Participant Handbook and Enrollment Agreement. A. The Contractor shall use the Participant Handbook specified by the Department and Enrollment Agreement template specified by the Department. B. The Contractor must give the Participant a copy of the Participant Handbook prior to the Participant enrolling in the Plan and annually thereafter. C. The Participant Handbook must include, at a minimum, the following: 1. A description of all Capitated Services provided through the Plan, in sufficient detail to enable the Participant or the Participant's representative, if appropriate, to understand the benefits available under the Plan. 2. The amount, duration, and scope of benefits available under the Plan in sufficient detail to enable the Participant or the Participant’s representative, if appropriate, to understand the benefits to which the Participant is entitled. 3. An explanation of the circumstances under which the Contractor is responsible for Post-Stabilization Care Services. 4. An explanation of the procedure for obtaining Capitated Services, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the Participant’s PCP. 5. Information on the Participant's right to choose his or her PCP and other Providers to the extent possible and appropriate, including information on any restrictions on the Participant's freedom of choice among Network Providers and the process for selecting and changing the Participant’s PCP. 6. Locations, telephone numbers, and procedures for obtaining health services in the event of a crisis. 7. Participant rights and responsibilities, as defined in this Section. 8. The disenrollment procedures, as described in Section 4.6 of this Agreement. 9. Information concerning transportation arrangements offered by the Contractor. 10. The extent to which and how Participants may obtain benefits, including family planning services and supplies from Out-of- Network Providers. This must include that the Contractor cannot require a Participant to obtain a referral before choosing a family planning provider. 11. How and where to access any benefits, including family planning services, that are available under the Medical Assistance Program but are not covered under this Agreement, including any cost sharing and how transportation is provided. 12. The extent to which, and how, after-hours and emergency coverage are provided, including: a. What constitutes an Emergency Medical Condition and Emergency Services. b. That prior authorization is not required for Emergency Services. c. That if the Participant has an Emergency Medical Condition, the Participant has a right to use any hospital or other setting for emergency care. d. When emergency behavioral consultation and support is warranted. 13. Information on how to report suspected Fraud and Abuse. 14. Information about how to exercise an Advance Directive in accordance with 42 CFR § 438.3(j). 15. Information about how to access Auxiliary Aids and Services, including additional information in alternative formats or languages. 16. The toll-free number for member services, medical management, and any other unit providing services directly to Participants. 17. The counseling or referral services the Contractor does not cover because of moral or religious objections and how Participants can obtain information from the Department about how to access these services. 18. The right to file a Complaint or Grievance and request a Fair Hearing, the methods for filing a Complaint or Grievance or requesting a Fair Hearing, the time frame for requesting a Fair Hearing after a Complaint or Grievance has been decided, the availability of assistance with filing a Complaint or Grievance or requesting a Fair Hearing, the ability to continue to receive requested services if the Participant files a Complaint or Grievance within ten (10) days from the mail date on the written notice to terminate or reduce currently Authorized Services or requests a Fair Hearing within ten (10) days from the mail date on the written notice of a Complaint or Grievance decision concerning the termination or reduction of currently Authorized Services. 19. How to file a discrimination complaint with the Office of Civil Rights of the Department of Health and Human Services. 20. The transition of care policy, including how the Supports Coordinator will assist the Participant with coordinating services and supports. 21. The taglines listed in Attachment V must be in a font size that is conspicuously visible. 22. Any additional content required by the Department. D. The Contractor must inform each Participant verbally and in the Participant Handbook of the following rights and responsibilities, at a minimum: 1. The Contractor's responsibility to respond to any questions or concerns the Participant has about the care rendered and to routinely check with the Participant about his or her satisfaction with the services being rendered. 2. The Contractor's responsibility to render services according to acceptable standards of care. 3. The Contractor's responsibility to provide care according to the ISP. 4. The Contractor's responsibility to notify the Participant in writing of any action taken which affects the status of the Participant's services. 5. The Contractor's responsibility to provide information on request regarding the structure and operation of the Plan. 6. The Participant's responsibility to treat employees of the Contractor and Providers with respect and to communicate problems immediately to the appropriate Contractor staff. 7. The Participant’s responsibility to notify the appropriate Contractor’s staff and Providers whenever the Participant is unable to keep an appointment. 8. The Participant's responsibility to pay for room and board if the Participant is receiving Residential Habilitation Services. 9. The Participant's responsibility to obtain a referral for services when required. 10. The Participant's right to be treated with respect and with due consideration for his or her dignity and privacy. 11. The Participant's right to receive all materials in a language, manner, and format that is easily understood. 12. The Participant's right to written information in the prevalent non-English languages of the Service Area and in an appropriate alternative format or manner that takes into consideration the special needs of Participants who, for example, are visually limited or have limited reading proficiency. 13. The Participant's right to free oral interpretation services in any language, written translation in prevalent non-English languages, Auxiliary Aids and Services upon request, and written materials in font that is no smaller than eighteen (18) point. 14. The Participant's right to file a Complaint or Grievance, the requirements and time frames for filing a Complaint or Grievance as specified in Appendix G, the availability of assistance in the filing process, the toll-free numbers that the Participant can use to file a Complaint or Grievance, and the ability to continue to receive requested services if the Participant files a Complaint or Grievance within ten (10) days of the notice to terminate or reduce currently Authorized Services. 15. The Participant's right to request a Fair Hearing, the methods for obtaining a Fair Hearing, the time frame for requesting a Fair Hearing after a Complaint or Grievance has been decided, the rules that govern representation at Fair Hearings, the ability to continue to receive requested services if the Participant files a request for a Fair Hearing within ten (10) days from the mail date on the written notice of a Complaint or Grievance decision to terminate or reduce currently Authorized Services. 16. The Participant's right to receive information on available treatment options and alternatives presented in a manner appropriate to the Participant's condition and ability to understand. 17. The Participant's right to participate in decisions regarding his or her health care, including the right to refuse treatment. 18. The Participant's right to be free from any form of Restraint used as a means of coercion, discipline, convenience or retaliation as specified in federal regulations on the use of Restraints and Seclusion. 19. The Participant's right to be free from Seclusion, Chemical Restraint, Mechanical Restraint, and Aversive Conditioning at any time and from Physical Restraint unless required by an emergency. 20. The Participant's right to request and receive copies of his or her medical records, and request that they be amended or corrected, as specified in 45 CFR §§ 164.524 and 164.526. 21. The Contractor’s responsibility to provide information on request regarding the Adult Protective Services Act, 35 P.S. §§ 10210.101 – 10210.704, and the Older Adults Protective Services Act, 35 P.S. §§ 10225.101 – 10225.5102. 22. The Participant’s right to be protected from Abuse, neglect, exploitation, and abandonment pursuant to the Adult Protective Services Act, 35 P.S. §§ 10210.101 – 10210.704, and the Older Adults Protective Services Act, 35 P.S. §§ 10225.101 – 10225.5102, as well as resources for Participants and how to report information required to be reported by the Acts. 23. The Participant's right to be free from discrimination on the basis of race, color, national origin, sex, age, or disability. 24. The Participant’s right to free exercise of the Participant’s rights and that the exercise of those rights may not adversely affect the way the Contractor or Network Provider treat the Participant. 25. Any additional rights and responsibilities identified in the Participant Handbook. E. Prior to enrollment, the Contractor shall: 1. Review the Participant Handbook and the Enrollment Agreement with each Participant or the Participant's representative, as appropriate; 2. Provide each Participant or the Participant's representative, as appropriate, with a copy of the Participant Handbook; 3. Obtain the signature of the Participant or the Participant's representative, as appropriate, on the Enrollment Agreement, which includes a statement that the Participant or, if appropriate, the Participant’s representative, received the Participant Handbook and the Participant Handbook was reviewed with the Participant or, if appropriate, the Participant’s representative; 4. Provide each Participant or the Participant's representative, as appropriate, with a copy of the signed Enrollment Agreement; 5. Provide the Participant or the Participant’s representative, as appropriate, with the contact information for the Participant’s Supports Coordinator. F. The Contractor must provide written notice to Participants of any change in the Participant Handbook or Enrollment Agreement, policies, or any other significant change as determined by the Department to the delivery of Covered Services provided under the Plan, at least thirty (30) days before the intended effective date of change. The change must be approved by the Department prior to providing notification to the Participants. G. The Contractor must inform Participants annually that they may obtain the information contained in the Participant Handbook upon request.
Appears in 2 contracts
Samples: Adult Community Autism Program Agreement, Adult Community Autism Program Agreement
Participant Handbook and Enrollment Agreement. A. The Contractor shall use the Participant Handbook specified by the Department and Enrollment Agreement template specified by the Department.
B. The Contractor must give the Participant a copy of the Participant Handbook prior to the Participant enrolling in the Plan and annually thereafter.
C. The Participant Handbook must include, at a minimum, the following:
1. A description of all Capitated Services provided through the Plan, in sufficient detail to enable the Participant or the Participant's representative, if appropriate, to understand the benefits available under the Plan.
2. The amount, duration, and scope of benefits available under the Plan in sufficient detail to enable the Participant or the Participant’s representative, if appropriate, to understand the benefits to which the Participant is entitled.the
3. An explanation of the circumstances under which the Contractor is responsible for Post-Stabilization Care Services.
4. An explanation of the procedure for obtaining Capitated Services, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the Participant’s PCP.
5. Information on the Participant's right to choose his or her PCP and other Providers to the extent possible and appropriate, including information on any restrictions on the Participant's freedom of choice among Network Providers and the process for selecting and changing the Participant’s PCP.
6. Locations, telephone numbers, and procedures for obtaining health services in the event of a crisis.
7. Participant rights and responsibilities, as defined in this Section.
8. The disenrollment procedures, as described in Section 4.6 of this Agreement.
9. Information concerning transportation arrangements offered by the Contractor.
10. The extent to which and how Participants may obtain benefits, including family planning services and supplies from Out-of- Network Providers. This must include that the Contractor cannot require a Participant to obtain a referral before choosing a family planning provider.
11. How and where to access any benefits, including family planning services, that are available under the Medical Assistance Program but are not covered under this Agreement, including any cost sharing and how transportation is provided.
12. The extent to which, and how, after-hours and emergency coverage are provided, including:
a. What constitutes an Emergency Medical Condition and Emergency Services.
b. That prior authorization is not required for Emergency Services.
c. That if the Participant has an Emergency Medical Condition, the Participant has a right to use any hospital or other setting for emergency care.
d. When emergency behavioral consultation and support is warranted.
13. Information on how to report suspected Fraud and Abuse.
14. Information about how to exercise an Advance Directive in accordance with 42 CFR § 438.3(j).
15. Information about how to access Auxiliary Aids and Services, including additional information in alternative formats or languages.
16. The toll-free number for member services, medical management, and any other unit providing services directly to Participants.
17. The counseling or referral services the Contractor does not cover because of moral or religious objections and how Participants can obtain information from the Department about how to access these services.
18. The right to file a Complaint or Grievance and request a Fair Hearing, the methods for filing a Complaint or Grievance or requesting a Fair Hearing, the time frame for requesting a Fair Hearing after a Complaint or Grievance has been decided, the availability of assistance with filing a Complaint or Grievance or requesting a Fair Hearing, the ability to continue to receive requested services if the Participant files a Complaint or Grievance within ten (10) days from the mail date on the written notice to terminate or reduce currently Authorized Services or requests a Fair Hearing within ten (10) days from the mail date on the written notice of a Complaint or Grievance decision concerning the termination or reduction of currently Authorized Services.
19. How to file a discrimination complaint with the Office of Civil Rights of the Department of Health and Human Services.
20. The transition of care policy, including how the Supports Coordinator will assist the Participant with coordinating services and supports.
21. The taglines listed in Attachment V must be in a font size that is conspicuously visible.
22. Any additional content required by the Department.
D. The Contractor must inform each Participant verbally and in the Participant Handbook of the following rights and responsibilities, at a minimum:
1. The Contractor's responsibility to respond to any questions or concerns the Participant has about the care rendered and to routinely check with the Participant about his or her satisfaction with the services being rendered.
2. The Contractor's responsibility to render services according to acceptable standards of care.
3. The Contractor's responsibility to provide care according to the ISP.
4. The Contractor's responsibility to notify the Participant in writing of any action taken which affects the status of the Participant's services.
5. The Contractor's responsibility to provide information on request regarding the structure and operation of the Plan.
6. The Participant's responsibility to treat employees of the Contractor and Providers with respect and to communicate problems immediately to the appropriate Contractor staff.
7. The Participant’s responsibility to notify the appropriate Contractor’s staff and Providers whenever the Participant is unable to keep an appointment.
8. The Participant's responsibility to pay for room and board if the Participant is receiving Residential Habilitation Services.
9. The Participant's responsibility to obtain a referral for services when required.
10. The Participant's right to be treated with respect and with due consideration for his or her dignity and privacy.
11. The Participant's right to receive all materials in a language, manner, and format that is easily understood.
12. The Participant's right to written information in the prevalent non-English languages of the Service Area and in an appropriate alternative format or manner that takes into consideration the special needs of Participants who, for example, are visually limited or have limited reading proficiency.
13. The Participant's right to free oral interpretation services in any language, written translation in prevalent non-English languages, Auxiliary Aids and Services upon request, and written materials in font that is no smaller than eighteen (18) point.
14. The Participant's right to file a Complaint or Grievance, the requirements and time frames for filing a Complaint or Grievance as specified in Appendix G, the availability of assistance in the filing process, the toll-free numbers that the Participant can use to file a Complaint or Grievance, and the ability to continue to receive requested services if the Participant files a Complaint or Grievance within ten (10) days of the notice to terminate or reduce currently Authorized Services.
15. The Participant's right to request a Fair Hearing, the methods for obtaining a Fair Hearing, the time frame for requesting a Fair Hearing after a Complaint or Grievance has been decided, the rules that govern representation at Fair Hearings, the ability to continue to receive requested services if the Participant files a request for a Fair Hearing within ten (10) days from the mail date on the written notice of a Complaint or Grievance decision to terminate or reduce currently Authorized Services.
16. The Participant's right to receive information on available treatment options and alternatives presented in a manner appropriate to the Participant's condition and ability to understand.
17. The Participant's right to participate in decisions regarding his or her health care, including the right to refuse treatment.
18. The Participant's right to be free from any form of Restraint used as a means of coercion, discipline, convenience or retaliation as specified in federal regulations on the use of Restraints and Seclusion.
19. The Participant's right to be free from Seclusion, Chemical Restraint, Mechanical Restraint, and Aversive Conditioning at any time and from Physical Restraint unless required by an emergency.
20. The Participant's right to request and receive copies of his or her medical records, and request that they be amended or corrected, as specified in 45 CFR §§ 164.524 and 164.526.
21. The Contractor’s responsibility to provide information on request regarding the Adult Protective Services Act, 35 P.S. §§ 10210.101 – 10210.704, and the Older Adults Protective Services Act, 35 P.S. §§ 10225.101 – 10225.5102.
22. The Participant’s right to be protected from Abuse, neglect, exploitation, and abandonment pursuant to the Adult Protective Services Act, 35 P.S. §§ 10210.101 – 10210.704, and the Older Adults Protective Services Act, 35 P.S. §§ 10225.101 – 10225.5102, as well as resources for Participants and how to report information required to be reported by the Acts.
23. The Participant's right to be free from discrimination on the basis of race, color, national origin, sex, age, or disability.
24. The Participant’s right to free exercise of the Participant’s rights and that the exercise of those rights may not adversely affect the way the Contractor or Network Provider treat the Participant.
25. Any additional rights and responsibilities identified in the Participant Handbook.
E. Prior to enrollment, the Contractor shall:
1. Review the Participant Handbook and the Enrollment Agreement with each Participant or the Participant's representative, as appropriate;
2. Provide each Participant or the Participant's representative, as appropriate, with a copy of the Participant Handbook;
3. Obtain the signature of the Participant or the Participant's representative, as appropriate, on the Enrollment Agreement, which includes a statement that the Participant or, if appropriate, the Participant’s representative, received the Participant Handbook and the Participant Handbook was reviewed with the Participant or, if appropriate, the Participant’s representative;
4. Provide each Participant or the Participant's representative, as appropriate, with a copy of the signed Enrollment Agreement;
5. Provide the Participant or the Participant’s representative, as appropriate, with the contact information for the Participant’s Supports Coordinator.
F. The Contractor must provide written notice to Participants of any change in the Participant Handbook or Enrollment Agreement, policies, or any other significant change as determined by the Department to the delivery of Covered Services provided under the Plan, at least thirty (30) days before the intended effective date of change. The change must be approved by the Department prior to providing notification to the Participants.
G. The Contractor must inform Participants annually that they may obtain the information contained in the Participant Handbook upon request.
Appears in 1 contract
Participant Handbook and Enrollment Agreement. A. The Contractor shall use the Participant Handbook specified by the Department and Enrollment Agreement template specified by the Department.
B. The Contractor must give the Participant a copy of the Participant Handbook prior to within a reasonable time after the Participant enrolling enrolls in the Plan and annually thereafterACAP.
C. The Participant Handbook must include, at a minimum, the following:
1. A description of all Capitated Services provided through the Plan, in sufficient detail to enable the Participant or the Participant's representative, if appropriate, to understand the benefits available under the Plan.
2. The amount, duration, and scope of benefits available under the Plan in sufficient detail to enable the Participant or the Participant’s representative, if appropriate, to understand the benefits to which the Participant is entitled.
3. An explanation of the circumstances under which the Contractor is responsible for Post-Stabilization Care Services.
4. An explanation of the procedure for obtaining Capitated Services, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the Participant’s PCP.
5. Information on the Participant's right to choose his or her PCP and other Providers to the extent possible and appropriate, including information on any restrictions on the Participant's freedom of choice among Network Providers and the process for selecting and changing the Participant’s PCP.
6. Locations, telephone numbers, and procedures for obtaining health services in the event of a crisis.
7. Participant rights and responsibilities, as defined in this Section.
8. The disenrollment procedures, as described in Section 4.6 4.5 of this Agreement.
9. Information concerning transportation arrangements offered by the Contractor.
10. The extent to which and how Participants may obtain benefits, including family planning services and supplies from Outnon-of- Network Providers. This must include that the Contractor cannot require a Participant to obtain a referral before choosing a family planning provider.
11. How and where to access any benefits, including family planning services, that are available under the Medical Assistance Program but are not covered under this Agreement, including any cost sharing and how transportation is provided.
12. The extent to which, and how, after-hours and emergency coverage are provided, including:
a. What constitutes an Emergency Medical Condition and Emergency Services.
b. That prior authorization is not required for Emergency Services.
c. That if the Participant has an Emergency Medical Condition, the Participant has a right to use any hospital or other setting for emergency care.
d. When emergency behavioral consultation and support is warranted.
13. Information on how to report suspected Fraud and Abuse.
14. Information about how to exercise an Advance Directive advance directive in accordance with 42 CFR § 438.3(j).
15. Information about how to access Auxiliary Aids and Services, including additional information in alternative formats or languages.
16. The toll-free number for member services, medical management, and any other unit providing services directly to Participants.
17. The counseling or referral services the Contractor does not cover because of moral or religious objections and how Participants can obtain information from the Department about how to access these services.
18. The right to file a Complaint or Grievance and request a Fair Hearing, the methods for filing a Complaint or Grievance or requesting a Fair Hearing, the time frame for requesting a Fair Hearing after a Complaint or Grievance has been decided, the availability of assistance with filing a Complaint or Grievance or requesting a Fair Hearing, the ability to continue to receive requested services if the Participant files a Complaint or Grievance within ten (10) days from the mail date on the written notice to terminate or reduce currently Authorized Services or requests a Fair Hearing within ten (10) days from the mail date on the written notice of a Complaint or Grievance decision concerning the termination or reduction of currently Authorized Services.
19. How to file a discrimination complaint with the Office of Civil Rights of the Department of Health and Human Services.
20. The transition of care policy, including how the Supports Coordinator will assist the Participant with coordinating services and supports.
21. The taglines listed in Attachment V must be in a font size that is conspicuously visible.
2221. Any additional content required by the Department.
D. The Contractor must inform each Participant verbally and in the Participant Handbook of the following rights and responsibilities, at a minimum:
1. The Contractor's responsibility to respond to any questions or concerns the Participant has about the care rendered and to routinely check with the Participant about his or her satisfaction with the services being rendered.
2. The Contractor's responsibility to render services according to acceptable standards of care.
3. The Contractor's responsibility to provide care according to the ISP.
4. The Contractor's responsibility to notify the Participant in writing of any action taken which affects the status of the Participant's services.
5. The Contractor's responsibility to provide information on request regarding the structure and operation of the Plan.
6. The Participant's responsibility to treat employees of the Contractor and Providers with respect and to communicate problems immediately to the appropriate Contractor staff.
7. The Participant’s responsibility to notify the appropriate Contractor’s staff and Providers whenever the Participant is unable to keep an appointment.
8. The Participant's responsibility to pay for room and board if the Participant is receiving Residential Habilitation Services.
9. The Participant's responsibility to obtain a referral for services when required.
10. The Participant's right to be treated with respect and with due consideration for his or her dignity and privacy.
11. The Participant's right to receive all materials in a language, manner, and format that is easily understood.,
12. The Participant's right to written information in the prevalent non-English languages of the Service Area and in an appropriate alternative format or manner that takes into consideration the special needs of Participants who, for example, are visually limited or have limited reading proficiency.
13. The Participant's right to free oral interpretation services in any language, written translation in prevalent non-English languages, Auxiliary Aids and Services upon request, and written materials in font that is no smaller than eighteen (18) point.
14. The Participant's right to file a Complaint or Grievance, the requirements and time frames for filing a Complaint or Grievance as specified in Appendix G, the availability of assistance in the filing process, the toll-free numbers that the Participant can use to file a Complaint or Grievance, and the ability to continue to receive requested services if the Participant files a Complaint or Grievance within ten (10) days of the notice to terminate or reduce currently Authorized Services.
15. The Participant's right to request a Fair Hearing, the methods for obtaining a Fair Hearing, the time frame for requesting a Fair Hearing after a Complaint or Grievance has been decided, the rules that govern representation at Fair Hearings, the ability to continue to receive requested services if the Participant files a request for a Fair Hearing within ten (10) days from the mail date on the written notice of a Complaint or Grievance decision to terminate or reduce currently Authorized Services.
16. The Participant's right to receive information on available treatment options and alternatives presented in a manner appropriate to the Participant's condition and ability to understand.
17. The Participant's right to participate in decisions regarding his or her health care, including the right to refuse treatment.
18. The Participant's right to be free from any form of Restraint used as a means of coercion, discipline, convenience or retaliation as specified in federal regulations on the use of Restraints and Seclusion.
19. The Participant's right to be free from Seclusion, Chemical Restraint, Mechanical Restraint, and Aversive Conditioning at any time and from Physical Restraint unless required by an emergency.
20. The Participant's right to request and receive copies of his or her medical records, and request that they be amended or corrected, as specified in 45 CFR §§ 164.524 and 164.526.
21. The Contractor’s responsibility to provide information on request regarding the Adult Protective Services Act, 35 P.S. §§ 10210.101 – 10210.704704, and the Older Adults Adult Protective Services Act, 35 P.S. §§ 10225.101 – 10225.5102-10225.5102.
22. The Participant’s right to be protected from Abuseabuse, neglect, and exploitation, and abandonment pursuant to the Adult Protective Services Act, 35 P.S. §§ 10210.101 – 10210.704704, and the Older Adults Protective Services Act, 35 P.S. §§ 10225.101 – - 10225.5102, as well as resources for Participants and how to report information required to be reported by the Acts.
23. The Participant's right to be free from discrimination on the basis of race, color, national origin, sex, age, or disability.
24. The Participant’s right to free exercise of the Participant’s rights and that the exercise of those rights may not adversely affect the way the Contractor or Network Provider treat the Participant.
25. Any additional rights and responsibilities identified in the Participant Handbook.
E. Prior to enrollment, the Contractor shall:
1. Review the Participant Handbook and the Enrollment Agreement with each Participant or the Participant's representative, as appropriate;
2. Provide each Participant or the Participant's representative, as appropriate, with a copy of the Participant HandbookHandbook and the Enrollment Agreement;
3. Obtain the signature of the Participant or the Participant's representative, as appropriate, on the Enrollment Agreement, which includes Agreement and on a written statement that the Participant or, if appropriate, the Participant’s representative, received verifying review and receipt of the Participant Handbook and give the Participant Handbook was reviewed with the Participant or, if appropriate, the Participant’s representative;
4. Provide each Participant or the Participant's representative, as appropriate, with a copy of the Enrollment Agreement and of the signed Enrollment Agreement;statement verifying review and receipt of the Participant Handbook.
54. Provide the Participant or the Participant’s representative, as appropriate, with the contact information for the Participant’s Supports Coordinator.
F. The Contractor must provide written notice to Participants of any change in the Participant Handbook or Enrollment Agreement, policies, or any other significant change as determined by the Department to the delivery of Covered Services provided under the Plan, at least thirty (30) days before the intended effective date of change. The change must be approved by the Department prior to providing notification to the Participants.
G. The Contractor must inform Participants annually that they may obtain the information contained in the Participant Handbook upon request.
Appears in 1 contract
Participant Handbook and Enrollment Agreement. A. The Contractor shall use the Participant Handbook specified by the Department and Enrollment Agreement template specified by the Department.
B. The Contractor must give the Participant a copy of the Participant Handbook prior to the Participant enrolling in the Plan and annually thereafter.
C. The Participant Handbook must include, at a minimum, the following:
1. A description of all Capitated Services provided through the Plan, in sufficient detail to enable the Participant or the Participant's representative, if appropriate, to understand the benefits available under the Plan.
2. The amount, duration, and scope of benefits available under the Plan in sufficient detail to enable the Participant or the Participant’s representative, if appropriate, to understand the benefits to which the Participant is entitled.
3. An explanation of the circumstances under which the Contractor is responsible for Post-Stabilization Care Services.
4. An explanation of the procedure for obtaining Capitated Services, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the Participant’s PCP.
5. Information on the Participant's right to choose his or her PCP and other Providers to the extent possible and appropriate, including information on any restrictions on the Participant's freedom of choice among Network Providers and the process for selecting and changing the Participant’s PCP.
6. Locations, telephone numbers, and procedures for obtaining health services in the event of a crisis.
7. Participant rights and responsibilities, as defined in this Section.
8. The disenrollment procedures, as described in Section 4.6 of this Agreement.
9. Information concerning transportation arrangements offered by the Contractor.
10. The extent to which and how Participants may obtain benefits, including family planning services and supplies from Out-of- non- Network Providers. This must include that the Contractor cannot require a Participant to obtain a referral before choosing a family planning provider.
11. How and where to access any benefits, including family planning services, that are available under the Medical Assistance Program but are not covered under this Agreement, including any cost sharing and how transportation is provided.
12. The extent to which, and how, after-hours and emergency coverage are provided, including:
a. What constitutes an Emergency Medical Condition and Emergency Services.
b. That prior authorization is not required for Emergency Services.
c. That if the Participant has an Emergency Medical Condition, the Participant has a right to use any hospital or other setting for emergency care.
d. When emergency behavioral consultation and support is warranted.
13. Information on how to report suspected Fraud and Abuse.
14. Information about how to exercise an Advance Directive advance directive in accordance with 42 CFR § 438.3(j).
15. Information about how to access Auxiliary Aids and Services, including additional information in alternative formats or languages.
16. The toll-free number for member services, medical management, and any other unit providing services directly to Participants.
17. The counseling or referral services the Contractor does not cover because of moral or religious objections and how Participants can obtain information from the Department about how to access these services.
18. The right to file a Complaint or Grievance and request a Fair Hearing, the methods for filing a Complaint or Grievance or requesting a Fair Hearing, the time frame for requesting a Fair Hearing after a Complaint or Grievance has been decided, the availability of assistance with filing a Complaint or Grievance or requesting a Fair Hearing, the ability to continue to receive requested services if the Participant files a Complaint or Grievance within ten (10) days from the mail date on the written notice to terminate or reduce currently Authorized Services or requests a Fair Hearing within ten (10) days from the mail date on the written notice of a Complaint or Grievance decision concerning the termination or reduction of currently Authorized Services.
19. How to file a discrimination complaint with the Office of Civil Rights of the Department of Health and Human Services.
20. The transition of care policy, including how the Supports Coordinator will assist the Participant with coordinating services and supports.
21. The taglines listed in Attachment V must be in a font size that is conspicuously visible.
22. Any additional content required by the Department.
D. The Contractor must inform each Participant verbally and in the Participant Handbook of the following rights and responsibilities, at a minimum:
1. The Contractor's responsibility to respond to any questions or concerns the Participant has about the care rendered and to routinely check with the Participant about his or her satisfaction with the services being rendered.
2. The Contractor's responsibility to render services according to acceptable standards of care.
3. The Contractor's responsibility to provide care according to the ISP.
4. The Contractor's responsibility to notify the Participant in writing of any action taken which affects the status of the Participant's services.
5. The Contractor's responsibility to provide information on request regarding the structure and operation of the Plan.
6. The Participant's responsibility to treat employees of the Contractor and Providers with respect and to communicate problems immediately to the appropriate Contractor staff.
7. The Participant’s responsibility to notify the appropriate Contractor’s staff and Providers whenever the Participant is unable to keep an appointment.
8. The Participant's responsibility to pay for room and board if the Participant is receiving Residential Habilitation Services.
9. The Participant's responsibility to obtain a referral for services when required.
10. The Participant's right to be treated with respect and with due consideration for his or her dignity and privacy.
11. The Participant's right to receive all materials in a language, manner, and format that is easily understood.
12. The Participant's right to written information in the prevalent non-English languages of the Service Area and in an appropriate alternative format or manner that takes into consideration the special needs of Participants who, for example, are visually limited or have limited reading proficiency.
13. The Participant's right to free oral interpretation services in any language, written translation in prevalent non-English languages, Auxiliary Aids and Services upon request, and written materials in font that is no smaller than eighteen (18) point.
14. The Participant's right to file a Complaint or Grievance, the requirements and time frames for filing a Complaint or Grievance as specified in Appendix G, the availability of assistance in the filing process, the toll-free numbers that the Participant can use to file a Complaint or Grievance, and the ability to continue to receive requested services if the Participant files a Complaint or Grievance within ten (10) days of the notice to terminate or reduce currently Authorized Services.
15. The Participant's right to request a Fair Hearing, the methods for obtaining a Fair Hearing, the time frame for requesting a Fair Hearing after a Complaint or Grievance has been decided, the rules that govern representation at Fair Hearings, the ability to continue to receive requested services if the Participant files a request for a Fair Hearing within ten (10) days from the mail date on the written notice of a Complaint or Grievance decision to terminate or reduce currently Authorized Services.
16. The Participant's right to receive information on available treatment options and alternatives presented in a manner appropriate to the Participant's condition and ability to understand.
17. The Participant's right to participate in decisions regarding his or her health care, including the right to refuse treatment.
18. The Participant's right to be free from any form of Restraint used as a means of coercion, discipline, convenience or retaliation as specified in federal regulations on the use of Restraints and Seclusion.
19. The Participant's right to be free from Seclusion, Chemical Restraint, Mechanical Restraint, and Aversive Conditioning at any time and from Physical Restraint unless required by an emergency.
20. The Participant's right to request and receive copies of his or her medical records, and request that they be amended or corrected, as specified in 45 CFR §§ 164.524 and 164.526.
21. The Contractor’s responsibility to provide information on request regarding the Adult Protective Services Act, 35 P.S. §§ 10210.101 – 10210.704704, and the Older Adults Adult Protective Services Act, 35 P.S. §§ 10225.101 – 10225.5102-10225.5102.
22. The Participant’s right to be protected from Abuseabuse, neglect, and exploitation, and abandonment pursuant to the Adult Protective Services Act, 35 P.S. §§ 10210.101 – 10210.704704, and the Older Adults Protective Services Act, 35 P.S. §§ 10225.101 – 10225.5102, as well as resources for Participants and how to report information required to be reported by the Acts.
23. The Participant's right to be free from discrimination on the basis of race, color, national origin, sex, age, or disability.
24. The Participant’s right to free exercise of the Participant’s rights and that the exercise of those rights may not adversely affect the way the Contractor or Network Provider treat the Participant.
25. Any additional rights and responsibilities identified in the Participant Handbook.
E. Prior to enrollment, the Contractor shall:
1. Review the Participant Handbook and the Enrollment Agreement with each Participant or the Participant's representative, as appropriate;
2. Provide each Participant or the Participant's representative, as appropriate, with a copy of the Participant Handbook;
3. Obtain the signature of the Participant or the Participant's representative, as appropriate, on the Enrollment Agreement, which includes a statement that the Participant or, if appropriate, the Participant’s representative, received the Participant Handbook and the Participant Handbook was reviewed with the Participant or, if appropriate, the Participant’s representative;
4. Provide each Participant or the Participant's representative, as appropriate, with a copy of the signed Enrollment Agreement;
5. Provide the Participant or the Participant’s representative, as appropriate, with the contact information for the Participant’s Supports Coordinator.
F. The Contractor must provide written notice to Participants of any change in the Participant Handbook or Enrollment Agreement, policies, or any other significant change as determined by the Department to the delivery of Covered Services provided under the Plan, at least thirty (30) days before the intended effective date of change. The change must be approved by the Department prior to providing notification to the Participants.
G. The Contractor must inform Participants annually that they may obtain the information contained in the Participant Handbook upon request.
Appears in 1 contract
Participant Handbook and Enrollment Agreement. A. The Contractor shall use the Participant Handbook specified by the Department and Enrollment Agreement template specified by the Department.
B. The Contractor must give the Participant a copy of the Participant Handbook prior to within a reasonable time after the Participant enrolling enrolls in the Plan and annually thereafterACAP.
C. The Participant Handbook must include, at a minimum, the following:
1. A description of all Capitated Services provided through the Plan, in sufficient detail to enable the Participant or the Participant's representative, if appropriate, to understand the benefits available under the Plan.
2. The amount, duration, and scope of benefits available under the Plan in sufficient detail to enable the Participant or the Participant’s representative, if appropriate, to understand the benefits to which the Participant is entitled.the
3. An explanation of the circumstances under which the Contractor is responsible for Post-Stabilization Care Services.
4. An explanation of the procedure for obtaining Capitated Services, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the Participant’s PCP.
5. Information on the Participant's right to choose his or her PCP and other Providers to the extent possible and appropriate, including information on any restrictions on the Participant's freedom of choice among Network Providers and the process for selecting and changing the Participant’s PCP.
6. Locations, telephone numbers, and procedures for obtaining health services in the event of a crisis.
7. Participant rights and responsibilities, as defined in this Section.
8. The disenrollment procedures, as described in Section 4.6 4.5 of this Agreement.
9. Information concerning transportation arrangements offered by the Contractor.
10. The extent to which and how Participants may obtain benefits, including family planning services and supplies from OutNon-of- Network Providers. This must include that the Contractor cannot require a Participant to obtain a referral before choosing a family planning provider.
11. How and where to access any benefits, including family planning services, that are available under the Medical Assistance Program but are not covered under this Agreement, including any cost sharing and how transportation is provided.
12. The extent to which, and how, after-hours and emergency coverage are provided, including:
a. What constitutes an Emergency Medical Condition and Emergency Services.
b. That prior authorization is not required for Emergency Services.
c. That if the Participant has an Emergency Medical Condition, the Participant has a right to use any hospital or other setting for emergency care.
d. When emergency behavioral consultation and support is warranted.
13. Information on how to report suspected Fraud and Abuse.
14. Information about how to exercise an Advance Directive advance directive in accordance with 42 CFR § 438.3(j).
15. Information about how to access Auxiliary Aids and Services, including additional information in alternative formats or languages.
16. The toll-free number for member services, medical management, and any other unit providing services directly to Participants.
17. The counseling or referral services the Contractor does not cover because of moral or religious objections and how Participants can obtain information from the Department about how to access these services.
18. The right to file a Complaint or Grievance and request a Fair Hearing, the methods for filing a Complaint or Grievance or requesting a Fair Hearing, the time frame for requesting a Fair Hearing after a Complaint or Grievance has been decided, the availability of assistance with filing a Complaint or Grievance or requesting a Fair Hearing, the ability to continue to receive requested services if the Participant files a Complaint or Grievance within ten (10) days from the mail date on the written notice to terminate or reduce currently Authorized Services or requests a Fair Hearing within ten (10) days from the mail date on the written notice of a Complaint or Grievance decision concerning the termination or reduction of currently Authorized Services.
19. How to file a discrimination complaint with the Office of Civil Rights of the Department of Health and Human Services.
20. The transition of care policy, including how the Supports Coordinator will assist the Participant with coordinating services and supports.
21. The taglines listed in Attachment V must be in a font size that is conspicuously visible.
2221. Any additional content required by the Department.
D. The Contractor must inform each Participant verbally and in the Participant Handbook of the following rights and responsibilities, at a minimum:
1. The Contractor's responsibility to respond to any questions or concerns the Participant has about the care rendered and to routinely check with the Participant about his or her satisfaction with the services being rendered.
2. The Contractor's responsibility to render services according to acceptable standards of care.
3. The Contractor's responsibility to provide care according to the ISP.
4. The Contractor's responsibility to notify the Participant in writing of any action taken which affects the status of the Participant's services.
5. The Contractor's responsibility to provide information on request regarding the structure and operation of the Plan.
6. The Participant's responsibility to treat employees of the Contractor and Providers with respect and to communicate problems immediately to the appropriate Contractor staff.
7. The Participant’s responsibility to notify the appropriate Contractor’s staff and Providers whenever the Participant is unable to keep an appointment.
8. The Participant's responsibility to pay for room and board Participant Liability, if the Participant is receiving Residential Habilitation Servicessuch liability exists.
9. The Participant's responsibility to obtain a referral for services when required.
10. The Participant's right to be treated with respect and with due consideration for his or her dignity and privacy.
11. The Participant's right to receive all materials in a language, manner, and format that is easily understood.
12. The Participant's right to written information in the prevalent non-English languages of the Service Area and in an appropriate alternative format or manner that takes into consideration the special needs of Participants who, for example, are visually limited or have limited reading proficiency.
13. The Participant's right to free oral interpretation services in any language, written translation in prevalent non-English languages, Auxiliary Aids and Services upon request, and written materials in font that is no smaller than eighteen (18) point.
14. The Participant's right to file a Complaint or Grievance, the requirements and time frames for filing a Complaint or Grievance as specified in Appendix G, the availability of assistance in the filing process, the toll-free numbers that the Participant can use to file a Complaint or Grievance, and the ability to continue to receive requested services if the Participant files a Complaint or Grievance within ten (10) days of the notice to terminate or reduce currently Authorized Services.
15. The Participant's right to request a Fair Hearing, the methods for obtaining a Fair Hearing, the time frame for requesting a Fair Hearing after a Complaint or Grievance has been decided, the rules that govern representation at Fair Hearings, the ability to continue to receive requested services if the Participant files a request for a Fair Hearing within ten (10) days from the mail date on the written notice of a Complaint or Grievance decision to terminate or reduce currently Authorized Services.
16. The Participant's right to receive information on available treatment options and alternatives presented in a manner appropriate to the Participant's condition and ability to understand.
17. The Participant's right to participate in decisions regarding his or her health care, including the right to refuse treatment.
18. The Participant's right to be free from any form of Restraint used as a means of coercion, discipline, convenience or retaliation as specified in federal regulations on the use of Restraints and Seclusion.
19. The Participant's right to be free from Seclusion, Chemical Restraint, Mechanical Restraint, and Aversive Conditioning at any time and from Physical Restraint unless required by an emergency.
20. The Participant's right to request and receive copies of his or her medical records, and request that they be amended or corrected, as specified in 45 CFR §§ 164.524 and 164.526.
21. The Contractor’s responsibility to provide information on request regarding the Adult Protective Services Act, 35 P.S. §§ 10210.101 – 10210.704704, and the Older Adults Adult Protective Services Act, 35 P.S. §§ 10225.101 – 10225.5102-10225.5102.
22. The Participant’s right to be protected from Abuseabuse, neglect, and exploitation, and abandonment pursuant to the Adult Protective Services Act, 35 P.S. §§ 10210.101 – 10210.704704, and the Older Adults Protective Services Act, 35 P.S. §§ 10225.101 – - 10225.5102, as well as resources for Participants and how to report information required to be reported by the Acts.
23. The Participant's right to be free from discrimination on the basis of race, color, national origin, sex, age, or disability.
24. The Participant’s right to free exercise of the Participant’s rights and that the exercise of those rights may not adversely affect the way the Contractor or Network Provider treat the Participant.
25. Any additional rights and responsibilities identified in the Participant Handbook.
E. Prior to enrollment, the Contractor shall:
1. Review the Participant Handbook and the Enrollment Agreement with each Participant or the Participant's representative, as appropriate;
2. Provide each Participant or the Participant's representative, as appropriate, with a copy of the Participant HandbookHandbook and the Enrollment Agreement;
3. Obtain the signature of the Participant or the Participant's representative, as appropriate, on the Enrollment Agreement, which includes Agreement and on a written statement that the Participant or, if appropriate, the Participant’s representative, received verifying review and receipt of the Participant Handbook and give the Participant Handbook was reviewed with the Participant or, if appropriate, the Participant’s representative;
4. Provide each Participant or the Participant's representative, as appropriate, with a copy of the Enrollment Agreement and of the signed Enrollment Agreement;statement verifying review and receipt of the Participant Handbook.
54. Provide the Participant or the Participant’s representative, as appropriate, with the contact information for the Participant’s Supports Coordinator.
F. The Contractor must provide written notice to Participants of any change in the Participant Handbook or Enrollment Agreement, policies, or any other significant change as determined by the Department to the delivery of Covered Services provided under the Plan, at least thirty (30) days before the intended effective date of change. The change must be approved by the Department prior to providing notification to the Participants.
G. The Contractor must inform Participants annually that they may obtain the information contained in the Participant Handbook upon request.’s
Appears in 1 contract
