360-10.13 Good cause for changing managed care providers or medical services providers.
(a) A participant has good cause to change his or her managed care
provider or medical services provider, including his or her primary care practitioner, if
the present provider has failed to furnish accessible, appropriate and high-quality
medical care, services or supplies to which the participant is entitled under the terms of
the managed care plan. This includes but is not limited to failure to:
(1) provide primary care services;
(2) arrange for in-patient care, consultation
with specialists, or laboratory and radiological services when reasonably necessary;
(3) arrange for consultation appointments;
(4) coordinate and interpret any consultation
findings with emphasis on continuity of medical care;
(5) arrange for services with qualified
licensed or certified providers; or
(6) coordinate the participant's overall
medical care such as periodic immunizations and diagnosis and treatment of any illness or
injury.
(b) Request for a participant to change his or her managed care
provider or medical services provider for good cause.
(1) If a participant wishes to change his or
her managed care provider or medical services provider for good cause, the participant or
the participant's representative must file a written grievance through the managed care
provider's grievance process. A participant who alleges an immediate risk of permanent
damage to the participant's health may immediately file a written request to change his or
her managed care provider or medical services provider for good cause with the social
services district and need not use the managed care provider's grievance process.
(2) The managed care provider must make a
determination within 10 days after receipt of a request to change managed care providers
or medical services providers for good cause and notify the participant in writing whether
the request to change managed care providers or medical services providers for good cause
is granted or denied.
(3) When a request to change managed care
providers or medical services providers for good cause is denied, the notice must state
the reason(s) for the denial and advise the participant of his or her right to appeal the
denial to the social services district.
(4) When a request to change managed care
providers or medical services providers for good cause is approved, the notice must state
the date the change is effective.
(c) Appeals to the social services district; responsibilities and
rights in the appeal process.
(1) A participant whose request to change his
or her managed care provider or medical services provider for good cause has been denied
by the managed care provider through the grievance process may file a written appeal to
the social services district within 10 days of receipt of the notice of denial.
(2) An appeal to the social services district
must be decided within five days of receipt of the appeal. A written decision must be
issued that either directs the managed care provider or medical services provider to
transfer the participant to another provider or affirms the denial of the request to
change providers for good cause.
(3) When denial of a request to change managed
care providers or medical services providers for good cause is affirmed by the social
services district, the written notice must explain the reason(s) for the determination,
state the facts upon which the determination is based, cite the relevant statutory or
regulatory authority for the determination, and advise the participant of his or her right
to appeal the determination to the commissioner.