PCP Selection

PCP selection/assignment monthly letters are sent to all new CommunityCARE eligibles. The letter includes a list of participating CommunityCARE PCPs and instructions for choosing a PCP. Members have a minimum of 10 calendar days to call the CommunityCARE Member Hotline and make their PCP selection. If the member does not take the action necessary to choose their PCP, the member(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 member and PCP, and the equitable distribution of members to participating PCPs accepting new members 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 members based on age and/or medical needs.

PCP Assignment Confirmation

Monthly letters are mailed to new CommunityCARE members 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 30 and 60 days for new Medicaid eligibles. Until a Medicaid member is linked to a PCP, as indicated by the REVS/MEVS/eMEVS system, the member 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 member, as indicated in the REVS/MEVS/eMEVS system, is authorized to provide services or referrals.

PCP Changes

CommunityCARE members 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. Members 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 from the 5th, through the last working day of the month, become effective the first day of the following month. PCP change requests received after the 5th, through the last working day of the month, become effective the first day of the second month after the change is requested. This deadline may change slightly from month to month due to weekends and holidays. Providers are encouraged to verify eligibility, including PCP linkage in the REVS/MEVS/eMEVS system.

Without Cause PCP change requests by member

The member is permitted to change a PCP linkage within 90 days of the effective date each time he/she is linked to a new PCP.

The member is permitted to change PCPs without cause at least once every 12 months as well as during annual open enrollment, which occurs from approximately October 23 to December 23 of each year. If an member does not change their PCP within this open enrollment period, they remain linked to their current PCP.

For Cause PCP change requests by member

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

• The member 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 member is experiencing difficulty obtaining transportation to their assigned PCP
• The member has an unresolved language barrier with his/her PCP
• A new CommunityCARE provider offers a specialty previously unavailable, within geographic proximity, that better meets his/her health care needs
• The member wants to remain linked to a CommunityCARE PCP who is changing practice affiliation and or location
• The member moved and is now closer to another CommunityCARE PCP
• The PCP does not cover the service an member seeks based on moral or religious objection
• The member does not have access to all the services to which he/she is entitled
• The patient/provider relationship is not mutually compatible and/or acceptable

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