Section 29-5605. EVIDENCE OF COVERAGE

 

5605.1The managed care provider shall provide each enrolled child with written evidence of coverage prior to the effective date of enrollment, which shall include the following:

 

(a)Notification of the child’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 managed care 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 enrolled child’s and family’s responsibility to report any third party payment source to the managed care provider and the consequences of not doing do;

 

(h)A copy 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

 

(i)Information regarding allowable reasons and procedures for disenrolling from the managed care provider’s plan.

 

source

Final Rulemaking published at 43 DCR 4833, 4841 (September 6, 1996).