5506. EVIDENCE OF COVERAGE

5506 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. SOURCE: Final Rulemaking published at 34 DCR 1550, 1558 (March 6, 1987).