Common use of ENROLLEE RIGHTS AND NOTIFICATION Clause in Contracts

ENROLLEE RIGHTS AND NOTIFICATION. 13.1 Information Requirements a) The Contractor shall provide new Enrollees with the information identified in PHL § 4408, SSL § 364-j, SSL § 369-ee and 42 CFR § 438.10 (f) and (g). b) The Contractor shall provide such information to the Enrollee within fourteen (14) days of the Effective Date of Enrollment. The Contractor may provide such information to the Enrollee through the Member Handbook referenced in Section 13.4 of this Agreement. c) The Contractor must provide Enrollees with an annual notice that this information is available to them upon request. d) The Contractor must inform Enrollees that oral interpretation service is available for any language and that information is available in alternative formats and how to access these formats. 13.2 Provider Directories/Office Hours for Participating Providers a) The Contractor shall maintain and update, on a quarterly basis, a listing by specialty of the names, addresses and telephone numbers of all Participating Providers, including facilities. Such a list/directory shall include names, office addresses, telephone numbers, board certification for physicians, information on language capabilities, and wheelchair accessibility of Participating Providers. The list should also identify providers that are not accepting new patients. b) New Enrollees must receive the most current complete listing in hardcopy, along with any updates to such listing. c) Enrollees must be notified of updates in writing at least annually in one of the following methods: (1) provide updates in hardcopy; (2) provide a new complete listing/directory in hardcopy; or (3) provide written notification that a new complete listing/directory is available and will be provided upon request either in hardcopy, or electronically if the Contractor has the capability of providing such data in an electronic format and the data is requested in that format by an Enrollee. d) In addition, the Contractor must make available to the LDSS the office hours for Participating Providers. This requirement may be satisfied by providing a copy of the list or Provider Directory described in this Section with the addition of office hours or by providing a separate listing of office hours for Participating Providers. 13.3 Member ID Cards a) The Contractor must issue an identification card to the Enrollee containing the following information: i) the name of the Enrollee's clinic (if applicable); ii) the name of the Enrollee's PCP and the PCP's telephone number (if an Enrollee is being served by a PCP team, the name of the individual shown on the card should be the lead provider); iii) the member services toll free telephone number; iv) the twenty-four (24) hour toll free telephone number that Enrollees may use to access information on obtaining services when his/her PCP is not available, and v) for ID Cards issued after October 1, 2004, the Enrollee’s Client Identification Number (CIN). b) PCP information may be embossed on the card or affixed to the card by a sticker. c) The Contractor shall issue an identification card within fourteen (14) days of an Enrollee’s Effective Date of Enrollment. If unforeseen circumstances, such as the lack of identification of a PCP, prevent the Contractor from forwarding the official identification card to new Enrollees within the fourteen (14) day period, alternative measures by which Enrollees may identify themselves such as use of a Welcome Letter or a temporary identification card shall be deemed acceptable until such time as a PCP is either chosen by the Enrollee or auto assigned by the Contractor. The Contractor agrees to implement an alternative method by which individuals may identify himself/herself as Enrollees prior to receiving the card (e.g., using a "welcome letter" from the Contractor) and to update PCP information on the identification card. Newborns of Enrollees need not present ID cards in order to receive Benefit Package services from the Contractor and its Participating Providers. The Contractor is not responsible for providing Benefit Package services to newborns excluded from the MMC Program pursuant to Appendix H of this Agreement, or when the Contractor does not offer an MMC product in the mother’s county of fiscal responsibility. d) If Contractor is certified as both a mainstream MCO and an HIV SNP, identification cards may distinguish the individual as an Enrollee of the HIV SNP only through use of an alphanumeric code. No plan shall use the words “HIV,” “AIDS,” “Special Needs Plan,” or “SNP” on a member card to denote participation in an HIV SNP.

ENROLLEE RIGHTS AND NOTIFICATION. 13.1 Information Requirements a) The Contractor shall provide new Enrollees with the information identified in PHL § 4408, SSL § 364-j, SSL § 369-ee j and 42 CFR §§ 438.10 (f) and (g). b) The Contractor shall provide such information to the Enrollee within fourteen (14) days of the Effective Date of Enrollment. The Contractor may provide such information to the Enrollee through the Member Handbook referenced in Section 13.4 of this Agreement. c) The Contractor must provide Enrollees with an annual notice that this information is available to them upon request. d) The Contractor must inform Enrollees that oral interpretation service is available for any language and that information is available in alternative formats and how to access these formats. 13.2 Provider Directories/Office Hours for Participating Providers a) The Contractor shall maintain and update, on a quarterly basis, a listing by specialty of the names, addresses and telephone numbers of all Participating Providers, including facilities. Such a list/directory shall include names, office addresses, telephone numbers, board certification for physicians, information on language capabilities, capabilities and wheelchair accessibility of Participating Providers. The list should also identify providers that are not accepting new patients. b) New Enrollees must receive the most current complete listing in hardcopy, along with any updates to such listing. c) Enrollees must be notified of updates in writing at least annually in one of the following methods: (1) provide updates in hardcopy; (2) provide a new complete listing/directory in hardcopy; or (3) provide written notification that a new complete listing/directory is available and will be provided upon request either in hardcopy, or electronically if the Contractor has the capability of providing such data in an electronic format and the data is requested in that format by an Enrollee. d) In addition, the Contractor must make available to the LDSS the office hours for Participating Providers. This requirement may be satisfied by providing a copy of the list or Provider Directory described in this Section with the addition of office hours or by providing a separate listing of office hours for Participating Providers. 13.3 Member ID Cards a) The Contractor must issue an identification card to the Enrollee containing the following information: i) the name of the Enrollee's clinic (if applicable); ii) the name of the Enrollee's PCP and the PCP's telephone number (if an Enrollee is being served by a PCP team, the name of the individual shown on the card should be the lead provider); iii) the member services toll free telephone number; iv) the twenty-four (24) hour toll free telephone number that Enrollees may use to access information on obtaining services when his/her PCP is not available, and v) and for ID Cards issued after October 1, 2004, the Enrollee’s Client Identification Number (CIN). b) PCP information may be embossed on the card or affixed to the card by a sticker. c) The Contractor shall issue an identification card within fourteen (14) days of an Enrollee’s =s Effective Date of Enrollment. If unforeseen circumstances, such as the lack of identification of a PCP, prevent the Contractor from forwarding the official identification card to new Enrollees within the fourteen (14) day period, alternative measures by which Enrollees may identify themselves such as use of a Welcome Letter or a temporary identification card shall be deemed acceptable until such time as a PCP is either chosen by the Enrollee or auto assigned by the Contractor. The Contractor agrees to implement an alternative method by which individuals may identify himself/herself as Enrollees prior to receiving the card (e.g., using a "welcome letter" from the Contractor) and to update PCP information on the identification card. Newborns of Enrollees need not present ID cards in order to receive Benefit Package services from the Contractor and its Participating Providers. The Contractor is not responsible for providing Benefit Package services to newborns excluded Excluded from the MMC Program pursuant to Appendix H of this Agreement, or when the Contractor does not offer an a MMC product in the mother’s county of fiscal responsibility. d) If Contractor is certified as both a mainstream MCO and an HIV SNP, identification cards may distinguish the individual as an Enrollee of the HIV SNP only through use of an alphanumeric code. No plan shall use the words “HIV,” “AIDS,” “Special Needs Plan,” or “SNP” on a member card to denote participation in an HIV SNP.