Section 810. Client Medical Management Program for individuals

A. Purpose. The Client Medical Management Program for individuals is designed to assist and educate Medicaid individuals in appropriately using essential medical and pharmacy services. Individuals who use these services excessively or inappropriately as determined by DMAS may be assigned to a single primary care provider or pharmacy, or both. The CMM Program for individuals also monitors individual compliance with program guidelines.

B. Authority.

1. The Act and federal regulations at 42 CFR 456.3 require the Medicaid agency to implement a statewide surveillance and utilization control program that (i) safeguards against unnecessary or inappropriate use of Medicaid services and against excess payments, (ii) assesses the quality of those services, (iii) provides for the control of the utilization of all services provided under the Plan, and (iv) provides for the control of the utilization of inpatient services.

2. Federal regulations at 42 CFR 431.54(e) allow states to restrict individuals to designated providers when the individuals have utilized services at a frequency or an amount that is not medically necessary in accordance with utilization guidelines established by the state.

C. Identification of participants for inclusion in the CMM Program for individuals. DMAS shall identify individuals for review from computerized reports such as but not limited to individual Java-Server Utilization Review System (JSURS), VAMMIS, Oracle or by written referrals from agencies, health care professionals, or other persons. Certain individuals who are reviewed may not be restricted when evidence indicates that the prescription or medical service utilization patterns, or both, are for appropriate therapy. Only individuals who are excluded, pursuant to 12VAC30-120-370 B, from receiving care from a managed care organization shall be reviewed and evaluated for restriction under the CMM Program for individuals.

D. Individual evaluation for restriction.

1. DMAS shall utilize data as indicated in subsection C of this section to conduct a review of individuals to determine if services are being utilized at a frequency or amount that results in a level of utilization or a pattern of services which is not medically necessary or which are excessive medical services or excessive medications, or both, as established by the department. Evaluation of utilization patterns can include but is not limited to review by the department of medical records or computerized reports, or both, generated by the department reflecting claims submitted for physician visits, drugs or prescriptions, outpatient and emergency room visits, lab or diagnostic procedures, or both, and hospital admissions.

2. Restricted individuals shall have reasonable access to all essential medical services. These restrictions shall not apply to hospital emergency services.

3. Abusive activities shall be investigated and, if appropriate, the individual shall be reviewed for educational intervention or restriction, or both.

a. If DMAS' review determines that an individual's data indicates (i) inappropriate use of Medicaid services, (ii) questionable patterns of utilization, or (iii) unreasonable levels of utilization, the department shall initiate the individual's restriction to either a physician or pharmacy, or both.

b. Once an individual is restricted, the restriction period shall last for 24 months from the enrollment date. During this restriction period, the individual shall be required to use the services of the designated physician or designated pharmacy, or both.

c. The individual may visit physicians or specialists other than those who are designated only by a written referral from the designated PCP.

d. The individual may obtain prescriptions from pharmacies other than the designated pharmacy only (i) in an emergency, (ii) when the designated pharmacy is closed, (iii) when the designated pharmacy does not stock the required medication, or (iv) when the designated pharmacy is not able to obtain the required medication in a timely manner.

E. Determination of restriction. DMAS may restrict an individual if any of the following activities or patterns or levels of utilization are identified. These activities, patterns, or levels of utilization include, for example:

1. Two occurrences of having prescriptions for the same drugs filled two or more times on the same or the subsequent day.

2. Utilizing services from three or more prescribers and three or more dispensing pharmacies in a three-month period.

3. Receiving more than 24 prescriptions in a three-month period.

4. Receiving more than 12 psychotropic prescriptions or more than 12 analgesic prescriptions or more than 12 prescriptions for controlled drugs with potential for abuse in a three-month period.

5. Exceeding the maximum therapeutic dosage of the same drug or multiple drugs in the same therapeutic class, which have been prescribed by two or more practitioners, for a period exceeding four weeks.

6. Receiving two or more drugs, duplicative in nature or potentially addictive (even within acceptable therapeutic levels), dispensed by more than one pharmacy or prescribed by more than one practitioner for a period exceeding four weeks.

7. Receiving narcotic prescriptions from two or more prescribers without supporting diagnoses indicative of use.

8. Utilizing three or more different physicians of the same type or specialty in a three-month period for treatment of the same or similar condition or conditions.

9. Two or more occurrences of seeing two or more physicians of the same type or specialty on the same or subsequent day for the same or similar diagnosis.

10. Duplicative, excessive, or contraindicated utilization of medications, medical supplies, or appliances dispensed by or prescribed by more than one provider for the time period specified by DMAS.

11. Use of emergency hospital services for three or more emergency room visits for nonemergency care during a three-month period.

12. One or more providers recommend restriction for medical management because the recipient has demonstrated inappropriate utilization practices.

13. A pattern of noncompliance that is inconsistent with sound fiscal or medical practices. For example, noncompliance may be characterized by:

a. Failure to disclose to a provider any treatment or services provided by another provider;

b. Failure to follow a drug regimen or other recommended treatment;

c. Requests for medical services or medications that are not medically necessary;

d. Use of hospital emergency services via self-referral for nonacute episodes of care or solely for nonacute management of the medical condition; or

e. Under-use or under-utilization of medically necessary services that results in higher costs for the management of the medical condition.

14. Any documented occurrences of use of the eligibility card to obtain drugs under false pretenses, which includes, but is not limited to the purchase or attempt to purchase drugs via a forged or altered prescription.

15. Any documented occurrences of card-sharing.

16. Any documented occurrences of alteration of the recipient eligibility card.

17. One or more documented occurrences of paying cash for controlled substances, analgesic drugs, or psychotropic drugs in addition to the use of the eligibility card to obtain similar or duplicative controlled substances.

F. Individual restriction procedures.

1. DMAS shall advise affected individuals by written notice of the proposed restriction under the CMM Program for individuals. Written notice shall include an explanation of restriction procedures and the individual's right to appeal the proposed action.

2. The individual shall have the opportunity to select a designated physician or pharmacy, or both. If an individual fails to respond by the date specified in the restriction notice, DMAS shall select a designated physician or pharmacy, or both.

3. DMAS shall not implement restriction if a valid appeal, consistent with 12VAC30-110-210, is noted. (See subsection K of this section.)

4. DMAS shall restrict individuals to their designated physician or pharmacy, or both, for 24 months.

G. Designated providers.

1. A designated physician or pharmacy, or both, must be a provider that is enrolled in Virginia Medicaid and that is unrestricted by DMAS. Providers who are restricted pursuant to 12VAC30-130-820 D and E shall not serve as designated providers for restricted individuals and shall not serve as referral or covering providers for restricted individuals.

2. Physicians or pharmacy providers, or both, who are under the CMM Program for providers shall not serve as designated providers, shall not provide services through referral, and shall not serve as covering providers for restricted individuals.

3. Physicians with practices limited to the delivery of emergency room services may not serve as designated primary providers.

4. Other physicians or pharmacies, or both, may be established as designated providers as needed but only with the approval of DMAS.

H. Provider reimbursement.

1. DMAS shall reimburse for covered medical or pharmaceutical services, or both, and physician services for restricted individuals only when they are provided by the designated providers, or by physicians seen on a written referral from the designated PCP, or in a medical emergency consistent with the methodologies established for such services in the State Plan for Medical Assistance.

2. DMAS shall require a written referral, in accordance with published procedures, from the designated PCP for payment of covered outpatient services by nondesignated practitioners unless there is a medical emergency requiring immediate hospital treatment. Services exempt from these written referral requirements include:

a. Family planning services;

b. Annual or routine vision examinations for individuals under the age of 21 years;

c. Dental services for individuals under the age of 21 years;

d. Emergency services;

e. EPSDT well-child exams/screenings for individuals under the age of 21 years;

f. Immunizations for individuals under the age of 21 years;

g. Home and community-based care services such as private duty nursing or respite services;

h. Renal dialysis services;

i. Expanded prenatal services, including prenatal group education, nutrition services, and homemaker services for pregnant women and care coordination for high-risk pregnant women and infants up to age two years; and

j. Hospice services.

3. Designated primary care providers (PCPs) shall receive a monthly case management fee for each assigned individual.

I. Changes in designated providers.

1. DMAS must give prior approval to all changes of designated providers.

2. The individual or the designated provider may initiate requests for change for the following reasons:

a. Relocation of the individual or provider.

b. Inability of the provider to meet the routine health or pharmaceutical needs of the individual.

c. Breakdown of the individual/provider relationship.

3. If the designated provider initiates the request and the individual does not select a new physician or pharmacy, or both, by established deadlines, DMAS shall select a provider, subject to concurrence from the provider or providers.

4. If DMAS denies the individual's request for a particular physician or pharmacy, or both, the individual shall be notified in writing and given the right to appeal the decision. (See subsection K of this section.)

J. Review of individual restriction status.

1. During the restriction period, DMAS shall monitor an individual's utilization no less frequently than every 12 months and follow up with the individual to promote appropriate utilization patterns.

2. DMAS shall also review an individual's utilization prior to the end of the restriction period to determine restriction termination or continuation.

a. DMAS shall extend utilization control restrictions for 12 months if any one of the following conditions is identified:

(1) The individual's utilization patterns include one or more conditions listed in subsection E of this section.

(2) The individual has not complied with procedures of the CMM Program for individuals resulting in services or medications received from any nondesignated provider, as demonstrated by his submitted claims, without a written referral or in the absence of a medical emergency.

(3) The individual has not complied with procedures of the CMM Program for individuals as demonstrated by a pattern of documented attempts to receive medications from any nondesignated pharmacy (i) in the absence of a medical emergency, (ii) when the designated pharmacy is closed, (iii) when the designated pharmacy does not stock the required medication, or (iv) when the designated pharmacy is unable to obtain the required medication in a timely manner.

(4) One or more of the designated providers recommends continued restriction status because the individual has demonstrated noncompliant behavior which is being controlled by restrictions within the CMM Program for individuals.

(5) Any changes of designated provider have been made due to the breakdown of the individual/provider relationship as a result of the individual's noncompliance.

b. DMAS shall notify the individual and designated physician or pharmacy, or both, in writing of the review decision. If restrictions are continued, written notice shall include the individual's right to appeal the proposed action. (See subsection K of this section.)

c. DMAS shall not implement the continued individual restriction if a valid appeal is noted pending the completion of the appeal action. Should the outcome of the appeal action support implementation of the restriction, the restriction shall be promptly implemented.

K. Individual appeals.

1. Individuals shall have the right to appeal any action, as defined in 42 CFR 431.201, that is taken by DMAS under this part.

2. Individual appeals shall be held pursuant to the provisions of Part I (12VAC30-110-10 et seq.) of 12VAC30-110, Eligibility and Appeals.

Historical Notes

Derived from VR460-04-8.3 § 2, eff. January 1, 1993; amended, Volume 14, Issue 10, eff. March 4, 1998; Volume 32, Issue 04, eff. December 3, 2015.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.