1. (a) The Health and Human Services Commission (HHSC), in accordance with federal requirements, identifies Texas Medicaid eligible recipients for the limited status program.

   1. (1) The recipient will be assigned to a designated provider for access to medical benefits and services when:

      1. (A) The recipient received duplicative, excessive, contraindicated or conflicting health care services, including drugs, or
      2. (B) A review indicates abuse, misuse or fraudulent actions related to Medicaid benefits and services or
   2. (2) The Limited Program may also warn providers that the recipients medical identification card was reportedly used by an unauthorized person or persons, or for an unauthorized purpose. If a warning card is issued, a message will be printed on the card alerting the provider to ask the Medicaid recipient for additional identification or to take other appropriate action.

2. (b) Identification of Recipients for Review and Possible Limited Status

   1. (1) Methods to identify recipients for review include, but are not limited to:

      1. (A) Primary Source: Analysis of acute care data for the entire Medicaid population or subsets of the population to determine medical usage per recipient and to identify recipients usages in excess of the standards established by HHSC. The analysis will be performed on a frequency as deemed necessary by the program.
      2. (B) Secondary Sources: Incoming referrals, such as referrals from medical providers, state agencies, law enforcement officials or members of the general public will be reviewed and analyzed on an individual basis.
   2. (2) All Medicaid eligible recipients are subject to being identified for limited status and/or for inclusion of the special message on their Medicaid identification form regardless of their age, their program type or their Medicare eligibility.
   3. (3) Recipients can be considered to be limited to a primary care provider or pharmacy provider regardless of the referral and/or review source(s). Consideration may also be given to the special message during the review.
   4. (4) The decision to limit a recipient to a designated provider and/or to issue a special message on the recipient's Medicaid Identification form will be made by HHSC or the designee.

3. (c) Limited Status Evaluation

   1. (1) The effectiveness of the limited status will be evaluated during the recipient's limited status period. If required, the designated provider will be changed or other interventions may be taken by HHSC to ensure success.
   2. (2) Evaluation of the need for the Medicaid recipient to continue in the limited program will be completed prior to the end of the limitation period.

   3. (3) Decisions to continue a recipient in the Limited Program will include, but are not limited to, review of the following:

      1. (A) Utilization pattern in excess of the established recognized standards;
      2. (B) Abuse, misuse or fraudulent actions related to Medicaid services and benefits;
      3. (C) Non-compliance resulting in services or medications received from one or more non-designated providers without a designated primary care provider referral or in the absence of a medical emergency, including cash payment for services;
      4. (D) Designated provider(s) recommendation to continue the limited status because the recipient has demonstrated non-compliant behavior; and/or
      5. (E) Any changes in designated provider made due to breakdown of the recipient/provider relationship as a result of the recipient's or the provider's non-compliance.
   4. (4) Effectiveness of the special message will be evaluated by HHSC and will remain in effect throughout the assigned time period as defined in §345.2405(c)(7) of this title (relating to Utilization Control Methods).

4. (d) Limited Status Termination

   1. (1) Termination of the limited status before or during the restriction period will be determined by HHSC. This may include but is not limited to:

      1. (A) the lack of a designated provider who will accept responsibility for the client's limited status; or
      2. (B) a request by the recipient or the designated provider for consideration of removal of the limited status based on evidence of medical necessity.
   2. (2) A medical review can be requested at any time.

Source Note:The provisions of this §354.2403 adopted to be effective April 2, 2000, 25 TexReg 2817; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4563; amended to be effective April 6, 2003, 28 TexReg 2738.