Title 10 — Subtitle 67. Maryland Healthchoice Program

Except as expressly limited, in COMAR 10.67.01.12 the following terms have the meanings indicated.

Terms Defined.

Criteria. Except as provided in §B of this regulation, a Program participant shall be enrolled in the Maryland Medicaid Managed Care Program, described in this chapter, if the participant is eligible for receipt of Medical Assistance benefits by qualifying:

A participant is not eligible for the Maryland Medicaid Managed Care Program if the participant:

The Department shall make available through its website and upon request provide a paper copy of the following:

Only the Department, or its designee, is authorized to enroll individuals into MCOs.

A participant found eligible for Maryland Medicaid under 42 U.S.C §1902(a)(10)A(i) shall be assigned to:

Except for a participant found eligible as described in §C of this regulation, a participant, including a child in foster care or kinship care, shall:

All Managed Care Program eligible family members who live in the same household shall be assigned to the same MCO.

Newborns.

Effective Date of Enrollment. Enrollment in an MCO shall be effective at 12:01 a.m. on the 10th calendar day beginning with the day on which the Department notifies the MCO of the enrollment.

Upon the approval of the Department and the MCO, a participant may select an MCO that does not serve the participant’s service area.

The Department or its designee shall submit the enrollee's choice of PCP to the enrollee's selected MCO at the time of enrollment.

The Department, MCO, or agents of the Department or MCO shall attempt to complete the health service needs information at the time of enrollment.

The Department shall transmit any information obtained from health service needs information to the enrollee’s MCO within 5 business days.

Upon its receipt and review of the health service needs information, an MCO shall take appropriate action to ensure that a new enrollee, who needs special or immediate health care services, as identified by the health service needs information, receives them in a timely manner.

If the Department does not transmit health services needs information for an enrollee to the MCO within 10 days of enrollment, the MCO shall make at least two attempts to conduct an initial screening of the enrollee’s needs, within 90 days of the effective date of enrollment. At least one of these attempts shall be during non-working hours.

The Department shall inform an enrollee identified in connection with the health service needs information as having a behavioral health problem that the individual may self-refer to the behavioral health ASO for services as described in COMAR 10.09.59 and 10.09.80.

Within 10 days of the notification of enrollment of a new enrollee or within 10 days of any event that requires a change in an existing enrollee's PCP, an MCO shall notify the enrollee of the enrollee's PCP assignment.

A Program recipient with no previous affiliation with any of the providers on the MCO's primary care provider panel who:

Before changing an enrollee’s PCP, the MCO shall obtain the Department’s approval at least 60 days before the reassignment is effective unless:

Once every 12 months, a Program recipient may elect to:

The Department shall notify the enrollee no less than 60 days before the start of each new enrollment period.

The Department shall reassign into the same MCO from which the recipient was last enrolled any recipient disenrolled from an MCO who, within 120 days of disenrollment, regains:

The MCO shall assign the recipient to the primary care provider of record at the time of the recipient's disenrollment.

A Program participant who has been disenrolled from an MCO because the Department terminated the MCO's contract shall be assigned to another MCO subject to Regulation .02D of this chapter.

Enrollee-Initiated Disenrollment for Cause.

Department-Initiated Disenrollment. The Department shall disenroll from an MCO an enrollee:

The Department may disenroll individuals from an MCO which the Maryland Insurance Administration has put into rehabilitation or liquidation pursuant to Health-General Article, §15-102.2, Annotated Code of Maryland.

MCO Initiated Disenrollment.

Effective Date of Disenrollment.

An MCO shall:

The Department shall notify enrollees who may change MCOs under §A(1)(e) of this regulation.

At the Department’s discretion, an MCO may be required to reimburse the Department for the costs associated with the mailing of the notifications in §G of this regulation.

When applying for participation in the Maryland Medicaid Managed Care Program as an MCO, an applicant shall submit an application to the Secretary in the form that the Secretary requires.

An applicant may omit from its application any information or documents that it has previously submitted to the Department, if:

An indication whether the applicant is an operating HMO with a certificate of authority from the Maryland Insurance Administration;

A written legal history of the applicant, specific as to dates and parties involved, that includes, but is not limited to:

A copy of the articles of incorporation of the applicant, and any amendments to it, certified by the Maryland Department of Assessments and Taxation;

A copy of the applicant's current bylaws, certified by the appropriate corporate officer;

A written description providing a reason if the applicant has ever defaulted on a contract or otherwise had a contract terminated;

If the applicant is an HMO, the most recent annual loss ratio report provided to the Maryland Insurance Administration pursuant to Insurance Article, §5-605, Annotated Code of Maryland;

A copy of the applicant's business plan provided to the Maryland Insurance Administration pursuant to Insurance Article, §5-605, Annotated Code of Maryland.

Evidence of compliance with Maryland Workers' Compensation Law, as follows:

The names, addresses, and official capacities of the managing employees or other individuals responsible for the conduct of the affairs of the applicant, including concise position descriptions and background, citing education, training, and experience, for, but not limited to, the applicant's:

A full disclosure of the extent and nature of any contracts or arrangements, including any possible conflicts of interest between the applicant and any individual specified in §I of this regulation;

The name and address of each person with a 5 percent or more ownership or controlling interest in the applicant or in any subcontractor or supplier in which the applicant has direct or indirect ownership of 5 percent or more, including identifying whether any person named is related to any other named person as either spouse, parent, child, or sibling;

A list of any subcontractors or suppliers owned by the applicant, indicating the percent of financial interest held;

A history of any subcontractors with whom the applicant has had business transactions totaling more than $25,000 during the 12-month period ending on the date of application;

A description of the applicant's corporate and organizational structure, and an organizational chart, with detailed lines of authority indicating the relationships among the board of directors, the administrative component, and the medical and health service delivery component of the applicant including, but not limited to, staff positions responsible for the plan's key management functions enumerated in §I of this regulation;

A description of all current contractual relationships between the applicant and subcontractors for administrative/management, health, and marketing services, including the subcontractors' names;

A description of any contracts the applicant intends to enter into before beginning operation as an MCO;

The name of any person or persons holding an ownership or controlling interest in excess of 5 percent in the applicant, or who is an agent or managing employee of the applicant, who has been subject to a conviction as defined at 42 U.S.C. §1320a-7(i), or a sanction for a Program-related offense;

Copies of all standard subcontracts with service and administrative providers who are not salaried employees of the applicant, including identification of any provision in subcontracts which differ from the standard subcontract;

A description of the method by which the applicant will accomplish cost avoidance or recovery in the case of third-party liability; and

Copies of the applicant’s written Medicaid marketing plan including:

A table labeled “Insurance Coverage”, specifying the applicant's coverage in insurance types including, but not limited to, reinsurance, risk of insolvency, medical malpractice, general liability, and fidelity bond, and detailing the:

Evidence of the applicant's insurance for general liability and medical malpractice in the minimum amounts of $1,000,000 per loss and $3,000,000 in the aggregate;

Evidence that the applicant has on hand sufficient liquid funds or a reasonably adequate cash flow to meet all organizational and administrative expenses incurred or expected to be incurred before commencing operations;

An explanation detailing how the applicant would, if approved, protect itself from insolvency;

A description of how the applicant would, if approved, limit its financial risk;

Document that the applicant has deposited, in a trust account with the State treasury, $100,000 in cash or government securities of the type described in Insurance Article, §5-701(b), Annotated Code of Maryland;

A financial statement audited by an independent certified public accountant of the financial condition of the applicant, including:

A power of attorney executed by the applicant appointing the Commissioner and the Commissioner's authorized deputies as the true and lawful attorney of the applicant in and for the State upon which may be served all lawful process in any action, proceeding, or cause of action arising in this State against the applicant regarding the solvency and financial condition of the applicant.

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

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

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

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

Written evidence of the applicant's preparedness to provide benefits equivalent to the benefit level mandated by the Maryland Medical Assistance Program as described in COMAR 10.67.05;

A description of any benefits the applicant proposes to provide in addition to those required by the Maryland Medicaid Managed Care Program, including:

A copy of the written procedures specifying how an enrollee may select and change primary care providers;

A written explanation of the applicant's plan to provide adequate case management and continuity of care, including its policies and procedures concerning:

Documentation of the applicant's preparedness to collaborate with providers of self-referral services, and reimburse at the Department's established fee-for-service rate, for permissible self-referred services as defined in COMAR 10.67.06.28;

Documentation of the applicant's preparedness to provide the full range of EPSDT services;

Documentation of the applicant’s preparedness to work with the Department’s behavioral health ASO for coordination of somatic care, behavioral health care, and all appropriate drug utilization review.

A written explanation of the prospective MCO's plan for providing monthly updates to primary care providers of the enrollees assigned to them;

Documentation of the applicant's plan to satisfy statutory requirements that enrollees be notified of due dates for obtaining immunizations, examinations, and other wellness services;

Documentation of how the applicant will provide timely access to health care services, including but not limited to:

Documentation of access provisions to address the needs of enrollees who:

The applicant's proposed written utilization management program that specifies, at a minimum, policies and procedures for:

The applicant's proposal to establish and utilize a consumer advisory board, including:

A written description of the applicant's proposed member services unit, including a consumer services hotline, describing how the applicant will use this:

A written Enrollee Outreach Plan that:

Documentation of any service the MCO elects not to provide, reimburse for, or provide coverage of, because of a moral or religious objection, which shall:

A description of the applicant's hiring and subcontracting policies, which shall correspond to the requirements of Insurance Article, §15-112, Annotated Code of Maryland;

A blank copy of the provider application form;

Documentary assurances that the applicant and its health care providers furnish access on a nondiscriminatory basis, in accordance with State and federal law, to all of their enrollees regardless of gender, race, age, religion, national origin, physical or mental disability, or type of illness or condition;

If the applicant is an HMO that will require its panel providers to participate in the MCO, documentation of the mechanism the MCO will use to make an equitable distribution of enrollees among its panel providers so that no provider is assigned a disproportionate number of enrollees;

Written evidence of the applicant's organizational capacity to provide special programs adequate to meet the individual needs of all enrollees, including:

A written explanation of the applicant's plan for ensuring that each primary and specialty care provider receives a copy of the MCO's Medicaid requirements manual, and any other information necessary to facilitate full compliance with all federal and State Medicaid requirements within 2 weeks after the provider has entered into a contract or has begun employment with the MCO, and updated as necessary thereafter; and

A description of the applicant's plan to accommodate the cultural and ethnic diversity of the populations to be served.

Effective July 1, 2012, an MCO applicant shall obtain NCQA health plan accreditation within 2 years of their effective date as an MCO.

Effective January 1, 2025, an MCO shall obtain NCQA health equity accreditation within 2 years of their effective date as an MCO.

The applicant's proposed quality assurance plan, that contains, at a minimum, all elements specified by Health-General Article, §15-103(b)(9)(i), Annotated Code of Maryland;

A description of any written procedures or protocols regarding physician and nursing care practice the applicant intends to use;

A description of the applicant's peer review committee structure and process;

A copy of the applicant's case management plan;

A description of all mechanisms to be used to ensure the quality of any services, including administrative and clinical, that the applicant intends to delegate to subcontractors;

The name and a description of the published standards or guidelines for maintenance of medical records the applicant will follow;

A description of how providers will be apprised of medical records, utilization review, and case management requirements;

A description of the applicant's system for ensuring inclusion in the medical record of reports of health care services or diagnostic testing performed in a referral setting;

A written description of the applicant's internal review system for the handling, monitoring, and resolution of provider complaints, grievances, and appeals;

Evidence of an adequate system for medical record retention and retrieval that meets, at minimum, all requirements of Health-General Article, §15-103(b)(9)(xiv), Annotated Code of Maryland;

Documentary evidence that the applicant requires school-based clinics to provide information concerning health care services provided to their enrollees;

A copy of the applicant's practice guidelines used to assist practitioners in approaching health care issues in a systematic, appropriate manner;

A copy of the applicant's health education plan;

A written description of the applicant's complaint resolution protocol, which shall, at minimum:

A copy of the MCO's provider education plan.

A narrative description of the clinical expertise and experience of the MCO's network for special needs populations in a format specified by the Department;

Written evidence of the applicant's ability to comply with specific quality access, data, and performance measurements to satisfy the general requirements for all special needs populations specified in COMAR 10.67.04.04;

Written evidence, including treatment protocols, of the applicant’s ability to provide the range of clinical and support services specified in COMAR 10.67.04.05—.10 and .13, to ensure appropriate and coordinated services to the following special populations:

Referral protocols that demonstrate the conditions under which PCPs will make the arrangements for children with special health care needs to be referred to MCO specialty care networks and when appropriate the behavioral health ASO for services as described in COMAR 10.09.59 or 10.09.80.

A description of the applicant's management information system, including, but not limited to:

A description of the applicant's operational procedures for generating service-specific encounter data;

Evidence of the applicant's ability to report, on a monthly basis, service-specific encounter data in UB04 or CMS1500 format;

A description of the applicant's operational procedures for generating financial reports, including, but not limited to:

Evidence of the applicant’s ability to collect and report all data necessary to derive indicators for Healthcare Effectiveness Data and Information Set (HEDIS); and

A description of the applicant’s procedures for verifying the accuracy and timeliness of reported data, including data from network providers the MCO was compensating on the basis of capitation payments or other payment arrangements that are not fee-for-service.

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.

An MCO shall comply with COMAR 10.09.36.

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.

Assurance Against Insolvency.

Health Care Delivery. An MCO shall:

An MCO:

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.

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.

MCO Local Access Area Participation.

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

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.

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:

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

Disclosure of Provider Incentive Plans.

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.

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

An MCO shall meet all program integrity requirements as set forth in COMAR 10.67.07.

The following applies to the Department's Health Home Program as described in COMAR 10.09.33:

An MCO shall have a continuous, systematic program designed to monitor, measure, evaluate, and improve the quality of health care services delivered to enrollees including individuals with special health care needs. At a minimum, the MCO shall:

An MCO shall participate in all quality assessment activities required by the Department to determine if the MCO is providing medically necessary enrollee health care. These activities include, but are not limited to:

If an MCO is assessed as deficient in accordance with federal and State standards, the MCO shall submit a plan of corrective action to the Department.

An MCO shall provide the Department a copy of its most recent NCQA accreditation, including:

The Department shall award a defined amount of funding annually to MCOs based on the county of residence of their members and the socioeconomic disadvantage index described in this regulation.

Socioeconomic Disadvantage Index.

The Department shall award available equity funding to MCOs serving members in Maryland service areas based on the following criteria:

Incentive funds awarded under the HealthChoice Health Equity Incentive Program are not appealable under 10.67.10.

Effective January 1, 2022, the Department shall establish the HealthChoice Population Health Incentive Program (PHIP).

An MCO may be eligible for an incentive payment for the following performance measures:

Each measure identified in §B of this regulation shall be valued equally at a proportional share of available incentive funds, except for measures §B(5)(a) and (b), which are each valued at half of the available incentive funds relative to one of the other measures.

There shall be two rounds of potential incentive payments an MCO may earn.

Subject to budget approval, total PHIP funding shall be determined prior to the measurement year and included in the MCO contract.

All PHIP payments shall be funded independently from and outside of MCO capitation payments during a given calendar year.

Each MCO shall be eligible for no more than 1 percent of the plan's measurement year capitation payments, excluding supplemental payments outside of capitation, as total payment from round one and round two.

If the Department determines that the score for any measure identified in §B of this regulation may not be comparable to the previous year's score due to alterations in measure specifications or other factors, the Department may exclude the measure from the PHIP and adjust the incentive valuation in accordance with the remaining performance measures.

Round One Incentives.

Round Two Incentive Payments.

If additional funds remain after both round one and round two, the Department may, within its discretion, allocate the funding as follows:

Effective measurement year 2025, an MCO with penalties under the HEDIS MCO Performance Monitoring Policy included in the HealthChoice MCO Agreement shall be excluded from all rounds of PHIP for that measurement year.

Incentives awarded under this regulation and exclusion from PHIP participation are not appealable under COMAR 10.67.10..

An MCO shall provide health care services to enrollees who are members of special needs populations.

Special needs populations consist of the following non-mutually exclusive populations:

General Requirements for Special Needs Populations.

An MCO shall meet the standards set forth in this regulation for treating children with special health care needs.

The Department shall maintain a record of the complaints received through the Department's enrollee and provider hotlines which involve the denial of care for children and review these complaint logs as part of its quality assurance system.

An MCO shall demonstrate that its therapies provider network is adequate by demonstrating its:

An MCO shall provide case management services to children with special health care needs as appropriate. For complex cases involving multiple medical interventions or social services, or both, a multidisciplinary team shall be used to review and develop the plan of care for special health care needs children.

An MCO shall provide coordinated care for special health care needs children in State-supervised care.

An MCO shall refer child victims of alleged abuse, neglect, or sexual offense to an appropriate provider capable of:

An MCO shall ensure coordination with the Department’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program.

An MCO shall establish protocols for effecting medically necessary service referrals to specialty care providers for children with special health care needs.

The service referrals referenced in §H of this regulation shall:

An MCO shall provide durable medical equipment to a special needs child in a timely manner.

When a child, who is an MCO enrollee, is diagnosed with a special health care need requiring a plan of care which includes specialty services, and that health care need was undiagnosed at the time of enrollment, the parent or guardian of that child may request approval from the MCO for a specific out-of-network specialty provider to provide those services when the MCO does not have a local in-network specialty provider with the same professional training and expertise who is reasonably available and provides the same service and modality, subject to the following provisions:

An MCO shall meet the standards set forth in this regulation for treating an individual with a physical disability.

An MCO shall demonstrate that its providers for durable medical equipment and assistive technology provide the appropriate services and are clinically qualified to provide these services to the individual with a physical disability.

Before placement of an individual with a physical disability into an intermediate or long-term care facility, an MCO shall:

An MCO shall utilize individuals with expertise in disabilities to review its marketing and informational forms and publications, which shall be provided in alternative formats with reasonable accommodation to people with a physical disability.

An MCO shall provide education for the MCO's member services staff, triage staff, and case managers on special communications requirements for individuals with physical disabilities.

An MCO shall meet the standards set forth in this regulation for treating an individual with a developmental disability.

An MCO shall ensure that its case managers have experience or training related to developmental disabilities.

An MCO shall utilize individuals with expertise in disabilities to review its marketing and informational forms and publications, which shall be provided in alternative formats with reasonable accommodation to people with developmental disabilities.

An MCO shall provide education for the MCO's member services staff, triage staff, and case managers on special communications requirements for individuals with developmental disabilities.

An MCO shall meet the standards set forth in this regulation for treating pregnant and postpartum women.

An MCO shall ensure access to prenatal care for pregnant women and postpartum care for postpartum women by:

An MCO shall ensure that prenatal providers:

The Department may not include questions about a woman's HIV infection status on the prenatal risk assessment instrument.

An MCO shall refer pregnant and postpartum women with a substance use disorder to the behavioral health ASO for substance use treatment within 24 hours of request.

An MCO shall refer pregnant and postpartum women, infants, and children younger than 5 years old to the WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) Program, and shall provide to WIC necessary medical information to determine WIC nutritional eligibility.

An MCO shall follow, at a minimum, the American College of Obstetricians and Gynecologists (ACOG) guidelines for pregnant and postpartum women.

An MCO shall provide risk-related medical and nonmedical preventive treatment services, including nutrition counseling by licensed nutritionists or dietitians and smoking cessation education and treatment for pregnant and postpartum women.

An MCO shall provide HIV counseling, including a risk assessment and information about possible transmission of HIV to the fetus.

An MCO shall offer its pregnant and postpartum enrollees voluntary HIV counseling and testing following the requirements of COMAR 10.67.06.

An MCO shall arrange for the appropriate emergency transfer of pregnant women, newborns, and infants to tertiary care centers.

An MCO shall meet the standards set forth in this regulation for treating individuals with HIV/AIDS.

HIV/AIDS Specialist.

AIDS Case Management Services.

Diagnostic Evaluation Service (DES) Assessment.

An individual with HIV/AIDS who has a substance use disorder shall be referred to the behavioral health ASO for substance abuse treatment within 24 hours of request.

Clinical Trials.

An MCO shall establish a consumer advisory board to facilitate the receipt of input from enrollees.

The consumer advisory board membership shall:

The consumer advisory board shall meet at least 6 times a year.

An MCO shall provide or arrange to provide all Medicaid-covered services required to comply with State statutes and regulations mandating health and mental health services for children in State-supervised care.

An MCO shall ensure the continuity and coordination of care, provided locally to the extent the services are available, to an enrollee who is a child in State-supervised care.

An enrollee who is a child in State-supervised care who moves shall be disenrolled from the recipient's MCO and enrolled in an alternative MCO if the recipient's current MCO does not serve the geographic region to which the child has been relocated.

An MCO shall expedite a change of providers within its provider panel upon the move of an enrollee who is a child in State-supervised care to a new geographic area served by the MCO.

On request of the responsible State or local agency, a child in State-supervised care may be disenrolled from the current MCO and enrolled in an MCO serving the group facility in which the child resides, members of the foster care family, or other children in foster care placement with the child.

Enrollee Self-Referral. An MCO shall permit the self-referral of a child in State-supervised care to an EPSDT certified provider for an initial examination, including a mental health screen, and shall pay for all portions of the examination except for the mental health screen, which shall be paid for by the Specialty Mental Health System.

Coordination with Responsible Agency. An MCO shall appoint a liaison to coordinate services to a child in State-supervised care with the responsible State or local agencies.

An MCO is responsible for providing medically necessary primary behavioral health services to their enrollees.

An enrollee may self-refer to the behavioral health ASO for services described in COMAR 10.09.59 or 10.09.80.

If an enrollee’s primary care physician determines that primary behavioral health services are not sufficient to meet the enrollee’s needs, the primary care physician shall refer the enrollee to the behavioral health ASO for services described in COMAR 10.09.59 or 10.09.80.

If an MCO determines that primary behavioral health services are not sufficient to meet the enrollee’s needs, the MCO shall refer the enrollee to the behavioral health ASO for services described in COMAR 10.09.59 or 10.09.80.

An MCO shall cooperate with the behavioral health ASO in developing referral procedures and protocols.

An MCO shall notify the Department immediately when it has knowledge of an enrollee's death.

Encounter Data.

Monthly Reports.

Quarterly Reports. An MCO shall submit to the Department:

Annual Reports. Except as provided in §E(5) of this regulation, an MCO shall submit to the Department annually, within 90 days after the end of the calendar year:

Unless the MCO is exempt for good cause, an MCO shall submit to the Department when requested the following reports for its enrollee/member services and provider/authorization/preauthorization lines:

If the MCO exits the HealthChoice Program for any reason, including those listed in COMAR 10.67.02.06A(1)(e) and (f):

Jurisdictional Reporting to Local Health Departments. The Department shall:

For the purposes of Maryland Medicaid Managed Care Program administration or monitoring MCO performance pursuant to this chapter, the MCO shall supply other information as the Department may from time to time request, given a reasonable period of notice.

Nonfederally qualified MCOs shall report a description of certain transactions with parties of interest, as described in §1903(m)(4)(A) of the Social Security Act.

Upon request, an MCO whose member has disenrolled shall transfer historical utilization data to the member's new MCO in the time frame and format specified by the Department.

Subcontracting Permitted.

Subcontractual Relations Reporting Requirements.

By entering into a subcontract to provide health care services on behalf of an MCO, the subcontractor becomes subject to all the requirements concerning audits and inspections by the Department and other government agencies that are imposed upon the MCO by statute or regulation, or by its contract with the Department.

An MCO shall monitor the performance of its subcontractors, including, but not limited to, the areas of enrollee and provider complaints, access issues, quality assurance activities, record keeping, and reporting requirements.

An MCO shall report to the Department any material deviations from required procedures by its subcontractor which, in the MCO's judgment, can be expected to have a significant effect on quality of care, or on enrollees' ability to access care.

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.

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.

The Department shall notify an MCO of any third-party liability identified during the course of eligibility determination.

The MCO shall submit to the Department any new or changed third-party information in an automated format on a monthly basis.

The Department shall provide the MCOs with any new or changed information on a monthly basis in an automated format.

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:

When both the Department and an MCO have a right of subrogation, they shall coordinate settlement negotiation, ensuring that the funds available are prorated to allow sufficient compensation to settle each party's claim amount.

For insurance coverage identified by an MCO with a retroactive effective date, an MCO shall comply with Insurance Article, §15-1008, Annotated Code of Maryland.

An MCO may not deny a provider’s request for a preauthorization solely because a recipient has, or is thought to have, third-party insurance.

The requirement in §I of this regulation may not apply if an MCO has a process in place to ensure that a claim will not be denied for lack of preauthorization if the claim ultimately becomes the MCOs responsibility for one of the following reasons:

If an MCO identifies another party as being responsible for retroactive denial of reimbursement, the MCO shall:

Capitation Rate Setting Methodology — Extraction of Graduate Medical Education Costs.

The Department shall use, in calculating the capitation rates set forth in Regulation .19B of this chapter, a capitation rate-setting methodology that:

Generally.

Capitation Rate-Setting Methodology.

The Department shall reimburse fee-for-service:

Interim Rates Adjustments.

Interim Rate Adjustment for Calendar Year 2025.

To reflect the higher level of risk associated with providing covered health care services pursuant to COMAR 10.67.06 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.

Identification of HIV/AIDS Enrollees with Hepatitis C.

Methodology for Determining MCO-specific HIV and AIDS Case Mix Measures. For each MCO, the Department shall:

Methodology for MCO-Specific Case Mix-Adjusted HIV and AIDS Rates. For each MCO, the Department shall:

Case Mix Updates. The Department shall:

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.

The encounter adjustment for each MCO shall be determined for the Family and Children RACs and for the Disabled RACs respectively.

Definitions.

For calculating an adjustment to MCO payment rates reflecting the relative level of risk of providing enrollees assigned to demographic rate cells covered health care services pursuant to COMAR 10.67.06, the Department shall, for each MCO, identify the enrollees to be considered as follows:

Methodology for Determining MCO-specific RAC Case Mix Measures. For each MCO, the Department shall:

Methodology for Determining MCO-specific Demographic Case Mix Measures. For each MCO, the Department shall:

MCO-Specific Case Mix Adjusted Demographic Rates. The Department shall, for each MCO:

Case Mix Updates. The Department shall:

By September 1 of the second calendar year following the MLR reporting year, each MCO shall provide to the Department a completed MLR Reporting Template, including the MCO attestation and any additional documentation supporting the MLR reporting template.

The MLR experienced for each MCO in an MLR reporting year is the ratio of the numerator, as defined in §D of this regulation, to the denominator, as defined in §E of this regulation.

An MLR may be increased by a credibility adjustment, in accordance with §G of this regulation.

Components of MLR — Numerator.

Components of MLR Denominator.

Allocation of Expense.

Credibility Adjustment.

Eligibility Groups.

An MCO shall provide a remittance for an MLR reporting year if the MLR for that MLR reporting year does not meet the minimum MLR standard of 85 percent.

Newly Contracted MCOs.

If the Department makes a retroactive change to the capitation payments for an MLR reporting year where the report has already been submitted to the Department, the MCO shall recalculate the MLR for all MLR reporting years affected by the change and submit a new report.

MCOs shall attest to the accuracy of the calculation of the MLR in accordance with requirements of this section when submitting its report to the Department.

MCOs shall report fraud prevention activities as required by 42 CFR §438.8.

Notice and Appeal.

MCO Payment for Self-Referred Services.

MCO Payment for Emergency Services Provided at a Hospital. An MCO shall reimburse a hospital emergency facility and provider, which is not required to obtain prior authorization or approval for payment from an MCO in order to obtain reimbursement under this regulation, for:

MCO Payment to an Out-of-Network Federally Qualified Health Center for Services Immediately Required Due to an Unforeseen Illness, Injury, or Condition.

MCO Payment for Provider Services.

Payment for Hospital Services.

FQHC’s shall be reimbursed under the Alternative Payment System (APS).

For self-referred services described in Regulation .20 of this chapter, the MCO shall pay the FQHC’s usual rate in accordance with §A of this regulation, regardless of the FQHC’s contracted status with the MCO.

An MCO shall qualify for protection under the Stop Loss Program if:

An MCO shall notify the Department that the acute inpatient hospital costs of an enrollee are expected to exceed the Stop Loss limit as soon as it knows that this is likely to occur.

Upon confirming eligibility for stop loss protection, the Department shall assume liability for reimbursement of 90 percent of accrued acute inpatient hospital charges according to established Medicaid fee-for-service rates for medically necessary acute inpatient treatment rendered to the enrollee above the stop loss limit throughout the remainder of the calendar year.

An MCO shall remain financially liable for reimbursing 10 percent of accrued acute inpatient hospital charges for medically necessary treatment rendered to the enrollee above the stop loss limit throughout the remainder of the calendar year, and shall maintain full responsibility for the provision of health care services to the enrollee.

At the beginning of the next calendar year, an MCO shall reassume full financial responsibility and full discretion for developing medical treatment plans for any enrollee who qualified for the Stop Loss Program.

The Department's Extended Stop Loss Period.

For calendar year 2001 and beyond, the MCO shall submit the MCO's Stop Loss Reinsurance Plan or Self-Insurance Plan to the Maryland Insurance Administration.

If an MCO chooses to have the Department provide its Stop Loss coverage, an adjustment will be made to the capitation amount the MCO is paid.

Upon the termination of the provider agreement between the enrollee's MCO and the Department, if an MCO has failed to fulfill its financial liability under this regulation, the Department shall assume responsibility only for costs that exceed the Stop Loss limit as specified in §C of this regulation.

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.

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:

An MCO may not engage in any cold call marketing, including activities using or involving any of the following mechanisms:

Standards for Departmental Approval of MCO Advertising.

An MCO shall submit to the Department, on an annual basis, a written enrollee outreach plan that:

Submission Date.

An MCO may terminate its provider agreement with the State as provided in §§B—D of this regulation.

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.

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 10.67.03.

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.

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.

The newborn coordinator shall provide services for a newborn:

The newborn coordinator shall:

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:

Special Access.

Written Materials. An MCO shall provide all its written materials in the following manner:

An MCO may provide enrollee information electronically so long as all of the following requirements are met:

An MCO shall inform and educate its enrollees about:

An MCO shall, at the time of enrollment, and anytime upon request, furnish each enrollee with a copy of the MCOs enrollee handbook that includes all language in the template provided by the Department and the following current information:

Provider Directory.

An MCO shall notify all enrollees of their right to request and obtain the information listed in §§B and C of this regulation at least once a year.

The Department may consider the information listed in §§B and C of this regulation to be provided if the MCO:

An MCO shall update its online provider directory no later than 30 days after the MCO receives updated provider information.

An MCO shall update its paper directory:

An MCO shall make provider directories available on its website in a machine-readable file and format as specified by the Secretary for the U.S. Department of Health and Human Services.

An MCO is responsible for delivering needed health care services even when the enrollee is difficult to reach or misses appointments.

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.

Adults.

Child Younger than 2 Years Old Needing EPSDT Screening Services.