Common use of Enrollee Handbook Clause in Contracts

Enrollee Handbook. DVHA and AHS shall coordinate the development of the Global Commitment to Health Demonstration enrollee handbook, which shall help enrollees and potential enrollees understand the requirements and benefits of the various programs available through the Global Commitment to Health Demonstration. DVHA shall mail the enrollee handbook to all new enrollee households within 45 business days of determination of eligibility for the Global Commitment to Health Demonstration. Enrollees may request and obtain an enrollee handbook at any time. The enrollee handbook must be specific to the Global Commitment to Health Demonstration and be written in language that is clear and easily understood by an elementary-level reader. The enrollee handbook must include a comprehensive description of the Global Commitment to Health Demonstration, including a description of covered benefits, how to access services in urgent and emergent situations, how to access services in other situations (including family planning services and providers not participating in the Vermont Medicaid program), complaint and grievance procedures, appeal procedures (for eligibility determinations or service denials), enrollee disenrollment rights, advance directives, and the methods by which a member can select a provider based on specific language requirements. With respect to information on grievance, appeal and Fair Hearing procedures and timeframes, the Global Commitment to Health Demonstration enrollee handbook must include the following information: • Right to a State of Vermont Fair Hearing, method for obtaining a hearing, timeframe for filing a request, and rules that govern representation at the hearing; • Right to file grievances and appeals; • Requirements and timeframes for filing a grievance or appeal; • Availability of assistance in the filing process; • Toll-free numbers that the enrollee can use to obtain assistance in filing a grievance or an appeal, including the Long-Term Care Ombudsmen and/or other independent advocates designated by the State to assist participants; • The fact that, when requested by the enrollee, benefits will continue if the enrollee files an appeal or a request for a State of Vermont Fair Hearing within the timeframes specified for filing; and that the enrollee may be required to pay the cost of any services furnished while the appeal is pending if the denial is upheld; • Any appeal rights that the State of Vermont makes available to providers to challenge the failure of DVHA to cover a service; and • Information about Advance Directives and the service providers’ obligation to honor the terms of such directives. The following additional information must also be included in the enrollee handbook: • Information on the amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled. • Information for potential enrollees about the basic functions of managed care; which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; and DVHA responsibilities for coordination of enrollee care. • Information on specialty referrals, including long term services and supports under the Choices for Care Program; • Information on unrestricted access to family planning services; • Information on accessing emergent and urgent care (including post-stabilization services and after- hours care); • Information on enrollee disenrollment; • Information on enrollees' right to change providers; • Information on restrictions to freedom of choice among network providers; • Information on enrollee rights and protections, as specified in 42 CFR 438.100; • Information on enrollee cost sharing; • Additional information that is available upon request, including information on the structure of the • Global Commitment to Health Demonstration and any physician incentive plans; and • Information on how enrollees can access benefits including information about prior authorization requirements and services from out-of-network providers. The enrollee handbook also will include: • What constitutes an emergency medical condition and emergency services; • That prior authorization is not required for emergency services; • That the enrollee has the right use any hospital or other setting for emergency care; • Toll-free and TTY/TDY numbers for member services and any unit providing services directlyto enrollees. DVHA provides to its enrollees information about providers, which at a minimum, includes primary care physicians, specialists, and hospitals. The information on providers: • Includes provider names, locations, and telephone numbers; • Identifies providers that speak any non-English languages; • Information on specialty referrals; and • Identifies providers that are not accepting new patients. DVHA’s provider directory for physicians, including specialists, hospitals, pharmacies, behavioral health providers, and LTSS providers will include the following information: • The provider’s name and any group affiliation. • Street address(es). • Telephone number(s). • Web site URL, as appropriate. • Specialty, as appropriate. • Whether the provider will accept new enrollees. • The provider’s cultural and linguistic capabilities, including languages (including AmericanSign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training. • Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment. The provider directory will be available in paper format upon request and must be updated at least monthly; electronic provider directories must be updated no later than 30 calendar days after DVHA receives updated provider information. Electronic provider directories must be made available on DVHA’s web site in a machine-readable file and format. DVHA will assure that the following information about its formulary is available on their web site in a machine-readable file and format and provide: • Which medications are covered (both generic and name brand); and • Identify which tier each medication is on. DVHA shall notify its enrollees in writing of any change that AHS defines as significant to the information in the Global Commitment to Health Demonstration enrollee handbook at least 30 business days before the intended effective date of the change. DVHA will assure that: • All informational material will adopt uniform AHS definitions of the following managed care terms: o Appeal, o Copayment, o Durable medical equipment, o Emergency medical condition, o Emergency medical transportation, o Emergency room care, o Emergency services, o Excluded services, o Grievance, o Habilitation services and devices, o Health insurance, o Home health care, o Hospice services, o Hospitalization, o Hospital outpatient care, o Medically necessary, o Network, o Non-participating provider, o Physician services plan, o Preauthorization, o Participating provider, o Premium, o Prescription drug coverage, o Prescription drugs, o Primary care physician, o Primary care provider, o Provider, o Rehabilitation services and devices, o Skilled nursing care, o Specialist, and o Urgent care; • Any information provided to enrollees electronically is: o In a readily accessible format, o Placed in a location on the Web site that is prominent and readily accessible, o In an electronic form, which can be electronically retained and printed, o Consistent with the content and language requirements of 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and provided upon request within 5 business days. • All written materials for potential enrollees and enrollees must: o Use easily understood language and format; o Use a font size no smaller than 12 point; o Be available in alternative formats and through the provision of auxiliary aids and services in an appropriate manner that takes into consideration the special needs of enrollees or potential enrollees with disabilities or limited English proficiency; and o Include a large print tagline and information on how to request auxiliary aids and services, including the provision of the materials in alternative formats. Largeprint means printed in a font size no smaller than 18 point.

Enrollee Handbook. DVHA and AHS shall will coordinate the development of the Global Commitment to Health Demonstration enrollee handbook, which shall is intended to help enrollees and potential enrollees understand the requirements and benefits of the various programs available through the Global Commitment to Health Demonstration. DVHA shall will mail the enrollee handbook to all new enrollee households within 45 business days of determination of eligibility for the Global Commitment to Health Demonstration. Enrollees may request and obtain an enrollee handbook at any time. The enrollee handbook must be specific to the Global Commitment to Health Demonstration and be written in language that is clear and easily understood by an elementary-level reader. The enrollee handbook must include a comprehensive summary description of the Global Commitment to Health Demonstration, including a description of covered benefits, how to access services in urgent and emergent situations, how to access services in other situations (including family planning services and providers not participating in the Vermont Medicaid program), complaint and grievance procedures, appeal procedures (for eligibility determinations or service denials), enrollee disenrollment rights, advance directives, and the methods by which a member can select a provider based on specific language requirements. With respect to information on grievance, appeal and Fair Hearing procedures and timeframes, the Global Commitment to Health Demonstration enrollee handbook must include the following informationinformation on: • Right Rights to a State of Vermont Fair Hearing, method for obtaining a hearing, timeframe for filing forfiling a request, and rules that govern representation at the hearing; • Right Rights to file grievances and appeals; • Requirements and timeframes for filing a grievance or appeal; • Availability of assistance in the filing process; • Toll-free numbers that the enrollee can may use to obtain assistance in filing a grievance or an appeal, including the Long-Term Care Ombudsmen and/or other independent advocates designated by the bythe State to assist participants; • The fact that, when requested by the enrollee, benefits will continue if the enrollee files an appeal or a request for a State of Vermont Fair Hearing within the timeframes specified for filing; and that the enrollee may be required to pay the cost of any services furnished while the appeal is pending if the denial is upheld; • Any appeal rights that the State of Vermont makes available to providers to challenge the failure of a denial by DVHA to cover a service; and • Information about Advance Directives and the service providers’ obligation to honor the terms of such directives. The following additional information must also be included in the enrollee handbook: • Information Sufficient information on the amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled. ; • Information for potential enrollees about the basic functions of managed care; which • Which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; and • DVHA responsibilities for coordination of enrollee care. ; • Information on specialty referrals, including long term services and supports under the Choices for Care Programprogram; • Information on unrestricted access to family planning services; • Information on accessing emergent and urgent care (including post-stabilization services and after- andafter- hours care); • Information on enrollee disenrollment; • Information on enrollees' right to change providers; • Information on restrictions to freedom of choice among network providers; • Information on enrollee rights and protections, as specified in 42 CFR 438.100; • Information on enrollee cost sharing; • Additional information that is available upon request, including information on the structure of the • Global Commitment to Health Demonstration and any physician incentive plans; and • Information on how enrollees can access benefits benefits, including information about prior authorization requirements and services from out-of-network providers. The enrollee handbook also will include: • What constitutes an emergency medical condition and emergency services; • That prior authorization is not required for emergency services; • That the enrollee has the right to use any hospital or other setting for emergency careemergencycare; • Toll-free and TTY/TDY numbers for member services and any unit providing services directlyto directly to enrollees. DVHA provides to its enrollees information about providers, which at a minimum, includes primary care physicians, specialists, and hospitals. The information on providers: • Includes provider names, locations, and telephone numbers; • Identifies providers that speak any non-English languages; • Information on specialty referrals; and • Identifies providers that are not accepting new patients. DVHA’s provider directory for physicians, including specialists, hospitals, pharmacies, behavioral health providers, and LTSS providers will include the following information: • The provider’s name and any group affiliation. • Street address(es). • Telephone number(s). • Web site URL, as appropriate. • Specialty, as appropriate. • Whether the provider will accept new enrollees. enrollees • The provider’s cultural and linguistic capabilities, including languages (including AmericanSign American Sign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training. training • Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment. The provider directory will be available in paper format upon request and must be updated at least monthly; electronic provider directories must be updated no later than 30 calendar days after DVHA receives updated provider information. Electronic provider directories must be made available on DVHA’s web site in a machine-readable file and format. DVHA will assure that the following information about its formulary is available on their its web site in a machine-readable file and format and provide: • Which medications are covered (both generic and name brand); and • Identify which tier each medication is on. DVHA shall will notify its enrollees in writing of any change that AHS defines as significant to the information in the Global Commitment to Health Demonstration enrollee handbook at least 30 business days before the intended effective date of the change. DVHA will assure that: • All informational material will adopt uniform AHS definitions of the following managed care terms: o Appeal, o Copayment, o Durable medical equipment, o Emergency medical condition, o Emergency medical transportation, o Emergency room care, o Emergency services, o Excluded services, o Grievance, o Habilitation services and devices, o Health insurance, o Home health care, o Hospice services, o Hospitalization, o Hospital outpatient care, o Medically necessary, o Network, o Non-participating provider, o Physician services plan, o Preauthorization, o Participating provider, o Premium, o Prescription drug coverage, o Prescription drugs, o Primary care physician, o Primary care provider, o Provider, o Rehabilitation services and devices, o Skilled nursing care, o Specialist, and o Urgent care; • Any information provided to enrollees electronically is: o In a readily accessible format, o Placed in a location on the Web site that is prominent and readily accessible, o In an electronic form, which can be electronically retained and printed, o Consistent with the content and language requirements of 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon chargeupon request and provided upon request within 5 business days. • All written materials for potential enrollees and enrollees must: o Use easily understood language and format; o Use a font size no smaller than 12 point; o Be available in alternative formats and through the provision of auxiliary aids and services in an inan appropriate manner that takes into consideration the special needs of enrollees or potential enrollees with disabilities or limited English proficiency; and o Include a large print tagline and information on how to request auxiliary aids and services, including the provision of the materials in alternative formats. Largeprint Large print means printed in a font size no smaller than 18 point.

Enrollee Handbook. DVHA and AHS shall will coordinate the development of the Global Commitment to Health Demonstration enrollee handbook, which shall is intended to help enrollees and potential enrollees understand the requirements and benefits of the various programs available through the Global Commitment to Health Demonstration. DVHA shall will mail the enrollee handbook to all new enrollee households within 45 business days of determination of eligibility for the Global Commitment to Health Demonstration. Enrollees may request and obtain an enrollee handbook at any time. The enrollee handbook must be specific to the Global Commitment to Health Demonstration and be written in language that is clear and easily understood by an elementary-level reader. The enrollee handbook must include a comprehensive summary description of the Global Commitment to Health Demonstration, including a description of covered benefits, how to access services in urgent and emergent situations, how to access services in other situations (including family planning services and providers not participating in the Vermont Medicaid program), complaint and grievance procedures, appeal procedures (for eligibility determinations or service denials), enrollee disenrollment rights, advance directives, and the methods by which a member can select a provider based on specific language requirements. With respect to information on grievance, appeal and Fair Hearing procedures and timeframes, the Global Commitment to Health Demonstration enrollee handbook must include the following informationinformation on: • Right Rights to a State of Vermont Fair Hearing, method for obtaining a hearing, timeframe for filing a request, and rules that govern representation at the hearing; • Right Rights to file grievances and appeals; • Requirements and timeframes for filing a grievance or appeal; • Availability of assistance in the filing process; • Toll-free numbers that the enrollee can may use to obtain assistance in filing a grievance or an appeal, including the Long-Term Care Ombudsmen and/or other independent advocates designated by the State to assist participants; • The fact that, when requested by the enrollee, benefits will continue if the enrollee files an appeal or a request for a State of Vermont Fair Hearing within the timeframes specified for filing; and that the enrollee may be required to pay the cost of any services furnished while the appeal is pending if the denial is upheld; • Any appeal rights that the State of Vermont makes available to providers to challenge the failure of a denial by DVHA to cover a service; and • Information about Advance Directives and the service providers’ obligation to honor the terms of such directives. The following additional information must also be included in the enrollee handbook: • Information Sufficient information on the amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled. • Information for potential enrollees about the basic functions of managed care; which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; and DVHA responsibilities for coordination of enrollee care. • Information on specialty referrals, including long term services and supports under the Choices for Choicesfor Care Programprogram; • Information on unrestricted access to family planning services; • Information on accessing emergent and urgent care (including post-stabilization services and after- hours care); • Information on enrollee disenrollment; • Information on enrollees' right to change providers; • Information on restrictions to freedom of choice among network providers; • Information on enrollee rights and protections, as specified in 42 CFR 438.100; • Information on enrollee cost sharing; • Additional information that is available upon request, including information on the structure of the • Global Commitment to Health Demonstration and any physician incentive plans; and • Information on how enrollees can access benefits benefits, including information about prior authorization requirements and services from out-of-network providers. The enrollee handbook also will include: • What constitutes an emergency medical condition and emergency services; • That prior authorization is not required for emergency services; • That the enrollee has the right use any hospital or other setting for emergency care; • Toll-free and TTY/TDY numbers for member services and any unit providing services directlyto enrollees. DVHA provides to its enrollees information about providers, which at a minimum, includes primary care physicians, specialists, and hospitals. The information on providers: • Includes provider names, locations, and telephone numbers; • Identifies providers that speak any non-English languages; • Information on specialty referrals; and • Identifies providers that are not accepting new patients. DVHA’s provider directory for physicians, including specialists, hospitals, pharmacies, behavioral health providers, and LTSS providers will include the following information: • The provider’s name and any group affiliation. • Street address(es). • Telephone number(s). • Web site URL, as appropriate. • Specialty, as appropriate. • Whether the provider will accept new enrollees. • The provider’s cultural and linguistic capabilities, including languages (including AmericanSign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training. • Whether the provider’s office/facility has accommodations for people with physical disabilitiesphysicaldisabilities, including offices, exam room(s) and equipment. The provider directory will be available in paper format upon request and must be updated at least monthly; electronic provider directories must be updated no later than 30 calendar days after DVHA receives updated provider information. Electronic provider directories must be made available on DVHA’s web site in a machine-readable file and format. DVHA will assure that the following information about its formulary is available on their its web site in a machine-readable file and format and provide: • Which medications are covered (both generic and name brand); and • Identify which tier each medication is on. DVHA shall will notify its enrollees in writing of any change that AHS defines as significant to the information in the Global Commitment to Health Demonstration enrollee handbook at least 30 business days before the intended effective date of the change. DVHA will assure that: • All informational material will adopt uniform AHS definitions of the following managed care terms: o Appeal, o Copayment, o Durable medical equipment, o Emergency medical condition, o Emergency medical transportation, o Emergency room care, o Emergency services, o Excluded services, o Grievance, o Habilitation services and devices, o Health insurance, o Home health care, o Hospice services, o Hospitalization, o Hospital outpatient care, o Medically necessary, o Network, o Non-participating provider, o Physician services plan, o Preauthorization, o Participating provider, o Premium, o Prescription drug coverage, o Prescription drugs, o Primary care physician, o Primary care provider, o Provider, o Rehabilitation services and devices, o Skilled nursing care, o Specialist, and o Urgent care; • Any information provided to enrollees electronically is: o In a readily accessible format, o Placed in a location on the Web site that is prominent and readily accessible, o In an electronic form, which can be electronically retained and printed, o Consistent with the content and language requirements of 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and provided upon request within 5 business days. • All written materials for potential enrollees and enrollees must: o Use easily understood language and format; o Use a font size no smaller than 12 point; o Be available in alternative formats and through the provision of auxiliary aids and services in an appropriate manner that takes into consideration the special needs of enrollees or potential enrollees with disabilities or limited English proficiency; and o Include a large print tagline and information on how to request auxiliary aids and services, including the provision of the materials in alternative formats. Largeprint means printed in a font size no smaller than 18 point.

Enrollee Handbook. DVHA The OVHA and the AHS shall coordinate the development of the Global Commitment to Health Demonstration Waiver enrollee handbook, which shall help enrollees and potential enrollees understand the requirements and benefits of the various programs available through the Global Commitment to Health DemonstrationWaiver. DVHA The OVHA shall mail the enrollee handbook to all new enrollee households enrollees within 45 business days of determination of eligibility for the Global Commitment to Health Demonstration. Enrollees may request and obtain an enrollee handbook at any timeWaiver. The enrollee handbook must be specific to the Global Commitment to Health Demonstration Waiver and be written in language that is clear and easily understood by an elementary-level reader. The enrollee handbook must include a comprehensive description of the Global Commitment to Health DemonstrationWaiver, including a description of covered benefits, how to access services in urgent and emergent situations, how to access services in other situations (including family planning services and providers not participating in the Vermont Medicaid program)situations, complaint and grievance procedures, appeal procedures (for eligibility determinations or service denials), enrollee disenrollment dis-enrollment rights, and advance directives, and the methods by which a member can select a provider based on specific language requirements. With respect to information on grievance, appeal and Fair Hearing procedures and timeframes, the Global Commitment to Health Demonstration Waiver enrollee handbook must include the following information: • Right to a State of Vermont Fair Hearing, method for obtaining a hearing, timeframe for filing a request, timeframes for resolution of the Fair Hearing, and rules that govern representation at the hearing; • Right to file grievances and appeals; • Requirements and timeframes for filing a grievance or appeal; • Availability of assistance in the filing process; • Toll-free numbers that the enrollee can use to obtain assistance in filing a grievance or an appeal, including the Long-Term Care Ombudsmen and/or other independent advocates designated by the State to assist participants; • The fact that, when requested by the enrollee, benefits will continue if the enrollee files an appeal or a request for a State of Vermont Fair Hearing within the timeframes specified for filing; and that the enrollee may be required to pay the cost of any services furnished while the appeal is pending if the denial is upheld; • Any appeal rights that the State of Vermont makes available to providers to challenge the failure of DVHA the OVHA to cover a service; and • Information about Advance Directives and the service providers’ obligation to honor the terms of such directives. The following additional information must also be included in the enrollee handbook: • Information on the amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled. • Information for potential enrollees about the basic functions of managed care; which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; and DVHA responsibilities for coordination of enrollee care. • Information on specialty referrals, including long term services and supports under the Choices for Care Program; • Information on unrestricted access to family planning services; • Information on accessing emergent and urgent care (including post-stabilization services and after- hours care); • Information on enrollee disenrollment; • Information on enrollees' right to change providers; • Information on restrictions to freedom of choice among network providers; • Information on enrollee rights and protections, as specified in 42 CFR 438.100; • Information on enrollee cost sharing; • Additional information that is available upon request, including information on the structure of the • Global Commitment to Health Demonstration Waiver and any physician incentive plans; and • Information on how enrollees can access benefits including information about prior authorization requirements and services from out-of-network providers. The enrollee handbook also will include: • What constitutes an emergency medical condition and emergency services; • That prior authorization is not required for emergency services; • That the enrollee has the right use any hospital or other setting for emergency care; • Toll-free and TTY/TDY numbers for member services and any unit providing services directlyto enrollees. DVHA provides to its enrollees information about providers, which at a minimum, includes primary care physicians, specialists, and hospitals. The information on providers: • Includes provider names, locations, and telephone numbers; • Identifies providers that speak any non-English languages; • Information on specialty referrals; and • Identifies providers that are not accepting new patients. DVHA’s provider directory for physicians, including specialists, hospitals, pharmacies, behavioral health providers, and LTSS providers will include the following information: • The provider’s name and any group affiliation. • Street address(es). • Telephone number(s). • Web site URL, as appropriate. • Specialty, as appropriate. • Whether the provider will accept new enrollees. • The provider’s cultural and linguistic capabilities, including languages (including AmericanSign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training. • Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment. The provider directory will be available in paper format upon request and must be updated at least monthly; electronic provider directories must be updated no later than 30 calendar days after DVHA receives updated provider information. Electronic provider directories must be made available on DVHA’s web site in a machine-readable file and format. DVHA will assure that the following information about its formulary is available on their web site in a machine-readable file and format and provide: • Which medications are covered (both generic and name brand); and • Identify which tier each medication is on. DVHA OVHA shall notify its enrollees in writing of any change that the AHS defines as significant to the information in the Global Commitment to Health Demonstration Waiver enrollee handbook at least 30 business days before the intended effective date of the change. DVHA will assure that: • All informational material will adopt uniform AHS definitions of the following managed care terms: o Appeal, o Copayment, o Durable medical equipment, o Emergency medical condition, o Emergency medical transportation, o Emergency room care, o Emergency services, o Excluded services, o Grievance, o Habilitation services and devices, o Health insurance, o Home health care, o Hospice services, o Hospitalization, o Hospital outpatient care, o Medically necessary, o Network, o Non-participating provider, o Physician services plan, o Preauthorization, o Participating provider, o Premium, o Prescription drug coverage, o Prescription drugs, o Primary care physician, o Primary care provider, o Provider, o Rehabilitation services and devices, o Skilled nursing care, o Specialist, and o Urgent care; • Any information provided to enrollees electronically is: o In a readily accessible format, o Placed in a location on the Web site that is prominent and readily accessible, o In an electronic form, which can be electronically retained and printed, o Consistent with the content and language requirements of 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and provided upon request within 5 business days. • All written materials for potential enrollees and enrollees must: o Use easily understood language and format; o Use a font size no smaller than 12 point; o Be available in alternative formats and through the provision of auxiliary aids and services in an appropriate manner that takes into consideration the special needs of enrollees or potential enrollees with disabilities or limited English proficiency; and o Include a large print tagline and information on how to request auxiliary aids and services, including the provision of the materials in alternative formats. Largeprint means printed in a font size no smaller than 18 point.

Enrollee Handbook. DVHA and AHS shall will coordinate the development of the Global Commitment to Health Demonstration enrollee handbook, which shall is intended to help enrollees and potential enrollees understand the requirements and benefits of the various programs available through the Global Commitment to Health Demonstration. DVHA shall will mail the enrollee handbook to all new enrollee households within 45 business days of determination of eligibility for the Global Commitment to Health Demonstration. Enrollees may request and obtain an enrollee handbook at any time. The enrollee handbook must be specific to the Global Commitment to Health Demonstration and be written in language that is clear and easily understood by an elementary-level reader. The enrollee handbook must include a comprehensive summary description of the Global Commitment to Health Demonstration, including a description of covered benefits, how to access services in urgent and emergent situations, how to access services in other situations (including family planning services and providers not participating in the Vermont Medicaid program), complaint and grievance procedures, appeal procedures (for eligibility determinations or service denials), enrollee disenrollment rights, advance directives, and the methods by which a member can select a provider based on specific language requirements. With respect to information on grievance, appeal and Fair Hearing procedures and timeframes, the Global Commitment to Health Demonstration enrollee handbook must include the following informationinformation on: • Right Rights to a State of Vermont Fair Hearing, method for obtaining a hearing, timeframe for filing a request, and rules that govern representation at the hearing; • Right Rights to file grievances and appeals; • Requirements and timeframes for filing a grievance or appeal; • Availability of assistance in the filing process; • Toll-free numbers that the enrollee can may use to obtain assistance in filing a grievance or an appeal, including the Long-Term Care Ombudsmen and/or other independent advocates designated by the State to assist participants; • The fact that, when requested by the enrollee, benefits will continue if the enrollee files an appeal or a request for a State of Vermont Fair Hearing within the timeframes specified for filing; and that the enrollee may be required to pay the cost of any services furnished while the appeal is pending if the denial is upheld; • Any appeal rights that the State of Vermont makes available to providers to challenge the failure of a denial by DVHA to cover a service; and • Information about Advance Directives and the service providers’ obligation to honor the terms of such directives. The following additional information must also be included in the enrollee handbook: • Information Sufficient information on the amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled. ; • Information for potential enrollees about the basic functions of managed care; which • Which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; and • DVHA responsibilities for coordination of enrollee care. ; • Information on specialty referrals, including long term services and supports under the Choices for Care Programprogram; • Information on unrestricted access to family planning services; • Information on accessing emergent and urgent care (including post-stabilization services and after- hours care); • Information on enrollee disenrollment; • Information on enrollees' right to change providers; • Information on restrictions to freedom of choice among network providers; • Information on enrollee rights and protections, as specified in 42 CFR 438.100; • Information on enrollee cost sharing; • Additional information that is available upon request, including information on the structure of the • Global Commitment to Health Demonstration and any physician incentive plans; and • Information on how enrollees can access benefits benefits, including information about prior authorization requirements and services from out-of-network providersnetworkproviders. The enrollee handbook also will include: • What constitutes an emergency medical condition and emergency services; • That prior authorization is not required for emergency services; • That the enrollee has the right to use any hospital or other setting for emergency careemergencycare; • Toll-free and TTY/TDY numbers for member services and any unit providing services directlyto directly to enrollees. DVHA provides to its enrollees information about providers, which at a minimum, includes primary care physicians, specialists, and hospitals. The information on providers: • Includes provider names, locations, and telephone numbers; • Identifies providers that speak any non-English languages; • Information on specialty referrals; and • Identifies providers that are not accepting new patients. DVHA’s provider directory for physicians, including specialists, hospitals, pharmacies, behavioral health providers, and LTSS providers will include the following information: • The provider’s name and any group affiliation. • Street address(es). • Telephone number(s). • Web site URL, as appropriate. • Specialty, as appropriate. • Whether the provider will accept new enrollees. enrollees • The provider’s cultural and linguistic capabilities, including languages (including AmericanSign American Sign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training. training • Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment. The provider directory will be available in paper format upon request and must be updated at least monthly; electronic provider directories must be updated no later than 30 calendar days after DVHA receives updated provider information. Electronic provider directories must be made available on DVHA’s web site in a machine-readable file and format. DVHA will assure that the following information about its formulary is available on their its web site in a machine-readable file and format and provide: • Which medications are covered (both generic and name brand); and • Identify which tier each medication is on. DVHA shall will notify its enrollees in writing of any change that AHS defines as significant to the information in the Global Commitment to Health Demonstration enrollee handbook at least 30 business days before the intended effective date of the change. DVHA will assure that: • All informational material will adopt uniform AHS definitions of the following managed care terms: o Appeal, o Copayment, o Durable medical equipment, o Emergency medical condition, o Emergency medical transportation, o Emergency room care, o Emergency services, o Excluded services, o Grievance, o Habilitation services and devices, o Health insurance, o Home health care, o Hospice services, o Hospitalization, o Hospital outpatient care, o Medically necessary, o Network, o Non-participating provider, o Physician services plan, o Preauthorization, o Participating provider, o Premium, o Prescription drug coverage, o Prescription drugs, o Primary care physician, o Primary care provider, o Provider, o Rehabilitation services and devices, o Skilled nursing care, o Specialist, and o Urgent care; • Any information provided to enrollees electronically is: o In a readily accessible format, o Placed in a location on the Web site that is prominent and readily accessible, o In an electronic form, which can be electronically retained and printed, o Consistent with the content and language requirements of 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and provided upon request within 5 business days. • All written materials for potential enrollees and enrollees must: o Use easily understood language and format; o Use a font size no smaller than 12 point; o Be available in alternative formats and through the provision of auxiliary aids and services in an appropriate manner that takes into consideration the special needs of enrollees or potential enrollees with disabilities or limited English proficiency; and o Include a large print tagline and information on how to request auxiliary aids and services, including the provision of the materials in alternative formats. Largeprint Large print means printed in a font size no smaller than 18 point.

Enrollee Handbook. DVHA and AHS shall coordinate the development of the Global Commitment to Health Demonstration Waiver enrollee handbook, which shall help enrollees and potential enrollees understand the requirements and benefits of the various programs available through the Global Commitment to Health DemonstrationWaiver. DVHA shall mail the enrollee handbook to all new enrollee households within 45 business days of determination of eligibility for the Global Commitment to Health DemonstrationWaiver. Enrollees may request and obtain an enrollee handbook at any time. The enrollee handbook must be specific to the Global Commitment to Health Demonstration Waiver and be written in language that is clear and easily understood by an elementary-level reader. The enrollee handbook must include a comprehensive description of the Global Commitment to Health DemonstrationWaiver, including a description of covered benefits, how to access services in urgent and emergent situations, how to access services in other situations (including family planning services and providers not participating in the Vermont Medicaid program), complaint and grievance procedures, appeal procedures (for eligibility determinations or service denials), enrollee disenrollment rights, and advance directives, and the methods by which a member can select a provider based on specific language requirements. With respect to information on grievance, appeal and Fair Hearing procedures and timeframes, the Global Commitment to Health Demonstration enrollee handbook must include the following information: • Right to a State of Vermont Fair Hearing, method for obtaining a hearing, timeframe for filing a request, and rules that govern representation at the hearing; • Right to file grievances and appeals; • Requirements and timeframes for filing a grievance or appeal; • Availability of assistance in the filing process; • Toll-free numbers that the enrollee can use to obtain assistance in filing a grievance or an appeal, including the Long-Term Care Ombudsmen and/or other independent advocates designated by the State to assist participants; • The fact that, when requested by the enrollee, benefits will continue if the enrollee files an appeal or a request for a State of Vermont Fair Hearing within the timeframes specified for filing; and that the enrollee may be required to pay the cost of any services furnished while the appeal is pending if the denial is upheld; • Any appeal rights that the State of Vermont makes available to providers to challenge the failure of DVHA to cover a service; and • Information about Advance Directives and the service providers’ obligation to honor the terms of such directives. ; The following additional information must also be included in the enrollee handbook: • Information on the amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled. • Information for potential enrollees about the basic functions of managed care; which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; and DVHA responsibilities for coordination of enrollee care. • Information on specialty referrals, including long term services and supports under the Choices for Care Program; • Information on unrestricted access to family planning services; • Information on accessing emergent and urgent care (including post-stabilization services and after- hours care); • Information on enrollee disenrollment; • Information on enrollees' enrollee right to change providers; • Information on restrictions to freedom of choice among network providers; • Information on enrollee rights and protections, as specified in 42 CFR 438.100438.100 and IGA Section 2.15; • Information on enrollee cost sharing; and • Additional information that is available upon request, including information on the structure of the • Global Commitment to Health Demonstration and any physician incentive plans; and • Information on how enrollees can access benefits including information about prior authorization requirements and services from out-of-network providers. The enrollee handbook also will include: • What constitutes an emergency medical condition and emergency services; • That prior authorization is not required for emergency services; • That the enrollee has the right use any hospital or other setting for emergency care; • Toll-free and TTY/TDY numbers for member services and any unit providing services directlyto enrollees. DVHA MCE provides to its enrollees information about providerson providers which, which at a minimum, includes primary care physicians, specialists, and hospitals. The information on providersinformation: • Includes provider names, locations, and telephone numbers; , • Identifies providers that speak any non-English languages; . • Information on specialty referrals; and . • Identifies providers that are not accepting new patients. DVHA’s provider directory for physicians, including specialists, hospitals, pharmacies, behavioral health providers, and LTSS providers will include the following information: • The provider’s name and any group affiliation. • Street address(es). • Telephone number(s). • Web site URL, as appropriate. • Specialty, as appropriate. • Whether the provider will accept new enrollees. • The provider’s cultural and linguistic capabilities, including languages (including AmericanSign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training. • Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment. The provider directory will be available in paper format upon request and must be updated at least monthly; electronic provider directories must be updated no later than 30 calendar days after DVHA receives updated provider information. Electronic provider directories must be made available on DVHA’s web site in a machine-readable file and format. DVHA will assure that the following information about its formulary is available on their web site in a machine-readable file and format and provide: • Which medications are covered (both generic and name brand); and • Identify which tier each medication is on. DVHA shall notify its enrollees in writing of any change that AHS defines as significant to the information in the Global Commitment to Health Demonstration Waiver enrollee handbook at least 30 business days before the intended effective date of the change. DVHA will assure that: • All informational material will adopt uniform AHS definitions of the following managed care terms: o Appeal, o Copayment, o Durable medical equipment, o Emergency medical condition, o Emergency medical transportation, o Emergency room care, o Emergency services, o Excluded services, o Grievance, o Habilitation services and devices, o Health insurance, o Home health care, o Hospice services, o Hospitalization, o Hospital outpatient care, o Medically necessary, o Network, o Non-participating provider, o Physician services plan, o Preauthorization, o Participating provider, o Premium, o Prescription drug coverage, o Prescription drugs, o Primary care physician, o Primary care provider, o Provider, o Rehabilitation services and devices, o Skilled nursing care, o Specialist, and o Urgent care; • Any information provided to enrollees electronically is: o In a readily accessible format, o Placed in a location on the Web site that is prominent and readily accessible, o In an electronic form, which can be electronically retained and printed, o Consistent with the content and language requirements of 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and provided upon request within 5 business days. • All written materials for potential enrollees and enrollees must: o Use easily understood language and format; o Use a font size no smaller than 12 point; o Be available in alternative formats and through the provision of auxiliary aids and services in an appropriate manner that takes into consideration the special needs of enrollees or potential enrollees with disabilities or limited English proficiency; and o Include a large print tagline and information on how to request auxiliary aids and services, including the provision of the materials in alternative formats. Largeprint means printed in a font size no smaller than 18 point.