South carolina department of health and human services medicaid policy and procedures manual

101.14 Responsibilities of Applicants/Beneficiaries/Agency (Eff. 10/01/05)

101.14.01 Applicants/Beneficiaries (Eff. 10/01/05)

Medicaid applicants/beneficiaries have the following responsibilities:

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  Provide Complete and Accurate Information
  

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  Cooperation
  

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  Report Changes
  

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  Repayment
  

101.14.02 Agency (Eff. 10/01/05)

As employees of the State Department of Health and Human Services, eligibility staff will be committed to the following agency goals:

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  To provide a benefit plan that improves member health, is evidence-based and market-driven;
  
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  To provide a credible and continually improving eligibility process that is accurate and efficient; and
  
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  To provide administrative support at the best possible value to ensure programs operate effectively.
  

To achieve this goal, staff will adhere to certain standards that will reflect positively on the agency as a whole, as well as, promote its mission to use the available resources to ensure the health and well-being of every South Carolinian.

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  Respectful, patient, responsible customer service;
  
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  Effective, cooperative teamwork;
  
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  The highest standards of ethical and professional conduct;
  
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  Competency in the function to which staff have been assigned; and
  
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  A willingness to respond positively to the inevitable changes that occur in Medicaid policy.
  

101.15 Beneficiary Lock-In Program (Eff. 11/01/08)

The purpose of the Medicaid Beneficiary Lock-In Program is to address issues such as coordination of care, patient safety, quality of care, improper or excessive utilization of benefits, and potential fraud and abuse associated with the use of multiple pharmacies and/or prescriptions. The policy implements SC Code of Regulations R 126-425.

101.15.01 Beneficiary Lock-In Program Selection Criteria (Eff. 11/01/08)

The Division of Program Integrity, through the Department of Recipient Utilization, will review beneficiary profiles in order to identify beneficiaries appropriate for the Lock-In Program. If these beneficiaries meet the lock-in criteria established by SCDHHS, they will be placed in the Medicaid Lock-In Program to monitor their drug utilization and to require them to utilize one designated pharmacy. Factors that can be considered include:

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  Evidence that a beneficiary’s medical outcomes and health status may be improved by following treatment pathways and coordinated care.
  
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  Medical factors such as diagnoses, hospitalizations, etc.
  
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    Patient utilization history indicating:
    
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    Non-compliance with medical advice and treatment pathways
    
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    Use of multiple pharmacies and/or prescribers
    
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    Any history of prior misutilization
    
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    Utilization patterns inconsistent with their peers
    
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    Duplication and inappropriate use of controlled or psychotropic drugs
    
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    Contra-indications or potential harm to the patient
    
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    Abusive, duplicative, and wasteful utilization practices
    
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    Drug-seeking behaviors.
    

In addition to data analysis, referrals based on indications of overuse or abuse of Medicaid services may be used to identify a beneficiary for potential inclusion in the Medicaid Lock-In Program. Referrals to the Medicaid Lock-In program can be initiated by various sources, such as the Medicaid Fraud and Abuse Hotline, the Medicaid Beneficiary Fraud Unit in the SC Attorney General’s Office, physicians, county eligibility offices, and other SCDHHS programs. Common referral reasons for the Medicaid Lock-In program include:

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   Receipt of duplicated services from physicians, pharmacies and emergency rooms.
   
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   Repeated use of emergency rooms for non-emergency situations or conditions.
   
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   Drug-seeking behavior, such as doctor or pharmacy shopping or falsifying prescriptions.
   
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   Excessive use of prescription drugs not indicated by the beneficiary’s medical condition or diagnosis, especially narcotics and pain medications.
   
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   Other abuse of the Medicaid benefit.
   

The Division of Program Integrity will establish criteria for priority for pharmacy lock-in. Once identified for Lock-In, a beneficiary will be locked in to one pharmacy for one (1) year. After a beneficiary has been removed from lock-in, his or her benefits usage pattern will be reviewed again once six months worth of claims data is available. A decision will be made at that time to put them back into the Lock-in program or allow them to continue being able to choose their pharmacy providers.