SUMMARY PLAN DESCRIPTION BOOKLET AND ORIENTATION PROGRAMS MARKETING PROVISIONS. 1. The INSURER shall be responsible for the preparation, printing and distribution, at its own cost, of booklets, in the Spanish language, that describe the plan and the benefits covered therein. The Insurer agrees to submit before the effective date of the contract a translated copy of the beneficiaries' booklet in the English language by the proper revision of federal authorities. These booklets will be delivered to each subscriber upon enrollment, along with the required identification card(s).
2. The booklets shall serve as guarantee of the benefits to be provided and shall contain the following information:
a) Schedule of benefits covered, all services and items that are available and that are covered either directly or through methods of referral and/or prior authorization, a written description of how and where the services that have been available through the plan services may be obtained.
b) Benefit's exclusions and limitations. For benefits that enrollees are entitled to but are not available through the MCO, a written description on how and where to obtain benefits; description of procedures for requesting disenrollments/changes.
c) Beneficiary's rights and responsibilities, in accordance with specific rights and requirements to be afforded in accordance with Medicaid Program regulations as amended, the Puerto Rico Patient Bill of Rights Law 194 of August 25, 2000, the Puerto Xico Mental Health Code, of October 2, 2000, as amended and implemented by their regulations, and Law 11 creating the Office of Patients Solicitor General of April 11, 2001.
d) Instructions on how to access benefits, including a list of (1) available HCO's and its participating providers, PCP or Specialists (its locations and qualifications), (2) providers from which to obtain benefits under the Special Coverage. Said list can be provided in a separate booklet.
e) Official grievances and appeal filing procedures.
f) In the event a Physician Incentive Plan affects the use of referral services and/or places physicians at substantial risk, the INSURER shall provide the following information upon beneficiaries' requests: the type of incentive arrangements, whether stop-loss insurance is provided and the survey results of any enrollee/disenrollee surveys that will have to be conducted by INSURER.
g) Unless otherwise specified, subscription materials must be written at the 4th-6th grade reading comprehension level.
h) Explanations of instances under which a beneficiary's disenrol...
SUMMARY PLAN DESCRIPTION BOOKLET AND ORIENTATION PROGRAMS MARKETING PROVISIONS. 1. INSURER shall be responsible, at its sole cost, for the preparation, printing, and distribution of booklets in Spanish, which shall describe the plan, the benefits covered and the rights of enrollees. A translated copy of the enrollee’s booklet shall be made available in the English language for access to English-speaking enrollees, and for the proper revision of federal authorities. These booklets shall be delivered to each subscriber upon enrollment, along with the required identification card(s).
2. The information booklets shall serve as guarantee of the benefits to be provided to enrollees and potential enrollees and must be provided in easily understandable format and in other appropriate alternative formats considering the special needs of enrollees that may be visually limited, or have a limited reading proficiency. In the event that oral interpretation services may be necessary in a language other than Spanish, INSURER shall make those services available free of charge, and inform the enrollee and potential enrollee how to access such formats. The booklet shall contain the following information:
a) Schedule of benefits covered, amount, duration and scope of all services and items that are available and that are covered either directly or through methods of referral and/or prior authorization, a written description of how and where the services that have been available through the plan services may be obtained. Information of the extent to which and how after hours and emergency services coverage are provided: what constitutes emergency medical condition, services and postabilization care services, the fact that prior authorization is not required for emergency service, the process for obtaining services, including use of 911- telephone system, locations of emergency settings at which providers and hospitals furnish emergency care and postabilization services, the fact that subject to contract provisions the enrollee has a right to use any hospital or setting for emergency care.
b) Benefit’s exclusions and limitations. For benefits that enrollees are entitled to but are not available through the INSURER; a written description on how and where to obtain benefits; description of procedures for requesting disenrollments/changes.
c) Beneficiary’s rights and responsibilities, in accordance with specific rights and requirements set forth under 42 CFR 438.100 of the Medicaid Regulations and the Puerto Rico Patient Bxxx of Rights Law 194 of August 25, 2...
SUMMARY PLAN DESCRIPTION BOOKLET AND ORIENTATION PROGRAMS MARKETING PROVISIONS. 1. The INSURER shall be responsible for the preparation, printing and distribution, at its own cost, of booklets, in the Spanish language, that describe the plan and the benefits covered therein. The Insurer agrees to submit before the effective date of the contract a translated copy of the beneficiaries booklet in the English language by the proper revision of federal authorities. These booklets will be delivered to each subscriber upon enrollment, along with the required identification card(s).
3. The booklets shall serve as guarantee of the benefits to be provided and shall contain the following information:
a) Schedule of benefits covered, all services and items that are available and that are covered either directly or through methods of referral and/or prior authorization, a written description of how and where the services that have been available through the plan services may be obtained. b) Benefit's exclusions and limitations. For benefits that enrollees are entitled to but are not available through the MCO, a written description on how and where to obtain benefits; description of procedures for requesting disenrollments/changes.
