SECTION 354.2403. Monitoring and Review

(a) The Health and Human Services Commission (HHSC), in accordance with the Code of Federal Regulations, Chapter 42, §431.54(e), conducts a review and analysis of data and/or incoming referrals, such as referrals from medical providers, managed care organizations, state agencies, law enforcement officials, or members of the general public, to identify Texas Medicaid eligible recipients for lock-in.

(1) HHSC may impose a lock-in if it finds that:

(A) a recipient received duplicative, excessive, contraindicated, or conflicting health care services, including drugs; or

(B) a review indicates abuse, misuse or fraudulent actions related to Medicaid benefits and services.

(2) All Texas Medicaid eligible recipients are subject to lock-in regardless of age, program type, or Medicare eligibility.

(b) HHSC may continue the lock-in, change a designated provider(s), and/or take other interventions based on:

(1) utilization pattern(s) indicating excessive use or overuse;

(2) abuse, misuse, or fraud related to Medicaid services or benefits;

(3) non-compliance resulting in receipt of services or medications from one or more non-designated providers in the absence of a designated provider referral or emergency medical condition, including cash payment for services, or obtaining services through illicit methods that result in overutilization or duplicative medication or services;

(4) a designated provider's recommendation to continue the lock-in because the recipient demonstrated non-compliant behavior; or

(5) any change in designated provider due to the recipient's or provider's non-compliance.

(c) HHSC may terminate a recipient's lock-in status for:

(1) the lack of a designated provider accepting responsibility for the recipient; or

(2) evidence of medical necessity provided by the recipient or the designated provider.

(d) The recipient or designated provider may request a medical review of the lock-in at any time.

Source Note: The provisions of this §354.2403 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