Current through Register Vol. 49, No. 18, September 16, 2024
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.
