§ 50793. Utilization Restrictions.

(a) A beneficiary who has been determined by the Department to be misusing or abusing Medi-Cal benefits by obtaining drugs or other services at a frequency or amount not medically necessary may be subjected to one or more of the following forms of utilization restriction:

(1) Prior authorization for all Medi-Cal services.

(2) Prior authorization for specific Medi-Cal services.

(3) Restriction to utilization of a specific, beneficiary- or Department-selected pharmacy.

(4) Restriction to a specific, beneficiary- or Department-selected primary provider of medical services.

(b) Utilization restriction shall not apply in the following situations:

(1) Emergencies as defined in Section 51056.

(2) Referral of the restricted beneficiary to another provider by the beneficiary- or Department-selected primary provider of medical services.

(c) The Department shall impose utilization restriction upon a beneficiary only on the written order of the Director or the Director's designee. The written order, hereinafter referred to as the Notice of Action, shall:

(1) Include the reasons for the action.

(2) State the dates of the restriction period.

(3) Explain the beneficiary's right to and procedures for requesting a hearing.

(4) Be mailed to the beneficiary by regular mail at least ten days prior to the effective date.

(d) The restriction as described in (a) above shall be for a period of two (2) years from the effective date on the Notice of Action.

(e) Should the Department find during the term of the restriction that the potential for abuse still exists, so as to warrant continued restriction beyond the two (2) year period, the Department may extend the period of restriction. Each such extension shall:

(1) Be for an additional period of two (2) years.

(2) Require a separate Notice of Action in accordance with (c) above except that the Notice of Action must be mailed at least ninety (90) days prior to the effective date of the action.

(f) Should the beneficiary's request for a hearing be received prior to the effective date of the action:

(1) Said action will not be taken until the hearing has been held and a final decision rendered.

(2) The effective date of the action will be the first day of the month following the adoption, by the Director, of the final hearing decision, provided the notice of decision was mailed at least ten (10) days prior to the effective date of the action.

(g) Should the beneficiary's request for a hearing be received on or subsequent to the effective date of the action, said action will remain in full force and effect until the hearing has been held and a final decision rendered.

(h) Under no circumstances shall the months wherein a beneficiary is off restricted status solely due to requesting a hearing be counted toward the two year period as provided for in (d) or (e) above.

(i) There is no right to a hearing when a beneficiary is placed on restricted status as a result of his or her conviction of any misdemeanor or felony involving fraud or abuse of medical assistance benefits or services or in connection with any public assistance program.

HISTORY

1. Amendment filed 8-16-78 as an emergency; designated effective 8-16-78 (Register 78, No. 32).

2. Certificate of Compliance filed 12-12-78 (Register 78, No. 50).

3. Amendment filed 6-22-87; operative 7-22-87 (Register 87, No. 28).

Note

Note: Authority cited: Sections 10725 and 14124.5, Welfare and Institutions Code. Reference: Section 14124.5, Welfare and Institutions Code.