Factor Intrínseco de Humedad Del Suelo

A Member without SSI shall be offered an opportunity to: (1) choose a new PCP who is affiliated with the Contractor’s network or (2) stay with their current PCP as long as such PCP is affiliated with the Contractor’s network. Each Member shall be allowed to choose his or her Primary Care Provider from among all available Contractor Network Primary Care Providers and specialists as is reasonable and appropriate for Member. The Contractor shall have procedures for serving Members from the date of notification of enrollment, whether or not the Member has selected a Primary Care Provider. The Contractor shall send Members a written explanation of the Primary Care Provider selection process within ten (10) business days of receiving enrollment notification from the Department, either as a part of the Member Handbook or by separate mailing. Members will be asked to select a Primary Care Provider by contacting the Contractor’s Member Services department with their selection. The written communication shall include the timeframe for selection of a Primary Care Provider, an explanation of the process for assignment of a Primary Care Provider if the Member does not select a Primary Care Provider and information on where to call for assistance with the selection process.

A Member shall be allowed to select, from all available, but not less than two (2) Primary Care Providers in the Contractor’s Network.

Contractor shall assign the Member to a Primary Care Provider:

A. Who has historically provided services to the Member, meets the

Primary Care Provider criteria and participates in the Contractor’s Network;

Member’s residence or place of employment in an urban area or within forty-five (45) miles or forty-five (45) minutes from the Member’s residence or place of employment in a rural area. The assignment shall be based on the following:

(1) The need of children and adolescents to be followed by

pediatric or adolescent specialists;

(2) Any special medical needs, including pregnancy;

(3) Any language needs made known to the Contractor; and

(4) Area of residence and access to transportation.

C. If there is no Primary Care Provider in the Contractor’s Network that

meets the criteria listed in paragraphs A and B directly above, the Contractor shall assign the Member to any Network Primary Care Provider in an adjoining county to the Member’s county of residence or within the Contractor’s Region.

The Contractor shall monitor and document in a quarterly report to the Department the number of eligible individuals that are assigned a PCP. The Contractor shall notify the Member, in writing, of the PCP assignment, including the Provider’s name, and office telephone number. The Contractor shall make available to the PCP a roster on the first day of each month of Members who have selected or been assigned to his/her care.

23.2 Members who have SSI and Non Dual Eligibles

A Member who has SSI but is not a dual eligible shall be offered an opportunity to: (1) choose a new PCP who is affiliated with the Contractor’s network or (2) stay with their current PCP as long as such PCP is affiliated with the Contractor’s network. Each Member shall be allowed to choose his or her Primary Care Provider from among all available Contractor Network Primary Care Providers and specialists as is reasonable and appropriate for Member.

The Contractor will send Members information regarding the requirement to select a PCP, or one will be assigned to them accordingly to the following:

A. Upon Enrollment, Member will receive a letter requesting them to select a PCP. This letter may be included in the Member Welcome Kit. After one month, if the Member has not selected a PCP, the Contractor must send a second letter requesting the Member to select a PCP within thirty (30) days or one will be chosen for the Member.

B. At the end of the third thirty (30) day period, if the Member has not

selected a PCP, the Contractor may select a PCP for the Member and send a card identifying the PCP selected for the

Member and informing the Member specifically that the Member can contact the Contractor and make a PCP change.

C. Except for Members who were previously enrolled, the Contractor

cannot auto-assign a PCP to a member with SSI within the first ninety (90) days from the date of the Member’s initial enrollment.

23.3 Enrollment Procedures for Foster Children, Adoption and Guardianship

DCBS and DAIL staff will apply for Medicaid on behalf of foster children (DCBS) and guardianship clients (DAIL) through an expedited application process agreed on by the Department and the DCBS and DAIL.

Members who are children in foster care and adult guardianship clients may move frequently from one placement to another. The parties agree that the following procedures will be used to determine the residence of these Members for the purpose of maintaining Enrollment.

Foster Children. For members who are in foster care, assignment will be based on where the foster child’s DCBS case is located (which is usually the region where the child’s family of origin resides). When a foster child is placed outside the Contractor’s Region but DCBS continues to maintain the child’s case within the Contractor’s Region, the Contractor’s Region shall remain as the child’s official residence and Contractor shall be responsible for arranging medical care for the Member. It is the responsibility of the DCBS to notify the Contractor of a foster child’s change in placement. Within ten (10) Days of notification, the Contractor must assign a PCP based on the DCBS selection.

Adopted Children. For members who have been adopted, the Member’s region of residence shall be determined by the adoptive parent’s official residence.

Adult Guardianship. For members who are in adult guardianship status, the county of residence shall be where the Member is living. Brief absences, such as for respite care or hospitalization, not to exceed one month, do not change the county of residence. When a Member is transferred outside of the region, the Contractor will continue to be responsible for arranging care for the Member until removed from the HIPAA 834.

The DCBS shall notify the Department when a Member’s case is transferred outside the Contractor’s Region. The Department will include notice of the transfer in the HIPAA 834.

23.4 Primary Care Provider Changes

The Contractor shall have written policies and procedures for allowing Members to select or be assigned to a new PCP when such a change is mutually agreed to by the Contractor and Member, when a PCP is terminated from coverage, or when a PCP change is as part of the resolution to an Appeal. The Contractor shall allow Members to select another PCP within ten (10) days of the approved change or the Contractor shall assign a PCP to the Member if a selection is not made within the time frame.

A Member shall have the right to change the PCP ninety (90) days after the initial assignment and once a year regardless of reason, and at any

time for any reason as approved by the Member’s Contractor. The

Member may also change the PCP if there has been a temporary loss of eligibility and this loss caused the Member to miss the annual opportunity, if Medicaid or Medicare imposes sanctions on the PCP, or if the Member and/or the PCP are no longer located in the Contractor’s Region.

The Member shall also have the right to change the PCP at any time for cause. Good cause includes the Member was denied access to needed medical services; the Member received poor quality of care; and the Member does not have access to providers qualified to treat his or her health care needs. If the Contractor approves the Member’s request, the assignment will occur no later than the first day of the second month following the month of the request.

PCPs shall have the right to request a Member’s Disenrollment from his/her practice and be reassigned to a new PCP in the following circumstances: incompatibility of the PCP/patient relationship or inability to meet the medical needs of the Member. PCPs shall not have the right to request a Member’s Disenrollment from their practice for the following: a change in the Member’s health status or need for treatment; a Member’s utilization of medical services; a Member’s diminished mental capacity; or, disruptive behavior that results from the Member’s special health care needs unless the behavior impairs the ability of the PCP to furnish services to the Member or others. Transfer requests shall not be based on race, color, national origin, handicap, age or gender. The Contractor shall authority to approve all transfers.

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.

The provider shall make the change for request in writing. Member may request a PCP change in writing, face to face or via telephone.

The Contractor shall provide written notice within fifteen (15) Days to a member whose PCP has been voluntarily or involuntarily disenrolled or been terminated from participation in the Contractor’s network.