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.

Return to DSS Regs Table of Contents| Search DSS Regs