10.09.24.14-1

.14-1 Recipient Abuse.

A. Forms of Abuse. Recipient abuse exists when:

(1) A recipient utilizes an inappropriate type of provider for care;

(2) A recipient utilizes an appropriate type of provider at an inappropriate frequency for care;

(3) A recipient utilizes an appropriate provider in an inappropriate manner; or

(4) A recipient utilizes a Medical Assistance card in an inappropriate manner.

B. Examples. The following are examples of circumstances that may be recipient abuse:

(1) Misrepresenting to a provider material facts regarding symptoms, circumstances, or treatment by other providers;

(2) Failing to affirmatively disclose to a provider any treatment or services being provided by another provider;

(3) Losing or failing to maintain security sufficient to prevent loss or theft of more than one Medical Assistance card during a certification period;

(4) Utilizing an emergency room of a hospital or a specialty outpatient clinic of a hospital as a primary care provider when primary care providers are available in the service area in which the recipient resides;

(5) Underutilizing the appropriate providers for the proper care and management of an existing health condition;

(6) Obtaining medications that require close physician monitoring while not appropriately using the physician services which could provide the monitoring;

(7) Using or maintaining custody or possession of a Medical Assistance card in such a manner that it is used for an unauthorized or illegal purpose.

C. Procedures.

(1) The Department or its designee, shall determine whether recipient abuse exists using the procedures in §C(2)—(8) of this regulation.

(2) Cases may be reviewed on the basis of statistical reports, outside complaints, referrals from other agencies, or other appropriate sources.

(3) A preliminary review shall be conducted to determine whether the recipient's alleged or noted behavior is of the form specified under §A(1)—(3) of this regulation or is of the form specified under §A(4) of this regulation.

(4) If the alleged or noted behavior is one of the types listed in §A(1)—(3) of this regulation, all relevant and available information shall be forwarded for medical review as specified under §B(5) of this regulation.

(5) If the alleged or likely behavior is of the type listed in §A(4) of this regulation, all relevant and available information shall be forwarded for administrative review as specified under §C(7) of this regulation.

(6) When a case is referred for medical review, a medical professional employed by the Department or its designee shall determine whether the recipient's use of medical services constitutes abuse, as defined under §A(1), (2), or (3) of this regulation. The medical reviewer shall consider all relevant and available information including Medical Assistance payment records and information secured from interviews, if conducted, in making a decision. The reviewer may, when appropriate, obtain records from other sources, including providers of medical services.

(7) When a case is referred for administrative review, a determination shall be made by the Department or its designee, regarding whether the recipient's use of benefits constitutes abuse as defined under §A(4) of this regulation.

(8) If a recipient has been convicted of a crime involving use of Medical Assistance benefits, as defined in §A of this regulation, the Department or its designee may consider the recipient to have committed abuse as described under §A(4) of this regulation.

D. Notice. A recipient determined to have abused the Medical Assistance entitlement shall receive notice to that effect. Notice includes the following:

(1) A statement of the reason or reasons why the recipient was found to have abused the Medical Assistance entitlement;

(2) If applicable, a statement that the recipient will be enrolled in the Corrective Managed Care Program and the effective date and duration of that enrollment;

(3) A statement regarding an opportunity to provide additional information which will be considered before enrollment becomes effective;

(4) If applicable, a statement regarding an opportunity to identify a preference for an assigned primary medical care provider or pharmacy; and

(5) A statement of appeal rights under Regulation .13 of this chapter.

E. Consideration of Recipient Information.

(1) Additional information received from the recipient under §D(3) of this regulation is considered relative to the appropriateness of the recipient's enrollment in the Corrective Managed Care Program.

(2) Notice of the determination of the Department or its designee regarding the additional information shall be sent to the recipient. The notice shall either confirm or reverse the decision to enroll the recipient.

(3) Information received from the recipient under §D(4) of this regulation is considered relative to the designation of a primary medical provider or pharmacy in accordance with §G(7) of this regulation.

F. Corrective Managed Care Program.

(1) A recipient determined to have abused the Medical Assistance entitlement shall be enrolled in the Corrective Managed Care Program in which the recipient shall be required to meet the requirements of §F(1)—(3) of this regulation.

(2) The recipient shall obtain all covered physician, hospital outpatient and inpatient, and clinic services, except methadone clinic and all other drug and alcohol abuse services and emergency services, from, or upon written referral by, a single primary medical provider.

(3) The recipient shall obtain prescribed drugs only from a single designated pharmacy provider, except in an emergency or pursuant to hospital inpatient treatment.

G. Provider Selection.

(1) The Department or its designee shall select primary medical and pharmacy providers for the recipient according to the requirements of §G(2)—(7) of this regulation.

(2) The primary medical provider may be any physician who participates in the Medical Assistance Program and whose practice ischiefly in one of the following specialties which include general practice, family practice, pediatrics, obstetrics-gynecology, or internal medicine.

(3) The Department or its designee may also designate a physician group, community health center, or clinic which participates in the Program as a physician provider and which assigns practitioners in one or more of the specialties named under §G(2) of this regulation to be the designated primary medical provider for the recipient.

(4) The Department or its designee may designate a provider which delivers limited or specialty services if the designation is in the recipient's best interest and the provider agrees to deliver or manage the recipient's primary care and refer the recipient for other services as necessary.

(5) The pharmacy provider may be any pharmacy, or any single branch of a pharmacy chain, which participates in the Medical Assistance Program.

(6) The recipient shall be afforded an opportunity to suggest primary medical and pharmacy providers. However, the Department or its designee is not bound by the recipient's suggestion and may designate other providers if, in its sole discretion, the recipient's choice of provider would not serve the recipient's best interest in achieving appropriate use of the health care system and of Medical Assistance benefits.

H. The Program may designate a new primary medical or pharmacy provider if the:

(1) Recipient moves out of the service area of the provider;

(2) Provider originally selected refuses to serve as the recipient's provider;

(3) Program determines that the provider is not reasonably accessible to the recipient or does not meet accepted standards of medical or pharmacy practice;

(4) Recipient has not responded affirmatively to the imposition of restrictions; or

(5) Recipient's best interest in achieving appropriate use of the health care system and of Medical Assistance benefits would, in the Program's sole discretion, be better served by an alternative designation.

I. Time of Period of Enrollment for the Corrective Managed Care Program.

(1) The period of enrollment is 24 months.

(2) A recipient who has completed the period of enrollment and who is subsequently found, through the procedures specified under §C of this regulation, to have resumed abusive practices, shall be enrolled for an additional period of 36 months.

(3) A recipient found to have abused Medical Assistance benefits while enrolled in the Corrective Managed Care Program shall have the enrollment period extended for 24 months.

(4) A recipient who has been found on three separate determinations under §C(5)—(7) of this regulation to have abused Medical Assistance benefits shall be enrolled for a period of 60 months.

J. If an enrolled recipient loses and regains eligibility for Medical Assistance benefits, the recipient shall be re-enrolled at the resumption of eligibility for a full enrollment period.

K. The final determination of abuse, the decision to enroll the recipient for the Corrective Managed Care Program, and the designation of primary medical and pharmacy providers shall be the responsibility of the Department or its designee.

L. The recipient shall be given notice of an opportunity for a hearing in conformity with COMAR 10.01.04.