Title: Section 360-10.7 - Good cause for changing primary care practitioners

Effective Date

05/07/2014

Section 360-10.7 Good cause for changing primary care practitioners.

(a) An MMCO must allow enrollees to change PCPs without cause within 30 days of the enrollee's first appointment with the PCP. After the first 30 days, the MMCO may elect to limit enrollees to changing PCPs every six months without cause. This subdivision does not apply to enrollees restricted pursuant to section 360-6.4 of this Part or the MMCO’s recipient restriction program.

(b) If the MMCO has elected to restrict PCP changes, or an enrollee has been restricted pursuant to section 360-6.4 of this Part or the MMCO's recipient restriction program, an enrollee nevertheless has good cause to change PCPs at any time if:

(1) the provider 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:

(i) provide primary care services;

(ii) arrange for inpatient care, consultations with specialists, or laboratory or radiological services when reasonably necessary;

(iii) arrange for consultation appointments;

(iv) coordinate and interpret any consultation findings with an emphasis on continuity of medical care;

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

(vi) coordinate the enrollee's overall medical care such as periodic immunizations and diagnosis and treatment of any illness or injury; or

(2) the enrollee disagrees with a treatment plan; or

(3) the enrollee and provider are not able to communicate due to a language barrier or other impediment to communication; or

(4) the provider is not able to reasonably accommodate the enrollee's special needs; or

(5) there is a change in the provider's practice, including but not limited to the following:

(i) the provider moves to a location that is not convenient for the enrollee; or

(ii) there is a significant change in the hours the provider is available and the enrollee cannot reasonably make appointments during the new hours; or

(iii) the provider no longer has hospital privileges; or

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

(7) the enrollee and the provider agree that a change would be in the best interest of the enrollee; or

(8) the provider leaves the MMCO's network.

(c) Requests to change PCPs.

(1) An enrollee must submit a request to change PCPs to the MMCO according to the procedures established by the MMCO.

(2) The MMCO must provide the enrollee with a decision on the enrollee's request within 30 days of receipt of the request.

(3) If approved, the change must be effective no later than the first day of the second month following the month in which the request is received.

Volume

VOLUME A-1 (Title 18)

up