(a) Any Qualified provider.  The Medicaid Agency assures that any individual eligible for Medicaid, may obtain services from any institution, agency, pharmacy, person, or organization that is qualified to perform the services.

(b) Recipient lock-in.  Medicaid recipients who have demonstrated Medicaid usage above the statistical norm, during a 12-month period, may be "locked-in" to one primary physician and/or one pharmacy in accordance with Federal Regulation 42 CFR 431.54.

• (1) Over-utilization patterns by Medicaid recipients may be  identified either by referral or by OHCA automated computer systems.  Medicaid records, for a 12-month period, of those identified recipients are then reviewed.  Medical histories are ordered and reviewed by OHCA medical consultants to determine if high usage is medically justified.
• (2) If it is determined that Medicaid has been over-utilized, the recipient may be notified, by letter, of the need to select a primary physician and/or pharmacy and of their opportunity for a fair hearing.  If they do not select a physician one is selected for them.  The primary-care provider must be a general practice, family practice, OB-GYN, pediatrician or internal-medicine physician and currently be enrolled as a Medicaid provider.  In some cases recipients may be sanctioned under OAC 317:35-13-7.
• (3) The provider of choice, unless that provider has been identified as having problems with Medicaid over-utilization, is notified by letter and is given an opportunity to accept or decline to be the recipient's primary physician.
• (4) When the provider accepts, a confirmation letter is sent to both recipient and provider showing the effective date of the arrangement.  The recipient will be issued a monthly Medicaid identification card which will designate them as a participant in the lock-in program.
• (5) After the lock-in arrangement is made, the provider may file claims for services provided in accordance with OHCA procedure.
• (6) Locked-in recipients may obtain emergency services from an emergency room facility for an emergency medical condition or as part of an inpatient admission.
• (7) Medicaid-compensable visits to a specialist are covered when referred by the primary-care physician.  The primary-care physician must be shown as the referring physician on Item 17 of HCFA-1500 submitted by the specialist.
• (8) If a claim is filed by another provider, it is reviewed to see if a referral was given or services were for an acute physical injury.  Claims not meeting this criteria are denied and the recipient is responsible for charges.
• (9) When a recipient is enrolled into the lock-in program, usage is monitored when necessary and reviewed every 24  months.  A provider may send a written request for recipient review.  If review indicates utilization patterns meet lock-in removal criteria, the recipient may be removed from lock-in at the discretion of OHCA staff.
• (10) During a review, OHCA may elect to continue lock-in, remove the recipient from lock-in because of medical necessity, remove them because of decreased utilization, or impose sanctions under OAC 317:35-13-7.
• (11) The recipient in the lock-in program may make a written request to change providers after the initial three months; when the recipient moves to a different city or if the recipient feels irreconcilable differences will prevent necessary medical care.  Change of providers based on irreconcilable differences must be approved by OHCA staff.
• (12) OHCA may make a provider change when the provider makes a written request for change or may initiate a change anytime it is determined necessary to meet program goals.