Current through Register Vol. 46, No. 39, September 25, 2024
(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.
