Enhanced Benefit Program Sample Clauses
The Enhanced Benefit Program clause establishes additional or superior benefits for eligible participants beyond the standard offerings. Typically, this clause outlines the specific criteria for eligibility, the nature of the enhanced benefits—such as increased coverage, extra services, or higher reimbursement rates—and the process for accessing these benefits. Its core practical function is to incentivize participation or reward certain behaviors by providing greater value, thereby promoting engagement and satisfaction among participants.
Enhanced Benefit Program a. The Agency has identified a combination of covered and non-covered services as healthy behaviors that will earn credits for an enrollee. The Agency shall assign a specific credit to an enrollee’s account for each healthy behavior service received and notify each enrollee of the availability of the credits in the account. The credits in the enrollee’s account shall be available if the enrollee enrolls in a different Health Plan and for a period of up to one (1) year after loss of Medicaid eligibility.
b. The Agency shall administer the program with assistance from the Health Plan.
(1) For covered services identified as healthy behaviors, the Health Plan shall submit a monthly report to the Medicaid Bureau of Contract Management (MCM) by the tenth calendar day of the month for the previous month’s paid claims. See Attachment II, Section XII, Reporting Requirements. A list of procedure codes and healthy behaviors will be provided in the Agency Report Guide posted on the Agency’s website at: ▇▇▇▇://▇▇▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇/Medicaid/medicaid_reform/index.shtml#eb.
(2) For non-Medicaid services, the Health Plan shall assist the enrollee in obtaining and submitting documentation to MCM to verify participation in a healthy behavior without a procedure code. A universal form shall be available with the Agency’s website at: ▇▇▇▇://▇▇▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇/Medicaid/medicaid_reform/index.shtml#eb and must be submitted to the Health Plan to document participation in healthy behaviors without a procedure code.
c. The Agency may add or delete healthy behaviors with thirty (30) calendar days’ written notice. This provision replaces Attachment II, Section III, Eligibility and Enrollment, Item A., Enrollee Services, sub-item 5.b., of this Contract as follows: The Health Plan shall assign a PCP to those enrollees who did not choose a PCP at the time of Health Plan selection. All HIV/AIDS enrollees who are assigned to a PCP must be assigned to a provider experienced in the provision and management of medical and psycho-social health care for persons with HIV/AIDS. The Health Plan shall also take into consideration, when possible, the enrollee’s last PCP if the PCP is known and available in the Health Plan’s network. If the last PCP is unknown, then the Health Plan shall take into consideration the PCP closest to the enrollee’s home address and zip code location, age (adults versus children/adolescents) and gender (OB/GYN), and keep children/adolescents within the same family together....