Or. Admin. Code § 410-141-3585 - MCE Member Relations: Education and Information
(1) Managed Care Entity's (MCEs) may engage
in activities for existing members related to outreach, health promotion, and
health education. MCE must obtain approval of the Authority prior to
distribution of any written communication by the MCE or its subcontractors and
providers that:
(a) Is intended solely for
members; and
(b) Pertains to
requirements for obtaining coordinated care services at service area sites or
benefits.
(2) MCEs may
communicate with providers, caseworkers, community agencies, and other
interested parties for informational purposes or to enable care coordination
and address social determinants of health or community health. The intent of
these communications should be informational only for building community
linkages to impact social determinants of health or member care coordination
and not to entice or solicit membership. Communication methodologies may
include but are not limited to brochures, pamphlets, newsletters, posters,
fliers, websites, health fairs, or sponsorship of health-related events. MCEs
shall address health literacy issues by preparing these documents at a low
literacy reading level, incorporating graphics and utilizing alternate
formats.
(3) MCEs shall have a
mechanism to help members understand the requirements and benefits of the MCE's
coordinated care model. The mechanisms developed shall be culturally and
linguistically appropriate. Written materials, including provider directories,
member handbooks, appeal and grievance notices, and all denial and termination
notices are made available in the prevalent non-English languages as defined in
OAR 410-141-3575 in its particular
service area and be available in formats noted in section (5) of this rule for
members with disabilities. MCEs shall accommodate requests made by other
sources such as members, family members, or caregivers for language
accommodation, translating to the member's language needs as
requested.
(4) MCEs shall have
written procedures, criteria, and an ongoing process of member education and
information sharing that includes member orientation, member handbook, and
health education. MCEs shall update their educational material as they add
coordinated services. Member education shall:
(a) Be made available in the prevalent
non-English languages in the MCEs service area and provided in alternate
formats upon request and free of charge in compliance with
42 CFR
438.10. Auxiliary aids and services must also
be made available upon request at no cost;
(b) Include information about the care
coordination approach and how to navigate the coordinated health care system
and where applicable for Full Benefit Dual Eligible (FBDE) members, the process
for coordinating Medicaid and Medicare benefits;
(c) Clearly explain how members may receive
assistance from certified and qualified health care interpreters and
Traditional Health Workers as defined in OAR
950-060-0010;
(d) Inform all members of the availability of
Ombudsperson services.
(5) Written member materials shall comply
with the following language and access requirements:
(a) Materials shall be translated in the
prevalent non-English languages as defined in OAR
410-141-3575 in the service area
as well as include a tagline in large print (font size 18) explaining the
availability of written translation or oral interpretation to understand the
information provided, as well as alternate formats, and the toll-free and
TTY/TDY telephone number of the MCE's member/customer service unit;
(b) Materials shall be made available in
alternative formats upon request of the member at no cost. Auxiliary aids and
services must also be made available upon request of the member at no cost. The
MCE's process for providing alternative formats and auxiliary aids to members
may not in effect deny or limit access to covered services, grievance, appeals,
or hearings;
(c) Electronic
versions of member materials shall be made available on the MCE website,
including provider directories, formularies, and handbooks in a form that can
be electronically retained and printed, available in a machine-readable file
and format, is searchable and Readily Accessible. For any required member
education materials on the MCE website, the member is informed that the
information is available in paper form without charge upon request to Members
and Member representatives, and the MCE shall provide it upon request within
five business days.
(6)
MCE provider directories shall be a single, comprehensive resource that
encompasses the MCE's entire Provider Network, including any Providers
contracted by Subcontractors that serve the MCE's Members. MCEs may not utilize
a Subcontractor's separate or standalone provider directory to meet the
Provider Directory requirement and shall include:
(a) The provider's name as well as any group
affiliation;
(b) Street
address(es);
(c) Telephone
number(s);
(d) Website URL, as
appropriate;
(e) Provider
Specialty, as appropriate;
(f)
National Provider Identifier (NPI), as appropriate;
(g) Whether the provider shall accept new
members;
(h) Whether the provider
offers both telehealth and in-person appointments;
(i) Information about the provider's race and
ethnicity, cultural and linguistic capabilities, including languages (including
American Sign Language) offered by the provider or an Authority-approved
qualified and, as applicable, certified health care interpreter(s) at no cost
to members at the provider's office;
(j) Availability of auxiliary aids and
services for all members with disabilities upon request and at no
cost;
(k) Narrative space that is
optional for providers to list biographical, cultural, linguistic, or other
relevant information.
(l) Whether
the provider's office or facility is accessible and has accommodations for
people with physical disabilities, including but not limited to information on
specific accessibility features of provider's offices, exam rooms, and
equipment (e.g., wide entries, wheelchair access, accessible exam tables and
rooms, lifts, scales, restrooms, grab bars, or other equipment).
(m) The information for each of the following
provider types covered under the contract, as applicable to the MCE contract:
(A) Physicians, including specialists,
available to members on an outpatient basis and not solely available in a
nursing facility or other institutional setting;
(B) Hospitals;
(C) Pharmacies;
(D) Behavioral health providers; including
specifying substance use treatment providers;
(E) Dental providers;
(F) HRSN Service Providers.
(n) Information included in the
provider directory shall be updated at least monthly, and electronic provider
directories shall be updated no later than thirty (30) days after the MCE
receives updated provider information. Updated materials shall be available on
the MCE website in a readily accessible and machine-readable file per form upon
request and another alternative format.
(7) Each MCE shall make available in
electronic or paper form the following information about its formulary:
(a) Which medications are covered both
generic and name brand;
(b) What
tier each medication is on.
(8) Within fourteen (14) days of an MCE's
receiving notice of a member's enrollment, MCEs shall mail a welcome packet to
new members and to members returning to the MCE twelve (12) months or more
after previous enrollment. The packet shall include, at a minimum, a welcome
letter, a member handbook, and information on how to access a provider
directory, including a list of any in-network retail and mail-order
pharmacies.
(9) For existing MCE
members, an MCE shall notify members annually of the availability of a member
handbook and provider directory and how to access those materials. MCEs shall
send hard copies upon request within five days. MCEs must also notify members
of their nondiscrimination policies annually and as otherwise specified in
45 CFR
92.10.
(10) MCEs must notify enrollees:
(a) That interpreter services in any language
required by the member, including American Sign Language, auxiliary aids and
alternative format materials are available free of charge to MCE members in its
health programs and activities as stated in
42 CFR
438.10. This notice must be provided in the
manner specified in 45 CFR
92.11;
(b) The process for requesting and accessing
interpreters or auxiliary aids and alternative formats, including where
appropriate how to contact specific providers responsible through sub-contracts
to ensure provision of language and disability access;
(c) Language access services also applies to
member representatives, family members and caregivers with hearing impairments
or limited English proficiency who need to understand the member's condition
and care.
(11) An MCE
shall electronically provide to the Authority for approval each version of the
printed welcome packet that includes a welcome letter, member handbook, and
information on how to access a provider directory.
(12) MCEs shall adopt the language in the
Authority's Model Member Handbook. MCE Member Handbooks shall comply with the
Authority's formatting and readability standards.
(13) Member health education shall include:
(a) Information on specific health care
procedures, instruction in self-management of health care, promotion and
maintenance of optimal health care status, patient self-care, and disease and
accident prevention. MCE providers or other individuals or programs approved by
the MCE may provide health education. MCEs shall make every effort to provide
health education in a culturally sensitive and linguistically appropriate
manner in order to communicate most effectively with individuals from
non-dominant cultures;
(b)
Information specifying that MCEs shall not prohibit or otherwise restrict a
provider acting within the lawful scope of practice from advising or advocating
on behalf of a member who is their patient for the following:
(A) The member's health status, medical care,
or treatment options, including any alternative treatment that may be
self-administered;
(B) Any
information the member needs to decide among all relevant treatment
options;
(C) The risks, benefits,
and consequences of treatment or non-treatment.
(c) MCEs shall ensure development and
maintenance of an individualized health educational plan for members whom their
provider has identified as requiring specific educational intervention. The
Authority may assist in developing materials that address specifically
identified health education problems to the population in need;
(d) An explanation of care coordination and
how members may participate in those services. MCEs shall ensure that care
coordination related education is provided to members with special health care
needs as defined in OAR
410-141-3500;
(e) The appropriate use of the delivery
system, including proactive and effective education of members on how to access
emergency services and urgent care services appropriately;
(f) MCEs shall provide written notice to
affected members of any Material Changes to Delivery System as defined in OAR
410-141-3500 or any other
significant changes in provider(s), program, or service sites that affect the
member's ability to access care or services from MCE's participating providers.
The MCE shall provide, translated as appropriate, the notice at least thirty
(30) days before the effective date of that change, or within fifteen (15)
calendar days after receipt or issuance of the termination notice if the
participating provider has not given the MCE sufficient notification to meet
the thirty (30) day notice requirement. The Authority shall review and approve
the materials within two (2) working days.
(14) MCEs shall provide an identification
card to members, unless waived by the Authority, that contains simple,
readable, and usable information on how to access care in an urgent or
emergency situation. The cards are solely for the convenience of the MCE,
members, and providers.
Notes
Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065 & 414.727
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