PENNSYLVANIA, June 5 - information or a general allegation regarding the managed care

plan.

(e) For purposes of subsection (c)(5), a request based on

poor quality of care shall be supported by objective information

substantiating a circumstance affecting the eligible person's

health, safety, access to covered services, continuity of care

or ability to receive medically necessary services. The

department shall consider substantiated complaints, grievance or

appeal determinations, critical incident reports, missed service

records, service plan or authorization records, provider

documentation, care management records, external quality review

findings, corrective action plans, sanctions, quality measure

performance, Consumer Assessment of Healthcare Providers and

Systems results, Healthcare Effectiveness Data and Information

Set measures, National Committee for Quality Assurance

accreditation or ratings, Medicaid and CHIP Quality Rating

System measures or other reliable information identified by the

department. A request based on poor quality of care may not be

approved solely on the basis of an unsupported assertion,

general dissatisfaction or preference for another managed care

plan.

(f) Nothing in this section shall be construed to permit a

general or categorical waiver of subsection (a) permitting

eligible persons to change managed care plans at any time

without cause unless required by Federal law or approved by

statute.

(g) The department shall establish procedures for notice,

review and appeal of a denial of a plan-change request under

this section.

(h) The secretary shall seek any amendment, modification,

20260SB1371PN1776 - 3 -

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30