360-6.8 Medical care coordinator program (MCCP).
(a) Policy. Effective July 1, 1992, an recipient who is eligible for
medical assistance (MA) solely as a result of being eligible for or in receipt of Home
Relief (HR) and who is at least 21 years of age but under the age of 65 (MA/HR recipient),
may receive certain MA services only if the recipient is enrolled in a health maintenance
organization or other entity which provides comprehensive health services, a managed care
program, a primary provider program, or a voluntary medical care coordinator program
(MCCP).
(b) Scope. This section defines the MCCP; specifies the rights of
participating recipients; establishes the qualifications and responsibilities of
participating primary physicians, diagnostic and treatment centers, hospital out-patient
departments and pharmacies in providing and coordinating medical care, services and
supplies for participating recipients; and sets forth the responsibilities of social
services districts in administering the MCCP.
(c) Definitions. As used in this section, unless expressly stated
otherwise or unless the context of the subject matter requires a different interpretation:
(1) MCCP means a program in which an MA/HR
recipient voluntarily enrolls with a primary physician, diagnostic and treatment center or
hospital out-patient department and a primary pharmacy which will provide or refer the MA
recipient to medically necessary services and will further coordinate the use of medical
services to assure that the recipient receives appropriate medical care, services and
supplies and that MA is provided in an appropriate and cost-effective manner.
(2) MA/HR recipient means a person who is
eligible for MA solely as a result of being eligible for or in receipt of HR and who is at
least 21 years of age but under the age of 65.
(3) Primary provider means a physician,
diagnostic and treatment center, or hospital out-patient department enrolled in the MA
program which has agreed to coordinate the health care of an MA/HR recipient and to
provide and/or direct all medically necessary care, services and supplies for which the
MA/HR recipient is eligible.
(4) Primary pharmacy means a pharmacy enrolled
in the MA program which has agreed to provide all drugs and pharmaceutical supplies
ordered for an MA/HR recipient enrolled in the MCCP.
(d) Recipient participation. Participation by an MA/HR recipient in the
MCCP is voluntary.
(e) Recipient responsibilities.
(1) An MA/HR recipient who wishes to
participate in the MCCP must obtain a copy of the provider selection form from his or her
social services district, complete the form and return it to the social services district.
(2) The MA/HR recipient must identify on such
form his or her choice of primary physician, diagnostic and treatment center or hospital
out-patient department, and his or her choice of primary pharmacy, and obtain agreement
from the providers that they will be the primary provider and primary pharmacy. An
identified provider agrees to be a primary provider or primary pharmacy for an MA/HR
recipient by signing a selection form.
(3) An MA/HR recipient who participates in the
MCCP may change his or her primary provider or primary pharmacy by completing a provider
change form furnished by the social services district if another primary provider or
primary pharmacy satisfactory to the recipient agrees to act as the primary provider or
primary pharmacy.
(4) An MA/HR recipient who participates in the
MCCP may withdraw from the MCCP at any time by completing a recipient withdrawal form
furnished by the social services district.
(5) If an MA/HR recipient volunteers to
participate in the MCCP but no primary provider or primary pharmacy is sufficiently
accessible or no primary provider or primary pharmacy which is sufficiently accessible
agrees to be the recipient's primary provider or primary pharmacy, the recipient may
receive the MA services which are available to participating MA/HR recipients without
enrolling in the MCCP. The recipient will continue to receive these services until a
provider or pharmacy affiliated with a health maintenance organization or other entity
which provides comprehensive health services, a managed care program, a primary provider
program, or the MCCP is sufficiently accessible and agrees to provide medical care or
pharmacy services to the recipient, at which time the MA/HR recipient must enroll in such
program in order to continue to receive such MA services.
(f) Provider responsibilities.
(1) A primary provider or primary pharmacy must
furnish written confirmation to a social services district, prior to acting as a primary
provider or primary pharmacy, of the provider's agreement to act as primary provider or
primary pharmacy and to comply with all requirements of this section. A provider confirms
such agreement by signing the provider selection form presented by the MA/HR recipient.
(2) A primary provider or primary pharmacy may
act as a primary provider or primary pharmacy with respect to a particular MA/HR recipient
only on and after the effective date of the recipient's enrollment in the MCCP. The social
services district will inform the primary provider or primary pharmacy in writing of the
recipient's enrollment in the MCCP.
(3) A primary provider is responsible for
providing, either directly or through referral to another qualified MA provider, all MA
covered care, services and supplies to an MA/HR recipient enrolled in the MCCP. The
primary provider is responsible for ordering or directing the following services for an
enrolled MA/HR recipient:
(i) laboratory
services;
(ii) durable medical
equipment;
(iii) pharmacy
services; and
(iv) medically
necessary and appropriate non-emergency transportation services.
(4) A physician acting as primary provider for
an enrolled MA/HR recipient will receive a monthly management fee of $10.00 for managing
and coordinating the care of each MA/HR recipient for which the physician is the primary
provider.
(5) A pharmacy acting as primary pharmacy must
institute and maintain a current patient profile for each enrolled MA/HR recipient. A
current patient profile must contain: the identity of the prescriber of a drug or
pharmaceutical supply; the strength, quantity and dosage regimen of a drug; and the date
of service for the dispensing of a drug or pharmaceutical supply. A current patient
profile must be readily accessible to the department and its designated agents upon
request. The primary pharmacy also must adhere to all drug utilization review requirements
under the MA program.
(g) Social services district responsibilities.
(1) Each social services district will be
primarily responsible for administration of the MCCP.
(2) Each social services district must take
actions necessary for the efficient and effective functioning of the MCCP, including:
(i) assisting MA/HR
recipients to enroll in the MCCP;
(ii) assisting enrolled
MA/HR recipients to choose primary providers and primary pharmacies;
(iii) processing the
provider selection forms promptly and determining the effective dates of recipients
enrollment in the MCCP;
(iv) providing written
notice to MA/HR recipients and identified primary providers and primary pharmacies
confirming the MA/HR recipients' effective dates of enrollment in the MCCP;
(v) processing primary
provider and primary pharmacy change forms and recipient withdrawal forms promptly and
determining the effective dates of changes or withdrawals from the MCCP;
(vi) providing to MA/HR
recipients and the primary providers and primary pharmacies a written notices confirming
the effective dates of MA/HR recipients' participation in or withdrawals from the MCCP and
providing to MA/HR recipients a list of the MA services which the recipients will become
ineligible to receive upon the effective dates of withdrawals unless the MA/HR recipients
have enrolled in other managed care programs;
(vii) determining
whether available primary providers are sufficiently accessible to MA/HR recipients so
that services can be reasonably provided to recipients;
(viii) advising the
department when recipients have problems obtaining access to primary providers or primary
pharmacies; and
(ix) entering necessary
data into WMS to support timely implementation of the MCCP and recipients' enrollment,
changes in primary providers or primary pharmacies, or withdrawals from MCCP.