reglab/statecodes huggingface dataset:
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 10.67.04.15 - Data Collection and Reporting

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall
				  notify the Department immediately when it has knowledge of an enrollee's
				  death.
B. Encounter Data.
(1) An MCO shall submit encounter data
				  reflecting 100 percent of provider-enrollee encounters, in CMS1500 and UB04
				  format or an alternative format previously approved by the
				  Department.
(2) An MCO may use
				  alternative formats including:
(a) ASC X12N
				  837 and NCPDP formats; and
(b) ASC
				  X12N 835 format, as appropriate.
(3) An MCO shall submit encounter data that
				  identifies the provider who delivers any items or services to enrollees at a
				  frequency and level of detail to be specified by CMS and the Department,
				  including, at a minimum:
(a) Enrollee and
				  provider identifying information;
(b) Service, procedure, and diagnoses
				  codes;
(c) Allowed, paid, enrollee
				  responsibility, and third-party liability amounts; and
(d) Service, claims submission, adjudication,
				  and payment dates.
(4) An
				  MCO shall report encounter data within 60 calendar days after receipt of the
				  claim from the provider.
(5) An
				  MCO shall submit encounter data utilizing a secure on-line data transfer
				  system.
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 10.67.04.18 - Third-Party Liability

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO
				  is responsible for the identification of, and collection of, moneys owing from
				  responsible third parties liable for the cost of medical care furnished by the
				  MCO to enrollees.
B. Upon request
				  from the Department or the U.S. Department of Health and Human Services, an MCO
				  shall convey any information regarding third-party liability to the Department,
				  to the U.S. Department of Health and Human Services, or to another
				  MCO.
C. The Department shall notify
				  an MCO of any third-party liability identified during the course of eligibility
				  determination.
D. The MCO shall
				  submit to the Department any new or changed third-party information in an
				  automated format on a monthly basis.
E. The Department shall provide the MCOs with
				  any new or changed information on a monthly basis in an automated
				  format.
F. In order to facilitate
				  the Department's and the U.S. Department of Health and Human Services'
				  monitoring of its third-party liability collection activities, an MCO shall:
(1) Submit to the Department, on a monthly
				  basis, reports on third-party collections and activities during the month,
				  including but not limited to amounts the MCO has cost-avoided and recovered and
				  current accounts receivable for all third-party liability cases;
(2) Submit to the Department, on a quarterly
				  basis and in a format specified by the Department, amounts the MCO has
				  cost-avoided and recovered and the number of cases the MCO has handled in each
				  case area during the quarter;
(3)
				  Cooperate in site inspections by either the Department or the U.S. Department
				  of Health and Human Services for monitoring purposes; and
(4) Submit a detailed report of third-party
				  liability collection activities including, but not limited to, cost avoidance,
				  recovered amounts, and current amounts receivable for cases selected by the
				  Department.
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 10.67.04.18-1 - MCO Reimbursement - GME Exclusion

Current through Register Vol. 51, No. 14, July 12, 2024
A. Capitation Rate Setting
				  Methodology-Extraction of Graduate Medical Education Costs.
(1) Percentage of Teaching Hospitals' Rates
				  Representing GME Costs. The Department, in consultation with the HSCRC, shall:
(a) Determine the amount, expressed as a
				  percentage, of payments by the Program that are attributable to GME, based on
				  historic cost and discharge abstract data that:
(i) Are specific to each individual teaching
				  hospital,
(ii) Are specific to
				  Program recipients who would have been MCO-eligible if COMAR 10.67.62-10.67.75
				  had been in effect at the time the activity reflected in the data
				  occurred,
(iii) Reflect services
				  that would be, if performed during the contract year to which calculations
				  utilizing a teaching hospital's GME percentage amount relate, included in the
				  mandatory MCO benefits package described in COMAR 10.67.67, and
(iv) Represent activity in FY 1995;
				  and
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 10.67.04.19 - MCO Reimbursement

Current through Register Vol. 51, No. 14, July 12, 2024
A. Generally.
(1) Payment to an MCO for each enrollee shall
				  be at a fixed capitation rate, as specified in §B(4) of this
				  regulation.
(2) An MCO shall be
				  reimbursed at rates set forth in this regulation only for individuals enrolled
				  under the Maryland Medicaid Managed Care Program.
(3) The capitation rate paid to an MCO by the
				  Department shall be accepted as payment in full for all benefits provided by
				  the MCO.
(4) An MCO shall conform
				  to the Department's computer coding requirements.
(5) A capitation payment may not be made to
				  an MCO on behalf of an enrollee for whom capitation payment for the same period
				  has been made to any other MCO having an agreement with the
				  Department.
(6) The Department may
				  consider a retroactive capitation payment to an MCO, if the MCO notifies the
				  Department within 9 months of the first missed capitation payment for an
				  enrollee for whom the MCO has not received all appropriate capitation
				  payments.
(7) Monies collected by
				  an MCO for third party liability, as described in Regulation .18 of this
				  chapter, are considered when calculating the capitation payments in §B(4)
				  of this regulation.
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 10.67.04.19-1 - MCO-Specific Case Mix Adjustment for HIV and AIDS with Hepatitis C

Current through Register Vol. 51, No. 14, July 12, 2024
A. To reflect the
				  higher level of risk associated with providing covered health care services
				  pursuant to COMAR 10.67.67 to HIV/AIDS enrollees who also have Hepatitis C, the
				  Department shall, to the extent provided by this regulation, make MCO-specific
				  adjustments to payments for enrollees in HIV and AIDS payment categories to
				  reflect the proportion of an MCO's HIV/AIDS enrollees who also have Hepatitis
				  C.
B. Identification of HIV/AIDS
				  Enrollees with Hepatitis C.
(1) For each MCO,
				  the Department shall consider historical encounter and fee-for-service data for
				  enrollees assigned to HIV and AIDS payment categories:
(a) For the initial assessment period, as of
				  June of the calendar year before the rate year; and
(b) For the mid-year assessment period, as of
				  December of the calendar year before the rate year.
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 10.67.04.19-2 - MCO Supplemental Payment for Transitional Encounter Data Adjustment

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Department
				  may grant an adjustment to those MCOs for whom the uniform encounter data
				  adjustment results in completeness factors that are below the Statewide
				  average.
B. The encounter
				  adjustment for each MCO shall be determined for the Family and Children RACs
				  and for the Disabled RACs respectively.
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 10.67.04.19-3 - MCO-Specific Case Mix Adjustment

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Definitions.
(1) In this regulation, in
				  addition to the definitions set forth in COMAR 10.67.01, the following terms
				  have the meanings indicated.
(2)
				  Terms Defined.
(a) "Demographic rate cell"
				  means a cell in one of the rates tables in Regulation .19B(4) of this chapter
				  to which an MCO's enrollees are assigned pursuant to Regulation .19B(1)(b) and
				  B(2)(b) of this chapter.
(b)
				  "Initial rate adjustment period" means the 6-month period beginning January 1
				  of the rate year.
(c) "Mid-year
				  rate adjustment period" means the 6-month period beginning July 1 of the rate
				  year.
(d) "RAC rate cell" means a
				  cell in one of the rates tables in Regulation .19B(4) of this chapter to which
				  an MCO's enrollees are assigned pursuant to Regulation .19B(1)(a) and (2)(a) of
				  this chapter.
(e) "Rate adjustment
				  period" means a 6-month period within the rate year that includes:
(i) The initial rate adjustment period
				  beginning January 1 of the rate year; and
(ii) The mid-year rate adjustment period
				  beginning July 1 of the rate year.
(f) "Rate year" means the calendar year to
				  which the rates calculated pursuant to this regulation apply.
(g) "Risk Adjustment Category (RAC)" means a
				  grouping of adjusted clinical groups (ACGs), each of which is associated with a
				  similar level of risk.
(h) "Risk
				  assessment cohort" means each of the eight groupings of enrollees, assigned on
				  the basis of their:
(i) Program eligibility
				  category, either "families and children", as specified in Regulation .19B(1) of
				  this chapter, or "disabled", as specified in Regulation .19B(2) of this
				  chapter;
(ii) Region of residence
				  category, either in "Baltimore City" or in the "rest of State"; and
(iii) Age category, either at least 1 year
				  old but younger than 21 years old, or 21 years old or older.
(i) "Risk assessment year" means
				  the calendar year 2 years before the rate year.
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 10.67.04.19-5 - Recodified

Current through Register Vol. 51, No. 14, July 12, 2024
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 10.67.04.20 - MCO Payment for Self-Referred, Emergency, Physician, and Hospital Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. MCO Payment
				  for Self-Referred Services.
(1) For undisputed
				  claims that are submitted to the MCO within 6 months of the date of service, an
				  MCO shall reimburse out-of-plan providers within 30 days for eligible services
				  performed upon an enrollee who has self-referred:
(a) To a school-based health clinic pursuant
				  to COMAR 10.67.67.28B, for services described in COMAR 10.67.68;
(b) For family planning services, pursuant to
				  COMAR 10.67.67.28A;
(c) For an
				  initial medical examination for an enrollee who is a child in State-supervised
				  care, pursuant to Regulation .13F of this chapter;
(d) For one annual diagnostic and evaluation
				  service visit for an enrollee diagnosed with human immunodeficiency virus or
				  acquired immune deficiency syndrome (HIV/AIDS) pursuant to COMAR
				  10.67.67.28E;
(e) For obstetric and
				  gynecologic care provided to a pregnant woman, under the circumstances
				  described in COMAR 10.67.67.28C; and
(f) For an initial medical examination of a
				  newborn when the:
(i) Examination is
				  performed in a hospital by an on-call physician; and
(ii) MCO failed to provide for the service
				  before the newborn's discharge from the hospital.
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 10.67.04.21 - Payments to Federally Qualified Health Centers (FQHC)

Current through Register Vol. 51, No. 14, July 12, 2024
A. FQHC's shall be reimbursed under the
				  Alternative Payment System (APS) .
(1) The
				  Department shall:
(a) Pay the MCO a
				  prospective payment based on encounter data; and
(b) Reconcile the prospective amount paid to
				  the MCO with the MCO's actual expenditure amount, after receipt of MCO
				  encounter data; and
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 10.67.04.22 - Stop Loss Program

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall
				  qualify for protection under the Stop Loss Program if:
(1) It was participating in HealthChoice as
				  of April 1, 1999;
(2) It was unable
				  to self-insure or obtain a contract with another entity for Stop Loss
				  reinsurance after July 1, 1999; and
(3) By July 1, 1999, the MCO requested the
				  Department to continue to provide Stop Loss Protection at a rate determined by
				  the Department.
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 10.67.04.23 - Marketing

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO may not
				  have face-to-face or telephone contact with a recipient, or otherwise solicit a
				  recipient who is not an enrollee of the MCO, unless authorized by the
				  Department or the recipient initiates the contact.
B. Subject to prior approval by the
				  Department, an MCO may engage in marketing activities designed to make
				  recipients aware of their availability, as well as any special services they
				  offer. Unless they involve face-to-face solicitation, these marketing
				  activities may involve campaigns using but not limited to:
(1) Television;
(2) Radio;
(3) Newspaper;
(4) Informational booths at public
				  events;
(5) Billboards and other
				  public displays;
(6)
				  Addressee-blind informational mailings, but only when mailed to the MCO's
				  entire service area;
(7)
				  Magazines;
(8) Airborne marketing
				  displays; or
(9) Public
				  conveyances.
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 10.67.04.25 - Enrollee Outreach Plan

Current through Register Vol. 51, No. 14, July 12, 2024
A. An
				  MCO shall submit to the Department, on an annual basis, a written enrollee
				  outreach plan that:
(1) Describes how the MCO
				  intends to comply, in the upcoming year, with the outreach requirements of
				  Health-General Article, §15-103(b)(9), Annotated Code of Maryland;
				  and
(2) Provides evidence of the
				  MCO's compliance during the previous year, with the outreach requirements of
				  Health-General Article, §15-103(b)(9), Annotated Code of
				  Maryland.
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 10.67.04.26 - Time Period for Termination of Provider Agreement

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO may terminate its provider
				  agreement with the State as provided in §§B-D of this
				  regulation.
B. The MCO shall
				  provide written notification to the Department of the MCO's intent to terminate
				  the MCO's provider agreement with the State for any given calendar year by the
				  previous October 1.
C. An MCO that
				  has previously terminated the provider agreement with the State and would like
				  to sign a new agreement with the State, shall follow the application process as
				  specified under COMAR 10.67.64.
D.
				  The Department may waive the requirement under §B of this regulation if
				  the Department determines that the circumstances warrant, including but not
				  limited to a reduction in rates outside the normal rate setting process or an
				  MCO exit from the program.
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 10.67.04.27 - Newborn Coordinator

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO
				  shall identify a newborn coordinator who shall be available to providers during
				  the MCO's business hours as a contact for concerns related to eligibility and
				  provision of services to newborns.
B. The newborn coordinator shall provide
				  services for a newborn:
(1) Whose mother is
				  enrolled in the MCO on the date of the newborn's birth; and
(2) Who is enrolled or who is autoassigned to
				  the MCO after birth.
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 10.67.05.01 - Access Standards: Addressing Enrollees' Individualized Needs

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall
				  provide access to health care services and information in a manner that
				  addresses the individualized needs of its enrollees, regardless of gender,
				  sexual orientation, or gender identity, including, but not limited to, the
				  delivery of services and information to enrollees:
(1) In a culturally sensitive
				  manner;
(2) At an appropriate
				  reading comprehension level;
(3) In
				  the prevalent non-English languages identified by the State; and
(4) In a manner that accommodates individuals
				  with disabilities consistent with the requirements of the Americans with
				  Disabilities Act of 1990, P.L. 101-330,
				  42 U.S.C. §
												12101 et seq., and regulations promulgated
				  under it.
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 10.67.05.02 - Access Standards: Enrollee Handbook and Provider Directory

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall
				  inform and educate its enrollees about:
(1)
				  Basic information about the MCO;
(2) The availability of health care services
				  and how to access them;
(3) The
				  definitions of managed care terminology in accordance with
				  42 CFR §
												438.10(c)(4)(i);
				  and
(4) Enrollee's rights and
				  responsibilities in the MCO, and that the exercise of those rights does not
				  adversely affect the way the MCO, its providers, or the Department treats the
				  enrollee.
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 10.67.05.03 - Access Standards: Outreach

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  An MCO is responsible for delivering needed health care services even when the
				  enrollee is difficult to reach or misses appointments.
B. The assistance of local health departments
				  in contacting and bringing into care enrollees who are difficult to reach or
				  miss appointments is available for the specific categories of enrollees
				  identified in this regulation, but only after the MCO has made documented
				  attempts to contact and bring into care an enrollee who is difficult to reach
				  or misses appointments before seeking the assistance of the local health
				  department.
C. Adults.
(1) An MCO shall, before referring the
				  enrollee to the local health department, make documented attempts to ensure
				  that follow-up appointments are scheduled in accordance with the enrollee's
				  treatment plan by attempting a variety of contact methods, which may include:
(a) Written correspondence;
(b) Telephone contact; and
(c) Face-to-face contact.
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 10.67.05.05 - Access Standards: Specialty Provider Network

Current through Register Vol. 51, No. 14, July 12, 2024
A. Primary Care Provider (PCP).
(1) An MCO shall assign each enrollee to a
				  primary care provider who is:
(a) Chosen by
				  the enrollee from the MCO's panel of qualified providers; or
(b) Chosen by the MCO from its panel of
				  qualified providers if the enrollee has failed to choose a PCP.
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 10.67.05.05-1 - Access Standards: Specialty Provider Network

Current through Register Vol. 51, No. 14, July 12, 2024
A. Standards and Regions.
(1) The Department shall review an MCO's
				  specialty provider network for MCO's overall network as defined in this
				  regulation.
(2) Overall Network
				  Standards.
(a) An MCO shall meet either the
				  time or distance standard set forth in Regulation .06A of this chapter for
				  core, major, and pediatric specialties.
(b) The 8 core specialties are:
(i) Cardiology;
(ii) Otolaryngology (ENT);
(iii) Gastroenterology;
(iv) Neurology;
(v) Ophthalmology;
(vi) Orthopedics;
(vii) Surgery; and
(viii) Urology.
(c) The 6 major specialties are:
(i) Allergy and immunology;
(ii) Dermatology;
(iii) Endocrinology;
(iv) Infectious disease;
(v) Nephrology; and
(vi) Pulmonology.
(d) The 4 pediatric subspecialties are:
(i) Cardiology;
(ii) Gastroenterology;
(iii) Neurology; and
(iv) Surgery.
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 10.67.05.06 - Geographical Access

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except as
				  provided in §C of this regulation, an MCO shall develop and maintain a
				  provider network that meets the following time and distance standards:
(1) For adult and pediatric primary care,
				  pharmacy, diagnostic laboratory and x-ray, and gynecology:
(a) In urban areas, within 15 minutes or 10
				  miles;
(b) In suburban areas,
				  within 30 minutes or 20 miles; and
(c) In rural areas, within 40 minutes or 30
				  miles;
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 10.67.05.07 - Access Standards: Clinical and Pharmacy Access

Current through Register Vol. 51, No. 14, July 12, 2024
A. Appointments.
(1) New Enrollees: Initial Appointment.
(a) On its receipt and review of the health
				  service needs information of a new enrollee, an MCO shall take appropriate
				  action to ensure that the new enrollee who needs special or immediate health
				  care services, as identified by the health service needs information, receives
				  them in a timely manner.
(b) Unless
				  the new enrollee is assigned to a PCP who was the enrollee's established
				  provider of care immediately before the enrollee's enrollment, and, consistent
				  with any applicable periodicity schedule, the PCP concludes that no immediate
				  initial appointment is necessary:
(i) Unless
				  a shorter time frame otherwise applies, the MCO shall ensure that a new
				  enrollee's initial appointment is scheduled to occur within 90 days of the date
				  of enrollment;
(ii) Unless the PCP
				  confirms that the enrollee has elected to continue prenatal care with her
				  established provider pursuant to COMAR 10.67.67.28C, the MCO shall ensure that
				  an initial prenatal appointment is scheduled to occur within 10 days of the
				  date that the MCO receives the enrollee's completed health risk assessment, or
				  within 10 days of the enrollee's request for an appointment, whichever is
				  sooner;
(iii) If the new enrollee
				  is a person requesting family planning services, the MCO shall ensure that an
				  initial appointment is scheduled to occur within 10 days of the date of the
				  enrollee's request for an appointment; or
(iv) If the new enrollee is identified to be
				  at high risk by the health service needs information form, the MCO shall ensure
				  that an initial appointment is scheduled to occur within 15 business days of
				  the MCO's receipt of the enrollee's completed health risk assessment.
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 10.67.05.08 - Emergency Services Access

Current through Register Vol. 51, No. 14, July 12, 2024
A. An
				  MCO shall develop and maintain policies and procedures for the adequate
				  provision of emergency services for all its enrollees, including:
(1) Instituting and monitoring a system for
				  responding to enrollees' emergency medical conditions, with provisions for
				  immediate attention to and appropriate disposition of emergency calls;
				  and
(2) Informing and educating its
				  enrollees in the procedures to be followed in the event of an emergency,
				  whether within or outside of the MCO's service area.
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 10.67.05.09 - Access: Hospitals

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO
				  shall comply with the access standards specified in Regulation .06A of this
				  chapter.
B. If an MCO's service
				  area includes a county that is designated as a medically underserved area and
				  there is only one hospital in the county, the MCO shall include the hospital in
				  its network.
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 10.67.06.01 - Required Benefits Package - In General

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except for non-covered services set forth
				  in Regulation .27 of this chapter and the non-capitated services described in
				  COMAR 10.67.70, an MCO shall provide its enrollees with a benefits package that
				  includes the covered services specified in this chapter when these services are
				  deemed to be medically necessary including services covered under the Maryland
				  Medicaid State Plan in the amount, duration, and scope set forth in the State
				  Plan and in accordance with 42 CFR §
											440.230.
B. An MCO shall ensure that the services
				  provided are sufficient in amount, duration, or scope to reasonably achieve the
				  purpose for which the services are furnished.
C. An MCO is not required to provide
				  non-covered services even when the service is medically necessary.
D. Any limitations set forth in this chapter
				  on covered services are not applicable to services required by enrollees who
				  are younger than 21 years old when it is shown that the services are medically
				  necessary to correct or lessen health problems detected or suspected by EPSDT
				  screening services, as described in Regulation .20 of this chapter.
E. An MCO may place appropriate limits on a
				  service on the basis of criteria applied under the State plan, such as medical
				  necessity.
F. Cost Sharing and
				  Prohibitions.
(1) Except for the following,
				  an MCO may not charge its enrollees any copayments, premiums, or cost sharing:
(a) Up to a $3 copayment for brand-name
				  drugs;
(b) Up to a $1 copayment for
				  generic drugs;
(c) Any other charge
				  up to fee-for-service limits as approved by the Department.
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 10.67.06.02 - Benefits - Primary Care Services

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall provide to its enrollees medically necessary
					 primary care services that are provided:
A. By the enrollee's PCP;
B. At the direction of the enrollee's PCP;
				  or
C. With respect to a primary
				  care service that is self-referred pursuant to Regulation .28 of this chapter:
(1) By an appropriate practitioner, acting
				  within the scope of the practitioner's license, certification, or other legal
				  authorization, and in accordance with the practitioner's training and
				  experience; or
(2) By a clinic that
				  furnishes health care services by or under the direction of a
				  physician.
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 10.67.06.03 - Benefits - Physician and Advanced Practice Nurse Specialty Care Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall
				  provide to its enrollees medically necessary specialty care services that are
				  outside of the enrollee's PCP's scope of practice, or, in the judgment of the
				  enrollee's PCP, are not services that the PCP customarily provides, is
				  specifically trained for, or is experienced in and are provided by:
(1) A physician or an advanced practice
				  nurse, acting within the scope of the individual's license or certification,
				  training, and experience;
(2) A
				  practitioner other than a physician or an advanced practice nurse when the
				  practitioner is in a physician's employ, is under the physician's direct
				  supervision, and performs the service within the scope of the practitioner's
				  license, certification, or other legal authorization, for the purpose of
				  assisting in the provision of the specialty care service;
(3) A clinic that furnishes health care
				  services by or under the direction of a physician; or
(4) For enrollees who are younger than 21
				  years old, a doctor of dental medicine or dental surgery, if the services are
				  surgical services that are also typically performed by physicians.
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 10.67.06.04 - Benefits - Pharmacy Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall
				  provide outpatient drugs as defined in §1927(k) (2) of the Social Security
				  Act.
B. An MCO shall provide to its
				  enrollees all medically necessary pharmaceutical services and pharmaceutical
				  counseling, including but not limited to:
(1)
				  Legend drugs;
(2)
				  Insulin;
(3) All FDA approved
				  contraceptives;
(4) Hypodermic
				  needles and syringes;
(5) Enteral
				  nutritional and supplemental vitamins and mineral products given by
				  nasogastric, jejunostomy, or gastrostomy tube in the home;
(6) Enteric coated aspirin prescribed for the
				  treatment of arthritic conditions;
(7) Nonlegend ferrous sulfate oral
				  preparations;
(8) Nonlegend
				  chewable tablets of any ferrous salt when combined with vitamin C,
				  multivitamins, multivitamins and minerals, or other minerals in the formulation
				  when the enrollee is younger than 12 years old;
(9) Medical supplies used in the preparation
				  of compounded prescriptions for home intravenous therapy;
(10) Medical supplies or equipment used in
				  the administration or monitoring of medication prescribed or ordered for an
				  enrollee by a qualifying provider as specified in §B of this
				  regulation;
(11) Latex
				  condoms;
(12) Nonlegend
				  ergocalciferol liquid (Vitamin D); and
(13) Emergency contraceptives for female
				  recipients.
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 10.67.06.05 - Benefits - Home Health Services

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Subject to the conditions specified in §B of this regulation, an MCO shall
				  provide to its enrollees medically necessary home health services, including:
(1) Skilled nursing services, including the
				  supervisory visits required by §A(2) of this regulation;
(2) Home health aide services, including
				  biweekly supervisory visits by a registered nurse in the recipient's home,
				  every second visit of which includes observations of the delivery of services
				  by the aide to the enrollee;
(3)
				  Physical therapy services;
(4)
				  Occupational therapy services;
(5)
				  Speech pathology services; and
(6)
				  Medical supplies that are used during a home health visit.
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 10.67.06.06 - Benefits - Habilitation Services for Medicaid Expansion Populations

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall
				  provide the following medically necessary habilitation services to enrollees
				  eligible for Medical Assistance under § 1902(a)(10)(A)(i)(VIII) of the
				  Social Security Act:
(1) Physical
				  therapy;
(2) Occupation therapy;
				  and
(3) Speech therapy.
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 10.67.06.07 - Benefits - Inpatient Hospital Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall provide to its enrollees
				  medically necessary inpatient hospital services as specified in this
				  regulation.
B. Admission to
				  Long-Term Care Facility.
(1) An MCO shall
				  provide to its enrollees medically necessary long-term care facility services
				  for:
(a) The first 90 continuous days
				  following the enrollee's admission; and
(b) Any days following the first 90
				  continuous days of an admission until the date the MCO has obtained the
				  Department's determination that the admission is medically necessary as
				  specified in §B(2) of this regulation.
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 10.67.06.08 - Benefits - Outpatient Hospital Services

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO's benefits package shall include medically necessary
					 outpatient hospital 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 10.67.06.09 - Benefits - Transplants

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall provide to its enrollees medically necessary
					 transplants.
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 10.67.06.11 - Benefits - Diagnostic and Laboratory Services

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall provide to its enrollees medically
					 necessary:
A. Diagnostic services;
				  and
B. Laboratory services,
				  performed by a provider who:
(1) Is Clinical
				  Laboratory Improvement Amendments (CLIA) certified; or
(2) Has a waiver of a certificate
				  registration along with a CLIA identification number.
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 10.67.06.12 - Benefits - Long-Term Care Facility Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall provide to its enrollees
				  medically necessary services in a chronic hospital, a chronic rehabilitation
				  hospital, or a nursing facility for:
(1) The
				  first 90 continuous days following the enrollee's admission; and
(2) Any days following the first 90
				  continuous days of an admission until the date the MCO has obtained the
				  Department's determination that the admission is medically necessary as
				  specified in §C of this regulation.
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 10.67.06.13 - Benefits - Disposable Medical Supplies and Durable Medical Equipment

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall
				  provide to its enrollees medically necessary disposable medical supplies and
				  durable medical equipment, including but not limited to:
(1) All supplies and equipment used in the
				  administration or monitoring of prescriptions by the enrollees; and
(2) Incontinency pants and disposable
				  underpads for medical conditions associated with prolonged urinary or bowel
				  incontinence if necessary to prevent institutionalization or
				  infection.
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 10.67.06.14 - Benefits - Vision Care Services

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  An MCO shall provide to its enrollees medically necessary vision care services
				  as specified in this regulation.
B.
				  For enrollees who are 21 years old or older, the MCO is responsible for
				  providing at least one eye examination every 2 years.
C. For its enrollees who are younger than 21
				  years old, the MCO is responsible for providing medically necessary vision
				  services, including but not limited to:
(1)
				  At least one eye examination every year in addition to any vision screen
				  performed as part of an EPSDT screen;
(2) Eyeglasses, limited to one pair per year
				  unless lost, stolen, broken, or no longer vision appropriate; and
(3) Contact lenses, if medically necessary
				  and if eyeglasses are not efficacious for the condition.
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 10.67.06.15 - Benefits - Podiatry Services

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  An MCO shall provide for its enrollees medically necessary podiatry services.
B. In addition to the services
				  described in §A of this regulation, an MCO shall provide:
1. Diabetes care services specified in COMAR
				  10.67.67.24A; and
2. Routine foot
				  care for enrollees, 21 years old or older with vascular disease affecting the
				  lower extremities.
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 10.67.06.16 - Benefits - Outpatient Rehabilitative Services

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall provide to its enrollees medically necessary
					 outpatient rehabilitative services, including but not limited to physical
					 therapy for adult enrollees.
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 10.67.06.17 - Benefits - Oxygen and Related Respiratory Equipment

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall provide to its enrollees medically necessary
					 oxygen and related respiratory equipment 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 10.67.06.18 - Benefits - Dialysis Services

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall provide to its enrollees medically necessary
					 dialysis 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 10.67.06.19 - Benefits - Family Planning Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall provide to its enrollees
				  comprehensive family planning services, including but not limited to medically
				  necessary office visits and laboratory tests, all FDA-approved contraceptive
				  devices, methods, and supplies, and voluntary sterilizations.
B. An MCO may place appropriate limits on
				  family planning services for the purpose of utilization control, provided that
				  the services are provided in a manner that protects and enables the enrollee's
				  freedom to choose the method of family planning to be used consistent with
				  42 CFR §
											441.20.
C. An MCO may not apply a copayment or
				  coinsurance requirement for contraceptive drugs or devices.
D. An MCO shall provide coverage for a single
				  dispensing of a supply of prescription contraceptives for a 12-month
				  period.
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 10.67.06.20 - Benefits - EPSDT Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. An
				  MCO shall provide, to enrollees younger than 21 years old, medically necessary
				  Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services,
				  including:
(1) EPSDT comprehensive well-child
				  services provided in accordance with the EPSDT periodicity schedule and
				  performed by an EPSDT-certified provider, including:
(a) A comprehensive health and developmental
				  history, including an evaluation of both physical and mental health
				  development;
(b) A comprehensive
				  unclothed physical exam;
(c)
				  Immunizations appropriate to age and health history;
(d) Laboratory tests, including blood lead
				  level assessment, as appropriate to age and risk;
(e) Health education, including anticipatory
				  guidance; and
(f) Vision, hearing,
				  and dental screening;
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 10.67.06.21 - Benefits - Pregnancy-Related Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall provide to its pregnant and
				  postpartum enrollees medically necessary pregnancy-related services, including:
(1) Comprehensive prenatal, perinatal, and
				  postpartum care, including high-risk specialty care when appropriate;
(2) Prenatal risk assessment and development
				  of an individualized plan of care that specifies the actions required to
				  address each identified need and is appropriately modified during the course of
				  care;
(3) Enriched maternity
				  services, including:
(a) Prenatal and
				  postpartum counseling and education;
(b) Basic nutritional education;
(c) Substance abuse treatment, as provided in
				  Regulation .10 of this chapter;
(d)
				  Appropriate referrals to services that may improve the pregnancy outcome,
				  including:
(i) Special Supplemental Nutrition
				  Program for Women, Infants, and Children (WIC), and
(ii) Healthy Start services;
(e) High-risk nutrition counseling
				  services for nutritionally high-risk pregnant women;
(f) Appropriate levels of inpatient care,
				  including emergency transfer of pregnant women and newborns to tertiary care
				  centers;
(g) Smoking cessation
				  education and treatment;
(h) Doula
				  services; and
(i) Home visiting
				  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 10.67.06.22 - Benefits - Case Management Services for HIV-Infected Individuals

Current through Register Vol. 51, No. 14, July 12, 2024
An MCO shall provide medically necessary case management
					 services to its qualifying enrollees, as specified in COMAR
					 10.67.65.10C.
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 10.67.06.23 - Benefits - Hospice Care Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall include in its benefits
				  package medically necessary hospice care services to enrollees who are
				  terminally ill.
B. The Department
				  shall allow an enrollee to disenroll from an MCO and choose a new MCO if:
(1) The enrollee was auto-assigned to the
				  MCO; and
(2) The enrollee's hospice
				  provider does not contract with the enrollee's assigned MCO.
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 10.67.06.24 - Benefits - Diabetes Prevention and Care Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. An MCO shall provide to its qualifying
				  enrollees medically necessary diabetes prevention and care services as
				  specified in this regulation.
B.
				  National Diabetes Prevention Program.
(1) In
				  addition to the services included in its usual benefits package, an MCO shall
				  make available to its enrollees who meet the Centers for Disease Control and
				  Prevention (CDC) eligibility criteria defined in §B(2) of this regulation
				  the National Diabetes Prevention Program through a CDC-recognized lifestyle
				  change organization.
(2) To be
				  eligible for participation in the National Diabetes Prevention Program, a
				  HealthChoice enrollee:
(a) Shall be 18
				  through 64 years old;
(b) Shall be
				  overweight or obese;
(c) Shall have
				  an elevated blood glucose level or a history of gestational diabetes
				  mellitus;
(d) May not have a
				  previous diagnosis of type 1 or type 2 diabetes prior to enrollment;
				  and
(e) May not be currently
				  pregnant.