At enrollment Clause Samples
At enrollment. At the time a participant's needs necessitate the disclosure and delivery of such information in order to allow the participant to make an informed choice. Be encouraged to involve caregivers or family members in treatment discussions and decisions. Have advance directives explained and to establish them, if the participant so desires, in accordance with 42 C.F.R. §§ 489.100 and 489.102. Receive reasonable advance notice, in writing, of any transfer to another treatment setting and the justification for the transfer. Be afforded the opportunity to file an Appeal if services are denied that he or she thinks are medically indicated, and to be able to ultimately take that Appeal to an independent external system of review. The right to receive medical and non-medical care from a team that meets the beneficiary's needs, in a manner that is sensitive to the beneficiary's language and culture, and in an appropriate care setting, including the home and community. The right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. The right to freely exercise his or her rights, and to be assured that exercising those rights will not adversely affect the way the Contractor and its providers or the State Agency treat the Enrollee. The right to receive the information required pursuant to the Contract; The right to receive timely information about plan changes. This includes the right to request and obtain the information listed in the Orientation materials at least once per year, and the right to receive notice of any significant change in the information provided in the Orientation materials at least 30 days prior to the intended effective date of the change. See 42 C.F.R. § 438.10(g). The right to be protected from liability for payment of any fees that are the obligation of the Contractor. The right not to be charged any cost sharing for Medicare Parts A and B services. APPENDIX D – RELATIONSHIP WITH FIRST TIER, DOWNSTREAM, AND RELATED ENTITIES Contractor shall ensure that any contracts or agreements with First Tier, Downstream and Related Entities performing functions on Contractor’s behalf related to the operation of the plan offered by the Contractor are in compliance with 42 C.F.R. §§ 422.504, 423.505, and 438.6(l). Contractor shall specifically ensure: Prior to contracting with any First Tier, Downstream and Related Entities, the Contractor has evaluated their ability to perform the activities to...
At enrollment. At the time a participant's needs necessitate the disclosure and delivery of such information in order to allow the participant to make an informed choice.
At enrollment. At the time a Potential Enrollee’s or Enrollee’s needs necessitate the disclosure and delivery of such information in order to allow the Potential Enrollee or Enrollee to make an informed choice.
At enrollment. 2.5.1.1.1.1. The Contractor shall complete a Comprehensive Assessment within thirty (30) calendar days of each Enrollee’s Effective Enrollment Date.
2.5.1.1.1.2. The Contractor shall make subsequent attempts beyond the thirty (30) days if the initial attempt to contact the Enrollee is unsuccessful. The Contractor shall incorporate the following into their policies and procedures for unreachable Enrollees:
2.5.1.1.1.2.1. The Contractor shall submit a weekly no contact list to EOHHS outlining frequency and type of outreach efforts,
2.5.1.1.1.2.2. The Contractor’s Medical Director or designee shall review past and/or current claims utilization to find provider(s) and/or pharmacies connected to the Enrollee, and
2.5.1.1.1.2.3. The Contractor shall notify EOHHS of Enrollees who remain unreachable after 180 days, have not actively participated in Care Coordination, Assessment and Care Planning, and who have no claims for physical and/or behavioral health treatment.
2.5.1.1.1.3. With the Member’s consent, the Contractor may complete the assessment in advance of the Effective Enrollment Date for new SCO program Enrollees.
2.5.1.1.1.4. For Enrollees participating in the Frail Elder Waiver, the assessment at the time of enrollment is completed by an ASAP RN.
2.5.1.1.1.5. The Contractor is not required to conduct a new Comprehensive Assessment for individuals who were enrolled in the Contractor’s SCO Plan prior to January 1, 2026, and for whom that Comprehensive Assessment is still current.