Medicaid Managed Care PCP Auto-Assignment Changes Based on Evidence of Active Beneficiary Treatment Relationship

Tuesday, December 15, 2020

As Medicaid and NC Health Choice transition to managed care, beneficiaries will be notified to select a NC Medicaid Managed Care Prepaid Health Plan (PHP) as well as a Primary Care Provider/Advanced Medical Home (PCP/AMH). Beneficiaries who do not self-select a PHP will be auto assigned by the Department following a set of established criteria.   

Consistent with 42 C.F.R. § 438.3(l), the NC Medicaid Managed Care PHPs must then ensure that each beneficiary has the choice to self-select a PCP/AMH. When a choice is made, the PHP must assign the beneficiary to their self-selected PCP/AMH. However, any beneficiary who does not make a selection during open enrollment will be assigned to a network PCP/AMH by the Health Plans. Note that PCP/AMH assignment will be made at the practice/site, not individual provider level.

Auto-Assignment Methodology

The PHP’s methodology for assigning beneficiaries to an PCP/AMH includes the following components to the extent that such information is available:

  1. Prior PCP/AMH assignment;
  2. Member claims history;
  3. Family member’s PCP/AMH assignment;
  4. Family member’s claims history;
  5. Geographic proximity;
  6. Special medical needs; and
  7. Language/cultural preference

During initial and subsequent beneficiary enrollment periods, PHPs have the option to re-assign beneficiaries when claims history fails to demonstrate an “active relationship” with their currently assigned PCP provided the auto assignment does not create any undue hardships for beneficiaries being reassigned. An “active relationship’ is defined as at least one claim in the last 18 months (non-ABD beneficiaries) or last 12-months (ABD beneficiaries). 

PHPs must look for an active relationship at both the PCP/AMH site level and within the same Tax Identification Number (TIN) as the historically assigned PCP/AMH. PHPs will also look for evidence of an active relationship when assigning members to a family member’s PCP/AMH. If a PHP finds no active relationship to a PCP/AMH for a member they should assign the member to a PCP/AMH of a family member where an active relationship is demonstrated.  

Current PCPs enrolled in Medicaid are encouraged to ensure that the “active relationship” criterion is met for currently enrolled beneficiaries. PCPs should also encourage their Medicaid and NC Health Choice patients to self-select their PHP and PCP/AMH during the open enrollment period.

PHPs are required to follow appropriate processes outlined in their Department/PHP contract for notifying the beneficiary of a change to their PCP/AMH assignment. The notification must outline the beneficiary’s rights and the process to follow if they wish to remain with their originally assigned PCP/AMH (in Medicaid Direct) or to select another participating PCP/AMH. PHPs are also required to update all provider-facing materials (i.e. provider manuals) any time the auto-assignment guidelines are updated.  

PCP/AMH providers must complete contracting with a health plan and appear in its provider directory to be recognized for auto assignment processes. See Health Plan Contacts and Resources for more information. 

Contact

Medicaid Contact Center: (888) 245-0179