Q. Why am I restricted?
A. A recipient can be restricted for several different reasons. A restriction is implemented if it is found that you have received duplicate, more than recommended, or conflicting health care services, drugs, or supplies; or if you have committed fraud using your benefit card (i.e., forged prescriptions, card loaning, doctor shopping).
Q. How do I get the restriction removed?
A. Your restricted will be removed (lifted) on your lift due date. Your lift due date will be listed on the letter sent to you in the mail. If you wish to appeal the restriction decision, you may request a Fair Hearing within 60 days of receiving your letter stating you will be restricted.
Q. How do I request a Fair Hearing?
A. You can ask for a fair hearing by calling (800) 342-3334, or online at https://otda.ny.gov/hearings/request/#online
Q. How long will I be restricted?
A. If this is your first restriction, the length of the restriction is two years. If you are restricted again after that two-year period is completed, the restriction is three years. Any subsequent restriction is for six years.
Q. How do I know who I am restricted to?
A. When you are restricted, a letter will be sent to you. The letter will include the names of the providers you are restricted to. If you do not remember your providers, contact your Managed Care Plan, Local Department of Social Services (LDSS) (upstate recipients), NY State of Health (if your coverage was obtained through the NY State of Health), or NYC Human Resources Administration (NYC recipients).
Q. How do I change my assigned medical provider(s)?
A. If you do NOT have a Managed Care Plan, contact your LDSS (upstate recipients), NY State of Health (if your coverage was obtained through the NY State of Health), or NYC Human Resources Administration (NYC recipients) for all provider changes.
If you have a Managed Care Plan, contact your Managed Care Plan.
Q. How do I change my assigned pharmacy?
A. Contact your LDSS (upstate recipients), NY State of Health (if your coverage was obtained through the NY State of Health), or NYC Human Resources Administration (NYC recipients) for all provider changes.
Q. What if my pharmacy is closing/going out of business?
A. You will need to choose a different pharmacy location to obtain your medications and pharmaceutical supplies. After selecting a new pharmacy provider, contact your LDSS (upstate recipients), NY State of Health (if your coverage was obtained through the NY State of Health), or NYC Human Resources Administration (NYC recipients) to get your restriction updated.
Q. What is a good cause to change my assigned provider(s)?
A. There are several different good cause reasons to request a change in providers. Some examples include: if the provider no longer wishes to be your provider, if the provider has retired, if the provider has closed their office or relocated out of your area, or if you have moved to a different location.
Q. How do I get transportation?
A. When you are restricted, it is the responsibility of the assigned primary care provider to make transportation arrangements for you.
Q. Can I see a specialist if my assigned doctor cannot treat my current health issues?
A. Yes, your assigned primary care provider can refer you to any necessary specialist for services that you require.
Q. What if I have a prescription from a provider who is not my assigned primary care provider; how do I get the prescription filled?
A. Your assigned pharmacy can fill prescriptions from another provider only if you were referred to that other provider by your assigned primary care provider. The pharmacy will verify the information with your assigned primary care provider.
Q. What if I have a prescription for a specialty medication that the restricted pharmacy cannot supply?
A. A second pharmacy can be utilized if you require a specialty medication and/or for short-term rehabilitation stays. In the instance where you are also restricted to a second pharmacy, both pharmacies will be able to provide pharmacy services. To get a second pharmacy added to your profile, contact your LDSS (upstate recipients), NY State of Health (if your coverage was obtained through the NY State of Health), NYC Human Resources Administration (NYC recipients) or OMIG.
Q. What if I have an emergency, do I need to go through my assigned primary care provider to obtain care?
A. A restriction does not apply to emergency services and therefore a referral from your primary care provider is not required to obtain emergency care.
Q. What happens if I need to enter a rehab facility for drug and alcohol treatment?
A. Your assigned primary care provider can provide a referral for inpatient drug and/or alcohol treatment.