New York Codes, Rules and Regulations
Title 18 - DEPARTMENT OF SOCIAL SERVICES
Chapter II - Regulations of the Department of Social Services
Subchapter B - Public Assistance
Article 2 - Determination of Eligibility-Categorical
Part 360 - MEDICAL ASSISTANCE
Subpart 360-10 - MEDICAID MANAGED CARE PROGRAMS
Section 360-10.6 - Good cause for changing or disenrolling from an MMCO
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 360-10.6
Current through Register Vol. 46, No. 39, September 25, 2024
(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 (1)(i) or (ii) 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 section
360-10.5(e)(2)(iii)
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 section
358-2.2(a)
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 section
358-2.2(a)
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 section
358-2.2(a)
of this Title.
Disclaimer: These regulations may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
