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CT | DE | DC | FLMH
| HI | HIBH | IL |
IN | IA | IABH | KS
|KY | ME
MD | MA | MABH | MI | MN | MO | MT | NE | NEBH | NV | NH | NJ | NM | NY | ND | OH
OK | OR | ORMH | PA | PABH | RI | SC | TN | TX | UT | UTMH | VA | WA | WV | WI
"8. MEMBER INFORMATION...
The Contractor shall produce and provide the following printed information to each member or family within 10 days of receipt notification of the enrollment date:
1. A Member Handbook which, at a minimum, should include the following items that are also listed in the Office of Managed Care, Operations Policy #404, Member Information Policy: ...
b. A general description of how managed care works, particularly in regards to member responsibilities, appropriate utilization of services and the PCP's role as gatekeeper of services...
d. Information on what to do when family size changes...
g. How to make, change and cancel appointments with a PCP or dentist
h. List of applicable copayments (including a statement that care will not be denied due to lack of copayment). The member handbook must clearly state that members cannot be billed for covered services (other than applicable copayments), what to do if they are billed, and under what circumstances a member may be billed for non-covered services.
i. Dual eligibility (i.e. Medicare and Medicaid); services received in and out of the Contractor's network; copayments. See Section D, paragraph 41, Medicare services and cost sharing.
j. The process of referral to specialists and other providers, including access to behavioral health services provided by the ADHS RBHA system.
k. How to contact Member Services and a description of its function...
n. EPSDT services...
o. Maternity and family planning services...
r. Out of county/out of state moves...
t. Contributions the member can make towards his/her own health, member responsibilities, appropriate and inappropriate behavior, and any other information deemed essential by the Contractor or AHCCCS...
v. Advance directives for adults
w. Use of other sources of insurance. See Section D, Paragraph 40, coordination of benefits.
x. The last revision date
y. Member's notification of rights and responsibilities under AAC R9-22, Article 13 and AHCCCS policy
z. A description of Fraud and Abuse including instructions on how to report suspected fraud or abuse.
bb. Member's right to be treated fairly regardless of race, religion, sex, age or ability to pay.
cc. Instructions for obtaining culturally competent materials, including translated member materials." Arizona Contract, pages 21-22.
"MEMBER HANDBOOK AND PROVIDER MANUAL...
At a minimum the member handbook shall include: .
c. How to obtain behavioral health services.
d. How to make, change and cancel appointments with a provider.
e. List of any applicable copayments (including a statement that care will not be denied due to lack of copayment). The member handbook must clearly state that Title XIX and Title XXI members cannot be billed for covered services (other than applicable copayments) and under what circumstances a Title XIX and Title XXI member may be billed for non-covered services.
f. How to contact the appropriate 'member services' office (including telephone numbers) and a description of its function...
i. Out of county/out of state-moves-referrals and records release...
k. Contributions the member can make toward his or her own health, member responsibilities, appropriate and inappropriate behavior, and any other information deemed essential by the subcontracted RBHA...
m. Use of other sources of insurance.
n. An explanation that sharing of medical record information with the PCP for coordination of care will likely occur.
o. Member's notification rights and responsibilities under AHCCCS Rules and policy. The description should include a brief explanation of the ADHS or RBHA approval and denial process.
p. A description of Fraud and Abuse including instructions on how to report suspected fraud and abuse. This shall include a statement that misuse of a member's identification card, including loaning, selling or giving it to others could result in loss of the member's eligibility and/or legal action against the member.
q. Member's right to be treated fairly and with respect regardless of race, religion, sex, age, sexual preference, race, religion, sex, age or ability to pay.
r. The last revision date." Arizona Behavioral Health Contract, page 13.
"188.8.131.52 Written Policy: Member Rights
The Contractor's written policy regarding Member rights will include the Member's right to be treated with respect, to be provided with information about the organization and its services... to participate in decision making regarding their own health care... to formulate advance directives... to have access to their Medical Record." California Contract, page 96.
"6.7.7 HEALTH EDUCATION
184.108.40.206 General Requirements
The Contractor will implement and maintain a system for providing Member health education services, clinical preventive services, health education and promotion and patient education and counseling. The system will utilize one to one and group interventions, written and audio-visual materials... The Contractor will maintain a health education system which includes, at a minimum, the following services:
A. Member Education
1. Use of Clinical Preventive Services.
2. Promote Appropriate Use of Managed Care Plan Services.
3. Availability of Local Social and Health Care Programs.
B. Clinical Preventive Services, Education
2. Tobacco Prevention and Cessation
3. HIV/STD Prevention
4. Family Planning." California Contract, page 128.
"6.9.5 Membership Services Guide
Contractor shall develop and distribute a Membership Services Guide that includes the following information...
E. The purpose and value of scheduling an initial health assessment appointment.
F. The appropriate use of health care services in a managed care system...
I. Process for referral to specialists...
K. The causes for which a Member shall lose entitlement to receive services under this Contract. (See Article III, Section 3.23.5, Disenrollment)...
Q. DHS' Office of Family Planning's toll free telephone number (1-800-942-1054) providing consultation and referral to family planning clinics.
R. Any other information determined by DHS to be essential for the proper receipt of Covered Services...
T. Information on the availability of transitional Medi-Cal eligibility and how the Member may apply for this program. Contractor shall include this information with all Membership Service Guides sent to Members after the date such information is furnished to Contractor by DHS...
V. Information concerning the provision and availability of services covered under the CCS program from providers outside Contractor's provider network and how to access these services...
Z. An explanation of an American Indian Member's right to access Indian Health Service facilities and to disenroll from Contractor's plan at any time, without cause...
6.9.6 Enrollee Information
The Contractor will provide the following information to the Member or Member's family unit either in the form of a cover letter or insert in the above prescribed Membership Services Guide:
A. Each Member's effective date of Enrollment and term of Enrollment.
B. The name, telephone number, and Service Site address of the Primary Care Physician chosen by or assigned to the Member." California Contract, pages 135-138.
"V. COSTS AND REIMBURSEMENT." Colorado
Contract, page 20.
8. When a third party is primarily liable for the payment of the costs of a Member's medical benefits, prior to receiving nonemergency medical care, the Member shall comply with the protocols of the third party, including using providers within the third party's network. Any Member failing to follow the third party's protocols is liable for the payment or the cost of any care or any service that the third party would have been liable to pay; except that, if the third party or the service provider substantively fails to communicate the protocols to the Member, the items or services are non-reimbursable and the Member is not liable to the provider.
10. The Contractor shall include information in the Contractor's Member Handbook regarding its rights and the Member's obligations under this section of the Contract. This information shall include notification that the Member, or Member's guardian, executor, administrator or other appropriate representative must provide the Contractor with written notice, within fifteen (15) days after filing an action or asserting a claim against a third party alleged to be responsible for illness or injury to a Member. The required notice by the Member must be provided by personal service or certified mail." Colorado Contract, pages 20, 24-25.
I. Where a subcontract termination involves a Primary Care Physician, all Members that receive Covered Services through that Primary Care Physician shall also be notified. Such notice shall describe how services provided by the Subcontractor will be replaced, and inform the Member of Disenrollment procedures." Colorado Contract, page 39.
"XIV. SERVICE DELIVERY
1. Access to services: .
The Contractor shall provide Members with information about Contractor standards for the availability and accessibility of services through the Member Handbook or other Member materials." Colorado Contract, page 46.
"XIV. SERVICE DELIVERY...
3. Coordination with the EPSDT Program...
a. The following requirements relate to the provision of EPSDT services and must be incorporated into the Contractor's preventive health services:
1. The Contractor shall notify all Members about EPSDT benefits.." Colorado Contract, page 52.
"XV. QUALITY ASSURANCE
A. Internal Quality Assurance Program...
5. The Contractor shall make available information about its internal quality assurance program to Members, the Department, and the public upon request. This information shall include but not be limited to:
a. An annual written summary of the quality assurance program;
b. Its accomplishments during the last contract year, if applicable." Colorado Contract, page 54.
MEMBER HANDBOOK REQUIREMENTS
To inform Members of their rights and responsibilities, the Plan shall publish and distribute to all Members a Member Handbook that shall include but is not limited to the following information:
1. A complete statement of Member rights and responsibilities: ...
5. Hours of service...
13. Maximum number of days between appointment request and actual visit with appropriate provider, as follows:
a. Urgent care within forty-eight (48) hours.
b. Non-urgent care and EPSDT screens within two (2) weeks.
c. Adult non-symptomatic well care physical examinations within four (4) months...
4. EPSDT services;
5. Family planning policies;
6. Procedures for obtaining the names, qualifications, and titles of professionals providing and/or responsible for members' care;
7. Circumstances under which Members may have to pay for care.
9. How Members will be notified of any change in benefits, services, or service delivery offices/sites;
10. Information regarding the Member's right to formulate Advanced Directives, according to applicable statutes
and regulation and the Contractor's policies respecting the implementation of such rights.
11. How to request information about the Contractor's Quality Management and Improvement program as described in
Section XV of the Contract; and,
13. Information regarding Member participation on the Contractor's Consumer Advisory Board, and notification of right to attend meetings of the board. Such information shall include telephone contact number
14. Information concerning a Member's responsibility for providing the Contractor with written notice to the Contractor after filing a claim or action against a third party responsible for illness or injury to the Member.
15. Information concerning a Member's responsibility for following any protocols of a liable third party payor prior to receiving non-Emergency services." Colorado Contract, Exhibit E, pages 1-2.
"3.28 Services to Members...
b. The MCO shall mail the Member handbook and provider directory to Members within one week of enrollment notification. The Member handbook shall address and explain, at a minimum, the following: ...
9. who to call to schedule appointments;
10. Members' rights and responsibilities;
11. Member services, including hours of operation;
12. coordination of benefits and third-party liability;
13. limited liability for services from non-MCO providers; and
14. other features of the MCO's program..." Connecticut Contract, page 38-39.
"STANDARDS FOR INTERNAL QUALITY ASSURANCE
PROGRAMS FOR HEALTH PLANS...
Standard X: Enrollee Rights and Responsibilities...
D. Communication of policies to enrollees/members - Upon enrollment, members are provided a written statement that includes information on the following:
1. Rights and responsibilities of members." Connecticut Contract, Appendix I, pages 1-10
"11.5 MCO Member Services
5.1 New Member Orientation
The MCO must have written policies and procedures for orienting new members about the following: ...
(b) The role of the primary care provider and selecting a PCP
(c) How to make appointments and utilize services.
(f) Members' rights and responsibilities..." Delaware RFP, page II.14.
"5.10 Member Handbook
The MCO must agree to mail a member handbook with information on how to access services, to all members within ten (10) business days of being notified of their enrollment...
5.10.2 Member Handbook Minimum Contents
The member handbook shall follow QARI standard X.D. (`Enrollee Rights and Responsibilities, Communication of Policies to Enrollees/Members') for the minimum level of information to be communicated. QARI standards can be found in Appendix G. The handbook shall include:
(a) Table of contents
(b) Information about choosing and changing primary care providers
(c) Information about what to do when family size changes
(d) Appointment procedures
(e) Guidance to seeking care when out-of-area services are required
(f) A description of all available MCO services and an explanation of any service limitations or exclusions from coverage
(g) How to contact member services and a description of its function...
(i) Provider network listing, including a list of the names, telephone numbers, and service site addresses of primary care providers available for selection.
(k) How to obtain emergency transportation, medically necessary transportation, and non-emergency transportation
(1) How to obtain early and periodic screening, diagnosis and treatment services
(m) How to obtain maternity, family planning and sexually transmitted diseases services
(n) How to obtain behavioral health services
(o) What to do in the case of out of county and out of State moves
(p) Inform the member that if he or she has a worker's compensation claim, or pending personal injury or medical malpractice law suit, or has been involved in an auto accident, to immediately contact the DSS Third Party Liability Unit
(q) Inform member of contributions that they can make towards his or her own health, member responsibilities, appropriate and inappropriate behavior, and any other information deemed essential by the MCO or the State
(r) Inform member that multilingual interpreters will be offered when needed; handbooks shall be available in alternative formats, i.e., large print, Braille, or cassette and diskette for participants with sensory impairments; the MCO must agree to make member handbooks available in Spanish at all times and in all other languages upon request (see Sections 5.5 and 5.6 above)
(s) Telephone numbers for the HBM and for filing a State grievance
(t) Information regarding advance directives
(u) Information about the role of the member advocate and how to reach the advocate.
Some of the above information may be included as inserts to the handbook...
11.6 Service Delivery and Coordination
6.1 Federal Requirements
6.1.1 Early and Periodic Screening, Diagnosis, and Treatment Services...
MCOs must have written policies and procedures providing the full range of EPSDT services to all eligible children and young adults up to age twenty-one (21). This information must be available for the hearing-and visually-impaired, and in Spanish at all times. Other translation services should be made available as necessary.The full scope of EPSDT service requirements is described below.
220.127.116.11 Required Activities
The MCO must provide for a combination of written and oral methods designed to effectively inform all EPSDT eligible individuals (or their families) about the EPSDT program.
The MCO must inform all EPSDT eligible
individuals (or their families) about the EPSDT program using clear and
non-technical language and provide
(a) The benefits of preventive health care
(b) The services available under the EPSDT program and where and how to obtain those services
(c) That the services provided under the EPSDT program are without cost to eligible individuals under twenty-one (21) years of age
(d) That necessary transportation and scheduling assistance is available to the EPSDT eligible individual upon request (non-emergency transportation is paid for by the State, for Diamond State Health plan, Medicaid members only)" Delaware RFP, pages II.20-II.24.
"4. Evidence of coverage
a. Within ten (10) business days of the date on which the District notifies Provider that an individual has been enrolled with Provider, Provider shall issue to each enrollee the following:
(2) a Member Handbook written at the 5th grade reading level and containing at a minimum the following information:
(b) an explanation of the fact that services must be obtained from or through Provider and its network in order to have coverage as well as the procedures which enrollees must follow in order to obtain covered primary care and specialty services covered under the contract;
[(c)] an explanation of the enrollee's right to select and change their PCP...
(f) an explanation of enrollees' right to obtain family planning services covered under this contract from Provider of their choice regardless of the family planning provider's membership in Provider's network...
(h) an explanation of the right to receive assistance from personal representative of the enrollee's choice to initiate a grievance...
(5) a separate brochure explaining the EPSDT program at a 5th grade reading level which shall be pre-approved by the District and which lists all of the services available to children, clarifies that services are free, and that includes a telephone number which care givers can call to get assistance in scheduling an appointment and getting transportation." District of Columbia Contract, pages 16-18.
5. Upon enrollment, the contractor shall provide the following
information to the new enrollee: ...
c. Effective date of enrollment...
f. Member Handbook, which shall include the following:
(1) Terms and conditions of enrollment...
(8) Member responsibilities." Florida Mental Health RFP, pages 37-38.
"30.500 Care Coordination/Case Management
The health plan shall educate members on accessing services and assisting them in making informed decisions about their care." Hawaii RFP, page 12.
"33.100 Other Services to be Provided...
* Recipient education...
The health plan should also have education which outlines the risks associated with alcohol, tobacco and other substances. The health plan may use classes, individual or group sessions, videotapes, written material and media campaigns...
Recipient education also includes educating its members on the concepts of managed care and the procedures which recipients need to follow such as informing the health plan of any changes in status." Hawaii RFP, pages 31-32.
"40.440 Notification of Enrollment...
The health plan shall provide the new recipient a confirmation of enrollment and other pertinent informational material within 15 days of enrollment." Hawaii RFP, page 47.
"40.450 Responsibilities of the Health
* Provide the recipient with a member handbook which explains the operations of the plan including the procedures to follow to make an appointment...
*... explain...the procedures to be followed to obtain needed services...
* Explain to the recipient the information that needs to be provided by the recipient to the health plan and DHS upon changes in the status of the recipient...
* Provide written policies and procedures related to advance directives (right to refuse treatment) to recipients at the time of enrollment." Hawaii RFP, page 48.
"42.140 Provider and Recipient Education
The health plan is responsible for educating and informing its members and providers of the circumstances/situations under which a member may be billed for services or assessed charges or fees." Hawaii RFP page 57.
"44.020 Quality Assurance Programs...
* Recipient Rights and Responsibilities - The QAP shall have written policies and procedures related to the rights and responsibilities of the recipients, including treatment of minors, which shall be communicated to the providers and the recipients." Hawaii RFP, pages 59, 61.
"48.000 Educational Material...
48.020 Plan's Responsibilities...
The following is the minimum information to be included in the booklet or pamphlet: ...
* Making an appointment...
* Reporting changes in status and family composition
* Reporting of a third party liability...
* Using the membership card
* Penalties for fraudulent activities
* Co-payments, fees and charges...
* Failure to pay for non-covered services will not result in loss of Medicaid benefits" Hawaii RFP, pages 71-72.
"30.900 Other Services to be Provided...
* Member Education
The BHMC care plan shall effectively communicate with members so that the plan members understand their behavioral health condition, the suggested treatment and the effect of the treatment and the effect on their condition including side effects. Educational efforts should emphasize preventive care and that members adhere to their specified treatment programs, maintaining contact with their case manager/care coordinator, etc.
Member education also includes educating the members on the concepts of managed care.At a minimum, the plan shall also provide members with information on the procedures which members need to follow related to.utilization of case manager/care coordinator services, informing the plan of any changes in member status.and notice of off island travel." Hawaii Behavioral Health RFP, page 31.
"40.440 Responsibilities of the BHMC
The following describes the responsibilities of the BHMC plan upon enrollment of a member...
* Explain the role of the care coordinator/case manager to the member and the procedures to be followed to obtain needed services...
* Orient and familiarize, then provide each member with a member handbook explains the operations of the plan including the procedures to follow to make an appointment.change BHP or prescribing psychiatrist, member rights and responsibilities...
* Explain to the member the information that needs to be provide by the member to the BHMC plan and DHS upon changes in the status of the member including marriage, divorce, birth of a child, adoption of a child, death of a spouse or child, acceptance of a job, obtaining other health insurance, etc." Hawaii Behavioral Health RFP, pages 39-40.
"47.000 Notification of Changes in
47.010 Member and Plan Responsibilities
As part of the education conducted by DHS, members shall be notified that they are to provide the BHMC plan and DHS with any information affecting their member status...
48.000 Educational Materials...
48.020 Plan's Responsibilities
A booklet or pamphlet shall explain in more detail the procedures to be followed by the member and the responsibility of the member...
The following is the minimum information to be included in the booklet or pamphlet:
* Role and selection of a BHP
* CC/CM system: role and selection of a CC/CM; how to access CC/CM services
* Changing BHPs
* Making an appointment
* What to do in an emergency (regardless of service area)
* Reporting changes in status and family composition
* Reporting a third party liability...
* Toll-free number to call for questions and assistance
* Using the membership card
* Penalties for fraudulent activities...
* Charges and failure to pay for non-covered services will not result in low of Medicaid benefits." Hawaii Behavioral Health RFP, pages 60-62.
"(4) The Contractor shall conduct all Enrollment activities in such a manner as to maximize Eligible Enrollees' ability to make a choice between Enrollment with the Contractor and their current health care plan under the Medical Assistance Program or KidCare. Such activities shall be designed and implemented so as to maximize Eligible Enrollees' understanding of the following:
(A) how to use the Plan;
(B) that the scope of services provided in the Plan is as comprehensive as that which Eligible Enrollees receive under the Department's usual reimbursement system;
(C) that all Covered Services must be received from or through the Plan with the exception of family planning and other Medical Assistance services as described in Article V(b)(5) with provisions made to clarify when such services may also be obtained elsewhere;
(D) that once enrolled, the Beneficiaries who are Clients will receive a MediPlan Card from the Department which restricts such Clients to the Contractor for all Covered Services and that this restricted card can be used by such Beneficiary for securing Medical Assistance services not covered by the Plan from any Provider
(E) that once enrolled, the Beneficiaries who are KidCare Phase II Participants will receive an identification card from the Department which restricts such KidCare Phase 11 Participants to the Contractor for all Covered Services and that this restricted card can be used by such Beneficiary for securing Medical Assistance services not covered by the Plan from any Provider...
The Contractor must inform Eligible Enrollees of any Covered Services that will not be offered by the Contractor due to the Contractor's exercise of a right of conscience.
(11) The Contractor must provide new Beneficiaries with the following materials no later than ten (10) business days following receipt of the Prelisting:
(A) The Beneficiary handbook in conformance with Article V(w) and a membership packet of information detailing all aspects of the Contractor's Plan, which must include, at a minimum. Contractor's principal business address, telephone numbers described in Article V(b)(10)...
(B) An identification card bearing: the name of the Contractor's Plan; the effective date of coverage; the twenty-four hour telephone number to confirm eligibility for benefits and authorization for services and the name and phone number of the Primary Care Provider or Women's Health Care Provider. The identification of the site must appear on the card until such time as the name and phone number of the Primary Care Provider and Women's Health Care Provider can be placed on the card." Illinois HMO Contract, pages 11-14.
"(m) Health Education
The Contractor shall establish and maintain an ongoing program of health education which will advise Beneficiaries concerning appropriate health care practices and the contributions they can make to the maintenance of their own health. The program shall provide, at a minimum, the following: ...
(2) Information on preventive care
including the value and need for screening and preventive maintenance.
(3) Information on disease states, which may affect the general population and specific information for persons who have a specific disease.
(4) Educational material in the form of printed, audio, visual or personal communication.
(5) Information will be provided in language which the Beneficiary understands and which meets the requirements set forth in Article II(d).
(6) The Contractor will appoint a single individual to be responsible for the coordination and implementation of the program.
(7) The Contractor shall provide counseling and patient education as to the health risks of obesity, smoking, alcoholism, substance abuse and improper nutrition.
The Contractor further agrees to review the health education program, at reasonable intervals, for the purpose of amending same, in order to improve said program. The Contractor further agrees to supply the Department or its designee with the information and reports prescribed in its approved health education program or the status of such program. This information shall be furnished upon request by the Department." Illinois HMO Contract, pages 39-40.
"3.2.4 The Enrollment Process
During the Medicaid enrollment process, Benefit Advocates (BAs) ensure that all Hoosier Healthwise enrollees receive either a face-to-face or telephone interview during which they are educated about the usefulness of primary and preventive care; the differences between Hoosier Healthwise and the traditional Medicaid program; and the PCCM and RBMC delivery systems. During this interview, potential enrollees also typically receive brochures describing the program and watch a video on Hoosier Healthwise. At time of writing this RFP, a process for handling potential Hoosier Healthwise enrollee education at Medicaid application outstations is being developed.
BAs provide potential enrollees with a list of their provider options and explain that they have thirty days from the date they are eligible for Medicaid to choose a PMP. Whether the choice leads to enrollment in PCCM or RBMC will depend on the PMP's enrollment status at the time of selection. The education provided by the BAs focuses on the choice of a physician, but the implications of network choice is also discussed. MCOs are required to provide information regarding their network, grievance procedure, and any other information requested by the State, for use in potential education and enrollment...
4.63 Provider Network and Access to
Care Requirements and Reporting Standards
The MCO must meet the following provider network and access to care requirements: ...
* The MCO must update the network directory monthly using addenda and/or through reprints, and made available for use by the enrollment broker in each location where potential enrollees are enrolled in the Hoosier Healthwise program and any other location specified by the State...
18.104.22.168 Enrollee Education Requirements
The MCO will be responsible for developing and maintaining enrollee education programs designed to provide the enrollees with clear, concise, and accurate information about the MCO's health plan. Enrollee education materials should include, but are not limited to the following:
* An enrollee handbook which describes in full detail the terms and nature of services offered by the MCO, including covered services and benefits, preventive services, limitations and exclusions, self-referral services (specified in Section 22.214.171.124 of this RFP), wellness programs and other enhanced services, coordination of benefits, disenrollment, enrollee rights and responsibilities, grievance procedures, and any other terms and conditions pertinent to the enrollee. For a complete description of the information that must be included in the enrollee handbook, refer to Chapter 4 of the MCO Procedure Manual and the readiness review criteria located in the Procurement Library.
* MCO bulletins or newsletters specific to the Medicaid population issued not fewer than three times a year which provide updates related to covered services, access to providers, and updated policies and procedures.
* Literature regarding health/wellness promotion programs offered by the MCO are encouraged.
MCO's educational activities and services should focus on the special needs of the Medicaid population. MCOs should demonstrate how these educational interventions will reduce barriers to health care for enrollees. All materials must be approved by the OMPP prior to distribution." Indiana RFP, pages 3-9, 4-20, 4-26.
"4.6 Health Education and Prevention...
At a minimum, the HMO shall provide health education on WIC eligibility, family planning and reproductive health services, preconception and prenatal care, immunization, and well-child health management." Iowa Contract, page 26.
"4.12 Enrollee Information...
The HMO shall mail an Enrollee handbook to the Enrollee within ten calendar days of enrollment notification to the HMO, which, at a minimum, shall include: ...
- hours of service...
- access to Family Planning Services...
- limited HMO liability for services from Non-Participating Providers;
- access to after hour care;
- Enrollee rights and responsibilities; ...
- procedures for notifying Enrollee's affected by changes in Covered Services, or service delivery site;
- policy on referrals for specialty care, and
- procedures for recommending changes in policies and services." Iowa Contract, pages 30-31.
"48.0 OUTREACH TO IOWA PLAN ENROLLEES
Within 10 working days of the date of enrollee information is provided to the Contractor, the Contractor shall provide the Medicaid enrollee(s) with information about the Iowa Plan.Enrollment information must include:....procedures for notifying enrollees of a change in benefits or office sites.statement of customer rights and responsibilities.availability of toll-free telephone information and crisis assistance; appropriate use of the referral system...
Mental health educational information shall be provided no less than annually to all those enrolled at the time the information is provided." Iowa Behavioral Health Contract, pages 33-34.
"N. HEALTH EDUCATION AND PREVENTION.
The HMO shall provide health education such as toll-free phone numbers, videos, and member handbooks to the extent that the member is apprised of the appropriate use of health care and is instructed in ways to assist in the maintenance of his or her own health.
O. MEMBER HANDBOOK.
At a minimum, the member handbook shall include: ...
Telephone number to call with questions.
* How to contact member services and
a description of its function...
* Out-of-county and out-of-state moves.
* Inform the member that if he or she has a worker's compensation claim, or a pending personal injury or medical malpractice law suit, or has been involved in an auto accident, to immediately contact the Commission of Adult and Medical Services, Third Party Liability Manager...
* Contributions the member can make toward his or her own health, member responsibilities, appropriate and inappropriate behavior, and any other information deemed essential by the HMO or SRS.
* Rights and responsibilities of the member.
* The HMO's policy regarding copayments and charges to members (copayments may not be charged except for non-Medicaid services)...
* The HMO's procedures for notifying members about terminations and/or changes in benefits, services or delivery dates" Kansas Contract, pages 21-23.
"The Member Service staff shall be
responsible for the following services and tasks: ...
* Explaining rights and responsibilities to Members or to those who are unclear about their rights or responsibilities;
* Explaining Partnership's rights and responsibilities, including the responsibility to assure minimal waiting periods for scheduled Member office visits and telephone requests, and avoiding undue pressure to select specific providers or services;
* Sending each Member written information upon enrollment notification. This will include a Member Handbook and how to access services; alternate notification methods must be available for persons who have reading difficulties or visual impairments;
* Explaining, at enrollment, the use of the Member Handbook." Kentucky RFA, page 53.
"7.8.4 Member Education
The Partnership shall develop, administer, implement, monitor and evaluate a member education program...
Health education topics to be considered
by The Partnership include, but are not limited to:
Prevention and Primary Care...
* Secondary and Tertiary Care." Kentucky RFA, pages 56-58.
"3.2 MEMBER SERVICES...
B. ORIENTATION OF NEW MEMBERS
1. Orientation. The Contractor shall
provide a written description of its Health Plan to each Enrollee within five
(5) calendar days of the Enrollee's
effective date of enrollment. At a minimum, the description shall include
explanations of the following:
a. the role of the member services department;
b. the role of the PCP;
c. the process for selecting a PCP, if the Enrollee did not do so through the HBA;
d. how to change a PCP;
e. how to obtain access to specialists;
f. what to do in an emergency or urgent medical situation;
g. what benefits are covered by the Health Plan...
i. that no cost sharing is required...
2. Member Packet. The Contractor shall
also provide each Enrollee's household, within five (5) calendar days of an
Enrollee's effective date of enrollment,
with a member packet, which shall include, at a minimum: ...
c. the member handbook. The handbook shall include, at a minimum, information on: ...
ii. the proper use of the membership card;
iii. that there is no cost sharing for Enrollees;
iv. how to change primary care providers;
v. what to do when family size changes;
vi. what to do when the Enrollee moves...
xiii. the rights and responsibilities of the Enrollee;
xiv. policies and procedures on advance directives..." Maine Contract, pages 14-15.
"5. Family Planning. The Contractor
a. provide Enrollees with information to allow them to make informed choices regarding the types of family planning services available, their right to access these services in a timely and confidential manner and their freedom to choose a provider within or outside of the HMO network;
b. educate Enrollees regarding the importance of coordinated care on their health outcomes, specifically as it relates to family planning services." Maine Contract, page 23.
"G. HEALTH EDUCATION AND PREVENTIVE
The Contractor shall incorporate health education and preventive activities in its service delivery network by ensuring that Enrollees have access to the following:
1. information and educational services on contributions Enrollees can make to the maintenance of their own health and the proper use of health care services;
2. information and educational services on disease states that affect the general population and their prevention and management including specific information for persons who have or who are at risk of developing such health problems (e.g., hypertension);
3. programs for health education and prevention, including, but not limited to exercise and smoking cessation;
4. education on the importance of age/sex appropriate services such as EPSDT services and prenatal care;
5. information on and promotion of other available prevention services offered outside of the Contractor, e.g., Women, Infants and Children (WIC) Program, child nutrition programs, parenting classes." Maine Contract, page 29.
.06 Access and Capacity: Benefits and Appointments.
An MCO applicant shall include in its application the following information or descriptions: .
I. Documentation of the applicant's plan to satisfy statutory requirements that enrollees be notified of due dates for obtaining immunizations, examinations, and other wellness services." Maryland COMAR 10.09.64.06.
G. Health Care Delivery. An MCO shall: ...
(4) Provide enrollees written notice when there is a significant change in the nature or location of services provided." Maryland COMAR 10.09.65.02.
K. An MCO shall notify new enrollees of the need for health screening and services in writing." Maryland COMAR
B. An MCO shall, at the time of enrollment and annually thereafter at the time of reassignment, furnish each enrollee with a copy of the MCO's enrollee handbook that includes the following current information pertaining to the county in which the enrollee resides:
(1) The enrollee's rights and responsibilities in the MCO.
(6) Any policies and procedures necessary to facilitate accessing needed services in compliance with the Maryland Medicaid Managed Care Program,
(7) Information about the MCO, including its primary care service locations and hours of operation.
(12) A description of any benefits the MCO offers in addition to those required by the Maryland Medicaid Managed Care Program, including applicable terms and conditions for accessing those benefits.
(14) Information regarding the importance of scheduling and maintaining appointments for preventive services." Maryland COMAR 10.09.66.02.
"Section 2.3 Enrollment Activities...
2. The Contractor shall: ...
f. Provide new Enrollees with a new member packet, including but not limited to, either a MassHealth Standard or MassHealth Basic member handbook as appropriate...
The member handbook shall include, but not be limited to the following: ...
8) the rights and responsibilities of Enrollees." Massachusetts Contract, pages 25-27.
The Contractor shall: ...
1.03.03 Create, maintain, and update educational and informational material regarding... access to the Provider Network... which shall be submitted to the division for its prior review and approval prior to distribution of this material to any party including, but not limited to, enrollees, Providers, enrollees, family members, and other interested parties." Massachusetts MH/SAP Contract, Appendix B, pages 3-4.
"3.0 CUSTOMER SERVICES
The contractor shall: ...
3.02 Operate a toll-free Customer Services Department telephone line at a minimum or with hours per day during normal business hours, Monday through Friday, which shall: ...
f. inform Enrollees of the tool-free telephone number, provide an overview of Covered Services and the role of the Contractor, through multi-lingual brochures placed in local Department of Transitional Assistance offices, the Division's MassHealth regional offices, DMH's area offices, the Division's Health Benefits Management vendor, and through written materials distributed to Network Providers." Massachusetts MH/SAP Contract, Appendix B, page 24.
"II-T MEMBER AND ENROLLEE SERVICES...
3. Member Handbook...
At a minimum the member handbook must include: ...
*How Enrollees can contribute toward their own health by taking responsibility, including appropriate and inappropriate behavior.
*Any other information deemed essential by the Contractor and/or the DCH." Michigan Contract, pages 48-50.
"Section 3.2.3. Enrollment Materials.
A. Enrollment Information. The HEALTH PLAN shall present to all new Enrollees the following information within 15 calendar days of the receipt of readable enrollment data from the STATE.
1) A Certificate of Coverage (COC)
that has been prior-approved by the STATE and that will include the following:...
b) notification of the free choice of Family Planning Services;
c) information about providing coverage for prescriptions that are dispensed as written (DAW);
d) a statement informing Enrollees that upon request an Enrollee can obtain a COC in Spanish, Hmong, Laotian, Russian, Somali, Vietnamese or Cambodian...
g) a description of medical necessity for mental health services under Minnesota Statutes, Section 62Q.53...
5) An explanation of the HEALTH PLAN's Early and Periodic Screening, Diagnosis and Treatment (EPSDT), known in Minnesota and hereinafter as the Child and Teen Checkup (C&TC) program for preventive care for children.
8) General descriptions of the coverage for durable medical equipment...
10) A description of the Enrollee's right to request the results of an external quality review study. See Section 4705(a) of the Balanced Budget Act of 1997." Minnesota Contract, page 23-25.
"Section 8.7.3. The HEALTH PLAN shall provide for a second opinion for chemical dependency services as provided for in Minnesota Statutes, Section 62D.103 and Minnesota Rules, Part 9530.6655. The HEALTH PLAN shall inform the Enrollee in writing of the Enrollee's right to make a written request for a second assessment at the time the Enrollee is assessed for a program placement." Minnesota Contract, page 83.
"Article 17. Advance Directives Compliance. For purposes of this Section, the term `advance directives' has the meaning given in 42 C.F.R. 489.100. Pursuant to 42 U.S.C. 1396a(a)(57) and (58) and 42 C.F.R. 434.28 and 42 C.F.R. 489.100-104, the HEALTH PLAN agrees:
Section 17.1. To inform all Enrollees at the time of enrollment of their right to
Section 17.1.1. accept or refuse treatment and to execute a living will, durable power of attorney for health care decisions, or other advance directive, and
Section 17.1.2. receive the HEALTH PLAN's written policies on implementation of that right." Minnesota Contract, page 96.
"Educating the family about managed care in general, including the requirement to enroll in a MC+ health plan, the way services typically are accessed under managed care, the role of primary care provider, and the responsibilities of the health plan member and.Educating members about their right to choose a primary care provider subject to the capacity of the provider." Missouri RFP, page 34.
"p. At a minimum, the member handbook
1) Table of contents...
3) Information about what to do when family size changes;
4) Appointment procedures...
7) The definition of medical necessity used in determining whether benefits will be covered...
12) Notice that a member with a condition which requires ongoing care from a specialist may request a standing referral to such a specialist and the procedure for requesting and obtaining such a standing referral;
13) Notice that a member with a life-threatening condition or disease or degenerative and disabling condition or disease either of which requires specialized medical care cover a prolonged period of time may request a specialist responsible for providing or coordinating the member's medical care and the procedure for requesting and obtaining such a specialist;
14) Notice that a member with a life-threatening condition or disease or degenerative and disabling condition or disease either of which requires specialized medical care over a prolonged period of time may request access to a specialty care center and the procedure by which such access may be obtained...
15) A description of the mechanisms by which members may participate in the development of the policies of the health maintenance organization:
16) Notice of all appropriate mailing address and telephone numbers to be utilized by health plan members seeking information or authorization...
18) How to contact member services and a description of its function...
20) Cost sharing responsibilities (if applicable): ...
24) Early and periodic screening, diagnosis and treatment services including immunization guidelines designated by the state agency;
25) Maternity, family planing and sexually transmitted diseases services;
26) Behavioral health services, including information on how to obtain behavioral health services, the rights the member has to request such services, and how to access services when in crisis;
27) How to obtain services when out of the member MC+ geographic region and for after-hours coverage;
28) Out of county and out of state moves;
29) Statement that the health plan will not hold a member liable for:
*debts of the organization in the case of health plan insolvency;
* for services provided to an MC+ member in the event the health plan failed to receive payment from the state agency for such service
30) Inform the MC+ member that
if he or she has a worker's compensation claim, or a pending personal injury
or medical malpractice law suit, or has been involved in an auto accident,
to immediately contact the Division of Medical
Services Third Party Liability Unit;
31) Inform the MC+ member that if he or she has another health insurance policy, all prepayment requirements must be met as specified by the other health insurance plan;
32) Inform the MC+ member of the Health Insurance Premium Payment program which pays for health insurance for MC+ persons when it is determined cost effective;
33) Contributions the member can make towards his or her own health, member responsibilities, appropriate and inappropriate behavior, and any other information deemed essential by the health plan or the State including the member's rights and responsibilities." Missouri RFP, pages 43-45.
"2.6.6 Health Education and Prevention
Each CONTRACTOR shall be encouraged to provide a continuous program of general health education for disease prevention and identification without additional cost to the ENROLLEE. Such a program may include publications, media presentations, and classroom instruction and must comply with the State HMO statute. Programs of wellness education including stress management, smoking cessation, nutritional education, physical fitness programs may be offered to ENROLLEES on a voluntary basis. These programs shall be conducted by qualified personnel.
As required by the Montana HMO Act, CONTRACTORS must make preventive services available to ENROLLEES. CONTRACTORS shall periodically remind and encourage their Medicaid ENROLLEES to utilize benefits including physical examinations which are available and designed to prevent illness." Montana Contract, page 49.
"2.8 ENROLLEE HANDBOOK
Mail a Medicaid specific ENROLLEE Handbook to a new ENROLLEE'S household within seven working days of initial enrollment notification to the CONTRACTOR, which at a minimum, shall include: ...
(4) hours of service availability to the HMO...
(6) EPSDT policies;
(7) family planning policies...
(9) limited CONTRACTOR liability for services from non-PARTICIPATING PROVIDERS, i.e., only emergency care, family planning services, and certain public health clinic services and referrals can be obtained from non-PARTICIPATING PROVIDERS;
(10) education regarding the appropriate use of health care services in a managed care system;
(11) a written description of treatment policies and any restrictions or limitations on services...
(13) referral to evidence of coverage for details on benefits, including how to obtain a copy of the evidence of coverage." Montana Contract, page 51.
"STANDARD ENROLLMENT HANDBOOK LANGUAGE
The following standard language must be included in MEDICAID ENROLLEES' member handbook unless alternate language is approved by the DEPARTMENT in writing...
Birth Control and Family Planning
Birth control, pregnancy testing, and reproductive health services are available to all ENROLLEES. They are confidential, even if you are a minor. You can receive these services from your PRIMARY CARE PROVIDER or from any family planning PROVIDER. In _________ County, these PROVIDERS include [clinic name] available by phone at [phone number]. You can ask for help in choosing a family planning PROVIDER. Call [Contractor's name] at [phone number] for help.
County Public Health Clinics
Lead poison testing and immunization are available to all ENROLLEES. You can receive these services from your PRIMARY CARE PROVIDER or from any county public health clinic. In ________ County, these PROVIDERS include [clinic name] available by phone at [phone number]. You can ask for help in choosing a PROVIDER for these services. Call [CONTRACTOR's name] at [phone number] for help...
EPSDT is a special health program for children. The EPSDT child health program provides regular health checkups.
EPSDT also provides care for any health problems that are found during a EPSDT health checkup. Routine EPSDT checkups are a good way to keep your child healthy. These checkups can detect childhood health problems early and treat them before they become serious. EPSDT health checkups can also help parents know about free child health services available to MEDICAID ENROLLEES.
EPSDT checkups include a physical exam, hearing and vision tests, blood and urine lab tests, and immunizations to protect your child from illness. Children will also be given help in choosing a dentist for preventive dental care. Transportation assistance to and from EPSDT appointments may be requested by calling 1-800-292-7114...
Women's Health Care Needs
If you are pregnant, or are due for your annual exam of female organs, or are having trouble with your female organs, you have a choice of who to see. Some women like seeing their Primary care Provider(PCP). Others would rather see an 'OB-GYN' -- a doctor who specializes in pregnancy and women's health care. The choice is yours.
[CONTRACTOR to insert self referral process for recipient to follow if recipient is pregnant. Example: You have the choice to choose a provider within the HMO-or a provider of your choice, but you must return to your HMO physician after the birth of your child.]." Montana Contract, pages 59-60.
"9.10 Client Notification of NHC Coverage
9.10.1 Client Notification: The client or the client's legal representative shall be notified of NHC coverage and shall be issued a notice of finding and NHC Identification (ID) Document.
9.10.2 Client Notice of Right to Change: Through the EBS functions, and written materials and notice, the client shall be kept informed of his/her right to change PCP and/or plan." Nebraska Contract, page 38.
"11.3 Enrollment Activities: The EBS
shall complete the following enrollment activities for mandatory clients (and
also for potential mandatory clients, if requested), in coordination with
the plan and the Department:
(a) Educate clients concerning the full range of Medicaid benefits, including all NHC options and covered services, including: ...
(2) Mandatory and excluded groups of clients;
(3) The purpose/benefits of managed care, including the 'medical home' concept and the difference between fee-for-service and managed care;
(4) The role of the PCP;
(5) An explanation of how the client shall choose a PCP/plan;
(6) An explanation of auto-assignment;
(7) An explanation that the PCP/plan shall either provide or approve services included in the Basic Benefits Package...
(12) An explanation of transfers and disenrollment;
(13) An explanation of client/provider rights and responsibilities...
(15) An explanation of how to be an effective health care consumer." Nebraska Contract, pages 61-62.
"17.2 Rights and Responsibilities for Clients Enrolled in the Basic Benefits Package: The following rights and responsibilities apply to clients participating in the NHC. Each plan shall inform the client, in writing and orally, about his/her rights and responsibilities.
17.2.1 Client Rights: The client has
the right to:
(a) Be treated with respect and without discrimination;
(b) Be given information about his/her illness or medical condition; understand the treatment options, risks and benefits; and make an informed decision about whether s/he shall receive a treatment;
(c) Talk with the PCP and know his/her medical information will be kept confidential;
(d) Choose his/her PCP and plan;
(e) Receive medical care in a timely manner...
(i) Receive proper medical care 24 hours a day, seven days a week;
(j) Change his/her PCP or plan;
(k) Formulate advance directives, if desired;
(l) Have materials explained or interpreted...
(n) Have access to the PCP/plan...
17.2.4 Adequate Notice: The Department shall send adequate notice sent notifying the client of any action(s) affecting his/her NHC enrollment. The notice shall include a statement describing the action(s) is, the reason(s) for the intended action and the specific manual reference supporting the action(s) or the federal or state law that requires the action(s). The plan shall notify the client of any action(s) regarding the provision of a service." Nebraska Contract, pages 139-140.
"15.2 Rights and Responsibilities for Clients Enrolled in the Mental Health/Substance Abuse (MH/SA) Package: The following rights and responsibilities apply to clients participating in the NHC. The PHP shall inform the client, in writing and orally, about his/her rights and responsibilities, including the right to a fair hearing under 465 NAC in the event of a denial, termination or reduction of services, or other action adverse to the interests of the client.
15.2.1 Client Rights: The client has
the right to:
(a) Be treated with respect and without discrimination;
(b) Be given information about his/her illness or medical condition; understand the treatment options, risks and benefits; and make an informed decision about whether s/he shall receive a treatment;
(c) Talk with the PHP and/or MH/SA provider and know his/her medical information will be kept confidential;
(d) Choose his/her MH/SA provider within the PHP;
(e) Receive medical care in a timely manner...
(g) Receive information about services included in the MH/SA Package...
(i) Receive proper care 24 hours a day, seven days a week;
(j) Change his/her MH/SA provider within the PHP;
(k) Formulate advance directives, if desired." Nebraska Behavioral Health Contract, page 103.
"IV. Participant Services
A. New Participant Orientation. The Contractor must have written policies and procedures for orienting new participants about the following: ...
6. Participants' rights and responsibilities. Information regarding Advance Directives to participants 18 and older; a signed copy of DHCFP's 'Acknowledgement of Patient Information on Advance Directives' form must be included in the participant's medical record.
As part of its orientation process, the Contractor may hold informational orientation sessions for new participants. The Contractor must make, at a minimum, orientations available by phone and in their business office.
Interpreter services must be available if more than 10% of the Medicaid participants in each geographic service area speak a primary language other than English and should be offered in person where practical. Otherwise they must be offered by telephone. The Contractor will be responsible for effectively informing individuals under EPSDT, regardless of any thresholds.
Contractors must also develop appropriate methods for communicating with their visually and hearing impaired participants and accommodating their physically disabled participants in accordance with the requirements of the Americans with Disabilities Act of 1990." Nevada Contract, page 32.
A. Enrolment Sessions. DHCFP will conduct enrollment orientation sessions prior to enrollment of participants in the Contract. Recipients will be scheduled to attend an orientation session where they are requested to select a Contractor.
The content of the enrollment sessions includes information as follows:
1. Rights and responsibilities of the participant...
7 . When information is available, performance and quality of services provided by the HMOs, including a comparison chart regarding benefits, cost sharing, and service area...
10. Explanation of enrollment populations as explained in Attachment C, Eligibility...
DHCFP will draft, print and distribute the enrollment information, excluding Contractor marketing materials..." Nevada Contract, pages 46-47.
"D. COMMUNICATION OF POLICIES TO PARTICIPANTS
Upon enrollment, participants are provided a written statement that includes information on the following:
1. Rights and responsibilities of participants." Nevada Contract, page 66.
Functions and Duties of Contractor
In consideration of the Agreement of the State contained in Article III, Contractor agrees: ...
2.8 HEALTH EDUCATION ----- To inform each Enrollee of contributions which they can make to the maintenance of their own health and the proper use of health care services...
2.10 GENERAL INFORMATION ----- To provide to Medicaid Enrollees in the Enrollment Area, from time to time, general information about services offered by Contractor, location of facilities, hours of service...
2.23 MEMBER SERVICES-----The Contractor
shall ensure to Enrollees the following:
A. The provision of all necessary information required to utilize HMO Covered Services and other benefits appropriately...
(2) Enrollee Orientation and Educational
Materials: The Contractor shall provide an orientation. by telephone, mail
or in person, to Enrollees regarding
the Plan's delivery system within thirty (30) days of the initial date or
enrollment...At a minimum, the curriculum and materials for orientation and
ongoing educational efforts shall include, but not be limited to: ...
a. the role of the PCP;
b. how to obtain access to specialists;
c. use of the emergency room and any available alternatives to emergency room care;
d. the importance of age/sex appropriate services such as EPSDT services and prenatal care;
e. how to obtain assistance from member services...
g. a needs assessment of all Enrollees, which shall be utilized to provide appropriate services to Enrollees;
h. a meaningful range of health promotion/wellness information and activities to its membership. The focus and content of this information shall be relevant to the specific health status needs and characteristics of the Plan's membership including special populations. Examples of special populations include, but are not limited to, adolescents, persons with disabilities and pregnant individuals who are diagnosed as substance abusers; and
i. how to convert to the Contractor's non-State paid plan when Medicaid eligibility has terminated." New Hampshire General Service Agreement, pages 9, 13-14.
11.2 The contractor will prepare...marketing materials for distribution to enrollees or, where applicable, an authorized person, and will include basic information about its plan. All marketing materials and presentations must, at a minimum:...
R. Where applicable, explain any cost-sharing requirements." New Jersey Contract, pages 63-65.
12.1 Prior to the effective date of enrollment, the contractor shall provide each enrolled case or, where applicable, an authorized person, with a . member handbook, the content and format of which shall have.in writing, the correct use of the contractor's plan, and other relevant information, including but not limited to: ...
G. ... for children eligible solely through the NJ KidCare Program, the identification card must clearly indicate 'NJ KidCare'; for children who are participating in NJ KidCare - Plan C or Plan D (cost-sharing in the form of personal contributions to care [PCCs] for Plan C and in the form of copayaments for Plan D), the PCC or copayment amount must be listed on the card...
R. for beneficiaries subject
to cost sharing (i.e., those eligible through NJ KidCare - Plan C with annual
family incomes of between 150% and up to and including 200% of the federal
poverty level of plan D with family incomes of between 201% and up to and
including 350% of the federal poverty level), information that specifically
1. The limitation on cost-sharing;
2. The dollar limit that applies to the family based on the reported income;
3. The need for the family to keep track of the cost-sharing amounts paid;
4. Instructions on what to do if the cost-sharing requirements are exceeded; and...
12.7 The contractor shall inform each
enrollee or, where applicable, an authorized person of their rights and responsibilities
which should include at a minimum:
A. Provision for 'Advance Directives', pursuant to 42 C.F.R., Part 489, Subpart I;
B. Participation in decision-making regarding their health care;
C. Provision for the opportunity for enrollees or, where applicable, an authorized person to offer suggestions for changes in policies and procedures; and
D. A policy on the treatment of minors." New Jersey Contract, pages 68-71.
QUALITY MANAGEMENT AND UTILIZATION REVIEW...
15.4 The contractor shall establish implement, and adhere to a written Quality Management Program (QMP)...
15.6 The contractor's QMP shall include the following standards: ...
J. Enrollee Rights and Responsibilities, including:
1. Written policy on enrollee rights;
2. Written policy on enrollee responsibilities." New Jersey Contract, pages 76-79.
"Standards for Internal Quality Assurance
Programs of HMOs, HIOs, and PHPs Contracting with Medicaid...
STANDARD X: ENROLLEE RIGHTS AND RESPONSIBILITIES - The organization demonstrates a commitment to treating members in a manner that acknowledges their rights and responsibilities.
A. Written policy on enrollee rights - The organization has a written policy that recognizes the following
rights of members:
1. To be treated with respect, and recognition of their dignity and need for privacy;
2. To be provided with information about the organization, its services, the practitioners providing care, and members rights and responsibilities
3. To be able to choose primary care practitioners, within the limits of the plan network, including the right to refuse care from specific practitioners;
4. To participate in decision-making regarding their health care;
5. To voice grievances about the organization or care provided;
6. To formulate advance directives; and
7. To have access to his/her medical records in accordance with applicable Federal and state laws.
B. Written policy on enrollee
responsibilities - The organization has a written policy that addressees members'
responsibility for cooperating with
those providing health care services. This written policy addresses members'
1. Providing, to the extent possible, information needed by professional staff in caring for the member; and
2. Following instructions and guidelines given by those providing health care services...
D. Communication of policies
to enrollees/members - Upon enrollment, members are provided a written statement
that includes information on the following:
1. Rights and responsibilities of members." New Jersey Contract, pages 203-214.
"2.A.1.e.ii The CONTRACTOR shall provide
each member with written information that instructs members about how to
obtain primary and specialty care,
(B) the means for obtaining more information about providers who participate in the MCO...
(E) the means for obtaining care after normal office hours...
(H) the means by which the CONTRACTOR will notify members affected by the termination or change in any benefit, service or service delivery office/site.
2.A1.e.iii The CONTRACTOR shall provide
each member and/or legal guardian with written policies and procedures
(A) is policy on freedom of provider choice;
(B) the procedures for changing assigned provider, if applicable...
(F) all other policies regarding member rights and responsibilities." New Mexico Contract, pages 4-5
"2.A.1.g Members' Bill of Rights
The CONTRACTOR shall have a written policy which is approved by HSD and complies with any applicable ADA requirements to ensure that members are treated in a manner that respects their rights... The CONTRACTOR shall distribute the policy on members' rights and responsibilities to members and/or legal guardians and participating practitioners. The CONTRACTOR's staff, staff of any subcontractor, and network providers shall honor the policies. The policy shall address the following at a minimum:
2.A.1.g.i Members and/or legal guardians
have a right to ensure equitable treatment, with respect and recognition
of the member's dignity and need for
2.A.1.g.iii Members and their families and/or legal guardians have a right to participate with practitioners in decision making regarding all aspects of their health care, including development of the treatment plan.
(A) The policy shall contain procedures for obtaining informed consent.
(B) The policy shall ensure that legally determined surrogate decision makers will be involved, as appropriate, to facilitate care decisions...
2.A.1.g.v Members and/or legal guardians have a right and the means to be able to choose from among the available providers within the limits of the plan network.
2.A.1.g.vi Members have a right to formulate advance directives consistent with Federal and State laws and regulations.
2.A.1.g.vii Members have a right to have access to his/her medical records in accordance with the applicable Federal and State laws and regulations.
2.A.1.g.viii Members and/or legal guardians, to the extent possible, have a responsibility to provide information that the MCO, its practitioners, and providers need in order to care for them.
2.A.1.g.ix Members and/or legal guardians, to the degree possible, have a responsibility to participate in understanding their health problems and developing mutually agreed upon treatment goals.
2.A.1.g.x Members and/or legal guardians have a responsibility to follow the plans and instructions for care that they have agreed upon with their practitioners.
2.A.1.g.xi Members and/or legal guardians have a responsibility to keep reschedule, or cancel a scheduled appointment rather than to simply fail to keep it." New Mexico Contract, pages 6-8.
"2.A.6.e Member Handbook
The CONTRACTOR is responsible for providing members with a member handbook...The handbook must include: ...
2.A.6.e.iii MCO demographic information including the organization's hotline phone number...
2.A.6.e.vii Members rights and responsibilities...
2.A.6.e.x MCO operating rules: ...
2.A.6.e.xiii Other information determined by the State to be essential during the member's initial contact with the MCO." New Mexico Contract, pages 20-21.
New York State Department of Health
Member Handbook Guidelines...
l) Rights and Responsibilities of Enrollees
i) Explanation of what an Enrollee has the right to expect from the Contractor in the way of medical care and treatment of the Enrollee.
ii) Responsibilities of the Enrollee (general).
iii) Enrollee's financial responsibility for payment when services are furnished by a provider who is not part of the Contractor's network or by any provider without required authorization or when a procedure, treatment, or service is not a covered benefit; also note exceptions such as family planning and HIV counseling/testing.
iv) Enrollee's rights under State law to formulate advance directives.
v) The manner in which Enrollees may participate in the development of plan policies." New York Contract, Appendix E, pages E-1-E-5.
"2.15 Enrollee handbook and Membership
Upon request, the Contractor shall provide a Medicaid specific enrollee handbook, to potential enrollees and to the recipient household within one week of initial enrollment notification to the Contractor, which at a minimum, shall include: .
(7) Health Tracks policies;
(8) Family planning policies...
(10)Limited Contractor liability for services from nonparticipating, i.e., only emergency care, family planning services, and certain public health clinic services and referrals can be obtained from non-participating providers;
(11)Education regarding the appropriate use of health care services in a managed care system...
(14)Rights and responsibilities of members.
(15)Contractor's policy on referrals for specialty care.
(16)Procedures for changing practitioners." North Dakota Contract, Attachment C, pages 16-17.
"ATTACHMENT E: STANDARD ENROLLEE HANDBOOK
The following standard language must be included in Medicaid enrollees' member handbooks unless alternate language is approved by the Department. This language is not intended to be comprehensive: .
Birth Control and Family Planning
Birth control, pregnancy testing, and reproductive health services are available to all enrollees. They are confidential. You can receive these services from your primary care provider or from any family planning provider. In ___ County, these providers include [clinic names] available by phone at [phone number]. You can ask for help in choosing a family planning provider. Call [Contractor's name] at [phone number] for help.
Immunization are available to all enrollees. You can receive these services from your primary care provider or from any county public health clinic. In ___ County, these providers include [clinic names] available by phone. You can ask for help in choosing a provider for these services. Call [Contractor's name] at [phone number] for help...
Health Tracks is a special health program for children which provides regular health checkups. Health Tracks provides care for any health problems that are found during a health checkup.Routine Health Tracks checkups are a good way to keep your child healthy. These checkups can detect childhood health problems early and treat them before they become serious. Health Tracks checkups can also help parents know about free child health services available to Medicaid enrollees." North Dakota Contract, Attachment E, pages 1,3-4.
1. Mental Health Services...
MCPs must advise enrollees via the member handbook of the ability to self-refer to mental health services offered through community mental health centers (CMHSC)...
2. Substance Abuse Services...
MCPs must advise enrollees via the member handbook of the ability to self-refer to substance abuse services offered through programs certified by the Ohio Department of Alcohol and Drug Addiction Services (ODADAS) which are Medicaid providers..." Ohio RFP, pages 13.
"5101:3-26-02 Managed care plan: Eligibility,
enrollment and automatic enrollment...
(C) Commencement of coverage...
(2) An MCP is not liable for the provision of covered services for an assistance group member who is hospitalized prior to the effective date of coverage and who remains hospitalized on the effective date of coverage...
(e) All initial enrollment forms and enrollment change forms must contain language that informs the assistance group of the provisions of paragraph (C)(2)(a) TO (C)(2)(d) of this rule and of their obligation to notify the enrolling MCP about the hospitalized assistance group member." Ohio RFP, Appendix E, OAC 5101:3-26-02, pages 1-7.
The following bullets outline the required elements of each Health Plan member handbook...
Member handbooks must contain the
following information (sections referenced can be found in the Health Plans
* Description of member rights and responsibilities." Oklahoma RFP, pages 164, 166.
"APPENDIX 5.6.1 Required Language
for Member Handbook
This Appendix includes the required language (by section) to be included in the Health Plan member handbook...
L-1 SoonerCare Plus Members' 'Rights and Responsibilities'." Oklahoma RFP, page 168.
"(9) Develop informational materials for potential OMAP Members consistent with OAR 410-141-0280, OHP Prepaid Health Plan Informational Requirements.
(10) Have an ongoing process of OMAP Member education and information sharing which includes orientation to Contractor, health education and... consistent with OAR 410-141-0300, OHP Prepaid Health Plan Member Education." Oregon Contract, page 6.
"b. Preventive and Early Intervention
(d) Contractor shall have mechanisms to inform its OMAP Members, Family Members, Health care professionals, and the community about its preventive and Psychoeducational programs." Oregon Mental Health Contract, page 13
"F. Informational Materials and Education
of OMAP Members
Contractor shall develop or provide informational materials and educational programs as described in OAR 410-141-0280, Oregon Health Plan Prepaid Health plan Information Requirements and OAR 410-141-0300, Oregon Health Plan Prepaid Health Plan Member Education. These materials and programs shall be tailored the backgrounds and special needs of OMAP Members." Oregon Mental Health Contract, page 27.
"G. OMAP Member Rights...
2. Contract shall assure that OMAP Members receive information on the rights specified in OAR 410-141-0320, Oregon Health Plan Prepaid Health Plan Members Rights and Responsibilities. Contract shall give particular attention to the following rights: ...
b. The right to be actively involved in the development of Treatment Plans if Covered Services are to be provided and to have parents to be involved in such Treatment Planning consistent with OAR 309-032-0950 through 309-032-1080, Standards for Community Treatment Services for Children;
c. The right to consent to Treatment and refuse Covered Services;
d. The right to be informed as required in ORS 127.703, Required Policies Regarding Mental Health Treatment Rights Information; Declaration for Mental Health Treatment;
e. The right to gain access to his or her own records, unless access is restricted in accordance with ORS 179.505 or other applicable law.
i. The right to have access to Covered services which at least equals access available to other persons served by Contractor;
j. The right to receive a Notice of Action when a service, benefit, Request for Service Authorization or request for Claim Payment is denied; or Notice of Intended Action prior to termination, suspension or reduction of a benefit or service as described in Exhibit G, Oregon Health Plan Mental Health Services Complaint and Hearings Process...
m. The right to request Continuation of Benefit until a decision in a hearing is rendered. The OMAP member may be required to repay any benefits continued if the issue is resolved in favor of the contractor...
o. The right to have written materials explained in a manner which is understandable; and
p. The right to access protective services as described in ors 430.735 through 430.765, Abuse Reporting for Mentally Ill and OAR 309-040-0200 through 309-040-0290, Abuse Reporting and Protective Services in Community Programs and Community Facilities." Oregon Mental Health Contract, pages 28-30.
"D. Member Enrollment and Disenrollment...
12. Member Handbook
The HMO must agree to mail a member handbook, or other written materials with information on how to access services, to all members within five (5) business days of being notifies of their enrollment...
a. Required Information...
At a minimum, the member handbook shall include: ...
* Information regarding recipients' rights and HMOs' responsibilities per Section 1867 of the Social Security Act...
* Contributions the member can make towards his/her own health, member responsibilities, and appropriate and inappropriate behavior...
* Information regarding members rights and responsibilities." Pennsylvania RFP, pages 20-31.
"c. Member Services (Part IV, Section
2) Describe the development of member communication materials, including member handbook, notification of client rights, public education programs, and outreach." Pennsylvania Behavioral Health RFP, pages 22-23.
"3) The MCO must publish and distribute
a member handbook to all members and make it available to other interested
parties upon request. The handbook
must be printed at no higher than a fourth grade reading level, delineating
a member's rights and responsibilities,
as well as covering...
b) how to contact Member Services and a description of its function...
d) no co-pay or cost sharing obligation by the member...
h) out-of-county/out-of-state moves or visits;
i) explanation of the procedures for accessing behavioral health services, including self-referred services;
j) confidentiality protections, including access to clinical records by oversight agencies and through the quality assurance/utilization management program;
k) information concerning methods for coordinating services for members." Pennsylvania Behavioral Health RFP, page 55.
"2.05.14.01 Required information
the member handbook must be written at no higher than a sixth-grade level and contain at least the following: ...
- Information on what to do when family size changes
- Appointment procedures and information on what to do in a medical emergency...
Also to be included are the following required by the Health Care Accessibility and Quality Assurance Act (may be included as an insert):
- How does the Health Plan review and approve covered services?
- What if I refuse referral to a participating provider?
- Does the Health Plan require that I get a second opinion for any services?
- How does the Health Plan make sure that my personal health information is protected and kept confidential?
- How am I protected from discrimination?
- If I refuse treatment, will it affect my future treatment?
- How does the Health Plan pay providers?
- If I am covered by two or more Health Plans, what do I do?..." Rhode Island RFP, pages 17-19.
"8.4 Member's Rights and Responsibilities
The Contractor shall furnish Medicaid HMO Program members with both verbal and written information about the nature and extent of their rights and responsibilities as a member of the Contractor's plan..The minimum information shall include: .information regarding advanced directives as described in 42 CFR 417.436 and 42 CFR 489, Subpart I and any information that affects the member's enrollment into the Contractor's plan. The Contractor shall provide the member written evidence of coverage." South Carolina Contract, page 45-46.
"Quality Assurance and Utilization
All HMOs that contract with the SCDHHS to provide Medicaid HMO Program Services must have a Quality Assurance (QA) and Utilization Review (UR) process that meets the following standards: .
10. The HMO shall furnish Medicaid members with approved written information about the nature and extent of their rights and responsibilities as a member of the HMO. The minimum information shall include: ...
(b) The practitioners providing their health care...
(g) Information that affects the members enrollment into the HMO." South Carolina Contract, Appendix G, pages 1,6.
"8.3 Member Education...
The Contractor must inform potential Medicaid members of any Medicaid covered services that it will not be offered by the Contractor due to the Contractor's exercise of a Right of Conscience. The Contractor shall inform members and potential members in writing that such services are available under Medicaid fee-for-service. If the Contractor changes its policies with regard to the Right of Conscience, the Contractor must provide notification to its Medicaid HMO members within 90 days of the change...
The Contractor shall inform Medicaid HMO Program members that they have the freedom to receive family planning services outside the Contractor's provider network by appropriate Medicaid providers without any restrictions. No referral is needed for these services. The Contractor shall be responsible for reminding pregnant members that their newborn will be automatically enrolled for the first ninety (90) calendar days from birth unless the mother indicates otherwise prior to delivery." South Carolina Contract, page 44.
"MARKETING AND EDUCATIONAL MATERIALS
SDHHS has established the following minimum requirements for the Contractor's Medicaid managed care marketing/educational materials: ...
* The Contractor must provide a description of its family planning services and services for communicable diseases such as TB, STD, and HIV. This document must contain a statement of the member's right to obtain family services from the plan or from any approved Medicaid enrolled provider. This document must contain a statement of the member's right to obtain TB, STD, HIV services from any state public health agency.
* The Contractor's written materials must include procedures for making appointments for medical care including appointments with a specialist, how to obtain medical advice, and how to access the Contractor's member/patient services.
* The Contractor's written materials must provide the following information on the responsibilities and rights of a Medicaid HMO program member...
* Provide information on member disenrollment and termination. An explanation of the Medicaid HMO program member(s) effective date of enrollment and coverage;
* The plan's toll-free telephone number; and
* A statement that any brochure or mailer may contain only a brief summary of the plan and that detailed information can be found in other documents, e.g. evidence of coverage, or obtained by contacting the plan." South Carolina Contract, pages 21-22.
b. Enrollment Procedures
1. The CONTRACTOR shall give a full written explanation of the MCO's plan to enrollees after their enrollment in the plan. This written explanation shall, at a minimum, include:
(b) Description of services provided including...deductibles, copayments, special fees...
(h) Member responsibilities;
(k) The member's responsibility to notify the CONTRACTOR and the TENNCARE agency each and every time the member moves to a new address." Tennessee Contract, pages 34-39.
"Guidelines for Internal Quality Monitoring
Programs of Managed Care Organizations Contracting with TennCare...
STANDARD IX: ENROLLEE RIGHTS AND RESPONSIBILITIES - The organization demonstrates a commitment to treating members in a manner that acknowledges their rights and responsibilities.
B. Written Policy on Enrollee Responsibilities
- The organization has a written policy that addresses members' responsibility
for cooperating with those providing health care services. This written policy
addresses members' responsibility
1. providing, to the extent possible, information needed by professional staff in caring for the member; and
2. following instructions and guidelines given by those providing health care services." Tennessee Contract,
"6.14 HEALTH EDUCATION AND WELLNESS
AND PREVENTION PLANS
6.14.1 Health Education Plan. HMO must develop and implement a Health Education plan. The health education plan must tell Members how HMO system operates, how to obtain services, including emergency care and out-of-plan services. The plan must emphasize the value of screening and preventive care and must contain disease-specific information and educational materials.
6.14.2 Wellness Promotion Programs.
HMO must conduct wellness promotion programs to improve the health status
of its Members. HMO may cooperatively conduct Health Education classes for
all enrolled STAR Members with one or more HMOs also contracting with TDH
in the service area to provide services to Medicaid recipients in all counties
the service area." Texas Contract, page 50.
"3. Member Handbook...
At a minimum, the member handbook must explain in clear terms the following information: ...
f. Description on Enrollee cost-sharing requirements (if applicable) ...
l. Clients' rights and responsibilities..." Utah Contract, Attachment B, page 8.
"C. General Information to be Provided
The CONTRACTOR will make the following information available to Enrollees and potential enrollees on request:...
2. The rights and responsibilities of Enrollees..." Utah Contract, Attachment B, page 28.
"5. Medicaid Enrollee Information...
a. The CONTRACTOR will develop written policy describing client rights and responsibilities and distribute the
policy to Enrollees.
b. Before implementation of the Contract, the CONTRACTOR will produce an informational brochure. At a minimum the brochure must explain in clear terms the benefits available to Enrollees, including.any toll-free telephone numbers.unauthorized care, hospital admission procedures.other information necessary to assist Enrollees in gaining access to services covered by this Contract. The brochure must also include a statement that the Contractor does not discriminate against any Enrollee on the basis of race, color, national origin, disability, or age in admission, treatment, or participation in its programs, services and activities. In addition, the materials must include the phone number of the nondiscrimination coordinator for Enrollees to call if they have questions about the nondiscrimination policy or desire to file a complaint or grievance alleging violations of the nondiscrimination policy...
e. When possible, DHCF will distribute the brochures to new Enrollees and will explain how the Enrollee can access mental health services." Utah Mental Health Contract, page 10.
"17. Enrollee Information Packet
The Enrollee Information Packet must include at a minimum the following sections.
b. Recipient Eligibility
i. Effective date and term of coverage.
ii. Terms and conditions under which coverage may be terminated.
c. Choosing or Changing an HMO
i. Procedures to be followed if the enrollee wishes to change HMOs.
ii. A description of the right of the enrollee to convert his or her HMO coverage to an individual contract issued by the Contractor...
e. Making Appointments and Accessing
i. Appointment-making procedures and appointment access standards.
ii. A description of how to access all services, including specialty care.
iii. The role of the PCP and the Contractor in directing care.
f. Recipient Services...
iii. Instructions on how to contact Member or Customer Services of the Contractor and a description of the functions of Member or Customer Services.
iv. Notification that each enrollee is entitled to a copy of his or her medical records and instructions on how to request those records from the Contractor.
v. Instructions on how to utilize the after-hours Medicaid Advice and Customer Services departments of the Contractor...
h. Enrollee Identification Cards...
i. Recipient Responsibilities
i. A description of procedures to follow if:
A. The enrollee's family size changes;
B. The enrollee's address changes;
C. The enrollee moves out of the Contractor's service area; or
D. He or she obtains or has health coverage under another policy or for Medicaid enrollees, changes to that coverage.
ii. Actions the enrollee can
make towards improving his or her own health, enrollee responsibilities, appropriate
and inappropriate behavior, and any other information deemed essential by
iii. Information about advance directives, such as living wills or durable power of attorney.
iv. Notification that the enrollee will not be required to pay deductibles or copayments.
j. HMO Responsibilities." Virginia Contract, pages 30-33.
"I. ENROLLEE EDUCATION PROGRAM
The Contractor must develop, administer, implement, monitor, and evaluate a program to promote health education services for its new and continuing Medallion II enrollees, as indicated below. The Contractor shall maintain a written plan for health education and prevention which is based on the needs of its enrollees." Virginia Contract, page 62.
"2.3 Client Notification: DSHS shall notify eligible clients of their rights and responsibilities as Healthy Options enrollees at the time of initial eligibility determination and eligibility review. The Contractor shall provide members with additional information as described in the 1998 Quality Improvement program standards, which are included by reference." Washington Contract, page 6.
"IV MEMBERS' RIGHTS AND RESPONSIBILITIES...
B. DISTRIBUTION OF RIGHTS STATEMENTS TO MEMBERS AND PRACTITIONERS [RR 2]
The contractor must distribute the policy on members' rights and responsibilities to members and participating practitioners." Washington Contract, QIP-2000 Standards, page 24.
"E. MEMBER INFORMATION [RR 5].
1. The contractor must provide written information about benefits and charges applicable to the members. [RR 5.1]
This information must include: ...
b) whether the contractor has a drug formulary. It also describes how to obtain the formulary, the extent to which nonformulary medications are a covered benefit, and any exceptions policy for receiving coverage for nonformulary medications. [RR 126.96.36.199] (D) RCW 48.43.095 (d)
c) any restrictions on benefits that apply to services obtained outside the contractor's system or outside the
contractor's service area. [RR 5.1.3] (A)
2. The contractor must provide written
information that instructs members about how to obtain primary and specialty
care. This includes the following: ...
c) how to obtain specialty care, behavioral health services, and hospital services; [RR 5.2.3]
d) how to obtain care after normal office hours...
4. Additional Requirements for Health
Options, BHP-Plus, and BHP/S clients must include:
a) how to choose a practitioner; how to change a primary care provider; informed consent; how to convert to an individual plan; how to request a disenrollment if they choose to do so; information regarding advance directives; and how to recommend changes in the contractor's policies and procedures." Washington Contract, QIP-2000 Standards, pages 26, 27-28.
"V. PREVENTIVE HEALTH SERVICES...
C. HEALTH PROMOTION with MEMBERS [PH 3]
The contractor must encourage its members to use preventive health services.
1. The contractor must distribute preventive health guidelines to members. [PH 3.1]" Washington Contract, QIP-2000, page 31.
"2.1.2 Early and Periodic Screening,
Diagnosis and Treatment (EPSDT) Services...
188.8.131.52 Required Activities...
The MCP must inform all EPSDT eligible individuals (or their families) about the EPSDT program using clear and non-technical language. The MCP must meet the federal EPSDT informing requirements as specified in 42 CFR 441.56 and must provide information that includes the following areas:
a) The benefits of preventive health care;
b) The services available under the EPSDT program and where and how to obtain those services;
c) A statement that the services provided under the EPSDT program are without cost to eligible individuals under twenty-one (21) years of age." West Virginia RFA, page 8
"3.10 Health Education
The Managed Care Plan must provide a continuous program of general health education for disease and injury prevention and identification without cost to the enrollees.
3.15 Enrollee Handbook and Member
The Managed Care Plan shall mail an enrollee handbook to the enrollee's household within one week of official enrollment notification to the Managed Care Plan. The enrollee handbook at a minimum, shall include: ...
* the Managed Care Plan's hours of service (e.g., member services)...
* information concerning policies on advance directives...
* the phone numbers of the HBM." West Virginia Contract, pages 13, 16.
"184.108.40.206 Member Handbook Minimum Contents
The member handbook must include standards for enrollee rights as specified in Standard X of Appendix E. The handbook must include the following: ...
c) Information about what to do when family composition changes;
d) Appointment procedures and access standards including travel time, scheduling standards and the MCP's standard waiting time...
o) A listing of the behavioral health MCO's 24-hour toll-free telephone number (when it becomes available)...
q) What to do in the case of out-of-county and out-of-state moves2E;
r) What to do if the member has a worker's compensation claim, or pending personal injury or medical malpractice
law suit, or has been involved in an auto accident;
s) Information of contributions that enrollees can make toward their own health, enrollee responsibilities, appropriate and inappropriate behavior and any other information deemed essential by the MCP or DHHR...
u) Information regarding advance directives (see section 4.4.3)...
4.5.1 New Member Orientation
The MCP must have written policies and procedures for orienting new Medicaid enrollees about the following: ...
c) How to make appointments and utilize services...
f) Members' rights and responsibilities...
4.5.2 Health Education and Preventive
The MCP must provide a continuous program of general health education for disease and injury prevention and identification without cost to the enrollees...
The MCP must provide programs of wellness education. Such programs may include stress management, smoking cessation, nutritional education, prenatal care, human development, care of newborn infants and programs focused on the importance of physical activity in maintaining health." West Virginia RFA, pages 32-34.
"D. Communication of policies to members
- Upon enrollment, members are provided a written statement that includes
information on the following:
1. Rights and responsibilities of members...
4. The organization's policy on referrals for specialty care;
5. Charges to members, if applicable, including:
a. Policy on payment of charges; and
b. Co-payment and fees for which the member is responsible.
6. Procedures for notifying those members affected by the termination or change in any benefit services, or service delivery office/site." West Virginia RFA, Appendix E, page E10.
The MCO must provide enrollees with a written statement, at the time of enrollment and at least annually thereafter, with information on: .
* Policies on referrals for specialty care and other services not furnished by the enrollee's primary care provider;
* Charger to enrollees, if applicable...
* Procedures for changing primary care providers; and
* Procedures for recommending changes in policies or services.
The MCO must also provide written notice to any enrollee who requests it regarding:
* The right to receive the information listed above...
* The financial condition of the MCO, including the most recently audited information regarding its condition.
Each MCO must provide sufficient notice to enrollees affected by termination of or changes in benefits, services, service sites, or affiliated providers, To the extent practical, enrollees are informed of such terminations or changes 30 days prior. effective date, and no later than the actual effective date." West Virginia Contract, Exhibit F, page 9.
"S. HEALTH EDUCATION AND PREVENTION-(1)
Inform all enrollees of contributions which they can make to the maintenance
of their own health and the proper use of health care services. (2) Have a
program of health education and
prevention available and within reasonable geographic proximity to its enrollees...
The program shall provide: ...
2. Information on how to obtain these services (locations, hours, phones, etc.).
3. Health-related educational materials in the form of printed, audiovisual, and/or personal communication.
4. Information on recommended check-ups and screenings, and prevention and management of disease states which affect the general population. This includes specific information for persons who have or who are at risk of developing such health problems (e.g., hypertension, diabetes, STD, asthma, breast and cervical cancer, or osteoporosis)...
6. Promotion of the health education and prevention program, including use of languages understood by the population served, and use of facilities accessible to the population served.
7. Information on and promotion of other available prevention services offered outside of the HMO including child nutrition programs, parenting classes, programs offered by local health departments and other programs." Wisconsin Contract, pages 17-18.