Section 405 IAC 10-8-2 - Changing managed care organizationsAuthority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 2.
(a) A member shall remain enrolled with the same managed care organization during the member's benefit period. If a member leaves the program and returns during the same benefit period, the member shall remain enrolled in the same MCO. A member may change managed care organizations upon request only in the following circumstances:(1) Without cause for new conditional or fast track members, before making the member's fast track prepayment or initial POWER account contribution or within sixty (60) days of being assigned to a managed care organization, whichever comes first.(2) For cause at any time. A member under this subsection may request to change managed care organizations at any time by submitting a grievance to the managed care organization and receiving the managed care organization's or the division's approval.(b) For purposes of subsection (a)(2), "for cause" includes any of the following:(1) The causes for disenrollment set forth in 42 CFR 438.56(d)(2)(i) - (iii).(2) Receiving poor quality care.(3) Failure of the managed care organization to provide covered services.(4) Failure of the managed care organization to comply with established standards of medical care administration.(5) Lack of access to providers experienced in dealing with the member's health care needs.(6) Significant language or cultural barriers.(7) Corrective action levied against the managed care organization by the office.(8) Limited access to a primary care clinic or other health services within reasonable proximity to a member's residence.(9) A determination that another managed care organization's formulary is more consistent with a new member's existing health care needs.(10) Member was unable to select a managed care organization in the MCO selection period due to the member's eligibility status during the MCO selection period.(11) Other circumstances determined by the office to constitute poor quality of health care coverage.(c) A member who receives an unfavorable decision from the managed care organization under subsection (a)(2) may submit a request for reconsideration pursuant to the instructions in the managed care organization's notice of decision. A request for reconsideration shall be deemed approved if official action is not taken on the request by the first day of the second month following the month in which the individual submits the request. A member who files a grievance with the managed care organization and completes the reconsideration process shall be considered to have met the requirements of 405 IAC 10-5-2 for purposes of filing an appeal with the state. Filed 5/18/2015, 12:34 p.m.: 20150617-IR-405140339FRAFiled 1/19/2018, 8:42 a.m.: 20180214-IR-405170484FRAFiled 3/18/2019, 2:27 p.m.: 20190417-IR-405180371FRA