Enrollee Access to Services Clause Samples
Enrollee Access to Services. A. General
1. The Contractor must provide services to Enrollees as follows:
a. Authorize, arrange, coordinate and provide to Enrollees all Medically Necessary Covered Services as specified in Section 2.4, Appendix A and Appendix B, in accordance with the requirements of the Contract; Offer adequate choice and availability of primacy, specialty, acute care, behavioral health and long term services and support providers that meet CMS and EOHHS standards as provided in Section 2.8.B; Reasonably accommodate persons and ensure that the programs and services are as accessible (including physical and geographic access) to an individual with disabilities as they are to an individual without disabilities. The Contractor and its Network Providers must comply with the American with Disabilities Act (ADA) (28 C.F.R. § 35.130) and Section 504 of the Rehabilitation Act of 1973 (Section 504) (29 U.S.C. § 794) and maintain capacity to deliver services in a manner that accommodates the needs of its Enrollees. The Contractor shall have written policies and procedures to assure compliance, including ensuring that physical, communication, and programmatic barriers do not inhibit individuals with disabilities from obtaining all Covered Services from the Contractor by: Providing flexibility in scheduling to accommodate the needs of the Enrollees; Ensuring that individuals with disabilities are provided with reasonable accommodations to ensure effective communication, including auxiliary aids and services. Reasonable accommodations will depend on the particular needs of the individual and include but are not limited to: Providing large print (at least 16-point font) versions of all written materials to individuals with visual impairments; Ensuring that all written materials are available in formats compatible with optical recognition software; Reading notices and other written materials to individuals upon request; Assisting individuals in filling out forms over the telephone; Ensuring effective communication to and from individuals with disabilities through email, telephone, and other electronic means; TTY, computer-aided transcription services, telephone handset amplifiers, assistive listening systems, closed caption decoders, videotext displays and qualified American Sign Language interpreters for the Deaf; and Individualized forms of assistance; Ensuring safe and appropriate physical access to buildings, services and equipment; Demonstrating compliance with the ADA by conduc...
Enrollee Access to Services. General The Contractor: Must demonstrate its ability to meet the needs of Enrollees competently and promptly; Must offer adequate choice and availability of Providers, and allow each Enrollee to choose his or her Provider to the extent possible and appropriate; Must provide adequate access to Covered Services (listed in Appendix A), including physical and geographic access. Such access must be designed to accommodate the needs of Enrollees who are disabled or non-English speaking, including access to TTY (for the deaf and hard of hearing) and translation services; Must provide all Covered Services in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services provided under MassHealth fee for service. Must provide all Covered Services that are medically necessary pursuant to 130 CMR 450.204, including those Covered Services that: Prevent, diagnose, and treat health impairments; Achieve age-appropriate growth and development; Attain, maintain, or regain functional capacity; and Provide an opportunity for an Enrollee receiving long-term services and supports to have access to the benefits of community living, to achieve person-centered goals, and live and work in the setting of his or choice. Must ensure that all Covered Services are sufficient in an amount, duration, or scope to reasonably achieve the purpose for which the services are furnished; May place appropriate limits on a Covered Service for the purpose of utilization control, provided that: The furnished services can reasonably be expected to achieve their purpose; Services supporting Enrollees with ongoing or chronic conditions or who require LTSS are authorized in a manner that reflects the Enrollee’s ongoing need for such services and supports; and Family planning services are provided in a manner that protects and enables the Enrollee’s freedom to choose the method of family planning to be used. May place appropriate limits on a Covered Service on the basis of Medical Necessity. The Contractor’s Medical Necessity guidelines must, at a minimum, be: Developed with input from practicing physicians throughout the Contractor’s Regions; Developed in accordance with standards adopted by national accreditation organizations where applicable and available; Developed in accordance with the definition of Medical Necessity in this Contract and therefore no more restrictive than MassHealth Medical Necessity guidelines; Updated at least annually or as new treatme...
Enrollee Access to Services. The Contractor must provide services to Enrollees as follows:
Enrollee Access to Services. A. General The Contractor must:
1. Demonstrate its ability to meet the needs of Enrollees competently and promptly;
2. Offer adequate choice and availability of PCPs and PCTs, if Complex Care Needs are present, as well as behavioral health and long term care Providers;
3. Provide adequate access to Covered Services (listed in Appendix A), including physical and geographic access. Such access must be designed to accommodate the needs of Enrollees who are disabled or non-English speaking, including access to TTY (for the deaf and hard of hearing) and translation services;
4. Provide all Covered Services in a manner that is no more restrictive than MassHealth fee for service; and is responsible for covering, at a minimum, all medically necessary services pursuant to 130 CMR 450.204; and
5. Comply with all federal requirements regarding the provision of services, including but not limited to 42 CFR 431.51(b)(2) and 42 CFR 441.202.
Enrollee Access to Services