Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 2
Subtitle 09 - MEDICAL CARE PROGRAMS
Chapter 10.09.24 - Medical Assistance Eligibility
Section 10.09.24.14-1 - Recipient Abuse
Universal Citation: MD Code Reg 10.09.24.14-1
Current through Register Vol. 51, No. 19, September 20, 2024
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 Division of Utilization and
Eligibility Review, Medical Care Compliance Administration, 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 Program
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
Program 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 Chief, Division of
Utilization and Eligibility Review, or his 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 Program 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 Program 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 Program;
(2) 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) 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
Program's determination regarding the additional information shall be sent to
the recipient by the Department. 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 Program 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 Program 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
is chiefly in one of the following specialties which include general practice,
family practice, pediatrics, obstetrics-gynecology, or internal
medicine.
(3) The Program 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 Program 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 recipient may enroll in a Health Maintenance Organization-Medical
Assistance.
(6) The pharmacy
provider may be any pharmacy, or any single branch of a pharmacy chain, which
participates in the Medical Assistance Program. The Health Maintenance
Organization-Medical Assistance shall be the pharmacy provider as well as the
primary medical provider for any recipient choosing to enroll.
(7) The recipient shall be afforded an
opportunity to suggest primary medical and pharmacy providers. However, the
Program 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. A recipient who has chosen to enroll in a Health Maintenance Organization-Medical Assistance may select another Health Maintenance Organization-Medical Assistance or elect to have the Program designate new primary medical and pharmacy providers without cause, but shall first complete and process for voluntary disenrollment specified in the Program's contract with the Health Maintenance Organization-Medical Assistance.
J. 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.
K. 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.
L. 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 Chief, Division of Utilization and Eligibility Review.
M. The recipient shall be given notice of an opportunity for a hearing in conformity with Regulation .13 of this chapter.
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