§17-1741-7 - Restriction.

§17-1741-7 Restriction.

         (a) If over-utilization or abuse continues, the recipient shall be administratively restricted for no less than twenty-four months to a primary care physician who is:

(1) Of the client's choice;
(2) Willing to provide and coordinate services to the client; and
(3) Certified by the department to participate in the medical assistance program.

         (b) A recipient who over-utilizes services which are provided by psychotherapists, pharmacies and dentists shall also be restricted to those providers if necessary, to further curb recipient abuse.

         (c) The individual who is restricted shall be afforded advance notice and appeals process.

         (d) Emergency medical services shall not require the referral, assistance, or approval of the designated primary care physician.

         (e) The restricted recipient shall receive a medical authorization card bearing the designated primary care physician until:

(1) Responsibility for care is transferred to another physician;
(2) The recipient requests a change in the primary care physicians and the department and the affected physician concurs; or
(3) Control is no longer considered necessary by the designated primary care physician and the department's medical consultant concurs.

         (f) If a recipient fails to select a primary care physician within thirty days following receipt of notice of medical service restrictions, the department shall select a physician who is in good standing with the medical program.

         (g) When a physician willing to participate as the primary care physician cannot be found, the department's medical consultant shall provide prior approval for all health service required by the restricted recipient with the exception of emergency care.

         (h) The designated physician shall:

(1) Provide and coordinate all medical services to the client, except for emergency services;
(2) Make referrals for other needed health services; and
(3) Inform the department when the designated physician is no longer able to provide medical services to the recipient.

         (i) A recipient shall continue to be restricted to a designated provider(s) until:

(1) There is documented evidence of that individual's compliance for at least one full year; and
(2) The primary care physician and the department's medical consultant concur.

         (j) When the decision is made to continue restriction, the recipient shall be afforded advance notice and the appeals process.

         (k) The recipient whose restriction has been terminated shall be monitored for no less than twenty-four months and placed back on restriction if there is evidence of recurrent over-utilization or abuse of medicaid services during that period.

        [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §§456.3, 456.23)

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