360-10.12 Changing managed care providers or medical services providers.
Certain managed care providers may restrict the ability of a participant to change managed
care providers or medical services providers. This section sets forth the circumstances
and conditions under which a participant may be restricted from changing managed care
providers or medical services providers or may be permitted to change such providers.
(a) As provided for in section 360-10.4 of this Subpart, a participant
in an MCP may have available to him or her a choice of managed care providers or medical
services providers. The participant's choice of a particular managed care provider may
have the effect of limiting the participant's ability to change from that managed care
provider to another managed care provider at a later date. The participant will be
informed by the MCP prior to choosing a managed care provider, as described in section
360-10.8(f) of this Subpart, whether the choice of a particular managed care provider will
affect the ability to later change from such provider. If a choice of managed care
providers or medical services providers is available, a participant is permitted to change
from one such provider to another subject to the limitations in this section.
(b) If the participant is enrolled with a managed care provider which
is not authorized under law to restrict the ability of a participant to change a managed
care provider or a medical services provider, a participant may change his or her managed
care provider or medical services provider at any time for any reason.
(c) A managed care provider may restrict a participant from changing a
managed care provider or medical services provider if the managed care provider is
authorized under section 1903(m) or 1915 of the federal Social Security Act to impose such
a restriction.
(d) If the participant is enrolled with a managed care provider which
is authorized under law to restrict the ability of a participant to change a managed care
provider or a medical services provider, the participant may change his or her managed
care provider or medical services provider for any reason during the initial 30 day
enrollment period. After the initial 30-day enrollment period, no participant enrolled
with such managed care provider may change his or her managed care provider or medical
services provider other than during a 30-day period occurring once every six months,
except that the participant may change his or her managed care provider or medical
services provider at any time for good cause as provided in section 360-10.13 of this
Subpart.