Section 360-10.6 - Good cause for changing or disenrolling from an MMCO

Section 360-10.6 Good cause for changing or disenrolling from an MMCO

(a) Medicaid recipients

(1) A recipient who is required to enroll in an MMCO and who resides in a social services district with more than one MMCO available has good cause to change his or her MMCO during the lock-in period if:

(i) the MMCO has failed to furnish accessible and appropriate medical care, services or supplies to which the enrollee is entitled under the terms of the contract under which the MMCO has agreed to provide services. This includes, but is not limited to the failure to:

(a) arrange for the provision of primary care services;

(b) arrange for the provision of inpatient care;

(c) arrange for consultation with specialists and other ancillary service providers;

(d) arrange for covered services with qualified licensed or certified providers; or

(ii) the MMCO fails to adhere to the standards prescribed by the commissioner and such failure negatively and specifically impacts the enrollee; or

(iii) it is determined by the social services district, the commissioner, or its agent that the enrollment was not consensual; or

(iv) the enrollee, the MMCO and the social services district agree that a change of MMCOs would be in the best interest of the enrollee; or

(v) the MMCO has elected not to cover the Medicaid managed care benefit package service that the enrollee seeks and the service is offered by one or more other MMCOs in the enrollee's service area; or

(vi) the enrollee's medical condition requires related services to be performed at the same time, but all such related services cannot be arranged by the MMCO because the MMCO has elected not to cover one of the services the enrollee seeks and the enrollee's primary care provider or another provider determines that receiving the services separately would subject the enrollee to unnecessary risk; or

(vii) there exists any other good cause reason or another programmatic requirement for change or disenrollment, as provided for in the contract between the MMCO and the State.

(2) If there are no other MMCOs available in the enrollee's social services district, an enrollee seeking to disenroll from his or her current MMCO will be required to remain enrolled in the MMCO unless the reason for the disenrollment is described in subparagraph (i) or (ii) of paragraph (1) of this subdivision.

(3)(i) If an enrollee wishes to change or disenroll from an MMCO for good cause, the enrollee or the enrollee's representative must file a written or verbal request with the social services district.

(ii) The social services district must make a determination on the request in sufficient time to ensure that a change, if approved, is effective no later than the first day of the second month following the month in which the request was received, unless the enrollee has requested an expedited change pursuant to subparagraph (iii) of paragraph (2) of subdivision (e) of section 360-10.5 of this Subpart. If the social services district fails to make the determination before the first day of such second month, the request is considered approved.

(iii) An enrollee whose request for a change of MMCO has been denied by the social services district shall be provided with a written notice which states the decision, the reasons for the denial, the facts upon which the denial is based, cites the relevant statutory and regulatory authority and advises the enrollee of his or her right to a fair hearing. The notice must comply with the requirements specified in subdivision (a) of section 358-2.2 of this Title.

(b) Family health plus enrollees

(1) If there is another MMCO available in the enrollee's social services district, an enrollee may change his or her MMCO during the lock-in period if:

(i) the MMCO has failed to furnish accessible and appropriate medical care, services or supplies to which the enrollee is entitled under the terms of the contract under which the MMCO has agreed to provide services. This includes, but is not limited to, the failure to:

(a) arrange for the provision of primary care services;

(b) arrange for the provision of inpatient care;

(c) arrange for consultation with specialists and other ancillary service providers;

(d) arrange for covered services with qualified licensed or certified providers; or

(ii) the MMCO fails to adhere to the standards prescribed by the commissioner and such failure negatively and specifically impacts the enrollee; or

(iii) it is determined by the social services district, the commissioner, or its agent that the enrollment was not consensual; or

(iv) the enrollee, the MMCO and the social services district agree that a change of MMCOs would be in the best interest of the enrollee; or

(v) the MMCO has elected not to cover the FHP benefit package service that the enrollee seeks and the service is offered by one or more other MMCOs in the enrollee's service area; or

(vi) the enrollee's medical condition requires related services to be performed at the same time, but all such related services cannot be arranged by the MMCO because the MMCO has elected not to cover one of the services the enrollee seeks and the enrollee's primary care provider or another provider determines that receiving the services separately would subject the enrollee to unnecessary risk; or

(vii) there exists any other good cause reason or another programmatic reason for disenrollment, as provided for in the contract between the MMCO and the State.

(2) If the enrollee resides in a social services district in which there are no other MMCOs available, the enrollee will be required to remain enrolled in the MMCO unless the enrollee chooses to discontinue his or her participation in the FHP program.

(3)(i) If an enrollee wishes to change or disenroll from an MMCO for good cause, the enrollee or the enrollee's representative must file a written or verbal request with the social services district.

(ii) The social services district must make a determination on the request in sufficient time to ensure that a change, if approved, is effective no later than the first day of the second month following the month in which the request was received, unless the enrollee has requested an expedited change pursuant to subparagraph (iv) of this paragraph. If the social services district fails to make the determination before the first day of such second month, the request is considered approved.

(iii) An enrollee whose request for a change of MMCO has been denied by the social services district shall be provided with a written notice which states the decision, the reasons for the denial, the facts upon which the denial is based, cites the relevant statutory and regulatory authority and advises the enrollee of his or her right to a fair hearing. The notice must comply with the requirements specified in subdivision (a) of section 358-2.2 of this Title.

(iv) An enrollee may request an expedited disenrollment or change if: an immediate risk to the enrollee's health exists; the enrollment was non-consensual; or for other reasons as set forth in the contract between the MMCO and the State. The social services district may request documentation to substantiate the request. The effective date of the expedited disenrollment or change must comply with the timeframes found in the contract between the MMCO and the State.

(a) The social services district must notify the recipient in writing of its determination to approve or deny the request for an expedited disenrollment.

(b) When a request is denied, the social services district must provide a written notice that explains the reason for the denial, states the facts upon which the denial is based, cites the relevant statutory or regulatory authority for the denial, and advises the Medicaid recipient of his or her right to a fair hearing. The notice must comply with subdivision (a) of section 358-2.2 of this Title.

Doc Status: 
Complete
Effective Date: 
Wednesday, May 7, 2014