Md. Code Regs. 10.67.03.05

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.03.05 - Access and Capacity

A. An MCO applicant shall include in its application the following information or descriptions:

(1) A map or maps showing the county or counties in which the applicant proposes to provide health care services, and the service area boundaries.

(2) The name and address of each of the applicant's service delivery sites, and, if applicable, the type of facility licensure of each site, grouped by county;

(3) If the applicant is an HMO, the applicant's total prepaid enrollment or client population as of the date of application, with a breakdown by payment source, including Medicare, Medicaid, commercial group, commercial individual, and other enrollment;

(4) If the applicant is an HMO, the total of the applicant's current unduplicated fee-for-service patient count, with a breakdown by payment source, including Medicaid, Medicare, commercial group, commercial individual, and other patients (including self-pay);

(5) The name and address of each of the applicant's primary and specialty care providers, provided in a format specified by the Department, for distribution to recipients in enrollment packets;

(6) The following information, grouped by medical specialty and county, regarding each individual practitioner, including primary care providers and specialists, who will act as a health care provider for the applicant:

(a) Name, address, and practice location or locations, including a separate line for each location;

(b) State licensure number;

(c) Specialty, if applicable, indicating the type of services to be provided on behalf of the applicant;

(d) Whether the provider will be a primary care provider;

(e) A description of the practitioner's employment relationship to the applicant, including but not limited to:

(i) A salaried employee;

(ii) A subcontractor;

(iii) An employee of a subcontractor; or

(iv) Any other form of contractual or employment relationship;

(f) Any restrictions as to age of patients or numbers of enrollees the provider will serve;

(7) The procedures for assuring proper credentialing and recredentialing of providers;

(8) Documentation that the MCO applicant is able to meet the access standards set forth in COMAR 10.67.66 in each service area the MCO applicant plans to enter;

(9) Documentation of any reasons for which they are unable to meet the access requirements of COMAR 10.67.66 in any service area;

(10) For each primary care practice location, a specification of:

(a) The name, address, and hours of operation; and

(b) The staffing at each location, expressed in full-time equivalencies and grouped by medical specialty

(i) General practice;

(ii) Family practice;

(iii) Internal medicine;

(iv) Pediatrics;

(v) Obstetrics and gynecology; and

(vi) Advanced practice nursing; and

(11) Written protocols detailing how the applicant will provide 24-hour per day, 7-day per week coverage for emergency medical situations, including compliance with MIEMSS protocols and the federal Emergency Medical Treatment and Active Labor Act.

B. The service area in §A(1) of this regulation shall include at least two underserved counties as defined in §C of this regulation.

C. An underserved county is a county in which less than three current MCOs are participating and accepting new enrollments.

D. If there are no underserved counties, applications will not be accepted.

Md. Code Regs. 10.67.03.05

Regulations .05 recodified from 10.09.64.05 effective 46:22 Md. R. 976, eff. 11/1/2019