18 Del. Admin. Code § 1403-8.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1403-8.0 - Enrollee Rights and Responsibilities

8.1 The MCO shall establish and implement written policies and procedures regarding the rights of enrollees and the implementation of these rights.

8.2 The MCO shall disclose to each new enrollee, and any enrollee upon request, in a format and language understandable to a layperson, the following minimum information:

8.2.1 Benefits covered and exclusions or limitations, including restrictions related to preexisting conditions;

8.2.2 Out-of-pocket costs to the enrollee;

8.2.3 Lists of participating providers;

8.2.4 Policies on the use of primary care physicians, referrals, use of out of network providers, and out of area services;

8.2.5 Policies governing the provision of emergency and urgent care;

8.2.6 Written explanation of the internal and external review processes;

8.2.7 For staff model MCOs, the location and hours of its inpatient and outpatient health services;

8.2.8 A statement of enrollee's rights that includes at least the right:

8.2.8.1 To available and accessible services when medically necessary, including availability of care 24 hours a day, seven days a week for urgent or emergency conditions;

8.2.8.2 To be treated with courtesy and consideration, and with respect for the enrollee's dignity and need for privacy;

8.2.8.3 To be provided with information concerning the MCO's policies and procedures regarding products, services, providers, grievance procedures and other information about the organization and the care provided;

8.2.8.4 To choose a primary care provider within the limits of the covered benefits and plan network, including the right to refuse care of specific practitioners;

8.2.8.5 To receive from the enrollee's physician(s) or provider, in terms that the enrollee understands, an explanation of his complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives. If the enrollee is not capable of understanding the information, the explanation shall be provided to his next of kin or guardian and documented in the enrollee's medical record;

8.2.8.6 To formulate advance directives;

8.2.8.7 To all the rights afforded by law or regulation as a patient in a licensed health care facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the enrollee understands;

8.2.8.8 To prompt notification of termination or changes in benefits, services or provider network;

8.2.8.9 To file a grievance with the MCO and to receive a response to the grievance within a reasonable period of time; and

8.2.8.10 To file a petition for arbitration or appeal for review by an Independent Utilization Review Organization, as appropriate.

8.2.9 A complete statement of responsibilities of enrollees.

8.3 In the case of nonpayment by the MCO to a participating provider for a covered service in accordance with the enrollee's health care contract, the provider may not bill the enrollee. This does not prohibit the provider from collecting coinsurance, deductibles or co-payments as determined by the MCO. This does not prohibit the provider and enrollee from agreeing to continue services solely at the expense of the enrollee, as long as the provider clearly informs the enrollee that the MCO will not cover these services.

18 Del. Admin. Code § 1403-8.0