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Issue Alert - 04-01-01

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Date:

Jan 05, 2004

Issue Summary:

The Beneficiary Monitoring Program (BMP) policy describes the criteria used to identify beneficiaries potentially misusing or overusing Medicaid services.

Persons Affected:

Medicaid recipients

For More Information:

Center for Civil Justice320 S. Washington, 2nd Floor Saginaw, MI 48607 (989) 755-3120, (800) 724-7441 (989) 755-3558 FaxEmail: info@ccj-mi.org


Background

Medicaid

What's Happening?

The Medical Services Administration has issued revised policy on the Beneficiary Monitoring Program (BMP). State and federal regulations mandate that every state conduct reviews of Medicaid benefits to insure that no recipients are receiving services beyond what is medically necessary, including prescription medication. The objectives of the policy are to identify beneficiaries that are misusing and/or overusing Medicaid services, evaluate the services being used, and if it is found that misuse appears to be occurring, place the beneficiary in a "control mechanism".There are two types of control mechanisms, one for pharmaceutical misuse and one for misuse of Medicaid services (other than pharmaceuticals). These are called "lock-ins". The Pharmaceutical Lock-In control mechanism monitors all prescription drug claims for the Michigan Department of Community Health (MDCH). Requests for prescriptions will be evaluated against other prescriptions for 34 days. Beneficiaries will not be allowed to fill or refill prescriptions in certain drug categories until 95% of the medication would have been consumed if used according to the prescribed dose.The Restricted Primary Provider control mechanism is used for those persons identified as abusing or misusing Medicaid services other than pharmaceuticals. It is the responsibility of the restricted beneficiary's primary care physician to supervise the case. Beneficiaries are placed into the program for a minimum of 24 months. The use of medical services and drugs is routinely monitored and the the effectiveness of the controls evaluated. Beneficiaries may appeal MDCH's action in placing them in the pharmaceutical lock-in and/or primary care provider utilization control.

What Should Advocates Do?

For a full description of the policy, please see: http://www.michigan.gov/documents/All_Provider_03-13_80692_7.pdf

Finding Help

Most legal aid and legal services office handle these type of cases, and they do not charge a fee. You can locate the free legal services or legal aid office that serves your county on the Michigan LawHelp website (http://www.MI.LawHelp.org) or look in the yellow pages under "attorneys" or call the toll-free lawyer referral number, (800) 968-0738.