Existence of algorithm for allocation of enrollees
AL | GA | MT | NC | OK | VT | WV"Section Six: PMP Enrollment...
A. Regional Provider Panels
Regional provider panels will be established for each county compromised of those providers who have contractually agreed to serve as a PMP, are willing to serve a minimum of 25 patients and are located in or within 30 miles/30 minutes of the county line. The purpose of the regional provider panel is so that recipients can be assigned or choose a PMP based on historical patterns of care, which may be out of county providers. Regional provider panels will also offer more choices to the recipients when choosing a PMP and is less disruptive to established patient/physician relationship.NOTE: Providers may be added to the regional provider panel on a case-by-case basis when certain criteria cannot be met (e.g. being within 30 miles of county line).
B. Panel Specifications
PMPs may serve multiple counties and or sites; however, the maximum panel a PMP can serve collectively is 1200, with the minimum being 25. PMPs may specify the number or Patient 1st enrollees they will accept per county and/or sites.NOTE: If a nontraditional PMP has been assigned based on a case need, the minimum enrollee requirement will not apply.
C. Panel Extensions
1. In cases where a physician utilizes physician extenders (e.g. nurse practitioner or physician assistants) an additional 400 enrollees per extender may be assigned. No more than two extenders per physician will be considered for panel extension. (NOTE: A physician extender can only be counted once.)2. In cases in which the availability of PMPs is limited so that accessibility is limited, the cap may be extended based on an assessment of the positive impact of increasing the cap as it relates to increasing the availability of care.
3. In cases in which the PMP provides documentation that the level of case management is less than comprehensive due to the PMP's designation or blanket referral of EPSDT screenings and immunizations to other providers, the cap may be increased.
4. In cases in which the PMP can document that the PMP's patient load in its entirety is limited to Medicaid enrollees or that the PMP has historically seen a high percentage of Medicaid patients, an assessment will be made of the PMP's dedication to Medicaid enrollees as that dedication impacts the extension of the PMP to enrollee cap.
D. Requests for Panel Extensions
The request from the PMP for an extension of the PMP enrollee cap should address, at a minimum, the following:
1. The PMP's name and Medicaid number;2. The total number of enrollees over the cap that the PMP is requesting;
3. The reason for the request to extend the PMP enrollee cap;
4. The total number of patients the PMP is seeing who are not Medicaid (PMP may provide the actual total of patients broken down by payor source, and/or PMP's percentage of Medicaid enrollees to total patients and/or the percentage of Medicaid income to total income);
5. The length of time the PMP has been in practice in the area;
6. Description of PMP's practice, such as, is the PMP in private or group practice;
7. Other extenuating documentation and explanations that would justify the request for an extension of the cap.
The request can be submitted at the time the Provider Agreement is signed or by contracting the Customer Service Unit at (334) 353-5773." Alabama PMP, pages 11-13."
"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.
"VII. GENERAL TERMS AND CONDITIONS. A. Assignment of enrollees:
1. Limits on number of enrollees per PCP:a. No PCP may have assigned more than 1,000 enrollees or the number specified by the PCP, whichever is less, except as provided in Item VII.A.1.c
b. No clinic participating as a clinic (i.e. with assignments directly to the clinic) may have more than 1,000 enrollees times the number of full time equivalent primary care providers or the number specified by the clinic, whichever is less, except as provided in Item VII.A.1.c below. Interns and residents shall not be included in such calculations.
c. The upper limits on enrollees may be waived by written agreement of the Department if the Department determines that the waiver is necessary to provide sufficient enrollee access to health care." Montana Agreement, page 7.
"Limits on the Number of Enrollees per Provider - A Contractor may specify a limit on the number of enrollees on the Carolina ACCESS Application for Participation subject to the following terms and conditions:
a. Maximum enrollment is set at 2,000 enrollees per physician or physician extender unless otherwise approved by the Carolina ACCESS program.
b. Notwithstanding the enrollment limits specified above, a Contractor may receive an enrollment that slightly exceeds these limits due tot he nature and timing of the enrollment process.
c. A Contractor may set enrollment criteria on the Carolina ACCESS Application for Participation, but must accept recipients who meet the enrollment criteria up to the limit specified.
d. A Contractor may change the enrollee limit by notifying the local Carolina ACCESS Plan Representative at the county Department of Social Services or the state Carolina ACCESS office." North Carolina Agreement, page 4.
"ARTICLE 3
ENROLLMENTC. The Contractor may specify a limit to the number of Medicaid recipients he/she is willing to accept under this contract. The number shall not be less than one hundred fifty (150) each for individual providers nor less than 200 each for providers participating as part of a provider group except at the discretion of the program administrator, or more than two thousand five hundred (2500), unless the Contractor is a full-time physician practicing in conjunction with licensed Physician Assistant or Nurse Practitioner. If the Contractor is practicing in conjunction with a Physician Assistant or Nurse Practitioner, the maximum capacity may be extended by eight hundred seventy-five (875) for each Nurse Practitioner or Physician Assistant so long as a Physician Assistant or Nurse Practitioner who extends the capacity does not have a separate PCP/CM contract.
D. If the Contractor is a medical resident practicing in an urban area, his/her enrollment shall not exceed two hundred fifty (250) recipients. If the Contractor is a medical resident practicing in a rural area as defined by the Authority as all non-urban counties where managed care services are delivered through HMOs, his/her enrollment shall not exceed eight hundred seventy-five (875) recipients.
E. The Authority does not guarantee the Contractor any minimum enrollment level nor will the Authority pay for recipients who are not eligible for the program." Oklahoma Agreement, page 11.
"18. The PCD agrees to accept at least 20 PCCM enrollees and not more than 1,500 enrollees. The PCD may have fewer than 20 enrollees, if fewer beneficiaries have either selected the PCD or fewer have been assigned by OVHA." Vermont Agreement, 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.