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:

1. (a) Notification of the recipient's effective date of enrollment;
2. (b) A plan membership card;
3. (c) Information about the conditions of enrollment in the plan and scope, content, duration and limitation of coverage;
4. (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;
5. (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;
6. (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);
7. (g) Notification of the enrollee's responsibility for reporting any third party payment source;
8. (h) A description of the grievance process; and
9. (i) Information regarding allowable reasons and procedures for disenrolling from the plan.

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