Medicaid recipients eligible for the CommunityCARE program are encouraged to choose their PCP during the enrollment process. Enrollment in the CommunityCARE program occurs when the enrollee is linked to a PCP. The Medicaid recipient can access health services from any Medicaid-enrolled provider until the time the PCP linkage is effective.

PCP Selection

Informed: Monthly letters are sent to all new CommunityCARE eligibles (those who reside in a CommunityCARE parish and are in a Medicaid eligibility category mandating their participation). The letter includes a list of participating CommunityCARE PCPs and instructions for choosing a PCP.

PCP Selection: Recipients usually have 10 calendar days to call the CommunityCARE Enrollee Hotline and make their PCP selection. If the recipient does not take the action necessary to choose their PCP, the recipient (s) are "auto-assigned" a PCP. The PCP auto-assignment process was designed with careful attention to the existing provider/individual relationships, geographic proximity of the enrollee and PCP, and the equitable distribution of enrollees to participating PCPs accepting new enrollees to their practice. When possible, the entire family is linked to the same PCP. However, it is acceptable for a family to choose a different PCP for family recipients based on age and or medical needs.

PCP Assignment Confirmation: Monthly letters are mailed to new CommunityCARE enrollees to confirm their PCP choice or notify them of their PCP auto-assignment.

PCP Linkage Effective Date: In most cases, the PCP linkage will take between three and four months for new Medicaid eligibles. Until a Medicaid recipient is linked to a PCP as indicated by the REVS/MEVS system, the recipient is not enrolled in the CommunityCARE program and can access health care services from any Medicaid-enrolled provider. CommunityCARE effective dates always begin on the first of any given month. Once enrollment occurs, only the PCP linked to an enrollee, as indicated in the REVS/MEVS system, is authorized to provide services or referrals.

PCP Changes

CommunityCARE enrollees may change their PCP linkage without cause at any time during the first 90 days of an enrollment period and at any time "for cause" during their participation in the CommunityCARE program. Enrollees can request to change their PCP in writing or verbally by calling the CommunityCARE Hotline.

The timing of the PCP change request drives the date the new PCP linkage is effective. PCP change requests received by the CommunityCARE contractor by the 23rd of each month become effective the first day of the following month. PCP change requests received after the 23rd of each month become effective the first day of the second month after the change is requested. Providers are encouraged to verify eligibility, including PCP linkage in the REVS/MEVS system.

Without Cause PCP change requests by enrollee:

The enrollee is permitted to change a PCP linkage within 90 days of the effective date. This allows the enrollee 90 days to change a PCP without cause each time he/she is linked to a new PCP.

The enrollee is permitted to change PCPs at least once every 12 months. Enrollees may elect to change PCPs without cause with each new 12-month enrollment period which is based on the calendar year. All CommunityCARE enrollees are notified approximately 60 days prior to the end of the annual enrollment period - October 23 to December 23 of each year. This 60-day period is referred to as "open enrollment". If an enrollee does not change their PCP within this open enrollment period, they remain linked to their current PCP.

For Cause PCP change requests by enrollee:

Enrollees may request to change their PCP for cause at any time. Cause is established automatically for any of the reasons listed below:

• The enrollee was homeless or a migrant worker at the time of enrollment and was enrolled by default and never received notice of enrollment or of the 90-day disenrollment period.

• The enrollee is experiencing difficulty obtaining transportation to their assigned PCP. The enrollee has an unresolved language barrier with the PCP.

• A new CommunityCARE provider offers a specialty previously unavailable within geographic proximity that better meets his/her health care needs.

• The enrollee feels the current PCP is not experienced in dealing with his/her health care needs.

• The enrollee wants to remain linked to a CommunityCARE PCP who is changing practice affiliation and or location.

• The enrollee moved and is now closer to another CommunityCARE PCP.

• The PCP does not cover the service an enrollee seeks based on moral or religious objection.

• The enrollee does not have access to all the services he/she is entitled.

• The patient/provider relation is not mutually compatible and or acceptable.

Note: Any enrollee request to change a PCP that does not meet the criteria described above will be reviewed by the state (BHSF). The state will approve and or disapprove these exceptions on a case by case basis. All disenrollment denials issued by the state (BHSF) include notifying the enrollee of his/her rights to a Fair Hearing within the Grievance System.