Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.04 - Maryland Medicaid Managed Care Program: Managed Care Organizations › Section 10.67.04.17 - Subcontractual Relationships

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Subcontracting Permitted.
(1) Consistent with
				  this regulation, an MCO may subcontract services that it is required to provide
				  to its enrollees under COMAR 10.67.67 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's license or
				  certification under applicable State law, solely on the basis of that license
				  or certification.
(3) An MCO shall
				  have written agreements with subcontractors that comply with
				  42 CFR §§
												438.214 and
				  455.105, as amended, and include
				  at least the following:
(a) A provision that
				  the subcontractor be subject to all of the requirements to which the MCO is
				  subject under its contract with the Department and pursuant to the Department's
				  regulations;
(b) A clear
				  description of the services to be performed under the subcontract sufficient to
				  definitively inform the Department which of the MCO's obligations have been
				  subcontracted;
(c) A provision for
				  the subcontractor's release to the MCO and to the Department, upon request, of
				  any information necessary for the MCO to perform any of its contractual and
				  regulatory obligations under its contract with the Department, including, but
				  not limited to, its records, reporting, and quality assurance duties;
(d) A provision requiring that the
				  subcontractor complies with all State and federal requirements regarding audit,
				  inspection, and evaluation;
(e) A
				  provision that copies of the subcontractor's medical records pertaining to the
				  MCO's enrollees shall be furnished to the MCO upon request for transfer to a
				  subsequent provider in the event of a termination of the subcontract;
(f) A provision to the effect that no
				  termination of the subcontract shall be effective without prior written notice
				  to the Department;
(g) An agreement
				  that the subcontractor will look solely to the MCO for compensation for covered
				  services provided to the MCO's enrollees under the subcontract;
(h) An assurance that evidence of the
				  subcontractor's professional liability coverage will be submitted annually to
				  the MCO;
(i) A provision that no
				  assignment of the subcontract by the subcontractor is effective without prior
				  written notice to the Department;
(j) If the subcontractor is authorized by the
				  MCO to make referrals, a provision requiring the subcontractor to use the
				  uniform consultation referral form adopted by the Maryland Insurance
				  Administration at COMAR
				  31.10.12.06;
(k) A provision to the effect that each
				  provision of the subcontract that is required under this section supersede and
				  be controlling over any conflicting terms that appear in the subcontract;
(I) A provision for revocation of
				  the delegation of activities or obligations, or specifying other remedies in
				  instances where the Department or the MCO determines that the subcontractor has
				  not performed satisfactorily;
(m) A
				  provision stating that the MCO has the right to audit the subcontractor
				  pursuant to 42 CFR §
													438.230(c)(3)(i) for 10
				  years from the final date of the contract period or from the date of completion
				  of any audit, whichever is later; and
(n) A provision to the effect that all
				  providers and subcontractors are subject to a grievance and appeal system
				  consistent with the requirements of COMAR 10.67.71.
(4) An MCO may not subcontract for hospital
				  services with a hospital or an entity related to a hospital unless that
				  hospital is in compliance with COMAR 10.37.12 (fixed price contracting
				  regulations).
(5) An MCO may not
				  prohibit or otherwise restrict a health care professional, acting within the
				  lawful scope of practice, from advising or advocating on behalf of an enrollee
				  who is the provider's patient for:
(a) The
				  enrollee's health status, medical care, or treatment options, including any
				  alternative treatment that may be self-administered;
(b) Any information the enrollee needs in
				  order to decide among all relevant treatment options;
(c) The risks, benefits, and consequences of
				  treatment or nontreatment; or
(d)
				  The enrollee's right to participate in decisions regarding the enrollee's own
				  health care, including the right to refuse treatment, and to express
				  preferences about future treatment decisions.