D.C. Mun. Regs. tit. 22, r. 22-B5506

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 22-B5506 - EVIDENCE OF COVERAGE

5506.1

Each QO shall prepare and submit for prior written approval of the Department a form that is evidence of coverage.

5506.2

The QO 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 about the conditions of enrollment in the plan and scope, content, duration and limitation of coverage;

(d) An explanation of the procedure for obtaining benefits, including the address and telephone number of primary care physicians, and the hours and days the facilities are open and service is available;

(e) Where and how emergency medical care is 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 likewise result in loss of plan enrollment under Medicaid sponsorship (except as otherwise provided in the contract);

(g) Notification of the enrollee's responsibility for reporting any third party payment source;

(h) A description of the grievance process; and

(i) Information regarding allowable reasons and procedures for disenrolling from the plan.

D.C. Mun. Regs. tit. 22, r. 22-B5506

Final Rulemaking published at 34 DCR 1550, 1558 (March 6, 1987)