General | PCCM Patient Population | Physician Network | Reimbursement | Primary Care Physician/Provider Responsibilities | Utilization Management and Quality Improvement | Patient Enrollment and Education | Patient Education
Q: What is the Primary Care Case Management (PCCM) model?
A: PCCM is a managed fee-for-service arrangement, utilizing a network of primary care physicians and health care providers to serve as the "medical home" for Medicaid patients. It is administered by the Texas Medicaid and Healthcare Partnership (TMHP), a collaborative between the Health and Human Services Commission and a private contractor, ACS/Birch & Davis Health Management Corporation. PCCM is not a Medicaid HMO; it involves no financial risk or capitation.
Q: Is a physician required to submit an application to participate in PCCM?
A: The state requires primary care physicians and providers (PCPs) to sign an attestation form to participate in PCCM. The attestation is an addendum to PCPs' current Medicaid provider agreement and specifies physicians' responsibilities as a PCP. The attestation also allows PCPs to provide important information about their practice to the state, such as whether you will accept current patients only or also new patients; practice hours; special services offered by you or your staff, such as after-hours care; and any age or gender limitations on the patients you accept.
Specialists participating in Medicaid are not required to submit additional information unless they want to be designated a PCP.
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PCCM Patient Population
Q: Will all Medicaid recipients be required to enroll in PCCM?
A: Most Medicaid patients will be required to enroll, including pregnant women, children, low-income parents, and adult patients with disabilities receiving Supplemental Security Income (SSI). Children with disabilities receiving SSI may enroll voluntarily. Patients who are dually eligible for Medicaid and Medicare are not eligible for PCCM nor are patients receiving long-term care services, such as patients in nursing homes or states schools.
Q: Is there a limit on the number of patients that can be assigned to a PCP practice? I've been told the maximum is 1,500.
A: No, there is no limit imposed by the state. PCP practices, however, can limit the number of patients they willing to accept.
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Q: What specialties are eligible to become primary care physicians within PCCM?
A: General practice, family practice, OB-Gyn, internal medicine, and pediatrics. Additionally, certified nurse midwives, advanced nurse practitioners (pediatrics/family practice), rural health clinics, and federally qualified health centers can be designated as PCPs. Physician assistants (PAs) may not be designated as PCPs since PAs do not have an individual Medicaid provider number. However, they may provide services under physician designation just as in traditional Medicaid. Specialists may also opt to act as PCPs for patients with chronic illnesses.
Q: Can a family physician provide OB services under PCCM?
A: Yes. PCCM maintains existing Medicaid rules regarding the services physicians may provide.
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Q: How are primary care physicians reimbursed within PCCM? How are specialists reimbursed?
A: PCCM payments will be made by the current Medicaid claims payer, TMHP, according to the current Medicaid fee schedule. PCPs are paid the current Medicaid fee schedule plus a $2.97-per member/per month case management fee. PCPs should submit claims according to current guidelines. The monthly case management fee will be sent automatically at the beginning of each month. Specialists are paid the traditional Medicaid fee schedule.
All existing Medicaid claims requirements remain in place.
Q: PCPs are paid an additional case management for each patient enrolled with the practice. How do I know how many patients are assigned to my practice each month?
A: Each month, TMHP sends PCPs a list of patients in the practice. Panel reports are sent to PCPs between the first and sixth of each month. PCPs also may view panel reports online at www.tmhp.com .
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Primary Care Physician/Provider Responsibilities
Q: Patients often do not know who their PCP is. What should I do if a patient schedules an appointment with me and I am not the PCP? Will I be paid if services are provided?
A: The patient's Medicaid ID form lists the name of the PCP. If you are not the PCP of record, but the patient is seeking services, you may contact the PCP of record to obtain a referral. If the patient's PCP prefers to treat the patient, you should refer the patient back to the PCP, unless there is an emergency situation requiring immediate attention. Physicians also can contact TMHP to request an in-house referral, which is assessed on a case-by-case basis.
Q: I'm in a solo practice. When I'm temporarily away from the office, I refer my patients to a nearby physician to cover my practice. Will the physician who covers my practice have to obtain prior authorization before treating my patients?
A: Prior authorization is not needed in this situation. When billing, the physician covering your practice would simply submit claims and put your name and TPI number in boxes 17 and 17a ("referring provider" fields), respectively.
Q: I work in a group practice where some physicians accept Medicaid and others do not. Will the transition to PCCM affect our ability to provide "call" coverage?
A: To receive Medicaid reimbursement, a physician or provider must be enrolled in the Medicaid program. Physicians providing on-call services for emergency care can apply for retroactive coverage. To assure timely payment, it is recommended that physicians providing on-call coverage maintain a Medicaid number. A Medicaid number does not obligate a physician or provider to accept Medicaid patients on a routine basis but will expedite billing and payment in emergency situations.
Q: Are hospitals required to obtain PCP approval prior to providing emergency services?
A: No. Federal law requires hospitals to screen and stabilize emergency patients before seeking prior authorization or inquiring about insurance status. After the patient is screened and stabilized, the emergency department may contact the PCP to discuss and coordinate additional, medically necessary services. PCCM utilization management guidelines abide by the "prudent layperson" definition of an emergency.
Q: Must primary care physicians and providers be on call 24 hours per day, seven days a week?
A: The state requires PCPs participating in the PCCM program to provide or arrange patient telephone access to needed medical information or care 24 hours per day, seven days a week. The intent of the requirement is to ensure that patients have continuous access to medical services or advice. Acceptable coverage requirements including the following:
- Have an answering machine or professional answering service answer the phone after hours directing a patient how to reach you or a designated back-up,
- Have your after-hours calls answered by an answering machine that directs the patient to another medical facility where he or she can discuss with a health professional whether emergency treatment is necessary, and
- Have your after hours calls transferred to another location where you or a back-up provider can be reached.
In parts of the state where limited back up providers are available, the state and the PCCM administrator will work with physicians to develop acceptable solutions.
Q: Can I limit the number of PCCM patients I accept?
A: Yes. Primary care physicians can limit their practices to current/established patients only or indicate that they also will accept new patients.
Q: As an OB-Gyn, am I obligated to serve as a patient's primary care physician?
A: No. If you prefer, you may designate your practice as a specialist, allowing PCPs to refer pregnant patients to you. Referrals can be made for the length of the pregnancy, but the patient would rely on her regular PCP for treatment not related to the pregnancy. For OB-Gyns not acting as a PCP, women may self refer for the following services: annual well-woman exams; care related to pregnancy; care for all active gynecological conditions; and diagnosis, treatment, and referral to a Medicaid OB-Gyn for any disease or condition within the scope of the professional practice of a licensed OB-Gyn, including treatment of medical conditions concerning the breasts.
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Utilization Management and Quality Improvement
Q: What services are required to be preauthorized?
A: Prior authorization is limited to high-cost or unusual services. Services requiring prior authorization include:
- MRIs, MRAs, all laser surgeries, endoscopic procedures, all podiatry procedures, pH probe tests, and sleep studies;
- Specialist-to-specialist referrals;
- All nonemergent surgical procedures, including those performed during a hospital admission; and
- All nonemergent inpatient admissions ( excluding routine deliveries).
For detailed information regarding services requiring prior authorization, physicians should refer to the Medicaid Provider Manual , which can also be found at www.tmhp.com .
Q: What type of referral management to specialty care is anticipated?
A: PCPs can refer patients to any specialist participating in Medicaid. As the patient's medical home, PCPs are responsible for coordinating the referral. TMHP provides PCPs a referral form to help coordinate and arrange specialty care, but PCPs are not required to use the form.
To arrange a referral, the PCP must give the specialist his or her Medicaid provider number at the time of the referral. PCPs may authorize one visit, a specified number of visits, or a specified period of time.
When submitting a claim for specialty care, specialists must include the PCP's Medicaid ID number on the claim. Refer to the PCCM provider manual for additional information.
Q: Can I refer to specialists out-of-network?
A: PCPs can refer to any specialist within the state who accepts Medicaid. For example, if you practice along the border but want to refer a patient to a subspecialist in Houston, you may do so. PCPs must follow the referral guidelines listed above.
Q: I am a specialist. If a patient seeks my services without a PCP referral, what should I do?
A: Referrals are required for specialty services. You may contact the PCP via phone to obtain a referral. The PCP's name is listed on the patient's Medicaid ID form. If the treating physician is unable to obtain a referral, you may contact TMHP, which can assign an in-house referral number on a case-by-case basis after evaluation. If the patient presents with an emergency condition, physicians should not delay medically necessary services. TMHP should be contacted subsequently to obtain an authorization number for treatment.
Q: I am a specialist. If I treat a Medicaid patient on referral from a PCP but subsequently determine that additional specialty consultation is required, can I refer the patient to another specialist, or must the PCP do this?
A: Specialty-to-specialty referrals must be communicated to the PCP. The PCP may then authorize a referral to the second specialist, following the procedure outlined above. For further details, refer to the PCCM provider manual.
Q: Are PCPs required to obtain prior authorization for specialty care?
A: No. Preapproval is not required for specialty services, just a referral (see above).
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Patient Enrollment and Education
Q: How do Medicaid patients select a primary care physician or provider (PCP)?
A: The Health and Human Services Commission, in collaboration with TMHP, conducts patient education and enrollment. Materials are developed in both English and Spanish and were sent to patients about two-and-a-half months prior to implementation. The educational material explain the concept of a "medical home," including the importance of establishing a relationship with a PCP who will coordinate and manage that patient's care.
Enrollment material for Medicaid recipients will list a "suggested PCP" for the patient, based on recent medical history. Patients who want to keep the PCP named in the letter will not have to take further action. Patients who wish to select another PCP may call the PCCM Client Hotline toll-free at (888)-302-6688 to make a change. The member education packet will contain a list of local PCPs participating in the network. Patients may also go to www.tmhp.com to find a participating PCP in their area. If a patient does not select a PCP, the state will make an assignment based on previous patient-physician relationships, location, and other factors. Patients can subsequently change their PCP assignment.
Q: If a patient does not select a PCP within the allotted time frame, what will the patient default mechanism be?
A: Patients who do not select a primary care physician will be assigned to one by the state. Criteria used in making the assignment are previous or existing patient-provider relationships, family-provider relationships, and geographic access. Patients who are dissatisfied with their assignment may request a change by contacting the patient enrollment broker. Patients can change their PCP up to four times per year or at any other time for cause.
Q: How frequently can a patient change his or her PCP?
A: Patients can change their PCP up to four times per year or any other time if there is a good cause (e.g., moved to a new location or current PCP does not offer necessary services.)
Q: If a patient changes his or her PCP, when will the change become effective?
A: If a request to change a PCP is received in the first half of the month, the change will go into effect on the first day of the month following the request. If the request is received in the latter two weeks of the month, the change will be effective on the first day of the second month following the request. In emergency situations, TMHP can work with the patient to make a PCP change more quickly.
Q: Will the PCCM model limit the number of Medicaid patients I can accept?
A: No. In older iterations of the PCCM model, the state did limit physicians to 1,500 patients per practice. However, the limit was repealed several years ago. Physicians determine the number of Medicaid patients accepted in the practice.
Q: Will the expansion of PCCM require physicians to accept new Medicaid patients?
A. No. Physicians can indicate on the PCP attestation form that they are accepting current/established patients only. Physicians can change this designation should the practice decide to accept new patients.
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Q: Can physician offices assist in patient education?
A: Within limits. Physicians are allowed to inform patients whether or not they are participating in PCCM and whether they are accepting new patients. Physicians may also distribute state-developed patient educational materials. If a patient is in the office and asks to call the PCCM Client Hotline to change his or her PCP selection, the patient may make the call from the PCP office so long as it is the patient's choice.
Physicians may not provide incentives or inducements for patients to select their office as their primary care medical home. Physicians also are not allowed to collect PCP change request reforms and return them on behalf of the patient.
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