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: a. Providers Qualifying as Primary Care Providers (PCP) i. Pediatricians; ii. Family and General Practitioners; iii. Internists; iv. Obstetrician/Gynecologists; v. Nurse Practitioners; vi. Physician Assistants; vii. Specialists who perform primary care functions, e.g., surgeons, clinics, including but not limited to Federally Qualified Health Centers, Rural Health Clinics, Health Departments, and other similar community clinics; or viii. Other providers approved by the Division. b. Specialists as PCPs

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: a. Providers Qualifying as Primary Care Providers (PCP)) The following types of specialty providers may perform as Primary Care Providers: i. Pediatricians; ii. Family and General Practitioners; iii. Internists; iv. Obstetrician/Gynecologists; v. Nurse Practitioners; vi. Physician Assistants; vii. Specialists who perform primary care functions, e.g., surgeons, clinics, including but not limited to Federally Qualified Health Centers, Rural Health Clinics, Health Departments, and other similar community clinics; or viii. Other providers approved by the Division. b. Specialists as PCPsPCPs Enrollees with disabling conditions, chronic illnesses, or child(ren) with special health care needs may request that their primary care provider be a specialist. The Contractor shall make a good faith effort to ensure that a child for whom the PCP is a specialist receives EPSDT services, including immunizations and dental services. The Contractor shall have in place procedures for ensuring access to needed services for these enrollees or shall grant these PCP requests, as is reasonably feasible and in accordance with Contractor’s credentialing policies and procedures. Unless required by the Affordable Care Act (ACA), a specialist serving as a PCP will not be entitled to be paid the increased rate required by the ACA. c. Enrollee Choice of PCP The Contractor shall offer each enrollee covered under this Contract the opportunity to choose from at least two (2) PCPs affiliated with the Contractor based on availability.

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: a. Providers Qualifying as Primary Care Providers (PCP) i. Pediatricians; ii. Family and General Practitioners; iii. Internists; iv. Obstetrician/Gynecologists; v. Nurse Practitioners; vi. Physician Assistants; vii. Specialists who perform primary care functions, e.g., surgeons, clinics, including but not limited to Federally Qualified Health Centers, Rural Health Clinics, Health Departments, and other similar community clinics; or viii. Other providers approved by the Division. b. Specialists as PCPs