contractor, including information on: (i) change at least 30 days prior to the Contractor’s policy for selection of Participating Providers (staff and subcontractors) and what is required of them; and (ii) that information is available on request regarding the Contractor’s Physician Incentive Plan, if any. (18) A description intended effective date of the circumstances in which change. The Department agrees to notify the Enrollee may Contractor of information deemed to be responsible for payment including when: (i) the Enrollee has given advanced written consent “significant” at least 60 calendar days prior to the Provider to pay for and obtain a service that is not a benefit of the plan; (ii) the Enrollee has given advanced written consent to the Provider to pay for the services and has obtained a services not authorized by the Contractor; (iii) the Enrollee has had an Appeal or State fair hearing decisions adverse to the Enrollee and disputed services were continued during the Appeal or State fair hearing process at the Enrollee’s request; and (iv) the Enrollee has become ineligible for Medicaid for any portion of the time period during which services were providedintended effective date. (19) Description of Member Services function; and (20) Information that Indian Enrollees may obtain Covered Services at an eligible Indian Health Care Provider.

Member Handbook. (A) After execution If there are changes to the content of the Contract, and upon request of material in the DepartmentContractor’s member handbook, the Contractor shall submit its update the member handbook and submit a draft to the Department for review and approvalapproval before distribution to Enrollees. The Department shall notify the Contractor in writing of its approval or disapproval within thirty working days after receiving the member handbookhandbook unless the Department and Contractor agree to another timeframe. If the Department does not respond within thirty daysthe agreed upon time frame, the Contractor may deem its member handbook such materials approved by the Department. (B) At minimum, the member handbook shall explain in clear terms the following information: (1) The amount, duration, and scope of benefits provided by the Contractor described in sufficient detail to ensure that Enrollees understand scope of service and the benefits to which they are entitled; (2) Contractor’s procedures for obtaining benefits, including service authorization Service Authorization Request requirements; (3) The extent to which, and how, enrollees may obtain benefits benefits, including family planning services, from Non-Participating Providers; (4) The extent to which, and how, after-hours emergency coverage is provided including: (i) what constitutes an Emergency Medical Condition, Emergency Services, and Post-Stabilization Care Services with reference to the definitions in 42 CFR 438.114(a); (ii) the fact that prior authorization is not required for Emergency Services; (iii) the process and procedures for obtaining Emergency Services including use of the 911 telephone system or its local equivalent; (iv) the location of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Care Services covered under Contract; and (v) the fact that the Enrollee has the right to use any hospital or other setting for emergency care. (5) The Post-Stabilization Care Services rules set forth at 42 CFR 422.113(c); (6) Contractor’s policy Policy on referrals for specialty care and for other benefits not furnished by the Enrollee’s Primary Care Provider and that the Enrollee may have direct access to Specialty Care without referral from a Primary Care Provider; (7) Description of Enrollee cost-sharing requirements, where applicable; (8) How and where to access any benefits that are available under the State plan but are not covered under the Contract, including any cost sharing, and how transportation is provided; (9) A statement that the Contractor does not discriminate against any Enrollee on the basis of race, color, national origin, disability, sex, religion, or age in admission, treatment or participation in its programs, services, and activities; (10) The importance of establishing a primary care relationship with a Participating Provider, and processes for selecting or changing Primary Care Providers, and that Enrollees who are Indians may elect to use an Indian Health Care Provider as their Primary Care Provider; (11) The phone number of the nondiscrimination coordinator for Enrollees to call if they have questions about the nondiscrimination policy or desire to file a complaint or Grievance alleging violations of the nondiscrimination policy; (12) Information on the availability of oral interpretation, including the fact that it is available for any language and that written information is available in prevalent languages, and includes a statement on how to access these services; (1113) Information on the availability of written materials in alternative formats and in an appropriate manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency, and a statement on how to access these formats; (1214) Names, locations, telephone numbers of, and non-English languages spoken by, current, Participating Providers in the Enrollee’s service area, including identification of Participating Providers that are not accepting new patients. This includes, at a minimum, information on Primary Care Providers, specialists, and hospitals; (1315) Any restrictions on the Enrollee’s freedom of choice among Participating Providers; (1416) Enrollee rights and protections, as specified in Article 9 of this Contract; (1517) Information on Grievance, Appeal, and State fair hearing procedures and timeframes as provided in 42 CFR 438.400 through 42 CFR 438.424, in a Department approved description that shall include the following: (i) the Enrollee’s right to a State fair hearing, how to obtain a hearing, and representation rules at a hearing; (ii) the Enrollee’s right to file Grievances and Appeals; (iii) the requirements and timeframes for filing a Grievance or Appeal; (iv) the availability of assistance in the filing process; (v) the Enrollee’s ability to file a Grievance with the Contractor if the Enrollee has a complaint or concern with regard to a Provider; (vi) the toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone; and (vii) the fact that, when requested by the Enrollee: (a) disputed services will continue if the Enrollee files an Appeal or a request for a State fair hearing within the timeframes specified for filing, and (b) The Enrollee may be required to pay the cost of disputed services furnished while the Appeal is pending, if the final decision is adverse to the Enrollee. (16) Information to adult Enrollees on Advance Directives policies, including a description of applicable State law as set forth in 42 CFR 422.128; (17) A statement that additional information is available upon an Enrollee’s request regarding structure and operation of the Contractor, including information on: (i) the Contractor’s policy for selection of Participating Providers (staff and subcontractors) and what is required of them; and (ii) that information is available on request regarding the Contractor’s Physician Incentive Plan, if any. (18) A description of the circumstances in which the Enrollee may be responsible for payment including when: (i) the Enrollee has given advanced written consent to the Provider to pay for and obtain a service that is not a benefit of the plan; (ii) the Enrollee has given advanced written consent to the Provider to pay for the services and has obtained a services not authorized by the Contractor; (iii) the Enrollee has had an Appeal or State fair hearing decisions adverse to the Enrollee and disputed services were continued during the Appeal or State fair hearing process at the Enrollee’s request; and (iv) the Enrollee has become ineligible for Medicaid for any portion of the time period during which services were provided. (19) Description of Member Services function; and (20) Information that Indian Enrollees may obtain Covered Services at an eligible Indian Health Care Provider.

Member Handbook. (A) After execution of the Contract, and upon request of the DepartmentOn a yearly basis, the Contractor shall submit its member handbook to the Department for review and approvalapproval prior to general distribution. During open enrollment, the Contractor shall submit its member handbook to the Department for review within the thirty days after the Department has notified the Contractor of benefit changes for the new plan year. The Department shall notify the Contractor in writing of its approval or disapproval within thirty working days after receiving the member handbookhandbook unless the Department and the Contractor agree to another timeframe. If the Department does not respond within thirty daysthe agreed upon time frame, the Contractor may deem its member handbook such materials approved by the Department. (B) At minimum, the member handbook shall explain in clear terms the following information: (1) The amount, duration, and scope of benefits provided by the Contractor described in sufficient detail to ensure that Enrollees understand the scope of service and the benefits to which they are entitled; (2) The Contractor’s procedures for obtaining benefitsCovered Services, including any service authorization requirements; how and under what circumstances out of area services are covered; policy on referrals to specialty care; and procedures for resolving Enrollee issues related to authorization of coverage or payment for services; (3) The extent to which, and how, enrollees may obtain benefits from Non-Participating Providers; (4) The extent to which, and how, after-hours emergency coverage is provided including: (i) what constitutes an Emergency Medical Condition, Emergency Services, and Post-Stabilization Care Services with reference to the definitions in 42 CFR 438.114(a)Services; (ii) the fact that prior authorization is not required for Emergency Services; (iii4) the process Information about immunizations and procedures for obtaining Emergency Services including use of the 911 telephone system or its local equivalentwell-child visits; (iv) the location of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Care Services covered under Contract; and (v) the fact that the Enrollee has the right to use any hospital or other setting for emergency care. (5) The Post-Stabilization Care Services rules set forth at 42 CFR 422.113(c); (6) Contractor’s policy on referrals for specialty care and for other benefits not furnished by the Enrollee’s Primary Care Provider; (7) Description A description of Enrollee cost-sharing requirements, where applicable; (6) Toll free Member Services telephone number; (7) A description of the Member Services function; (8) How and where to access any benefits that are available under the State plan but are not covered under the Contract, including any cost sharing, and how transportation is provided; (9) A statement that the Contractor does not discriminate against any Enrollee on the basis of race, color, national origin, disability, sex, religion, or age in admission, treatment or participation in its programs, services, and activities; (10) Information on the availability of oral interpretation, including the fact that it is available for any language and that written information is available in prevalent languages, and includes a statement on how to access these services; (11) Information on the availability of written materials in alternative formats and in an appropriate manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency, and a statement on how to access these formats;; and (129) How the Enrollee may file a Complaint, Grievance, or Appeal. (10) Names, locations, telephone numbers of, and non-English languages spoken by, current, Participating Providers in the Enrollee’s service area, including identification of Participating Providers that are not accepting new patients. This includes, at a minimum, information on Primary Care Providers, specialists, and hospitals; (1311) Any restrictions on the Enrollee’s freedom of choice among Participating Providers; (1412) Enrollee rights and protections, as specified in Article 9 of this Contract;The Post-Stabilization Care Services rules set forth at 42 CFR 422.113(c); and (1513) Information on Grievance, Appeal, and State fair hearing procedures and timeframes as provided in 42 CFR 438.400 through 42 CFR 438.424, in a Department approved description that shall include the following: (i) the Enrollee’s right to a State fair hearing, how to obtain a hearing, and representation rules at a hearing; (ii) the Enrollee’s right to file Grievances and Appeals; (iii) the requirements and timeframes for filing a Grievance or Appeal; (iv) the availability of assistance in the filing process; (v) the Enrollee’s ability to file a Grievance with the Contractor if the Enrollee has a complaint or concern with regard to a Provider; (vi) the toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone; and; (vii) the fact that, when requested by the Enrollee: (a) disputed services will continue if the Enrollee files an Appeal or a request for a State fair hearing within the timeframes specified for filing, and (b) The Enrollee may be required to pay the cost of disputed services furnished while the Appeal is pending, if the final decision is adverse to the Enrollee. (16C) Information The Contractor shall notify the Department when it makes changes to adult Enrollees on Advance Directives policies, including a description of applicable State law as set forth in 42 CFR 422.128; (17) A statement that additional information is available upon an Enrollee’s request regarding structure and operation the member handbook at least 90 days prior to the changes taking effect. If the Department deems the changes being made to the member handbook to be “significant” the Contractor shall give each enrollee written notice of the Contractor, including information on: (i) change at least 30 days prior to the Contractor’s policy for selection of Participating Providers (staff and subcontractors) and what is required of them; and (ii) that information is available on request regarding the Contractor’s Physician Incentive Plan, if any. (18) A description intended effective date of the circumstances in which change. The Department agrees to notify the Enrollee may Contractor of information deemed to be responsible for payment including when: (i) the Enrollee has given advanced written consent “significant” at least 60 calendar days prior to the Provider to pay for and obtain a service that is not a benefit of the plan; (ii) the Enrollee has given advanced written consent to the Provider to pay for the services and has obtained a services not authorized by the Contractor; (iii) the Enrollee has had an Appeal or State fair hearing decisions adverse to the Enrollee and disputed services were continued during the Appeal or State fair hearing process at the Enrollee’s request; and (iv) the Enrollee has become ineligible for Medicaid for any portion of the time period during which services were providedintended effective date. (19) Description of Member Services function; and (20) Information that Indian Enrollees may obtain Covered Services at an eligible Indian Health Care Provider.

Member Handbook. (A) After execution of the Contract, and upon request of the DepartmentOn a yearly basis, the Contractor shall submit its member handbook to the Department for review and approvalapproval at least 45 days prior to general distribution. The Department shall notify the Contractor in writing of its approval or disapproval within thirty working days after receiving the member handbookhandbook unless the Department and Contractor agree to another timeframe. If the Department does not respond within thirty daysthe agreed upon time frame, the Contractor may deem its member handbook such materials approved by the Department. (B) At minimum, the member handbook shall explain in clear terms the following information: (1) The amount, duration, and scope of benefits provided by the Contractor described in sufficient detail to ensure that Enrollees understand the scope of service and the benefits to which they are entitled; (2) The Contractor’s procedures for obtaining benefitsCovered Services, including any service authorization requirements; how and under what circumstances out of area services are covered; policy on referrals to specialty care; and procedures for resolving Enrollee issues related to authorization of coverage or payment for services; (3) The extent to which, and how, enrollees may obtain benefits from Non-Participating Providers; (4) The extent to which, and how, after-hours emergency coverage is provided including: (i) what constitutes an Emergency Medical Condition, Emergency Services, and Post-Stabilization Care Services with reference to the definitions in 42 CFR 438.114(a)Services; (ii) the fact that prior authorization is not required for Emergency Services; (iii4) the process and procedures for obtaining Emergency Services including use of the 911 telephone system or its local equivalent; (iv) the location of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Care Services covered under Contract; and (v) the fact that the Enrollee has the right to use any hospital or other setting for emergency care. (5) The Post-Stabilization Care Services rules set forth at 42 CFR 422.113(c); (6) Contractor’s policy on referrals for specialty care and for other benefits not furnished by the Enrollee’s Primary Care Provider; (7) Description A description of Enrollee cost-sharing requirements, where applicable; (8) How and where to access any benefits that are available under the State plan but are not covered under the Contract, including any cost sharing, and how transportation is provided5) Toll free Member Services telephone number; (96) A statement that description of the Contractor does not discriminate against any Enrollee on the basis of race, color, national origin, disability, sex, religion, or age in admission, treatment or participation in its programs, services, and activitiesMember Services function; (10) Information on the availability of oral interpretation, including the fact that it is available for any language and that written information is available in prevalent languages, and includes a statement on how to access these services; (117) Information on the availability of written materials in alternative formats and in an appropriate manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency, and a statement on how to access these formats; (12) Names, locations, telephone numbers of, and non-English languages spoken by, current, Participating Providers in the Enrollee’s service area, including identification of Participating Providers that are not accepting new patients. This includes, at a minimum, information on Primary Care Providers, specialists, and hospitals; (13) Any restrictions on the Enrollee’s freedom of choice among Participating Providers; (14) Enrollee rights and protections, as specified in Article 9 of this Contract; (15) Information on Grievance, Appeal, and State fair hearing procedures and timeframes as provided in 42 CFR 438.400 through 42 CFR 438.424, in a Department approved description that shall include the following: (i) the Enrollee’s right to a State fair hearing, how to obtain a hearing, and representation rules at a hearing; (ii) the Enrollee’s right to file Grievances and Appeals; (iii) the requirements and timeframes for filing a Grievance or Appeal; (iv) the availability of assistance in the filing process; (v) the Enrollee’s ability to file a Grievance with the Contractor if the Enrollee has a complaint or concern with regard to a Provider; (vi) the toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone; and (vii) 8) How the fact thatEnrollee may file a Complaint, when requested by the Enrollee:Grievance, or Appeal. (aC) disputed services will continue if The Contractor shall notify the Department when it makes changes to the member handbook at least 90 days prior to the changes taking effect. If the Department deems the changes being made to the member handbook to be “significant” the Contractor shall give each enrollee written notice of the change at least 30 days prior to the intended effective date of the change. The Department agrees to notify the Contractor of information deemed to be “significant” at least 60 calendar days prior to the intended effective date. (D) The Contractor shall also provide the information described in Section 3.6.3(B) to the Enrollee files an Appeal or a upon request for a State fair hearing within the timeframes specified for filing, and (b) The Enrollee may be required to pay the cost of disputed services furnished while the Appeal is pending, if the final decision is adverse to from the Enrollee. (16) Information to adult Enrollees on Advance Directives policies, including a description of applicable State law as set forth in 42 CFR 422.128; (17) A statement that additional information is available upon an Enrollee’s request regarding structure and operation of the Contractor, including information on: (i) the Contractor’s policy for selection of Participating Providers (staff and subcontractors) and what is required of them; and (ii) that information is available on request regarding the Contractor’s Physician Incentive Plan, if any. (18) A description of the circumstances in which the Enrollee may be responsible for payment including when: (i) the Enrollee has given advanced written consent to the Provider to pay for and obtain a service that is not a benefit of the plan; (ii) the Enrollee has given advanced written consent to the Provider to pay for the services and has obtained a services not authorized by the Contractor; (iii) the Enrollee has had an Appeal or State fair hearing decisions adverse to the Enrollee and disputed services were continued during the Appeal or State fair hearing process at the Enrollee’s request; and (iv) the Enrollee has become ineligible for Medicaid for any portion of the time period during which services were provided. (19) Description of Member Services function; and (20) Information that Indian Enrollees may obtain Covered Services at an eligible Indian Health Care Provider.

Member Handbook. (A) After execution of the Contract, and upon request of the DepartmentOn a yearly basis, the Contractor shall submit its member handbook to the Department for review and approvalapproval prior to general distribution. During open enrollment, the Contractor shall submit its member handbook to the Department for review within the thirty days after the Department has notified the Contractor of benefit changes for the new plan year. The Department shall notify the Contractor in writing of its approval or disapproval within thirty working days after receiving the member handbookhandbook unless the Department and the Contractor agree to another timeframe. If the Department does not respond within thirty daysthe agreed upon time frame, the Contractor may deem its member handbook such materials approved by the Department. (B) At minimum, the member handbook shall explain in clear terms the following information: (1) The amount, duration, and scope of benefits provided by the Contractor described in sufficient detail to ensure that Enrollees understand the scope of service and the benefits to which they are entitled; (2) The Contractor’s procedures for obtaining benefitsCovered Services, including any service authorization requirements; how and under what circumstances out of area services are covered; policy on referrals to specialty care; and procedures for resolving Enrollee issues related to authorization of coverage or payment for services; (3) The extent to which, and how, enrollees may obtain benefits from Non-Participating Providers; (4) The extent to which, and how, after-hours emergency coverage is provided including: (i) what constitutes an Emergency Medical Condition, Emergency Services, and Post-Stabilization Care Services with reference to the definitions in 42 CFR 438.114(a); (ii) the fact that prior authorization is not required for Emergency Services; (iii4) the process Information about immunizations and procedures for obtaining Emergency Services including use of the 911 telephone system or its local equivalentwell-child visits; (iv) the location of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Care Services covered under Contract; and (v) the fact that the Enrollee has the right to use any hospital or other setting for emergency care. (5) The Post-Stabilization Care Services rules set forth at 42 CFR 422.113(c); (6) Contractor’s policy on referrals for specialty care and for other benefits not furnished by the Enrollee’s Primary Care Provider; (7) Description A description of Enrollee cost-sharing requirements, where applicable; (6) Toll free Member Services telephone number; (7) A description of the Member Services function; (8) How and where to access any benefits that are available under the State plan but are not covered under the Contract, including any cost sharing, and how transportation is provided; (9) A statement that the Contractor does not discriminate against any Enrollee on the basis of race, color, national origin, disability, sex, religion, or age in admission, treatment or participation in its programs, services, and activities; (10) Information on the availability of oral interpretation, including the fact that it is available for any language and that written information is available in prevalent languages, and includes a statement on how to access these services; (11) Information on the availability of written materials in alternative formats and in an appropriate manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency, and a statement on how to access these formats;; and (129) How the Enrollee may file a Complaint, Grievance, or Appeal. (10) Names, locations, telephone numbers of, and non-English languages spoken by, current, Participating Providers in the Enrollee’s service area, including identification of Participating Providers that are not accepting new patients. This includes, at a minimum, information on Primary Care Providers, specialists, and hospitals; (1311) Any restrictions on the Enrollee’s freedom of choice among Participating Providers; (1412) Enrollee rights and protections, as specified in Article 9 of this Contract;The Post-Stabilization Care Services rules set forth at 42 CFR 422.113(c); and (1513) Information on Grievance, Appeal, and State fair hearing procedures and timeframes as provided in 42 CFR 438.400 through 42 CFR 438.424, in a Department approved description that shall include the following: (i) the Enrollee’s right to a State fair hearing, how to obtain a hearing, and representation rules at a hearing; (ii) the Enrollee’s right to file Grievances and Appeals; (iii) the requirements and timeframes for filing a Grievance or Appeal; (iv) the availability of assistance in the filing process; (v) the Enrollee’s ability to file a Grievance with the Contractor if the Enrollee has a complaint or concern with regard to a Provider; (vi) the toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone; and; (vii) the fact that, when requested by the Enrollee: (a) disputed services will continue if the Enrollee files an Appeal or a request for a State fair hearing within the timeframes specified for filing, and (b) The Enrollee may be required to pay the cost of disputed services furnished while the Appeal is pending, if the final decision is adverse to the Enrollee. (16C) Information The Contractor shall notify the Department when it makes changes to adult Enrollees on Advance Directives policies, including a description of applicable State law as set forth in 42 CFR 422.128; (17) A statement that additional information is available upon an Enrollee’s request regarding structure and operation the member handbook at least 90 days prior to the changes taking effect. If the Department deems the changes being made to the member handbook to be “significant” the Contractor shall give each enrollee written notice of the Contractor, including information on: (i) change at least 30 days prior to the Contractor’s policy for selection of Participating Providers (staff and subcontractors) and what is required of them; and (ii) that information is available on request regarding the Contractor’s Physician Incentive Plan, if any. (18) A description intended effective date of the circumstances in which change. The Department agrees to notify the Enrollee may Contractor of information deemed to be responsible for payment including when: (i) the Enrollee has given advanced written consent “significant” at least 60 calendar days prior to the Provider to pay for and obtain a service that is not a benefit of the plan; (ii) the Enrollee has given advanced written consent to the Provider to pay for the services and has obtained a services not authorized by the Contractor; (iii) the Enrollee has had an Appeal or State fair hearing decisions adverse to the Enrollee and disputed services were continued during the Appeal or State fair hearing process at the Enrollee’s request; and (iv) the Enrollee has become ineligible for Medicaid for any portion of the time period during which services were providedintended effective date. (19) Description of Member Services function; and (20) Information that Indian Enrollees may obtain Covered Services at an eligible Indian Health Care Provider.

Member Handbook. (A) After execution of the Contract, and upon request of the DepartmentOn a yearly basis, the Contractor shall submit its member handbook to the Department for review and approvalapproval at least 45 days prior to general distribution. The Department shall notify the Contractor in writing of its approval or disapproval within thirty working days after receiving the member handbookhandbook unless the Department and Contractor agree to another timeframe. If the Department does not respond within thirty daysthe agreed upon time frame, the Contractor may deem its member handbook such materials approved by the Department. (B) At minimum, the member handbook shall explain in clear terms the following information: (1) The amount, duration, and scope of benefits provided by the Contractor described in sufficient detail to ensure that Enrollees understand the scope of service and the benefits to which they are entitled; (2) The Contractor’s procedures for obtaining benefitsCovered Services, including any service authorization requirements; how and under what circumstances out of area services are covered; policy on referrals to specialty care; and procedures for resolving Enrollee issues related to authorization of coverage or payment for services; (3) The extent to which, and how, enrollees may obtain benefits from Non-Participating Providers; (4) The extent to which, and how, after-hours emergency coverage is provided including: (i) what constitutes an Emergency Medical Condition, Emergency Services, and Post-Post- Stabilization Care Services with reference to the definitions in 42 CFR 438.114(a)Services; (ii) the fact that prior authorization is not required for Emergency Services; (iii4) the process and procedures for obtaining Emergency Services including use of the 911 telephone system or its local equivalent; (iv) the location of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Care Services covered under Contract; and (v) the fact that the Enrollee has the right to use any hospital or other setting for emergency care. (5) The Post-Stabilization Care Services rules set forth at 42 CFR 422.113(c); (6) Contractor’s policy on referrals for specialty care and for other benefits not furnished by the Enrollee’s Primary Care Provider; (7) Description A description of Enrollee cost-sharing requirements, where applicable; (8) How and where to access any benefits that are available under the State plan but are not covered under the Contract, including any cost sharing, and how transportation is provided5) Toll free Member Services telephone number; (96) A statement that description of the Contractor does not discriminate against any Enrollee on the basis of race, color, national origin, disability, sex, religion, or age in admission, treatment or participation in its programs, services, and activitiesMember Services function; (10) Information on the availability of oral interpretation, including the fact that it is available for any language and that written information is available in prevalent languages, and includes a statement on how to access these services; (117) Information on the availability of written materials in alternative formats and in an appropriate manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency, and a statement on how to access these formats; (12) Names, locations, telephone numbers of, and non-English languages spoken by, current, Participating Providers in the Enrollee’s service area, including identification of Participating Providers that are not accepting new patients. This includes, at a minimum, information on Primary Care Providers, specialists, and hospitals; (13) Any restrictions on the Enrollee’s freedom of choice among Participating Providers; (14) Enrollee rights and protections, as specified in Article 9 of this Contract; (15) Information on Grievance, Appeal, and State fair hearing procedures and timeframes as provided in 42 CFR 438.400 through 42 CFR 438.424, in a Department approved description that shall include the following: (i) the Enrollee’s right to a State fair hearing, how to obtain a hearing, and representation rules at a hearing; (ii) the Enrollee’s right to file Grievances and Appeals; (iii) the requirements and timeframes for filing a Grievance or Appeal; (iv) the availability of assistance in the filing process; (v) the Enrollee’s ability to file a Grievance with the Contractor if the Enrollee has a complaint or concern with regard to a Provider; (vi) the toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone; and (vii) 8) How the fact thatEnrollee may file a Complaint, when requested by the Enrollee:Grievance, or Appeal. (aC) disputed services will continue if The Contractor shall notify the Department when it makes changes to the member handbook at least 90 days prior to the changes taking effect. If the Department deems the changes being made to the member handbook to be “significant” the Contractor shall give each enrollee written notice of the change at least 30 days prior to the intended effective date of the change. The Department agrees to notify the Contractor of information deemed to be “significant” at least 60 calendar days prior to the intended effective date. (D) The Contractor shall also provide the information described in Section 3.6.3(B) to the Enrollee files an Appeal or a upon request for a State fair hearing within the timeframes specified for filing, and (b) The Enrollee may be required to pay the cost of disputed services furnished while the Appeal is pending, if the final decision is adverse to from the Enrollee. (16) Information to adult Enrollees on Advance Directives policies, including a description of applicable State law as set forth in 42 CFR 422.128; (17) A statement that additional information is available upon an Enrollee’s request regarding structure and operation of the Contractor, including information on: (i) the Contractor’s policy for selection of Participating Providers (staff and subcontractors) and what is required of them; and (ii) that information is available on request regarding the Contractor’s Physician Incentive Plan, if any. (18) A description of the circumstances in which the Enrollee may be responsible for payment including when: (i) the Enrollee has given advanced written consent to the Provider to pay for and obtain a service that is not a benefit of the plan; (ii) the Enrollee has given advanced written consent to the Provider to pay for the services and has obtained a services not authorized by the Contractor; (iii) the Enrollee has had an Appeal or State fair hearing decisions adverse to the Enrollee and disputed services were continued during the Appeal or State fair hearing process at the Enrollee’s request; and (iv) the Enrollee has become ineligible for Medicaid for any portion of the time period during which services were provided. (19) Description of Member Services function; and (20) Information that Indian Enrollees may obtain Covered Services at an eligible Indian Health Care Provider.