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10.09.75.00.htm 10.09.75.00. Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 75 Maryland Medicaid Managed Care Program ― Corrective Managed Care Authority: Health-General Article, §15-102.1(b)9) and 15-103, Annotated Code of Maryland
10.09.75.01.htm 10.09.75.01. 01 General.. A. An MCO shall establish a corrective managed care plan that, at minimum, provides for:. 1) The identification of an enrollee that has abused MCO pharmacy benefits; and. 2) The enrollment of an enrollee that has been determined to have abused MCO pharmacy benefits in the MCO’s corrective managed care plan.B. Enrollee abuse exists when an enrollee:. 1) Has engaged in behaviors identified in COMAR 10.09.24.14-1; or.
10.09.75.02.htm 10.09.75.02. 02 Corrective Managed Care Plan.. A. An MCO’s corrective managed care plan:. 1) Shall cover enrollee abuse of medical assistance pharmacy benefits; and. 2) May cover enrollee abuse of nonpharmacy medical assistance benefits.. B. For all benefit abuse covered by an MCO’s corrective managed care plan, the plan shall:. 1) Use the criteria as described in Regulation .01B of this regulation to determine if enrollees have abused benefits;
10.09.75.03.htm 10.09.75.03. 03 Enrollee Notice.. The MCO shall provide an enrollee determined to have abused MCO benefits a written notice that includes the following:A. An explanation of the reason or reasons for the determination that the enrollee abused benefits;. B. A statement that the enrollee has 20 days to provide:. 1) Additional information for the MCO to consider before enrollment will become effective; and. 2) The address where the additional information shall be sent;. C. A statement that the e
10.09.75.04.htm 10.09.75.04. 04 Effective Date of Enrollment.. A. Except as provided in §B of this regulation, the effective date of enrollment shall be 20 days from the date of the notice described in Regulation .03A and B of this chapter, whichever is later.B. If an enrollee determined to have abused benefits appeals the determination, the effective date of the enrollment shall be tolled pending the outcome of the appeal.C. The duration of an enrollee’s enrollment in a plan may not be altered be
10.09.75.05.htm 10.09.75.05. 05 Enrollee Appeal.. A. An enrollee shall have 20 days to appeal an MCO’s determination of benefit abuse.. B. Except for the timeframe specified in §A of this regulation, an appeal shall be handled as specified in:1) COMAR 10.09.71.05; and. 2) COMAR 10.09.72.05.. C. If the appeal results in a hearing, an MCO shall. 1) Attend the hearing; and. 2) Provide justification for enrollment in the program..
10.09.75.9999.htm 10.09.75.9999. Administrative History Effective date: February 2, 2004 (31:2 Md. R. 82). Regulation .02A amended as an emergency provision effective November 1, 2008 (35:24 Md. R. 2069) amended permanently effective February 23, 2009 (36:4 Md. R. 353)Regulation .04 amended as an emergency provision effective January 5, 2005 (32:6 Md. R. 634) amended permanently effective April 11, 2005 (32:7 Md. R. 679)Regulation .04D amended effective October 5, 2009 (36:20 Md. R. 1528) April
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