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Title: Section 360-10.10 - MMCO unacceptable practices

Effective Date


Section 360-10.10 MMCO unacceptable practices

(a) In addition to the unacceptable practices set forth in Part 515 of this title, it is an unacceptable practice for an MMCO or any of its subcontractors to:

(1) fail to provide or arrange for medically necessary services that the MMCO is required to provide under its contract with the State;

(2) impose premiums or charges on enrollees that are in excess of the premiums or charges allowed under the Medicaid managed care program or the Family Health Plus program;

(3) discriminate among enrollees on the basis of their health status or need for health care services. This includes requests for termination of enrollment by the MMCO, refusal by the MMCO to re-enroll an enrollee, or any practice to discourage enrollment, except when an enrollee has been disenrolled at the request of the MMCO in accordance with the guidelines in the contract between the MMCO and the State;

(4) provide false or misleading information to a prospective enrollee, health care provider, social services district, the State, or the federal government;

(5) commit one of the prohibited marketing/outreach or enrollment practices defined in subdivision (j) of section 360-10.9 of this Part;

(6) violate any other applicable requirements of section 1903 or 1932 of the federal social security act and implementing regulations; or

(7) fail to comply with the material terms of the contract with the State.


VOLUME A-1 (Title 18)