Emerging Practices in Medicaid Primary Care Case Management Programs. Who Can Be a Primary Care Provider?

06/01/2001

Generally, PCPs in PCCM programs are those physicians who practice primary care, such as pediatricians, family practitioners, general practitioners, internists, and in some instances, obstetricians and gynecologists. States also contract with providers in those settings where many Medicaid beneficiaries customarily seek care: Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs), and local public health departments. In Oklahoma, contracting with Indian Health Service PCPs has been explored and is currently under review by HCFA(now known as CMS). All eight case-study states allow some of these providers to serve as PCPs. Chart J shows the range of state policies in this area.

In an effort to maximize access to primary care and to build a network of providers, states also turn to physician extenders to be PCPs. In five of the case-study states (Florida, Maine, North Carolina, Oklahoma, and Texas), nurse practitioners and/or physician assistants are allowed to enroll as PCPs. North Carolina and Texas also include nurse midwives as PCPs. In all instances, state officials comment that using these practitioners as PCPs is essential for increasing access to consistent primary care in their PCCM programs. Although several officials note that the inclusion of physician assistants and nurse practitioners is particularly important in providing access to care in rural areas where there may not be enough physicians, others report that it is equally important in urban areas where physicians cannot accommodate additional patients.

State Program # Providers Participating
(Latest Figures)
Allowable Provider Types
Chart J:
PCCM Providers
Alabama Patient 1st 1500 (both solo and group practices) GP, family practitioner, internist, pediatrician, OB/GYN, FQHC, RHC, specialist approved case by case
Florida MediPass 5000 (in 3000 practices) plus disease mgmt. orgs. and provider svc. network GP, family practitioner., internist, pediatrician, OB/GYN, FQHC, RHC, specialist approved case by case
Iowa MediPASS 1400 providers GP, family practitioner., internist, pediatrician, OB/GYN, FQHC, RHC, specialist approved case by case
Maine Maine PrimeCare 1215 PCPs at 420 sites GP, family practitioner, internist, pediatrician, OB/GYN, FQHC, RHC, NP, PA
MaineNET/ Partnership 15 GP, family practitioner, internist, NP, PA, specialists if part of a pilot practice site and doing primary care
North Carolina ACCESS I 1500 sites (not individual physicians)

GP, family practitioner, internist, pediatrician, OB/GYN, FQHC, RHC, NP, PA, nurse midwife, PH department

ACCESS II 139 practices (April)
ACCESS III
Oklahoma SoonerCare Choice PCCM Model 610 GP, family practitioner, internist, pediatrician, OB/GYN, FQHC, RHC, NP, PA
Texas Texas Health Network 2,554

GP, family practitioner, internist, pediatrician, OB/GYN, FQHC, RHC, NP, nurse midwife, psychiatrist or other specialist approved case by case

STAR+PLUS 806
Virginia MEDALLION 2042 (active providers) GP, family practitioner, internist, pediatrician, OB/GYN, FQHC, RHC, local PH depts., specialists approved case by case

States have varying criteria as to when they allow specialists to serve as PCPs. Among the case-study states, Alabama, Florida, Iowa, Texas, Virginia, and the MaineNET/Partnership program in Maine approve specialists as PCPs on a case-by-case basis. Officials in states that include persons with special needs in their managed care programs note the importance of identifying the provider who can best serve as the medical home for the member. For example, a pediatrician may remain the PCP for an individual with mental retardation who transitions to adulthood, or a specialist who has been caring for a child with cerebral palsy may be identified as the appropriate PCP when the child enrolls in managed care. Some states make provisions for a specialist to act as the PCP on a time-limited basis if the member's medical needs are better met by that physician for the duration of an illness or condition. The MaineNET program, which enrolls aged and disabled adults, will approve a specialist as the PCP if that physician also provides primary care.

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