Policies and Procedures for Core Functions. The Contractor shall develop, maintain, and provide to EOHHS upon request, policies and procedures for all core functions necessary to effectively and efficiently manage the MassHealth population and meet the requirements outlined in this Contract. All policies and procedures requiring EOHHS approval shall be documented and shall include the dates of approval by EOHHS. These policies and procedures shall include, but are not limited to, the following topics: a. Response to violations of Enrollees’ privacy rights by staff, Providers or subcontractors; b. Non-discrimination of MassHealth Enrollees; c. Non-restriction of Providers advising or advocating on an Enrollee’s behalf; d. Appeal rights for certain minors who under the law may consent to medical procedures without parental consent; e. Enrollee cooperation with those providing health care services; f. Marketing activities that apply to the Plan, Providers and subcontractors as well as the Contractor’s procedures for monitoring these activities; g. Cost-sharing by Enrollees; h. Advance directives; i. Assisting Enrollees in understanding their benefits and how to access them; j. Access and availability standards; k. Enrollees’ right to be free from restraint or seclusion used as a means of coercion or retaliation; l. The provision of Culturally and Linguistically Appropriate Services; m. Practice guidelines in quality measurement and improvement activities;
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Samples: Masshealth Managed Care Organization Contract, Accountable Care Partnership Plan Contract, Contract
Policies and Procedures for Core Functions. The Contractor shall develop, maintain, and provide to EOHHS upon request, policies and procedures for all core functions necessary to effectively and efficiently manage the MassHealth population effectively and efficiently and meet the requirements outlined in this Contract. All policies and procedures requiring EOHHS approval shall be documented and shall include the dates of approval by EOHHS. These policies and procedures shall include, but are not limited to, the following topics:
a. Response to violations of Enrollees’ privacy rights by staff, Providers staff or subcontractorsSubcontractors;
b. Non-discrimination of MassHealth Enrollees;
c. Non-restriction of Providers advising or advocating on an Enrollee’s behalf;
d. Appeal rights for certain minors who under the law may consent to medical procedures without parental consent;
e. Enrollee cooperation with those providing health care services;
f. d. Marketing activities that apply to the Plan, Providers and subcontractors as well as the Contractor’s procedures for monitoring these activities;
g. Cost-sharing by Enrolleese. Advance Directives;
h. Advance directives;
i. f. Assisting Enrollees in understanding their benefits and how to access them;
j. Access and availability standards;
k. g. Enrollees’ right to be free from restraint or seclusion used as a means of coercion or retaliation;
l. h. The provision of Culturally and Linguistically Appropriate Services; m. ;
i. Practice guidelines in quality measurement and improvement activities;
j. Handling of complaints/Grievances sent directly to EOHHS;
k. Process used to monitor PCP and Subcontractor implementation of amendments and improvements;
l. Retention of medical records;
m. Engagement and coordination with BH CPs and LTSS CPs, as described in Section 2.4.E;
n. Care Management;
o. Public health emergencies; and p. Risk stratification;
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Policies and Procedures for Core Functions. The Contractor shall develop, maintain, and provide to EOHHS upon request, request policies and procedures for all core functions necessary to effectively and efficiently manage the MassHealth population and meet the requirements outlined in this Contract. All policies and procedures requiring EOHHS approval shall be documented and shall include the dates of approval by EOHHS. These policies and procedures shall include, but are not limited to, the following topicsfollowing:
a. Response to violations of EnrolleesCovered Individuals’ privacy rights by staff, Providers Providers, or subcontractorsSubcontractors;
b. Non-discrimination of MassHealth EnrolleesCovered Individuals;
c. Non-restriction of Providers advising or advocating on an Enrolleea Covered Individual’s behalf;
d. Appeal rights for certain minors who under the law may consent to medical procedures without parental consent;
e. Enrollee Covered Individual’s cooperation with those providing health care services;
f. Marketing activities that apply to the PlanBH Contractor, Providers Providers, and subcontractors Subcontractors, as well as the Contractor’s procedures for monitoring these activities;
g. Cost-sharing by EnrolleesCovered Individuals;
h. Advance directives;
i. Assisting Enrollees Covered Individuals in understanding their benefits and how to access them;
j. Access and availability standards;
k. Enrollees’ Covered Individual's right to be free from restraint or seclusion used as a means of coercion or retaliation;
l. The provision of Culturally and Linguistically Appropriate Services; ;
m. Practice guidelines in quality measurement and improvement activities;
n. Compliance with Emergency Services and Post-stabilization Care Services requirements as identified in 42 C.F.R. 438.114(b);
o. Procedures for tracking Appeals when Covered Individuals become aware of the Adverse Action, in the event that no notice had been sent;
p. Handling of Complaints/Grievances;
q. Process used to monitor Subcontractor performance;
r. Claims processing;
s. Engagement and coordination with PCACOs, BH CPs, and other state agencies; and
t. Retention of medical records.
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