Medicaid Contract Purchasing SpecificationsPart 4Provider Selection and AssignmentTable of Contents §401. Selection of Primary Care Provider Commentary: There are two basic approaches to beneficiary choice of primary care provider. The more common is to offer the beneficiary a choice between two or more MCOs and, once enrolled in an MCO, a choice among primary care providers. This approach is reflected in §401(b). The other approach, reflected in §401(a), is to offer the beneficiary a choice among primary care providers and, once that selection has been made, to assign the beneficiary to an MCO based on its affiliation with the provider. For a review of these differing approaches, see Maloy, K. et al., Results of a Multi-Site Study of Mandatory Medicaid Managed Care Enrollment Systems: Implications for Policy and Practice (GWUMC School of Public Health and Health Services (CHSRP), May 1999). If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on primary care provider selection is for your consideration. K§401. Selection of Primary Care Provider (a) Duty to Allow Selection Prior to Enrollment — Contractor shall permit the family or caregiver of a child (including an adolescent) who is eligible to enroll under [drafter insert name of purchasing document] to select a primary care provider (as defined in §1401(u)) from among the primary care providers participating in Contractor's provider network and shall honor the selection unless a condition under subsection (f) applies. (b) Duty to Allow Selection on or after Enrollment — Contractor shall permit the family or caregiver of a child (including an adolescent) who has enrolled under [drafter insert name of purchasing document] to select a primary care provider (as defined in §1401(u)) from among the primary care providers participating in Contractor's provider network and shall honor the selection unless a condition under subsection (f) applies. (c) Duty to Allow Periodic Re-Selection (1) In General — Contractor shall permit the family or caregiver of an enrolled child (including an adolescent) to select a primary care provider for the child no less frequently than once every [ ] months after the most recent date of enrollment and shall honor the selection unless a condition under subsection (f) applies. (2) Special Rule for Foster Care Children — In the case of a child in foster care or other out-of-home placement, Contractor shall comply with the duty described in paragraph (1) and allow the child (or the foster family or [drafter insert name of child welfare agency on behalf of the child]) to select a primary care provider whenever there is a change in the child's foster residence or other out-of-home placement. (d) Inaccurate Provider Information — If Contractor fails to comply with the requirements of §§301(a)(3) and 302(c)(5) of Part 3 relating to accurate, current information regarding participation of providers in Contractor's provider network, and if the family or caregiver of an enrolled child, or if an enrolled adolescent, relies upon such information when enrolling with the Contractor, Contractor shall: (1) in the case of an enrolled child, permit the child's family or caregiver to disenroll the child for cause; and (2) in the case of an enrolled adolescent, permit the adolescent to disenroll for cause. (e) No Appropriate Provider — In the case of an enrolled child (including an adolescent) who has not (or on whose behalf the family or caregiver have not) been able to select a primary care provider because a condition under subsection (f) applies, Contractor shall: (1) in the case of an enrolled child, permit the child's family or caregiver to: (A) select a primary care provider who does not participate in Contractor's provider network and reimburse the provider for items and services covered under Part 1 in at least the same amounts and on terms at least as favorable as apply to primary care providers participating in Contractor's provider network; (B) disenroll the child for cause and enroll the child in another managed care plan that has entered into a purchasing agreement with purchaser if the primary care provider: (i) participates in the provider network of the managed care plan; and (ii) has the capacity to continue to serve as the child's primary care provider; and (2) in the case of an enrolled adolescent, permit the adolescent to: (A) select a primary care provider who does not participate in Contractor's provider network and reimburse the provider for items and services covered under Part 1 in at least the same amounts and on terms at least as favorable as apply to primary care providers participating in Contractor's network; (B) disenroll for cause and enroll in another managed care plan that has entered into a purchasing agreement with purchaser if the primary care provider: (i) participates in the provider network of the managed care plan; and (ii) has the capacity to continue to serve as the adolescent's primary care provider.1 (f) Conditions — Contractor shall honor the selection of a primary care provider under subsections (a), (b), (c), or of a dental care provider under §404, and shall not reassign an enrolled child to a primary care provider other than the provider selected by the child under subsections (a),(b), and (c),without the consent of the child or the child's family or caregiver, unless: (1) the provider is no longer participating in Contractor's provider network; or (2) the provider has timely notified Contractor as required under §502(c)(8) and §503(c)(4) of Part 5 that the provider is unable to accept any additional enrolled children as patients because the provider no longer has the capacity to accept any additional children as patients. KCompliance measure: Contractor shall make available to Purchaser on request: (1) the number of enrolled children whose families or caregivers select a primary care provider over most recent [ ] month period; and (2) the number of enrolled children who disenroll under this Part.
K§402. Pediatric Specialists as Primary Care Providers for Children with Special Health Care Needs (a) Children with Special Health Care Needs — In the case of an enrolled child with special health care needs (as defined in §1401(f)), Contractor shall offer the family or caregiver of such enrolled child (or in the case of an adolescent, the adolescent) the option of designating as the child's primary care provider either: (1) a primary care provider (as defined in §1401(u)) participating in Contractor's provider network who is willing and has the capacity to assume primary care provider responsibilities for the child; or (2) a pediatric specialist (as defined in §1401(s)) participating in Contractor's provider network who is willing and has the capacity to carry out the responsibilities of a primary care provider under §502(c).
K§403. Assignment of Non-Selecting Children and Reassignment (a) In General — In the event that the family or caregiver of an enrolled child (including an adolescent) who is not described in subsection (c), (d), or (e) fails to indicate a choice of primary care provider within [ ] days of enrollment, Contractor shall assign the enrolled child to: (1) a primary care provider participating in Contractor's provider network from whom the child has received care within the previous [ ] months;2 or (2) in the case of a child who has not received care within the previous [ ] months from a provider described in paragraph (1), to a primary care provider participating in Contractor's provider network in accordance with the following criteria: (A) the travel time (using public transportation)3 between the child's place of residence and the provider's practice site; and (B) any special health care needs of the enrolled child and the qualifications of the provider to serve such needs.4 (b) Involuntary Reassignment of an Enrolled Child to a Primary Care Provider (1) Grounds for Involuntary Reassignment — In the case of an enrolled child who has selected a primary care provider under §401, or who has been assigned to a primary care provider under subsection (a), Contractor may reassign the child to another primary care provider only if: (A) the child or the child's family or caregiver has requested reassignment to a different primary care provider; (B) the child's primary care provider: (i) reduces the number of enrolled children the provider accepts as patients; or (ii) no longer participates in Contractor's provider network; or (C) the child's current primary care provider certifies in the child's medical record that reassignment of the child to another primary care provider will not: (i) compromise the treatment of the child's health care needs, including the child's access to covered prescription drugs; or (ii) disrupt the child's access to pediatric specialists. (2) Notification — Contractor shall not involuntarily reassign an enrolled child under paragraph (1) unless Contractor has notified the child (and the child's family or caregiver) in writing at least [ ] weeks prior to the effective date of the reassignment of: (A) the effective date of the child's reassignment to a different primary care provider; and (B) the name, mailing address, phone number, practice site, practice hours, and the bus or subway line serving the practice site. (c) Children in Migratory or Seasonal Agricultural Worker Families (1) Assignment —In the event that the family or caregiver of an enrolled child (including an adolescent) who is in a migratory or seasonal agricultural worker family (as defined in §1401(r) and (y)) does not select a primary care provider within [ ] days of enrollment, Contractor shall make its best efforts to assign such child to a provider participating in Contractor's provider network with experience in providing health care to such children and families or caregivers. (2) Out-of-Network — If Contractor is unable to assign the child to a provider as required under paragraph (1), Contractor shall permit the family or caregiver of the child to select for the child a primary care provider who does not participate in Contractor's provider network and reimburse the provider for items and services covered under Part 1 in at least the same amounts and on terms at least as favorable as apply to a primary care provider participating in Contractor's provider network. (d) Children in Homeless Families (1) Assignment — In the event that the family or caregiver of an enrolled child (including an adolescent) who is in a homeless family (as defined in §1401 (n)) does not select a primary care provider within [ ] days of enrollment, Contractor shall make its best efforts to assign such child to a provider participating in Contractor's provider network with experience in providing health care to such children and families or caregivers. (2) Out-of Network Provider — If Contractor is unable to assign the child to a provider as required under paragraph (1), Contractor shall permit the family or caregiver of the child to select for the child a primary care provider who does not participate in Contractor's provider network and reimburse the provider for items and services covered under Part 1 in at least the same amounts and on terms at least as favorable as apply to a primary care provider participating in Contractor's provider network. (e) Children in Foster Care (1) Assignment — In the event that a child in foster care or other out-of-home placement (or a foster care parent or [drafter insert name of child welfare agency on behalf of such child]) does not select a primary care provider within [ ] days of enrollment, Contractor shall make its best efforts to assign such child to a provider participating in Contractor's provider network with experience in providing health care to such children and families or caregivers. (2) Out-of-Network Provider — If Contractor is unable to assign the child to a provider as required under paragraph (1), Contractor shall permit the family or caregiver of the child to select for the child a primary care provider who does not participate in Contractor's provider network and reimburse the provider for items and services covered under Part 1 in at least the same amounts and on terms at least as favorable as apply to a primary care provider participating in Contractor's provider network. KCompliance measure: Contractor shall make available to Purchaser on request: (1) the procedures and criteria used to assign enrolled children whose families or caregivers do not select primary care providers on their behalf; (2) the number of enrolled children who are assigned by Contractor to a primary care provider due to non-selection over the most recent [ ] month period and the total number of enrolled children; (3) the names of the primary care providers to whom non-selecting children are assigned by Contractor and the number of children so assigned over the most recent [ ] month period; and (4) the names of providers, with experience in providing health care to children in migratory and seasonal agricultural worker families, homeless children, and children in foster care or other out-of-home placements, participating in Contractor's provider network who have informed Contractor that they are willing and have the capacity to assume primary care responsibilities for such children.
K§404. Selection of, and Assignment to, Dental Care Provider (a) Selection — Contractor shall permit the family or caregiver of an enrolled child (including an adolescent) to select a dental care provider (as defined in §1401(j)) from among the dental care providers participating in Contractor's provider network and shall honor the selection unless a condition under §401(f) applies. (b) Assignment — In the event that the family or caregiver of an enrolled child (including an adolescent) fails to indicate a choice of dental care provider (as defined in §1401(j)) within [ ] days of enrollment, Contractor shall assign the enrolled child to: (1) a dental care provider participating in Contractor's provider network from whom the child has received care within the previous [ ] months; or (2) in the case of a child who has not received care within [ ] months from a dental care provider described in paragraph (1), to a dental care provider participating in Contractor's provider network who practices at a site that is within [ ] minutes travel time (using public transportation) from the child's place of residence. KCompliance measure: Contractor shall make available to Purchaser on request: (1) the procedures and criteria used to assign enrolled children whose families or caregivers do not select dental care providers on their behalf; (2) the number of enrolled children who are assigned by Contractor to a dental care provider due to non-selection over the most recent [ ] month period and the total number of enrolled children; and (3) the names of the dental care providers to whom non-selecting children are assigned by Contractor and the number of children so assigned over the most recent [ ] month period.
K§405. Information on Primary Care Providers, Pediatric Specialists, and Dental Care Providers (a) Information on Choices — Contractor shall make available to each enrolled child and potential enrolled child (and to the child's family or caregiver) information regarding the primary care providers, pediatric specialists, and dental care providers participating in Contractor's provider network in the form of a provider directory under §304 of Part 3. (b) Information on Enrollment Card — Within [ ] days following selection of or assignment to a primary care provider, Contractor shall furnish the enrolled child's family or caregiver an updated enrollment card (or a permanent decal which can be affixed to the enrolled child's enrollment card) that, in addition to the information on the original card issued under §305 of Part 3, adds the name, office address, telephone number, and emergency telephone number of the enrolled child's primary care provider. Endnotes
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If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on provider selection and assignment is for your consideration.Purchasers may also find it useful to review Negotiating the New Health System (3rd Ed.) which provides other options relating to selection and assignment of primary care providers used by state agency purchasers in contracting with Medicaid MCOs at Table 3.3, Vol. 2, Part 3, pages 3-150 through 3-197 (www.gwu.edu/~chsrp).