Common use of Information Requirements for Enrollees and Potential Enrollees Clause in Contracts

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 change PCPs. 3.2.5.3 How to access services outside the Contractor’s service area. 3.2.5.4 How to access Emergency, after hours and urgent services. 3.2.5.5 How to access hospital care and how to get a list of hospitals that are available to enrollees. 3.2.5.6 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. 3.2.5.7 Pharmacies available to enrollees and how to obtain specific information including a list of pharmacies that includes their identity, location, and hours of operation. 3.2.5.8 To assist the enrollee in selecting a PCP, what limitations on the availability of or referral to specialists there are including any medical group restrictions. 3.2.5.9 How to get direct access to a Woman’s Healthcare specialist within the Contractor’s network. 3.2.5.10 How to get information about Physician Incentive Plans (42 C.F.R. § 422.208 and 422.210). 3.2.5.11 How to get information on the Contractor’s structure and operations (42 C.F.R. § 438.10(g)). 3.2.5.12 Informed consent guidelines. 3.2.5.13 Conversion rights under RCW 48.46.450 or RCW 48.44.370. 3.2.5.14 How to request a termination of enrollment. 3.2.5.15 Information regarding advance directives to include (42 C.F.R. § 422.128 and 438.6(i)(1 and 3)): 3.2.5.15.1 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. 3.2.5.15.2 The Contractor’s written policies and procedures concerning advance directives, including any policy that would preclude the Contractor or subcontractor from honoring an enrollee’s advance directive. 3.2.5.15.3 An enrollee’s rights under state law, including the right to 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 Protections Section of this Contract. 3.2.5.16 How to recommend changes in the Contractor’s policies and procedures. 3.2.5.17 What health promotion, health education and preventive health services are available.

Information Requirements for Enrollees and Potential Enrollees. 3.2.1 5.2.1. The Contractor’s policies and procedures related to Information Requirements shall ensure compliance with the requirements described in this section. 5.2.1.1. 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 the provisions of this Section (SSA 1932(d)(2) and 42 CFR 438.10 and 438.104(b)(1)(iii)). 5.2.1.2. The Contractor shall provide to potential enrollees upon request and new enrollees sufficientto each enrollee, accurate 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 the provisions of this Section (42 C.F.R. § CFR 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 5.2.1.3. At least thirty (30) calendar days prior to distribution for review and approval. All other distribution, all enrollee materials information shall be submitted as informationalto DSHS for written approval. HCA DSHS may waive the thirty day requirement if, in HCA’s DSHS’ sole judgment, it is in the best interest of HCA DSHS and its clients to do soclients. 3.2.4 5.2.1.4. 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 HCADSHS, 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 DSHS shall notify the Contractor in writing of any significant change in writing (42 C.F.R. § CFR 438.6(i)(4) and 438.10(f)(4)). 3.2.5 5.2.1.5. The Contractor shall provide to enrollees and potential enrollees written information about: 3.2.5.1 5.2.1.5.1. 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 change 5.2.1.5.2. Changing PCPs. 3.2.5.3 How to access 5.2.1.5.3. Accessing services outside the Contractor’s service area. 3.2.5.4 How to access Emergency, after hours and urgent services. 3.2.5.5 How to access hospital care and how to get a list of hospitals that are available to enrollees. 3.2.5.6 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. 3.2.5.7 Pharmacies available to enrollees and how to obtain specific information including a list of pharmacies that includes their identity, location, and hours of operation. 3.2.5.8 To assist the enrollee in selecting a PCP, what limitations on the availability of or referral to specialists there are including any medical group restrictions. 3.2.5.9 How to get direct access to a Woman’s Healthcare specialist within the Contractor’s network. 3.2.5.10 How to get information about Physician Incentive Plans (42 C.F.R. § 422.208 and 422.210). 3.2.5.11 How to get information on the Contractor’s structure and operations (42 C.F.R. § 438.10(g)). 3.2.5.12 Informed consent guidelines. 3.2.5.13 Conversion rights under RCW 48.46.450 or RCW 48.44.370. 3.2.5.14 How to request a termination of enrollment. 3.2.5.15 Information regarding advance directives to include (42 C.F.R. § 422.128 and 438.6(i)(1 and 3)): 3.2.5.15.1 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. 3.2.5.15.2 The Contractor’s written policies and procedures concerning advance directives, including any policy that would preclude the Contractor or subcontractor from honoring an enrollee’s advance directive. 3.2.5.15.3 An enrollee’s rights under state law, including the right to 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 Protections Section of this Contract. 3.2.5.16 How to recommend changes in the Contractor’s policies and procedures. 3.2.5.17 What health promotion, health education and preventive health services are available.