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.
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