Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 482 - NEBRASKA MEDICAID MANAGED CARE
Chapter 4 - THE HERITAGE HEALTH MANAGED CARE CORE BENEFITS PACKAGE
Section 482-4-002 - MANAGED CARE ORGANIZATION REQUIREMENTS

(A) Provide the services in the core benefits package according to all provisions in Title 482 NAC 4 and Title 471 NAC and ensure the services in the core benefits package are provided in the same amount, duration, and scope as defined under Title 471 NAC, but can place appropriate limits on a service based on medical necessity or utilization control;

(B) Maintain an adequate network of primary care providers to ensure adequate access for members enrolled in Heritage Health, notify the Department via the provider network file prior to the effective date of any primary care provider change whenever possible and if required, notify the member of an interim primary care provider (see 482 NAC 3-004.03(E));

(C) Use only providers enrolled in Medicaid to provide the services in the core benefits package;

(D) Provide an appropriate range of services and access to preventive and primary care services statewide, and maintain a sufficient number, mix, and geographic distribution of providers that are skilled in areas such a cultural diversity and sensitivity, languages, and accessibility to members with mental, physical and communication disabilities;

(E) Accept the member choice of primary care provider and health plan;

(F) Provide care management (see 482-000-8, Care Management Requirements);

(G) Provide a member handbook to the members enrolled with the health plan, and other informational materials about Heritage Health benefits that are easy-to-read and understand. The health plan must also provide the information in the guidebook in the most prevalent non-English speaking languages and alternative formats in a manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency;

(H) Provide a comprehensive provider network directory;

(I) Medicaid prohibits the health plan from performing any direct solicitation to individual Medicaid members. The Department must approve any general marketing to Medicaid members prior to implementation. The health plan must comply with the following marketing materials:

(J) Meet all requirements of the Americans with Disabilities Act and provide appropriate accommodations for members with special needs. Ensure primary care providers and specialists are equipped in appropriate technologies, including teletype and telecommunications device for the deaf, and language services, or are skilled in various languages and areas of cultural diversity and sensitivity, and the network is appropriately staffed to ensure an adequate selection for those members who have special cultural, religious or other special requests;

(K) Coordinate activities with the Department, other Heritage Health contractors, and other providers for services outside the core benefits package, as appropriate, to meet the needs of the member, and ensure systems are in place to promote well managed patient care, including, but not limited to:

(L) Comply with regulations for advance directives;

(M) The health plan is prohibited from refusing enrollment of a member, disenrolling a member or otherwise discriminating against a member solely on the basis of age, sex, race, physical or mental handicap, national origin, or type of illness or condition;

(N) Require that all subcontractors meet the same requirements as are in effect for the health plan that are appropriate to the service or activity delegated under the subcontract;

(O) Provide member services;

(P) Maintain, at all times, an appropriate certificate of authority to operate issued by the Nebraska Department of Insurance;

(Q) Comply with all applicable state and federal regulations, such as the prohibition against assisted suicide; inappropriate use of funds/profits, lack of mental health parity, and the noncompliance with the provisions of the Hyde Amendment;

(R) Prohibit discrimination against providers based upon licensing;

(S) Prohibit hiring, employing, contracting with or otherwise conducting business with individuals or entities barred from participation in Medicaid or Medicare;

(T) Ensure adequate numbers of providers in its network to meet the needs of its members;

(U) Provide written notice to the member of any adverse action regarding the provision of services that complies with all federal and state requirements. Allow member to appeal decisions to deny, limit or terminate authorization, coverage, or payment of services. Plans must allow members to file complaints, grievances and appeals, according to Title 482 NAC 7;

(V) Comply with the Maternity and Mental Health Requirements in the Health Insurance Portability and Accountability Act of 1996 the maternity length of stay and mental health parity requirements specifically requiring coverage for a hospital stay following a normal vaginal delivery not be limited to less than forty-eight (48) hours for both the mother and newborn child, and the health coverage for a hospital stay in connection with childbirth following a cesarean section not be limited to less than ninety-six (96) hours for both the mother and newborn child;

(W) Report all fraud and abuse information to the Department;

(X) Comply with the provisions of Title 482 NAC 4-004 for provider payments;

(Y) Sign a contract with the Department and comply with all contract requirements and any other responsibilities specified by the Department in the overall operation of Heritage Health, and any other activities deemed appropriate by the Department and supported in regulations and contractual amendments;

(Z) Comply with all applicable requirements of the Health Insurance Portability and Accountability Act of 1996 and Balanced Budget Act of 1997; and

(AA) Provide access to behavioral health services necessary referrals twenty-four (24) hours per day, seven (7) days per week.