Common use of Choice of Health Professional Clause in Contracts

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. 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 d4a0te 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: