Section I – Definitions and Acronyms

Draft May 11, 2012 Health Plan Contract Attachment II – Core Contract Provisions ATTACHMENT II CORE CONTRACT PROVISIONS DRAFT 5-11-12 Comment [LG1]: Ensure update once final Table of Contents Section I – Definitions and Acronyms ................................................................................... 77 A. Definitions ............................................................................................................................ 77 B. Acronyms .......................................................................................................................... 2827 Section II - General Overview ............................................................................................3231 A. Background ....................................................................................................................... 3231 B. Purpose............................................................................................................................. 3231 C. Responsibilities of the State of Florida (state) and the Agency for Health Care Administration (Agency) ............................................................................................................................ 3231 D. General Responsibilities of the Health Plan ........................................................................ 3533 Section III - Eligibility and Enrollment ................................................................................3937 A. Eligibility ........................................................................................................................... 3937 1. Mandatory Populations ........................................................................................................... 3937 2. Voluntary Populations ............................................................................................................. 3937 3. Excluded Populations .............................................................................................................. 4038 B. Enrollment ........................................................................................................................ 4139 1. General Provisions ................................................................................................................... 4139 2. Enrollment in a Specialty Plan ................................................................................................. 4240 3. Unborn Activation and Newborn Enrollment .......................................................................... 4240 4. Stopping or Limiting Enrollment .............................................................................................. 4442 C. Disenrollment ................................................................................................................... 4542 1. General Provisions ................................................................................................................... 4542 2. When Disenrollment Can Occur .............................................................................................. 4543 3. Cause for Disenrollment .......................................................................................................... 4643 4. Involuntary Disenrollment Requests ....................................................................................... 4744 5. Disenrollment Notice ............................................................................................................... 4846 Section IV - Enrollee Services, Community Outreach and Marketing ..................................5047 A. Enrollee Services ............................................................................................................... 5047 1. General Provisions ................................................................................................................... 5047 2. Requirements for Written Material......................................................................................... 5148 3. New Enrollee Materials ........................................................................................................... 5249 4. Enrollee ID Card ....................................................................................................................... 5249 5. Enrollment with a Primary Care Provider (PCP) ...................................................................... 5350 6. Enrollee Handbook Requirements .......................................................................................... 5350 7. Provider Directory ................................................................................................................... 5855 8. New Enrollee Procedures ........................................................................................................ 5956 9. Enrollee Assessments .............................................................................................................. 6057 10. Enrollee Authorized Representative ..................................................................................... 6058 11. Toll-Free Help Line ................................................................................................................. 6058 12. Translation Services ............................................................................................................... 6159 13. Preferred Drug List (PDL) ....................................................................................................... 6259 Page 1 of 269 Draft May 11, 2012 Health Plan Contract Attachment II – Core Contract Provisions 14. Incentive Programs ................................................................................................................ 6259 15. Enhanced Benefits Program .................................................................................................. 6360 16. Notices of Action ................................................................................................................... 6360 17. Medicaid Redetermination Notices ...................................................................................... 6361 B. Community Outreach and Marketing ................................................................................. 6664 1. General Provisions ................................................................................................................... 6664 2. Prohibited Activities ................................................................................................................ 6765 3. Permitted Activities ................................................................................................................. 6966 4. Community Outreach Notification Process ............................................................................. 6967 5. Provider Compliance ............................................................................................................... 7068 6. Community Outreach Representatives ................................................................................... 7169 Section V - Covered Services .............................................................................................7270 A. Covered Services ............................................................................................................... 7270 B. Optional Services............................................................................................................... 7270 C. Expanded Services ............................................................................................................. 7270 D. Customized Benefit Packages ............................................................................................. 7371 E. Excluded Services .............................................................................................................. 7371 F. Moral or Religious Objections ............................................................................................ 7371 G. Copayments ...................................................................................................................... 7472 H. Coverage Provisions .......................................................................................................... 7472 1. Requirements .......................................................................................................................... 7472 2. Child Health Check-Up Program (CHCUP) ............................................................................... 7472 3. Dental Services ........................................................................................................................ 7674 4. Hearing Services ...................................................................................................................... 7674 5. Vision Services ......................................................................................................................... 7674 6. Diabetes Supplies and Education ............................................................................................ 7774 7. Emergency Services ................................................................................................................. 7774 8. Out-of-Plan Use of Non-Emergency Services .......................................................................... 7977 9. Family Planning Services .........................................................................................................

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