360-10.14 Participation in a mandatory MCP.
(a) If a social services district has received approval from the
commissioner and is authorized under section 1915 of the federal Social Security Act to
establish an MCP under which every MA recipient who resides in the district must
participate in the MCP (mandatory MCP), recipients must participate in the mandatory MCP
unless they are excluded from participating by subdivision (b) of this section or have
good cause to be exempt from participating as defined in section 360- 10.15 of this
Subpart.
(b) An MA recipient will be excluded from participating in a mandatory
MCP if the recipient:
(1) is receiving services provided by 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) has a disability, chronic infirmity or
condition, is receiving 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) is already enrolled in a health maintenance
organization (HMO) under a health insurance program other than the MA program or another
managed care program authorized by the department; or
(4) is restricted under the Recipient
Restriction Program.
(c) When an MA recipient is excluded from participating in a mandatory
MCP, the social services district must provide a written notice to the recipient which
explains the reason(s) for the exclusion, states the facts upon which the exclusion is
based, cites relevant statutory or regulatory authority for the exclusion, and advises the
recipient of his or her right to appeal the exclusion to the commissioner.
(d) A participant in a mandatory MCP must select a managed care
provider within 21 days from the date the participant is notified in writing by the social
services district of his or her enrollment in an MCP. A participant must be provided with
information to make an informed choice of a managed care provider. If a participant does
not select a managed care provider, the social services district will assign the
participant to a managed care provider selected from among all participating managed care
providers. The social services district will assign participants to managed care providers
on an equitable basis.
(e) Nothing contained in this section precludes a social services
district's managed care plan from permitting additional MA recipients to participate in
MCPs voluntarily.