Sec. 5-30.5. Managed care; automatic assignment.
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Sec. 5-30.5. Managed care; automatic assignment. The Department shall, within a reasonable period of time after relevant data from managed care entities has been collected and analyzed, but no earlier than January 1, 2017, seek input from the managed care entities and other stakeholders and develop and implement within each enrollment region an algorithm preserving existing provider-beneficiary relationships that takes into account quality scores and other operational proficiency criteria developed, defined, and adopted by the Department, to automatically assign Medicaid enrollees served under the Family Health Plan and the Integrated Care Program and those Medicaid enrollees eligible for medical assistance pursuant to the Patient Protection and Affordable Care Act (Public Law 111-148) into managed care entities, including Accountable Care Entities, Managed Care Community Networks, and Managed Care Organizations.
The quality metrics used shall be measurable for all entities. The algorithm shall not use the quality and proficiency metrics to reassign enrollees out of any plan in which they are enrolled at the time and shall only be used if the client has not voluntarily selected a primary care physician and a managed care entity or care coordination entity. Clients shall have one opportunity within 90 calendar days after auto-assignment by algorithm to select a different managed care entity.
The algorithm developed and implemented shall favor assignment into managed care entities with the highest quality scores and levels of compliance with the operational proficiency criteria established, taking into consideration existing provider-beneficiary relationship as defined by 42 CFR 438.50(f)(3) if one exists.