Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.21 - Information Requirements For Enrollees And Potential Enrollees

Current through Register Vol. 42, No. 9, June 28, 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.