5305.1 Each prepaid, capitated provider shall submit to the Department for its prior written approval all marketing plans, procedures, and materials including the following:

1. (a) Marketing policies and manuals;
2. (b) A written description of proposed marketing approaches;
3. (c) Marketing brochures and fliers;
4. (d) Advertising copy and public service announcements;
5. (e) Enrollment training guidelines;
6. (f) A written description of the basis on which marketing personnel will be compensated; and
7. (g) Nominal value marketing gifts.

5305.2 No prepaid, capitated provider shall engage in any deceptive marketing practice that misleads, confuses, or defrauds an eligible enrollee or the Department.

5305.3 Marketing materials distributed to Medicaid recipients for use in selecting a primary care provider, as defined in §5599, shall be clear and shall include at least the following:

1. (a) A statement that enrollment in the prepaid, capitated provider's plan is voluntary;
2. (b) A statement that all necessary health care, except emergency care and services excluded under managed care, must be obtained through the prepaid, capitated provider;
3. (c) A description of the benefits package and excluded services;
4. (d) The days and hours of service;
5. (e) The address of each facility or service site;
6. (f) A description of the procedures to follow to receive services after hours;
7. (g) Telephone numbers to access emergency care services;
8. (h) A statement that disenrollment from the prepaid, capitated provider's plan is

subject to the limitations described in Chapter 55;

(i) A description of the prepaid, capitated provider's grievance process, including methods for filing grievances and the right of a member to receive assistance from the personal representative of the member's choice; and

(j) A statement of the member's rights and responsibilities.

5305.4 A prepaid, capitated provider shall not provide cash, gift incentives, or rebates to prospective enrollees.

5305.5 A prepaid, capitated provider shall not claim or assert superior medical care or provider skills or make untruthful, misleading or deceptive statements regarding the merits of its plan.

5305.6 A prepaid, capitated provider shall not compensate marketing representatives based on commissions or other incentives that are based upon the number of new AFDC or AFDC-related Medicaid recipients enrolled.

5305.7 Each eligible AFDC and AFDC-related Medicaid recipient in the category or categories covered under the managed care provider agreement shall be considered a potential enrollee and may not be discriminated against on the basis of health status or need for health care services.

5305.8 Prepaid, capitated providers shall not solicit AFDC or AFDC -related Medicaid recipients already enrolled in another prepaid, capitated provider's plan, except during the period of open enrollment.

5305.9 No prepaid, capitated provider shall represent to an AFDC or AFDC-related Medicaid recipient that he or she is required to enroll in the prepaid, capitated provider's plan.

SOURCE: Final Rulemaking published at 42 DCR 1566, 1573 (March 31, 1995).