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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 29. PUBLIC WELFARE |
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Chapter 29-53. STANDARDS FOR MANAGED CARE PROVIDERS THAT ARE PAID ON A FIXED, PREPAID, CAPITATED BASIS FOR SERVICES RENDERED TO AFDC AND AFDC-RELATED MEDICAID RECIPIENTS |
Section 29-5306. EVIDENCE OF COVERAGE
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5306.1Each prepaid, capitated provider 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 regarding the conditions of enrollment in the plan and the scope, content, duration and limitation of coverage;
(d)An explanation of the procedure for obtaining benefits, including the address and telephone number of the prepaid, capitated provider’s office or facility and the days that the office or facility is open and service is available;
(e)Information as to where and how urgent and emergency medical care are 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 result in loss of plan enrollment under Medicaid sponsorship, except as otherwise provided in the Medicaid managed care provider agreement;
(g)Notification of the enrollee’s responsibility to report any third party payment source to the Department and the consequences of not doing so;
(h)A copy of the prepaid, capitated provider’s grievance process, including methods for filing grievances and the right of a member to receive assistance from the personal representative of the member’s choice; and
(i)Information regarding allowable reasons and procedures for disenrolling from the prepaid, capitated provider’s plan.