Health Plan, Version 6.0 P-MR 3 - Consumer Communications Plan

The Basics

This standard places an affirmative obligation on your organization to include in its consumer communications plan specific provisions on providing consumers with materials to explain:

  • how to receive help via e-mail, telephone, or in person;
  • covered benefits;
  • accessing covered benefits (including prior authorization requirements, special information for emergencies and receiving services when out of the organization's service area, and drug formulary);
  • cost sharing mechanisms in your benefits plan;
  • instructions on how to find out the cost of covered benefits;
  • any responsibilities imposed on the consumer to cooperate with the organization's medical management programs;
  • benefit exclusions;
  • instructions on how to obtain evidence-based health information;
  • directions on how to pursue complaints and appeals.

It will be important that you have access to a current copy of the communications plan and are familiar with how it addresses these issues.

Management Tips

Make sure that you don't rely exclusively on Internet access to comply with the standard.  Not everybody has a computer, and you're obligated to document how you will get this information to folks who don't.

URAC Accreditation Tips

Most of the elements of the standard are either mandatory or weighted 4.  One element, addressing information about the cost of covered benefits, is a Leading Indicator.

Naturally, the communications plan will be the central document that you submit for desktop review.  In addition, the documents that demonstrate compliance with your policies and procedures as articulated in the communications plan, such as member rights and responsibilities documents, newsletters, correspondence, or member handbook would be a good accompaniment to that plan.  In addition, documentation of training of employees and consultants in the requirements of the standard also would be helpful.  Remember, keep the number of documents you submit to nine or fewer.

During the on-site review, the reviewer will examine recent enrollment materials and documentation of how you handle consumer complaints and appeals.  In addition, interviews of marketing and customer service managers and staff members will cover not only their understanding of your policies and procedures, but also how thoroughly they've been trained.