Limited Services Due to Program Abuse

Recipients who seek out and repeatedly obtain unnecessary services are placed on Limited/Restricted Service Status. Providers are alerted through the MC verification system that for these recipients, prior authorization is required for certain services. Any MC recipient can be placed on Limited/Restricted Service Status.

DHCS Responsibility

DHCS prepares and sends a “Notice of Action, MC Coverage Restricted” (MC 1705) to the client at least 10 days before restricted service status becomes effective. A copy of the MC 1705 is sent to the County and forwarded to the EW. The NOA must be scanned into IDM.

Limited/Restricted Service is in effect for a minimum of one year, unless altered by DHCS or a state hearing decision.

Note: Limited/Restricted service status must not be lifted because of the hearing request.

The restricted service messages are:

  • Restricted Drugs, coded “R1”
  • Restricted Scheduled Drugs, coded “R5”
  • Restricted M.D. Visits, coded “R11”
  • Restricted Drugs/M.D., coded “R12”
  • Restricted to Primary M.D., coded “R14”
  • Restricted to Primary M.D./Drugs, coded “R15”

DHCS reviews and, if appropriate, authorizes all MC drug and/or M.D. visit requests for the customer. (Providers have been informed by provider bulletin that prior departmental approval is required by the special coding indicated.)

County Responsibility

EWs are responsible for accepting and forwarding requests for state hearing from individuals who want to appeal their restricted service status. Send the requests to the Appeals Unit.

  • Restricted service beneficiaries may request a state hearing within 90 days of the initial action by DHCS.
  • Restricted service status must not be lifted because of the hearing request.

There is no effect on the other MFBU members when a person in the MFBU is placed on limited/restricted status.

MC Benefits Issuances

There are NO special indicators which the EW must enter into CalSAWS for those individuals who have been placed on limited/restricted status.

  • DHCS will automatically input information into MEDS indicating the person has been placed on limited service status.
  • DHCS will also automatically input restricted service status information into MEDS for individuals with a SOC and who are placed on limited services.

Related Topics

Limited Services for MIAs in SNF/ICF

Severely Impaired Working Individuals Program

Spousal Impoverishment Provisions at Initial Request for Services

Waivers/Programs