Md. Code Regs. 10.67.04.02

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

Section 10.67.04.02 - Conditions for Participation

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.

E. Health Care Delivery. An MCO shall:

(1) Provide the services set forth in COMAR 10.67.67 promptly and continuously, consistent with good medical practice and community professional standards;

(2) Conform with and fulfill the requirements of 42 CFR § 422.128, as amended, and provide adult enrollees with written information on advance directives which shall:

(a) Include a description of applicable State law; and

(b) Reflect a change in State law as soon as possible, but not later than 90 days after the effective date of the change.

(3) Provide each enrollee within 10 days of notification to the MCO of the enrollee's enrollment with a distinctive, durable identification card, clearly indicating the bearer to be a member of the MCO and containing, at a minimum:

(a) The enrollee's Medicaid number;

(b) The MCO's consumer services hotline telephone number;

(c) The Department's enrollee hotline telephone number; and

(d) Enrollee's assigned primary care provider's name and telephone number;

(4) Provide enrollees, within 30 days before the intended effective date, written notice when there is a significant change in the nature or location of services provided; and

(5) Provide on the card required in §E(3) of this regulation, on a separate prescription benefit card, or other technology, prescription billing information that:

(a) Complies with the standards set forth in the National Council for Prescription Drug Programs pharmacy ID card prescription benefit card implementation guide at the time of issuance of the card or other technology; or

(b) Includes, at a minimum, the following data elements:

(i) The name or identifying trademark of the MCO;

(ii) The name and identification number of the recipient;

(iii) The telephone number that providers may call for pharmacy benefit assistance; and

(iv) All electronic transaction routing information and other numbers required by the MCO or its benefit administrator to process a prescription claim electronically.

F. An MCO:

(1) Shall comply with the standards in P.L. 101-336, Americans with Disabilities Act of 1990, 42 U.S.C. § 12101 et seq.;

(2) May not discriminate against an enrollee on any basis, including, but not limited to, age, sex, race, creed, color, marital status, sexual orientation, gender identity, national origin, physical or mental handicap, health status, or need for health care services;

(3) Shall prepare and make available all publications in a manner consistent with COMAR 10.67.66.01A, including, but not limited to:

(a) Provider directories;

(b) Enrollee handbooks;

(c) Health education materials; and

(d) Informational brochures

G. An MCO shall maintain enrollee medical records in compliance with Health-General Article, §4-301 et seq., Annotated Code of Maryland, and the utilization control requirement of 42 CFR Part 456, as amended.

H. An MCO shall permit the enrollment of a waiver-eligible Program recipient who is enrolled by the Department or who selects the MCO, unless the MCO's enrollment meets or exceeds any enrollment limits mutually agreed to by the Department and the MCO.

I. MCO Local Access Area Participation.

(1) Effective January 1, 2014, an MCO shall open in all local access areas located within the same county in which the MCO chooses to participate.

(2) The MCO shall provide written notification to the Department of the MCO's intent to participate and accept new enrollees in each of the counties by September 15 for the next calendar year.

(3) The MCO's decision to accept new enrollees is in effect from January 1 to December 31 unless the Department decides there is adequate justification to waive this requirement, which includes, but is not limited to, a rate cut or an MCO exit from the market.

(4) Unless the Department approves a shorter time frame, an MCO that exits the Program during the calendar year shall submit their exit transition plan to the Department 120 days prior to the effective date of the exit.

(5) If the MCO has not participated in a county for a period of 12 or more consecutive months, the MCO may participate and accept new enrollees in that county by notifying the Department at least 30 days before accepting new enrollees.

(6) An MCO that voluntarily freezes for new enrollments in a county shall remain frozen in that county for the remainder of the calendar year and the following calendar year.

(7) If system modifications require longer than 30 days to implement, the effective date may be extended.

(8) The MCO shall follow the access standards specified in COMAR 10.67.66.06 and .05-1.

J. In counties where the MCO decides to stop accepting new enrollees, the MCO shall:

(1) Continue to accept enrollees who regain eligibility within 120 days of becoming ineligible for the Program;

(2) Accept newborns if the mother is an MCO member at the time of birth; and

(3) Accept the family members of enrollees enrolled with the MCO before the effective date that the MCO stopped accepting new enrollees.

K. An HMO that is approved as an MCO and that requires its panel providers to participate in an MCO shall submit for review by the Secretary its plan to assure the equitable distribution of enrollees and to ensure that a provider is not assigned a disproportionate number of enrollees, as required by Health-General Article, §15-102.5, Annotated Code of Maryland.

L. An MCO shall comply with the provisions of Insurance Article, § 15-112, Annotated Code of Maryland when credentialing providers, and during the credentialing process the MCO:

(1) May not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment;

(2) May not employ or contract with providers excluded from participation in federal health care programs under either § 1128 or 1128A of the Social Security Act; and

(3) Shall give the affected providers written notice of the reason for its decision if the MCO declines to include the providers in its network.

M. The requirements of Regulation .17A(2) of this chapter, or §L(1) of this regulation, may not be construed to:

(1) Require an MCO to contract with providers beyond the number necessary to meet the needs of its enrollees;

(2) Preclude an MCO from using different reimbursement amounts:

(a) For different specialties; or

(b) For different practitioners in the same specialty; or

(3) Preclude an MCO from establishing measures that are designed to maintain quality of services and control costs, consistent with its responsibilities to enrollees.

N. Disclosure of Provider Incentive Plans.

(1) An MCO shall disclose to the Department the information on its provider incentive plans listed in 42 CFR § 417.479(h)(1):

(a) Prior to approval of its contract or agreement; and

(b) Upon the contract's or agreement's anniversary or renewal effective date.

(2) An MCO shall include in the disclosures required by §N(1) of this regulation information sufficient for the Department to determine whether the incentive plans meet the requirements of 42 CFR § 417.479(d) - (g) and, as applicable (i), when there exist compensation arrangements under which payment for designated health services furnished to an individual on the basis of a physician referral would otherwise be denied under § 1903(a) of the Social Security Act.

O. When making a referral, an MCO shall use the uniform consultation referral form adopted by the Maryland Insurance Administration at COMAR 31.10.12.06.

P. An MCO shall meet all other requirements of applicable State and federal law including but not limited to:

(1) Title VI of the Civil Rights Act of 1964;

(2) Title IX of the Education Amendments of 1972 regarding education programs and activities;

(3) The Age Discrimination Act of 1975;

(4) The Rehabilitation Act of 1973;

(5) Any laws regarding privacy and confidentiality;

(6) Any laws that pertain to enrollee rights;

(7) 45 CFR Part 74, as amended, including particular attention to requirements at 45 CFR §§ 74.42, 74.43, 74.44, 74.48, and 74 . 53(a) and (b), and Appendix A; and

(8) Section 1557 of the Affordable Care Act.

Q. An MCO shall meet all program integrity requirements as set forth in COMAR 10.67.68.

R. The following applies to the Department's Health Home Program as described in COMAR 10.67.33:

(1) The MCO may not provide services that duplicate the CMS reimbursed health home services for members participating in the State's Health Home Program;

(2) The State shall inform the MCO of members assigned to the State's Health Home Program so that the MCO can prepare to coordinate care with the health homes;

(3) The MCO shall provide a point of contact for the health homes to the State who shall share with all the enrolled health homes;

(4) The MCO shall make referrals to the health homes of members who meet the criteria for enrollment in the program;

(5) To facilitate this process, the State shall provide information to the MCO on all the enrolled health homes in the MCO's service areas; and

(6) The MCO shall assist the health homes as necessary in accessing somatic care services for health home recipients.

Md. Code Regs. 10.67.04.02

Regulations .02 recodified from 10.09.65.02 effective 46:22 Md. R. 976, eff. 11/1/2019