Section 2B.6 – How to Change a Managed Care Plan Last Updated: August 2012 In this section you will find... Changing Managed Care Plans Transferring from Managed Care Plan to Another Changing Primary Care Providers CHANGING MANAGED CARE PLANS Q. How does a client transfer from one managed care plan to another?1 A. If the client wants to transfer to another health plan and he/she is within the 90-day grace period, he/she can call NY Medicaid CHOICE at 1-800-5055678 and request a transfer packet. This packet will include a disenrollment form and an enrollment form. Both forms must be completed in order to be transferred to the new health plan. If the client wishes to transfer after the 90 day grace period and before the 9 month lock in period expires, they must have good cause. Good cause includes2: • The Contractor has failed to furnish accessible and appropriate medical care services or supplies to which the Enrollee is entitled under the terms of the contract under which the Contractor has agreed to provide services; or • The Contractor fails to adhere to the standards prescribed by SDOH and such failure negatively and specifically impacts the Enrollee; or • The Enrollee moves his/her residence out of the Contractor’s service area or to a county where the Contractor does not offer the product the Enrollee is eligible for; or • The Enrollee meets the criteria for an Exemption or Exclusion; or • It is determined by the LDSS, the SDOH, or its agent that the Enrollment was not consensual; or • The Enrollee, the Contractor and the LDSS agree that a change of MCOs would be in the best interest; or • The Contractor is a primary care partial capitation provider that does not have a utilization review process in accordance with Title I of Article 49 of the PHL and the Enrollee requests Enrollment in an MCO that has such a utilization review process; or • The Contractor has elected not to cover the Benefit Package service that an Enrollee seeks and the service is offered by one or more other MCOs in the Enrollee’s county of fiscal responsibility; or 45 • The Enrollee’s medical condition requires related services to be performed at the same time but all such related services cannot be arranged by the Contractor because the Contractor has elected not to cover one of the services the Enrollee seeks, and the Enrollee’s Primary Care Provider or another provider determines that receiving the services separately would subject the Enrollee to unnecessary risk; or • An FHPlus Enrollee is pregnant; or • The Contractor does not contract with an FQHC and one or more other MCOs in the Enrollee’s county of fiscal responsibility provide the service; or • [Applicable to HIV SNP Program only]: The Enrollee is an SSI beneficiary with severe and persistent mental illness or an SSI child with serious emotional disturbances whose behavioral health benefits are provided through the Medicaid fee-for-service program. Q.How often can your client change to a different primary care provider (PCP)?3 A. Managed care plans must let a consumer change PCPs “without cause” at least every six months. “Without cause” means that the consumer does not have to give the plan a reason. He/she can change PCPs more often if there is a “good cause,” or a good reason, that the plan accepts as important. A Restricted Recipient may change their PCP within 30 days of their first appointment with the provider or as provided in 18 NYCRR § 360-6.4(e).4 For example, a change would be considered “with cause” (and not count toward the twice a year limit) if a consumer moves and his/her PCP is too far away as a result; or if a consumer is diagnosed with an illness that requires treatment by a specialist as his/her PCP. Some plans may allow for more frequent PCP switching. Participants should call their managed care plan to find out how often they can switch PCPs. 1 N.Y. State Dep’t of Health, Medicaid, Family Health Plus and HIV+ SNP Model Contract Section 8 (April, 2011), available at http://www.health.ny.gov/health_care/managed_care/mltc/pdf/mltc_ contract.pdf 2 Model Contract at Appendix H 3 Model Contract at Section 21, Paragraph 21.9 4 Model Contract at Appendix Q 46