Section 360-11.5 Requirements for a managed care plan in an MCP that excludes special
care furnished on more than an incidental basis.
(a) In an MCP that excludes the provision of special care to
participants who require special care furnished on more than an incidental basis, the
managed care plan must meet the following requirements:
(1) exclude from enrollment in managed care
persons receiving SSI, except that:
(i) persons receiving
SSI who are enrolled in managed care on the effective date of this Subpart may continue
their managed care enrollment;
(ii) persons who begin
receiving SSI while enrolled in managed care may continue their managed care enrollment
with the agreement of the managed care provider; and
(iii) persons receiving
SSI may be enrolled with a health services only managed care provider.
(2) exclude from the managed care benefit
package the long term special care services for persons with chronic illness defined in
subdivision (c) of section 360-11.3 of this Subpart;
(3) require all managed care providers to sign
and adhere to a statement of principles that sets forth the basis for linkages between
managed care providers and special care providers that furnish services defined in
subdivision (c) of section 360- 11.3 of this Subpart, including provisions for timely
communication, use of managed care provider networks and timely authorization and payment
for services covered by the managed care provider and appropriately requested by the
special care provider;
(4) include provision for informing current and
prospective managed care enrollees of the managed care plan provisions and limitations
relating to special care services and managed care enrollment; and
(5) if approved prior to the effective date of
this Subpart, be amended before commencement of the third year of operation to conform to
the requirements of this section.
(b) An MCP that excludes the provision of special care to participants
who require special care furnished on more than an incidental basis may include health
services only managed care providers.