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 prospective Enrollees until it has been approved in writing by the HCA. 3.6.5.1.2 HCA-approved VABs may be included in supplemental, plan-specific materials, with information to distinguish what is offered above the Medicaid-covered service. 3.6.6 The Contractor shall include with all written materials a tagline and information on how the Enrollee can request Auxiliary Aids and Services including the provision of information in an alternative language and format that is understandable to the Enrollee. If the Enrollee requests the tagline in a conspicuously visible font size, the Contractor shall provide it to the Enrollee in either paper form or electronically within five (5) Business Days. 3.6.7 The Contractor shall submit Enrollee information developed by the Contractor that specifically mentions AH-IMC or the specific benefits provided under this Contract at least thirty (30) calendar days prior to distribution for review and approval, including any Enrollee materials regarding Utilization Management activities that are developed by the Contractor or its delegates. 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. 3.6.8 The Contractor shall notify all new AH-IMC Health Home-eligible Enrollees of their eligibility for the Health Home program. The notice shall include all of the following: 3.6.8.1 A description of the benefits of the program; 3.6.8.2 Confirmation that program participation is voluntary and not a condition for the Enrollee’s receipt of any other covered service; 3.6.8.3 Information about how to file Grievances and appeals; 3.6.8.4 A statement that a participant has the right to change Care Coordination Providers and the procedure for doing so; and 3.6.8.5 How to obtain more information about the program. 3.6.9 The Contractor shall notify all known pregnant Enrollees about their eligibility to participate and receive Maternity Support Services (MSS) through HCA First Steps program. 3.6.9.1 The Contractor must use HCA MSS informational letter template to notify these Enrollees. HCA will provide the template to the Contractor. No later than the twentieth of each month, the Contractor shall submit to HCA a list of all Enrollees who are newly identified within the preceding month as pregnant or are within sixty
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Information Requirements for Enrollees and Potential Enrollees. 3.6.1 The Contractor
3.2.1 HCA shall provide a managed care handbook to Potential Enrollees and new Enrollees the information needed to understand benefit coverage and obtain carepotential enrollees. The managed care 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 managed care handbook shall be translated or 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.potential enrollee
3.6.3 3.2.1.1 The HCA will produce and Contractor may submit up to two pages of plan specific information to be included in the Contractor shall use managed care handbook templatesprovided by HCA to potential enrollees. HCA-produced templates and HCA-approved Contractor handbooks This will provide sufficient, accurate and current written basic information to assist Potential Enrollees in making an informed decision about enrollmentthe Contractor’s program.
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 3.2.1.2 The Contractor may develop supplemental materials specific to the Contractor’s programs, in addition to the Managed Care handbooks managed care handbook that are sent the Contractor sends to newly enrolled and assigned Enrolleesenrollees. The Supplemental materials may not duplicate information, such as covered benefits, provided in the HCA-produced handbook, but may 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. This supplemental, plan-specificspecific material may be no longer than five (5) pages in length, material shall be incorporated into the Managed Care handbook templates as instructed by HCA. The supplemental, plan-specific, materials will and does not include mandatory materials such as NCQA-required materials and the annual notices that the Contractor is required to send to Enrolleesenrollees.
3.6.5.1 Supplemental, plan–specific, materials may 3.2.1.3 If the enrollee is 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, able to understand written information about the Contractor’s authorization processes, network Providers and/or VABs that provided by the Contractor provides.
3.6.5.1.1 Contractor may or only understands a language that is not include a VAB in any material distributed to Enrollees or prospective Enrollees until it has been approved in writing by translated, the HCA.
3.6.5.1.2 HCA-approved VABs may be included in supplemental, plan-specific materials, with information to distinguish what is offered above the Medicaid-covered service.
3.6.6 The Contractor shall include with all written materials a tagline and information on how provide the Enrollee can request Auxiliary Aids and Services including the provision of necessary information in an alternative language and format that is understandable to the Enrollee. If the Enrollee requests the tagline in a conspicuously visible font sizeenrollee.
3.2.2 As described above, HCA and the Contractor shall provide it 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 or only understands a language that is not translated, the Contractor will provide the necessary information in an alternative format that is understandable to the Enrollee in either paper form enrollee or electronically within five (5) Business Dayspotential enrollee.
3.6.7 3.2.2.1 The Contractor shall submit Enrollee branding materials developed by the Contractor that specifically mention Medicaid, AH or the specific benefits provided under this Contract for review and approval.
3.2.3 The Contractor shall submit enrollee information developed by the Contractor that specifically mentions AH-IMC AH or the specific benefits provided under this Contract at least thirty (30) calendar days prior to distribution for review and approval, including any Enrollee materials regarding Utilization Management activities that are developed by the Contractor or its delegates. All other Enrollee 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.
3.6.8 3.2.4 The Contractor shall notify all new AH-IMC Health Home-eligible Enrollees enrollees of their eligibility for the Health Home program. The notice shall include all of the following:
3.6.8.1 A a description of the benefits of the program;.
3.6.8.2 Confirmation that program participation 3.2.5 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 voluntary significant in regard to the enrollees’ quality of or access to care, which may include changes to: enrollment rights, grievance and not a condition for hearing procedures, benefits, authorizations or coverage of emergency services. HCA shall notify the Enrollee’s receipt Contractor in writing of any other covered service;significant change (42 C.F.R. § 438.6(i)(4) and 438.10(f)(4)).
3.6.8.3 Information about 3.2.6 HCA shall provide a managed care handbook for enrollees and potential enrollees that provides written information about:
3.2.6.1 Choosing a PCP, including general information on available PCPs and how to file Grievances obtain specific information including a list of PCPs that includes their identity, location, languages spoken, qualifications, practice restrictions, and appeals;availability.
3.6.8.4 3.2.6.2 How to change PCPs.
3.2.6.3 How to access services outside the Contractor’s service area.
3.2.6.4 How to access Emergency, after hours and urgent services.
3.2.6.5 How to access hospital care and how to get a list of hospitals that are available to enrollees.
3.2.6.6 Specialists available to enrollees, including mental health providers and how to obtain specific information including a list of specialists, their identity, location, languages spoken, qualifications, practice restrictions and availability.
3.2.6.7 Pharmacies available to enrollees and how to obtain specific information including a list of pharmacies that includes their identity, location, and hours of operation.
3.2.6.8 Limitations to the availability of or referral to specialists to assist the enrollee in selecting a PCP, including any medical group restrictions.
3.2.6.9 How to get direct access to a Woman’s Healthcare specialist within the Contractor’s network.
3.2.6.10 How to get information about Physician Incentive Plans (42 C.F.R. § 422.208 and 422.210).
3.2.6.11 How to get information on the Contractor’s structure and operations (42 C.F.R. § 438.10(g)).
3.2.6.12 Informed consent guidelines.
3.2.6.13 Conversion rights under RCW 48.46.450 or RCW 48.44.370.
3.2.6.14 How to request a termination of enrollment.
3.2.6.15 Information regarding advance directives to include (42 C.F.R. § 422.128 and 438.6(i)(1 and 3)):
3.2.6.15.1 A statement about an enrollee’s right to make decisions concerning an enrollee’s medical care, accept or refuse surgical or medical treatment, execute an advance directive, and revoke an advance directive at any time.
3.2.6.15.2 The Contractor’s written policies and procedures concerning advance directives, including any policy that a participant has would preclude the Contractor or subcontractor from honoring an enrollee’s advance directive.
3.2.6.15.3 An enrollee’s rights under state law, including the right to change Care Coordination Providers file a grievance with the Contractor or HCA regarding compliance with advance directive requirements in accord with the Advance Directive provisions of the Enrollee Rights and the procedure for doing so; andProtections Section of this Contract.
3.6.8.5 3.2.6.16 How to obtain more information about recommend changes in the programContractor’s policies and procedures.
3.6.9 The Contractor shall notify all known pregnant Enrollees about their eligibility to participate 3.2.6.17 What health promotion, health education and receive Maternity Support Services (MSS) through HCA First Steps programpreventive health services are available.
3.6.9.1 The Contractor must use HCA MSS informational letter template to notify these Enrollees. HCA will provide the template to the Contractor. No later than the twentieth of each month, the Contractor shall submit to HCA a list of all Enrollees who are newly identified within the preceding month as pregnant or are within sixty
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Sources: Managed Care Contract