Choice of Health Professional. Each Enrollee shall be allowed to choose his or her primary care health professional from among all the available Plan Providers to the extent possible, reasonable, and appropriate. The Contractor's panel of Plan Providers shall reflect, to the extent possible, the diversity of cultural and ethnic backgrounds of the population served, including those with limited English proficiency. If the Enrollee does not choose a primary health care professional, the Contractor may assign the Enrollee a primary health care professional. An Enrollee who has received prior authorization from the Contractor for referral to a specialist or for inpatient care shall be allowed to choose from among all the available specialists and hospitals within the Plan to the extent possible, reasonable, and appropriate. If an Enrollee’s primary care provider, specialist, or other provider is no longer available to the Enrollee through the Plan, the Contractor shall have a plan to ensure continuity and coordination of care and to assist the Enrollee in selecting a Plan Provider. The Plan shall include notice to the Enrollees affected by the loss of the provider, information about selecting a new provider, and a date after which Enrollees who are undergoing an active course of treatment cannot use the provider who is no longer among the Plan Providers. The Contractor must have written policies and procedures for assigning each of its enrollees to a primary care provider. Any changes or modifications to these policies and procedures must be submitted by the Contractor to the Division at least thirty (30) calendar days prior to implementation and must be approved by the Division. These policies and procedures shall include the features listed below:
Choice of Health Professional. The MCO must inform each Member about the full panel of participating providers in their network. To the extent possible and appropriate, the MCO must offer each Member covered under this contract the opportunity to choose among participating providers.
Choice of Health Professional. The Contract or must allow each enrollee to choose his or her health professional within this Insurer's Network to the extent possible and appropriate, provided that such selected professional complies with all credentialing requirements to provide services to the Medicare-Medicaid population.
Choice of Health Professional. To the extent reasonably possible, the MCO shall offer freedom of choice to Enrollees in selecting a Provider from within the MCO’s qualified Provider Network. MCO shall ensure a choice of at least two Providers for each service, except specialties specifically approved by DMA in writing. Requests for exceptions may be based on such factors as medical necessity and demand. For example, exemptions may be granted if the demand for services, particularly facility based services or niche services, does not support two Providers. An Enrollee who has received prior authorization from MCO for referral to a Network Provider or for inpatient care shall be allowed to choose from among all the available Network Providers and hospitals within MCO, to the extent reasonably possible. MCO shall coordinate its services with the services its Enrollees receive from other MCOs, Prepaid Inpatient Health Plans (PIHPs) and Prepaid Ambulatory Health Plans (PAHPs) in order to avoid unnecessary duplication. In accordance with 42 CFR 438.208, MCO shall share with other MCOs, PIHPs, and PAHPs serving the enrollee the results of its identification and assessment of any enrollee with special health care needs (see Section 6.13) so that those activities need not be duplicated.
Choice of Health Professional. Per 42 CFR 438.6(m), Global Commitment to Health enrollees will have choice of health professional within the network of Medicaid providers to the extent possible and appropriate.
Choice of Health Professional. Offer each enrollee covered under this Contract the opportunity to choose a primary health care professional affiliated with the HMO, to the extent possible and appropriate. If the HMO assigns recipients to primary physicians, then the HMO shall notify recipients of the assignment. HMOs must permit Medicaid BadgerCare enrollees to change primary providers at least twice in any calendar year, and to change primary providers more often than that for just cause, just cause being defined as lack of access to quality, culturally appropriate, health care. Such just cause will be handled as a formal grievance. If the HMO has reason to lock-in an enrollee to one primary provider and/or pharmacy in cases of difficult case management. the HMO must submit a written request in advance of such lock-in to the Department. Requests should be submitted to the Contract Monitor. Culturally appropriate care in this section means care by a provider who can relate to the enrollee and who can provide care with sensitivity, understanding, and respect for the enrollee's culture.
Choice of Health Professional. Per 42 CFR 438.6(m), Global Commitment to Health enrollees will have choice of health professional within the network of Medicaid providers to the extent possible and appropriate. DVHA shall not impose any restrictions on the choice of the provider from whom the person may receive family planning services and supplies.
Choice of Health Professional. To the extent reasonably possible, the LME shall offer freedom of choice to Enrollees in selecting a Provider from within the LME’s qualified Provider Network. The LME shall ensure a choice of at least two Providers for each service, except specialties specifically approved by DMA in writing. Requests for exceptions may be based on such factors as medical necessity and demand. For example, exemptions may be granted if the demand for services, particularly facility based services or niche services, does not support two Providers. An Enrollee who has received prior authorization from the LME for referral to a Network Provider or for inpatient care shall be allowed to choose from among all the available Network Providers and hospitals within the LME, to the extent reasonably possible. The LME shall coordinate its services with the services its Enrollees receive from other MCOs, Prepaid Inpatient Health Plans (LMEs) and Prepaid Ambulatory Health Plans (PAHPs) in order to avoid unnecessary duplication. In accordance with 42 CFR 438.208, the LME shall share with other MCOs, LMEs, and PAHPs serving the enrollee the results of its identification and assessment of any enrollee with special health care needs (as defined by the state) so that those activities need not be duplicated.
