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MEDICAL SERVICES POLICY MANUAL,SECTION F

F 100 Non Financial Eligibility Requirements

Each Health Care recipient must choose a Primary Care Physician (PCP) except those who: • Have Medicare as their primary insurance; • Are in nursing facility or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID); • Are Medically Needy Spend Down only; • Have retroactive eligibility only; or • Are temporarily absent from the state.

Generally, a recipient must receive medical services from only the PCP or from the medical provider referred to by the PCP. There are some services which are excluded from the Primary Care Case Management (PCCM) system. A recipient can receive these services without a referral from the PCP. Refer to Form DCO-2613, Notice to Health Care Applicants/Recipients, for a list of these excluded services.

F-162 Recipient Responsibilities MS Manual 07/01/20 A Primary Care Physician(PCP) must be chosen for each family member who is a recipient. Each member may have a different physician. The recipient must choose a physician who provides services in the recipient’s county of residence, in a county which adjoins the county of residence, or in a county whichadjoins the adjoining county. A recipient who lives in a county which borders another state may choose a physician in the bordering state. If a recipient chooses to see a health care provider other than the primary care physician, or otherthan a provider to whom the primary care physician has made a referral, therecipient will be responsible for payment for any services received.

F-164 Changes in Primary Care Physicians MS Manual 07/01/20 Achange in a recipient’s Primary Care Physician can be made in the following circumstances: 1. A physician moves from the county, closes his office, orwithdraws from the program 2. A recipient moves from the county