Restricted Recipient Programs Sample Clauses

Restricted Recipient Programs. The state may require individuals participating in a restricted recipient program administered under 42 CFR § 431.54(e) to enroll in MMMC. Furthermore, MCOs may establish and administer restricted recipient programs, through which they identify individuals that have utilized Medicaid services at a frequency or amount that is not medically necessary, as determined in accordance with utilization guidelines established by the state, and restrict them for a reasonable period of time to obtain Medicaid services from designated providers only. The state must adhere to the following terms and conditions in this regard.
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Restricted Recipient Programs. The State may require individuals participating in a restricted recipient program administered under 42 CFR 431.54(e) to enroll in MMC. Furthermore, MCOs may establish and administer restricted recipient programs, through which they identify individuals that have utilized Medicaid services at a frequency or amount that is not medically necessary, as determined in accordance with utilization guidelines established by the State, and restrict them for a reasonable period of time to obtain Medicaid services from designated providers only. The State must adhere to the following terms and conditions in this regard. i Restricted recipient programs operated by MCOs must adhere to the requirements in 42 CFR 431.54(e)(1) through (3), including the right to a hearing conducted by the State. ii The State must require MCOs to report to the State whenever they want to place a new person in a restricted recipient program. The State must maintain summary statistics on the numbers of individuals placed in restricted recipient programs, and the reasons for those placements, and must provide the information to CMS upon request.
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