16 Del. Admin. Code § 14000-14910
Certain recipients who are exempt from the Diamond State Health Plan are restricted or locked-in when it has been determined that they are engaged in abusive or fraudulent practices such as overutilization of emergency room services or prescription drugs, lending a Medical Assistance card to an unauthorized person, etc. In general, restriction means that fee for service payments are limited to one primary physician and one primary pharmacy. Women are also permitted one obstetrician/gynecologist. Upon referral from the primary physician, any recipient with a special medical condition is permitted to have a specialist as an additional caretaker. If the restricted recipient visits other doctors or has prescriptions filled at other pharmacies, the Delaware Medical Assistance Program will not pay for these unauthorized claims and the recipient can be held responsible for such claims. Refer to the Delaware Medical Assistance Provider Manual for more information about restricted recipients.
16 Del. Admin. Code § 14000-14910