Auto-enrollment process
AL | FL | GA | IN | IA | MS | MT | NE | NC | PA | VA | WV "Section Twelve: Recipient Enrollment/Assignment
A. Enrollment
To facilitate enrollment into the Patient 1st system, recipients are assigned to a PMP. Federal law requires that recipients be given the ability to change PMP providers on a monthly basis (refer to Section Thirteen for further information). Dependent upon when a person becomes Medicaid eligible, they may not yet be enrolled in Patient 1st.Recipients who are added to the eligibility file or move along counties are notified of their PMP assignment approximately 45 days prior to the effective date of assignment. Initial assignments are made based on recipients who have historical relationship with a provider based on claims history. The historical provider must be enrolled into the regional provider panel. If a recipient has seen one or more providers an equal number of times, then assignment is made to a provider in the same town; then zip code, then lowest number of enrollees. If there is no history in the Medicaid claims system primary care, assignments are made based on physical location between recipient and provider (city then zip). If neither of the two above apply, assignment is done using a random assignment process based on provider's panel size within the county.
The purpose of the 45 day lead time is to allow recipients to change providers prior to actual restriction. A second notification will be mailed to recipients approximately 5 days prior to restriction, that will confirm the original assignment if no change is made, or confirming the requested change. Providers will be notified at this time of recipients that are assigned as of the 1st of the next month.
The assignment process takes into account group practices and/or clinic affiliation." Alabama PMP, pages 19-20.
"16. Patient Choice of MediPass Provider...
b. Each patient who does not chose a provider will be assigned to a participating provider in the patient's county of residence." Florida Agreement, page 10."Recipients are given an opportunity to select a primary care case manager. For those who do not make a selection, a computer algorithm is used to assign the recipient to a provider. The assignment process involves up to three steps to ensure an appropriate match. Whenever possible, the recipient is matched based on his or her historical usage or the historical usage of a family member. Lacking any historical usage, the recipient is assigned based on a geographic convenience to a primary care provider." Georgia Agreement, Overview.
"Individual caseload
Each physician enrolled as a PMP will be assigned patients in one of two ways: ...
2. A recipient is assigned by the program to a PMP through a rotational assignment system." Indiana Addendum, page A-1."7. Recipients who do not make a selection of patient manager shall be assigned to a patient manager based on enrollment of other family members, if any, and appropriate physician specialty." Iowa Agreement, page 5.
"4.12 Client Enrollment...
The eligibility worker refers the client to the EDS Managed Care Enrollment Specialists at 1-800-627-8488, or, if available, an area Client Services Field Representative for enrollment with a PCP. When the applicant or client chooses a PCP, the assignment is as described in Section 4.13 and 4.14. Clients who do not indicate a PCP preference will be assigned a PCP appropriate for the age and sex of the applicant/client based on PCP location and availability. Clients will be notified of any PCP changes through the mailing of cardholders on a monthly basis. (See Attachment D for forms regarding Requests for Client Enrollment.)...4.14.3 Mass Reassignment
HeaIthMACS enrollees are assigned to a different PCP if a PCP dies, moves out of the service area, or loses Medicaid and/or HealthMACS provider status. Such reassignment is usually accomplished by automated means. DOM sends a notice to the affected clients, telling them of the reassignment, the reason for the reassignment and that they may select another PCP if the reassignment is not satisfactory." Mississippi Manual, pages 83, 85."IV. RESPONSIBILITIES OF THE PRIMARY CARE PROVIDER (PCP)...
A. The PCP agrees to: ...
2. Accept enrollees who choose the PCP themselves and those who are mandatorily assigned to the PCP, as long as the enrollee meets the PCP-defined caseload limits (recipients who fail to choose a PCP by the 10th of the month following month in which recipient became PASSPORT-eligible will be assigned by the Department to a PCP, taking into account residence, age, sex, historical and household usage, and PCP-defined caseload limits).VII. GENERAL TERMS AND CONDITIONS...
2. Recipient Selection of Providers...
b. Recipients who do not choose a PCP will be mandatory aassigned by the Department based on historical or household usage if appropriate, or randomly by rotating assignment as appropriate, to participating PCPs who are accepting new enrollees in the recipient's county of residence or an adjacent county." Montana Agreement, pages 4-5, 7."3.11.3 Auto Assignment Priorities: The following priorities shall apply:
(a) The Department's Auto Assignment algorithm shall give priority to provider client proximity and shall maintain family members with the same PCP/Contractor, if appropriate; and
(b) For a client in the Blind/Disabled and Department Ward/Foster Care Categories, the EBS shall facilitate an assignment by default enrolling a PCP/Contractor by taking into consideration eligibility and claims history information known about the client.3.11.4 Distribution of Clients During Auto Assignment: The Department shall use its best efforts to create, an equal distribution of clients to available Contractors during Auto Assignment." Nebraska Contract, pages 26-28.
"c. Eligible recipients who do not choose a primary care provider available to their service area based on historical usage, location and/or randomly by rotating assignment as appropriate." North Carolina Agreement, page 4.
"C. LCHP Recipients...
The Contractor must develop and implement a plan to: ...
a. Establish standard procedures to identify recipients who must be enrolled based on the criteria provided by the Program Office...
e. Assign recipients to a PCCM within 5 working days in the even that no selection has been made within the 30 day time period. Assignments should be based on, but not limited to the following criteria:
(1.) PCCMs located no more than 30 minutes traveling distance from their home in urban areas.
(2.) PCCMs located no more than 60 minutes traveling distance from their home in rural areas.
(3.) Provider/patient caseload list." Pennsylvania Program Standards, Rider 2."4. The Department agrees to: ...
B. Enroll up to 1,200 eligible clients per Clinic PCP with the Clinic on a month to month basis under the following conditions: ...
2) AN/AI clients who do not choose a Healthy Options plan or PCCM clinic will be assigned to the Clinic by the Department if they live in the Clinic's catchment area." Washington State Healthy Options, page 3."VI. GENERAL TERMS AND CONDITIONS: ...
A. Assignment of Enrollees: ...
2. Recipient Choice
b. Recipients who do not choose a PAAS provider will be assigned one by PAAS based on historical usage if appropriate, or by rotation to proximate participating PAAS providers." West Virginia PAAS, page 5.