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10.09.57.00.htm 10.09.57.00. Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 57 Partially Capitated Programs Authority: Health-General Article, §2-104(b) 15-103, and 15-105, Annotated Code of Maryland
10.09.57.01.htm 10.09.57.01. 01 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) "Applicant" means an entity which submits an application to become a partially capitated provider.2) "Capitation payment" means the sum of money paid by the Program on behalf of an enrollee on a regular periodic per capita basis for capitated services.3) "Capitated services" means a service provided by a PCP or one of its subcontractors for which the Department has agreed to
10.09.57.02.htm 10.09.57.02. 02 Application for Qualification as a Partially Capitated Provider.. A. An applicant shall demonstrate to the satisfaction of the Department that it has the managerial, financial, clinical, and administrative capability to carry out the duties required by these regulations.B. An applicant shall submit the following documents to the Department along with a completed application form:1) A narrative of the applicant's overall plan for providing and arranging for the provision of high
10.09.57.03.htm 10.09.57.03. 03 Conditions of Participation.. A. A PCP shall meet the general conditions for participation as set forth in COMAR 10.09.36.03.. B. In addition, the PCP shall:. 1) Ensure that all of its employees, subcontractors, and employees of its subcontractors are appropriately licensed in the jurisdiction in which they are practicing;2) Enter into and maintain contractual arrangements necessary to meet the medical and health needs of enrollees for which it is receiving a capitation
10.09.57.04.htm 10.09.57.04. 04 Covered Services.. Providers may be capitated for one of the following packages of services subject to the approval of the Department:A. Inpatient hospital services, as long as the applicant, if regulated by the Health Services Cost Review Commission, has received permission from that agency to receive capitation payments;B. Mental health services, including but not limited to, psychiatric inpatient treatment and community mental health outpatient services;
10.09.57.05.htm 10.09.57.05. 05 Enrollment and Termination of Enrollment.. A. The Department shall determine the boundaries of the geographic area that a PCP may serve. The Department shall limit enrollment in a PCP to recipients who live in that area.B. The PCP is responsible for the enrollment of recipients who have chosen to enroll in the PCP.. C. The PCP shall enter into an enrollment contract with a recipient on the form approved by the Department.D. The PCP shall enroll eligible recipients in the
10.09.57.06.htm 10.09.57.06. 06 Marketing.. A. The PCP shall specify in its provider agreement the methods by which the PCP will assure the Department that its marketing plans, procedures, and materials are accurate and do not mislead, confuse, or defraud the Department or recipients.B. The Department shall preapprove all marketing plans, procedures, and materials..
10.09.57.07.htm 10.09.57.07. 07 Quality Assurance.. A PCP shall maintain an internal quality assurance system based on written policies, standards, and procedures that is in accordance with accepted medical practices and professional standards and that includes, at a minimum, the following:A. A comprehensive quality assurance plan which:. 1) Addresses both the quality of clinical care and nonclinical aspects of service such as accessibility, coordination, and continuity of care,2) Provides for review by
10.09.57.08.htm 10.09.57.08. 08 Record Keeping and Reports.. A. The PCP shall have an effective procedure for reporting to the Department the following information:1) The cost of operations;. 2) Patterns of utilization;. 3) The health status of enrollees;. 4) Information demonstrating that the PCP has a fiscally sound operation; and. 5) Complaints and grievances made by enrollees.. B. The PCP shall collect and submit to the Department service specific encounter data by service type in the format and at th
10.09.57.09.htm 10.09.57.09. 09 Confidentiality.. Subject to the requirements of 42 CFR 431F (1994) the PCP and its subcontractors may not release or disclose any information concerning an enrollee except with the written permission of the:A. Department;. B. Enrollee; or. C. Enrollee's attorney, legal representative, or guardian..
10.09.57.10.htm 10.09.57.10. 10 Financial Solvency.. A. The PCP shall include in its provider agreement a clause that the PCP will hold harmless both the Department and its enrollees from any liability for payment for the legal obligations of the PCP.B. The PCP shall give the Department access to the PCP's financial records at reasonable intervals in order to monitor the PCP's financial solvency.C. The PCP shall file annual audited financial statements with the Department. A PCP in operation fo
10.09.57.11.htm 10.09.57.11. 11 Subcontracts.. A. The PCP shall ensure that the following provisions are contained in all subcontracts:. 1) A description of the services to be provided by the subcontractor;. 2) A description of other activities to be performed by the subcontractor;. 3) Providing for release to the PCP of any information necessary for the PCP to perform any of its obligations under its contract with the Department, including but not limited to compliance with the reporting and quality ass
10.09.57.12.htm 10.09.57.12. 12 Internal Grievance Procedure.. A. The PCP shall have an internal grievance procedure which has been preapproved by the Department. The PCP shall provide a copy of its internal grievance procedures to all enrollees.B. The internal grievance procedure may:. 1) Provide for the prompt resolution of any complaints of enrollees or their representatives;. 2) Assure the participation of individuals with the authority to require corrective action; and. 3) Require that a written
10.09.57.13.htm 10.09.57.13. 13 Payment Procedure.. A. The Department shall pay a PCP a per capita capitation payment for capitated services.. B. The Department shall calculate the capitation payment as a percentage of the cost to the Program of providing the same services on a fee-for-service basis to an actuarially equivalent non-enrolled group.
10.09.57.14.htm 10.09.57.14. 14 Recovery and Reimbursement.. Recovery and reimbursement under this chapter are as set forth in COMAR 10.09.36.07..
10.09.57.15.htm 10.09.57.15. 15 Cause for Suspension or Removal and Imposition of Sanctions.. Causes for suspension or removal and imposition of sanctions under this chapter are as set forth in COMAR 10.09.36.08.
10.09.57.16.htm 10.09.57.16. 16 Appeal Procedures.. Appeal procedures under this chapter are as set forth in COMAR 10.09.36.09..
10.09.57.17.htm 10.09.57.17. 17 Interpretive Regulation.. Interpretation of this regulation is subject to COMAR 10.09.36.10..
10.09.57.9999.htm 10.09.57.9999. Administrative History Effective date. Regulations .01―17 adopted as an emergency provision effective June 14, 1995 (22:14 Md. R. 1051) adopted permanently effective October 23, 1995 (22:21 Md. R. 1616)
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