Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.05 - Maryland Medicaid Managed Care Program: Access › Section 10.67.05.04 - Access Standards: Information for Providers

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall develop and make available
				  either electronically or by hard copy to all of its PCP and specialty care
				  providers a Medicaid requirements manual, including periodic updates as
				  appropriate, and shall:
(1) Before
				  distribution, file a copy of its manual with the Department for
				  review;
(2) Include in its manual
				  the information necessary to facilitate the providers' full compliance with
				  federal and State Medicaid requirements, including information on:
(a) Medicaid statutes and
				  regulations;
(b) The benefits
				  package, including optional benefits;
(c) Access requirements, which, at a minimum,
				  comply with the requirements of this chapter;
(d) Quality requirements, which shall, at a
				  minimum, comply with the requirements of COMAR 10.67.65.03;
(e) Continuity of care
				  requirements;
(f) Requirements for
				  referral to specialist, ancillary, and other providers as necessary to provide
				  the full range of medically necessary services that are covered by the Maryland
				  Medicaid Managed Care Program; and
(g) The MCO's practice guidelines as
				  described in 42 CFR §
													438.236.
(3) Inform the MCO's primary and specialty
				  care providers of their responsibility to provide or arrange for medically
				  necessary accessible health care services that are continuous, comprehensive,
				  and coordinated for each enrollee, including:
(a) Preventive health services;
(b) Primary acute medical care;
(c) Chronic medical care;
(d) Substance abuse screening treatment and
				  referral services, including an explanation of the notification requirements
				  applicable to enrollees who are adult or minor parent TCA recipients, and the
				  MCO's procedures for facilitating the required notice;
(e) Consultation, referral, and follow-up in
				  areas including medical specialties and child dental care;
(f) Referral for ancillary and
				  support-related services including but not limited to:
(i) Drug therapies,
(ii) Diagnostic tests,
(iii) Medical supplies,
(iv) Durable medical equipment, and
(v) Case management when appropriate for
				  complex conditions;
(g)
				  24-hour per day, 7-day per week provider coverage for medically necessary
				  services;
(h) Detection of mental
				  health problems or substance use disorder during routine or follow-up
				  screening, to be treated either through the MCO or referred to the behavioral
				  health ASO for services; and
(4) Inform the providers of the following
				  enrollee appeal, grievance, and fair hearing procedures and time frames:
(a) The enrollee's right to a State fair
				  hearing, how to obtain a hearing, and representation rules at a
				  hearing;
(b) The enrollee's right
				  to file appeals and grievances, and the enrollee's requirements and time frames
				  for filing;
(c) The availability of
				  assistance in filing;
(d) The
				  toll-free numbers to file verbal appeals and grievances;
(e) The enrollee's right to request
				  continuation of benefits during an appeal or State fair hearing filing, and
				  that if the MCO action is upheld in a hearing, the enrollee may be liable for
				  the cost of any continued benefits; and
(f) The provider's right to appeal, on the
				  enrollee's behalf, the failure of the MCO to cover a service.