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<regulation prefix="Regulation" num=".06" citation="COMAR 10.67.03.06" title_num="10" subtitle_num="67" chapter_num="03" heading="Access and Capacity: Benefits and Appointments.">
  <text>An MCO applicant shall include in its application the following information or descriptions:</text>
  <paragraph num="A.">
    <text>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;</text>
  </paragraph>
  <paragraph num="B.">
    <text>A description of any benefits the applicant proposes to provide in addition to those required by the Maryland Medicaid Managed Care Program, including:</text>
    <paragraph num="(1)">
      <text>Whether there are any limitations on these services; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The name, medical specialty, location, and employment status as enumerated in Regulation .05F(5) of this chapter, of any providers rendering additional services;</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>A copy of the written procedures specifying how an enrollee may select and change primary care providers;</text>
  </paragraph>
  <paragraph num="D.">
    <text>A written explanation of the applicant's plan to provide adequate case management and continuity of care, including its policies and procedures concerning:</text>
    <paragraph num="(1)">
      <text>Case management;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Making appointments;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Appointment no-shows;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Follow-up for appointment no-shows who are at-risk patients; and</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Referral claims and reimbursement for authorized noncontractual and out-of-plan provider services;</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>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;</text>
  </paragraph>
  <paragraph num="F.">
    <text>Documentation of the applicant's preparedness to provide the full range of EPSDT services;</text>
  </paragraph>
  <paragraph num="G.">
    <text>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.</text>
  </paragraph>
  <paragraph num="H.">
    <text>A written explanation of the prospective MCO's plan for providing monthly updates to primary care providers of the enrollees assigned to them;</text>
  </paragraph>
  <paragraph num="I.">
    <text>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;</text>
  </paragraph>
  <paragraph num="J.">
    <text>Documentation of how the applicant will provide timely access to health care services, including but not limited to:</text>
    <paragraph num="(1)">
      <text>Waiting time for telephone calls to be answered;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Obtaining appointments; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Waiting times in practitioners' offices;</text>
    </paragraph>
  </paragraph>
  <paragraph num="K.">
    <text>Documentation of access provisions to address the needs of enrollees who:</text>
    <paragraph num="(1)">
      <text>Do not speak English;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Are deaf; or</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Have one or more physical, mental, or developmental disabilities;</text>
    </paragraph>
  </paragraph>
  <paragraph num="L.">
    <text>The applicant's proposed written utilization management program that specifies, at a minimum, policies and procedures for:</text>
    <paragraph num="(1)">
      <text>Referral processes;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Services requiring preauthorization, including mechanisms for ensuring consistent application and requesting provider consultation when appropriate;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Criteria for determining medical necessity;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Provider responsibilities for utilization management activities;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Case management processes;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Utilization tracking mechanisms and the determination of over-utilization and under-utilization of health care services;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Integration of activities with quality improvement for provider profiling; and</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Appeals and grievance processes;</text>
    </paragraph>
  </paragraph>
  <paragraph num="M.">
    <text>The applicant's proposal to establish and utilize a consumer advisory board, including:</text>
    <paragraph num="(1)">
      <text>The anticipated composition of the board;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Identifying staff responsible for serving board needs; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Proposed mechanisms by which the board will furnish the MCO with regular enrollee input;</text>
    </paragraph>
  </paragraph>
  <paragraph num="N.">
    <text>A written description of the applicant's proposed member services unit, including a consumer services hotline, describing how the applicant will use this:</text>
    <paragraph num="(1)">
      <text>As an information source for enrollees;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>To respond to enrollees' needs and requests in a timely manner; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>To facilitate enrollees' access to needed health care services, including how the hotline will function as a point of entry for complaint resolution and internal grievance procedures;</text>
    </paragraph>
  </paragraph>
  <paragraph num="O.">
    <text>A written Enrollee Outreach Plan that:</text>
    <paragraph num="(1)">
      <text>Describes how the MCO intends to comply with the outreach, quality assurance, and provision of health care services requirements of Health-General Article, §15-103(b)(9), Annotated Code of Maryland; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>To the extent that the materials are relevant to the requirements of §O(1) of this regulation, may incorporate by reference written materials provided by the applicant in response to other elements of its application; and</text>
    </paragraph>
  </paragraph>
  <paragraph num="P.">
    <text>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:</text>
    <paragraph num="(1)">
      <text>Be provided to the Department whenever an MCO adopts the policy during the term of the contract;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Be consistent with the provisions of 42 CFR §438.10, as amended; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Be provided to enrollees within 90 days after adopting the policy with respect to any particular service.</text>
    </paragraph>
  </paragraph>
</regulation>