<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".03" citation="COMAR 10.07.11.03" title_num="10" subtitle_num="07" chapter_num="11" heading="Quality Assurance Requirements — Program Planning and Evaluation.">
  <paragraph num="A.">
    <text>The HMO shall have a written program plan that is updated and reviewed at least every 3 years.</text>
  </paragraph>
  <paragraph num="B.">
    <text>The plan shall include the following information:</text>
    <paragraph num="(1)">
      <text>Statistics on age, sex, and other general demographic data used to determine the health care needs of its population;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Identification of the major health problems in the enrolled population;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Identification of enrolled special groups that have unique health problems such as the poor, the elderly, the mentally ill, and educationally disadvantaged;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>A description of community health resources and how they will be used.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Priorities and Objectives. The HMO shall state its priorities and objectives in writing, describing how the priorities and objectives relating to the health problems and needs of the enrolled population will be provided for.</text>
  </paragraph>
  <paragraph num="D.">
    <text>Services. At the time membership is solicited, the HMO shall provide a general description of services available to enrollees including:</text>
    <paragraph num="(1)">
      <text>Benefit limitations and exclusions;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Location of facilities or providers; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Procedures by which a member would obtain medical services.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>On each enrollment card or application, the HMO shall:</text>
    <paragraph num="(1)">
      <text>Place the following statement in bold print: “If you have any questions concerning the benefits and services that are provided by or excluded under this agreement, please contact a membership services representative before signing this application or card”; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Provide information on how a prospective member may contact a membership services representative.</text>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>The plan shall contain evidence that:</text>
    <paragraph num="(1)">
      <text>Programs and services offered are based on the health problems of, and the community health services available to, the enrolled population;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>There is an active program for preventing illness, disability, and hospitalization among enrollees;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Services designed to prevent the major health problems identified among child and adult enrollees and to improve their general health are provided by the HMO.</text>
    </paragraph>
  </paragraph>
</regulation>