| (a) The Health and Human Services Commission (HHSC)
controls a recipient's inappropriate use of Medicaid benefits or services
by restricting the recipient to a designated provider(s).
(b) HHSC will send a recipient written notification
of intent to restrict the recipient to a designated provider. The
notice will include a form allowing the recipient the opportunity
to select a designated provider and will inform the recipient of the
length of the lock-in period and the recipient's right to a hearing.
HHSC will select a designated provider for the recipient if it does
not receive the completed form within ten days from the date of the
initial notice.
(c) HHSC assigns a lock-in period to a recipient. A
recipient remains in lock-in status regardless of a change in address
or eligibility program type. HHSC will review and determine whether
to continue a recipient's lock-in status prior to the end of a lock-in
period.
(1) A recipient who has never been in lock-in status
will be assigned a 36-month lock-in period. If a recipient's Medicaid
eligibility ends and reactivates during the 36-month lock-in period,
then upon reenrollment in Medicaid, that recipient will be locked
in for the remaining number of months in the original lock-in period.
(2) A recipient who has completed the 36-month lock-in
period and is reinstated to lock-in status will be assigned a 60-month
lock-in period. If a recipient's Medicaid eligibility ends or reactivates
during the 60-month lock-in period, then upon reenrollment in Medicaid,
that recipient will be locked in for the remaining number of months
in the lock-in period.
(3) A recipient is assigned a lifetime lock-in period
if the recipient:
(A) has completed the 60-month lock-in period;
(B) is arrested, indicted, or convicted of a crime
relating to Medicaid fraud, or of a felony offense relating to controlled
substances; or
(C) admits guilt of Medicaid fraud, or a felony offense
related to controlled substances.
(d) A recipient may request a change of a designated
provider(s) during a lock-in period.
(1) HHSC determines whether a change in the designated
provider is required or warranted.
(2) A designated provider change that is not the result
of a recipient's request during the course of the lock-in period does
not require recipient approval.
(3) HHSC may change a designated provider for, but
not limited to, the following reasons:
(A) a change of the recipient's residence from the
geographic area of the designated provider(s);
(B) notice from the designated provider(s) that they
will no longer serve as the designated provider;
(C) closure or relocation of a designated provider's
office;
(D) death of the designated provider;
(E) disenrollment of the designated provider(s) from
the Medicaid program;
(F) notice that the designated provider is under administrative
action, sanction or investigation or failure to comply with Medicaid
rules or acceptable Medicaid practice;
(G) notice that the designated provider is under sanction
or other administrative actions by a state licensing board or other
regulatory entity that prevents the provider from practicing;
(H) the primary health care provider may be overprescribing
medication or services;
(I) the designated pharmacy provider is filling prescriptions
from multiple providers other than the designated primary health care
provider or a prescriber to whom the recipient was referred by the
designated primary health care provider; or
(J) a change in the recipient's medical condition that
the designated primary health care provider is unable to treat or
refer to another provider.
(e) A change in the designated provider or Medicaid
provider does not affect the status of the lock-in period unless the
recipient was receiving prescriptions pursuant to subsection (d)(3)(H)
or (I) of this section.
|
| Source Note: The provisions of this §354.2405 adopted to be effective April 2, 2000, 25 TexReg 2817; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4563; amended to be effective April 6, 2003, 28 TexReg 2738; amended to be effective April 2, 2013, 38 TexReg 2095 |
