"22.
PRIMARY CARE PROVIDER STANDARDS...
The
Contractor shall include with the enrollment notification a list of all
the Contractor's available PCPs and the process for changing the PCP assignment,
should the member desire to do so. The Contractor shall confirm any
PCP change in writing to the member. Members may make both their
initial PCP selection and any subsequent PCP changes either verbally or
in writing…" Arizona Contract, page 32.
CA
"6.9.9
Primary Care Physician Selection...
Contractor
shall ensure that Members are allowed to change a Primary Care Physician,
nurse practitioner or certified nurse midwife, upon request, by selecting
a different Primary Care Provider from Contractor's network of providers."
California Contract, page 138.
DE
"5.4
Changing PCPs
The
MCO must have written policies and procedures for allowing members to select
or be assigned to a new primary care provider when such a change is mutually
agreed to by the MCO and member, when a primary care provider is terminated
from the MCO, or when a primary care provider change is ordered as part
of the resolution to a formal grievance proceeding. In cases where a primary
care provider has been terminated, the MCO must allow members to select
another primary care provider or make a reassignment within fifteen (15)
business days of the termination effective date. If the MCO fails to do
this, the MCO then agrees the member will be allowed to see this provider
until the requirement is fulfilled.
The
MCO may initiate a PCP change for a member under the following circumstances
(a)
The member requires specialized care for an acute or chronic condition,
and the member and MCO agree that reassignment to a different PCP is in
the member's interest
(b)
The member's PCP ceases to participate in the MCO's network
(c)
The member's behavior toward the PCP is disruptive, and the PCP has made
all reasonable efforts (three attempts within ninety (90) calendar days)
to accommodate the member
(d)
The member has taken legal actions against the PCP
Members shall have the right to change primary care providers three (3) times a year for any reason. Their right to request a change of a primary care provider through the grievance procedure shall not be restricted…" Delaware RFP, pages II.15-II.17.
DC
"5.
Selection of Primary Care Provider
a. Provider shall allow each enrollee the freedom to choose from
among its participating PCPs and change PCPs as requested. Where
an enrollee has a preexisting relationship with a member of Provider's
primary care network, Provider shall allow the that enrollee to remain
with his or her existing PCP." District of Columbia Contract, page
18.
FL
"B.
Manner of Service Provision...
7.
Physician Choice...
b.
For Title XXI MediKids…the plan shall assign primary care physicians taking
into consideration last primary care provider for services (if the provider
is known and available in the plan's network), closet location within the
services area, zip code location, keeping children within the same family
together, age (adults versus children), and sex (OB/GYN).
The
plan shall inform members of the following:
(1)
their primary care physician assignment,
(2)
their ability to choose a different primary care provider,
(3)
list of providers from which to make a choice; and
(4)
the procedures for making a change. The plan shall provide this written
notice to assigned members by the first day of enrollment…" Florida
Contract, pages 10, 18.
"18.
Member Notification...
d.
After the agency's choice counseling contractor's implementation of face-to-face
choice counseling and enrollment activities, the plan shall provide the
following additional items to voluntary recipients:
(1) A notice advising the member on how to change primary care providers..."
Florida Contract, pages 36-38.
HI
"30.420
Primary Care Provider (PCP)...
The
plan shall establish policies and procedures, subject to DHS approval,
for selecting a new PCP, including establishing reasonable limits on the
frequency that a recipient may choose a new PCP, and the criteria for changing
to a new PCP…" Hawaii RFP, pages 9-10.
IL
"(i)
Change of Site and Primary Care Provider or Women's Health Care Provider
The
Contractor shall permit a Beneficiary to change site, Primary Care Provider
and Women's Health Care Provider upon request. The Contractor shall
process such changes within thirty (30) days of receipt of a Beneficiary's
request." Illinois HMO Contract, page 18.
IN
"4.5.2
Recipient Enrollment in Hoosier Healthwise RBMC
Initial
applicants and re-applicants for Medical Assistance will receive a presentation
by the Enrollment Broker on Medicaid managed care and assistance in selecting
a Primary Medical Provider (PMP)...
Each recipient is given the opportunity at any time during the 90 day period beginning on the date the recipient receives notice of enrollment with the MCO, and every twelve months thereafter to change his/her PMP without a documented cause. The recipient will be allowed at any time to change PMPs for a documented cause approved by OMPP. Requests for a PMP change are made through the Hoosier Healthwise Helpline department and are documented, tracked, and monitored. For more information regarding acceptable reasons for a recipient requesting a PMP change, refer to Chapter 6 of the MCO Procedure Manual located in the Procurement Library." Indiana RFP, pages 4-11 - 4-12.
"Section 3. General Contents of State Child Health Plan (Section 2102)(a)(4)) Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan, and continue on to Section 4.
3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children: (Section 2102)(a)(4)...
Families of children enrolled in Hoosier HealthWise have 30 days to select a PMP from a list provided to them... With certain restrictions, opportunities are available for changing PMPs. A family may change their child's PMP at any time with cause (including auto-assignment), and every six months without cause." Indiana SCHIP Amendment, Attachment C-3, page 12.
IA
"4.11.2
Choice of Health Professional
If
applicable, the HMO shall allow each new Enrollee the opportunity to choose
a PCP… The Enrollee may change PCPs, pursuant to 441 Iowa Administrative
Code 88.7(1).
The Enrollee shall have the opportunity to refuse care from a Provider and select a different Provider unless the HMO has a single Provider for a service that does not involve a personal encounter with a practitioner (e.g., clinical laboratory service). If the HMO has only one Provider to provide a service (e.g., single highly specialized service Provider within the service area) the Enrollee must demonstrate "good cause" for refusing care from such Provider…" Iowa Contract, page 29.
IABH
"38.2
DISENROLLMENT OF DPH PARTICIPANTS
The
Contractor may not disenroll DPH participants. Contractor shall have
the right, however, to change the substance abuse care provider."
Iowa Behavioral Health Contract, page 26.
KS
"I.
CULTURAL COMPETENCY...
The
HMO shall permit members to choose providers from among the HMO's network
based on cultural preference. The HMO shall submit members to change
primary providers based on cultural preference…" Kansas Contract, page 12.
"A.
ENROLLMENT PROCESS
Enrollment
of Medicaid beneficiaries in managed care will include the following components:
…
o
The HMO may choose to assign new members to a PCP immediately, notify the
member of that assignment in writing and allow the member not less than
10 days to change this assignment if it is not acceptable." Kansas Contract, pages 44-45.
"B.
ENROLLMENT RESPONSIBILITIES
HMO
Responsibilities…
The
HMO may choose to assign new members to a PCP immediately, notify the member
of that assignment in writing and allow the member not less than 10 days
to change this assignment if it is not acceptable…
The
HMO must have written policies and procedures for assigning each of its
members to a primary care provider to the extent that the option exists.
The process must include at least the following features:
•
If a member requests a change to his or her primary care provider following
the initial visit, the HMO must agree to grant the request to the extent
possible and practical and in accordance with its policies for other enrolled
groups or product lines…
The HMO must have written policies and procedures for allowing members to select or be assigned to a new primary care provider when such a change is mutually agreed to by the HMO and member, when a primary care provider is terminated from the managed care plan, or when a primary care provider change is ordered as part of the resolution to a formal grievance proceeding. In cases where a primary care provider has been terminated, the managed care plan must allow members to select another primary care provider or make a re-assignment within twenty (20) days of the termination effective date." Kansas Contract, pages 47-50.
KY
"7.8.7
Choice of health Professional...
Upon enrollment in a Partnership, a Member shall have the right to change
the PCP after the initial visit and once a year regardless of reason, and
at any time for any reason as approved by the Member's Partnership...
PCPs have the right to request a Member's transfer to another PCP. Transfer requests shall not be based on the grounds of race, color, national origin, handicap, age or gender. All transfers shall be approved by The Partnership. The initial provider must serve until the new provider begins serving the member, barring ethical or legal issues. The member has the right to appeal such a transfer in the formal appeals process." Kentucky RFA page 59.
ME
"F.
CHANGING PCPs WITHIN THE HMO
1.
By Enrollees. The Contractor shall accord Enrollees the right to change
PCPs at any time.
2.
By Contractor. The Contractor may not initiate a PCP change because of
the Enrollee's utilization of medically necessary services. The Contractor
may, however, initiate a PCP change for an Enrollee for, among other reasons,
the following:
a.
the Enrollee needs specialized care for an acute or chronic condition,
and the Enrollee and the Contractor agree that reassignment to a different
PCP is in the Enrollee's best interest;
b.
the Enrollee's PCP ceases to participate in the Contractor's network;
c.
the Enrollee's behavior toward the PCP is disruptive, and the PCP has made
two (2) reasonable attempts within sixty (60) calendar days to accommodate
the Enrollee; or
d.
the Enrollee has taken legal action against the PCP.
3. Protocol. The Contractor shall follow its existing protocol for changing an Enrollee's PCP. The Contractor shall make PCP changes effective the first day of the month following the request for a change. The Contractor shall document the change of PCP and shall submit the documentation along with the reasons for the change to the Department on a quarterly basis." Maine Contract, page 12.
MA
"2.3
Enrollment Activities…
F.
PCP Selection, Assignment and Transfers...
3.
PCP Transfers
The
Contractor shall: a. At the Enrollee's request, allow the Enrollee
to change his or her PCP with or without cause…" Massachusetts Contract,
pages 25-35.
MABH
"4.0
ACCESS AND AVAILABILITY
The
Contractor shall: ...
4.01.07
Develop and submit to the Division for prior review and approval, a plan
to be implemented within the first four months of the first Contract Year
that ensures that Enrollees have the option of changing Providers within
the Provider Network." Massachusetts MH/SAP Contract, Appendix B,
pages 27-28.
MN
"Section
3.1.2. Enrollment...
G.
Notice to Student Enrollees. HEALTH PLANS meeting the definition of a closed
panel health plan, as defined in Minnesota Statutes, Section 62Q.43, Subdivision
1, shall at least annually notify full-time student Enrollees under the
age of 25 of their right to change their designated clinic or physician
at least once per month, providing that the HEALTH PLAN may require from
the student at least 15 days notice of intent to change their designated
clinic or physician, and as long as the clinic or physician is part of
the HEALTH PLAN'S statewide clinic or physician network." Minnesota
Contract, page 20.
MO
"k.
Assignment of Primary Care Providers: ...
1)...The
health plan shall provide information that the member has fifteen (15)
calendar days to choose another primary care provider if they do not approve
of the primary care provider assigned to them, and if they have not notified
the health plan of their preferred primary care provider within that time
frame, the member will remain with the primary care provider previously
assigned to the member…" Missouri RFP, page 41.
"l. Changing Primary Care Providers: The health plan must have written policies and procedures for allowing members to select or be assigned to a new primary care provider when such a change is mutually agreed to by health plan and member, when a primary care provider no longer participates with the health plan, or when a primary care provider change is ordered as part of the resolution to a formal grievance proceeding. In cases where the primary care provider no longer participates, the health plan must allow members to select another primary care provider or make a re-assignment within fifteen (15) calendar days to the termination effective date. Members shall have the right to change primary care providers at least twice a year for any reason. Children in State Custody may change primary care providers (PCP's) at will..." Missouri RFP, page 42.
"Transfers and Disenrollment: Members, as part of the complaint and grievance system, may request transfers among providers within a health plan…" Missouri RFP, page 74.
"Children in state custody or foster care placement will be allowed automatic and unlimited… provider choice as often as circumstances necessitate…" Missouri RFP, page 75.
MT
"2.4.1
Choice of Primary Care Provider (PCP)...
The
CONTRACTOR may limit an ENROLLEE'S ability to change PRIMARY CARE PROVIDERS
without cause…" Montana Contract, page 35.
NE
"9.4
Reenrollment for the Basic Benefits Package
9.4.1
Reenrollment Rules Within Two Months of Disenrollment: ...
The
client is free to choose a different PCP/plan; however, the reenrollment
process shall be 'automatic' and shall be activated prospectively unless
the client contacts the EBS. The client’s choice shall take precedence
over the systematic process, if the choice is made prior to system cutoff."
Nebraska Contract, page 34.
"9.15
Client Requested Transfers
9.15.1
Definition of a Transfer: A transfer is a change in a client’s enrollment
from one PCP to another PCP or from one plan to another. A transfer may
be made at the client’s request pursuant to Section 9.15 of this contract
or at the PCP/plan’s request pursuant to 9.16 of this contract.
9.15.2
Client Transfer Requests: The client shall contact the EBS to request a
transfer. A client may request a transfer at any time. The transfer shall
be effective the month following the request but no later than the second
month following the request. The EBS shall assist the client in selecting
a new PCP or plan by:
(a)
Discussing the reasons for transfer with the client and attempting to resolve
any conflicts, when in the client’s best interest; and
(b)
Reviewing the client’s needs to facilitate the client’s choice of PCP or
plan...
9.15.5
Exception to the Transfer Rules: The following rules apply for a mother
and her unborn/newborn:
(a)
When requested by the client, the mother and unborn/newborn may be enrolled
in separate plans based on good cause. Good cause includes, but is not
limited to, situations in which one plan is unable to meet the needs of
both clients despite reasonable efforts to accommodate their needs; and
(b)
The request for enrollment in separate plans must be submitted to the EBS,
who shall gather any additional information needed. The request shall be
submitted to the Department within two (2) working days. The Department
shall approve or deny the request within five (5) working days. The Department
shall notify the client and PCP/plans of the approval or denial of the
request" Nebraska Contract, pages 40-41.
NV
"V.
Medical Provider Requirements...
C.
Changing PCP At Participant's Initiative...
'Participants may change PCPs or PCSs for any reason.'" Nevada Amendment
#1, page 6.
Section
V. Medical Provider Requirements, Paragraph E. Changing PCP
At Contractor's Initiative, 2. on page 34 of the Contract as follows:
'Residence has changed such that distance to the PCP is no longer reasonable.'"
Nevada Amendment #1, page 6.
NH
"Article
II
Functions
and Duties of Contractor
In
consideration of the Agreement of the State contained in Article III, Contractor
agrees: ...
2.12 CHOICE OF HEALTH PROFESSIONAL.... In the event an Enrollee becomes dissatisfied with his Primary Care Physician, Contractor shall allow the Enrollee to choose another Contractor primary care professional." New Hampshire General Service Agreement, page 9.
NJ
"ARTICLE
7
ENROLLMENT…
7.3…The
enrollee or where applicable an authorized person has the freedom to request
a change of PCPs or CNPs/CNSs which must become effective no later than
the beginning of the first of the month following a full month after the
request to the change the enrollee's PCP…" New Jersey Contract, page
40.
NM
"2.A.4.b.ii
Subsequent change in PCP initiated by Member. Members may initiate
a PCP change at any time, for any reason. The request can be made
in writing or by telephone.
2.A.5.b.iii
Subsequent Change in PCP Initiated by the CONTRACTOR. The CONTRACTOR
may initiate a PCP change in for a member under the following circumstances:
(A)
The member and CONTRACTOR agree that assignment to a different PCP in the
MCO is in the member's best interest, based on the member's medical condition:
(B)
A member's PCP ceases to participate in the MCO's network;
(C)
A member's behavior toward the PCP is such that is not feasible to safely
or prudently provide medical care and the PCP has made all reasonable efforts
to accommodate the member; or
(D)
A member has initiated legal actions against the PCP
In instances where a PCP has been terminated, the CONTRACTOR shall allow affected members to select another PCP or make an assignment within fifteen (15) days of the termination effective date." New Mexico Contract, pages 18-19.
NY
"21.7
PCP Changes
a)
The Contractor must allow Enrollees the freedom to change PCPs, without
cause, within thirty (30) days of the Enrollee’s first appointment with
the PCP. After the first thirty (30) days PCP may be changed once
every six (6) months without cause.
b) The Contractor must process a request to change PCPs and advise the Enrollee of the effective date of the change within forty-five (45) days of receipt of the request...
c) The Contractor will provide Enrollees with an opportunity to select a new PCP in the event that the Enrollee's current PCP leaves the network or otherwise becomes unavailable. Such changes shall not be considered in the calculation of changes for cause allowed within a six (6) month period….
e)
In addition to those conditions and circumstances under which the Contractor
may assign an Enrollee a PCP when the Enrollee fails to make an affirmative
choice of a PCP, the Contractor may initiate a PCP change for an Enrollee
under the following circumstances:
i) The Enrollee requires specialized care for an acute or chronic condition
and the Enrollee and Contractor agree that reassignment to a different
PCP is in the Enrollee’s interest.
ii) The Enrollee's place of residence has changed such that he/she has
moved beyond the PCP travel time/distance standard.
iii) The Enrollee's PCP ceases to participate in the Contractor's network.
iv) The Enrollee's behavior toward the PCP is disruptive and the PCP has
made all reasonable efforts to accommodate the Enrollee.
v) The Enrollee has taken legal action against the PCP.
f) Whenever initiating a change, the Contractor must offer affected Enrollees the opportunity to select a new PCP in the manner described in this Section…" New York Contract, pages 21-1-21-5.
ND
"2.17
Choice of Health Professional...
To
the extent possible and appropriate, the Contractor must offer each enrollee
covered under this contract the opportunity to choose a primary care provider
at the time of enrollment... The Contractor may limit an enrollee's
ability to change a primary care provider without cause." North Dakota
Contract, Attachment C, page 19.
OK
"2.4.10.2
PCP Changes
2.4.10.2.1
At Member's Initiative
Health
Plan agrees to permit members the freedom to change PCPs, without cause,
at least once in the first thirty days of enrollment, and at least once
more in the following eleven-month period. Such changes must be approved
within thirty (30) days of the member's initial request and must be executed
within forty-five (45) days of the member's initial request. Health Plan
must permit members to change PCPs any time good cause is shown or as ordered
through the Authority appeal process.
Health Plan also must allow any member who is a Native American the freedom to change PCPs at any time, if the member wishes to receive services from an IHS or Tribal provider serving as a PCP in the Health Plan's network.
2.4.10.2.2
Health Plan's Initiative
Health
Plan shall initiate a PCP change only under the following circumstances:
•
The member cannot be contacted within 90 days of enrollment. The Health
Plan shall reassign the member from the assigned PCP to the nearest network
FQHC with available capacity;
•
The member requires specialized care for an acute or chronic condition
and the member and Health Plan agree that reassignment to a different PCP
is in the member's interest;
•
The member's place of residence has changed such that he or she has moved
beyond the PCP travel time distance standard;
•
The member's PCP ceases to participate in Health Plan's network;
•
The member's behavior toward the PCP is disruptive and the PCP has made
all reasonable efforts to accommodate the member and
•
The member has taken legal action against the PCP.
Whenever initiating a change, Health Plan must offer affected members the opportunity to select a new PCP in the manner described in Section 2.4.10.2.1…" Oklahoma RFP, pages 22-23.
"2.7
Provider Network...
2.7.6
Dental Providers...
Health
Plan must allow members thirty (30) days in which to change dental PCPs,
following the effective date of dental PCP choice or assignment..."
Oklahoma RFP, pages 32, 38.
PA
"D.
MEMBER ENROLLMENT AND DISENROLLMENT...
9.
Assignment of PCPs
•
If a member requests a change in his or her PCP selection following the
initial visit, the HMO must agree to grant the request...
10.
Changing PCPs
The
HMO must have written policies and procedures for allowing members to select
or be assigned to a new PCP whenever requested by the member, when a PCP
is terminated by the HMO, or when a PCP change is ordered as part of the
resolution to a formal grievance proceeding…" Pennsylvania RFP, pages
20-28.
RI
"2.05.12
Changing PCPs
Contractor
shall have written policies and procedures for allowing members to select
or be assigned to a new PCP including when a PCP is terminated from Health
Plan, or when a PCP change is ordered as part of the resolution to a formal
grievance proceeding. In cases where a PCP has been terminated, Contractor
must allow members to select another PCP or make a re-assignment within
ten (10) days of the termination effective date." Rhode Island RFP,
page 15-16.
SC
"The PCP selected for the Medicaid HMO Program member should be a provider that is located geographically close to the Medicaid HMO Program member's home, and/or best meets the needs of the member. However, the Medicaid HMO program member has the freedom to request a change of primary care provider within the time frames and guidelines established by the Contractor." South Carolina Contract, page 25.
TN
"2-3.
Benefits/Services Requirements and Limitations...
b.
Availability and Accessibility of Services...
3...The CONTRACTOR shall establish policies and procedures to enable enrollees
reasonable opportunities to change primary care providers/primary care
case managers. Such policies and procedures may specify a minimum length
of time not greater than twelve (12) months between changes under normal
circumstances; however, if a time restriction for change is imposed, the
CONTRACTOR must include provisions for more frequent changes with good
cause…" Tennessee Contract, pages 7-14.
TX
"7.8
PRIMARY CARE PROVIDERS…
7.8.12
PCP Selection and Changes… Members may change PCPs at any time, but these
changes are limited to four (4) times per year.
7.8.12.1
Voluntary SSI Members. PCP changes cannot be performed retroactively for
voluntary SSI Members. If an SSI Member requests a PCP change on
or before the 15th of the month, the change will be effective the first
day of the next month. If an SSI Member requests a PCP change after the
15th of the month, the change will be effective the first day of the second
month that follows. Exceptions to this policy will be allowed for reasons
of medical necessity or other extenuating circumstances.
7.8.12.2
Mandatory Members. Retroactive changes to a Member’s PCP should only
be made if it is medically necessary or there are other circumstances which
necessitate a retroactive change…" Texas Contract, pages 63, 66.
UT
"E.
Choice
The
CONTRACTOR must allow Enrollees the opportunity to select a participating
Primary Care Provider... If an Enrollee's Primary Care Provider ceases
to participate in the CONTRACTOR's network, the CONTRACTOR must offer the
Enrollee the opportunity to select a new Primary Care Provider."
Utah Contract, Attachment B, page 30.
VA
"12.
Choice of Health Professional…
f.
Change of PCP
The
Contractor must allow enrollees to select or be assigned to a new PCP when
requested by the enrollee, when a PCP has been terminated by the Contractor,
or when a PCP change is ordered as part of the resolution to a formal grievance
proceeding. When an enrollee changes his or her PCP, the Contractor
must make the enrollee's medical records or copies thereof available to
the new PCP within ten (10) business days from receipt of request."
Virginia Contract, pages 28-29.
WA
"4.3 Member Choice of PCP: ... The Contractor shall allow a member to change PCP or clinic in the first thirty (30) days of enrollment with the PCP and once during a twelve-month period for any reason. Any subsequent change of PCP or clinic during the twelve-month period may be made for documented good cause (WAC 388-538-090)…" Washington Contract, page 16.
WV
"II-3
SPECIFICATION OF RIGHTS...
MCOs
must have policies and procedures to protect and promote these right, as
follows...
Provider
choice...
New
enrollees must be informed of the primary care providers available and
the procedures for selecting a provider. In the event that the enrollee
fails to make a selection within a reasonable time period, the MCO may
assign a provider. The enrollee must be notified of this assignment
and of the procedures for changing the designated provider…" West
Virginia Contract, pages 15-16, Exhibit F, pages 7-8.
"3.2.6
PCP Transfers
The
MCP must have written policies and procedures for allowing Medicaid enrollees
to select or be assigned to a new PCP when such a change is requested by
the enrollee, when a primary care provider is terminated from the MCP,
or when a PCP change is ordered as part of the resolution to a formal grievance
proceeding. In cases where a PCP has been terminated, the MCP must allow
affected members to select other PCPs or make a reassignment within 15
days of the termination effective date.
Enrollees may initiate a PCP change at any time, for any reason. The request can be made in writing or over the phone.
The
MCP may initiate a PCP change for a Medicaid enrollee under the following
circumstances:
a) The enrollee requires specialized care for an acute or chronic
condition, and the enrollee and MCP agree that reassignment to a different
PCP is in the enrollee's interest;
b) The enrollee's PCP ceases to participate in the MCP's network;
c) The enrollee's behavior toward the PCP is disruptive, and the
PCP has made all reasonable efforts (three attempts within 90 calendar
days) to accommodate the enrollee; or
d) The enrollee has taken legal actions against the PCP." West
Virginia RFA, page 17.
WI
"X.
CHOICE OF HEALTH PROFESSIONAL...
HMOs must permit Medicaid enrollees to change primary providers
at least twice in any calendar year, and to change primary providers more
often than that for just cause, just cause being defined as lack of access
to quality, culturally appropriate, health care. Such just cause will
be handled as a formal grievance. If the HMO has reason to lock-in an
enrollee to one primary provider and/or pharmacy in cases of difficult case
management, the HMO must submit a written request in advance of such lock-in
to the Department…" Wisconsin Contract, page 21.