Consumer Rights: A Doctor or Health Care Provider Who Will Meet Your Needs

Applies to Managed Care Organizations only.

Your Right to an MCO With Enough Health Care Providers:

MCOs must have enough HCPs within a reasonable distance from where its members live to meet the members’ needs.

Every member must have a choice of at least three (3) PCPs, primary care providers.

The Health Commissioner must look at the following to decide if the MCO can meet the needs of the people it says it wants to serve:

The requirements in the Americans with Disability Act,

Whether an MCO is able to meet the needs of people who have trouble communicating in English or are from different cultures, and

Complaints about waiting times to get appointments or referrals to HCPs.

Your right to specialty care:

Out-of-network referrals:
If your MCO, consulting with your primary care provider, decides that the MCO doesn’t have a provider in their network with the training and experience you need, the MCO must refer you out of their network at no extra charge to you. This decision must be part of a treatment plan
approved by the MCO.

Standing Referrals to Specialists:
If the MCO, consulting with your PCP and your specialist, decides that you need ongoing care from that specialist, you can get a series of referrals at one time so you don’t have to go back and get a new referral from your PCP each time you need to see the specialist. This is called a
standing referral.

For people with life-threatening or disabling & degenerative diseases or conditions:

If you need specialized medical care over a long period of time, you can, at no extra cost to you:

Get a referral to a specialist who will then act as your PCP and coordinate your care.

Get a referral to a specialty care center (such as a cancer institute).

Either of these must be part of a treatment plan that your MCO has approved after consulting with you, your specialist, your PCP, and the MCO’s medical director.

Your right to continue to see your current health care provider:

When you join an MCO, if you are getting ongoing treatment from a provider who is not in that MCO’s network, the MCO must pay for you to continue seeing your provider, as long as your provider meets the MCO’s requirements and agrees to their payment rates, in the following 2 cases only:

If you have a life threatening or disabling & degenerative disease AND you are undergoing a course of treatment for it, you can continue to see your current provider for up to 60 days.

If you are in the second or third trimester of pregnancy, you can continue seeing your current HCP through your delivery and for a period of time after your delivery, usually 60 days.

When your HCP leaves the plan if you are getting ongoing treatment from that provider, the MCO must pay for you to continue seeing that provider, (except if the HCP has left or been dismissed for fraud, imminent harm to patient care or State sanctions), as long as your provider meets the MCO’s requirements and agrees to their payment rates, for:

Up to 90 days after you’ve been notified that your provider is no longer in the plan

If you are in the second or third trimester of pregnancy, through your delivery and for a period of time after your delivery, usually 60 days.

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