reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.06 - Maryland Medicaid Managed Care Program: Benefits › Section 10.67.06.25 - Benefits - Blood and Blood Products

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall provide to its enrollees medically necessary
					 blood, blood products, derivatives, components, biologics, and serums to
					 include autologous services, whole blood, red blood cells, platelets, plasma,
					 immunoglobulin, and albumin.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.06 - Maryland Medicaid Managed Care Program: Benefits › Section 10.67.06.26 - Benefits - Primary Mental Health Services

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall provide to its enrollees medically necessary
					 primary mental health services, including appropriate referrals for service to
					 the Department's behavioral health ASO as described in COMAR 10.67.59
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.06 - Maryland Medicaid Managed Care Program: Benefits › Section 10.67.06.26-1 - Clinical Trial Items and Services - Coverage for Routine Costs

Current through Register Vol. 51, No. 14, July 12, 2024
A. Subject to
				  the conditions specified in §§B-F of this regulation, an MCO shall
				  provide coverage for cost to an enrollee in an approved clinical trial for:
(1) Treatment provided for life-threatening
				  conditions; or
(2) Prevention,
				  early detection, and treatment studies on cancer.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.06 - Maryland Medicaid Managed Care Program: Benefits › Section 10.67.06.26-2 - Plastic and Restorative Surgery

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall provide to an enrollee medically necessary
					 surgery to correct a deformity from disease, trauma, congenital or
					 developmental anomalies, or to restore body functions.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.06 - Maryland Medicaid Managed Care Program: Benefits › Section 10.67.06.26-3 - Gender-Affirming Treatment

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall
				  provide medically necessary gender-affirming treatment services which include
				  but are not limited to the following:
(1)
				  Hormone therapy, hormone blockers, and puberty blockers;
(2) Hair alteration for the purposes of
				  altering secondary sex characteristics and surgical site preparation;
(3) Alterations to voice, voice therapy, and
				  voice lessons;
(4) Alterations to
				  abdomen, chest, trunk, and buttocks;
(5) Alterations to the face and
				  neck;
(6) Alterations to the
				  genitals and gonads;
(7) Laser
				  treatment for scars from gender-affirming treatment;
(8) Standard fertility preservation
				  procedures as set forth in Insurance Article, §
											15-810.1, Annotated Code of
				  Maryland;
(9) Revisions to previous
				  treatments and reversal of treatments;
(10) Combinations of gender-affirming
				  procedures; and
(11) Other
				  treatments as prescribed to suppress the development of endogenous secondary
				  sex characteristics, align the individual's appearance of physical body with
				  gender identity, and alleviate symptoms of clinically significant distress
				  resulting from gender dysphoria.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.06 - Maryland Medicaid Managed Care Program: Benefits › Section 10.67.06.26-4 - Audiology

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall provide enrollees medically necessary
					 audiology services as described in COMAR 10.67.51, including:
A. Hearing aids;
B. Cochlear implants;
C. Auditory osseointegrated devices;
				  and
D. Related services.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.06 - Maryland Medicaid Managed Care Program: Benefits › Section 10.67.06.26-5 - Remote Patient Monitoring

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall provide its enrollees medically necessary
					 remote patient monitoring services as described in COMAR
					 10.67.96.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.06 - Maryland Medicaid Managed Care Program: Benefits › Section 10.67.06.26-6 - Mobile Integrated Health Services

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall provide its enrollees medically necessary
					 mobile integrated health services as described in COMAR
					 10.09.31.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.06 - Maryland Medicaid Managed Care Program: Benefits › Section 10.67.06.26-7 - Social Determinants of Health

Current through Register Vol. 51, No. 14, July 12, 2024
Subject to COMAR 10.09.63, an MCO shall provide coverage
					 for community violence prevention
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.06 - Maryland Medicaid Managed Care Program: Benefits › Section 10.67.06.27 - Benefits - Limitations

Current through Register Vol. 51, No. 14, July 12, 2024
A. The benefits
				  or services not required to be provided by an MCO are as follows:
(1) Experimental or investigational services,
				  including organ transplants determined by Medicare to be experimental, except
				  when an enrollee is participating in an authorized clinical trial as specified
				  in Regulation .26-1 of this chapter;
(2) Any service or treatment that is not
				  medically necessary;
(3) Services
				  performed or prescribed under the direction of a person who is not a health
				  care practitioner;
(4) Services
				  that are beyond the scope of practice of the health care practitioner
				  performing the service;
(5)
				  Transportation services provided through grants to local governments pursuant
				  to COMAR 10.67.19, other than assisting enrollees to access nonemergency
				  transportation services through their local transportation grantee
				  agency;
(6) Health-related services
				  and targeted case management services provided to children when the services
				  are:
(a) Specified in the enrollee's
				  individualized family service plan (IFSP), or an individualized education
				  program (IEP); and
(b) Delivered in
				  the schools or through Children's Medical Services community-based
				  providers;
(7)
				  Autopsies;
(8) Immunizations
				  required for travel outside the continental United States;
(9) Services received while the enrollee is
				  outside the United States;
(10)
				  Abortions;
(11) Diet and exercise
				  programs for the loss of weight;
(12) Prescriptions or injections for central
				  nervous system stimulants and anorectic agents when used for controlling
				  weight;
(13) In vitro
				  fertilization, ovum transplants and gamete intrafallopian tube transfer, zygote
				  intrafallopian transfer, or other techniques used in these or similar
				  procedures;
(14) Services to
				  reverse a voluntary sterilization procedure;
(15) Lifestyle improvements, including
				  smoking cessation, nutrition counseling, or physical fitness programs, unless
				  specifically included as a covered service;
(16) Nonmedical ancillary services such as
				  vocational rehabilitation, employment counseling, or educational
				  therapy;
(17) Private duty nursing
				  for adults 21 years old and older;
(18) Services incurred before the effective
				  date of coverage for an enrollee;
(19) Dental or orthodontic care;
(20) Piped-in oxygen or oxygen prescribed for
				  standby purposes or on an as-needed basis; and
(21) Cosmetic surgery when performed solely to
				  maintain normal physical appearance or enhance beyond average level toward an
				  aesthetic ideal.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.06 - Maryland Medicaid Managed Care Program: Benefits › Section 10.67.06.28 - Benefits - Self-Referral Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall
				  be financially responsible for reimbursing, in accordance with COMAR
				  10.67.04.20, an out-of-plan
				  provider chosen by the participant for the following services:
(1) Family planning services specified in COMAR
				  10.67.65.20A(2), (6), and (7);
(2)
				  Services performed by school-based health centers (SBHCs), as provided in COMAR
				  10.67.76;
(3) Pregnancy-related
				  services for women who are pregnant and, at the time of initial enrollment,
				  have received prenatal care during their current pregnancy from an out-of-plan
				  provider, and this pre-enrollment care consists of at least the following:
(1) A full prenatal examination;
(2) A risk assessment; and
(3) Appropriate laboratory
				  services;
(4) Initial
				  medical examination for children in State custody when performed by an EPSDT
				  certified provider;
(5) One annual
				  diagnostic and evaluation service (DES) visit for any enrollee diagnosed with
				  HIV/AIDS, which the MCO is responsible for facilitating on the enrollee's
				  behalf;
(6) Renal dialysis services
				  performed in a Medicare-certified facility;
(7) Initial medical examination of a newborn when the:
(1) Examination is performed in a hospital by
				  an on-call physician; and
(2) MCO
				  failed to provide for the service before the newborn's discharge from the
				  hospital;
(8) Emergency
				  services as described in COMAR
				  10.67.05.08B;
(9) Prenatal, intrapartum, and postpartum
				  services performed at a free-standing birth center located in Maryland or a
				  contiguous state; and
(10) Doula
				  services, through December 31, 2025.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.06 - Maryland Medicaid Managed Care Program: Benefits › Section 10.67.06.29 - Optional Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO
				  may provide its enrollees with additional health care services that are not
				  required by this chapter.
B.
				  Optional health care services that an applicant intends to include in its
				  benefits package shall be specified, including the terms and conditions for,
				  and limitations to the provision of these services, in the applicant's initial
				  application to the Department, as well as for periodic Departmental
				  review.
C. An MCO's provision of
				  optional services that it has represented to be available to its enrollees is
				  subject to monitoring of complaints and consumer satisfaction surveys, and to
				  random audits.
D. An MCO's
				  provision of additional services that are not required by this regulation may
				  not be taken into account when setting the MCO's capitation rate.
E. Effective January 1, 2015, any changes to
				  the health care services being offered by the MCO under §A of this
				  regulation, including reducing or waiving pharmacy co-pays, shall be effective
				  for an entire calendar year.
F. An
				  MCO shall notify the Department of any changes to their optional services by
				  September 15 for the following calendar year.
G. The Department may waive the requirement
				  under §E of this regulation if the Department determines that the
				  circumstance warrant, including but not limited to a reduction in rates outside
				  the normal rate setting process.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.06 - Maryland Medicaid Managed Care Program: Benefits › Section 10.67.06.30 - Fertility Preservation

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall
				  provide medically necessary fertility preservation services for the following
				  individuals:
(1) Individuals who have
				  iatrogenic infertility;
(2)
				  Individuals who are receiving medical treatment that may directly or indirectly
				  cause iatrogenic infertility; or
(3) Individuals who are receiving
				  gender-affirming treatment.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.06 - Maryland Medicaid Managed Care Program: Benefits › Section 10.67.06.31 - Benefits - Telemedicine Services

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall provide to its enrollees medically necessary
					 telemedicine services as described in COMAR 10.67.49.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.07 - Maryland Medicaid Managed Care Program: Program Integrity › Section 10.67.07.01 - Requirements to Detect and Prevent Fraud, Waste and Abuse

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO or its responsible subcontractor
				  shall implement and maintain arrangements or procedures that are designed to
				  detect and prevent fraud, waste, and abuse, which includes a compliance program
				  that has, at a minimum, the following elements:
(1) Written policies, procedures, and
				  standards of conduct that include the MCO's commitment to comply with all
				  applicable:
(a) Requirements and standards
				  under the contract; and
(b) Federal
				  and State requirements including:
(i) Written
				  policies for all employees and those of any contractor or agent that provide
				  detailed information about the False Claims Act and other Federal and State
				  laws described in section 1902(a) (68)of the Social Security Act; and
(ii) Information about rights of employees to
				  be protected as whistle blowers.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.07 - Maryland Medicaid Managed Care Program: Program Integrity › Section 10.67.07.02 - Access to Information

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO,
				  its subcontractors, and its subcontractor's subcontractors shall permit the
				  following organizations or their designees to inspect, evaluate, or audit
				  books, records, contracts, computer or other electronic systems, premises, and
				  facilities that pertain to the MCO's Medicaid enrollees, and any aspect of
				  services and activities performed, or determination of amounts payable under,
				  the MCO's contract with the Department:
(1)
				  The Department and its agents;
(2)
				  The Medicaid Fraud Control Unit of the Office of the Attorney
				  General;
(3) The Insurance Fraud
				  Division of the Maryland Insurance Administration;
(4) The Centers for Medicare and Medicaid
				  Services;
(5) The Inspector General
				  of the Department of Health and Human Services;
(6) The Comptroller General; and
(7) Other authorized State or federal
				  agencies.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.07 - Maryland Medicaid Managed Care Program: Program Integrity › Section 10.67.07.03 - Reporting

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall
				  submit to the Department the following:
(1)
				  Encounter data in the form and manner described in COMAR 10.67.65.15B,
				  42 CFR §
												438.242(c), and
				  42 CFR §
												438.818.
(2) Data required by the Department in order
				  to certify the actuarial soundness of capitation rates to an MCO, under
				  42 CFR §
												438.3, including base data described in
				  42 CFR §
												438.5(c) that is generated
				  by the MCO.
(3) Data required by
				  the Department to determine compliance of the MCO with the medical loss ratio
				  requirement described in 42
				  CFR §
												438.8.
(4) Data required by the Department and the
				  Maryland Insurance Administration to determine that the MCO has made adequate
				  provision against the risk of insolvency as required under
				  42 CFR §
												438.116.
(5) Documentation described in
				  42 CFR §
												438.207(b) on which the
				  Department bases its certification that the MCO has complied with the State's
				  requirements for availability and accessibility of services, including the
				  adequacy of the provider network, as set forth in
				  42 CFR §
												438.206
(6) In accordance with §F of this
				  regulation, information on ownership and control described in
				  42 CFR §
												455.104 from an MCO and its subcontractors,
				  as governed by 42 CFR §
												438.230.
(7) An annual report of overpayment
				  recoveries as required in 42
				  CFR §
												438.608(d)(3).
(8) Any other data, documentation, or
				  information relating to the performance of the entity's obligations under its
				  contract with the Department, or required by the Department or the Secretary of
				  the Department of Health and Human Services.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.08 - Maryland Medicaid Managed Care Program: Non-Capitated Covered Services › Section 10.67.08.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter describes the services that are not the
					 responsibility of the MCOs but are covered by the Department on a
					 fee-for-service basis.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.08 - Maryland Medicaid Managed Care Program: Non-Capitated Covered Services › Section 10.67.08.02 - Behavioral Health Non-Capitated Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO is
				  not responsible for reimbursing for the following substance use disorder
				  services, regardless of diagnosis:
(1)
				  Services delivered by a community-based provider as described in COMAR 10.09.80
				  with the following procedure codes:
H0001
Alcohol/drug assessment
H0004
Alcohol/drug individual counseling and therapy
H0005
Alcohol/drug group counseling
H0014
Alcohol and/or drug services; ambulatory
							 detoxification
H0015
Alcohol and/or drug services; intensive outpatient
H0016
Alcohol and/or drug services; buprenorphine
							 induction
H0020
Alcohol and/or drug services; methadone administration
							 and/or service
H0024
Group peer recovery support services
H0038
Individual peer recovery support services
H0047
Alcohol and/or drug services; buprenorphine
							 administration and/or service
H2036
Alcohol and/or drug services; partial
							 hospitalization
J8499
Prescription drug, oral, non-chemotherapeutic;
							 buprenorphine
J0571
Buprenorphine, oral, 1 mg
J0572
Buprenorphine/naloxone, oral, less than or equal to 3
							 mg of buprenorphine
J0573
Buprenorphine/naloxone, oral, greater than 3 mg, but
							 less than or equal to 6 mg buprenorphine
J0574
Buprenorphine/naloxone, oral, greater than 6 mg, but
							 less than or equal to 10 mg buprenorphine
Q9991
Injection, Buprenorphine extended-release, less than
							 or equal to 100 mg
Q9992
Injection, Buprenorphine extended-release, greater
							 than 100 mg
(2) Substance use disorder services provided
				  to children in an ICF-A with the revenue code 0100, Residential Services, child
				  and adolescent.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.08 - Maryland Medicaid Managed Care Program: Non-Capitated Covered Services › Section 10.67.08.03 - Nonbehavioral Health Fee-For-Service Benefits

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO may not be required to provide any of the following
					 benefits or services that are reimbursed directly by the Department:
A. The remaining days of a hospital admission
				  following enrollment in the MCO if the recipient was admitted to the hospital
				  before the date of the recipient's enrollment;
B. Long-term care services except for those
				  outlined in COMAR 10.67.67.07B and COMAR 10.67.67.12A;
C. Intermediate Care Facilities for
				  Individuals with Intellectual Disabilities or Persons with Related Conditions
				  (ICF/IID) services;
D. Personal
				  care services pursuant to COMAR 10.67.20;
E. Medical day care services, for adults and
				  children;
F. The following HIV/AIDS
				  services:
(1) Genotypic, phenotypic, or other
				  HIV/AIDS drug resistance testing used in the treatment of HIV/AIDS, if the
				  service is:
(a) Rendered by a
				  Department-approved provider; and
(b) Medically necessary;
				  and
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.09 - Maryland Medicaid Managed Care Program: MCO Dispute Resolution Procedures › Section 10.67.09.01 - MCO Enrollee Services

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall:
A.
				  Maintain a member services unit that operates an enrollee services line at
				  least during normal business hours;
B. Operate its enrollee services line as a
				  triage device to handle or properly refer enrollees' questions or complaints;
				  and
C. Provide information in the
				  member handbook about how to use the MCO enrollee services line to obtain
				  information and assistance.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.09 - Maryland Medicaid Managed Care Program: MCO Dispute Resolution Procedures › Section 10.67.09.02 - MCO Enrollee Complaint Process

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  An MCO shall have written complaint procedures by which an enrollee who is
				  dissatisfied with the MCO or its network providers, or decisions made by the
				  MCO or a provider, may seek recourse verbally or in writing within the MCO at
				  any time.
B. An MCO shall:
(1) Submit its written internal complaint
				  procedures to the Department for its approval;
(2) Give enrollees any reasonable assistance
				  in completing forms and taking other procedural steps related to a grievance or
				  appeal in a manner consistent with COMAR 10.67.66.01A;
(3) Prepare the document describing the MCO's
				  internal complaint process:
(a) In a
				  culturally sensitive manner;
(b) At
				  an appropriate reading comprehension level; and
(c) In the prevalent non-English languages,
				  identified by the State;
(4) Deliver a copy of the MCO's complaint
				  procedures to each enrollee:
(a) With the
				  MCO's initial contact -with a new enrollee; and
(b) At any time upon an enrollee's
				  request;
(5) Maintain an
				  accurate and accessible record of grievances and appeals for monitoring by the
				  State and CMS, which includes, at a minimum:
(a) A general description of the reason for
				  the appeal or grievance;
(b) The
				  date received;
(c) The date of each
				  review or, if applicable, review meeting;
(d) Resolution at each level of the appeal or
				  grievance, if applicable;
(e) Date
				  of resolution at each level, if applicable; and
(f) Name of the enrollee for whom the appeal
				  or grievance was filed; and
(6) Provide in its written procedures that an
				  enrollee may file appeals and grievances orally or in writing.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.09 - Maryland Medicaid Managed Care Program: MCO Dispute Resolution Procedures › Section 10.67.09.02-1 - Member Complaints - Time Frames for MCOs to Respond to the Department

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall:
A.
				  Acknowledge an enrollee appeal or grievance reported to it by the Department's
				  complaint resolution unit within 1 business day;
B. Respond to the Department's request for
				  information regarding disputed nonemergency medical care actions within 3
				  business days;
C. Provide updates
				  in a timeframe specified by the Department;
D. Provide medical records within 5 days of
				  the request; and
E. Provide a
				  corrective action plan upon request and within the timeframe specified, but not
				  later than 10 days from the date of the request.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.09 - Maryland Medicaid Managed Care Program: MCO Dispute Resolution Procedures › Section 10.67.09.03 - MCO Provider Complaint Process

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  An MCO shall have a complaint procedure for providers that is:
(1) Documented in writing;
(2) Disseminated in writing to all of the
				  MCO's providers at the time they join the MCO's provider panel, and furnished
				  to a provider at any time, upon request; and
(3) Linked to the MCO's internal quality
				  assurance program.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.09 - Maryland Medicaid Managed Care Program: MCO Dispute Resolution Procedures › Section 10.67.09.03-1 - Independent Review Organization (IRO)

Current through Register Vol. 51, No. 14, July 12, 2024
For provider disputes involving medical necessity, an MCO
					 shall participate in the IRO process as specified in COMAR
					 10.67.86.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.09 - Maryland Medicaid Managed Care Program: MCO Dispute Resolution Procedures › Section 10.67.09.03-2 - Provider Complaints - Time Frames for MCOs to Respond to the Department

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall:
A.
				  Acknowledge provider grievances within 3 business days;
B. Provide findings to the Department within
				  5 days; and
C. Provide a corrective
				  action plan to the Department within 10 days from the date of the
				  request.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.09 - Maryland Medicaid Managed Care Program: MCO Dispute Resolution Procedures › Section 10.67.09.04 - MCO Actions and Decisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. For
				  certain services to enrollees that require preauthorization the following
				  conditions apply:
(1) For standard
				  authorization decisions, the MCO shall make a determination within 2 business
				  days of receipt of necessary clinical information, but not later than 14
				  calendar days from the date of the initial request so as not to adversely
				  affect the health of the enrollee;
(2) For expedited authorization decisions,
				  the MCO shall make a determination and provide notice no later than 72 hours
				  after receipt of the request for service if the provider indicates or the MCO
				  determines that the standard time frame stated in §A(1) of this regulation
				  could jeopardize:
(a) The enrollee's
				  life;
(b) The enrollee's health;
				  or
(c) The enrollee's ability to
				  attain, maintain, or regain maximum function;
(3) For all covered outpatient drug
				  authorization decisions, the MCO shall provide notice by telephone or other
				  telecommunication device within 24 hours of a preauthorization request in
				  accordance with section 1927(d)(5)(A) of the Social Security Act;
(4) Standard and expedited authorization
				  decisions may be extended up to 14 calendar days, if the following conditions
				  are met:
(a) The enrollee or the provider
				  requests an extension; or
(b) The
				  MCO justifies to the Department, upon request, a need for additional
				  information and how the extension is in the enrollee's interest; and
(5) If the MCO successfully
				  justifies extending the standard service authorization decision time frame, the
				  MCO shall:
(a) Give the enrollee written
				  notice of the reason for the decision to extend the timeframe;
(b) Inform the enrollee of the right to file
				  a grievance if he or she disagrees with the extension decision; and
(c) Issue and carry out the MCO's
				  determination as expeditiously as the enrollee's health condition requires but
				  not later than the date the extension expires.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.09 - Maryland Medicaid Managed Care Program: MCO Dispute Resolution Procedures › Section 10.67.09.05 - MCO Appeal Process for Enrollees

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO's appeal process shall:
(1) Require that an enrollee, or a provider
				  acting on the enrollee's behalf, file an appeal within 60 days from the date on
				  the MCO's notice of action;
(2)
				  Include procedures for acknowledging receipt of appeals within 5 business
				  days;
(3) Permit an enrollee to
				  request an appeal either orally or in writing;
(4) Provide that oral requests for appeal are
				  considered the initiation of the appeal to establish the earliest possible
				  filing date;
(5) Provide reasonable
				  opportunity to present evidence and allegations of fact or law, in person as
				  well as in writing, and in the case of expedited appeals, the MCO shall inform
				  the enrollee of the limited time available for the enrollee to present this
				  evidence;
(6) Provide the case
				  file upon request to the enrollee and the enrollee's representative, free of
				  charge and sufficiently in advance of the resolution time frame for appeals,
				  which includes:
(a) Medical
				  records;
(b) Other documents and
				  records; and
(c) Any new or
				  additional evidence considered, relied upon, or generated by the MCO in
				  connection with the action.
(7) Allow a provider or authorized representative
				  acting on behalf of an enrollee to file an appeal with the enrollee's written
				  consent;
(8) Consider the enrollee,
				  the enrollee's representative, or the estate representative of a deceased
				  enrollee as parties to the appeal;
(9) Establish and maintain an expedited review
				  process, when the MCO determines or the provider indicates that taking the time
				  for a standard resolution could seriously jeopardize the enrollee's life,
				  physical or mental health, or ability to attain, maintain, or regain maximum
				  function; and
(10) Ensure that
				  punitive action is not taken against a provider who requests an expedited
				  resolution or supports an enrollee's appeal.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.10 - Maryland Medicaid Managed Care Program: Sanctions › Section 10.67.10.01 - Sanction by the Department

Current through Register Vol. 51, No. 14, July 12, 2024
A. If
				  the Department determines, after a sufficient investigation, that an MCO or any
				  agent or employee of the MCO, or any person with an ownership interest in an
				  MCO, or related party of the MCO, has failed to comply with any applicable law,
				  regulation, or contract term, or for other good cause shown, the Department may
				  impose sanctions on the MCO, including but not limited to:
(1) Fines;
(2) Suspension of further
				  enrollment;
(3) Withholding all or
				  part of the capitation payment;
(4)
				  Termination of the current HealthChoice Managed Care Organization
				  Agreement;
(5) Disqualification
				  from future participation in the Maryland Medicaid Managed Care
				  Program;
(6) Orders to provide a
				  benefit or service to enrollees; and
(7) Those outlined in
				  42 CFR §§
												438.700-
				  438.708, as amended.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.10 - Maryland Medicaid Managed Care Program: Sanctions › Section 10.67.10.01-1 - Sanction by Center for Medicare and Medicaid Services (CMS)

Current through Register Vol. 51, No. 14, July 12, 2024
The Department shall comply with notification requirements
					 of CMS at 42 CFR §
											438.730 for sanction determinations as
					 specified in 42 CFR §
											438.700(b)(1)
					 -(b)(6).
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.10 - Maryland Medicaid Managed Care Program: Sanctions › Section 10.67.10.02 - Appeal

Current through Register Vol. 51, No. 14, July 12, 2024
A. From the
				  decisions set forth in §B(1)-(8) of this regulation, an MCO may exercise
				  the appeal rights set forth in §C of this regulation.
B. The following Department decisions are
				  appealable by the MCO or MCO applicant:
(1)
				  Denial of an entity's completed application to become an MCO;
(2) Decision to terminate the MCO's
				  participation in the Maryland Medicaid Managed Care Program;
(3) Decision to impose a fine or other
				  sanction on the MCO as described in Regulation .01 of this chapter;
(4) Order to provide benefits or services to
				  enrollees as described in COMAR 10.67.71.05;
(5) Order that the MCO is impaired or in
				  "hazardous financial condition";
(6) An adverse decision by the IRO as
				  described in COMAR 10.67.86.08;
(7)
				  The amount of a penalty or incentive as described in COMAR
				  10.67.65.03;
(8) The denial of a
				  hepatitis C payment as described in COMAR 10.67.65.19;
(9) Overpayments recovered by the Department
				  as described in COMAR 10.67.68.01; and
(10) Remittances to the Department as
				  described in COMAR 10.67.65.19-5.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.10 - Maryland Medicaid Managed Care Program: Sanctions › Section 10.67.10.03 - Incentives

Current through Register Vol. 51, No. 14, July 12, 2024
A. All monies
				  collected from the MCOs as a result of the imposition of a financial sanction
				  shall be deposited in the HealthChoice Performance Incentive Fund.
B. This nonlapsing fund shall include all
				  sanctions imposed on the MCOs starting in calendar year 1999.
C. The fund shall be used to provide
				  financial incentive awards to the MCOs that meet or exceed specific performance
				  targets as established by the Department, unless otherwise directed by
				  law.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.11 - Maryland Medicaid Managed Care Program: Contribution to Graduate Medical Education Costs › Section 10.67.11.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to teaching hospitals that provide
					 health care services to recipients enrolled in Maryland Medicaid Managed Care
					 Program MCOs.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.11 - Maryland Medicaid Managed Care Program: Contribution to Graduate Medical Education Costs › Section 10.67.11.02 - GME Allocation Payment

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Purpose. GME allocation payments to teaching hospitals are intended to:
(1) Reaffirm the Program's historic
				  commitment to preserving graduate medical education at each of the State's
				  teaching hospitals, by maintaining Program payments supporting graduate medical
				  education at levels equivalent to inflation-adjusted FY 1995
				  expenditures;
(2) Promote the
				  training of primary care practitioners;
(3) Promote the development of innovative
				  approaches to improve the Program population's access to health care services;
				  and
(4) Ameliorate the new funding
				  procedure's impact on MCOs that historically have experienced low utilization
				  of teaching hospitals, by adopting an initial moderate reduction, pursuant to
				  §B(4) of this regulation and COMAR 10.67.65.18A -1A(2), of the amount of
				  GME-allocatable dollars included in teaching hospitals' GME allocation payments
				  during the first 3 years of separate GME funding.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.12 - Maryland Medicaid Managed Care Program: Corrective Managed Care › Section 10.67.12.01 - General

Current through Register Vol. 51, No. 14, July 12, 2024
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.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.12 - Maryland Medicaid Managed Care Program: Corrective Managed Care › Section 10.67.12.02 - Corrective Managed Care Plan

Current through Register Vol. 51, No. 14, July 12, 2024
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.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.12 - Maryland Medicaid Managed Care Program: Corrective Managed Care › Section 10.67.12.03 - Enrollee Notice

Current through Register Vol. 51, No. 14, July 12, 2024
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;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.12 - Maryland Medicaid Managed Care Program: Corrective Managed Care › Section 10.67.12.04 - Effective Date of Enrollment

Current through Register Vol. 51, No. 14, July 12, 2024
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 because of changes in how the individual receives
				  medical assistance, including but not limited to a change in the enrollee's MCO
				  enrollment.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.12 - Maryland Medicaid Managed Care Program: Corrective Managed Care › Section 10.67.12.05 - Enrollee Appeal

Current through Register Vol. 51, No. 14, July 12, 2024
A. An enrollee
				  shall have 20 days to appeal an MCO's determination of benefit abuse.
B. Except for the time frame specified in
				  §A of this regulation, an appeal shall be handled as specified in COMAR
				  10.67.71.05.
C. If the appeal
				  results in a hearing, an MCO shall
(1) Attend
				  the hearing; and
(2) Provide
				  justification for enrollment in the program.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.13 - Maryland Medicaid Managed Care Program: Independent Review Organization (IRO) › Section 10.67.13.01 - Scope and Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter provides for a complaint resolution process
					 for disputes between managed care organizations (MCOs) and providers regarding
					 adverse medical necessity decision made by MCOs. Pursuant to this chapter,
					 providers that receive an adverse medical necessity decision on claims for
					 reimbursement may submit the adverse decision for review by an Independent
					 Review Organization (IRO) designated by the Department.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.13 - Maryland Medicaid Managed Care Program: Independent Review Organization (IRO) › Section 10.67.13.03 - Use of Independent Review Organizations

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Department shall procure the services
				  of an IRO to make determinations of medical necessity on provider complaints
				  regarding adverse decisions.
B. An
				  IRO that contracts with the Department shall assure, in accordance with its
				  contract with the Department, the:
(1)
				  Timeliness and quality of the reviews;
(2) Qualifications and independence of the
				  IRO and expert reviewers; and
(3)
				  Confidentiality of medical records and review materials, consistent with
				  federal and State laws.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.13 - Maryland Medicaid Managed Care Program: Independent Review Organization (IRO) › Section 10.67.13.04 - Conflicts of Interest Standards for Independent Review Organizations and Expert Reviewers

Current through Register Vol. 51, No. 14, July 12, 2024
A. An IRO
				  or expert reviewer may not be an affiliate or have a financial, familial or
				  professional relationship with any facility, provider, or organization that has
				  filed a complaint.
B. Upon request
				  by the Department, the IRO shall provide to the Department information
				  demonstrating compliance with the requirement in §A of this
				  regulation.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.13 - Maryland Medicaid Managed Care Program: Independent Review Organization (IRO) › Section 10.67.13.05 - Assignment of an Expert Reviewer

Current through Register Vol. 51, No. 14, July 12, 2024
A. The IRO shall ensure that an expert
				  reviewer:
(1) Has appropriate clinical
				  expertise in the treatment of the specific medical condition being reviewed and
				  holds a nonrestricted license as a health care provider in the United States;
				  and
(2) Has no history of
				  disciplinary investigations, actions, or sanctions, including loss of staff
				  privileges or participation restrictions that have been taken or are pending by
				  any hospital, governmental agency or unit, or regulatory body.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.13 - Maryland Medicaid Managed Care Program: Independent Review Organization (IRO) › Section 10.67.13.06 - Independent Review

Current through Register Vol. 51, No. 14, July 12, 2024
A. A provider
				  shall exhaust an MCO's provider appeal process before filing a complaint with
				  the IRO.
B. A provider shall file a
				  complaint with the IRO in the form provided by the IRO not later than 30
				  calendar days following the date of an MCO's adverse decision.
C. A review of an adverse decision shall be
				  based on the case record.
D. The
				  IRO shall, after reviewing the case record, issue a final decision as to
				  whether the health care services that are the subject of the complaint were
				  medically necessary.
E. The final
				  decision shall state in writing the factual bases for the decision of the
				  expert reviewer and reference the criteria and standards on which the expert
				  reviewer's decision was based.
F.
				  Final decisions shall be rendered within 45 days of submission of the case
				  record, unless the time period is extended by the Department.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.13 - Maryland Medicaid Managed Care Program: Independent Review Organization (IRO) › Section 10.67.13.07 - Payment of Fees and Sanctions

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  In the event that a provider's complaint is unsuccessful, the provider is
				  responsible for paying to the IRO the case review charge established by the
				  Department.
B. The case review
				  charge established by the Department shall be based on the contract between the
				  Department and the IRO arrived at through a competitive procurement
				  process.
C. An MCO that is
				  determined by the IRO to have improperly denied, either in whole or in part, a
				  provider's claim on medical necessity grounds is subject to the following:
(1) Within 60 calendar days of the date of an
				  adverse decision by an IRO, the MCO shall fully reimburse the provider for
				  claims determined to be medically necessary by the IRO, including any interest
				  owed under Health Insurance Article, §
											15-1005(f),
				  Annotated Code of Maryland; and
(2)
				  Within 60 calendar days of the date of invoice by the IRO, the MCO shall
				  reimburse the IRO the case review charge established by the
				  Department.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.13 - Maryland Medicaid Managed Care Program: Independent Review Organization (IRO) › Section 10.67.13.08 - Appeal

Current through Register Vol. 51, No. 14, July 12, 2024
A. As a
				  prerequisite for participating in the IRO complaint adjudication process, a
				  provider waives all other administrative and judicial appeal rights and accepts
				  the IRO's decision as final and binding.
B. An MCO that receives an adverse decision
				  from an independent review organization may file an appeal in accordance with
				  COMAR 10.67.73.02.