California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 7 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53881 - Marketing and Member Materials

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Evidence of Coverage, disclosure
					 form, and any marketing brochure developed by or for a plan in a designated
					 region and distributed to prospective members shall meet the requirements
					 contained in Health and Safety Code, section
					 1363.1,
					 and Title 10, section
					 1300.63(a), as to
					 print size, readability, and understandability of text.
(b) Evidence of coverage and disclosure forms
					 or member services guides distributed to eligible beneficiaries by a plan shall
					 fully disclose the availability of and restrictions upon the services provided
					 by the plan, and any exclusions from coverage. These materials shall, at a
					 minimum, specify:
(1) The scope, access to,
					 and availability of services, including service site locations and telephone
					 numbers, and the service area authorized in that plan's contract.
(2) A description of the membership
					 identification card issued by the plan, if applicable, and an explanation as to
					 its use in authorizing or assisting members to obtain services.
(3) That members shall obtain all Medi-Cal
					 health care services covered by the plan's contract through the plan's
					 providers.
(4) That medical
					 services required in an emergency may be obtained from specified plan providers
					 or from non-plan providers, if necessary.
(5) The disenrollment process, and an
					 explanation that disenrollment is possible only under the conditions specified
					 in section
					 53891 and is effective only after
					 the disenrollment transaction is completed by the Health Care Options Program
					 as specified in section
					 53889.
(6) The plan's grievance process, including
					 instructions on how to use it.
(7)
					 That members have the right to a fair hearing, including instructions on how to
					 request one.
(8) The interpreter,
					 linguistic, and cultural services available through plan personnel.
(9) Any transportation services to service
					 sites that are available through the plan or under the Medi-Cal program. This
					 shall include a description of both medical and non-medical transportation
					 services, and the conditions under which non-medical transportation is
					 available to members.
(10)
					 Information on the availability of and procedures for obtaining services at
					 Federally Qualified Health Centers and Indian Health Service
					 facilities.
(11) Information on the
					 member's right to seek family planning services from any qualified provider
					 eligible to provide family planning services under the Medi-Cal program,
					 including providers outside the plan's provider network, how to access these
					 services, and a description of the limitations on the services that
					 beneficiaries may seek outside the plan.
(12) Information on the availability and
					 procedures for obtaining nurse midwife and nurse practitioner
					 services.
(13) Information
					 concerning the availability of services covered under the State's California
					 Children Services (CCS) program from providers outside the plan's provider
					 network and how to access these services.
(14) An explanation of the disenrollment
					 process for members qualifying for expedited disenrollment as specified in
					 section 53889.
(15) Information on how to obtain minor
					 consent services through the plan, and an explanation of those
					 services.
(16) An explanation of an
					 American Indian beneficiary's right to not enroll in a plan, not be restricted
					 in their right to access Indian Health Facilities by a plan, and their right to
					 disenroll from a plan without cause.
(17) The information specified in section
					 53895(b).