Information Requirements for Enrollees and Potential Enrollees Clause Samples
Information Requirements for Enrollees and Potential Enrollees. The Contractor must provide to potential Enrollees and new Enrollees the information needed to understand benefit coverage and obtain care in accord with the provisions of this Section (42 C.F.R. § 438.10(b)(3) and 438.10(f)(3)). The information must be provided at least once a year, upon request and within fifteen (15) business days after the Contractor was notified of enrollment. The Contractor must notify Enrollees of their ability to request the information at any time. If the Enrollee or potential Enrollee is not able to understand written information, the Contractor will provide at no cost the necessary information in an alternative language or format that is understandable to the Enrollee or potential Enrollee.
Information Requirements for Enrollees and Potential Enrollees. 3.6.1 The Contractor shall provide to Potential Enrollees and new Enrollees the information needed to understand benefit coverage and obtain care. The information shall be provided at least once a year, upon request and within fifteen (15) Business Days after the Contractor was notified of enrollment.
3.6.2 The Contractor shall notify Enrollees of their ability to request the information at any time. If the Enrollee or Potential Enrollee is not able to understand written information, the Contractor will provide at no cost the necessary information in an alternative language or format that is understandable to the Enrollee or Potential Enrollee.
3.6.3 The HCA will produce and the Contractor shall use managed care handbook templates. HCA-produced templates and HCA-approved Contractor handbooks will provide sufficient, accurate and current written information to assist Potential Enrollees in making an informed decision about enrollment.
3.6.4 The Contractor shall provide to each Enrollee, and to each Potential Enrollee who requests it, HCA-approved Managed Care handbooks.
3.6.4.1 The Contractor shall provide HCA-approved Managed Care handbooks in a translated version or through Auxiliary Aids and Services in a manner that takes into consideration the special needs of Enrollees and Potential Enrollees with disabilities or limited English proficiency.
3.6.4.2 The Contractor shall develop content for the Managed Care handbooks in the sections labeled for Contractor use in the templates.
3.6.5 The Contractor may develop supplemental materials specific to the Contractor’s programs, in addition to the Managed Care handbooks that are sent to newly enrolled and assigned Enrollees. The supplemental, plan-specific, material shall be incorporated into the Managed Care handbook templates as instructed by HCA. The supplemental, plan-specific, materials will include mandatory materials such as NCQA-required materials and the annual notices that the Contractor is required to send to Enrollees.
3.6.5.1 Supplemental, plan–specific, materials may not duplicate information, such as covered benefits, contained in HCA’s approved handbook templates and the Contractor’s approved Managed Care handbooks, but may include contact numbers for Contractor’s customer service, information about the Contractor’s authorization processes, network Providers and/or VABs that the Contractor provides.
3.6.5.1.1 Contractor may not include a VAB in any material distributed to Enrollees or prospectiv...
Information Requirements for Enrollees and Potential Enrollees. 3.2.1 The Contractor shall provide to potential enrollees and new enrollees sufficient, accurate information needed to understand benefit coverage and obtain care in accord with the provisions of this Section (42 C.F.R. § 438.10(b)(3) and 438.10(f)(3)). The information shall be provided at least once a year, or upon request and within fifteen (15) working days of enrollment. The Contractor shall coordinate with the enrollee or potential enrollee to provide the information in an alternative format that the enrollee can understand.
3.2.2 Information provided by the Contractor must include contact numbers for Contractor’s customer service, information about the Contractor’s authorization processes, network providers and/or Value Added Benefits that the Contractor may provide.
3.2.2.1 If the enrollee is not able to understand written information provided by the Contractor or only understands a language that is not translated, the Contractor shall provide the necessary information in an alternative format that is understandable to the enrollee.
3.2.3 The Contractor shall submit enrollee information developed by the Contractor that specifically mentions WMIP or the specific benefits provided under this Contract at least thirty (30) calendar days prior to distribution for review and approval. All other enrollee materials shall be submitted as informational. HCA may waive the thirty day requirement if, in HCA’s sole judgment, it is in the best interest of HCA and its clients to do so.
3.2.4 Changes to State or Federal law shall be reflected in information to enrollees no more than ninety (90) calendar days after the effective date of the change and enrollees shall be notified at least thirty (30) calendar days prior to the effective date if, in the sole judgment of HCA, the change is significant in regard to the enrollees’ quality of or access to care, which may include changes to: enrollment rights, grievance and hearing procedures, benefits, authorizations or coverage of emergency services. HCA shall notify the Contractor in writing of any significant change (42 C.F.R. § 438.6(i)(4) and 438.10(f)(4)).
3.2.5 The Contractor shall provide to enrollees and potential enrollees written information about:
3.2.5.1 Choosing a PCP, including general information on available PCPs and how to obtain specific information including a list of PCPs that includes their identity, location, languages spoken, qualifications, practice restrictions, and availability.
3.2.5.2 How to ch...
Information Requirements for Enrollees and Potential Enrollees. 3.2.1 The Contractor shall provide sufficient, accurate oral and written information to potential enrollees to assist them in making an informed decision about enrollment (SSA 1932(d)(2) and 42 CFR 438.10).
3.2.2 The Contractor shall provide to potential enrollees upon request and to each enrollee, within fifteen (15) working days of enrollment, at any time upon request, and at least once a year, the information needed to understand benefit coverage and obtain care.
3.2.3 All enrollee information shall have the prior written approval of DSHS.
3.2.4 Changes to State or Federal law shall be reflected in information to enrollees no more than ninety (90) calendar days after the effective date of the change and enrollees shall be notified at least thirty (30) calendar days prior to the effective date if, in the sole judgment of DSHS, the change is significant in regard to the enrollees’ quality of or access to care. DSHS shall notify the Contractor of any significant change in writing.
3.2.5 The Contractor’s written information to enrollees and potential enrollees shall include:
3.2.5.1 How to choose a PCP, including general information on available PCPs and how to obtain specific information including a list of PCPs that includes their identity, location, languages spoken, qualifications, practice restrictions, and availability.
3.2.5.2 How to change a PCP.
3.2.5.3 How to access services outside the Contractor’s service area.
3.2.5.4 How to access Emergency Services.
3.2.5.5 General information about accessing hospital care and how to get a list of hospitals that are available to enrollees.
3.2.5.6 General information regarding specialists available to enrollees and how to obtain specific information including a list of specialists that includes their identity, location, languages spoken, qualifications, practice restrictions, and availability.
3.2.5.7 How to obtain information regarding any limitations to the availability of or referral to specialists to assist the enrollee in selecting a PCP.
3.2.5.8 How to obtain information regarding Physician Incentive Plans (42 CFR 422.208 and 422.210), and information on the Contractor’s structure and operations.
3.2.5.9 Informed consent guidelines.
Information Requirements for Enrollees and Potential Enrollees. The Contractor shall provide to new Enrollees the information needed to understand benefit coverage and obtain care in accordance with the provisions of this Section. Specifically, the Contractor shall provide information to Enrollees on the GFS services, including how to access them. The information shall be provided at least once a year upon request and within fifteen (15) working days of enrollment. In providing this information to the Enrollees, the Contractor may use an existing member handbook that is otherwise provided to Enrollees; however, such handbook must be prior approved in writing by the HCA. The Contractor shall submit branding materials developed by the Contractor that specifically mention GFS services for review and approval. No such materials shall be disseminated to Enrollees, providers or other members of the public without HCA’s approval. The Contractor shall submit Enrollee information developed by the Contractor that specifically mentions GFS services provided under this Contract at least thirty (30) calendar days prior to distribution for review and approval. All other Enrollee materials shall be submitted as informational. HCA may waive the thirty (30) day requirement if, in HCA’s sole judgment, it is in the best interest of HCA and its clients to do so.
Information Requirements for Enrollees and Potential Enrollees.
3.2.1 The Contractor shall provide to potential enrollees and new enrollees the information needed to understand benefit coverage and obtain care in accord with the provisions of this Section (42 C.F.R. § 438.10(b)(3) and 438.10(f)(3)). The information shall be provided at least once a year, or upon request and within fifteen (15) working days of enrollment. The Contractor shall notify enrollees of their ability to request the information at any time. If the enrollee or potential enrollee is not able to understand written information, the Contractor will provide at no cost the necessary information in an alternative language or format that is understandable to the enrollee or potential enrollee.
3.2.2 The HCA will produce a managed care handbook template for use by the Contractor. The HCA-produced template and HCA-approved Contractor handbook will provide sufficient, accurate written information to assist potential enrollees in making an informed decision about enrollment in accord with the provisions of this Section (SSA 1932(d)(2) and 42 C.F.R. § 438.10 and 438.104(b)(1)(iii)). The Contractor shall produce the 2016 managed care handbook according to the following schedule:
3.2.2.1 HCA shall provide the Contractor a pre-approved, managed care handbook template for production of a managed care handbook by September 1, 2015.
3.2.2.2 The Contractor shall complete an MCO-specific managed care handbook using the template and submit to HCA in MS Word format by September 30, 2015.
3.2.2.3 The HCA shall review and approve the Contractor’s MCO-specific managed care handbook no later than October 24, 2015.
3.2.2.4 Once approved, the Contractor shall be responsible for production, translation, printing and mailing costs of the HCA-approved managed care handbook.
3.2.2.5 The Contractor’s handbook shall go into production for January 1, 2016 enrollment.
3.2.2.6 The Contractor shall provide to each enrollee and to each potential enrollee who requests it, the HCA-approved managed care handbook.
3.2.3 The Contractor shall provide to each enrollee, and to each potential enrollee who requests it, the HCA-approved managed care handbook.
3.1 The Contractor shall ensure the HCA-approved managed care handbook is translated or provided in an alternative format that is understandable to the potential enrollee.
Information Requirements for Enrollees and Potential Enrollees. 3.2.1 The Contractor shall provide sufficient, accurate oral and written information to potential enrollees to assist them in making an informed decision about enrollment in accord with Section 3.2.5 (SSA 1932(d)(2) and 42 CFR 438.10).
3.2.2 The Contractor shall provide to potential enrollees upon request and to each enrollee, within fifteen (15) working days of enrollment, at any time upon request, and at least once a year, the information needed to understand benefit coverage and obtain care in accord with Section 3.2.5.
3.2.3 Prior to distribution, all enrollee information shall be submitted to HCA and DSHS for written approval.
3.2.4 Changes to State or Federal law shall be reflected in information to enrollees no more than ninety (90) calendar days after the effective date of the change and enrollees shall be notified at least thirty (30) calendar days prior to the effective date if, in the sole judgment of DSHS, the change is significant in regard to the enrollees’ quality of or access to care. HCA or DSHS shall notify the Contractor of any significant change in writing.
3.2.5 The Contractor’s written information to enrollees and potential enrollees shall include:
3.2.5.1 How to choose a PCP, including general information on available PCPs and how to obtain specific information including a list of PCPs that includes their identity, location, languages spoken, qualifications, practice restrictions, and availability.
3.2.5.2 How to change a PCP.
3.2.5.3 How to access services outside the Contractor’s service area.