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PARRIS N. GLENDENING, Governor
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S.B. 359
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CONTRACTED GROUP OF THE MANAGED CARE ORGANIZATION, THE MANAGED CARE
ORGANIZATION SHALL ASSIGN THE RECIPIENT TO THE PRIMARY CARE PROVIDER
(3) A PROGRAM RECIPIENT MAY REQUEST A CHANGE OF PRIMARY CARE
PROVIDERS WITHIN THE SAME MANAGED CARE ORGANIZATION AT ANY TIME AND, IF
THE PRIMARY CARE PROVIDER HAS A CONTRACT WITH THE MANAGED CARE
ORGANIZATION OR A CONTRACTED GROUP OF THE MANAGED CARE ORGANIZATION,
THE MANAGED CARE ORGANIZATION SHALL HONOR THE REQUEST.
(4) WHEN THERE IS A CHANCE OF MANAGED CARE ORGANIZATION
OWNERSHIP OR WHEN A MANAGED CARE ORGANIZATION TERMINATES ITS
CONTRACT WITH THE DEPARTMENT, A PROGRAM RECIPIENT MAY DISENROLL FROM
A MANAGED CARE ORGANIZATION IN ACCORDANCE WITH WRITTEN GUIDANCE
PROVIDED BY THE FEDERAL HEALTH CARE FINANCING ADMINISTRATION.
(4) IN ACCORDANCE WITH THE FEDERAL HEALTH CARE FINANCING
ADMINISTRATION'S GUIDELINES, A PROGRAM RECIPIENT MAY ELECT TO DISENROLL
FROM A MANAGED CARE ORGANIZATION IF THE MANAGED CARE ORGANIZATION
TERMINATES ITS CONTRACT WITH THE DEPARTMENT OR IS ACQUIRED BY ANOTHER
ENTITY.
(5) A PROGRAM RECIPIENT MAY DISENROLL FROM A MANAGED CARE
ORGANIZATION TO MAINTAIN CONTINUITY OF CARE WITH A PRIMARY CARE
PROVIDER IF:
(I) THE CONTRACT BETWEEN THE PRIMARY CARE PROVIDER AND
THE MANAGED CARE ORGANIZATION OR CONTRACTED GROUP OF THE MANAGED
CARE ORGANIZATION TERMINATES BECAUSE:
1. THE MANAGED CARE ORGANIZATION OR CONTRACTED
GROUP OF THE MANAGED CARE ORGANIZATION TERMINATES THE PROVIDER'S
CONTRACT FOR A REASON OTHER THAN QUALITY OF CARE OR THE PROVIDER'S
FAILURE TO COMPLY WITH CONTRACTUAL REQUIREMENTS RELATED TO QUALITY
ASSURANCE ACTIVITIES; OR
2. A. THE MANAGED CARE ORGANIZATION OR
CONTRACTED GROUP OF THE MANAGED CARE ORGANIZATION PROPOSES TO REDUCE
REDUCES THE PRIMARY CARE PROVIDER'S COMPENSATION RATE CAPITATED OR
APPLICABLE FEE FOR SERVICES RATES:
B. THE REDUCTION IN RATES IS GREATER THAN THE
ACTUAL CHANGE IN RATES OR CAPITATION PAID TO THE MANAGED CARE
ORGANIZATION BY THE DEPARTMENT; AND
C. THE PROVIDER AND THE MANAGED CARE ORGANIZATION
OR CONTRACTED GROUP OF THE MANAGED CARE ORGANIZATION ARE UNABLE TO
NEGOTIATE A MUTUALLY ACCEPTABLE RATE; AND OR
3. THE PROVIDER CONTRACT BETWEEN THE PROVIDER AND
THE MANAGED CARE ORGANIZATION IS TERMINATED BECAUSE THE MANAGED CARE
ORGANIZATION IS ACQUIRED BY ANOTHER ENTITY; AND
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- 3831 -
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