Mo. Code Regs. tit. 13 § 65-3.010

Current through Register Vol. 49, No. 23, December 2, 2024

Section 13 CSR 65-3.010 - Participant Lock-In Program

PURPOSE: This rule establishes a process to safeguard against unnecessary or inappropriate utilization of care and services by MO HealthNet participants by identifying excessive use patterns in order to rectify overutilization practices of participants.

(1) Definitions applicable to the administration of this program are as follows:

(A) "Lock-In" means limiting or restricting a participant's ability to access services to a single physician and/or a single pharmacy to reduce excessive MO HealthNet benefits usage;

(B) "Medically necessary" means health care services or supplies that are needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine;

(C) "Misutilization" or "misuse" means overusing, underusing, or using MO HealthNet services in a way that is harmful, wasteful, and uncoordinated or using services provided under the MO HealthNet program in an improper or incorrect manner, whether that use is intentional or unintentional;

(D) "Overlap" means at least one (1) day of overlapping dispensing of prescriptions written by two (2) or more different prescribers; and

(E) "Therapeutic class" means a class of medications that are used to treat similar medical conditions.

(F) MMAC approved pharmacy" means a licensed pharmacy that is currently enrolled with MO HealthNet and is not currently sanc- tioned or under investigation by any federal or state authority.

(G) MMAC approved physician" means a licensed physician that is currently enrolled with MO HealthNet and is not currently sanc- tioned or under investigation by any federal or state authority.

(2) Unless a participant shows that the service or product provided to the participant was otherwise medically necessary, the Missouri Medicaid Audit and Compliance Unit (MMAC) may place the participant in the Lock-In Program if the participant's utilization of benefits exceeds one (1) or more of the following parameters during a three- (3-) month period:

(A) Use of three (3) or more drugs in the same therapeutic class such that the prescriptions of such drugs overlap;

(B) Use of three (3) or more pharmacies;

(C) Use of sixteen (16) or more prescriptions for therapeutic classes such as, but not limited to, analgesics, anticonvulsants, skeletal muscle relaxants, anxiolytics, or other potential drugs of misuse;

(D) Use of three (3) or more providers that specialize in a same or similar service or product;

(E) Use of three (3) or more different emergency departments; or

(F) Use by referral, review, or other analysis that indicates possible overutilization or that identifies a patient safety issue.

(3) Placement in the Lock-In Program.

(A) The decision to place a participant in the Lock-In Program is at MMAC's discretion. MMAC is to consider the following factors when deciding whether to place the participant in the Lock-In Program:

1. Seriousness of the findings - MMAC will consider the seriousness of the findings including, but not limited to, overlaps of the same therapeutic class of prescription medications, the use of multiple pharmacies, the prescription of the same therapeutic class of prescription medications by multiple, like, or different prescribers, emergency department visits for non-emergent services, the use of multiple emergency departments in different locations, and the use of multiple primary care clinics;

2. Extent of Inappropriate Utilization of Services - MMAC will consider the extent as measured by, but not limited to, the number of overlapping prescriptions within the same therapeutic class prescribed by different prescribers and the number of emergency department visits and locations for diagnoses that are non-emergent such as back pain, lumbago, pain in limb, or toothache;

3. Prior History of Action Taken by the Lock-In Section - MMAC will consider whether or not the participant has been given prior education by the Lock-In Section which includes any education letters, warning letters, or previous placement in the Lock-In Program.

(4) A participant shall be placed in the Lock-In Program if the participant's utilization of benefits was misused by any of the following methods:

(A) Lending or giving the participant's Medicaid ID card to ineligible individuals who are not eligible for Medicaid;

(B) Submitting, or causing to be submitted, forged documents to providers for medical benefits or services;

(C) Refusing to submit to, or failing to have predicted, urine or blood levels following testing for medications prescribed to the participant and covered by the MO HealthNet program while engaged in a pain management or substance use disorder treatment program; or

(D) Paying cash for prescribed medications covered by the MO HealthNet program.

(5) Once MMAC identifies a participant that falls under subsection (2) or (3) of this rule and notifies the participant of its decision to place the participant in the Lock-In Program, the participant is to provide MMAC with the following:

(A) Notification within twenty (20) days of the participant's selection of a single physician and a single pharmacy that must be approved by MMAC. In the event the participant fails to select an MMAC approved physician and pharmacy, MMAC will select a single physician and a single pharmacy on behalf of the participant;

(B) Notification if the participant requires more than one (1) physician or pharmacy for the purposes of specialized medical treatment. MMAC may permit a participant to select more than one (1) physician or pharmacy upon showing of such need; and

(C) Notification of any request to change a selected physician and/or pharmacy. A participant may not request to change selection of physician and/or pharmacy more than once within a three (3) consecutive month period unless additional provider changes within that three (3) consecutive month period are approved upon verification of just cause. A participant may only change a selected physician and/or pharmacy if any of the following occur:

1. The physician or pharmacy moves, retires, dies, discontinues MO HealthNet participation, or refuses to provide care to the participant; or

2. The participant moves from the physician's service area.

(6) A participant who is subject to the Lock-In Program may not select a single physician and single pharmacy if the single physician and/or single pharmacy decline to serve as the participant's single physician or pharmacy.

(7) A participant who is subject to the Lock-In Program may only receive services from a provider who is not the designated physician and/or a pharmacy that is not the designated pharmacy in the following circumstances:

(A) Documented medical emergencies;

(B) Upon referral by the participant's designated Lock-In provider; or

(C) As otherwise authorized by MMAC.

(8) A participant who is placed in the Lock-In Program will be subject to Lock-In for a minimum of twenty-four (24) months. If after twenty-four (24) months, MMAC determines that the participant is continuing to misuse the MO HealthNet program as set forth in this rule, MMAC may impose an additional Lock-In period for up to twenty-four (24) additional months.

(9) Any participant who is aggrieved by a decision made under this regulation may seek administrative review under section 208.080, RSMo.

13 CSR 65-3.010

Adopted by Missouri Register January 15, 2019/Volume 44, Number 2, effective 2/28/2019