360-10.15 Good cause to be exempt from participating in a mandatory MCP.

    (a) An MA recipient has good cause to be exempt from participation in a mandatory MCP if:

        (1) a managed care provider is not geographically located so as to afford the recipient reasonable access to services;

        (2) the recipient has received medical care and services from a non- participating primary care practitioner for at least a one year period (except that the period may be less than one year for a pregnant woman who has been receiving on-going pre-natal care and services from the provider) before the social services district determines that the recipient must participate in the MCP. In order to qualify for this exemption, the primary care practitioner must have hospital admitting privileges and/or be able to manage the recipient's care in a hospital;

        (3) the recipient cannot be served by a physician who participates in an MCP due to a language barrier and the recipient has a relationship with a physician who speaks the recipient's language;

    (4) the recipient has an established treatment relationship with a provider of special care as secified in subdivision (b) of section 360-11.4 of this Title.

    (b) Procedure for MA recipients to obtain an exemption from participating in a mandatory MCP.

        (1) If an MA recipient requests an exemption from participation in an MCP for good cause, the recipient or the recipient's representative must file a written request with the appropriate social services district. The social services district may require the recipient to provide documentation to support the request for an exemption.

        (2) The social services district must make a determination within 30 days after receipt of the request and notify the recipient in writing whether the request for an exemption is granted or denied.

        (3) When a request for an exemption is denied, the social services district must explain in writing the reason(s) for the denial, state the facts upon which the denial is based, cite the relevant statutory or regulatory authority for the denial, and advise the MA recipient of his or her right to appeal the denial to the commissioner.

        (4) An MA recipient will not be required to enroll in an MCP while awaiting a final determination of a request for an exemption. If the final determination is a denial of the request, the MA recipient must enroll in an MCP.

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