386.2 Plan Enrollment Process

Information in  CIS eligibility records  is used to select individuals who must/may enroll in either the Health Choices mandatory MCOs.  If an individual is not kept out of a plan because of one of the conditions listed in Section 386.12 Fee-For-Service.  CIS will display which plan option the individual has.  CAO staff cannot enter or change the medical assistance plan option.

 

CAO staff must do the following:

386.21 Selecting a Primary Care  Provider

After an individual has been enrolled in a plan, the contractor running the plan has thirty days to link the individual with a PCP. If the individual does not contact the contractor at the toll-free number to select a PCP, the contractor must try to contact the individual  by telephone or mail to explain the plan and help the individual  select a PCP. If the contractor cannot reach the individual, the contractor must select a PCP for the individual  from the area where the  individual lives.

 

If the contractor needs to select a PCP for the individual, the contractor must use the MA paid claims history file to find a PCP the individual has already been to. Travel time from the individual’s  home to the PCP’s office must be thirty minutes or less for individuals  living in urban areas and sixty minutes or less for those living in rural areas.

 

The contractor must send all of  the following to the individual :

386.22 Changing a Primary Care  Provider

The individual may change his or her PCP for any reason. Requests for changes must be handled by the contractors. CAOs must refer individuals to the contractor at their toll-free numbers. A change becomes effective on the first day of the calendar month after the month in which the individual asked for the change, as long as the request was received by the fifteenth day of the month. If the request is received after the fifteenth day, the change becomes effective on the first day of the second month after the individual asked for the change.

 

The PCP may ask for an individual to be switched to another PCP , but only for good cause. For example, the PCP may ask for a change if an individual does not follow a treatment plan or if the PCP believes the individual’s medical condition could be managed better by another PCP . The PCP must send a written request for the change to the contractor who is running the plan. The PCP must keep serving the individual until the change is in effect.

 

An individual must be dropped from a managed care plan  by the contractor or the system if the individual moves from a county covered by the plan to one not covered by the plan. An individual  must also be dropped if he or she meets one of the conditions listed in Section 386.12,  Fee-For-Service.

386.23 MCO Disenrollment for Active MA Recipients Due to Long Term Care Facility Placement

MCOs are responsible to provide payment for up to 30 days of Long Term Care (LTC) facility services (including hospital reserve days and therapeutic bed hold days) for its enrolled members. Non-timely disenrollment results in the LTC facility having problems billing for admissions greater than 30 days. When the CAO is notified of an active MA recipient’s admission to an LTC facility via an Admission and Discharge Transmittal (MA 103), a Medical Evaluation (MA 51) form, an e-mail from DMSSC Tech Support, by another CAO, or by the recipient, the following procedures should be followed:

 

Reminder: The Office of Long Term Living reviews all MA cases in facilities to assure that correct billing has been completed.

Updated  March 11, 2013,  Replacing February 14, 2012