New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES
Subchapter 1 - GENERAL PROVISIONS
Section 10:74-1.5 - Provider lock-in program under managed care
Universal Citation: NJ Admin Code 10:74-1.5
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The managed care contractor may implement a lock-in program that restricts its enrollees to a single pharmacy and/or other provider type for a reasonable period of time. The program shall include policies, procedures, and criteria for establishing the need for the lock-in, which shall be prior approved by DMAHS and shall include the following components to the program:
1. Enrollees shall be notified prior to the
lock-in and shall be permitted to choose or change providers for good
cause;
2. The lock-in restrictions
do not apply to emergency services furnished to the enrollee. A 72hour
emergency supply of medication at pharmacies other than the designated lock-in
pharmacy shall be permitted to assure the provision of necessary medication
required in an interim/urgent basis when the assigned pharmacy does not
immediately have the medication;
3.
The lock-in restriction shall not apply while the beneficiary is receiving
services on an inpatient basis, including, but not limited to, medical and
pharmacy services provided in a hospital, rehabilitation facility, or nursing
facility. Upon discharge from the inpatient facility, the beneficiary shall
resume accessing services from the pharmacy and/or provider previously
designated by the lock-in program.
4. Care management and education
reinforcement of appropriate medication/provider use shall be provided. A plan
for an education program for enrollees shall be developed and submitted to the
Division for review and approval;
5. The continued need for lock-in shall be
periodically evaluated by the contractor, but no less frequently than every two
years, for each enrollee in the program;
6. Prescriptions from all participating
prescribers shall be honored and shall not be required to be written by the PCP
only; and
7. The contractor shall
submit quarterly reports on Provider Lock-in participants, as determined by the
DMAHS.
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