Health Information System. The Contractor shall maintain a health information system or systems consistent with the requirements established in the Contract, the objectives of 42 C.F.R. Part 438, Subpart D, including 42 C.F.R. § 438.242, and that supports all aspects of the QI Program. Marketing, Outreach, and Enrollee Communications Standards General Marketing, Outreach, and Enrollee Communications Requirements The Contractor is subject to rules governing marketing and Enrollee Communications as specified under section 1851(h) of the Social Security Act, 42 C.F.R. §422.111, §422.2260 et. seq., §423.120(b) and (c), §423.128, §423.2260 et. seq., and § 438.10, and §438.104; the Medicare Communications and Marketing Guidelines as updated from time to time, and the Medicare‑Medicaid marketing guidance, with the following exceptions or modifications: The Contractor must refer Enrollees and Eligible Beneficiaries who inquire about Capitated Financial Alignment Model eligibility or enrollment to the enrollment broker, although the Contractor may provide Enrollees and Eligible Beneficiaries with information about the Contractor’s plan and its benefits prior to referring a request regarding eligibility or enrollment to the enrollment broker; The Contractor must make available to CMS and EOHHS, upon request, current schedules of all educational events conducted by the Contractor to provide information to Enrollees or Eligible Beneficiaries; The Contractor must convene all educational and marketing/sales events at sites within the Contractor’s Service Area that are physically accessible to all Enrollees or Eligible Beneficiaries, including persons with disabilities and persons using public transportation. The Contractor must distribute all materials to its entire Service Area. The Contractor may not offer financial or other incentives, including private insurance, to induce Enrollees or Eligible Beneficiaries to enroll with the Contractor or to refer a friend, neighbor, or other person to enroll with the Contractor; The Contractor may not directly or indirectly conduct door‑to‑door, telephone, email, texting, or other unsolicited contacts (with the exception of direct mail, which is permissible); Calls made by the Contractor to Medicare‑Medicaid eligible individuals enrolled in the Contractor’s other product lines, are not considered unsolicited direct contact and are permissible. Therefore, as provided in the Medicare Communications and Marketing Guidelines and the Medicare‑Medicaid marketing guidance, the Contractor may call such individuals, including those who have previously opted out of passive enrollment into the One Care Plan, about the One Care Plan. Contractors may not call One Care Enrollees with information about other product lines unless the contact is expressly initiated by the One Care Enrollee. The Contractor may not use any Marketing, Outreach, or Enrollee Communications materials that contain any assertion or statement (whether written or oral) that: The recipient must enroll with the Contractor in order to obtain benefits or in order not to lose benefits; The Contractor is endorsed by CMS, Medicare, Medicaid, the Federal government, EOHHS, or similar entity; and Annually, the Contractor shall present its marketing plan to EOHHS for review and approval. The Contractor’s Marketing, Outreach, and Enrollee Communications materials must be: Made available in Alternative Formats, upon request and as needed to assure effective communication for blind and vision‑impaired Enrollees; Provided in a manner, format and language that may be easily understood by persons with limited English proficiency, or for those with developmental disabilities or cognitive impairments; Translated into Prevalent Languages; Sent in Spanish to members whose primary language is known to be Spanish, if the materials are pre‑enrollment or enrollment materials; and As applicable, mailed with non‑English language taglines that alert Enrollees with limited English proficiency to the availability of language assistance services, free of charge, and how those services can be obtained, consistent with the requirements of 45 C.F.R. Part 92 as well as the following languages: English, Spanish, Cambodian, Chinese, Haitian Creole, Laotian, Portuguese, Russian and Vietnamese. As applicable, mailed with a non‑discrimination notice or statement, consistent with the requirements of 45 C.F.R. Part 92. Developed utilizing definitions as specified by EOHHS and CMS, consistent with 42 C.F.R. § 438.10(c)(4)(i). Submission, Review, and Approval of Marketing, Outreach, and Enrollee Communications Materials The Contractor must receive prior approval of all marketing and Enrollee Communications materials in categories of materials that CMS and EOHHS require to be prospectively reviewed. Contractor materials may be designated as eligible for the File & Use process, as described in 42 C.F.R. § 422.2262(b) and § 423.2262(b), and will therefore be exempt from prospective review and approval by both CMS and EOHHS. CMS and EOHHS may agree to defer to one or the other party for review of certain types of marketing and Enrollee Communications, as agreed in advance by both parties. Contractors must submit all materials that are consistent with the definition of marketing materials at 42 C.F.R. § 422.2260, whether prospectively reviewed or not, via the CMS HPMS Marketing Module. CMS and EOHHS may conduct additional types of review of Contractor Marketing, Outreach, and Enrollee Communications activities, including, but not limited to: Review of on‑site marketing facilities, products, and activities during regularly scheduled Contract compliance monitoring visits. Random review of actual Marketing, Outreach, and Enrollee Communications pieces as they are used in the marketplace. “For cause” review of materials and activities when Complaints are made by any source, and CMS or EOHHS determine it is appropriate to investigate. “Secret shopper” activities where CMS or EOHHS request Contractor materials, such as enrollment packets. All marketing and Enrollee Communications materials used and submitted for review for the Contractor’s One Care Plan shall be tailored for use for the Massachusetts One Care Plan. Beginning of Marketing, Outreach, and Enrollee Communications Activity The Contractor may not begin Marketing, Outreach, and Enrollee Communications activities to new Enrollees more than ninety (90) days prior to the effective date of enrollment for the following Contract year. Requirements for Dissemination of Marketing, Outreach, and Enrollee Communications Materials Consistent with the timelines specified in the Medicare Communications and Marketing Guidelines and the Medicare‑Medicaid marketing guidance, the Contractor must provide new Enrollees with the following materials which, with the exception of the material specified in Section 2.14.5.1.4 below, must also be provided annually thereafter: An Evidence of Coverage (EOC)/Member Handbook document, or a distinct and separate Notice on how to access the Member Handbook online and how to request a hard copy, that is consistent with the requirements at 42 C.F.R. § 438.10, 42 C.F.R. § 422.111, and 42 C.F.R. § 423.128; includes information about all Covered Services, as outlined below, and that uses the model document developed by CMS and EOHHS. Enrollee rights (see Appendix C); An explanation of the Centralized Enrollee Record and the process by which clinical information, including diagnostic and medication information, will be available to key caregivers; How to obtain a copy of the Enrollee’s Centralized Enrollee Record; How to obtain access to specialty, behavioral health, pharmacy and LTSS providers; How to obtain services and prescription drugs for Emergency Conditions and Urgent Care in and out of the Provider Network and in and out of the Service Area; including: What constitutes emergency medical condition, Emergency Services, and Post‑stabilization Services, with reference to the definitions is 42 C.F.R. § 438.114(a); The fact that prior authorization is not required for Emergency Services; The process and procedures for obtaining Emergency Services, including the use of the 911 telephone system or its local equivalent; The locations of any emergency settings and other locations at which providers and hospitals furnish Emergency Services and Post‑stabilization Services covered under the Contract; That the Enrollee has a right to use any hospital or other setting for emergency care; and The Post‑stabilization Care Services rules at 42 C.F.R. § 422.113(c). Information about Advance Directives (at a minimum those required in 42 C.F.R. § 489.102 and 42 C.F.R. § 422.128, and § 438.3(j)), which information shall be updated to reflect any changes in Commonwealth law as soon as possible, but no later than ninety (90) days after the effective date of changes, including Enrollee rights under the law of the Commonwealth; the Contractor’s policies respecting the implementation of those rights, including a statement of any limitation regarding the implementation of Advance Directives as a matter of conscience; that Complaints concerning noncompliance with the Advance Directive requirements may be filed with EOHHS; designating a health care proxy, and other mechanisms for ensuring that future medical decisions are made according to the desire of the Enrollee; How to obtain assistance from ESRs; How to file Grievances and Internal and External Appeals, including: Grievance, Appeal and fair hearing procedures and timeframes; Toll free numbers that the Enrollee can use to file a Grievance or an Appeal by phone; A statement that when requested by the Enrollee, benefits will continue at the plan level for all benefits, and if the Enrollee files an Appeal or a request for State Fair Hearing within the timeframes specified for filing, and the Enrollee may be required to pay to EOHHS the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Enrollee; and How the Enrollee can identify who the Enrollee wants to receive written notices of denials, terminations, and reductions; How to obtain assistance with the Appeals processes through the ESR and other assistance mechanisms as EOHHS or CMS may identify, including an Ombudsman; The extent to which, and how Enrollees may obtain benefits, including family planning services, from out‑of‑network providers; How and where to access any benefits that are available under the State plan but are not covered under the Contract, including any cost sharing in accordance with 42 C.F.R. § 447.50 through 42 C.F.R. § 447.60, and how transportation is provided; How to change providers; and How to disenroll voluntarily. A Summary of Benefits (SB) that contains a concise description of the important aspects of enrolling in the One Care Plan, as well as the benefits offered under the Contractor’s plan, including any cost sharing, applicable conditions and limitations, and any other conditions associated with receipt or use of benefits, and uses the model document developed by CMS and the Commonwealth. The SB should provide sufficient detail to ensure that Enrollees understand the benefits to which they are entitled. For new Enrollees, the SB is required only for individuals enrolled through Passive Enrollment. A combined provider and pharmacy directory that is consistent with the requirements in Section 2.14, or a distinct and separate notice on how to access this information online and how to request a hard copy, as specified in the Medicare Managed Care Manual and the Medicare‑Medicaid marketing guidance. A single identification (ID) card for accessing all Covered Services under the plan that uses the model document developed by CMS and the Commonwealth; A comprehensive, integrated formulary that includes prescription drugs and over‑the‑counter products required to be covered by Medicare Part D and the Commonwealth’s outpatient prescription drug benefit and that uses the model document developed by CMS and the Commonwealth, or a distinct and separate notice on how to access this information online and how to request a hard copy, as specified in the Medicare Communications and Marketing Guidelines and the Medicare‑Medicaid marketing guidance. The procedures for an Enrollee to change One Care Plans or to opt out of the Demonstration. The Contractor must provide the following materials to current Enrollees on an ongoing basis: An Annual Notice of Change that summarizes all major changes to the Contractor’s covered benefits from one contract year to the next, and that uses the model document developed by CMS and the Commonwealth. The Contractor must provide all Medicare Part D required notices, with the exception of the LIS Rider, the creditable coverage notices required under Chapter 4 of the Prescription Drug Benefit Manual, and the late enrollment penalty notices required under Chapter 13 of the Prescription Drug Benefit Manual. Consistent with the requirement at 42 C.F.R. § 423.120(b)(5), the Contractor must provide Enrollees with at least thirty (30) days advance notice regarding certain changes to the comprehensive, integrated formulary. The Contractor must ensure that all information provided to Enrollees and Eligible Beneficiaries (and families when appropriate) is provided in a manner and format that is easily understood and that is: Made available in large print (at least 18‑point font) to Enrollees as an Alternative Format, upon request; For vital materials, available in Prevalent Languages, as provided for in the Medicare‑Medicaid marketing guidance; Written with cultural sensitivity and at a sixth‑grade reading level or below; and
Appears in 3 contracts
Samples: www.mass.gov, www.mass.gov, www.mass.gov
Health Information System. The Contractor shall maintain a health information system or systems consistent with the requirements established in the Contract, the objectives of 42 C.F.R. Part 438, Subpart D, including 42 C.F.R. § 438.242, and that supports all aspects of the QI Program. Marketing, Outreach, and Enrollee Communications Standards General Marketing, Outreach, and Enrollee Communications Requirements The Contractor is subject to rules governing marketing and Enrollee Communications as specified under section 1851(h) of the Social Security Act, 42 C.F.R. §422.111, §422.2260 et. seq., §423.120(b) and (c), §423.128, §423.2260 et. seq., and § 438.10, and §438.104; the Medicare Communications and Marketing Guidelines as updated from time to time, and the Medicare‑Medicaid marketing guidance, with the following exceptions or modifications: The Contractor must refer Enrollees and Eligible Beneficiaries who inquire about Capitated Financial Alignment Model eligibility or enrollment to the enrollment broker, although the Contractor may provide Enrollees and Eligible Beneficiaries with information about the Contractor’s plan and its benefits prior to referring a request regarding eligibility or enrollment to the enrollment broker; The Contractor must make available to CMS and EOHHS, upon request, current schedules of all educational events conducted by the Contractor to provide information to Enrollees or Eligible Beneficiaries; The Contractor must convene all educational and marketing/sales events at sites within the Contractor’s Service Area that are physically accessible to all Enrollees or Eligible Beneficiaries, including persons with disabilities and persons using public transportation. The Contractor must distribute all materials to its entire Service Area. The Contractor may not offer financial or other incentives, including private insurance, to induce Enrollees or Eligible Beneficiaries to enroll with the Contractor or to refer a friend, neighbor, or other person to enroll with the Contractor; The Contractor may not directly or indirectly conduct door‑to‑door, telephone, email, texting, or other unsolicited contacts (with the exception of direct mail, which is permissible); Calls made by the Contractor to Medicare‑Medicaid eligible individuals enrolled in the Contractor’s other product lines, are not considered unsolicited direct contact and are permissible. Therefore, as provided in the Medicare Communications and Marketing Guidelines and the Medicare‑Medicaid marketing guidance, the Contractor may call such individuals, including those who have previously opted out of passive enrollment into the One Care Plan, about the One Care Plan. Contractors may not call One Care Enrollees with information about other product lines unless the contact is expressly initiated by the One Care Enrollee. The Contractor may not use any Marketing, Outreach, or Enrollee Communications materials that contain any assertion or statement (whether written or oral) that: The recipient must enroll with the Contractor in order to obtain benefits or in order not to lose benefits; The Contractor is endorsed by CMS, Medicare, Medicaid, the Federal government, EOHHS, or similar entity; and Annually, the Contractor shall present its marketing plan to EOHHS for review and approval. The Contractor’s Marketing, Outreach, and Enrollee Communications materials must be: Made available in Alternative Formats, upon request and as needed to assure effective communication for blind and vision‑impaired Enrollees; Provided in a manner, format and language that may be easily understood by persons with limited English proficiency, or for those with developmental disabilities or cognitive impairments; Translated into Prevalent Languages; Sent in Spanish to members whose primary language is known to be Spanish, if the materials are pre‑enrollment or enrollment materials; and As applicable, mailed with non‑English language taglines that alert Enrollees with limited English proficiency to the availability of language assistance services, free of charge, and how those services can be obtained, consistent with the requirements of 45 C.F.R. Part 92 as well as the following languages: English, Spanish, Cambodian, Chinese, Haitian Creole, Laotian, Portuguese, Russian and Vietnamese. As applicable, mailed with a non‑discrimination notice or statement, consistent with the requirements of 45 C.F.R. Part 92. Developed utilizing definitions as specified by EOHHS and CMS, consistent with 42 C.F.R. § 438.10(c)(4)(i). Submission, Review, and Approval of Marketing, Outreach, and Enrollee Communications Materials The Contractor must receive prior approval of all marketing and Enrollee Communications materials in categories of materials that CMS and EOHHS require to be prospectively reviewed. Contractor materials may be designated as eligible for the File & Use process, as described in 42 C.F.R. § 422.2262(b) and § 423.2262(b), and will therefore be exempt from prospective review and approval by both CMS and EOHHS. CMS and EOHHS may agree to defer to one or the other party for review of certain types of marketing and Enrollee Communications, as agreed in advance by both parties. Contractors must submit all materials that are consistent with the definition of marketing materials at 42 C.F.R. § 422.2260, whether prospectively reviewed or not, via the CMS HPMS Marketing Module. CMS and EOHHS may conduct additional types of review of Contractor Marketing, Outreach, and Enrollee Communications activities, including, but not limited to: Review of on‑site marketing facilities, products, and activities during regularly scheduled Contract compliance monitoring visits. Random review of actual Marketing, Outreach, and Enrollee Communications pieces as they are used in the marketplace. “For cause” review of materials and activities when Complaints are made by any source, and CMS or EOHHS determine it is appropriate to investigate. “Secret shopper” activities where CMS or EOHHS request Contractor materials, such as enrollment packets. All marketing and Enrollee Communications materials used and submitted for review for the Contractor’s One Care Plan shall be tailored for use for the Massachusetts One Care Plan. Beginning of Marketing, Outreach, and Enrollee Communications Activity The Contractor may not begin Marketing, Outreach, and Enrollee Communications activities to new Enrollees more than ninety (90) days prior to the effective date of enrollment for the following Contract year. Requirements for Dissemination of Marketing, Outreach, and Enrollee Communications Materials Consistent with the timelines specified in the Medicare Communications and Marketing Guidelines and the Medicare‑Medicaid marketing guidance, the Contractor must provide new Enrollees with the following materials which, with the exception of the material specified in Section 2.14.5.1.4 below, must also be provided annually thereafter: An Evidence of Coverage (EOC)/Member Handbook document, or a distinct and separate Notice on how to access the Member Handbook online and how to request a hard copy, that is consistent with the requirements at 42 C.F.R. § 438.10, 42 C.F.R. § 422.111, and 42 C.F.R. § 423.128; includes information about all Covered Services, as outlined below, and that uses the model document developed by CMS and EOHHS. Enrollee rights (see Appendix C); An explanation of the Centralized Enrollee Record and the process by which clinical information, including diagnostic and medication information, will be available to key caregivers; How to obtain a copy of the Enrollee’s Centralized Enrollee Record; How to obtain access to specialty, behavioral health, pharmacy and LTSS providers; How to obtain services and prescription drugs for Emergency Conditions and Urgent Care in and out of the Provider Network and in and out of the Service Area; including: What constitutes emergency medical condition, Emergency Services, and Post‑stabilization Services, with reference to the definitions is 42 C.F.R. § 438.114(a); The fact that prior authorization is not required for Emergency Services; The process and procedures for obtaining Emergency Services, including the use of the 911 telephone system or its local equivalent; The locations of any emergency settings and other locations at which providers and hospitals furnish Emergency Services and Post‑stabilization Services covered under the Contract; That the Enrollee has a right to use any hospital or other setting for emergency care; and The Post‑stabilization Care Services rules at 42 C.F.R. § 422.113(c). Information about Advance Directives (at a minimum those required in 42 C.F.R. § 489.102 and 42 C.F.R. § 422.128, and § 438.3(j)), which information shall be updated to reflect any changes in Commonwealth law as soon as possible, but no later than ninety (90) days after the effective date of changes, including Enrollee rights under the law of the Commonwealth; the Contractor’s policies respecting the implementation of those rights, including a statement of any limitation regarding the implementation of Advance Directives as a matter of conscience; that Complaints concerning noncompliance with the Advance Directive requirements may be filed with EOHHS; designating a health care proxy, and other mechanisms for ensuring that future medical decisions are made according to the desire of the Enrollee; How to obtain assistance from ESRs; How to file Grievances and Internal and External Appeals, including: Grievance, Appeal and fair hearing procedures and timeframes; Toll free numbers that the Enrollee can use to file a Grievance or an Appeal by phone; A statement that when requested by the Enrollee, benefits will continue at the plan level for all benefits, and if the Enrollee files an Appeal or a request for State Fair Hearing within the timeframes specified for filing, and the Enrollee may be required to pay to EOHHS the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Enrollee; and How the Enrollee can identify who the Enrollee wants to receive written notices of denials, terminations, and reductions; How to obtain assistance with the Appeals processes through the ESR and other assistance mechanisms as EOHHS or CMS may identify, including an Ombudsman; The extent to which, and how Enrollees may obtain benefits, including family planning services, from out‑of‑network providers; How and where to access any benefits that are available under the State plan but are not covered under the Contract, including any cost sharing in accordance with 42 C.F.R. § 447.50 through 42 C.F.R. § 447.60, and how transportation is provided; How to change providers; and How to disenroll voluntarily. A Summary of Benefits (SB) that contains a concise description of the important aspects of enrolling in the One Care Plan, as well as the benefits offered under the Contractor’s plan, including any cost sharing, applicable conditions and limitations, and any other conditions associated with receipt or use of benefits, and uses the model document developed by CMS and the Commonwealth. The SB should provide sufficient detail to ensure that Enrollees understand the benefits to which they are entitled. For new Enrollees, the SB is required only for individuals enrolled through Passive Enrollment. A combined provider and pharmacy directory that is consistent with the requirements in Section 2.14, or a distinct and separate notice on how to access this information online and how to request a hard copy, as specified in the Medicare Managed Care Manual and the Medicare‑Medicaid marketing guidance. A single identification (ID) card for accessing all Covered Services under the plan that uses the model document developed by CMS and the Commonwealth; A comprehensive, integrated formulary that includes prescription drugs and over‑the‑counter products required to be covered by Medicare Part D and the Commonwealth’s outpatient prescription drug benefit and that uses the model document developed by CMS and the Commonwealth, or a distinct and separate notice on how to access this information online and how to request a hard copy, as specified in the Medicare Communications and Marketing Guidelines and the Medicare‑Medicaid marketing guidance. The procedures for an Enrollee to change One Care Plans or to opt out of the Demonstration. The Contractor must provide the following materials to current Enrollees on an ongoing basis: An Annual Notice of Change that summarizes all major changes to the Contractor’s covered benefits from one contract year to the next, and that uses the model document developed by CMS and the Commonwealth. The Contractor must provide all Medicare Part D required notices, with the exception of the LIS Rider, the creditable coverage notices required under Chapter 4 of the Prescription Drug Benefit Manual, and the late enrollment penalty notices required under Chapter 13 of the Prescription Drug Benefit Manual. Consistent with the requirement at 42 C.F.R. § 423.120(b)(5), the Contractor must provide Enrollees with at least thirty (30) days advance notice regarding certain changes to the comprehensive, integrated formulary. The Contractor must ensure that all information provided to Enrollees and Eligible Beneficiaries (and families when appropriate) is provided in a manner and format that is easily understood and that is: Made available in large print (at least 18‑point font) to Enrollees as an Alternative Format, upon request; For vital materials, available in Prevalent Languages, as provided for in the Medicare‑Medicaid marketing guidance; Written with cultural sensitivity and at a sixth‑grade reading level or below; and
Appears in 1 contract
Samples: www.mass.gov
