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10.09.65.00.htm 10.09.65.00. Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 65 Maryland Medicaid Managed Care Program: Managed Care Organizations Authority: Health-General Article, §2-104, 15-102.3, and 15-103; Insurance Article, §15-112, 15-605, and 15-1008; Annotated Code of Maryland
10.09.65.01.htm 10.09.65.01. 01 Incorporation by Reference ― Repealed.
10.09.65.02.htm 10.09.65.02. 02 Conditions for Participation.. A. An MCO shall have sufficient provider capacity to provide health care services to Program recipients residing in a geographic region no smaller in size than one county or the City of Baltimore.B. An MCO's service area shall contain a minimum of 10,000 waiver-eligible residents.. C. An MCO shall comply with COMAR 10.09.36.. D. An MCO shall enter a memorandum of understanding with each local health department (LHD) in its service area addressing th
10.09.65.03.htm 10.09.65.03. 03 Quality Assessment and Improvement.. A. An MCO shall have a continuous, systematic program designed to monitor, measure, evaluate, and improve the quality of health care services delivered to enrollees including individuals with special health care needs. At a minimum, the MCO shall:1) Comply with all applicable federal and State laws and regulations;. 2) Comply with all access and quality standards and levels of performance established by the Department including all standar
10.09.65.04.htm 10.09.65.04. 04 Special Needs Populations.. A. An MCO shall provide health care services to enrollees who are members of special needs populations.B. Special needs populations consist of the following non-mutually exclusive populations:. 1) Children with special health care needs;. 2) Individuals with a physical disability;. 3) Individuals with a developmental disability;. 4) Pregnant and postpartum women;. 5) Individuals who are homeless;. 6) Individuals with HIV/AIDS; and.
10.09.65.05.htm 10.09.65.05. 05 Special Needs Populations ― Children with Special Health Care Needs.. A. An MCO shall meet the standards set forth in this regulation for treating children with special health care needs.B. The Department shall maintain a record of the complaints received through the Department's enrollee and provider hotlines which involve the denial of care for children and review these complaint logs as part of its quality assurance system.
10.09.65.06.htm 10.09.65.06. 06 Special Needs Populations ― Individuals with a Physical Disability.. A. An MCO shall meet the standards set forth in this regulation for treating an individual with a physical disability.B. An MCO shall demonstrate that its providers for durable medical equipment and assistive technology provide the appropriate services and are clinically qualified to provide these services to the individual with a physical disability.C. Before placement of an individual with a physic
10.09.65.07.htm 10.09.65.07. 07 Special Needs Populations ― Individuals with a Developmental Disability.. A. An MCO shall meet the standards set forth in this regulation for treating an individual with a developmental disability.B. An MCO shall ensure that its case managers have experience or training related to developmental disabilities.C. An MCO shall utilize individuals with expertise in disabilities to review its marketing and informational forms and publications, which shall be provided in alternative for
10.09.65.08.htm 10.09.65.08. 08 Special Needs Populations ― Pregnant and Postpartum Women.. A. An MCO shall meet the standards set forth in this regulation for treating pregnant and postpartum women.B. An MCO shall ensure access to prenatal care for pregnant women and postpartum care for postpartum women by:1) Scheduling an appointment for the first prenatal visit and seeing the woman within 10 days of request;2) Scheduling an appointment for a postpartum woman and seeing the woman within 10 days of request:.
10.09.65.09.htm 10.09.65.09. 09 Special Needs Populations ― Homeless Individuals.. An MCO's initial health screen shall attempt to identify homeless individuals and link them to the appropriate provider of services.
10.09.65.10.htm 10.09.65.10. 10 Special Needs Populations ― Individuals with HIV/AIDS.. A. An MCO shall meet the standards set forth in this regulation for treating individuals with HIV/AIDS.B. HIV/AIDS Specialist.. 1) An MCO shall allow an enrollee with HIV/AIDS to choose an HIV/AIDS specialist for treatment and coordination of primary and specialty care.2) To qualify as an HIV/AIDS specialist, a health care provider shall be board certified in the field of infectious diseases by a member board of the
10.09.65.11.htm 10.09.65.11. 11 Special Needs Populations ― Individuals in Need of Substance Abuse Treatment ― Repealed.
10.09.65.11-1.htm 10.09.65.11-1. 11-1 Substance Abuse Identification and Treatment ― TCA Recipients ― Notification Requirements ― Repealed
10.09.65.11-2.htm 10.09.65.11-2. 11-2 Substance Abuse Identification and Treatment ― TCA Recipients ― Responsibility of the MCO and MCO Liaison to the Local Department of Social Services ― Repealed
10.09.65.12.htm 10.09.65.12. 12 Consumer Advisory Board.. A. An MCO shall establish a consumer advisory board to facilitate the receipt of input from enrollees.B. The consumer advisory board membership shall:. 1) Consist of enrollees and enrollees' family members, guardians, or caregivers; and. 2) Be comprised of no less than one third representation from the MCO’s special needs populations, or their representatives and the MCO’s special needC. The consumer advisory board shall meet at least 6 times a year..
10.09.65.13.htm 10.09.65.13. 13 Children in State-Supervised Care.. A. An MCO shall provide or arrange to provide all Medicaid-covered services required to comply with State statutes and regulations mandating health and mental health services for children in State-supervised care.B. An MCO shall ensure the continuity and coordination of care, provided locally to the extent the services are available, to an enrollee who is a child in State-supervised care.C. An enrollee who is a child in State-supervised
10.09.65.14.htm 10.09.65.14. 14 Referral to Behavioral Health ASO.. A. An MCO is responsible for providing medically necessary primary behavioral health services to their enrollees.B. An enrollee may self-refer to the behavioral health ASO for services described in COMAR 10.09.59 or 10.09.80.C. If an enrollee’s primary care physician determines that primary behavioral health services are not sufficient to meet the enrollee’s needs, the primary care physician shall refer the enrollee to th
10.09.65.15.htm 10.09.65.15. 15 Data Collection and Reporting.. A. An MCO shall notify the Department immediately when it has knowledge of an enrollee's death.. B. Encounter Data.. 1) An MCO shall submit encounter data reflecting 100 percent of provider-enrollee encounters, in CMS1500 and UB04 format or an alternative format previously approved by the Department.2) An MCO shall report encounter data within 60 calendar days after receipt of the claim from the provider.
10.09.65.16.htm 10.09.65.16. 16 Repealed..
10.09.65.17.htm 10.09.65.17. 17 Subcontractual Relationships.. A. Subcontracting Permitted.. 1) Consistent with this regulation, an MCO may subcontract services that it is required to provide to its enrollees under COMAR 10.09.67 to a health care provider that is licensed, certified, or otherwise legally authorized to provide those services.2) An MCO may not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of the provider
10.09.65.18.htm 10.09.65.18. 18 Third-Party Liability.. A. An MCO is responsible for the identification of, and collection of, moneys owing from responsible third parties liable for the cost of medical care furnished by the MCO to enrollees.B. Upon request from the Department or the U.S. Department of Health and Human Services, an MCO shall convey any information regarding third-party liability to the Department, to the U.S. Department of Health and Human Services, or to another MCO.C. The Department shall n
10.09.65.18-1.htm 10.09.65.18-1. 18-1 MCO Reimbursement ― GME Exclusion.. A. Capitation Rate Setting Methodology―Extraction of Graduate Medical Education Costs.. 1) Percentage of Teaching Hospitals' Rates Representing GME Costs. The Department, in consultation with the HSCRC, shall:a) Determine the amount, expressed as a percentage, of payments by the Program that are attributable to GME, based on historic cost and discharge abstract data that:i) Are specific to each individual teaching hospital,.
10.09.65.19.htm 10.09.65.19. 19 MCO Reimbursement.. A. Generally.. 1) Payment to an MCO for each enrollee shall be at a fixed capitation rate, as specified in §B(4) of this regulation.2) An MCO shall be reimbursed at rates set forth in this regulation only for individuals enrolled under the Maryland Medicaid Managed Care Program.3) The capitation rate paid to an MCO by the Department shall be accepted as payment in full for all benefits provided by the MCO.
10.09.65.19-1.htm 10.09.65.19-1. 19-1 MCO-Specific Case Mix Adjustment for HIV and AIDS with Hepatitis C.. A. To reflect the higher level of risk associated with providing covered health care services pursuant to COMAR 10.09.67 to HIV/AIDS enrollees who also have Hepatitis C, the Department shall, to the extent provided by this regulation, make MCO-specific adjustments to payments for enrollees in HIV and AIDS payment categories to reflect the proportion of an MCO's HIV/AIDS enrollees who also have Hepatitis C.
10.09.65.19-2.htm 10.09.65.19-2. 19-2 MCO Supplemental Payment for Transitional Encounter Data Adjustment.. A. The Department may grant an adjustment to those MCOs for whom the uniform encounter data adjustment results in completeness factors that are below the Statewide average.B. The encounter adjustment for each MCO shall be determined for the Family and Children RACs and for the Disabled RACs respectively.
10.09.65.19-3.htm 10.09.65.19-3. 19-3 MCO Rural Access Incentive.. A. Eligibility for Rural Access Incentive. During the months specified in §B(1) and (2) of this regulation, the Department shall make an incentive payment to an MCO for any rural county in which the MCO is accepting new members, provided the MCO has a current MCO provider agreement.B. Payment of Rural Access Incentive.. 1) June Payment. The June payments to MCOs meeting the requirements specified in §A of this regulation from January 1 through
10.09.65.19-4.htm 10.09.65.19-4. 19-4 MCO-Specific Case Mix Adjustment.. A. Definitions.. 1) In this regulation, in addition to the definitions set forth in COMAR 10.09.62, the following terms have the meanings indicated.2) Terms Defined.. a) "Demographic rate cell" means a cell in one of the rates tables in Regulation .19B(4) of this chapter to which an MCO's enrollees are assigned pursuant to Regulation .19B(1)b) and B(2)b) of this chapter.
10.09.65.19-5.htm 10.09.65.19-5. 19-5 MCO Loss Ratio.. A. The Department shall determine an MCO's annual loss ratio as provided in this regulation.. B. The Department shall:. 1) Review an MCO's annual HFMR submitted pursuant to Regulation .15E of this chapter; and. 2) By December 30 of the calendar year following the service year, submit the HFMR data received from the MCOs to an accounting contractor retained by the Department to independently review the reports.C. The Department's accounting contractor shall:.
10.09.65.20.htm 10.09.65.20. 20 MCO Payment for Self-Referred, Emergency, Physician, and Hospital Administrative Days Services.. A. MCO Payment for Self-Referred Services.. 1) For undisputed claims that are submitted to the MCO within 6 months of the date of service, an MCO shall reimburse out-of-plan providers within 30 days for eligible services performed upon an enrollee who has self-referred:a) To a school-based health clinic pursuant to COMAR 10.09.67.28B, for services described in COMAR 10.09.68;
10.09.65.21.htm 10.09.65.21. 21 Payments to Federally Qualified Health Centers (FQHC). A. FQHC’s shall be reimbursed under the Alternative Payment System (APS). 1) The Department shall:. a) Pay the MCO a prospective payment based on encounter data; and. b) Reconcile the prospective amount paid to the MCO with the MCO's actual expenditure amount, after receipt of MCO encounter data; and2) MCOs shall reimburse any contracted FQHC, the FQHC’s rate established in accordance with COMAR 10B. For self-referred serv
10.09.65.22.htm 10.09.65.22. 22 Stop Loss Program.. A. An MCO shall qualify for protection under the Stop Loss Program if:. 1) It was participating in HealthChoice as of April 1, 1999;. 2) It was unable to self-insure or obtain a contract with another entity for Stop Loss reinsurance after July 1, 1999; and3) By July 1, 1999, the MCO requested the Department to continue to provide Stop Loss Protection at a rate determined by the Department.B. An MCO shall notify the Department that the acu
10.09.65.23.htm 10.09.65.23. 23 Marketing.. A. An MCO may not have face-to-face or telephone contact with a recipient, or otherwise solicit a recipient who is not an enrollee of the MCO, unless authorized by the Department or the recipient initiates the contact.B. Subject to prior approval by the Department, an MCO may engage in marketing activities designed to make recipients aware of their availability, as well as any special services they offer. Unless they involve face-to-face solicitation, these market
10.09.65.24.htm 10.09.65.24. 24 Repealed..
10.09.65.25.htm 10.09.65.25. 25 Enrollee Outreach Plan.. A. An MCO shall submit to the Department, on an annual basis, a written enrollee outreach plan that:. 1) Describes how the MCO intends to comply, in the upcoming year, with the outreach requirements of Health-General Article, §15-103(b)9) Annotated Code of Maryland; and2) Provides evidence of the MCO's compliance during the previous year, with the outreach requirements of Health-General Article, §15-103(b)9) Annotated Code of Maryland.
10.09.65.26.htm 10.09.65.26. 26 Time Period for Termination of Provider Agreement.. A. An MCO may terminate its provider agreement with the State as provided in §B―D of this regulation.B. The MCO shall provide written notification to the Department of the MCO's intent to terminate the MCO's provider agreement with the State for any given calendar year by the previous October 1.C. An MCO that has previously terminated the provider agreement with the State and would like to sign a new agreement with th
10.09.65.27.htm 10.09.65.27. 27 Newborn Coordinator.. A. An MCO shall identify a newborn coordinator who shall be available to providers during the MCO's business hours as a contact for concerns related to eligibility and provision of services to newborns.B. The newborn coordinator shall provide services for a newborn:. 1) Whose mother is enrolled in the MCO on the date of the newborn's birth; and. 2) Who is enrolled or who is autoassigned to the MCO after birth.. C. The newborn coordinator shall:.
10.09.65.28.htm 10.09.65.28. 28 Conflict of Interest Safeguards.. An MCO may not contract with the State unless safeguards at least equal to federal safeguards under 41 U.S.C. §423, as amended, are in place.
10.09.65.9999.htm 10.09.65.9999. Administrative History Effective date:. Regulations .01―23 adopted as an emergency provision effective November 8, 1996 (23:25 Md. R. 1730). Regulations .01―23 adopted effective March 10, 1997 (24:5 Md. R. 408). Regulation .01 amended as an emergency provision effective July 1, 2002 (29:15 Md. R. 1139) amended permanently effective October 28, 2002 (29:21 Md. R. 1645)Regulations .02C, .04C, .08, .11, .15, .17A, .18, .20B, and .22C amended and Regulation .11-1 adopte
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