Md. Code Regs. 10.67.05.05

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

Section 10.67.05.05 - Access Standards: Specialty Provider Network

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.

(2) An enrollee may request a change of PCP at any time if the PCP is within the recipient's current MCO's panel of providers.

(3) With respect to enrollees younger than 21 years old, an MCO shall assign the enrollee to a PCP who is certified by the EPSDT program, unless the enrollee or the enrollee's parent, guardian, or caretaker, as appropriate, specifically requests assignment to a PCP who is not EPSDT-certified.

(4) If the enrollee's parent, guardian, or caretaker, as appropriate, chooses a non-EPSDT certified PCP in accordance to §A(3) of this regulation, within 30 days of enrollment, the MCO shall:

(a) Notify the parent, guardian, or caretaker, by letter, that a non-EPSDT certified PCP has been chosen; and

(b) Include in the notification an explanation of the:

(i) EPSDT preventive screening services to which an enrollee is entitled according to the EPSDT periodicity schedule;

(ii) Importance of accessing the EPSDT preventive screening services; and

(iii) Process for requesting a change to an EPSDT-certified PCP to obtain preventive screening services.

(5) An MCO may include, as appropriate, any of the following practitioners to serve as the primary care provider for an enrollee:

(a) General practitioner;

(b) Family practitioner;

(c) Internist;

(d) Pediatrician;

(e) OB/GYN;

(f) Physician assistant;

(g) Certified nurse midwife;

(h) Nurse practitioner certified in any of the following areas of specialization:

(i) Adult;

(ii) Pediatric;

(iii) Geriatric;

(iv) OB/GYN;

(v) School nurse; or

(vi) Family; and

(i) A physician practicing in a specialty area other than those enumerated in §A(5)(b)-(e) of this regulation.

(6) The enrollee's designated primary care provider (PCP) is the enrollee's primary coordinator of care.

(7) For female enrollees, if the enrollee's PCP is not a women's health specialist, the MCO shall provide direct access, without the need for a referral, to a women's health specialist within the MCO's network for covered services necessary to provide women's routine and preventive health care services.

B. Adequacy of Provider Network.

(1) An MCO shall develop and maintain a complete network of adult and pediatric primary care, specialty care, ancillary service, vision, pharmacy, home health, and any other providers adequate to deliver the full scope of benefits as required by this chapter and COMAR 10.67.67.

(2) An MCO shall clearly define and specify referral requirements to specialty and other providers.

(3) An MCO shall require the PCP to maintain records of referral arrangements, and the feedback and outcomes of those referrals, within each enrollee's medical records.

(4) An MCO shall maintain a list of its proposed and existing subcontracts with health care providers who are necessary to fulfill the MCO's service delivery obligations.

(5) An MCO shall provide a list of its subcontractor providers to the Department.

(6) An MCO shall ensure services are delivered in a culturally competent manner to all enrollees, including enrollees:

(a) With limited English proficiency;

(b) With diverse cultural and ethnic backgrounds; and

(c) Of all genders, sexual orientations, and gender identities.

(7) For enrollees with physical or mental disabilities, an MCO shall ensure its network providers provide:

(a) Physical access;

(b) Reasonable accommodation; and

(c) Accessible equipment.

(8) Capacity.

(a) MCOs shall ensure adequate capacity and services, in compliance with 42 CFR § 438.206(b)(l)(i), as amended.

(b) The Department shall assess the MCO's provider network and determine its capacity to serve waiver-eligible recipients in each local access area in its service area.

(c) Unless the MCO can establish to the Department's satisfaction the adequacy of a higher ratio, the Department shall determine the MCO's capacity with respect to any local access area by assuming that in-plan individual practitioners, based on full-time equivalency, will be assigned no more than the number of enrollees that is consistent with a 200:1 ratio of enrollee to practitioner in the local access area.

(d) The Department may not approve an enrollee-to-PCP ratio that is higher than 2,000:1.

(9) To ensure compliance with the timely access requirements in Regulation .07 of this chapter, an MCO shall:

(a) Establish mechanisms to ensure that network providers comply with access requirements;

(b) Monitor regularly to determine compliance; and

(c) Take corrective action if there is a failure to comply.

Md. Code Regs. 10.67.05.05

Regulations .05 recodified from 10.09.66.05 effective 46:22 Md. R. 976, eff. 11/1/2019