CurrentMedStar Family Choice MarylandPolicy 217

Corrective Managed Care

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This policy governs MedStar Family Choice's Corrective Managed Care Program for Maryland Medicaid members who misuse pharmacy benefits or, when appropriate, other medical assistance benefits. It establishes eligibility, review, lock-in, notification, redetermination, and appeal procedures.

Policy Summary

PayerMedStar Family Choice Maryland

PolicyCorrective Managed Care

Policy CodePolicy 217

Change TypeExpanded and revised

Effective DateJuly 1, 2026

Last ReviewJul 1, 2018

Next Review DateN/A

Key ActionThe Medical Reviewer or designee must review monthly PBM pharmacy claims and verify the appropriateness of potential CMC candidates.

SourceLink

POLICY UPDATE CHANGES

The program scope was expanded to include all misuse of the plan pharmacy benefit and, when appropriate, misuse of non-pharmacy medical assistance benefits.

The policy expanded and aligned the criteria used to identify members for CMC enrollment, including inappropriate providers, inappropriate frequency or manner of use, and misuse of a Medical Assistance card.

An exception was added for specialty medications that cannot be dispensed by the member's regularly assigned pharmacy.

The approving role was changed from AVP Clinical Operations to Director, Pharmacy.

6+Controlled-medication prescriptions in 30 days

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CurrentMedStar Family Choice MarylandPolicy 217

Corrective Managed Care

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Policy Summary

PayerMedStar Family Choice Maryland

PolicyCorrective Managed Care

Policy CodePolicy 217

Change TypeExpanded and revised

Effective DateJuly 1, 2026

Last ReviewJul 1, 2018

Next Review DateN/A

Key ActionThe Medical Reviewer or designee must review monthly PBM pharmacy claims and verify the appropriateness of potential CMC candidates.

SourceLink

POLICY UPDATE CHANGES

The program scope was expanded to include all misuse of the plan pharmacy benefit and, when appropriate, misuse of non-pharmacy medical assistance benefits.

An exception was added for specialty medications that cannot be dispensed by the member's regularly assigned pharmacy.

The approving role was changed from AVP Clinical Operations to Director, Pharmacy.

6+Controlled-medication prescriptions in 30 days

Pharmacies or prescribers in 30 days

20 daysRedetermination period

24 monthsStandard enrollment duration

36 monthsContinued-abuse extension

6th/8th dayMonthly reporting deadlines

CMC Eligibility and Lock-In Requirements

CMC enrollment criteria

Members may be enrolled in CMC when benefit abuse is established and, for controlled-substance cases, claims meet the specified utilization thresholds.

Member abuse of benefits

The member engages in fraud as defined by COMAR 10.09.24.14.
The member utilizes an inappropriate type of provider for care.
The member utilizes an appropriate type of provider at an inappropriate frequency for care.
The member utilizes an appropriate provider in an inappropriate manner.
The member utilizes a Medical Assistance card in an inappropriate manner.

Controlled-substance enrollment criteria within 30 days

The member received six or more prescriptions for controlled medications.≥ 6 prescriptions within 30 days
The member used
- Three or more pharmacies.≥ 3 pharmacies within 30 days
- Three or more prescribers; all prescribers in a group practice are considered a single prescriber.≥ 3 prescribers within 30 days

Lock-in pharmacy and provider requirements

Once enrolled, the member must obtain prescribed drugs from one designated in-network provider and/or pharmacy unless an identified exception applies.

Prescribed drugs must be obtained from one designated provider and/or pharmacy that is in network with MedStar Family Choice.

Exceptions

The provider renders services in the context of an emergency department visit.
The provider renders services in the context of hospital inpatient treatment.
The medication is a specialty product as defined in COMAR 10.67.06 and cannot be dispensed from the regularly assigned pharmacy.

Thresholds, Durations, and Reporting Deadlines

Controlled-medication prescription count

ThresholdSix (6) or more prescriptions for controlled medications

Review periodWithin a 30-day period

UseThis is a controlled-substance criterion for CMC enrollment review

Pharmacy utilization count

ThresholdThree (3) or more pharmacies

Review periodWithin a 30-day period

UseThis may satisfy the pharmacy-utilization criterion for CMC enrollment review

Operational Procedures and Member Handling

Note

Review and Verify CMC Candidates

A Medical Reviewer or designee reviews contracted PBM pharmacy claims data monthly to identify members who may have abused controlled-substance pharmacy benefits. Candidates identified through PBM reports or by a Health Plan Pharmacy technician must have appropriateness verified by the Medical Reviewer, who makes the final enrollment decision.

Prior Authorization

Controlled-Substance Enrollment Threshold

Enroll a member in CMC for controlled-substance benefit abuse when claims within a 30-day period show the member received at least six controlled-medication prescriptions and used either at least three pharmacies or at least three prescribers. Prescribers in the same group practice count as one prescriber.

Minimum prescriptions: 6 controlled-medication prescriptions within 30 days.
Utilization threshold: 3 or more pharmacies, or 3 or more prescribers within the same 30-day period.
Group practices: All prescribers in a group practice are counted as a single prescriber.

Key Program Terms

Corrective Managed Care (CMC) program

ProgramCorrective Managed Care (CMC)

AuthorityDefined by COMAR 10.67.12

Policy contextThe program applies to Pharmacy Benefits, regardless of controlled or scheduled designation

Medical Reviewer

RoleMedical Reviewer

Qualified professionalsMedical Director or Health Plan Pharmacist

Review functionThe Medical Reviewer makes final decisions on individuals identified through PBM reports

Policy Summary

PayerMedStar Family Choice Maryland

PolicyCorrective Managed Care

Policy CodePolicy 217

Change TypeExpanded and revised

Effective DateJuly 1, 2026

Last ReviewJul 1, 2018

Next Review DateN/A

Key ActionThe Medical Reviewer or designee must review monthly PBM pharmacy claims and verify the appropriateness of potential CMC candidates.

SourceLink

On This Page

Prescriber utilization count

ThresholdThree (3) or more prescribers

Review periodWithin a 30-day period

Group-practice ruleAll prescribers in a group practice are considered a single prescriber

Redetermination period

Redetermination period20 days from the date of the notice

Member actionThe member may present additional documentation explaining the facts underlying the benefit-abuse determination

Effective-date impactEnrollment is postponed while the redetermination request is reviewed

Standard CMC enrollment duration

Standard duration24 months

ApplicabilityMembers found to have abused benefits are enrolled in the program for this period

ProgramCorrective Managed Care (CMC)

Continued-abuse extension

ExtensionAdditional 36 months

TriggerContinued abuse of MCO benefits while enrolled in the CMC program

Enrollment impactThe member remains enrolled in the plan for the additional period

MDH lock-in file deadline

DeadlineClose of business on the sixth business day of each month

Responsible entityMaryland Department of Health (MDH)

File contentsThe file includes patient information, lock-in span, and pharmacy NPI

New lock-in report deadline

DeadlineClose of business on the eighth business day of every month

SubmissionSubmit a spreadsheet by secured encrypted email to HealthChoice staff

Report scopeMembers who are new to lock-in since the previous report

Billing Rule

Single-Provider or Pharmacy Lock-In

Members enrolled in CMC must obtain prescribed drugs from one designated in-network provider and/or pharmacy. Members may suggest a provider or pharmacy, but the plan may reject a provider choice that is not in the member’s best interest for appropriate use of available services or an out-of-network pharmacy; a new pharmacy may be designated at the member’s request.

Exceptions include prescriptions or services provided during an emergency department visit.
Hospital inpatient treatment is exempt from the lock-in requirement.
Specialty products defined by COMAR 10.67.06 are exempt when they cannot be dispensed by the regularly assigned pharmacy.

Documentation Required

Enrollment Effective-Date Hold

The CMC enrollment effective date is 20 days after the notice date. If the member requests redetermination within that period, enrollment is postponed while MedStar Family Choice reviews the request and makes a decision.

Members have 20 days from the notice date to submit additional information or documentation.
The enrollment effective date is postponed pending the redetermination outcome.
Enrollment duration is not changed by a change in how the member receives medical assistance, including a change in MCO enrollment.
Initial enrollment is 24 months; continued abuse while enrolled results in an additional 36 months.

Documentation Required

Member Notification Requirements

Provide a written notice stating that the member will be enrolled in CMC and explaining the effective date, enrollment duration, reasons for the benefit-abuse determination, and the assigned provider and/or pharmacy. The notice must also explain the member’s preference rights, the 20-day redetermination period, where to send additional information, and that the effective date will be postponed during review.

Include the assigned provider and/or pharmacy name, address, and telephone number.
State that the member may identify a preferred primary care provider, specialty care provider, and/or pharmacy.
Explain how and where to submit additional information within 20 days.
Use the MDH-approved template for the applicable appeal level; initial notification letters must follow Appendix I.
Each member letter must be individually reviewed and approved by MDH before mailing.
After redetermination, notify the member whether the decision is affirmed or reversed; an affirming notice must include the enrollment effective date, duration, and appeal instructions.

Note

Late Request Handling

Requests made outside the 20-day period for initiating redetermination are treated as appeals and handled through the standard process under COMAR 10.67.09.05. If the appeal proceeds to a State Fair Hearing, MedStar Family Choice must attend and provide justification for the CMC enrollment.

Requests within 20 days are reviewed as redeterminations based on additional documentation.
The date of the notice of action is the date on the final letter after redetermination.

Billing Rule

Monthly Lock-In Administration

Each month, reconcile Maryland Department of Health (MDH) lock-in files with PBM reports, update plan and PBM systems, coordinate pharmacy lock-in assignments, communicate discrepancies, and report new lock-ins to HealthChoice staff.

By close of business on the sixth business day, MDH provides a Medicaid-portal file listing members currently locked in, lock-in span, patient information, and pharmacy NPI.
The Medical Reviewer or designee reviews MDH files and PBM reports, reconciles the lists monthly, and makes final enrollment decisions.
Contact the PBM to arrange lock-in to the designated pharmacy based on MDH information; communicate discrepancies to UMBC and/or HealthChoice staff.
By close of business on the eighth business day each month, submit a spreadsheet by secured encrypted email to HealthChoice staff for members new to lock-in since the prior report.
Include member name, date of birth, Medicaid ID, pharmacy NPI, lock-in beginning and ending dates, and MedStar Family Choice ID.

Member abuse of benefits

FraudFraud as defined by COMAR 10.09.24.14

Provider useUsing an inappropriate type of provider, or using an appropriate provider at an inappropriate frequency or in an inappropriate manner

Medical Assistance cardUsing a Medical Assistance card in an inappropriate manner

Lock-in

RequirementObtain prescribed drugs only from one designated provider and/or pharmacy in the MedStar Family Choice network

Emergency exceptionServices provided in the context of an emergency department visit are excepted

Other exceptionsHospital inpatient treatment and qualifying specialty products unavailable from the regularly assigned pharmacy are excepted