Section 7 AAC 105.600 - Restriction of recipient's choice of providers(a) The department may restrict a recipient's choice of medical providers if the department finds that a recipient has used Medicaid services at a frequency or amount that is not appropriate as provided in (b) of this section.(b) A recipient's use of Medicaid services is not appropriate if one or more of the following occur: (1) the department identifies that the recipient(A) received prescriptions from one or more providers for medications in total average daily doses that exceed those recommended in Drug Facts and Comparisons, adopted by reference in 7 AAC 160.900;(B) during a period of three consecutive months, received prescription drugs from three or more pharmacy locations;(C) during a period of three consecutive months, received an opioid prescription from two or more prescribers;(D) during a period of three consecutive months, paid cash two or more times for a United States Drug Enforcement Administration-designated Schedule II - V drug;(E) during a 30-day period, received concurrent prescriptions for an opioid and benzodiazepine from more than one prescriber;(F) over a period of nine consecutive months or longer, was dispensed medication containing buprenorphine with an average daily dose of greater than 16 milligrams; (G) during a period of not less than three consecutive months, used a medical item or service with a frequency that exceeds two standard deviations from the arithmetic mean of the frequency of use of the medical item or service by recipients of medical assistance programs administered by the department who have used the medical item or service as shown in the department's most recent statistical analysis of usage of that medical item or service;(H) during a period of 12 consecutive months, received treatment through an emergency department three or more times for a non-emergent condition;(I) for a reason that was within the control of the recipient, traveled using department-authorized transportation and failed to receive services for which the travel was authorized; or(J) during a period of six consecutive months, failed to keep three or more appointments for services covered under 7 AAC 105-7 AAC 160;(2) a qualified health care professional employed by or designated by the department determines that a recipient's use of Medicaid services was at a frequency or amount that is not medically necessary based on an evaluation of the recipient's medical or billing history, and with consideration of one or more of the following: (A) data from the prescription drug monitoring program (PDMP) controlled substance prescription database established under AS 17.30.200;(B) application of clinical judgment using available information within the scope of practice of the qualified health care professional;(C) the recipient's age, diagnosis, complications, chronic illnesses, use of different medical providers and hospitals, and medical care received;(D) a referral made to the department indicating that the recipient has used a medical item or service at a frequency or amount that is not appropriate; and(E) other tracking tools or information available to the department.(c) Following identification of one or more instances identified in (b) of this section, the department will (1) monitor the recipient's use of Medicaid services for 90 days; or(2) notify the recipient, in writing,(A) that the department will restrict the recipient's choice of provider as provided in (d) of this section; and(B) of the recipient's fair hearing rights under 7 A AC 49.(d) The department will assign a restricted recipient one primary care provider and one pharmacy within reasonable proximity to the recipient's home, and may assign one dental provider and one behavioral health provider, also within reasonable proximity. The department will include the word "RESTRICTED" and will identify the designated providers on the recipient's Medicaid identification card.(e) A restricted recipient may obtain services and items from only the designated providers identified under (d) of this section, except that (1) the recipient may receive medical services from a non-designated enrolled provider if the designated provider refers the recipient to the non-designated enrolled provider;(2) the recipient may receive emergency services from any enrolled provider.(f) The department may restrict provider choice for a reasonable period of time, not to exceed 24 months of eligibility upon initial placement, and 36 months for each subsequent placement. The department will review the restriction before the end of each placement. The department will notify the recipient, in writing before each subsequent placement, (1) of the department's decision to continue to restrict the recipient's choice of provider under (d) of this section; and(2) of the recipient's fair hearing rights under 7 AAC 49.(g) The designation of a provider under (d) of this section may be changed only if the (1) provider requests the change;(2) provider disenrolls from the Medicaid program;(3) recipient moves to a new geographic area; or(4) department finds that the recipient does not have reasonable access to Medicaid services of adequate quality.(h) Except as provided in (e) of this section, the department will pay for a service covered under 7 AAC 105-7 AAC 160 that is provided to a recipient who is restricted under this section only if the service is performed by a provider designated on the recipient's Medicaid identification card.(i) In this section, (1) "emergency service" means (A) inpatient hospital care provided to a recipient admitted into the hospital from the emergency room of that hospital;(B) outpatient hospital services and physician services provided to a recipient in response to the sudden and unexpected onset of an illness or accidental injury that requires immediate medical attention to safeguard the recipient's life; in this subparagraph, "immediate medical attention" means medical care that the department determines cannot be delayed for 24 hours or more after the onset of the illness or occurrence of the accidental injury; (2) "non-emergent condition" means a condition that does not require an emergency service;(3) "qualified health care professional" means a health care provider who is licensed under AS 08 and whose area of licensure relates to the service or item identified under (b) of this section.Eff. 2/1/2010, Register 193; am 1/1/2021, Register 236, January 2021Authority:AS 47.05.010
AS 47.07.030
AS 47.07.040