Q. Why does a recipient get restricted?
A. The goal of the Recipient Restriction Program (RRP) is to coordinate medical services and improve quality of care for Medicaid recipients. A restriction is implemented if a recipient is identified as having a pattern of receiving duplicative, excessive, contraindicated, or conflicting health care services, drugs, or supplies, or if a recipient commits fraudulent acts with their benefit card, i.e., forged prescriptions, card loaning, doctor shopping.
Q. How long is a recipient restricted?
A. A recipient’s initial restriction is two years. A continuation or a subsequent restriction will be three years. A continuation occurs when it is determined that the restricted recipient is non-compliant with their current restriction and it is determined that the restriction should be extended (i.e., continuing to use the emergency department for routine medical needs). A subsequent restriction occurs if the recipient’s previous restriction has ended, and it is determined that they should be restricted again. Any additional restrictions are for six years.
Q. How do I know if a recipient is restricted?
A. When a recipient is restricted, a letter is sent to the recipient and to those providers to whom the recipient is assigned. The letter contains information about the restriction as well as contact information for the recipient or provider to use if they have questions. A provider can also identify a restriction via the ePaces system at https://epaces.emedny.org/. For ePaces log in assistance, please call 800-343-9000.
Q. How do I know if a restricted recipient is assigned to me for care?
A. If a restricted recipient is assigned to you for care, you will receive written confirmation from the Office of the Medicaid Inspector General (OMIG), the recipient’s Managed Care Plan, the Local Department of Social Services (LDSS), the New York City Human Resources Administration (NYC HRA), or the New York State of Health (NYSoH) stating the recipient’s name, the effective date of the restriction, restriction limitations, and provisions for handling referrals.
Q. Can a recipient be restricted to a physician group or clinic?
A. Yes, a recipient can be restricted to a physician, physician group, clinic, or nurse practitioner as their Primary Care Provider (PCP). If a recipient is restricted to a physician group or clinic, any enrolled Medicaid provider in that group or clinic can provide services for that recipient as long as they are listed as an affiliated provider. Note, a recipient cannot be restricted to a physician assistant.
Q. How do I update physician group or clinic affiliates?
A. Individual practitioners may affiliate/disaffiliate with a group on the Provider Enrollment Portal at Provider Enrollment Portal. The provider may also visit the Provider Enrollment page at www.eMedNY.org and navigate to its profession/organization type. Complete the Enrollment Form at: 610202_REQGRPPRT_Request_for_Medicaid_Participation_as_a_Group_Member.pdf found in the “Requirements & Additional Forms” box.
Q. How does a pharmacy know who the assigned primary care provider is for a restricted recipient?
A. The Pharmacy will receive a letter indicating a recipient is restricted to their pharmacy and the other provider(s) they are assigned to will be listed. If the pharmacist is unsure if a recipient is assigned to them, the pharmacist can check ePaces, ask the recipient, or contact the following: OMIG, the recipient’s Managed Care Plan, LDSS (for upstate recipients), or NYC HRA (for NYC recipients).
Q. What if a restricted recipient needs emergency care?
A. If there is an emergency, the recipient should call 911 or go to the nearest hospital emergency room. A recipient can receive emergency services from any hospital without a referral from their assigned primary care provider.
Q. What if a restricted recipient has a prescription from the emergency department?
A. If the prescription was written as part of an emergency department visit and the PCP is unavailable to verify the prescription (i.e., after hours), the primary pharmacy is responsible for using professional judgement with filling the prescription without regard to restriction requirements. However, the primary pharmacy is responsible for contacting the PCP the next business day regarding the prescription obtained by the recipient.
Q. As a primary care provider do I have to accept a restricted recipient as a patient?
A. No, you do not have to accept a restricted recipient as a new patient. If the recipient is a current patient enrolled in a Managed Care Plan and you no longer wish to provide their care, you must notify the recipient’s Managed Care Plan that you no longer wish to treat the recipient and follow the appropriate process and directions to discharge the patient. If the recipient is a current patient enrolled in fee-for-service, you must notify the LDSS (upstate recipients), NYC HRA (NYC recipients) or OMIG, that you no longer wish to treat the recipient and follow the appropriate process and directions to discharge the patient.
Q. As a primary pharmacy provider do I have to accept a restricted recipient as a patient?
A. No, you do not have to accept a restricted recipient as a new patient. If the recipient is a current patient and you no longer wish to provide pharmacy services, either you or the recipient must notify the LDSS (upstate recipients), NYC HRA (NYC recipients), or OMIG.
Q. Does the pharmacy need to re-issue prescriptions written by a specialist?
A. No. The restricted pharmacy is required to verify the referral if the prescription was not written by the assigned PCP. To submit the claim, the assigned pharmacy must:
- Verify the referral with the assigned PCP
- Enter the specialist as the ordering provider
- Enter the assigned PCP as the referring/PCP
To assist the pharmacy, the specialist may include the name of the referring PCP on the prescription.
Q. Are all medications subject to the restriction process?
A. No. Any prescriber can prescribe Medication Assisted Treatment (MAT) drugs, Emergency Contraceptives, and Immunizations for restricted recipients without a referral from the PCP. However, these medications must still be obtained through the assigned pharmacy.
Q. Are all medical services subject to the restriction process?
A. No. According to current Medicaid program and policy requirements, a restricted recipient can receive emergency services or opioid treatment program (OTP) services (formerly known as methadone maintenance treatment programs) without a referral from their assigned PCP. If/when policies are modified, OMIG will update the RRP information on this website to reflect those changes.
Q. Are Health Home services subject to the restriction process?
A. No. A recipient can receive Health Home services without a referral from their assigned PCP. Health Home services provide recipients with a care manager to develop a care plan and connect a recipient to health care providers, medications, and community assistance programs. Per the Department of Health website (Guide to Restriction Exception (RE) Codes and Health Home Services): “Individuals can be in a Restricted Recipient Program (RRP) and enrolled in Health Home, but the Care Manager should work with the recipient and contact their Managed Care Plan, if applicable, to ensure compliance with any restrictions.”
Medicaid Managed Care Plan Billing and Payment Protocol for Health Home Services can be found at: Medicaid Managed Care Plan Billing and Payment Protocol for Health Home Services.
Health Home questions can be emailed to: [email protected]
Q. Does the primary care provider and/or primary pharmacy need to make transportation arrangements for restricted recipients that are assigned to me?
A. Yes, the assigned PCP or a designee from the provider’s office are the only ones to make transportation arrangements for the recipient by contacting MAS or Modivcare (Nassau, and Suffolk counties).
A primary pharmacy cannot make transportation arrangements for a restricted recipient.
Q. How can a recipient be recommended for restriction?
A. All Medicaid Fraud Allegations can be reported to the NYS OMIG Bureau of Medicaid Fraud Allegations here. Allegations are categorized and distributed to the appropriate units. Recipient allegations are reviewed by the Recipient Investigations Unit (RIU) and/or the RRP medical team.
Q. Can a restriction be removed before the date a restriction ends?
A. To discuss removing a recipient’s restriction, contact the OMIG’s RRP by email at: [email protected], or call the RRP Helpline at: 518-474-6866