OMS accepts beneficiary PCP selections by:
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:
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:
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.
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.
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.
The State notifies beneficiaries