Involuntary Changes in PCPs Clause Samples

Involuntary Changes in PCPs a. The Contractor shall not request EOHHS to involuntarily, or without the Enrollee’s request, transfer an Enrollee from their current PCP to a new PCP because of: 1) an adverse change in the Enrollee’s health status; 2) the Enrollee’s utilization of medical services, including but not limited to the Enrollee making treatment decisions with which a provider, including the PCP, or the Contractor disagrees (such as declining treatment or diagnostic testing); 3) missed appointments by the Enrollee; 4) the Enrollee’s diminished mental capacity, or 5) the Enrollee’s uncooperative or disruptive behavior resulting from their special needs (except when the Enrollee’s continued enrollment with the PCP seriously impairs the PCP’s ability to furnish services to either the particular Enrollee or other Enrollees). b. The Contractor may request EOHHS to involuntarily transfer an Enrollee from their current PCP to a new PCP if the Contractor follows all policies and procedures specified by EOHHS relating to such transfer, including but not limited to the following: 1) The Contractor shall, and shall require the PCPs to, take all serious and reasonable efforts specified by EOHHS prior to such a transfer; 2) The Contractor shall provide EOHHS and require the PCP to include with any request the PCP makes to the Contractor to transfer an Enrollee, the information and supporting documentation specified by EOHHS, including demonstrating that the PCP took the serious and reasonable efforts specified by EOHHS and, despite such efforts, the Enrollee’s continued enrollment with the PCP seriously impairs the PCP’s ability to furnish services to either the particular Enrollee or other Enrollees; 3) The Contractor and PCP shall provide any EOHHS-specified notices to the Enrollee relating to the request; and 4) The Enrollee’s new PCP to which EOHHS transfers the Enrollee shall be determined by EOHHS and may, but is not required to be, be the PCP suggested by the Contractor.