I’ve been placed in the Medicaid Recipient Restriction Program. What should I know?

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What is the Medicaid Recipient Restriction Program (RRP)?

The Medicaid Recipient Restriction Program (RRP) is a set of New York State Medicaid rules that force some people with Medicaid to see specific healthcare providers, such as a primary care physician (PCP), pharmacy, or hospital. The goal of this program, according to the New York State Department of Health (DOH) and the Office of the Medicaid Inspector General (OMIG), is to improve care and lower costs. However, many people with Medicaid, especially people with complex health needs like substance use disorders, say that these restrictions keep them from getting the care and services they need.

Why might you be placed in the RRP?

You may be put in the RRP if Medicaid sees patterns in how you use your Medicaid. Medicaid often puts people in the RRP because of:

  • Frequent Emergency Room (ER) Visits: If you are going to the ER often for non-emergency issues, Medicaid may put you in the RRP so that you see your primary care doctor instead.
  • Multiple Healthcare Providers for the Same Issue: If you are seeing multiple doctors for the same condition, Medicaid may see this as overuse.
  • Using More than One Pharmacy: If you fill prescriptions at more than one pharmacy, especially for the same medication, you may be put in the RRP.
  • Unnecessary or Excessive Services: If you are getting services that seem unneeded or excessive, like medications or supplies that do the same things, or unnecessary tests and procedures.

Medicaid often flags people for RRP because of patterns in Medicaid use, not your actual medical needs. People with complex health conditions —such as chronic illnesses, mental health issues, or substance use disorders—are often unfairly put in RRP simply because they need care from multiple providers or take several medications.

What does RRP enrollment mean for you?

If you are put in the RRP, you must:

  • Use an assigned Primary Care Provider (PCP): Medicaid will assign you a primary care provider (PCP) who must approve all other healthcare services.
  • Use a specific pharmacy: You must fill all prescriptions at one pharmacy. You cannot use any other pharmacy unless your PCP approves it.
  • See your PCP for referrals: If you need to see a specialist, get tests, or have procedures done, you will need a referral from your PCP.

These restrictions are meant to help your PCP organize your care, but they often keep people with Medicaid from getting services they need—particularly when the assigned provider or pharmacy is not convenient or familiar. Unfortunately, switching Medicaid plans will not remove the restriction. Once you’re in the RRP, it carries over to your Medicaid coverage and plans even if you go off Medicaid and then back on.

The first time you’re put in RRP, it will last twenty-four months. Before the twenty-four months end, Medicaid will review your case to decide if the RRP should continue. If Medicaid decides to continue the RRP, Medicaid and/or your health plan must send a new notice to restrict. A second restriction will last three years; any restrictions after that are six years.

How will you know if you are in the RRP?

You should get a written notice in the mail from Medicaid or your Medicaid plan if you are being put in the RRP. This notice will say:

  • The name of your assigned PCP and the pharmacy you must use;
  • The reasons you are being put in the RRP;
  • The date that you will be put in the RRP; and
  • Instructions on how to request a Fair Hearing if you believe you should not be in the RRP.

If you get a letter saying you will be put in the RRP (“Notice of Intent to Restrict”), you must ask for a fair hearing before the date you will be put in the RRP. Requesting a fair hearing before this date should keep you from being put in the RRP until you have the fair hearing. If you couldn’t ask for the fair hearing before the RRP’s start date, you should still ask for one—you have 60 days from the date of the notice to ask for a fair hearing.

Fair hearing requests are handled by a New York State agency called the Office of Temporary and Disability Assistance (OTDA). You can ask for a fair hearing:

  • Online here 
  • Phone: 518-474-8781 or 800-342-3334

If you did not get a letter in the mail but find out that you are in the RRP, you should still ask for a fair hearing. When you request the fair hearing, tell them you did not get a notice and your Medicaid coverage has been restricted.

In your fair hearing request, include:

  • Your name, date of birth, address, and Medicaid ID number;
  • A short explanation for why you think you should not be in the RRP.

You should get a notice from OTDA with your Medicaid fair hearing number within a few weeks.

What are your other rights under the RRP?

You have several rights when you are put in the RRP, besides written notice and fair hearing rights:

  1. Emergency Services: You can still get emergency care, including emergency room visits and urgent care services, at any provider that accepts Medicaid, even if the RRP has assigned you to a certain PCP or pharmacy.
  2. Changing Providers: If your assigned PCP or pharmacy is inaccessible, unavailable, or unsatisfactory, you have the right to ask for a change. Medicaid must change your PCP or pharmacy if there is a good reason for the request. For example, if the PCP is too far away or can’t meet your healthcare needs.
  3. Provider Continuity: If you already see a healthcare provider who you need for continued care, you can ask Medicaid to let you keep seeing that provider, especially if you have complicated care needs.

Special Notes About Substance Use Disorders

If you have a substance use disorder, the RRP can make it difficult to get the care you need. The RRP makes many people in recovery go to specific providers or pharmacies, but that is not always helpful in recovery care, where you may need flexibility to find the right provider and get specialized services.

In some cases, Medicaid has raised concerns about clients in recovery who may use multiple providers or pharmacies to fill the different prescriptions needed for their treatment. If you are in recovery, make sure to:

  • Document your healthcare needs: Give Medicaid detailed information from your treatment providers about why you need to see multiple doctors or use more than one pharmacy.
  • Ask to change providers: If your assigned providers do not know how to work with patients in recovery or meet your needs, you can ask for a change to someone who specializes in addiction recovery.

Additional Resources and Legal Help:

For free legal help, call Legal Services NYC at 917-661-4500 Monday through Friday from 9:30 a.m. to 4 p.m. Learn more about our intake process here.

* The information does not constitute legal advice. You should always consult an attorney regarding your matter. Legal help subject to capacity and location.

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