Section 98-1.14 - Enrollee services and grievance procedures

98-1.14 Enrollee services and grievance procedures. (a) The MCO shall supply enrollee handbooks to each enrollee, and upon request to each prospective enrollee, which explain the operation of the plan. The MCO shall also provide information as required by section 4408 of the Public Health Law. Except where precluded by applicable law or regulation, changes in operations that affect the enrollee shall be communicated to the enrollee prior to the effective date of the change via the enrollee handbook or by other direct means of communication.

(1) For MLTCPs, the enrollee handbook and complete provider network directory shall be provided to individuals who have expressed a desire for enrollment. MLTCPs shall also comply with the provisions of paragraph (i) of subdivision 98-1.16 of this Subpart.

(2) Information disclosed in the enrollee handbook and changes made thereto shall be approved prior to use of the handbook by:

(i) for programs authorized by title XIX, the commissioner and, when such approval is required, the federal agency with oversight responsibility for programs authorized by title XIX;

(ii) for programs authorized by title XXI, the commissioner;

(iii) for commercial and private pay insurance products, the commissioner; and

(iv) for MLTCPs, the superintendent in consultation with the commissioner and director of the State Office for Aging and, as appropriate, the federal agencies with oversight responsibility for programs authorized by title XIX and title XVIII of the Social Security Act.
(b) The MCO shall establish written policies regarding the rights of enrollees and shall list these rights in the enrollee handbook. Enrollee rights shall include the following:
(1) to obtain complete current information concerning a diagnosis, treatment and prognosis from a physician or other provider in terms the enrollee can be reasonably expected to understand. When it is not advisable to give such information to the enrollee, the information shall be made available to an appropriate person acting on the enrollee's behalf;
(2) to receive information from a physician or other provider necessary to give informed consent prior to the start of any procedure or treatment; and
(3) to refuse treatment to the extent permitted by law and to be informed of the medical consequences of that action.
(c) The MCO shall have written grievance and complaint procedures, including an appeals procedures consistent with section 4408-a of the Public Health Law and/or in the case of an entity participating in federally sponsored programs, consistent with federal law and regulation. Such procedures shall be approved by the commissioner and/or, as appropriate, the federal agency with oversight responsibility for programs authorized by title XIX and title XVIII of the Social Security Act prior to the start of enrollment.
(d) The MCO shall document the receipt and disposition of each grievance or complaint, comply with all applicable reporting requirements of section 210 of the Insurance Law, and retain these records for not less than three years.

(e) Within 15 business days of receipt, the MCO shall provide written acknowledgement to the complainant or grievant of grievances, written complaints, or verbal complaints that are not immediately resolved. Such acknowledgement shall include the name, address and telephone number of the individual or department designated by the MCO to respond. In addition, the MCO shall provide either a written explanation of the determination resulting from the investigation, without releasing protected peer review information, including detailed reasons for the determination for all grievances and for complaints related to quality of care, access to care and billing, including the clinical rationale for the determination when the determination has a clinical basis, or a written statement that insufficient information was presented or available to reach a determination. When the complainant or grievant is dissatisfied with a determination made by the MCO, other than determinations subject to the provisions of article 49 of the Public Health Law, the appeal provisions of article 4408-a of the Public Health Law apply. In the case of an entity participating in a federally sponsored program, the requirements for written acknowledgement of grievances, written or verbal complaints and MCO determinations shall be consistent with federal law and regulations. For purposes of this Subpart, a "complaint" is any issue of dissatisfaction with the MCO’s operations other than those grievances identified in article 4408-a of the Public Health Law.
(f) With respect to its responsibilities to the enrollee, the MCO shall comply with all provisions of section 700.5 (Advance Directives) of this Title. For purposes of this section, the term "facility/agency" as used in section 700.5 shall be deemed to mean "MCO" and the term "patient" shall be deemed to mean "enrollee." The phrase "admission as an inpatient or outpatient" shall be deemed to mean "enrollment in an MCO," and "medical record" shall be deemed to mean "the medical record maintained by the primary care provider in an MCO or care management record in an MLTCP".

Effective Date: 
Wednesday, June 29, 2005
Doc Status: 
Complete