Section 29-5604. MARKETING

 

5604.1The managed care provider shall submit to the Department for its prior written approval all marketing plans, procedures, and materials including the following:

 

(a)Marketing policies and manuals;

 

(b)Written descriptions of proposed marketing approaches;

 

(c)Marketing brochures and fliers;

 

(d)Advertising copy and public service announcements;

 

(e)Enrollment training guidelines; and

 

(f)Examples of any nominal value marketing gifts.

 

5604.2The managed care provider shall not engage in any deceptive marketing practice that misleads, confuses, or defrauds an eligible child or the Department.

 

5604.3Marketing materials distributed to eligible children for use in selecting a primary care provider, as defined in §5799, shall be clear and shall include at least the following:

 

(a)A statement that enrollment in the managed care provider’s plan is voluntary;

 

(b)A statement that all necessary health care must be obtained through the managed care provider;

 

(c)A description of the evidence of coverage, including excluded services and limitations;

 

(d)The days and hours of service;

 

(e)The address of each facility or service site;

 

(f)A description of the procedures to follow to receive services after hours;

 

(g)A description of the procedures to follow to receive urgent care and emergency services;

 

(h)Telephone numbers to access emergency care services;

 

(i)A statement that disenrollment from the managed care provider’s plan is subject to the limitations described in Chapter 57;

 

(j)A description of the managed care provider’s grievance process, including methods for filing grievances and the right of an enrolled child to receive assistance from a personal representative of the child’s or family’s choice; and

 

(k)A statement of the enrolled child’s rights and responsibilities.

 

5604.4The managed care provider shall not provide cash, gift incentives, or rebates to eligible children.

 

5604.5The managed care provider shall not claim or assert superior medical care or provider skills or make untruthful, misleading or deceptive statements regarding the merits of its plan.

 

5604.6The managed care provider shall not compensate marketing representatives based on commissions or other incentives that are based upon the number of eligible children enrolled in the provider’s plan.

 

5604.7Each eligible child in the category or categories covered under the managed care provider agreement shall be considered a potential enrollee and may not be discriminated against on the basis of health status or need for health care services.

 

5604.8The managed care provider shall not represent to an eligible child that he or she is required to enroll in the provider’s plan.

 

source

Final Rulemaking published at 43 DCR 4833, 4839 (September 6, 1996).