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

Current through June 17, 2024
Heritage health administers the core benefits package to Medicaid
	 members through one (1) or more health plans. The following provisions describe
	 the health plan responsibilities.
002.01
GENERAL
  REQUIREMENTS.
The health plan is required to comply with, but is
  not limited to, the following general requirements and as specified in the
  contract between the Department and the health plan:
(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:
(i) Obtain Departmental
  approval for all marketing materials;
(ii) Ensure marketing materials do not
  contain any false or potentially misleading information in a manner that does
  not confuse or defraud the Department;
(iii) Ensure marketing materials are
  available for members being served within the State;
(iv) Avoid offering other insurance products
  as an inducement to enroll;
(v)
  Comply with federal requirements for provision of information including
  accurate oral and written information sufficient for the member to make an
  informed decision about treatment options; and
(vi) Avoid any direct or indirect
  door-to-door, telephonic or other "cold-car marketing.
(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:
(i) Management
  and integration of health care through the primary care provider, and
  coordination of care issues with other providers outside the health plan, for
  services not included in the core benefits package, including behavioral health
  services, pharmacy, and dental services, or for services requiring additional
  Departmental authorization, which may include abortions and transplants (except
  corneal);
(ii) Provision of or
  arrangement for emergency medical services, twenty-four (24) hours per day,
  seven (7) days per week, including an education process to help assure members
  know where and how to obtain medically necessary care in emergency
  situations;
(iii) Unrestricted
  access to protected services such as emergency room services, family planning
  services, and tribal clinics in accordance with Title 471 NAC;
(iv) Retention of plan-maintained records and
  other documentation during the period of contracting, and for ten (10) years
  after the final payment is made and all pending matters are closed, plus
  additional time if an audit, litigation, or other legal action involving the
  records is started before or during the original ten (10) year period ends;
  and
(v) Adequate policy regarding
  the distribution of the member's medical records if a member changes from one
  primary care physician to another.
(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.