Current through Register Vol. 35, No. 18, September 24, 2024
The MCO shall ensure that each member is assigned a primary
care provider (PCP), except a member that is dually eligible for medicare and
medicaid (dual eligible). The PCP shall be a provider identified in Subsection
A below, participating in the MCO's network who will assume the responsibility
for supervising, coordinating, and providing primary health care to its member,
initiating referrals for specialist care, and maintaining the continuity of the
member's care. For a dual-eligible member, the MCO will be responsible for
coordinating the primary, acute, behavioral health and long-term care services
with the member's medicare PCP.
A.
Types of PCPs: The MCO shall designate the following types of providers as a
PCP as appropriate:
(1) medical doctors or
doctors of osteopathic medicine with the following specialties: general
practice, family practice, internal medicine, gerontology, gynecology and
pediatrics;
(2) certified nurse
practitioners, certified nurse midwives and physician assistants;
(3) specialists, on an individual basis, for
members whose care is more appropriately managed by a specialist, such as
members with infectious diseases, chronic illness, complex behavioral health
conditions, or disabilities;
(4) a
primary care team consisting of residents and a supervising faculty physician
for contracts with teaching facilities or teams that include mid-level
practitioners who, at the member's request, may serve as the point of first
contact; in both instances the MCO shall organize its team to ensure continuity
of care to the member and shall identify a "lead physician" within the team for
each member; the "lead physician" shall be an attending physician; medical
students, interns and residents may not serve as "lead physicians";
(5) federally qualified health centers
(FQHC), rural health clinics (RHC), or Indian health service (IHS), tribal
health providers, and urban Indian providers (I/T/U); or
(6) other providers that meet the
credentialing requirements for PCPs.
B. Selection of or assignment to a PCP: The
MCO shall maintain and implement written policies and procedures governing the
process of member selection of a PCP and requests for change.
(1) Initial enrollment: At the time of
enrollment, the MCO shall ensure that each member has the freedom to choose a
PCP within a reasonable distance from his or her place of residence.
(2) Subsequent change in PCP initiated by a
member: the MCO shall allow its member to change his or her PCP at any time for
any reason. The request can be made in writing or verbally via telephone:
(a) if a request is made on or before the
20th calendar day of the month, the change shall be effective as the first of
the following month;
(b) if a
request is made after the 20th calendar day of the month, the change shall be
effective the first calendar day of the second month following the
request.
(3) A
subsequent change in PCP initiated by the MCO: The MCO may initiate a PCP
change for its member under the following circumstances:
(a) the member and the MCO agree that
assignment to a difference PCP in the MCO's provider network is in the member's
best interest, based on the member's medical condition;
(b) a member's PCP ceases to be a contracted
provider;
(c) a member's behavior
toward his or her PCP is such that it is not feasible to safely or prudently
provide medical care and the PCP has made reasonable efforts to accommodate the
member;
(d) a member has initiated
legal actions against the PCP; or
(e) the PCP is suspended for any
reason.
(4) The MCO
shall make a good faith effort to give written notice of termination of a
contracted provider, within 15 calendar days after receipt or issuance of the
termination notice, to each member who received his or her primary care from or
was seen on a regular basis by the terminated provider. In such instances, the
MCO shall allow affected members to select a PCP or the MCO shall make an
assignment within 15 calendar days of the termination effective date.