Current through Register Vol. 43, No. 02, November 27, 2024
(1) As
used in this rule, the following terms have the meanings set forth below:
(a) Enrollee means a Medicaid beneficiary
enrolled as a member of an Integrated Care Network (ICN).
(b) Large Print means printed in a font size
no smaller than 18 point.
(c)
Limited English Proficient (LEP) means Enrollees and Potential Enrollees who do
not speak English as their primary language and who have a limited ability to
read, write, speak or understand English. LEP individuals may be eligible to
receive language assistance for a particular type of service, benefit or
encounter.
(d) Potential Enrollee
means a Medicaid beneficiary subject to mandatory enrollment in an ICN or who
may voluntarily be required to enroll as a member of an ICN.
(e) Prevalent means those non-English
languages determined to be spoken by a significant number or percentage of
Enrollees and Potential Enrollees that are limited English proficient. The
following languages are defined as Prevalent:
1. Spanish or Spanish Creole;
(f) Readily Accessible means electronic
information and services which comply with modern accessibility standards such
as section 508 guidelines, section 504 of the Rehabilitation Act and W3C s Web
Content Accessibility Guidelines (WCAG) 2.0 AA and successor
versions.
(2) The ICN
shall be responsible for the development of outreach and educational materials
addressing prevention of illness and disease, disease management, healthy
lifestyles, and the availability of and how to access non-emergency
transportation services. All materials used by the ICN must be approved by the
Medicaid Agency prior to their use.
(3) The Medicaid Agency shall be responsible
for the development of all other information and materials for Enrollees and
Potential Enrollees not listed in paragraph (2) above, including but not
limited to, the Enrollee handbook and notices in accordance with
42 C.F.R. §
438.10(e).
(4) All materials provided to Enrollees or
Potential Enrollees must be in a manner and format that may be easily
understood and is Readily Accessible, the information required herein,
including the process to enroll in an ICN, the rights and responsibilities of
Enrollees, as well as the grievance and appeals process in order to help
Enrollees and Potential Enrollees understand the requirements, benefits and
services of the Integrated Care Network (ICN) Program.
(5) General Information Requirements. The
below requirements shall apply to the ICN to the extent it develops and
distributes materials in accordance with paragraph (2) and to the Agency to the
extent it develops and distributes materials in accordance with paragraph (3).
Herein, the term "Organization" shall mean both the Agency and the ICN to the
extent each entity is responsible for developing and distributing materials.
(a) The Organization must have policies and
procedures in place regarding providing assistance to Enrollees and Potential
Enrollees in making informed decisions and in understanding the ICN program's
benefits and services (hereafter collectively the "services").
(b) The Organization must give each Enrollee
notice of any significant change, as determined by the Medicaid Agency, in the
written material and the information required by this rule and by
42 C.F.R. §
438.10, at least thirty (30) calendar days
before the intended effective date of the change.
(c) The Organization shall ensure that all
its representatives who have contact with Enrollees and Potential Enrollees are
properly trained and fully informed of the policies, procedures, and forms of
the Organization including those applicable to enrollment, disenrollment and
the grievance system set forth under the ICN program.
(d) Enrollee information required hereunder
may not be provided electronically by the Organization unless:
1. The format is Readily
Accessible.
2. The information is
placed in a location on the Organization's website that is prominent and
Readily Accessible.
3. The
information is provided in an electronic form which can be electronically
retained and printed.
4. The
information is consistent with the content and language requirements of this
rule.
5. The Enrollee is informed
that the information is available in paper form without charge upon request and
the Organization provides such information within five (5) business days of the
request.
(e) The ICN
must also use the managed care terminology established by the Alabama Medicaid
Agency pursuant to
42 C.F.R. §
438.10(c)(4).
(2) Language and Format
(a) All written materials that are critical
to obtaining services, including at a minimum, provider directories, Enrollee
handbooks, appeal and grievance notices, and denial and termination notices
available to Enrollees and Potential Enrollees are available in an easily
understandable language that meets the requirements of this section, in English
and all other Prevalent Non-English Languages in the ICN's service area.
Auxiliary aids and services must be made available at no cost to Enrollees or
Potential Enrollees upon his or her request.
(b) Written materials referenced in
subsection (a) must include taglines in the Prevalent non-English languages, as
well as Large Print, explaining the availability of written translation or oral
interpretation to understand the information provided and the toll-free and
TTY/TDY telephone number of the Organization's Enrollee/customer service
unit.
(c) The Organization shall
make interpretation services available to Potential Enrollees and Enrollees and
provide those services free of charge. This includes oral interpretation and
the use of auxiliary aids such as TTY/TDY and American Sign Language. Oral
interpretation requirements apply to all non-English languages, not just those
the Agency has identified as Prevalent.
(d) The Organization shall notify Enrollees
that oral interpretation is available for any language and written translation
available in Prevalent languages; that auxiliary aids and services are
available upon request at no cost for Enrollees with disabilities; and how to
access the services in this subsection.
(e) Upon request by and at no charge to
Enrollees and Potential Enrollees, the Organization must make all written
material available in easily understood language and format, in alternative
formats and in an appropriate manner that takes into consideration the special
needs of Enrollees or Potential Enrollees with disabilities or limited English
proficiency. The Organization must inform Enrollees and Potential Enrollees
that written information is available in alternative formats and how to access
these formats. Except as otherwise expressly provided herein, the written
materials referenced herein shall use a font size no smaller than 12 point,
except the Organization shall include a Large Print tagline and information on
how to request auxiliary aids and services, including the provision of
materials in alternate formats.
(3) Information Packet. Within fifteen (15)
calendar days of an of an Enrollee's enrollment in the ICN program, the Agency
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 ICN and an Enrollee handbook. Alternatively, Enrollees may
elect but are not required to receive the 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 five (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 fifteen (15) calendar days of an Organization
receiving notice of an Enrollee's enrollment in the ICN program 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.
(a) The Enrollee handbook shall also be
maintained on the Agency's website.
(b) At least once a year, the Agency shall
provide notice to Enrollees that a copy of the Enrollee handbook is available
upon request.
(c) The Enrollee
handbook shall list the ICN's location, mailing address, web address, telephone
number and office hours.
(4) Information for Enrollees. The Medicaid
Agency must provide information required by
42 C.F.R. §
438.10(f) and hereunder to
all Enrollees including:
(a) At least
annually, and within ten (10) calendar days of request, the Medicaid Agency
must notify Enrollees of their disenrollment rights, including an explanation
of the process for exercising disenrollment rights and the alternatives
available to the Enrollee based on their specific circumstances;
(b) The right of Enrollees to request and
obtain all information listed herein at least once a year;
(c) The right of Enrollees to request all
information listed herein within a reasonable time after the Organization
receives notice of the Enrollee's enrollment in the ICN program; and
(d) Written notice of any significant changes
in the information required under this rule provided at least thirty (30)
calendar days before the intended effective date of the change.
(5) Enrollee Handbook. In addition
to any requirements set forth in a contract between the ICN and the Medicaid
Agency:
(a) Each Organization must provide
each Enrollee an Enrollee handbook, within a reasonable time, not to exceed
fifteen (15) calendar days, after receiving notice of the Enrollee's
enrollment, which serves a similar function as the summary of benefits and
coverage described in
45 C.F.R.
§
147.200(a). At least
once a year, the Agency must provide notice to Enrollees that the Handbook is
available upon request.
(b) The
content of the Enrollee handbook must include information that enables the
Enrollee to understand how to effectively use the ICN program. The information
must include at a minimum:
1. Services
provided by the ICN;
2. Enrollee
rights, responsibilities and protections, including the applicable elements set
forth in 42 C.F.R. §
438.100;
3. A description of how to access auxiliary
aids and services, including additional information in alternative formats and
languages;
4. The toll-free number
for Enrollee services, medical management, and any other unit providing
services directly to Enrollees;
5.
Information on how to report suspected fraud or abuse;
6. How to access and understand forms
provided by the Organization and how to obtain assistance in completing and
submitting forms; and
7. The
Enrollee's right to request and obtain copies of their medical records and
whether they may be charged a reasonable copying fee.
(c) Information required by this Rule will be
considered to be provided by the Organization if the Organization:
1. Mails a printed copy of the information to
the Enrollee's mailing address;
2.
Provides information by email after obtaining the Enrollee's agreement to
receive the information by email;
3. Post the information on the Organization's
website and advises the Enrollee in paper or in electronic form that the
information is available on the internet and includes the applicable internet
address, provided that Enrollees with disabilities who cannot access this
information online are provided auxiliary aids and services upon request at no
cost; or
4. Provides the
information by any other method that can reasonably be expected to result in
the Enrollee receiving the information.
(d) The Organization must give each Enrollee
notice of any significant change, as determined by the Medicaid Agency, in the
written material and the information required by this paragraph and by
42 C.F.R. §
438.10(g) (4), at least
thirty (30) calendar days before the intended effective date of the
change.
(6) Marketing.
(a) The ICN may not directly market to
individual Medicaid recipients or Potential Enrollees, except as specified in
this rule, and must adhere to the requirements specified by
42 C.F.R. §§
438.10 and
438.104 and
section 1557 of the Affordable Care Act. The ICN is prohibited from
door-to-door, telephone, email, texting or other cold-call marketing or
engaging in marketing activities that could mislead, confuse or defraud
Medicaid recipients, Enrollees or Potential Enrollees. Marketing materials must
receive Agency approval prior to use and cannot contain any assertion or
statement whether written or oral that:
1.
Potential Enrollees must enroll with the ICN in order to obtain benefits or in
order not to lose benefits; or
2.
The ICN is endorsed by CMS, the Federal or State government or similar
entity.
(b) When
distributing approved marketing materials, the ICN must distribute the
materials throughout the entire State.
(c) The ICN marketing activities and
materials must not seek to influence enrollment in conjunction with the sale or
offering of any private insurance.
(d) The ICN may only conduct marketing
activities in health care settings in common areas, such as cafeterias,
recreational rooms or conference rooms. The ICN may not conduct marketing
activities in areas where Enrollees primarily receive health care services, or
wait to receive health care services. Areas where the ICN is prohibited from
conducting marketing activities include, but are not limited to, the following:
3. Hospital patient rooms; and
4. Dialysis center treatment areas.
(7) Sanctions may be
imposed in accordance with Alabama Medicaid Administrative Code Chapter 64 if
the ICN distributes information or materials to Enrollees, Potential Enrollees
or providers is misrepresented, falsified, or distributed without prior
authorization by the Medicaid Agency.
(8) Compliance with state and federal law. In
addition to the information required by this rule, the ICN must provide an
Enrollee and Potential Enrollee any additional information required by
applicable state and federal law. All such information must be provided in a
format required by this rule and other applicable law.
Author: Stephanie Lindsay, Administrator,
Administrative Procedures Office
Statutory Authority: State Plan; Title XIX,
Social Security Act;
42 C.F.R. §
438.10.