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<regulation prefix="Regulation" num=".04" citation="COMAR 10.67.05.04" title_num="10" subtitle_num="67" chapter_num="05" heading="Access Standards: Information for Providers.">
  <paragraph num="A.">
    <text>An MCO shall develop and make available either electronically or by hard copy to all of its PCP and specialty care providers a Medicaid requirements manual, including periodic updates as appropriate, and shall:</text>
    <paragraph num="(1)">
      <text>Before distribution, file a copy of its manual with the Department for review;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Include in its manual the information necessary to facilitate the providers’ full compliance with federal and State Medicaid requirements, including information on:</text>
      <paragraph num="(a)">
        <text>Medicaid statutes and regulations;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The benefits package, including optional benefits;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Access requirements, which, at a minimum, comply with the requirements of this chapter;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Quality requirements, which shall, at a minimum, comply with the requirements of COMAR 10.67.04.03;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Continuity of care requirements;</text>
      </paragraph>
      <paragraph num="(f)">
        <text>Requirements for referral to specialist, ancillary, and other providers as necessary to provide the full range of medically necessary services that are covered by the Maryland Medicaid Managed Care Program; and</text>
      </paragraph>
      <paragraph num="(g)">
        <text>The MCO’s practice guidelines as described in 42 CFR §438.236.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>Inform the MCO’s primary and specialty care providers of their responsibility to provide or arrange for medically necessary accessible health care services that are continuous, comprehensive, and coordinated for each enrollee, including:</text>
      <paragraph num="(a)">
        <text>Preventive health services;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Primary acute medical care;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Chronic medical care;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Consultation, referral, and follow-up in areas including medical specialties and child dental care;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Referral for ancillary and support-related services including but not limited to:</text>
        <paragraph num="(i)">
          <text>Drug therapies;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Diagnostic tests;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Medical supplies;</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>Durable medical equipment; and</text>
        </paragraph>
        <paragraph num="(v)">
          <text>Case management when appropriate for complex conditions;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(f)">
        <text>24-hour per day, 7-day per week provider coverage for medically necessary services;</text>
      </paragraph>
      <paragraph num="(g)">
        <text>Maintenance of a medical record, including records of referral arrangements and outcomes of those referrals; and</text>
      </paragraph>
      <paragraph num="(h)">
        <text>Detection of mental health problems or substance use disorder during routine or follow-up screening, to be treated either through the MCO or referred to the behavioral health ASO for services; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Inform the providers of the following enrollee appeal, grievance, and fair hearing procedures and time frames:</text>
      <paragraph num="(a)">
        <text>The enrollee's right to a State fair hearing, how to obtain a hearing, and representation rules at a hearing;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The enrollee's right to file appeals and grievances, and the enrollee's requirements and time frames for filing;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The availability of assistance in filing;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>The toll-free numbers to file verbal appeals and grievances;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>The enrollee's right to request continuation of benefits during an appeal or State fair hearing filing, and that if the MCO action is upheld in a hearing, the enrollee may be liable for the cost of any continued benefits; and</text>
      </paragraph>
      <paragraph num="(f)">
        <text>The provider's right to appeal, on the enrollee's behalf, the failure of the MCO to cover a service.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>An MCO shall ensure that its PCP and specialty care providers receive adequate information regarding the Medicaid Program to facilitate full compliance with all federal and State Medicaid requirements. The MCO shall:</text>
    <paragraph num="(1)">
      <text>Ensure that each PCP and specialty care provider receives, at the time they enter into a contract, a copy of the MCO's Medicaid requirements manual, and any other pertinent information; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Provide each PCP and specialty care provider, on an ongoing basis as appropriate, with periodic updates of the materials required to be provided under §B(1) of this regulation.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>An MCO shall provide to each PCP an updated list of the PCP’s assigned enrollees monthly.</text>
  </paragraph>
</regulation>