Medical Services

Managed Care

State Plan Amendment - Title XIX of the Social Security Act

Supplement 3 - Enrollment Proces

Enrollment Packages

  • Beneficiary Handbook
  • A list of PCPs serving the enrollee's geographical area including the identity, locations and availability of participating health care providers
  • Enrollment form
  • Self addressed stamped envelope

Enrollment Notifications

OMS accepts beneficiary PCP selections by:

  • Mail
  • Telephone
  • In person
  • Electronically (when available)

Assignment Process

Recipients who fail to select a PCP within the required notice period (at least 10 days) are assigned a PCP by OMS. Assigned PCPs usually practice in the same county as the recipient and usually do not have a closed caseload. OMS utilizes two mechanisms when assigning recipients to PCPs, system assignment and manual assignment.

System Assignments: A computer program queries information on PCCM recipients not enrolled with a PCP searching for specific criteria. If the search is successful the system will automatically assign the PCP who satisfies the search criteria. The search criteria consists of:

  • Previous PCP enrollment: Recipients who have previous MC (managed care) history with a currently active PCP.
  • PCP participation by a family member: Recipients who have a family member enrolled with a currently available PCP.
  • IHS accessibility: American Indian recipients who reside in a community where IHS PCP services are available.

System assignments may also be considered “convenience” assignments. Recipients may elect to forgo selecting a provider when they have prior participation with a PCP, or would like the same PCP as other family members.

Manual Assignments: Program staff manually assigns providers to recipients who are not system assigned. The search criteria for manual assignments consists of:

  • Locality: Assignments (in most circumstances) to PCPs whose resident county matches that of the recipient.
  • Provider type: Assignment to PCPs who generally provide services to that patient type (i.e. pediatricians for children, internists for adults, OB/GYNs for pregnant women only and family practice providers for households with children and adults).
  • Available Provider: Assignments to PCPs who are available and do not indicate full caseloads.
  • Claims history: Claims history is often checked in order to determine if recipients have recent non-managed care medical history with a PCP.

Changing Providers

Recipients are allowed to request to change PCPs at anytime in accordance to 42CFR §438.56(c). New PCPs are effective the first of the following month after receiving the request. If the State fails to process the disenrollment request within the specified timeframes, the disenrollment is considered automatically approved. All changes are approved by OMS unless circumstances exist such as unavailable or unacceptable PCP or the requested PCPs location does not meet distance standards. Change requests initiated from a beneficiary’s change in residence counties will result in the removal from program requirements for at least one month to allow the beneficiary time to select a new PCP in the new location.

Automatic Re-enrollment

Beneficiaries who are dis-enrolled solely because of the loss of medical assistance eligibility for a period of two months or less will be re-enrolled with the previous PCP.

Choice of Providers

Recipients have a choice of at least two providers with-in maximum geographical travel areas (75 miles or 90 minutes). Recipients who do not meet this criterion may be removed from the PCCM at their request. The State will restrict enrollment to who reside sufficiently near a PCP provider’s location to reach that location within a reasonable time (75 miles or 90 minutes) using available and affordable modes of transportation. OMS will allow enrollees to exceed these limits if a “good cause” reason is provided and accepted. An example of “good cause” reasons would be that the patient/provider relationship is currently established, on-going treatment regiment with PCP in progress, or other reasons where severing the relationship could harm that patients health.

Notifications

The State notifies beneficiaries

  • When a PCP selection is required – a minimum of ten days is required.
  • When a PCP is selected or assigned. An enrollment notice will be issued with a detachable enrollment card.
  • When a PCP is terminated. The State must notify beneficiaries of their PCP termination within 15 days of receiving notice of the termination.