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 10.67.04.02 - Conditions for Participation

Current through Register Vol. 51, No. 14, July 12, 2024
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 shall comply with COMAR
				  10.67.36.
C. An MCO shall enter a
				  memorandum of understanding with each local health department (LHD) in its
				  service area addressing the method by which the MCO and the LHD will
				  collaborate and communicate on matters of mutual interest and concern,
				  including but not limited to the responsibility of the LHD for contact tracing
				  for sexually transmitted diseases and directly observed therapy for
				  tuberculosis.
D. Assurance Against
				  Insolvency.
(1) An MCO shall be actuarially
				  sound.
(2) An applicant shall
				  possess an initial surplus in the amount of $1,500,000 as specified in
				  Health-General Article, §15-102.4(a)(2)(ii), Annotated Code of
				  Maryland.
(3) If the Commissioner
				  determines and reports to the Secretary that the applicant has an initial
				  surplus that is at least $1,250,000 but less than $1,500,000, before approval
				  the Department shall designate funds in trust sufficient to provide an initial
				  surplus of $1,500,000.
(4) If the
				  Commissioner determines and reports to the Secretary that the applicant's
				  initial surplus is less than $1,250,000 before approval the Department may, at
				  its discretion, designate funds in trust in an amount equal to:
(a) The sum of the amounts due to the owners
				  of the applicant from the Department for Medicaid services provided on a
				  fee-for-service basis, so long as the owners of the applicant have waived in
				  writing their right to receive Medicaid payments until such time as the
				  Department is permitted to remove its funds from the trust account pursuant to
				  §D(6) of this regulation; or
(b) If a financial guarantor with sufficient
				  net worth and an adequate history of generating net income agrees to pay claims
				  against the MCO in the case of insolvency, the difference between $1,250,000
				  and the applicant's initial surplus.
(5) If, in accordance with §D(4) of this
				  regulation, the Department designates funds sufficient to increase the
				  applicant's initial surplus to $1,250,000, the Department shall designate
				  $250,000 in trust for the applicant.
(6) Funds designated by the Secretary
				  pursuant to §D(3) - (5) of this regulation shall remain in trust until
				  such time as the Commissioner has determined that the MCO meets the minimum
				  statutory surplus requirements based on the MCO's annual report submitted
				  pursuant to Insurance Article, §
											5-605, Annotated Code of
				  Maryland.
(7) Before approval of an
				  applicant, the Secretary shall notify the Commissioner whether the Secretary
				  has placed any money in trust under this section.
(8) In the event of insolvency, the MCO shall
				  cover continuation of services to enrollees for the duration of the period for
				  which capitation payment has been made.
(9) An MCO shall meet the solvency standards
				  established by the State for private HMOs, or be licensed or certified by the
				  State as a risk-bearing entity except if the MCO:
(a) Is a public entity; or
(b) Is, or is controlled by, one or more
				  federally qualified health centers and meets the solvency standards established
				  by the State for those centers;
(c)
				  Has its solvency guaranteed by the State.