# COMAR Title 10 — Maryland Department of Health

## Subtitle 67 — Maryland Healthchoice Program

### Chapter 02 — Maryland Medicaid Managed Care Program: Eligibility and Enrollment

**Authority:** Health-General Article, Annotated Code of Maryland

**Administrative History:** Effective date:

**Administrative History:** Regulations .01—.06 adopted as an emergency provision effective November 8, 1996 (23:25 Md. R. 1730);adopted permanently effective March 10, 1997 (24:5 Md. R. 408)

**Administrative History:** Regulation .01 amended as an emergency provision effective July 1, 1998 (25:16 Md. R. 1261); amended permanently effective January 1, 1999 (25:26 Md. R. 1925)

**Administrative History:** Regulation .01A amended effective April 19, 2010 (37:8 Md. R. 615); March 14, 2016 (43:5 Md. R. 385); August 29, 2016 (43:17 Md. R. 955)

**Administrative History:** Regulation .01B amended effective February 18, 2002 (29:3 Md. R. 220); April 9, 2007 (34:7 Md. R. 698); November 5, 2007 (34:22 Md. R. 1977); December 24, 2012 (39:25 Md. R. 1612); October 14, 2013 (40:20 Md. R. 1652); April 28, 2014 (41:8 Md. R. 471); February 16, 2015 (42:3 Md. R. 316); May 22, 2017 (44:1 Md. R. 472)

**Administrative History:** Regulation .01C amended effective February 2, 2004 (31:2 Md. R. 82)

**Administrative History:** Regulation .01C repealed effective December 20, 2004 (31:25 Md. R. 1790)

**Administrative History:** Regulation.02 amended as an emergency provision effective July 1, 1998 (25:16 Md. R. 1261); amended permanently effective January 1, 1999 (25:26 Md. R. 1925)

**Administrative History:** Regulation .02 amended effective February 18, 2002 (29:3 Md. R. 220); October 22, 2018 (45:21 Md. R. 973)

**Administrative History:** Regulation .02A amended as an emergency provision effective July 1, 2002 (29:15 Md. R. 1139); amended permanently effective October 28, 2002 (29:21 Md. R. 1645)

**Administrative History:** Regulation .02A amended effective June 30, 2008 (35:13 Md. R. 1180); February 16, 2015 (42:3 Md. R. 316); February 26, 2018 (45:4 Md. R. 205)

**Administrative History:** Regulation .02D, E amended effective February 26, 2018 (45:4 Md. R. 205)

**Administrative History:** Regulation .02F amended effective April 28, 2014 (41:8 Md. R. 471)

**Administrative History:** Regulations .02H and .06F amended as an emergency provision effective July 1, 1997 (24:16 Md. R. 1151); emergency status expired December 31, 1997

**Administrative History:** Regulation .02H amended effective February 9, 1998 (25:3 Md. R. 144); February 2, 2004 (31:2 Md. R. 82)

**Administrative History:** Regulation .02I amended effective December 24, 2012 (39:25 Md. R. 1612)

**Administrative History:** Regulation .02L adopted effective June 25, 2001 (28:12 Md. R. 1109)

**Administrative History:** Regulation .03 amended effective October 28, 2013 (40:21 Md. R. 1775); April 28, 2014 (41:8 Md. R. 471); February 16, 2015 (42:3 Md. R. 316); February 26, 2018 (45:4 Md. R. 205)

**Administrative History:** Regulation.04 amended as an emergency provision effective July 1, 1998 (25:16 Md. R. 1261); amended permanently effective January 1, 1999 (25:26 Md. R. 1925)

**Administrative History:** Regulation.04 amended as an emergency provision effective January 5, 2005 (32:6 Md. R. 634); amended permanently effective April 11, 2005 (32:7 Md. R. 679)

**Administrative History:** Regulation .04 amended effective December 24, 2012 (39:25 Md. R. 1612)

**Administrative History:** Regulation .04C amended effective October 28, 2013 (40:21 Md. R. 1775)

**Administrative History:** Regulations .05 amended effective February 18, 2002 (29:3 Md. R. 220); February 16, 2015 (42:3 Md. R. 316)

**Administrative History:** Regulation.05B amended as an emergency provision effective November 1, 2008 (35:24 Md. R. 2069); amended permanently effective February 23, 2009 (36:4 Md. R. 353)

**Administrative History:** Regulation .05E amended effective October 22, 2018 (45:21 Md. R. 973)

**Administrative History:** Regulation.05F, G amended as an emergency provision effective January 5, 2005 (32:6 Md. R. 634); amended permanently effective April 11, 2005 (32:7 Md. R. 679)

**Administrative History:** Regulation .05G, H adopted effective June 30, 2008 (35:13 Md. R. 1180)

**Administrative History:** Regulation .05G, H repealed effective April 28, 2014 (41:8 Md. R. 471)

**Administrative History:** Regulation .06 amended effective June 25, 2001 (28:12 Md. R. 1109); February 18, 2002 (29:3 Md. R. 220); December 31, 2018 (45:26 Md. R. 1244)

**Administrative History:** Regulation.06A amended as an emergency provision effective January 5, 2005 (32:6 Md. R. 634); amended permanently effective April 11, 2005 (32:7 Md. R. 679)

**Administrative History:** Regulation .06A, B amended effective November 6, 2006 (33:22 Md. R. 1732)

**Administrative History:** Regulation .06A, D amended effective June 30, 2008 (35:13 Md. R. 1180)

**Administrative History:** Regulation .06B amended effective February 6, 2012 (39:2 Md. R. 141); October 14, 2013 (40:20 Md. R. 1652); February 26, 2018 (45:4 Md. R. 205)

**Administrative History:** Regulation .06B, F amended as an emergency provision effective January 1, 2001 (28:4 Md. R. 414)

**Administrative History:** Regulation .06B, F amended effective April 19, 2010 (37:8 Md. R. 615)

**Administrative History:** Regulation .06F amended effective February 9, 1998 (25:3 Md. R. 144)

**Administrative History:** Regulation .06F amended as an emergency provision effective July 1, 2002 (29:15 Md. R. 1139); amended permanently effective October 28, 2002 (29:21 Md. R. 1645)

**Administrative History:** Regulation .06F amended effective April 9, 2007 (34:7 Md. R. 698); February 16, 2015 (42:3 Md. R. 316)

**Administrative History:** Regulation .06G adopted effective June 30, 2008 (35:13 Md. R. 1180)

**Administrative History:** Regulation .06G amended effective April 28, 2014 (41:8 Md. R. 471); February 16, 2015 (42:3 Md. R. 316); February 1, 2016 (42:23 Md. R. 1434)

**Administrative History:** Regulation .06H adopted effective April 28, 2014 (41:8 Md. R. 471)

**Administrative History:** Regulation .06I adopted effective February 1, 2016 (42:23 Md. R. 1434)

**Administrative History:** Chapter transferred from COMAR 10.09.63 effective November 1, 2019 (46:22 Md. R. 977)

**Administrative History:** Regulation .01 amended effective November 13, 2023 (50:22 Md. R. 974)

**Administrative History:** Regulation .01A amended effective June 24, 2024 (51:12 Md. R. 620)

**Administrative History:** Regulation .06E amended effective November 18, 2019 (46:23 Md. R. 1065)

#### Regulation .01 Eligibility.

*COMAR 10.67.02.01*

A. 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:

  (1) As categorically needy or medically needy under COMAR 10.09.24, unless the participant is:

    (a) 65 years old or older;

    (b) Newly eligible and 64 1/2 years old or older;

    (c) Eligible to receive Medicare benefits;

    (d) Determined medically needy under a spend down; or

    (e) Otherwise certified for a period of less than 9 months;

  (2) For the Pregnant Women and Children's Program on or after January 1, 1997; or

  (3) For the Maryland Children’s Health Program on or after July 1, 1998; or

  (4) For the Separate CHIP Program and CHIP Health Services Initiative on or after July 1, 2023.

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

  (1) Has been, or is expected to be, continuously institutionalized for more than:

    (a) 90 successive days in a long-term care facility; or

    (b) 30 successive days in an institution for mental disease (IMD);

  (2) Is institutionalized in an intermediate care facility for individuals with intellectual disabilities or persons with related conditions (ICF/IID);

  (3) Is enrolled in:

    (a) Home Care for Disabled Children under a Model Waiver, pursuant to COMAR 10.09.27;

    (b) The Family Planning Waiver Program pursuant to COMAR 10.09.58; or

    (c) The Employed Individuals with Disabilities Program pursuant to COMAR 10.09.41;

  (4) Is a child receiving adoption subsidy who is covered under the parent's private insurance;

  (5) Is a child under State supervision receiving adoption subsidy who lives outside of the State;

  (6) Is a child in an out-of-State placement; or

  (7) Is an inmate as defined in COMAR 10.67.01.01.

#### Regulation .02 Enrollment.

*COMAR 10.67.02.02*

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

  (1) Materials regarding each MCO providing services in the eligible individual’s county of residence including, but not limited to:

    (a) Information about how to access the provider directory and drug formulary, with instructions for how to request paper copies if needed;

    (b) A schedule of the benefits offered, including any benefits offered beyond the basic required package described in COMAR 10.67.06;

    (c) Which, if any, benefits are provided directly by the Department;

    (d) If applicable, a list of services that the MCO does not provide, reimburse for, or provide coverage of, because of moral or religious objections, and information about where and how to obtain these services;

    (e) The requirements for each MCO to provide adequate access to covered services, including the network adequacy standards established in COMAR 10.67.05; and

    (f) Quality and performance indicators for each MCO, including enrollee satisfaction; and

  (2) Materials about the managed care program, including:

    (a) The MCO enrollment and disenrollment process; and

    (b) The basic features of managed care.

  (3) Any forms necessary to select an MCO; and

  (4) The toll-free telephone number of the enrollment unit.

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

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

  (1) The MCO the participant chooses at the time of application; or

  (2) If the participant does not choose, an MCO with available capacity that is accepting new participants in the participant’s service area.

D. 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:

  (1) Have 28 days from the day the Department mails its eligibility notification in which to select an MCO; or

  (2) Be assigned to an MCO with available capacity that is accepting new participants in the participant’s service area.

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

F. Newborns.

  (1) A newborn shall be automatically enrolled from birth in its biological mother’s MCO.

  (2) The MCO is responsible for the newborn’s health care from birth until the newborn enrolls into another MCO.

  (3) A newborn, automatically assigned to its biological mother’s MCO, is not eligible to change MCOs for family unity as described in COMAR 10.67.02.06A(1)(b) and (c) during the first 90 days of enrollment.

G. 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.

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

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

#### Regulation .03 Health Service Needs Information.

*COMAR 10.67.02.03*

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

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

C. 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.

D. 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.

E. 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.

#### Regulation .04 Assignment to Primary Care Provider (PCP).

*COMAR 10.67.02.04*

A. 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.

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

  (1) Indicates a preference for a participating PCP during the enrollment process shall be assigned to that PCP unless the MCO documents in writing, for good cause, its inability to assign the enrollee to that PCP; or

  (2) Fails to make known any preference for a PCP shall be assigned to a PCP whose location satisfies the access standards specified in COMAR 10.67.05.06E.

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

  (1) The PCP has decided to stop practicing;

  (2) The PCP has terminated the relationship with an enrollee due to the enrollee’s behavior;

  (3) The change is requested by the enrollee; or

  (4) The age limits of the PCP's practice no longer meet the needs of the enrollee.

#### Regulation .05 Reassignment.

*COMAR 10.67.02.05*

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

  (1) Maintain enrollment with the recipient's current MCO;

  (2) Enroll in another MCO in the recipient's local access area; or

  (3) Enroll in an MCO outside the recipient’s local access area, upon the approval of the Department and the MCO.

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

C. 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:

  (1) Eligibility for Medicaid; or

  (2) Maryland Medicaid Managed Care Program eligibility lost for any of the reasons listed in Regulation .06B of this chapter.

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

E. 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.

#### Regulation .06 Disenrollment.

*COMAR 10.67.02.06*

A. Enrollee-Initiated Disenrollment for Cause.

  (1) An enrollee may disenroll from an MCO and enroll into another MCO if:

    (a) The enrollee moves to a county that is not served by the enrollee's present MCO;

    (b) The family members are enrolled in different MCOs and the adult enrollee requests that other family members be enrolled in one of the MCOs in which another family member is currently enrolled;

    (c) The enrollee requests enrollment into the MCO that contracts with the PCP of any other family member who is not a HealthChoice enrollee;

    (d) The enrollee moves or becomes homeless, creating a transportation hardship that may be resolved by enrollment into another MCO serving the enrollee's new local access areas;

    (e) The enrollee requests a change of MCO within 90 days after the termination of the enrollee's primary care provider's (PCP's) contract if the PCP's contract with the enrollee's MCO, MCO's medical management group, or its subcontractors is terminating for the following reasons:

      (i) By the MCO for reasons other than the quality of care or the PCP's failure to comply with contractual requirements related to quality assurance activities; or

      (ii) The MCO's reduction of PCP's reimbursement to the extent that the reduction in rate is greater than the actual change in capitation paid to the MCO by the Department, and the MCO and PCP's inability to negotiate a mutually acceptable rate;

    (f) The enrollee is automatically assigned to an MCO or it is the enrollee's initial enrollment in an MCO as follows:

      (i) Only one request during the first 90 days of automatic assignment or initial enrollment into an MCO; and

      (ii) The enrollee is not hospitalized at the time of the request;

    (g) The MCO terminates its contract with the Department in which case:

      (i) The MCO shall provide written notice to the recipient at least 60 days before the date on which the MCO will exit the HealthChoice Program;

      (ii) The MCO shall include in the notice the name and provider number of the PCP assigned to the recipient and the telephone number of the enrollment broker;

      (iii) The Department shall send a notice to every enrollee of the MCO regarding the MCO's termination of its contract with the Department, at least 30 days before the effective date of the termination of the contract;

      (iv) An enrollee shall have at least 30 days before the effective date of the MCO's contract termination with the Department to choose another MCO, or will be assigned to another MCO; and

      (v) An enrollee may choose another MCO one additional time within at least 90 days after reenrollment into the new MCO;

    (h) The MCO is acquired by another entity in which case:

      (i) The MCO shall provide written notice to the recipient at least 60 days before the date on which the MCO will exit the HealthChoice Program;

      (ii) The MCO shall include in the notice the name and provider number of the PCP assigned to the recipient and the telephone number of the enrollment broker;

      (iii) The Department shall send a notice to every enrollee of the MCO regarding the change in ownership, 30 days before the effective date of the change of ownership;

      (iv) An enrollee shall have 30 days before the change of ownership to disenroll from the MCO into another participating MCO;

      (v) If an enrollee does not choose to disenroll in accordance with §A(1)(f)(ii) of this regulation, the enrollee will be reenrolled in the newly purchased MCO; and

      (vi) An enrollee may choose another MCO one additional time within at least 90 days after reenrollment in the newly purchased MCO;

    (i) The MCO does not, because of moral or religious objections, cover the service the enrollee seeks;

    (j) All of the following apply:

      (i) The enrollee needs related services to be performed at the same time;

      (ii) Not all related services are available within the network; and

      (iii) The enrollee's PCP or other provider determines that receiving the services separately would subject the enrollee to unnecessary risk; or

    (k) The Department imposes the intermediate sanction specified in 42 CFR §438.702(a) and (b), as amended.

  (2) The Department shall provide timely notification to the affected MCO of an enrollee's intention to disenroll under §A of this regulation.

  (3) The Department shall allow disenrollments, subject to the Department's approval, for other reasons, including but not limited to:

    (a) Poor quality of care;

    (b) Lack of access to services covered under the contract; or

    (c) Access to providers experienced in dealing with the enrollee's health care needs.

  (4) Enrollees shall make an oral or written request to the Department's enrollment agent for disenrollment.

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

  (1) Subject to the MCO or long-term care facility obtaining the Department’s determination that the enrollee’s institutionalization has been medically necessary, who has been continuously institutionalized for a period of more than 90 successive days in a long-term care facility;

  (2) Upon admission to an intermediate care facility for individuals with intellectual disabilities or persons with related conditions (ICF/IID);

  (3) Determined eligible for rare and expensive case management pursuant to COMAR 10.09.69;

  (4) Who loses Medicaid eligibility or who changes to an assistance category not eligible for MCO enrollment, subject, however, to Regulation .01 of this chapter;

  (5) Upon the termination of the contract between the enrollee's MCO and the Department;

  (6) Who has died;

  (7) Who has not been validly enrolled in the MCO;

  (8) Who is 65 years old or older;

  (9) Who is an inmate of a public institution, including a State operated institution or facility; or

  (10) Who is eligible to receive Medicare benefits.

C. 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.

D. MCO Initiated Disenrollment.

  (1) An MCO may request disenrollment of an enrollee who has:

    (a) Moved outside of the MCO's service area; or

    (b) Become ineligible for continued enrollment for one of the reasons specified in §B of this regulation.

  (2) An MCO may not request disenrollment as specified in 42 CFR §438.56(b)(2), as amended.

E. Effective Date of Disenrollment.

  (1) Except as specified in §E(2)—(6) of this regulation, an enrollee's disenrollment is effective on the 10th calendar day after the enrollee selects a new MCO.

  (2) An enrollee's disenrollment shall take effect:

    (a) Immediately when the enrollee dies;

    (b) From the first day of the month following the month that the enrollee lost Medicaid eligibility;

    (c) On the first day of the month following the month in which the Department receives the required notification, when the enrollee permanently relocates outside of the State; or

    (d) From the first day of the month following the month in which the Department verifies an enrollee is an inmate.

  (3) When an enrollee becomes eligible for Medicare, the enrollee’s disenrollment from the MCO is effective on the:

    (a) First day of the month following the month in which the Program receives notice of Medicare eligibility; or

    (b) Last day of the month before the month in which the enrollee turns 65 years old.

  (4) Termination of enrollment resulting from termination of the contract between the Department and an MCO shall be effective on the date the Department terminates the contract.

  (5) Termination of enrollment resulting from the MCO being placed into rehabilitation or liquidation by the Maryland Insurance Administration shall be effective on the date the Department notifies the MCO of the disenrollment.

  (6) In the case of an enrollee's death, the Department has the right to recover any capitation payments made on behalf of an enrollee for the period beginning on the date of death.

F. An MCO shall:

  (1) Make a good faith effort to give written notice to the Department when enrollees have the right to change MCOs under §A(1)(e) of this regulation 90 days before the effective date of the termination;

  (2) Provide the Department with a list of the affected enrollees in a format specified by the Department; and

  (3) If applicable, provide the termination survey required under COMAR 10.67.04.17B(4).

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

H. 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.