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 53895 - Information to New Members

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The plan shall send information to new members, as described below, by the
					 seventh day of the first month of enrollment in the plan by the new member and
					 annually thereafter.
(b) Each plan
					 shall provide to each member in writing, in addition to those items of
					 information contained in the Welfare and Institutions Code, section
					 14406,
					 the following information, as approved by the department:
(1) The plan name and the address and
					 telephone number within the plan's service area where member services are
					 available.
(2) The effective date
					 of enrollment.
(3) A description of
					 all available services and an explanation of any service limitations,
					 exclusions from coverage or charges for services, when applicable.
(4) An explanation of how to use the
					 fee-for-service system when Medi-Cal covered services are excluded or limited
					 under the plan and how to obtain additional information.
(5) Information on the availability of
					 transitional Medi-Cal eligibility and how the member may apply for this
					 program.
(6) The name, telephone
					 number, and service site address of the primary care provider selected by the
					 member or instructions to select a primary care provider within thirty days and
					 that failure to timely select a primary care physician will result in the
					 member being assigned a primary care provider by the plan, in accordance with
					 section 53890. The plan shall notify the
					 primary care provider of selection by or assignment of the eligible beneficiary
					 within ten days of selection or assignment.
(7) Procedures for changing the member's
					 primary care provider and an explanation that the member can make this change
					 at any time.
(8) Information
					 concerning any non-medical transportation services available to the member from
					 the plan and through the local EPSDT and CHDP programs, and how to obtain such
					 services.
(9) The appropriate use
					 of health care services in a managed care system and the contributions the
					 member can make toward the maintenance of the member's own health, including
					 the value of scheduling an initial health assessment appointment.
(10) An explanation of the member's right to
					 request a fair hearing under Welfare and Institutions Code section
					 10950,
					 et seq. without going through the plan's grievance procedures when a health
					 care service requested by the member or a provider has not been
					 provided.
(11) Information on the
					 availability of and procedures for obtaining services at Federally Qualified
					 Health Centers and Indian Health Services facilities.
(12) Information on the member's right to
					 seek family planning services from any provider eligible to provide family
					 planning services under the Medi-Cal program, including providers outside the
					 plan's provider network, and a description of those services.
(13) Information on the member's eligibility
					 for nurse midwife and nurse practitioner services and how to obtain these
					 services.
(14) Information
					 concerning the provision and availability of services covered under the CCS
					 program from providers outside the plan's provider network and how to access
					 these services.
(15) An explanation
					 of the expedited disenrollment process for members meeting the criteria in
					 section 53889(j).
(16) Information on how to obtain minor
					 consent services through the plan, and an explanation of those
					 services.
(17) A description of the
					 Medi-Cal Managed Care Ombudsman Program and the Department of Managed Health
					 Care's Office of Patient Advocate, including the toll-free telephone numbers
					 for each.