1. (a) The Health and Human Services commission (HHSC) controls the inappropriate use of medical services by recipients through the designation of a primary care provider(s).

   1. (1) Recipient notification--a notice of intent to identify as limited status will be sent to the recipient. The notice will include a form allowing the client the opportunity to select the provider as their designated provider. The HHSC Limited Program will select a designated provider for the recipient if the form is not completed and returned to HHSC no later than 20 days of the date of the notification letter.
   2. (2) Designated Primary Care Provider or Primary Care Pharmacy must be enrolled in the Title XIX Texas Medicaid Program, not be on payment review status, and not be under administrative action, sanction, or investigation for failure to comply with Medicaid rules or acceptable Medicaid practices, not be under sanction or certain administrative status by the state licensing board.

   3. (3) Changes to Designated Providers(s)

      1. (A) The recipient may request the Limited Program change the designated provider.
      2. (B) The HHSC shall make the determination when a change in the designated provider is required or warranted.
      3. (C) A provider change that is not the result of a recipient's request during the course of the restriction period does not require recipient approval.

      4. (D) Changes to a designated provider include but are not limited to:

         1. (i) Change of recipient's residence from the geographic area of the designated provider(s).
         2. (ii) Notice from the designated provider(s) that they will no longer serve as the limited provider.
         3. (iii) Closure of or the relocation of a designated provider's office.
         4. (iv) Death of the primary care provider.
         5. (v) Disenrollment of the designated provider(s) from the Medicaid program.
         6. (vi) Notice that the designated provider is under administrative action, sanction or investigation or failure to comply with Medicaid rules or acceptable Medicaid practice.
         7. (vii) Notice that the designated provider is under sanction or other certain administrative actions by their licensing boards.
         8. (viii) Primary care provider is over prescribing medication or services.
         9. (ix) Primary pharmacy provider is filling prescriptions from multiple providers other than the primary care provider and the designated primary care provider referrals.
         10. (x) Change in the recipient's medical condition, which the primary care provider is unable to treat or referred to another provider.

2. (b) Payment for services include, but are not limited to the following:

   1. (1) Authorization of non-emergency ambulatory services. The primary care provider must authorize non-emergency ambulatory services as determined by the state.
   2. (2) Payment for pharmacy services. The primary care pharmacy will assist the Limited Program in ensuring that prescriptions filled for recipients with limited status are written by the primary care provider or other health care providers that the primary care provider has made referrals to for the recipient. HHSC has identified by therapeutic class medications that require additional monitoring. When these medications are prescribed by the emergency room provider, the primary care pharmacy may dispense and be reimbursed for up to 72 hours or three business days of the prescribed dosage to allow for holidays and weekends. The primary care pharmacy may dispense and be reimbursed for the reminder of the medication after approval by the primary care provider or the other providers as deemed appropriate by HHSC.

3. (c) The length of limitation periods to a designated provider and/or limited status will be used as follows:

   1. (1) The initial limited status period will be for a minimum of 36 months or the duration of eligibility and subsequent periods of eligibility up to but not exceeding 36 months in the Limited Program. Continued limited status determination will be made prior to the end of the 36 months period.
   2. (2) The second limited status will be for an additional 60 months or the duration of eligibility and subsequent periods of eligibility up to but not exceeding 60 months. Continued limited status determination will be made prior to the end of the 60 months period.
   3. (3) The third limitation period will be for the duration of eligibility and all subsequent periods of Texas Medicaid eligibility.
   4. (4) Clients arrested, indicted or convicted for a crime related to Medicaid fraud will be assigned limited status for 60 months or the duration of eligibility and subsequent periods of eligibility up to or equal to 60 months. If the client admits guilt of Medicaid fraud the client will be limited for 60 months. If the decision is made to continue the recipient in the Limited Program at the end of the 60 months period the second limitation period will be for the duration of eligibility, including all subsequent periods of eligibility.
   5. (5) Clients returning to the Limited Program after being removed from the limited status by HHSC or its designee will be placed at the next level of limitation.
   6. (6) Recipients will remain in the limited status regardless of change in eligibility program type or change in address.
   7. (7) HHSC will utilize the time frames set forth in paragraphs (1) through (6) of this subsection for the special message stated on the recipient's Medicaid identification form.

Source Note:The provisions of this §354.2405 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.