10A NCAC 22F .0704       RECIPIENT MANAGEMENT LOCK‑IN SYSTEM

(a)  The Division shall have methods and procedures for the control of recipient overutilization of Medicaid benefits. These methods and procedures shall include Lock‑In of a recipient, shown to be an overutilizer, to specified providers of health care and services, as set out in 42 C.F.R. 440.230, 440.260, and 431.54(e), which are adopted and incorporated by reference with subsequent changes or amendments and available free of charge at https://www.ecfr.gov/.

(b)  Prior to implementing Lock-In, the following steps shall be taken:

(1)           Recipient's utilization pattern shall be documented as inappropriate;

(2)           Recipient shall be notified that the State is imposing a Lock‑In procedure;

(3)           Recipient shall be offered the opportunity to select a provider;

(4)           In the event the recipient fails to select a provider, a provider shall be selected for him or her by the Division; and

(5)           Recipient shall receive an eligibility card indicating the selected providers.

(c)  Recipient utilization patterns shall be reviewed to determine if changes have occurred. If the utilization pattern has been corrected, the Lock‑In status shall end; if the utilization pattern remains inappropriate Lock‑In status shall continue.

(d)  The Division may Lock‑In a recipient provided:

(1)           the recipient is given notice and an opportunity for a hearing before imposing restriction, pursuant to G.S. 150B-23; and

(2)           the Division assures that the recipient has reasonable access to Medicaid care and services of adequate quality, as set out in 42 C.F.R. 440.230, 440.260, and 431.54, which are adopted and incorporated by reference with subsequent changes or amendments and available free of charge at https://www.ecfr.gov/.

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 108A‑79; 42 C.F.R. 440.230; 42 C.F.R. 440.260; 42 C.F.R. Part 431; 42 C.F.R. 431.54; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984;

Readopted Eff. July 1, 2018.