Common use of Enrollment Information Clause in Contracts

Enrollment Information. The MCO shall present to all new Enrollees the following information within fifteen (15) calendar days of the availability of readable enrollment data from the STATE: (1) Certificate of Coverage (COC). The STATE will provide annually to the MCO a model Certificate of Coverage (COC) or COC Addendum as the base document. After the MCO has incorporated its specific information, the completed COC or COC Addendum will be submitted to the STATE for prior approval. The complete COC must include the following: (a) A description of the MCO’s medical and remedial care program, including specific information on benefits, limitations, and exclusions. (b) A description of the Enrollee’s rights and protections as specified in 42 CFR § 438.100. (c) Cost sharing, if applicable. (d) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, § 62Q.14. (e) Information about providing coverage for prescriptions that are dispensed as written (DAW). (f) A statement informing Enrollees that the MCO shall provide language assistance to Enrollees that ensures meaningful access to its programs and services. (g) A description of how American Indian Enrollees may directly access Indian Health Service and certain tribal Providers and how such Enrollees shall obtain referral services. In prior approving this portion of the COC, the STATE shall consult with tribal governments. (h) A description of how Enrollees may access services to which they are entitled under Medical Assistance, but that the MCO does not provide under this Contract. (i) A description of Medical Necessity for mental health services under Minnesota Statutes, § 62Q.53. (j) A description of how transportation is provided. (k) A description of how the Enrollee may obtain services, including: 1) hours of service; 2) appointment procedures; 3) Service Authorization requirements and procedures; 4) what constitutes Medical Emergency and Post Stabilization care;

Enrollment Information. The MCO shall present to all new Enrollees the following information within fifteen (15) calendar days of the availability of readable enrollment data from the STATE:STATE:‌ (1) Certificate of Coverage (COC). The STATE will provide annually to the MCO a model A Certificate of Coverage (COC) or COC Addendum as the base document. After the MCO that has incorporated its specific information, the completed COC or COC Addendum will be submitted to been prior-approved by the STATE for prior approval. The complete COC must and that will include the following: (a) A description of the MCO’s medical and remedial care program, including specific information on benefits, limitations, and exclusions. (b) A description of the Enrollee’s rights and protections as specified in 42 CFR § 438.100. (c) Cost sharing, if applicable. (d) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, § 62Q.14. (e) Information about providing coverage for prescriptions that are dispensed as written (DAW). (f) A statement informing Enrollees that the MCO shall provide language assistance to Enrollees that ensures meaningful access to its programs and services. (g) A description of how American Indian Enrollees may directly access Indian Health Service and certain tribal Providers and how such Enrollees shall obtain referral services. In prior approving this portion of the COC, the STATE shall consult with tribal governments. (h) A description of how Enrollees may access services to which they are entitled under Medical Assistance, but that the MCO does not provide under this Contract. (i) A description of Medical Necessity for mental health services under Minnesota Statutes, § 62Q.53. (j) A description of how transportation is provided. (k) A description of how the Enrollee may obtain services, including: 1) hours of service; 2) appointment procedures; 3) Service Authorization requirements and procedures; 4) what constitutes Medical Emergency and Post Stabilization care;; 5) the process and procedures for obtaining both Medical Emergency and Post Stabilization care, including a 24-hour telephone number for Medical Emergency Services; and 6) procedures for Urgent Care and Out of Plan care. The MCO must indicate that Service Authorization is not required for Medical Emergencies and that the Enrollee has a right to use any hospital or other setting for emergency care. If the MCO does not allow direct access to specialty care, the MCO must inform Enrollees the circumstances under which a referral may be made to such Providers. (l) A toll-free telephone number that the Enrollee may call regarding MCO coverage or procedures. (m) An explanation of the MCO’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT), known in Minnesota and hereinafter as the Child and Teen Checkups (C&TC) program for Children. (n) A description of all Grievance, Appeal and State Fair Hearing rights and procedures available to Enrollees, including the MCO’s Grievance System procedures, the availability of an expert medical opinion from an external organization pursuant to sections 8.9.8, the ability of Grievances, Appeals and State Fair Hearings to run concurrently, and the availability of a second opinion at the MCO’s expense. This includes, but is not limited to: (i) For State Fair Hearing: i) the right to hearing; ii) the method for obtaining a hearing; and iii) the rules that govern representation at the hearing. (ii) The right to file Grievances and Appeals. (iii) The requirements and timeframes for filing a Grievance or Appeal. (iv) The availability of assistance in the filing process. (v) The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone. (vi) The fact that, when an Appeal is requested by the Enrollee: a Benefits will continue if the Enrollee files an Appeal or a request for State Fair Hearing within the timeframes specified for filing; and b The Enrollee may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Enrollee. (vii) Any Appeal rights under state law available to Providers to challenge the failure of the MCO to cover a service. (viii) Appeal rights for denial of prescription drug coverage. (o) A description of the MCO’s obligation to assume financial responsibility and provide reimbursement for Medical Emergency Services, Post- Stabilization Care Services and Out of Service Area Urgent Care. (p) General descriptions of the coverage for durable medical equipment, level of coverage available, criteria and procedures for any Service Authorizations, and also the address and telephone number of an MCO representative whom an Enrollee can contact to obtain (either orally or in writing upon request) specific information about coverage and Service Authorization. The MCO shall provide information that is more specific to a prospective Enrollee upon request. (q) A description of the Enrollee’s right to request information about Physician Incentive Plans from the MCO, including whether the prepaid plan uses a Physician Incentive Plan that affects the use of referral services, the type of incentive arrangement, whether stop-loss protection is provided, and a summary of survey results. (r) A description of the Enrollee’s right to request the results of an external quality review study, and a description of the MCO’s Quality Assurance System pursuant to 42 CFR § 438.364.