42 CFR § 438.52 - Choice of MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities.
(3) Enroll in a PCCM entity, may limit a beneficiary to a single PCCM entity. Beneficiaries must be permitted to choose from at least two primary care case managers employed by or contracted with the PCCM entity.
(b) Exception for rural area residents.
(1) Under any managed care program authorized by any of the following, and subject to the requirements of paragraph (b)(2) of this section, a State may limit a rural area resident to a single MCO, PIHP, or PAHP:
(ii) A waiver under section 1115(a) of the Act.
(iii) A waiver under section 1915(b) of the Act.
(2) To comply with this paragraph (b), a State, must permit the beneficiary—
(i) To choose from at least two primary care providers; and
(2) If the provider chooses not to join the network, or does not meet the necessary qualification requirements to join, the enrollee will be transitioned to a participating provider within 60 calendar days (after being given an opportunity to select a provider who participates).
(D) The beneficiary's primary care provider or other provider determines that the beneficiary needs related services that would subject the beneficiary to unnecessary risk if received separately (for example, a cesarean section and a tubal ligation) and not all of the related services are available within the network.
(E) The State determines that other circumstances warrant out-of-network treatment.
(3) As used in this paragraph (b), “rural area” is any county designated as “micro,” “rural,” or “County with Extreme Access Considerations (CEAC)” in the Medicare Advantage Health Services Delivery (HSD) Reference file for the applicable calendar year.
(d) Limitations on changes between primary care providers. For an enrollee of a single MCO, PIHP, PAHP, or HIO under paragraph (b) or (c) of this section, any limitation the State imposes on his or her freedom to change between primary care providers may be no more restrictive than the limitations on disenrollment under § 438.56(c).
The following state regulations pages link to this page.
- OR Admin. Rule 410-141-3875 - 410-141-3875 - MCE Grievances & Appeals: Definitions and General Requirements
- OR Admin. Rule 410-141-5265 - 410-141-5265 - CCO ACQUISITIONS AND MERGERS: Procedure For Acquiring Controlling Interest
- 12 Va. Admin. Code § 30-50-600 - 12VAC30-50-600 - Section 1932 Medicare-Medicaid eligible individuals.