SECTION 354.2405. Utilization Control

(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