360-10.16 Withdrawal from an MCP.
(a) A participant will be required to withdraw from an MCP if the
participant:
(1) begins receiving services from a
residential health care facility, a residential treatment facility for children and youth,
the Long Term Home Health Care Program, a hospice, an institution operated by the
Veteran's Administration, a State hospital for the mentally-ill, the Physically
Handicapped Children's Program, a therapeutic community (drug-free residential program),
or an alcoholism community residence;
(2) develops a disability, chronic infirmity or
condition, receives certified home health agency services, and has medical needs which are
more appropriately met outside a managed care plan, as determined by the social services
district, in consultation with the recipient's certified home health services provider;
(3) becomes enrolled in an HMO under a health
insurance program other than the MA program; or
(4) is restricted under the Recipient
Restriction Program.
(b) When a participant is required to withdraw from an MCP, the social
services district must provide a written notice to the participant that states the date
the withdrawal from participation is effective, explains the reason(s) for the required
withdrawal, states the facts upon which the required withdrawal is based, cites the
relevant statutory or regulatory authority for the required withdrawal, and advises the
participant of his or her right to appeal the required withdrawal to the commissioner.
(c) A participant may withdraw from an MCP, in which participation is
voluntary, for any reason at any time unless the participant is enrolled with a managed
care provider, such as a federally qualified HMO, which is otherwise authorized under law
to restrict disenrollment. When disenrollment is restricted, the participant may withdraw
from the MCP by disenrolling from the provider for any reason during the initial 30 days
of a six month enrollment period, but thereafter may disenroll only for good cause as
provided in section 360-6.7 of this Part.
(d) A participant may withdraw from an MCP, in which participation is
mandatory, only for good cause as provided for in subdivision (e) of this section.
Withdrawal for good cause from an MCP may occur at any time.
(e) A participant has good cause to withdraw from a mandatory MCP if
the participant:
(1) has already changed from one managed care
provider to another managed care provider within the MCP for good cause, and the
participant and the social services district agree that withdrawal would be in the
participant's best interest; or
(2) moves to a geographic area not served by
the MCP.
(f) Request for withdrawal from participation in an MCP.
(1) If a participant wishes to withdraw from an
MCP for good cause, the participant or the participant's representative must file a
written request in accordance with the MCP withdrawal process, as set forth in the social
services district's managed care plan approved by the commissioner.
(2) The social services district must make a
determination within 10 days after receipt of the request and notify the participant in
writing of whether the request for withdrawal from participation is granted or denied.
(3) When a participant's request to withdraw
from participation is denied, the notice must state the facts upon which the denial is
based, cite the relevant statutory or regulatory authority for the determination and
advise the participant of his or her right to appeal the denial to the commissioner of the
department.
(4) When a participant's request to withdraw
from participation is approved, the notice must state the date the withdrawal from
participation is effective.