Section 22-B5506. EVIDENCE OF COVERAGE

 

5506.1 Each QO shall prepare and submit for prior written approval of the Department a form that is evidence of coverage.

 

5506.2 The QO shall provide each enrollee with written evidence of coverage prior to the effective date of enrollment which shall include the following:

 

(a)Notification of the recipient’s effective date of enrollment;

 

(b)A plan membership card;

 

(c)Information about the conditions of enrollment in the plan and scope, content, duration and limitation of coverage;

 

(d)An explanation of the procedure for obtaining benefits, including the address and telephone number of primary care physicians, and the hours and days the facilities are open and service is available;

 

(e)Where and how emergency medical care is available on a twenty-four (24) hour, seven (7) day a week basis, and an explanation of out-of-plan coverage;

 

(f)Notification that loss of Medicaid eligibility will likewise result in loss of plan enrollment under Medicaid sponsorship (except as otherwise provided in the contract);

 

(g)Notification of the enrollee’s responsibility for reporting any third party payment source;

 

(h)A description of the grievance process; and

 

(i)Information regarding allowable reasons and procedures for disenrolling from the plan.

 

 

source

Final Rulemaking published at 34 DCR 1550, 1558 (March 6, 1987).