Mont. Admin. R. 37.86.5303 - PASSPORT TO HEALTH'S TEAM CARE PROGRAM
(1)
A recipient may be subject to restrictions on, or prior approval for, physician
related services, pharmacy services or any other services covered by the
medicaid program if the department determines that the recipient's utilization
of service is excessive, inappropriate, or fraudulent with respect to medical
need.
(2) The restrictions
described in (1) may be imposed if any of the following events occur:
(a) the recipient seeks medical services that
are not medically necessary;
(b)
there is multiple provider usage that results in the receipt of unnecessary
services;
(c) there is repeated use
of emergency rooms for routine medical services;
(d) there is unwarranted multiple pharmacy
usage, indicated by the use of more than three pharmacies, that results in the
receipt of unnecessary prescriptions;
(e) there is admission of or conviction for
forgery of medicaid drug prescriptions by the recipient; or
(f) the recipient utilizes a medicaid card in
any unlawful or fraudulent manner.
(3) The department will use payment records,
reports from medical consultants, provider referrals or other pertinent
recipient or service information, to determine if recipient overutilization, or
other abuses, have occurred.
(4) A
recipient's restriction does not apply to other members of the
household.
(5) Restriction of
medicaid services may include limiting a recipient to a designated provider or
providers or requiring the recipient to obtain department approval to receive
non-emergent services. A recipient with restricted services is participating in
the team care program. Medicaid payment for medical services provided to a team
care participant will only be made to the recipient's designated provider(s)
except:
(a) when emergency services, as
defined at ARM
37.82.102(11),
are required;
(b) when the
designated provider refers the recipient to another provider; or
(c) when the department approved the service
prior to performance.
(6) A recipient restricted to the team care
program is required to participate in the passport to health program set forth
in this subchapter unless the recipient is ineligible, as that term is defined
in ARM 37.86.5102.
(7) A recipient whose medical service usage
meets the criteria for restriction listed in (2), but who is ineligible for the
passport to health program for the reasons listed in ARM 37.86.5102, may be
required to participate in the team care program. A recipient living in a
nursing home or institutional setting or a recipient whose eligibility period
is only retroactive cannot be required to participate in either the passport
for health or the team care programs.
(8) The department will notify a recipient in
writing at least 10 days prior to the date of the intended action restricting
medical services paid by the medicaid program.
(9) The department will determine the
provider type to which the recipient is restricted (pharmacy, physical health
provider or both). The recipient will have an opportunity to choose the
recipient's primary care provider and pharmacy unless:
(a) the department determines that the
selected provider has been sanctioned by the department in accordance with ARM
37.85.501;
(b) the designated review organization has
determined that the selected provider has not properly managed the medical care
of a recipient who has been restricted; or
(c) the selected provider will not accept the
recipient as a patient.
(10) The recipient will have 10 days from the
date of notification of restriction by the department to choose a primary care
provider and a pharmacy provider. If the recipient does not choose a primary
care provider and a pharmacy provider within 10 days, a primary care provider
and a pharmacy will be selected for the recipient. If the department is unable
to obtain a primary provider for the restricted recipient, all non-emergency
services must be prior authorized by the department.
(11) A restricted recipient may request a
change of provider. The request must be in writing and submitted to the
department for approval. Provider changes will not be approved unless the
department determines that there is good cause for the requested provider
change. The department will have 30 days to take action on the
request.
(12) The department will
review all restricted recipients annually unless the recipient's medical
service usage indicates an earlier review should occur. Restriction may be
continued if:
(a) the department determines
the recipient's use of services has remained excessive or unnecessary. Examples
of excessive or unnecessary usage include, but are not limited to, those listed
in (2) ;
(b) the designated
provider recommends, with supporting rationale, that the recipient should
remain restricted; or
(c) the
recipient has received or attempted to receive medicaid services not authorized
under the restricted card program.
Notes
Sec. 53-6-113, MCA; IMP, Sec. 53-6-104 and 53-6-113, MCA;
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