Information for Managed Care in the Recipient Restriction Program (RRP)

Information

In accordance with Appendix Q of the Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan/Health and Recovery Plan Model Contract, Managed Care Plans (MCP) are required to have a restricted recipient program.

The Recipient Restriction Program (RRP) is intended to coordinate medical services and improve quality of care for Medicaid recipients. Coordination of care reduces the potential over-utilization of health care services and prevents abusive or fraudulent behavior through increased coordination of medical services that control the number of providers the Recipient may select for care and the referrals to services, medications, and equipment. Recipients in the RRP are ensured access to medically necessary quality health care.

Medicaid members who have been assigned to a designated healthcare provider (i.e., physician or clinic, pharmacy, hospital) are REQUIRED to receive care only from the designated healthcare provider. 

A primary physician or primary clinic is responsible for providing all non-emergent medical care to the restricted recipient, either directly or through referral of a recipient to another medical provider for appropriate services. In accordance with The New York State Medicaid Program, Information For All Providers - General Policy Manual, emergency services, methadone maintenance claims, and/or a service provided in an inpatient setting when a recipient is admitted emergently, should not be denied based on the restriction.

The MCP must ensure a recipient is restricted to an RRP provider upon enrollment in the plan for recipients who have previously met the condition of a restriction on the effective date of enrollment, or within 45 days of confirming a recipient has met the conditions of a new restriction.

The MCP must monitor benefit package services provided to the restricted recipient and identify when a restricted recipient attempts to access restricted services from a provider other than their RRP provider. When a restriction is in place, the recipient may only access services through the RRP provider(s), except where the recipient is referred to an alternate provider authorized by the MCP or the RRP provider.

The MCP must identify participating providers who can function as RRP providers and meet the requirements for providing necessary health care services and referrals for restricted recipients.

The MCP must send written notice confirming a recipient’s restriction to the RRP provider, including: the date of the restriction; the scope, type, and length of restriction; and any other recipient restrictions and associated RRP providers. The MCP must inform the RRP provider of their responsibilities for providing care and referrals for the restricted recipient. Such notice shall be made when the MCP imposes, modifies, or continues a restriction or when the MCP changes the restricted recipient’s RRP provider. 

The MCP must determine when a recipient has engaged in abusive practices or demonstrated a pattern of misuse of benefit package services where appropriate. 

The MCP, upon imposing, modifying, continuing, or administering a restriction, may assign an RRP provider or afford the recipient a choice of RRP providers.

Upon request, the MCP will allow a restricted recipient to change RRP providers every three months or at any time with good cause as determined by the MCP.

Good cause for a restricted recipient to change an RRP provider means one or more of the following circumstances exist:

  1. The RRP provider no longer wishes to be a provider for the recipient.
  2. The RRP provider has closed the servicing location or moved to a location that is not convenient for the restricted recipient.
  3. The RRP provider has been suspended, terminated, excluded or otherwise disqualified from participation in the Medicaid program.
  4. The restricted recipient’s place of residence has changed and has moved beyond time and distance standards as described in model contract Agreement; or
  5. Other circumstances exist that make it necessary to change RRP providers, including but not limited to, good cause reasons for changing PCPs as provided by applicable statute and regulations.

The MCP will process a request to change a PCP and submit a provider change form to the OMIG specifying the change at the time the change is made.

For recipients who fail to establish a relationship with a PCP, the plan should contact the recipient and discuss the benefits of having an established PCP as well as the rules of the restriction program with the recipient. The MCP must include a statement that if the recipient attempts to receive a restricted services from a provider other than the RRP provider, the MCP may not approve or pay for the services.

Notification forms to send to OMIG:

Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan Model Contract Appendix Q

April 2023 meeting presentation

Local Department of Social Services directory