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<regulation prefix="Regulation" num=".02" citation="COMAR 10.67.05.02" title_num="10" subtitle_num="67" chapter_num="05" heading="Access Standards: Enrollee Handbook and Provider Directory.">
  <paragraph num="A.">
    <text>An MCO shall inform and educate its enrollees about:</text>
    <paragraph num="(1)">
      <text>Basic information about the MCO;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The availability of health care services and how to access them;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>The definitions of managed care terminology in accordance with 42 CFR 438.10(c)(4)(i); and</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Enrollee's rights and responsibilities in the MCO, and that the exercise of those rights does not adversely affect the way the MCO, its providers, or the Department treats the enrollee.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>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:</text>
    <paragraph num="(1)">
      <text>The enrollee's rights and responsibilities in the MCO as described in 42 CFR §438.100(b)(1), as amended;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Information on how to access urgent care and emergency care services, including:</text>
      <paragraph num="(a)">
        <text>What constitutes an emergency medical condition and emergency services;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The following facts:</text>
        <paragraph num="(i)">
          <text>Prior authorization is not required for these services; and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>The enrollee has a right to use any hospital or other setting for emergency care;</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>The services included in the MCO's benefits package, including optional benefits provided by the MCO;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>The amount, duration, and scope of benefits available in sufficient detail to ensure that enrollees understand the benefits to which they are entitled;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>The availability of behavioral health services that are not included in the MCOs benefits package, and how to access these services;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Information on the availability of self-referral services as well as any restrictions on the enrollee's freedom of choice among network providers;</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Information about how enrollees may obtain benefits from out-of-network providers;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Any policies and procedures necessary to facilitate accessing needed services in compliance with the Maryland Medicaid Managed Care Program, including any requirements for service authorizations or referrals for specialty care and for other benefits not furnished by the enrollee's primary care provider;</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Information about the availability of EPSDT, prenatal care, family planning, and other wellness services, including education programs;</text>
    </paragraph>
    <paragraph num="(11)">
      <text>A statement that the MCO cannot require an enrollee to obtain a referral before choosing a family planning provider;</text>
    </paragraph>
    <paragraph num="(12)">
      <text>The process of selecting and changing the enrollee's primary care provider;</text>
    </paragraph>
    <paragraph num="(13)">
      <text>A description of any benefits the MCO offers in addition to those required by the Maryland Medicaid Managed Care Program, including applicable terms and conditions for accessing those benefits;</text>
    </paragraph>
    <paragraph num="(14)">
      <text>Information on how to access auxiliary aids and services, including additional information in alternative formats or languages;</text>
    </paragraph>
    <paragraph num="(15)">
      <text>The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees, including:</text>
      <paragraph num="(a)">
        <text>A description of each unit and number;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>An explanation of how the phone numbers can be used to obtain information and assistance; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>An explanation of the MCOs internal grievance procedure.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(16)">
      <text>Information regarding the importance of scheduling and maintaining appointments for preventive services;</text>
    </paragraph>
    <paragraph num="(17)">
      <text>If applicable, a list of services that are not covered by the MCO because of moral or religious objections, and a statement that informs the enrollee that the State will provide information on how and where to obtain these services;</text>
    </paragraph>
    <paragraph num="(18)">
      <text>The rule pertaining to poststabilization care services, as set forth in Regulation .08G of this chapter;</text>
    </paragraph>
    <paragraph num="(19)">
      <text>Appeal, grievance, and fair hearing procedures and time frames that include the following:</text>
      <paragraph num="(a)">
        <text>The right to a State fair hearing, including the method for obtaining a hearing and the rules that govern representation at the hearing;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The right to file appeals and grievances;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The requirements and time frames for filing an appeal or grievance;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>The availability of assistance in the filing process;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>The toll-free numbers that the enrollee may use to file an appeal or grievance by phone;</text>
      </paragraph>
      <paragraph num="(f)">
        <text>The fact that, if requested by the enrollee, the benefits will continue if the enrollee files an appeal or a request for a State fair hearing within the time frames specified for filing; and</text>
      </paragraph>
      <paragraph num="(g)">
        <text>That the enrollee may be required to pay the cost of the services furnished while the appeal is pending, if the final decision is adverse to the enrollee;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(20)">
      <text>Any appeal rights the State chooses to make available to providers;</text>
    </paragraph>
    <paragraph num="(21)">
      <text>Advanced directives as set forth in 42 CFR §438.3(j)(1), as amended;</text>
    </paragraph>
    <paragraph num="(22)">
      <text>Information on how to report suspected fraud or abuse;</text>
    </paragraph>
    <paragraph num="(23)">
      <text>Additional information that is available upon request, including the following:</text>
      <paragraph num="(a)">
        <text>Information on the structure and operation of the MCO; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Physician incentive plans.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(24)">
      <text>Information on how to access or obtain the MCOs provider directory.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Provider Directory.</text>
    <paragraph num="(1)">
      <text>An MCO shall provide enrollees with information regarding their provider networks including:</text>
      <paragraph num="(a)">
        <text>Its primary care service locations;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A listing of the MCOs hospital providers, of both inpatient and outpatient services, in the enrollee's county, their addresses, and services provided;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>A listing of the MCOs pharmacy providers in the enrollee's county and their addresses; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>A listing of the individual practitioners who are the MCOs primary and specialty care providers in the enrollee's county, grouped by medical specialty, giving:</text>
        <paragraph num="(i)">
          <text>Name;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Address;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Practice location or locations;</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>Telephone number or numbers;</text>
        </paragraph>
        <paragraph num="(v)">
          <text>Website URL, as appropriate;</text>
        </paragraph>
        <paragraph num="(vi)">
          <text>Any group affiliation, as appropriate;</text>
        </paragraph>
        <paragraph num="(vii)">
          <text>Cultural and linguistic capabilities, including languages offered by the provider or a skilled medical interpreter at the provider’s offices, American Sign Language interpretation;</text>
        </paragraph>
        <paragraph num="(viii)">
          <text>An indication of whether the provider's office or facility has accommodations for physical disabilities, including offices, exam room or rooms and equipment;</text>
        </paragraph>
        <paragraph num="(ix)">
          <text>An indication of whether or not the provider is accepting new patients;</text>
        </paragraph>
        <paragraph num="(x)">
          <text>An indication of the age range of patients accepted or whether there is no age limit; and</text>
        </paragraph>
        <paragraph num="(xi)">
          <text>If applicable, how access to the provider is otherwise limited.</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Upon request by an enrollee, an MCO shall furnish a paper copy of the provider directory.</text>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>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.</text>
  </paragraph>
  <paragraph num="E.">
    <text>The Department may consider the information listed in §§B and C of this regulation to be provided if the MCO:</text>
    <paragraph num="(1)">
      <text>Mails a printed copy of the information to the enrollee's mailing address;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Provides the information by email after obtaining the enrollee's agreement to receive the information by email;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Posts the information on the MCOs website and advises the enrollee in paper or electronic form that the information is available on the internet and includes the applicable internet address, provided that enrollees with disabilities who cannot access this information online are provided auxiliary aids and services upon request at no cost; or</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Provides the information by any other method that can reasonably be expected to result in the enrollee receiving that information.</text>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>An MCO shall update its online provider directory no later than 30 days after the MCO receives updated provider information.</text>
  </paragraph>
  <paragraph num="G.">
    <text>An MCO shall update its paper directory:</text>
    <paragraph num="(1)">
      <text>Monthly if the MCO does not have a mobile-enabled electronic directory; or</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Quarterly if the MCO has a mobile-enabled electronic directory.</text>
    </paragraph>
  </paragraph>
  <paragraph num="H.">
    <text>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.</text>
  </paragraph>
</regulation>