Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 354 - MEDICAID HEALTH SERVICES
Subchapter K - MEDICAID RECIPIENT UTILIZATION REVIEW AND CONTROL
Section 354.2405 - Utilization Control

Universal Citation: 1 TX Admin Code ยง 354.2405

Current through Reg. 49, No. 38; September 20, 2024

(a) The Health and Human Services Commission (HHSC) controls a recipient's inappropriate use of Medicaid benefits or services by restricting the recipient to a designated provider(s).

(b) HHSC will send a recipient written notification of intent to restrict the recipient to a designated provider. The notice will include a form allowing the recipient the opportunity to select a designated provider and will inform the recipient of the length of the lock-in period and the recipient's right to a hearing. HHSC will select a designated provider for the recipient if it does not receive the completed form within ten days from the date of the initial notice.

(c) HHSC assigns a lock-in period to a recipient. A recipient remains in lock-in status regardless of a change in address or eligibility program type. HHSC will review and determine whether to continue a recipient's lock-in status prior to the end of a lock-in period.

(1) A recipient who has never been in lock-in status will be assigned a 36-month lock-in period. If a recipient's Medicaid eligibility ends and reactivates during the 36-month lock-in period, then upon reenrollment in Medicaid, that recipient will be locked in for the remaining number of months in the original lock-in period.

(2) A recipient who has completed the 36-month lock-in period and is reinstated to lock-in status will be assigned a 60-month lock-in period. If a recipient's Medicaid eligibility ends or reactivates during the 60-month lock-in period, then upon reenrollment in Medicaid, that recipient will be locked in for the remaining number of months in the lock-in period.

(3) A recipient is assigned a lifetime lock-in period if the recipient:
(A) has completed the 60-month lock-in period;

(B) is arrested, indicted, or convicted of a crime relating to Medicaid fraud, or of a felony offense relating to controlled substances; or

(C) admits guilt of Medicaid fraud, or a felony offense related to controlled substances.

(d) A recipient may request a change of a designated provider(s) during a lock-in period.

(1) HHSC determines whether a change in the designated provider is required or warranted.

(2) A designated provider change that is not the result of a recipient's request during the course of the lock-in period does not require recipient approval.

(3) HHSC may change a designated provider for, but not limited to, the following reasons:
(A) a change of the recipient's residence from the geographic area of the designated provider(s);

(B) notice from the designated provider(s) that they will no longer serve as the designated provider;

(C) closure or relocation of a designated provider's office;

(D) death of the designated provider;

(E) disenrollment of the designated provider(s) from the Medicaid program;

(F) notice that the designated provider is under administrative action, sanction or investigation or failure to comply with Medicaid rules or acceptable Medicaid practice;

(G) notice that the designated provider is under sanction or other administrative actions by a state licensing board or other regulatory entity that prevents the provider from practicing;

(H) the primary health care provider may be overprescribing medication or services;

(I) the designated pharmacy provider is filling prescriptions from multiple providers other than the designated primary health care provider or a prescriber to whom the recipient was referred by the designated primary health care provider; or

(J) a change in the recipient's medical condition that the designated primary health care provider is unable to treat or refer to another provider.

(e) A change in the designated provider or Medicaid provider does not affect the status of the lock-in period unless the recipient was receiving prescriptions pursuant to subsection (d)(3)(H) or (I) of this section.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.