Program Overview

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CommunityCARE is a comprehensive health delivery system, which links Medicaid recipients to a Primary Care Physician (PCP). The PCP manages the care of each CommunityCARE enrollee by providing health education, preventive care, and acute care and refers the enrollee to specialists when needed. The PCP also admits enrollees to the hospital. The PCP shares medical information with the emergency room and other authorized health care providers. The CommunityCARE PCP arranges for medical care coverage 24-hours a day, seven days a week. PCPs are reimbursed fee-for-service payment for care provided and a monthly management fee for each CommunityCARE enrollee linked to their practice.

Each CommunityCARE enrollee is linked to a PCP which creates a medical home. The medical home is the first place enrollees turn to for their health care needs. The PCP performs the responsibilities mentioned earlier and establishes an on-going relationship with each CommunityCARE enrollee. There are many different types of CommunityCARE PCPs to choose from: Physicians certified in Family Practice, General Practice, Pediatrics, Internal Medicine, and certain Obstetricians/Gynecologists, Community Health Centers and Rural Health Clinics.

Goals of the CommunityCARE Program were developed to assure access to quality care for Medicaid eligibles in the CommunityCARE Program by: providing a "medical home"; strengthening the patient/physician relationship; promoting the educational/preventive aspects of health care; and promoting the responsibility of the recipient to use emergency room and other services appropriately, thereby reducing the cost associated with inappropriate and duplicative services.

Who is eligible for CommunityCARE?
Most low-income families with children, disabled adults and children who are Medicaid recipients are required to participate in CommunityCARE except:

• · Residents of long term care nursing facilities, psychiatric facilities, or intermediate care facilities for the mentally retarded (ICF/MR), such as state developmental centers and group homes.
· Recipients who are 65 years or older
· Recipients with Medicare benefits, including dual eligibles
· Foster children or children receiving adoption assistance
· Hospice Recipients
· Office of Youth Development clients (children in State custody)
· Recipients in the Medicaid physician/pharmacy Lock-In program (recipients that are pharmacy-only Lock-In are not exempt)
· Recipients who have other primary insurance with physician benefits, including HMOs
· Recipients who have an eligibility period of less than 3 months
· Recipients who have retroactive only eligibility (CommunityCARE does not make retroactive linkages).
· Native American Indians who reside in parish of Reservation (currently Jefferson Davis, St. Mary, LaSalle and Avoyelles parishes).
· Certain medically high risk recipients may warrant the direct care and supervision of a non-primary care specialist. Requests for medical exemptions are reviewed for approval on a case by case basis. Requests must be submitted in writing, along with supporting medical documentation of the recipient's medical condition(s). Requests for medical exemption should be mailed to: DHH- CommunityCARE Program, P.O. Box 91030, Baton Rouge, LA 70821, Attention: Angela Mastainich, Program Coordinator. A preprinted request form is available on the CommunityCARE web site, www.la-communitycare.com .
· Medicaid eligibles in the PACE program
· Recipients in pregnant woman eligibility categories (type cases 13, 53 and 104)
· SSI recipients under the age of 19
· Recipients under the age of 19 in the NOW and Children's Choice waiver programs
· Recipient under the age of 19 in the supports waiver and supports waiver SSI programs
· Recipients in the family planning waiver program (type case 115 and 116)

Who can be a CommunityCARE Provider?

General practitioners, family practitioners, pediatricians, internist, OBGYNs & Academic Health Center Teams who meet the following requirements:

1. Certified LA Medicaid provider

2. Provide or arrange for KIDMED screenings

3. Hospital admitting privileges or arrange for admission

4. Availability and Access to Linked Recipients

Covered Services

CommunityCARE enrollees are entitled to the same Medicaid covered services as those eligibles not in CommunityCARE. Providers and recipients need to be familiar with the policies specific to CommunityCARE such as referrals, prior authorization and appropriate use of the emergency room which may determine the service being deemed "covered".