Health Plan An appropriately licensed entity that has entered into a contract with Subcontractor, either directly or indirectly, under which Subcontractor provides certain administrative services for Health Plan pursuant to the State Contract. For purposes of this Appendix, Health Plan refers to UnitedHealthcare Insurance Company.
Disenrollment 2.3.2.1. The Contractor shall:
Product Warnings As of the Effective Date, all Products CORE sells and/or distributes for sale in California which do not qualify as Reformulated Products, will bear a clear and reasonable warning pursuant to this Section. CORE further agrees that the warning will be prominently placed with such conspicuousness when compared with other words, statements, designs or devices as to render it likely to be read and understood by an ordinary individual under customary conditions of use. For purposes of this Settlement Agreement, a clear and reasonable warning for the Products shall consist of a warning affixed directly to the product or product packaging, label, or tag, for Products sold in California and containing one of the following statements: WARNING: Reproductive Harm- xxx.X00Xxxxxxxx.xx.xxx OR WARNING: This product can expose you to chemicals, including DEHP, which are known to the State of California to cause birth defects or other reproductive harm. For more information go to xxx.X00Xxxxxxxx.xx.xxx
Supplier Diversity Seller shall comply with Xxxxx’s Supplier Diversity Program in accordance with Appendix V.
Hospital This plan covers behavioral health services if you are inpatient at a general or specialty hospital. See Inpatient Services in Section 3 for additional information. Residential Treatment Facility This plan covers services at behavioral health residential treatment facilities, which provide: • clinical treatment; • medication evaluation management; and • 24-hour on site availability of health professional staff, as required by licensing regulations. Intermediate Care Services This plan covers intermediate care services, which are facility-based programs that are: • more intensive than traditional outpatient services; • less intensive than 24-hour inpatient hospital or residential treatment facility services; and • used as a step down from a higher level of care; or • used a step-up from standard care level of care. Intermediate care services include the following: • Partial Hospital Program (PHP) – PHPs are structured and medically supervised day, evening, or nighttime treatment programs providing individualized treatment plans. A PHP typically runs for five hours a day, five days per week. • Intensive Outpatient Program (IOP) – An IOP provides substantial clinical support for patients who are either in transition from a higher level of care or at risk for admission to a higher level of care. An IOP typically runs for three hours per day, three days per week.
Other Directory Services 73.10.1 Both parties acknowledge that CenturyLink’s directory publisher is not a party to this Agreement and that the provisions contained in this Agreement are not binding upon CenturyLink’s directory publisher.
Staffing Plan 8.l The Board and the Association agree that optimum class size is an important aspect of the effective educational program. The Polk County School Staffing Plan shall be constructed each year according to the procedures set forth in Board Policy and, upon adoption, shall become Board Policy.
Medi Cal PII is information directly obtained in the course of performing an administrative function on behalf of Medi-Cal, such as determining Medi-Cal eligibility or conducting IHSS operations, that can be used alone, or in conjunction with any other information, to identify a specific individual. PII includes any information that can be used to search for or identify individuals, or can be used to access their files, such as name, social security number, date of birth, driver’s license number or identification number. PII may be electronic or paper. AGREEMENTS
HEALTH PROGRAM 3701 Health examinations required by the Employer shall be provided by the Employer and shall be at the expense of the Employer. 3702 Time off without loss of regular pay shall be allowed at a time determined by the Employer for such medical examinations and laboratory tests, provided that these are performed on the Employer’s premises, or at a facility designated by the Employer. 3703 With the approval of the Employer, a nurse may choose to be examined by a physician of her/his own choice, at her/his own expense, as long as the Employer receives a statement as to the fitness of the nurse from the physician. 3704 Time off for medical and dental examinations and/or treatments may be granted and such time off, including necessary travel time, shall be chargeable against accumulated income protection benefits.
Member Handbook The Contractor shall develop a member handbook for its members. The Contractor’s member handbook shall be submitted annually for OMPP’s review. The member handbook shall include the Contractor’s contact information and Internet website address and describe the terms and nature of services offered by the Contractor, including the following information required under 42 CFR 438.10(f), which enumerates certain required information. The member handbook may be offered in an electronic format as long as the Contractor complies with 42 CFR 438.10(c)(6). The Hoosier Healthwise MCE Policies and Procedures Manual outlines the member handbook requirements. The Hoosier Healthwise member handbook shall include the following: Contractor’s contact information (address, telephone number, TDD number, website address); The amount, duration and scope of services and benefits available under the Contract in sufficient details to ensure that participants are informed of the services to which they are entitled, including, but not limited to the differences between the benefit options; The procedures for obtaining benefits, including authorization requirements; Contractor’s office hours and days, including the availability of a 24-hour Nurse Call Line; Any restrictions on the member’s freedom of choice among network providers, as well as the extent to which members may obtain benefits, including family planning services, from out-of-network providers; The extent to which, and how, after-hours and emergency coverage are provided, as well as other information required under 42 CFR 438.10(f), such as what constitutes an emergency; The post-stabilization care services rules set forth in 42 CFR 422.113(c); The extent to which, and how, urgent care services are provided; Applicable policy on referrals for specialty care and other benefits not provided by the member’s PMP, if any; Information about the availability of pharmacy services and how to access pharmacy services; Member rights and protections, as enumerated in 42 CFR 438.100, which relates to enrollee rights. See Section 4.8 for further detail regarding member rights and protections; Responsibilities of members; Special benefit provisions (for example, co-payments, deductibles, limits or rejections of claims) that may apply to services obtained outside the Contractor’s network; Procedures for obtaining out-of-network services; Standards and expectations to receive preventive health services; Policy on referrals to specialty care; Procedures for notifying members affected by termination or change in any benefits, services or service delivery sites; Procedures for appealing decisions adversely affecting members’ coverage, benefits or relationship with the Contractor; Procedures for changing PMPs; Standards and procedures for changing MCEs, and circumstances under which this is possible, including, but not limited to providing contact information and instructions for how to contact the enrollment broker to transfer MCEs due to one of the “for cause” reasons described in 42 CFR 438.56(d)(2)(iv), including, but not limited to, the following: Receiving poor quality of care; Failure to provide covered services; Failure of the Contractor to comply with established standards of medical care administration; Lack of access to providers experienced in dealing with the member’s health care needs; Significant language or cultural barriers; Corrective action levied against the Contractor by the office; Limited access to a primary care clinic or other health services within reasonable proximity to a member’s residence; A determination that another MCE’s formulary is more consistent with a new member’s existing health care needs; Lack of access to medically necessary services covered under the Contractor’s contract with the State; A service is not covered by the Contractor for moral or religious objections, as described in Section 6.3.3; Related services are required to be performed at the same time and not all related services are available within the Contractor’s network, and the member’s provider determines that receiving the services separately will subject the member to unnecessary risk; The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls with another MCE; or Other circumstances determined by the office or its designee to constitute poor quality of health care coverage. The process for submitting disenrollment requests. This information shall include the following: Hoosier Healthwise members may change MCEs after the first ninety (90) calendar days of enrollment only for cause; Members are required to exhaust the MCE’s internal grievance and appeals process before requesting an MCE change ; Members may submit requests to change MCEs to the Enrollment Broker verbally or in writing, after exhausting the MCE’s internal grievance and appeals process; and The MCE shall provide the Enrollment Broker’s contact information and explain that the member must contact the Enrollment Broker with questions about the process. This information shall include how to obtain the Enrollment Broker’s standardized form for requesting an MCE change. The process by which an American Indian/ Alaska Native member may elect to opt-out of managed care pursuant to 42 USC § 1396u–2(a)(2)(C) and transfer to fee-for-service benefits through the State; Procedures for making complaints and recommending changes in policies and services; Grievance, appeal and fair hearing procedures as required at 42 CFR 438.10(g)(2)(xi), including the following: The right to file grievances and appeals; The requirements and timeframes for filing a grievance or appeal; The availability of assistance in the filing process; The toll-free numbers that the member can use to file a grievance or appeal by phone; The fact that, if requested by the member and under certain circumstances: (1) benefits will continue if the member files an appeal or requests a State fair hearing within the specified timeframes; and (2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member. For a State hearing describe (i) the right to a hearing, (ii) the method for obtaining a hearing, and (iii) the rules that govern representation at the hearing. Information about advance directives; How to report a change in income, change in family size, etc.; Information about the availability of the prior claims payment program for certain members and how to access the program administrator; Information on alternative methods or formats of communication for visually and hearing-impaired and non-English speaking members and how members can access those methods or formats; Information on how to contact the Enrollment Broker; Statement that Contractor will provide information on the structure and operation of the health plan; and In accordance with 42 CFR 438.10(f)(3), that upon request of the member, information on the Contractor’s provider incentive plans will be provided.
