Current through Register Vol. 43, No. 02, November 27, 2024
(1) Duty to Provide
Information to Enrollees and Potential Enrollees
(a) Regional Care Organizations and alternate
care providers (hereinafter collectively referred to as "organizations") shall
adopt policies and procedures designed to clearly and thoroughly explain the
process to enroll in an organization, the rights and responsibilities of
enrollees, the grievance and appeals process and the requirements and benefits
of the integrated and coordinated health care delivery system implemented
pursuant to Section
22-6-150, et seq., Code of Ala.
1975.
(b) As used in this section,
"enrollee" means a Medicaid beneficiary enrolled as a member of an
organization. As used herein "potential enrollee" means a Medicaid beneficiary
subject to mandatory enrollment in an organization or who may voluntarily or be
required to enroll as a member of an organization, but is not yet enrolled in
an organization.
(c) The
organization shall have written policies, procedures and forms approved by the
Medicaid Agency that provide the type of information required herein and that
satisfy applicable state and federal law, including but not limited to,
42 CFR
438.10. The organization shall have an
ongoing process of participating provider and enrollee education and
information sharing designed to effectuate the provisions of this rule.
Information for potential enrollees must comply with the marketing prohibitions
in
42 CFR
438.104.
(d) Organizations shall ensure that all
organization representatives who have contact with enrollees and potential
enrollees are properly trained and fully informed of the policies, procedures,
and forms of the organization applicable to enrollment, disenrollment and the
grievance system set forth under the RCO laws and regulations.
(e) The organization must provide all forms,
enrollment notices, informational materials and instructional materials in a
manner and format that may be easily understood. The organization must have
policies and procedures in place designed to assist enrollees and potential
enrollees in making informed decisions and in understanding the organization's
forms, policies and procedures, as well as the benefits and services provided
by the organization.
(f) Within 15
calendar days of an organization receiving notice of an enrollee's enrollment
in the organization, the organization shall mail an information packet to new
enrollees setting forth the information required herein. The packet shall
include, at a minimum, confirmation of enrollment in the organization, an
enrollee handbook and a participating provider directory. Alternatively,
enrollees may elect but are not required to receive the organization's
materials electronically via e-mail, an on-line enrollee portal, or similar
means. An organization wishing to make this option available must contact the
enrollee within 5 business days of enrollment to determine if the enrollee
prefers to receive information electronically. For enrollees who make this
election, the organization must mail written confirmation within 15 calendar
days of an organization receiving notice of an enrollee's enrollment in the
organization confirming the enrollee's decision to receive information
electronically and explaining the method(s) for doing so and how to opt-out and
return to paper communications.
1. The
directory shall list by specialty the names, addresses and telephone numbers of
all participating providers for the provider types required by the Medicaid
Agency.
2. The handbook,
participating provider directory, as well as forms, policies and procedures
provided by the organization pursuant to this rule, shall also be maintained on
the organization's website.
3.
After enrollment, the organization shall upon request provide enrollees the
enrollee handbook and a current participating provider directory, in print or
online, depending on the request.
4. At least once a year the organization
shall provide notice to enrollees that the handbook and directory are available
upon request.
5. The handbook shall
list the organization's location, mailing address, web address, telephone
number and office hours.
6. The
participating provider directory must be updated at least quarterly.
7. The organization shall also provide to
enrollees within 15 calendar days an identification card which contains easily
understood information on how to access care in an urgent or emergency
situation. The enrollee identification card shall also contain the enrollee
name, contractor identification number, if applicable, the name and contact
information of enrollee's primary care physician and the organization's toll
free number.
(2) Language. The organization must at a
minimum:
(a) Establish a methodology for
identifying the prevalent non-English languages spoken by enrollees and
potential enrollees throughout the region served by the organization.
"Prevalent" means a non-English language spoken by five (5) percent or more of
potential enrollees and enrollees in the region.
(b) Make available written information in
each Prevalent non-English language.
(c) Make oral interpretation services
available free of charge to each potential enrollee and enrollee in all
applicable non-English languages.
(d) Notify enrollees and potential enrollees
that oral interpretative services are available for any language and that
written information is available in Prevalent languages and how to access those
services.
(3) Format.
Written material required to be provided to enrollees and potential enrollees
must use easily understood language, not to exceed a fifth
(5th) grade reading level, and format. The material
must be available in alternative formats and in an appropriate manner that
takes into consideration special needs of those with visual impairments and/or
with limited reading proficiency. Enrollees and potential enrollees must be
informed that information is available in alternative formats and how to access
those formats.
(4) Information for
Potential Enrollees. In addition to any requirements on the part of the State
or its participating provider, upon ten business days of a request, the
organization must provide potential enrollees documents approved by the
Medicaid Agency that adequately describes:
(a)
The basic features of the RCO program;
(b) Which populations are excluded from
enrollment, subject to mandatory enrollment, or free to enroll voluntarily in
the program;
(c) The
responsibilities of the organization for coordination of care; and
(d) Information specific to the organization
operating in the potential enrollee's service area, including:
4. Names, locations and telephone numbers of
Non-English language spoken by current participating providers, including
identification of those not accepting new patients, including at minimum
information on contracted primary care physicians, specialists and
hospitals.
(e) Benefits
available under the State Plan that are not covered services in the
organization's network, including how and where the enrollee may obtain those
benefits, any cost sharing and how transportation may be provided. For
counseling or referral services the organization or its participating providers
do not cover because of moral or religious objections, information must be
provided for how and where to obtain the service.
(5) Information for Enrollees. The
organization must provide information required by
42 CFR
438.10(f) and hereunder to
all enrollees including:
(a) Within ten
calendar days of request, the organization must notify enrollees of their
disenrollment rights.
(b) The right
of enrollees to request and obtain the information listed herein at least once
a year.
(c) The right of enrollees
to request the information listed herein within a reasonable time after the
organization receives notice of the enrollee's enrollment in the RCO
program.
(d) Written notice of any
significant changes in the information required under this rule provided at
least 30 days before the intended effective date of the change.
(e) The organization must make a good faith
effort to provide written notice of termination of a participating provider,
within 15 days after receipt or issuance of the termination notice to the
participating provider, to each enrollee who received his or her care from, or
was seen on a regular basis by, the terminated provider.
(f) Names, locations, telephone numbers of
non-English languages spoken by current participating providers in the
enrollee's service area, including identification of participating providers
that are not accepting new patients. At a minimum, this must include
information on participating primary care physicians, specialists and
hospitals.
(g) Any restrictions on
the enrollee's freedom of choice among network providers.
(h) Enrollee rights and protections set forth
in
42 CFR §
438.100.
(i) Information on grievances and appeals
required by rule(s) promulgated by the Medicaid Agency.
(j) The amount, duration and scope of
benefits available under the contract between the organization and the Medicaid
Agency in sufficient detail to ensure that enrollees understand the covered
services to which they are entitled.
(k) Procedures for obtaining benefits,
including authorization requirements.
(l) The extent to which, and how, enrollees
may obtain covered services, including family planning services, from out of
network providers.
(m) How, when
and where after hours coverage, urgent care services and emergency coverage are
to be provided as required by
42 CFR
438.10(f)(6)(viii).
(n) Information on available
post-stabilization care as required by
42
CFR 422.113(c).
(o) Information on cost sharing, co-payments,
charges for non-covered services, and the enrollee's possible responsibility
for payments for services if he/she goes outside of the region for non-emergent
care.
(p) Information on contracted
hospitals in the enrollee's service area and, unless otherwise provided, the
enrollee has a right to use any hospital or other setting for emergency
care.
(q) Information on advance
directive policies.
(r) How to
access information on participating providers accepting new enrollees in an
organization.
(s) How to access and
understand forms provided by the organization and how to obtain assistance in
completing and submitting forms.
(t) The enrollee's right to request and
obtain copies of their clinical records and whether they may be charged a
reasonable copying fee.
(6) Grievances and appeals. The organization
must provide information to enrollees advising of their rights to file
grievances and appeals and of their rights to a hearing pursuant to Section
22-6-153 of the Alabama Code and
Rule No. 560-X-62-.19. The organization
must provide information which at a minimum advises enrollees:
(a) The right to file a grievance and the
time frame and process for which to do so.
(b) The process and time frame for which
notices of action are to be provided.
(c) The rights to file an appeal of an action
and the process and time frame for which to do so.
(d) The availability of assistance in the
filing process and the type of assistance available.
(e) An enrollee's right to hearings and
timeframes, rules and procedure related thereto.
(f) The toll free numbers that the enrollee
can use to file a grievance or an appeal by phone or seek interpretive
assistance by phone.
(g) That when
requested by the enrollee, covered services may continue if the enrollee files
a timely appeal and that 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.
(h) The
other rights and obligations of the enrollee set forth in Rule No.
560-X-62.-19.
(7)
Compliance with state and federal law. In addition to the information required
by this rule, the organization must provide an enrollee and potential enrollee
any additional information required by applicable state and federal law and
that may be required in a risk contract between the organization and the
Medicaid Agency. All such information must be provided in a format required by
applicable law or in the risk contract.