Required Information. The New member packet will be written at no higher than a sixth-grade level and contain at least the following: • Information on how to obtain a member handbook and Provider Directory • Information on how to obtain covered benefits, out of plan benefits and non-covered benefits • Information on how to contact member services, including information on behavioral health and the hours of operation • Information on Current Care and its benefits • What to do in case of an emergency • To the extent available, quality and performance indicators, including enrollee satisfaction The member handbook will be written at no higher than a sixth-grade level and contain at least the following: • Information on member services. • Information on how to choose a PCP. Each member may choose his or her PCP to the extent possible and appropriate. • Information on what to do when family size changes. • Information on obtaining transportation • Information on Interpreter and Translation Services • Any restrictions on the member’s freedom of choice among network providers. • Information that enrollment Medicaid Managed Care does not restrict the choice of the provider from whom the member may receive family planning services and supplies. • Information on member’s right to change PCP. • Information on amount, duration, and scope of Covered Services, including how to access Covered Services including behavioral health and long-term services and supports. This information must include sufficient detail to ensure that the member understands the benefits to which they are entitled. • Procedures for obtaining benefits, including authorization requirements. • Right to a second opinion. • Members may obtain benefits, including family planning services, from out-of-network providers. • The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition, emergency services, and Post-Stabilization Care Services, with references to the definitions in 42 CFR 438.114(a)v. o The fact that prior authorization is not required for Emergency Services. o The process and procedures for obtaining Emergency Services, including use of the 911-telephone system or its local equivalent. o The locations of any Emergency Services and Post-Stabilization Care Services covered under the Agreement. o The fact that, subject to the provisions of this section, the member has a right to use any hospital or other setting for emergency care. • Information on the post-stabilization care services rules set forth in 42 CFR 422.113vi. • Policy on referrals for specialty care and other benefits not furnished by the member’s Primary Care Provider. • Information on Advance Directives as set forth in 42 C.F.R. §438.3(j)and 42 CFR 422.128vii. The Contractor agrees to reflect any changes in State law with regards to Advance directives in its written material within ninety (90) days of the effective date of the change as set forth in 42 C.F.R. §438.3(j)(4). • Information on out-of-plan or out-of-network benefits • Information on member’s rights and responsibilities, including, in conformance with State and Federal law, the rights of mothers and newborns with respect to the duration of hospital stays. • Information on member’s rights and protections, as specified in 42 CFR 438.100viii. • Information on formal grievance, appeal and fair hearing procedures, and the information specified in 42 C.F.R. §438.3(g)(2)(xi) • Information that a member may request disenrollment at any time from the Health Plan • Information on cost-sharing responsibilities (if applicable; may be included as an insert) • Information on non-covered services. How and where to access any benefits that are available under the State plan but are not covered under this Agreement, including any cost sharing, and how transportation is provided. • Information on member and provider fraud, waste and abuse o Provide examples of possible Medicaid fraud and abuse which might be undertaken by providers, vendors and enrollees o Inform enrollees about how to report suspected Medicaid fraud and abuse, including any dedicated toll-free number established by the Contractor for reporting possible fraud and abuse o Instruct enrollees about how to contact EOHHS’s Fraud Unit • Information on grievance, appeal and fair hearing procedures and timeframes, as provided in 42 CFR 438.400ix through 42 CFR 438.424x, in a State-developed or State approved description that must include the following: o The member’s right to a State Fair Hearing, how to obtain a hearing, and the right to representation at a hearing o The member’s right to file grievances and appeals and their requirements and timeframes for filing o The availability of assistance in the filing process o The toll-free numbers that the enrollee can use to file a grievance or an appeal by phone o The member’s right to request continuation of Covered Benefits during an appeal or State Fair Hearing within the timeframes specified for filing; and the member may be liable for the cost of any continued benefits while the appeal is pending, if the final decision is adverse to the enrollee (as defined in 42 CFR 438.420xi). o Information on other resources to assist members • Additional information that is available upon reasonable request, including the following: o Information on the structure and operation of the Contractor o Reports of transactions between the Contractor and parties of interest that are provided to the State, or other agencies. 1903(m)(4)(B). o Information on any physician incentive plans as set forth in 42 CFR 438.6i Also, to be included are the following required by the RI General Laws Title 27 – Insurance Chapter 27-18.8 Rhode Island Health Care Accessibility and Quality Assurance Act (may be included as an insert): • How does the Health Plan review and approve Covered Services? • What if I refuse referral to a participating provider? • Does the Health Plan require that I get a second opinion for any services? • How does the Health Plan make sure that my personal health information is protected and kept confidential? • How am I protected from discrimination? • If I refuse treatment, will it affect my future treatment? • How does the Health Plan pay providers? • If I am covered by two or more Health Plans, what do I do? The Contractor must have written policies regarding enrollee rights that cover: • Each enrollee is guaranteed the right to be treated with respect and with due consideration for his or her dignity and privacy. • Each enrollee is guaranteed the right to receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand. • Each enrollee is guaranteed the right to participate in decisions regarding his or her health care, including the right to refuse treatment. • Each enrollee is guaranteed the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. • Each enrollee is guaranteed the right to request and receive a copy of his or her medical records, and to request that they be amended or corrected, as specified in 45 CFR Part 164xii. The Contractor must provide members, in adherence with 42 C.F.R. §438.3(g)(4)with written notice of any significant changes in enrollee rights or information at least thirty (30) days before the intended effective date of the change. The Contractor will comply with requirements as specified in 42 CFR 438.10(i)(1) as follows: (i) When appropriate Contractor must make available in electronic or paper form, the following information about its formulary: (1) Which medications are covered (both generic and name brand). What tier each medication is on. Formulary drug lists must be made available on the Contractor’s Web site in a machine readable file and format as specified by EOHHS.

Appears in 4 contracts

Samples: Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement

Required Information. The New member packet will be written at no higher than a sixth-grade level and contain at least the following: • Information on how to obtain a member handbook and Provider Directory • Information on how to obtain covered benefits, out of plan benefits and non-covered benefits • Information on how to contact member services, including information on behavioral health and the hours of operation • Information on Current Care and its benefits • What to do in case of an emergency • To the extent available, quality and performance indicators, including enrollee satisfaction The member handbook will be written at no higher than a sixth-grade level and contain at least the following: • Information on member services. • Information on how to choose a PCP. Each member may choose his or her PCP to the extent possible and appropriate. • Information on what to do when family size changes. • Information on obtaining transportation • Information on Interpreter and Translation Services • Any restrictions on the member’s freedom of choice among network providers. • Information that enrollment Medicaid Managed Care does not restrict the choice of the provider from whom the member may receive family planning services and supplies. • Information on member’s right to change PCP. • Information on amount, duration, and scope of Covered Services, including how to access Covered Services including behavioral health and long-term services and supports. This information must include sufficient detail to ensure that the member understands the benefits to which they are entitled. • Procedures for obtaining benefits, including authorization requirements. • Right to a second opinion. • Members may obtain benefits, including family planning services, from out-of-network providers. • The extent to which, and how, after-hours and emergency coverage are provided, including: .▸ o What constitutes an emergency medical condition, emergency services, and Post-Stabilization Care Services, with references to the definitions in 42 CFR 438.114(a)v. o The fact that prior authorization is not required for Emergency Services. o The process and procedures for obtaining Emergency Services, including use of the 911-telephone system or its local equivalent. o The locations of any Emergency Services and Post-Stabilization Care Services covered under the Agreement. o The fact that, subject to the provisions of this section, the member has a right to use any hospital or other setting for emergency care. .▸ • Information on the post-stabilization care services rules set forth in 42 CFR 422.113vi. • Policy on referrals for specialty care and other benefits not furnished by the member’s Primary Care Provider. .▸ • Information on Advance Directives as set forth in 42 C.F.R. §438.3(j)and 42 CFR 422.128vii. The Contractor agrees to reflect any changes in State law with regards to Advance directives in its written material within ninety (90) days of the effective date of the change as set forth in 42 C.F.R. §438.3(j)(4). • Information on out-of-plan or out-of-network benefits • Information on member’s rights and responsibilities, including, in conformance with State and Federal law, the rights of mothers and newborns with respect to the duration of hospital stays. .▸ • Information on member’s rights and protections, as specified in 42 CFR 438.100viii. • Information on formal grievance, appeal and fair hearing procedures, and the information specified in 42 C.F.R. §438.3(g)(2)(xi) • Information that a member may request disenrollment at any time from the Health Plan • Information on cost-sharing responsibilities (if applicable; may be included as an ~~insert) • Information~~ insert)Information on non-covered services. How and where to access any benefits that are available under the State plan but are not covered under this Agreement, including any cost sharing, and how transportation is provided. • Information on member and provider fraud, waste and abuse o Provide examples of possible Medicaid fraud and abuse which might be undertaken by providers, vendors and enrollees o Inform enrollees about how to report suspected Medicaid fraud and abuse, including any dedicated toll-free number established by the Contractor for reporting possible fraud and abuse o Instruct enrollees about how to contact EOHHS’s Fraud Unit • Information on grievance, appeal and fair hearing procedures and timeframes, as provided in 42 CFR 438.400ix through 42 CFR 438.424x, in a State-developed or State 10▸ ▸1 approved description that must include the following: o The member’s right to a State Fair Hearing, how to obtain a hearing, and the right to representation at a hearing o The member’s right to file grievances and appeals and their requirements and timeframes for filing o The availability of assistance in the filing process o The toll-free numbers that the enrollee can use to file a grievance or an appeal by phone o The member’s right to request continuation of Covered Benefits during an appeal or State Fair Hearing within the timeframes specified for filing; and the member may be liable for the cost of any continued benefits while the appeal is pending, if the final decision is adverse to the enrollee (as defined in 42 CFR 438.420xi). o Information on other resources to assist members • Additional information that is available upon reasonable request, including the following: o Information on the structure and operation of the Contractor o Reports of transactions between the Contractor and parties of interest that are provided to the State, or other agencies. 1903(m)(4)(B). o Information on any physician incentive plans as set forth in 42 CFR 438.6i Also, to be included are the following required by the RI General Laws Title 27 – Insurance Chapter 27-18.8 Rhode Island Health Care Accessibility and Quality Assurance Act (may be included as an insert): • How does the Health Plan review and approve Covered Services? • What if I refuse referral to a participating provider? • Does the Health Plan require that I get a second opinion for any services? • How does the Health Plan make sure that my personal health information is protected and kept confidential? • How am I protected from discrimination? • If I refuse treatment, will it affect my future treatment? • How does the Health Plan pay providers? • If I am covered by two or more Health Plans, what do I do? The Contractor must have written policies regarding enrollee rights that cover: • Each enrollee is guaranteed the right to be treated with respect and with due consideration for his or her dignity and privacy. • Each enrollee is guaranteed the right to receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand. • Each enrollee is guaranteed the right to participate in decisions regarding his or her health care, including the right to refuse treatment. • Each enrollee is guaranteed the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. • Each enrollee is guaranteed the right to request and receive a copy of his or her medical records, and to request that they be amended or corrected, as specified in 45 CFR Part 164xii. The Contractor must provide members, in adherence with 42 C.F.R. §438.3(g)(4)with written notice of any significant changes in enrollee rights or information at least thirty (30) days before the intended effective date of the change. The Contractor will comply with requirements as specified in 42 CFR 438.10(i)(1) as follows: (i) When appropriate Contractor must make available in electronic or paper form, the following information about its formulary: (1) Which medications are covered (both generic and name brand). What tier each medication is on. Formulary drug lists must be made available on the Contractor’s Web site in a machine readable file and format as specified by EOHHS.

Appears in 4 contracts

Samples: Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement

Appears in 3 contracts

Samples: Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement

Required Information. The New member packet will be written at no higher than a sixth-grade level and contain at least the following: •  Information on how to obtain a member handbook and Provider Directory •  Information on how to obtain covered benefits, out of plan benefits and non-covered benefits •  Information on how to contact member services, including information on behavioral health and the hours of operation •  Information on Current Care and its benefits •  What to do in case of an emergency •  To the extent available, quality and performance indicators, including enrollee satisfaction The member handbook will be written at no higher than a sixth-grade level and contain at least the following: •  Information on member services. •  Information on how to choose a PCP. Each member may choose his or her PCP to the extent possible and appropriate. •  Information on what to do when family size changes. •  Information on obtaining transportation •  Information on Interpreter and Translation Services •  Any restrictions on the member’s freedom of choice among network providers. •  Information that enrollment Medicaid Managed Care does not restrict the choice of the provider from whom the member may receive family planning services and supplies. •  Information on member’s right to change PCP. •  Information on amount, duration, and scope of Covered Services, including how to access Covered Services including behavioral health and long-term services and supports. This information must include sufficient detail to ensure that the member understands the benefits to which they are entitled. •  Procedures for obtaining benefits, including authorization requirements. •  Right to a second opinion. •  Members may obtain benefits, including family planning services, from out-of-network providers. •  The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition, emergency services, and Post-Stabilization Care Services, with references to the definitions in 42 CFR 438.114(a)v. o The fact that prior authorization is not required for Emergency Services. o The process and procedures for obtaining Emergency Services, including use of the 911-telephone system or its local equivalent. o The locations of any Emergency Services and Post-Stabilization Care Services covered under the Agreement. o The fact that, subject to the provisions of this section, the member has a right to use any hospital or other setting for emergency care. •  Information on the post-stabilization care services rules set forth in 42 CFR ~~422.113vi~~422.113 vi. •  Policy on referrals for specialty care and other benefits not furnished by the member’s Primary Care Provider. •  Information on Advance Directives as set forth in 42 C.F.R. §438.3(j)and 42 CFR 422.128vii. The Contractor agrees to reflect any changes in State law with regards to Advance directives in its written material within ninety (90) days of the effective date of the change as set forth in 42 C.F.R. §438.3(j)(4). •  Information on out-of-plan or out-of-network benefits •  Information on member’s rights and responsibilities, including, in conformance with State and Federal law, the rights of mothers and newborns with respect to the duration of hospital stays. •  Information on member’s rights and protections, as specified in 42 CFR ~~438.100viii~~438.100 viii. •  Information on formal grievance, appeal and fair hearing procedures, and the information specified in 42 C.F.R. §438.3(g)(2)(xi) •  Information that a member may request disenrollment at any time from the Health Plan •  Information on cost-sharing responsibilities (if applicable; may be included as an ~~insert) • Information~~ insert)Information on non-covered services. How and where to access any benefits that are available under the State plan but are not covered under this Agreement, including any cost sharing, and how transportation is provided. •  Information on member and provider fraud, waste and abuse o Provide examples of possible Medicaid fraud and abuse which might be undertaken by providers, vendors and enrollees o Inform enrollees about how to report suspected Medicaid fraud and abuse, including any dedicated toll-free number established by the Contractor for reporting possible fraud and abuse o Instruct enrollees about how to contact ~~EOHHS~~XXXXX’s Fraud Unit •  Information on grievance, appeal and fair hearing procedures and timeframes, as provided in 42 CFR 438.400ix through 42 CFR 438.424x, in a State-developed or State approved description that must include the following: o The member’s right to a State Fair Hearing, how to obtain a hearing, and the right to representation at a hearing o The member’s right to file grievances and appeals and their requirements and timeframes for filing o The availability of assistance in the filing process o The toll-free numbers that the enrollee can use to file a grievance or an appeal by phone o The member’s right to request continuation of Covered Benefits during an appeal or State Fair Hearing within the timeframes specified for filing; and the member may be liable for the cost of any continued benefits while the appeal is pending, if the final decision is adverse to the enrollee (as defined in 42 CFR 438.420xi). o Information on other resources to assist members •  Additional information that is available upon reasonable request, including the following: o Information on the structure and operation of the Contractor o Reports of transactions between the Contractor and parties of interest that are provided to the State, or other agencies. 1903(m)(4)(B). o Information on any physician incentive plans as set forth in 42 CFR 438.6i Also, to be included are the following required by the RI General Laws Title 27 – Insurance Chapter 27-18.8 Rhode Island Health Care Accessibility and Quality Assurance Act (may be included as an insert): •  How does the Health Plan review and approve Covered Services? •  What if I refuse referral to a participating provider? •  Does the Health Plan require that I get a second opinion for any services? •  How does the Health Plan make sure that my personal health information is protected and kept confidential? •  How am I protected from discrimination? •  If I refuse treatment, will it affect my future treatment? •  How does the Health Plan pay providers? •  If I am covered by two or more Health Plans, what do I do? The Contractor must have written policies regarding enrollee rights that cover: •  Each enrollee is guaranteed the right to be treated with respect and with due consideration for his or her dignity and privacy. •  Each enrollee is guaranteed the right to receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand. •  Each enrollee is guaranteed the right to participate in decisions regarding his or her health care, including the right to refuse treatment. •  Each enrollee is guaranteed the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. •  Each enrollee is guaranteed the right to request and receive a copy of his or her medical records, and to request that they be amended or corrected, as specified in 45 CFR Part 164xii. The Contractor must provide members, in adherence with 42 C.F.R. §438.3(g)(4)with written notice of any significant changes in enrollee rights or information at least thirty (30) days before the intended effective date of the change. The Contractor will comply with requirements as specified in 42 CFR 438.10(i)(1) as follows: (i) When appropriate Contractor must make available in electronic or paper form, the following information about its formulary: (1) Which medications are covered (both generic and name brand). What tier each medication is on. Formulary drug lists must be made available on the Contractor’s Web site in a machine readable file and format as specified by EOHHS.

Appears in 2 contracts

Samples: Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement

Required Information. The New member packet will be written at no higher than a sixth-grade level and contain at least the following: • Information on how to obtain a member handbook and Provider Directory • Information on how to obtain covered benefits, out of plan benefits and non-covered benefits • Information on how to contact member services, including information on behavioral health and the hours of operation • Information on Current Care and its benefits • What to do in case of an emergency • To the extent available, quality and performance indicators, including enrollee satisfaction The member handbook will be written at no higher than a sixth-grade level and contain at least the following: • Information on member services. • Information on how to choose a PCP. Each member may choose his or her PCP to the extent possible and appropriate. • Information on what to do when family size changes. • Information on obtaining transportation • Information on Interpreter and Translation Services • Any restrictions on the member’s freedom of choice among network providers. • Information that enrollment Medicaid Managed Care does not restrict the choice of the provider from whom the member may receive family planning services and supplies. • Information on member’s right to change PCP. • Information on amount, duration, and scope of Covered Services, including how to access Covered Services including behavioral health and long-term services and supports. This information must include sufficient detail to ensure that the member understands the benefits to which they are entitled. • Procedures for obtaining benefits, including authorization requirements. • Right to a second opinion. • Members may obtain benefits, including family planning services, from out-of-network providers. • The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition, emergency services, and Post-Stabilization Care Services, with references to the definitions in 42 CFR ~~438.114(a)v.~~ 438.114(a) v. o The fact that prior authorization is not required for Emergency Services. o The process and procedures for obtaining Emergency Services, including use of the 911-telephone system or its local equivalent. o The locations of any Emergency Services and Post-Stabilization Care Services covered under the Agreement. o The fact that, subject to the provisions of this section, the member has a right to use any hospital or other setting for emergency care. • Information on the post-stabilization care services rules set forth in 42 CFR 422.113vi. • Policy on referrals for specialty care and other benefits not furnished by the member’s Primary Care Provider. • Information on Advance Directives as set forth in 42 C.F.R. §438.3(j)and 42 CFR ~~422.128vii~~422.128 vii. The Contractor agrees to reflect any changes in State law with regards to Advance directives in its written material within ninety (90) days of the effective date of the change as set forth in 42 C.F.R. §438.3(j)(4). • Information on out-of-plan or out-of-network benefits • Information on member’s rights and responsibilities, including, in conformance with State and Federal law, the rights of mothers and newborns with respect to the duration of hospital stays. • Information on member’s rights and protections, as specified in 42 CFR ~~438.100viii~~438.100 viii. • Information on formal grievance, appeal and fair hearing procedures, and the information specified in 42 C.F.R. §438.3(g)(2)(xi) • Information that a member may request disenrollment at any time from the Health Plan • Information on cost-sharing responsibilities (if applicable; may be included as an insert) • Information on non-covered services. How and where to access any benefits that are available under the State plan but are not covered under this Agreement, including any cost sharing, and how transportation is provided. • Information on member and provider fraud, waste and abuse o Provide examples of possible Medicaid fraud and abuse which might be undertaken by providers, vendors and enrollees o Inform enrollees about how to report suspected Medicaid fraud and abuse, including any dedicated toll-free number established by the Contractor for reporting possible fraud and abuse o Instruct enrollees about how to contact ~~EOHHS~~XXXXX’s Fraud Unit • Information on grievance, appeal and fair hearing procedures and timeframes, as provided in 42 CFR ~~438.400ix~~ 438.400 ix through 42 CFR ~~438.424x~~438.424 x, in a State-developed or State approved description that must include the following: o The member’s right to a State Fair Hearing, how to obtain a hearing, and the right to representation at a hearing o The member’s right to file grievances and appeals and their requirements and timeframes for filing o The availability of assistance in the filing process o The toll-free numbers that the enrollee can use to file a grievance or an appeal by phone o The member’s right to request continuation of Covered Benefits during an appeal or State Fair Hearing within the timeframes specified for filing; and the member may be liable for the cost of any continued benefits while the appeal is pending, if the final decision is adverse to the enrollee (as defined in 42 CFR ~~438.420xi~~438.420 xi). o Information on other resources to assist members • Additional information that is available upon reasonable request, including the following: o Information on the structure and operation of the Contractor o Reports of transactions between the Contractor and parties of interest that are provided to the State, or other agencies. 1903(m)(4)(B). o Information on any physician incentive plans as set forth in 42 CFR 438.6i Also, to be included are the following required by the RI General Laws Title 27 – Insurance Chapter 27-18.8 Rhode Island Health Care Accessibility and Quality Assurance Act (may be included as an insert): • How does the Health Plan review and approve Covered Services? • What if I refuse referral to a participating provider? • Does the Health Plan require that I get a second opinion for any services? • How does the Health Plan make sure that my personal health information is protected and kept confidential? • How am I protected from discrimination? • If I refuse treatment, will it affect my future treatment? • How does the Health Plan pay providers? • If I am covered by two or more Health Plans, what do I do? The Contractor must have written policies regarding enrollee rights that cover: • Each enrollee is guaranteed the right to be treated with respect and with due consideration for his or her dignity and privacy. • Each enrollee is guaranteed the right to receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand. • Each enrollee is guaranteed the right to participate in decisions regarding his or her health care, including the right to refuse treatment. • Each enrollee is guaranteed the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. • Each enrollee is guaranteed the right to request and receive a copy of his or her medical records, and to request that they be amended or corrected, as specified in 45 CFR Part ~~164xii~~164 xii. The Contractor must provide members, in adherence with 42 C.F.R. §438.3(g)(4)with written notice of any significant changes in enrollee rights or information at least thirty (30) days before the intended effective date of the change. The Contractor will comply with requirements as specified in 42 CFR 438.10(i)(1) as follows: (i) When appropriate Contractor must make available in electronic or paper form, the following information about its formulary: (1) Which medications are covered (both generic and name brand). What tier each medication is on. Formulary drug lists must be made available on the Contractor’s Web site in a machine readable file and format as specified by EOHHS.

Appears in 1 contract

Samples: Medicaid Managed Care Services Agreement

Required Information. The New member packet will be written at no higher than a sixth-grade level and contain at least the following: • Information on how to obtain a member handbook and Provider Directory • Information on how to obtain covered benefits, out of plan benefits and non-covered benefits • Information on how to contact member services, including information on behavioral health and the hours of operation • Information on Current Care and its benefits • What to do in case of an emergency • To the extent available, quality and performance indicators, including enrollee satisfaction The member handbook will be written at no higher than a sixth-grade level and contain at least the following: • Information on member services. • Information on how to choose a PCP. Each member may choose his or her PCP to the extent possible and appropriate. • Information on what to do when family size changes. • Information on obtaining transportation • Information on Interpreter and Translation Services • Any restrictions on the member’s freedom of choice among network providers. • Information that enrollment Medicaid Managed Care does not restrict the choice of the provider from whom the member may receive family planning services and supplies. • Information on member’s right to change PCP. • Information on amount, duration, and scope of Covered Services, including how to access Covered Services including behavioral health and long-term services and supports. This information must include sufficient detail to ensure that the member understands the benefits to which they are entitled. • Procedures for obtaining benefits, including authorization requirements. • Right to a second opinion. • Members may obtain benefits, including family planning services, from out-of-network providers. • The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition, emergency services, and Post-Stabilization Care Services, with references to the definitions in 42 CFR ~~438.114(a)v.~~ 438.114(a).▸v. o The fact that prior authorization is not required for Emergency Services. o The process and procedures for obtaining Emergency Services, including use of the 911-telephone system or its local equivalent. o The locations of any Emergency Services and Post-Stabilization Care Services covered under the Agreement. o The fact that, subject to the provisions of this section, the member has a right to use any hospital or other setting for emergency care. .▸ • Information on the post-stabilization care services rules set forth in 42 CFR 422.113vi. • Policy on referrals for specialty care and other benefits not furnished by the member’s Primary Care Provider. ▸. • Information on Advance Directives as set forth in 42 C.F.R. §438.3(j)and 42 CFR 422.128vii. The Contractor agrees to reflect any changes in State law with regards to Advance directives in its written material within ninety (90) days of the effective date of the change as set forth in 42 C.F.R. §438.3(j)(4). • Information on out-of-plan or out-of-network benefits • Information on member’s rights and responsibilities, including, in conformance with State and Federal law, the rights of mothers and newborns with respect to the duration of hospital stays. .▸ • Information on member’s rights and protections, as specified in 42 CFR 438.100viii. • Information on formal grievance, appeal and fair hearing procedures, and the information specified in 42 C.F.R. §438.3(g)(2)(xi) • Information that a member may request disenrollment at any time from the Health Plan • Information on cost-sharing responsibilities (if applicable; may be included as an insert) • Information on non-covered services. How and where to access any benefits that are available under the State plan but are not covered under this Agreement, including any cost sharing, and how transportation is provided. • Information on member and provider fraud, waste and abuse o Provide examples of possible Medicaid fraud and abuse which might be undertaken by providers, vendors and enrollees o Inform enrollees about how to report suspected Medicaid fraud and abuse, including any dedicated toll-free number established by the Contractor for reporting possible fraud and abuse o Instruct enrollees about how to contact EOHHS’s Fraud Unit • Information on grievance, appeal and fair hearing procedures and timeframes, as provided in 42 CFR 438.400ix through 42 CFR 438.424x, in a State-developed or State 0.▸ 1▸ approved description that must include the following: o The member’s right to a State Fair Hearing, how to obtain a hearing, and the right to representation at a hearing o The member’s right to file grievances and appeals and their requirements and timeframes for filing o The availability of assistance in the filing process o The toll-free numbers that the enrollee can use to file a grievance or an appeal by phone 12▸ o The member’s right to request continuation of Covered Benefits during an appeal or State Fair Hearing within the timeframes specified for filing; and the member may be liable for the cost of any continued benefits while the appeal is pending, if the final decision is adverse to the enrollee (as defined in 42 CFR 438.420xi). o Information on other resources to assist members • Additional information that is available upon reasonable request, including the following: o Information on the structure and operation of the Contractor o Reports of transactions between the Contractor and parties of interest that are provided to the State, or other agencies. 1903(m)(4)(B). o Information on any physician incentive plans as set forth in 42 CFR 438.6i Also, to be included are the following required by the RI General Laws Title 27 – Insurance Chapter 27-18.8 Rhode Island Health Care Accessibility and Quality Assurance Act (may be included as an insert): • How does the Health Plan review and approve Covered Services? • What if I refuse referral to a participating provider? • Does the Health Plan require that I get a second opinion for any services? • How does the Health Plan make sure that my personal health information is protected and kept confidential? • How am I protected from discrimination? • If I refuse treatment, will it affect my future treatment? • How does the Health Plan pay providers? • If I am covered by two or more Health Plans, what do I do? The Contractor must have written policies regarding enrollee rights that cover: • Each enrollee is guaranteed the right to be treated with respect and with due consideration for his or her dignity and privacy. • Each enrollee is guaranteed the right to receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand. • Each enrollee is guaranteed the right to participate in decisions regarding his or her health care, including the right to refuse treatment. • Each enrollee is guaranteed the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. • Each enrollee is guaranteed the right to request and receive a copy of his or her medical records, and to request that they be amended or corrected, as specified in 45 CFR Part 164xii. The Contractor must provide members, in adherence with 42 C.F.R. §438.3(g)(4)with written notice of any significant changes in enrollee rights or information at least thirty (30) days before the intended effective date of the change. The Contractor will comply with requirements as specified in 42 CFR 438.10(i)(1) as follows: (i) When appropriate Contractor must make available in electronic or paper form, the following information about its formulary: (1) Which medications are covered (both generic and name brand). What tier each medication is on. Formulary drug lists must be made available on the Contractor’s Web site in a machine readable file and format as specified by EOHHS.

Appears in 1 contract

Samples: Medicaid Managed Care Services Agreement

Required Information. The New member packet will be written at no higher than a sixth-grade level and contain at least the following: • Information on how to obtain a member handbook and Provider Directory • Information on how to obtain covered benefits, out of plan benefits and non-covered benefits • Information on how to contact member services, including information on behavioral health and the hours of operation • Information on Current Care and its benefits • What to do in case of an emergency • To the extent available, quality and performance indicators, including enrollee satisfaction The member handbook will be written at no higher than a sixth-grade level and contain at least the following: • Information on member services. • Information on how to choose a PCP. Each member may choose his or her PCP to the extent possible and appropriate. • Information on what to do when family size changes. • Information on obtaining transportation • Information on Interpreter and Translation Services • Any restrictions on the member’s freedom of choice among network providers. • Information that enrollment Medicaid Managed Care does not restrict the choice of the provider from whom the member may receive family planning services and supplies. • Information on member’s right to change PCP. • Information on amount, duration, and scope of Covered Services, including how to access Covered Services including behavioral health and long-term services and supports. This information must include sufficient detail to ensure that the member understands the benefits to which they are entitled. • Procedures for obtaining benefits, including authorization requirements. • Right to a second opinion. • Members may obtain benefits, including family planning services, from out-of-network providers. • The extent to which, and how, after-hours and emergency coverage are provided, including: 6F o What constitutes an emergency medical condition, emergency services, and Post-Stabilization Care Services, with references to the definitions in 42 CFR 438.114(a)v. o The fact that prior authorization is not required for Emergency Services. o The process and procedures for obtaining Emergency Services, including use of the 911-telephone system or its local equivalent. o The locations of any Emergency Services and Post-Stabilization Care Services covered under the Agreement. o The fact that, subject to the provisions of this section, the member has a right to use any hospital or other setting for emergency care. • Information on the post-stabilization care services rules set forth in 42 CFR ~~422.113vi~~422.113 vi. • Policy on referrals for specialty care and other benefits not furnished by the member’s Primary Care Provider. • Information on Advance Directives as set forth in 42 C.F.R. §438.3(j)and 42 CFR ~~422.128vii~~422.128 vii. The Contractor agrees to reflect any changes in State law with regards to Advance directives in its written material within ninety (90) days of the effective date of the change as set forth in 42 C.F.R. §438.3(j)(4). • Information on out-of-plan or out-of-network benefits • Information on member’s rights and responsibilities, including, in conformance with State and Federal law, the rights of mothers and newborns with respect to the duration of hospital stays. • Information on member’s rights and protections, as specified in 42 CFR ~~438.100viii~~438.100 viii. • Information on formal grievance, appeal and fair hearing procedures, and the information specified in 42 C.F.R. §438.3(g)(2)(xi) • Information that a member may request disenrollment at any time from the Health Plan • Information on cost-sharing responsibilities (if applicable; may be included as an insert) • Information on non-covered services. How and where to access any benefits that are available under the State plan but are not covered under this Agreement, including any cost sharing, and how transportation is provided. • Information on member and provider fraud, waste and abuse o Provide examples of possible Medicaid fraud and abuse which might be undertaken by providers, vendors and enrollees o Inform enrollees about how to report suspected Medicaid fraud and abuse, including any dedicated toll-free number established by the Contractor for reporting possible fraud and abuse o Instruct enrollees about how to contact EOHHS’s Fraud Unit • Information on grievance, appeal and fair hearing procedures and timeframes, as provided in 42 CFR ~~438.400ix~~ 438.400 ix through 42 CFR ~~438.424x~~438.424 x, in a State-developed or State 10F 11F approved description that must include the following: o The member’s right to a State Fair Hearing, how to obtain a hearing, and the right to representation at a hearing o The member’s right to file grievances and appeals and their requirements and timeframes for filing o The availability of assistance in the filing process o The toll-free numbers that the enrollee can use to file a grievance or an appeal by phone o The member’s right to request continuation of Covered Benefits during an appeal or State Fair Hearing within the timeframes specified for filing; and the member may be liable for the cost of any continued benefits while the appeal is pending, if the final decision is adverse to the enrollee (as defined in 42 CFR ~~438.420xi~~438.420 xi). o Information on other resources to assist members • Additional information that is available upon reasonable request, including the following: o Information on the structure and operation of the Contractor o Reports of transactions between the Contractor and parties of interest that are provided to the State, or other agencies. 1903(m)(4)(B). o Information on any physician incentive plans as set forth in 42 CFR 438.6i Also, to be included are the following required by the RI General Laws Title 27 – Insurance Chapter 27-18.8 Rhode Island Health Care Accessibility and Quality Assurance Act (may be included as an insert): • How does the Health Plan review and approve Covered Services? • What if I refuse referral to a participating provider? • Does the Health Plan require that I get a second opinion for any services? • How does the Health Plan make sure that my personal health information is protected and kept confidential? • How am I protected from discrimination? • If I refuse treatment, will it affect my future treatment? • How does the Health Plan pay providers? • If I am covered by two or more Health Plans, what do I do? The Contractor must have written policies regarding enrollee rights that cover: • Each enrollee is guaranteed the right to be treated with respect and with due consideration for his or her dignity and privacy. • Each enrollee is guaranteed the right to receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand. • Each enrollee is guaranteed the right to participate in decisions regarding his or her health care, including the right to refuse treatment. • Each enrollee is guaranteed the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. • Each enrollee is guaranteed the right to request and receive a copy of his or her medical records, and to request that they be amended or corrected, as specified in 45 CFR Part ~~164xii~~164 13F . The Contractor must provide members, in adherence with 42 C.F.R. §438.3(g)(4)with written notice of any significant changes in enrollee rights or information at least thirty (30) days before the intended effective date of the change. The Contractor will comply with requirements as specified in 42 CFR 438.10(i)(1) as follows: (i) When appropriate Contractor must make available in electronic or paper form, the following information about its formulary: (1) Which medications are covered (both generic and name brand). What tier each medication is on. Formulary drug lists must be made available on the Contractor’s Web site in a machine readable file and format as specified by EOHHS.

Appears in 1 contract

Samples: Medicaid Managed Care Services Agreement

Required Information. The New member packet will be written at no higher than a sixth-grade level and contain at least the following: • Information on how to obtain a member handbook and Provider Directory • Information on how to obtain covered benefits, out of plan benefits and non-covered benefits • Information on how to contact member services, including information on behavioral health and the hours of operation • Information on Current Care and its benefits • What to do in case of an emergency • To the extent available, quality and performance indicators, including enrollee satisfaction The member handbook will be written at no higher than a sixth-grade level and contain at least the following: • Information on member services. • Information on how to choose a PCP. Each member may choose his or her PCP to the extent possible and appropriate. • Information on what to do when family size changes. • Information on obtaining transportation • Information on Interpreter and Translation Services • Any restrictions on the member’s freedom of choice among network providers. • Information that enrollment Medicaid Managed Care does not restrict the choice of the provider from whom the member may receive family planning services and supplies. • Information on member’s right to change PCP. • Information on amount, duration, and scope of Covered Services, including how to access Covered Services including behavioral health and long-term services and supports. This information must include sufficient detail to ensure that the member understands the benefits to which they are entitled. • Procedures for obtaining benefits, including authorization requirements. • Right to a second opinion. • Members may obtain benefits, including family planning services, from out-of-network providers. • The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition, emergency services, and Post-Stabilization Care Services, with references to the definitions in 42 CFR 438.114(a)v. o The fact that prior authorization is not required for Emergency Services. o The process and procedures for obtaining Emergency Services, including use of the 911-telephone system or its local equivalent. o The locations of any Emergency Services and Post-Stabilization Care Services covered under the Agreement. o The fact that, subject to the provisions of this section, the member has a right to use any hospital or other setting for emergency care. • Information on the post-stabilization care services rules set forth in 42 CFR 422.113vi. • Policy on referrals for specialty care and other benefits not furnished by the member’s Primary Care Provider. • Information on Advance Directives as set forth in 42 C.F.R. §438.3(j)and 42 CFR 422.128vii. The Contractor agrees to reflect any changes in State law with regards to Advance directives in its written material within ninety (90) days of the effective date of the change as set forth in 42 C.F.R. §438.3(j)(4). • Information on out-of-plan or out-of-network benefits • Information on member’s rights and responsibilities, including, in conformance with State and Federal law, the rights of mothers and newborns with respect to the duration of hospital stays. • Information on member’s rights and protections, as specified in 42 CFR 438.100viii. • Information on formal grievance, appeal and fair hearing procedures, and the information specified in 42 C.F.R. §438.3(g)(2)(xi) • Information that a member may request disenrollment at any time from the Health Plan • Information on cost-sharing responsibilities (if applicable; may be included as an insert) • Information on non-covered services. How and where to access any benefits that are available under the State plan but are not covered under this Agreement, including any cost sharing, and how transportation is provided. • Information on member and provider fraud, waste and abuse o Provide examples of possible Medicaid fraud and abuse which might be undertaken by providers, vendors and enrollees o Inform enrollees about how to report suspected Medicaid fraud and abuse, including any dedicated toll-free number established by the Contractor for reporting possible fraud and abuse o Instruct enrollees about how to contact ~~EOHHS~~XXXXX’s Fraud Unit • Information on grievance, appeal and fair hearing procedures and timeframes, as provided in 42 CFR 438.400ix through 42 CFR 438.424x, in a State-developed or State approved description that must include the following: o The member’s right to a State Fair Hearing, how to obtain a hearing, and the right to representation at a hearing o The member’s right to file grievances and appeals and their requirements and timeframes for filing o The availability of assistance in the filing process o The toll-free numbers that the enrollee can use to file a grievance or an appeal by phone o The member’s right to request continuation of Covered Benefits during an appeal or State Fair Hearing within the timeframes specified for filing; and the member may be liable for the cost of any continued benefits while the appeal is pending, if the final decision is adverse to the enrollee (as defined in 42 CFR 438.420xi). o Information on other resources to assist members • Additional information that is available upon reasonable request, including the following: o Information on the structure and operation of the Contractor o Reports of transactions between the Contractor and parties of interest that are provided to the State, or other agencies. 1903(m)(4)(B). o Information on any physician incentive plans as set forth in 42 CFR 438.6i Also, to be included are the following required by the RI General Laws Title 27 – Insurance Chapter 27-18.8 Rhode Island Health Care Accessibility and Quality Assurance Act (may be included as an insert): • How does the Health Plan review and approve Covered Services? • What if I refuse referral to a participating provider? • Does the Health Plan require that I get a second opinion for any services? • How does the Health Plan make sure that my personal health information is protected and kept confidential? • How am I protected from discrimination? • If I refuse treatment, will it affect my future treatment? • How does the Health Plan pay providers? • If I am covered by two or more Health Plans, what do I do? The Contractor must have written policies regarding enrollee rights that cover: • Each enrollee is guaranteed the right to be treated with respect and with due consideration for his or her dignity and privacy. • Each enrollee is guaranteed the right to receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand. • Each enrollee is guaranteed the right to participate in decisions regarding his or her health care, including the right to refuse treatment. • Each enrollee is guaranteed the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. • Each enrollee is guaranteed the right to request and receive a copy of his or her medical records, and to request that they be amended or corrected, as specified in 45 CFR Part 164xii. The Contractor must provide members, in adherence with 42 C.F.R. §438.3(g)(4)with written notice of any significant changes in enrollee rights or information at least thirty (30) days before the intended effective date of the change. The Contractor will comply with requirements as specified in 42 CFR 438.10(i)(1) as follows: (i) When appropriate Contractor must make available in electronic or paper form, the following information about its formulary: (1) Which medications are covered (both generic and name brand). What tier each medication is on. Formulary drug lists must be made available on the Contractor’s Web site in a machine readable file and format as specified by EOHHS.

Appears in 1 contract

Samples: Medicaid Managed Care Services Agreement

Required Information. The New member packet will be written at no higher than a sixth-grade level and contain at least the following: •  Information on how to obtain a member handbook and Provider Directory •  Information on how to obtain covered benefits, out of plan benefits and non-covered benefits •  Information on how to contact member services, including information on behavioral health and the hours of operation •  Information on Current Care and its benefits •  What to do in case of an emergency •  To the extent available, quality and performance indicators, including enrollee satisfaction The member handbook will be written at no higher than a sixth-grade level and contain at least the following: •  Information on member services. •  Information on how to choose a PCP. Each member may choose his or her PCP to the extent possible and appropriate. •  Information on what to do when family size changes. •  Information on obtaining transportation •  Information on Interpreter and Translation Services •  Any restrictions on the member’s freedom of choice among network providers. •  Information that enrollment Medicaid Managed Care does not restrict the choice of the provider from whom the member may receive family planning services and supplies. •  Information on member’s right to change PCP. •  Information on amount, duration, and scope of Covered Services, including how to access Covered Services including behavioral health and long-term services and supports. This information must include sufficient detail to ensure that the member understands the benefits to which they are entitled. •  Procedures for obtaining benefits, including authorization requirements. •  Right to a second opinion. •  Members may obtain benefits, including family planning services, from out-of-network providers. •  The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition, emergency services, and Post-Stabilization Care Services, with references to the definitions in 42 CFR 438.114(a)v. o The fact that prior authorization is not required for Emergency Services. o The process and procedures for obtaining Emergency Services, including use of the 911-telephone system or its local equivalent. o The locations of any Emergency Services and Post-Stabilization Care Services covered under the Agreement. o The fact that, subject to the provisions of this section, the member has a right to use any hospital or other setting for emergency care. •  Information on the post-stabilization care services rules set forth in 42 CFR ~~422.113vi~~422.113 vi. •  Policy on referrals for specialty care and other benefits not furnished by the member’s Primary Care Provider. •  Information on Advance Directives as set forth in 42 C.F.R. §438.3(j)and 42 CFR 422.128vii. The Contractor agrees to reflect any changes in State law with regards to Advance directives in its written material within ninety (90) days of the effective date of the change as set forth in 42 C.F.R. §438.3(j)(4). •  Information on out-of-plan or out-of-network benefits •  Information on member’s rights and responsibilities, including, in conformance with State and Federal law, the rights of mothers and newborns with respect to the duration of hospital stays. •  Information on member’s rights and protections, as specified in 42 CFR ~~438.100viii~~438.100 viii. •  Information on formal grievance, appeal and fair hearing procedures, and the information specified in 42 C.F.R. §438.3(g)(2)(xi) •  Information that a member may request disenrollment at any time from the Health Plan •  Information on cost-sharing responsibilities (if applicable; may be included as an ~~insert) • Information~~ insert)Information on non-covered services. How and where to access any benefits that are available under the State plan but are not covered under this Agreement, including any cost sharing, and how transportation is provided. •  Information on member and provider fraud, waste and abuse o Provide examples of possible Medicaid fraud and abuse which might be undertaken by providers, vendors and enrollees o Inform enrollees about how to report suspected Medicaid fraud and abuse, including any dedicated toll-free number established by the Contractor for reporting possible fraud and abuse o Instruct enrollees about how to contact EOHHS’s Fraud Unit •  Information on grievance, appeal and fair hearing procedures and timeframes, as provided in 42 CFR 438.400ix through 42 CFR 438.424x, in a State-developed or State approved description that must include the following: o The member’s right to a State Fair Hearing, how to obtain a hearing, and the right to representation at a hearing o The member’s right to file grievances and appeals and their requirements and timeframes for filing o The availability of assistance in the filing process o The toll-free numbers that the enrollee can use to file a grievance or an appeal by phone o The member’s right to request continuation of Covered Benefits during an appeal or State Fair Hearing within the timeframes specified for filing; and the member may be liable for the cost of any continued benefits while the appeal is pending, if the final decision is adverse to the enrollee (as defined in 42 CFR 438.420xi). o Information on other resources to assist members •  Additional information that is available upon reasonable request, including the following: o Information on the structure and operation of the Contractor o Reports of transactions between the Contractor and parties of interest that are provided to the State, or other agencies. 1903(m)(4)(B). o Information on any physician incentive plans as set forth in 42 CFR 438.6i Also, to be included are the following required by the RI General Laws Title 27 – Insurance Chapter 27-18.8 Rhode Island Health Care Accessibility and Quality Assurance Act (may be included as an insert): •  How does the Health Plan review and approve Covered Services? •  What if I refuse referral to a participating provider? •  Does the Health Plan require that I get a second opinion for any services? •  How does the Health Plan make sure that my personal health information is protected and kept confidential? •  How am I protected from discrimination? •  If I refuse treatment, will it affect my future treatment? •  How does the Health Plan pay providers? •  If I am covered by two or more Health Plans, what do I do? The Contractor must have written policies regarding enrollee rights that cover: •  Each enrollee is guaranteed the right to be treated with respect and with due consideration for his or her dignity and privacy. •  Each enrollee is guaranteed the right to receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand. •  Each enrollee is guaranteed the right to participate in decisions regarding his or her health care, including the right to refuse treatment. •  Each enrollee is guaranteed the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. •  Each enrollee is guaranteed the right to request and receive a copy of his or her medical records, and to request that they be amended or corrected, as specified in 45 CFR Part 164xii. The Contractor must provide members, in adherence with 42 C.F.R. §438.3(g)(4)with written notice of any significant changes in enrollee rights or information at least thirty (30) days before the intended effective date of the change. The Contractor will comply with requirements as specified in 42 CFR 438.10(i)(1) as follows: (i) When appropriate Contractor must make available in electronic or paper form, the following information about its formulary: (1) Which medications are covered (both generic and name brand). What tier each medication is on. Formulary drug lists must be made available on the Contractor’s Web site in a machine readable file and format as specified by EOHHS.

Appears in 1 contract

Samples: Medicaid Managed Care Services Agreement

Required Information. The ~~New member packet will~~ Member handbook shall be written at no higher than a sixth-grade level and contain at least the following: • Information on how to obtain a member handbook and Provider Directory • Information on how to obtain covered benefits, out of plan benefits and non-covered benefits • Information on how to contact member services, including information on behavioral health and the hours of operation • Information on Current Care and its benefits • What to do in case of an emergency • To the extent available, quality and performance indicators, including enrollee satisfaction The member handbook will be written at no higher than a sixth-grade level and contain at least the following: • Information on member servicesMember Services. • Information on how to choose a PCP. Each member may choose his or her PCP to the extent possible and appropriate. • Information on what to do when family size changes. • ~~Information on obtaining transportation • Information on Interpreter~~ Provider network listing (may be included as an insert). The information must include their names, locations, telephone numbers, and ~~Translation Services~~ non-English languages spoken by current providers in the member’s service area, including identification of providers that are not accepting new patients. This includes, at a minimum, information of primary care physicians, specialists, and hospitals. • Any restrictions on the member’s freedom of choice among network providers. • Information that enrollment ~~Medicaid Managed Care~~ in Rhody Health Options does not restrict the choice of the provider from whom the member may receive family planning services and supplies. • Information on member’s right to change PCP. • Information on amount, duration, and scope of Covered Services, including how to access Covered Services including behavioral health and long-term services and supports. This information must include sufficient detail to ensure that the ~~member~~ Member understands the benefits to which they are entitled. • Procedures for obtaining benefits, including authorization requirements. • Right to a second surgical opinion. • Members may obtain benefits, including family planning services, from out-~~of-~~of- network providers. • The extent to which, and how, after-hours and emergency coverage are provided, including: o ➢ What constitutes an emergency medical condition, emergency services, and Post-Stabilization Care Services, with references to the definitions in 42 CFR ~~438.114(a)v~~438.114(a). o ➢ The fact that prior authorization is not required for Emergency Services. o ➢ The process and procedures for obtaining Emergency Services, including use of the 911-telephone system or its local equivalent. o ➢ The locations of any Emergency Services and Post-Stabilization Care Services covered under the Agreement. o ➢ The fact that, subject to the provisions of this section, the member has a right to use any hospital or other setting for emergency care. • Information on the post-stabilization care services rules set forth in 42 CFR ~~422.113vi~~422.113(c). • Policy on referrals for specialty care and other benefits not furnished by the ~~member~~Member’s Primary Care Provider. • Information on Advance ~~Directives~~ Directives, as set forth in 42 ~~C.F.R. §438.3(j)and 42~~ CFR ~~422.128vii. The Contractor agrees to reflect any changes in State law with regards to Advance directives in its written material within ninety~~ 438.6 (90i) ~~days of the effective date of the change as set forth in 42 C.F.R. §438.3(j)(4~~(1). • Information on out-of-plan or out-of-network benefits • Information on member’s rights and responsibilities, including, in conformance with State and Federal law, the rights of mothers and newborns with respect to the duration of hospital stays. • Information on member’s rights and protections, as specified in 42 CFR ~~438.100viii~~438.100. • Information on formal grievance, appeal and fair hearing procedures, and the information specified in 42 ~~C.F.R. §438.3(g)(2)(xi~~CFR 438.10(g) (1) and described in Section 2.15 of this Agreement. • Information that a member may request disenrollment at any time from the Health Plan • Information on cost-sharing responsibilities (if applicable; may be included as an insert) • Information on non-covered services. How and where to access any benefits that are available under the State plan but are not covered under this Agreement, including any cost sharing, and how transportation is provided. • ~~Information on member and provider fraud, waste~~ Fraud and abuse o ➢ Provide examples of possible Medicaid fraud and abuse which might be undertaken by providers, vendors and enrollees o ➢ Inform enrollees about how to report suspected Medicaid fraud and abuse, including any dedicated toll-free number established by the Contractor for reporting possible fraud and abuse o ➢ Instruct enrollees about how to contact ~~EOHHS~~XXXXX’s Fraud Unit • Information on grievance, appeal and fair hearing procedures and timeframes, as provided in 42 CFR ~~438.400ix~~ 438.400 through ~~42 CFR 438.424x~~438.424, in a State-developed or State approved description that must include the following: o ➢ The member’s right to a State Fair Hearing, how to obtain a hearing, and the right to representation at a hearing o ➢ The member’s right to file grievances and appeals and their requirements and timeframes for filing o ➢ The availability of assistance in the filing process o ➢ The toll-free numbers that the enrollee can use to file a grievance or an appeal by phone o ➢ The member’s right to request continuation of Covered Benefits during an appeal or State Fair ~~Hearing within the timeframes specified for filing~~Hearing; and the ~~member~~ Member may be liable for the cost of any continued benefits while the appeal is pending, if the final decision is adverse to the enrollee (as defined in 42 CFR ~~438.420xi~~438.420). ~~o Information on other resources to assist members~~ • Additional information that is available upon ~~reasonable~~ request, including the following: o ➢ Information on the structure and operation of the Contractor ~~o Reports of transactions between the Contractor and parties of interest that are provided to the State, or other agencies. 1903(m)(4)(B). o~~ ➢ Information on any physician incentive plans as set forth in 42 CFR ~~438.6i Also,~~ 438.6(h) Also to be included are the following required by the ~~RI General Laws Title 27 – Insurance Chapter 27-18.8 Rhode Island~~ Health Care Accessibility and Quality Assurance Act (may be included as an insert): • How does the Health Plan review and approve Covered Services? • What if I refuse referral to a participating provider? • Does the Health Plan require that I get a second opinion for any services? • How does the Health Plan make sure that my personal health information is protected and kept confidential? • How am I protected from discrimination? • If I refuse treatment, will it affect my future treatment? • How does the Health Plan pay providers? • If I am covered by two or more Health Plans, what do I do? The Contractor must have written policies regarding enrollee rights that cover: • Each enrollee is guaranteed the right to be treated with respect and with due consideration for his or her dignity and privacy. • Each enrollee is guaranteed the right to receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand. • Each enrollee is guaranteed the right to participate in decisions regarding his or her health care, including the right to refuse treatment. • Each enrollee is guaranteed the right to be free from ~~any~~ and form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. • Each enrollee is guaranteed the right to request and receive a copy of his or her medical records, and to request that they be amended or corrected, as specified in 45 CFR Part 164xii. The Contractor must provide members, in adherence with 42 C.F.R. §438.3(g)(4)with written notice of any significant changes in enrollee rights or information at least thirty (30) days before the intended effective date of the change. The Contractor will comply with requirements as specified in 42 CFR 438.10(i)(1) as follows: (i) When appropriate Contractor must make available in electronic or paper form, the following information about its formulary: (1) Which medications are covered (both generic and name brand). What tier each medication is on. Formulary drug lists must be made available on the Contractor’s Web site in a machine readable file and format as specified by EOHHS164.

Appears in 1 contract

Samples: Medicaid Managed Integrated Adult Care Services Agreement

Appears in 1 contract

Samples: Medicaid Managed Care Services Agreement

Common use of Required Information Clause in Contracts