Chapter 05. Maryland Medicaid Managed Care Program: Access
Regulation .01 Access Standards: Addressing Enrollees' Individualized Needs.LinkCopy Citation
A.
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:
(1)
In a culturally sensitive manner;
(2)
At an appropriate reading comprehension level;
(3)
In the prevalent non-English languages identified by the State; and
(4)
In a manner that accommodates individuals with disabilities consistent with the requirements of the Americans with Disabilities Act of 1990, P.L. 101-330, 42 U.S.C. §12101 et seq., and regulations promulgated under it.
B.
Special Access.
(1)
An MCO shall notify enrollees of the following services and make them available free of charge to the enrollee:
(a)
Written materials in the prevalent non-English languages identified by the State;
(b)
Written materials in alternative formats;
(c)
Oral interpretation services in all non-English languages; and
(d)
Auxiliary aids and services, such as:
(i)
Teletypewriter/Telecommunication Device for the Deaf (TTY/TDD); and
(ii)
American Sign Language.
(2)
An MCO shall include taglines in the prevalent non-English languages identified by the State with its written materials critical to obtaining services that:
(a)
Explain the availability of written translation or oral interpretation to understand the information provided; and
(b)
Provide the toll-free and TTY/TDD telephone number of the MCO’s customer service unit.
C.
Written Materials. An MCO shall provide all its written materials in the following manner:
(1)
Using language and a format that is easily understood;
(2)
In a font size no smaller than 12 point;
(3)
Available in alternative formats and through the provision of auxiliary aids and services; and
(4)
Available in an appropriate manner that takes into consideration the special needs of enrollees or potential enrollees with disabilities or limited English proficiency.
D.
An MCO may provide enrollee information electronically so long as all of the following requirements are met:
(1)
The format is readily accessible;
(2)
The information is placed in a location on the MCO’s website that is prominent and readily accessible;
(3)
The information is provided in an electronic form which can be electronically retained and printed;
(4)
The information is consistent with the content and language requirements of this section;
(5)
The enrollee is informed that the information is available in paper form without charge upon request; and
(6)
Should the enrollee request it, the MCO provides the information in paper form within 5 business days.
Regulation .02 Access Standards: Enrollee Handbook and Provider Directory.LinkCopy Citation
A.
An MCO shall inform and educate its enrollees about:
(1)
Basic information about the MCO;
(2)
The availability of health care services and how to access them;
(3)
The definitions of managed care terminology in accordance with 42 CFR 438.10(c)(4)(i); and
(4)
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.
B.
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:
(1)
The enrollee's rights and responsibilities in the MCO as described in 42 CFR §438.100(b)(1), as amended;
(2)
Information on how to access urgent care and emergency care services, including:
(a)
What constitutes an emergency medical condition and emergency services;
(b)
The following facts:
(i)
Prior authorization is not required for these services; and
(ii)
The enrollee has a right to use any hospital or other setting for emergency care;
(3)
The services included in the MCO's benefits package, including optional benefits provided by the MCO;
(4)
How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided;
(5)
The amount, duration, and scope of benefits available in sufficient detail to ensure that enrollees understand the benefits to which they are entitled;
(6)
The availability of behavioral health services that are not included in the MCOs benefits package, and how to access these services;
(7)
Information on the availability of self-referral services as well as any restrictions on the enrollee's freedom of choice among network providers;
(8)
Information about how enrollees may obtain benefits from out-of-network providers;
(9)
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;
(10)
Information about the availability of EPSDT, prenatal care, family planning, and other wellness services, including education programs;
(11)
A statement that the MCO cannot require an enrollee to obtain a referral before choosing a family planning provider;
(12)
The process of selecting and changing the enrollee's primary care provider;
(13)
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;
(14)
Information on how to access auxiliary aids and services, including additional information in alternative formats or languages;
(15)
The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees, including:
(a)
A description of each unit and number;
(b)
An explanation of how the phone numbers can be used to obtain information and assistance; and
(c)
An explanation of the MCOs internal grievance procedure.
(16)
Information regarding the importance of scheduling and maintaining appointments for preventive services;
(17)
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;
(18)
The rule pertaining to poststabilization care services, as set forth in Regulation .08G of this chapter;
(19)
Appeal, grievance, and fair hearing procedures and time frames that include the following:
(a)
The right to a State fair hearing, including the method for obtaining a hearing and the rules that govern representation at the hearing;
(b)
The right to file appeals and grievances;
(c)
The requirements and time frames for filing an appeal or grievance;
(d)
The availability of assistance in the filing process;
(e)
The toll-free numbers that the enrollee may use to file an appeal or grievance by phone;
(f)
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
(g)
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;
(20)
Any appeal rights the State chooses to make available to providers;
(21)
Advanced directives as set forth in 42 CFR §438.3(j)(1), as amended;
(22)
Information on how to report suspected fraud or abuse;
(23)
Additional information that is available upon request, including the following:
(a)
Information on the structure and operation of the MCO; and
(b)
Physician incentive plans.
(24)
Information on how to access or obtain the MCOs provider directory.
C.
Provider Directory.
(1)
An MCO shall provide enrollees with information regarding their provider networks including:
(a)
Its primary care service locations;
(b)
A listing of the MCOs hospital providers, of both inpatient and outpatient services, in the enrollee's county, their addresses, and services provided;
(c)
A listing of the MCOs pharmacy providers in the enrollee's county and their addresses; and
(d)
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:
(i)
Name;
(ii)
Address;
(iii)
Practice location or locations;
(iv)
Telephone number or numbers;
(v)
Website URL, as appropriate;
(vi)
Any group affiliation, as appropriate;
(vii)
Cultural and linguistic capabilities, including languages offered by the provider or a skilled medical interpreter at the provider’s offices, American Sign Language interpretation;
(viii)
An indication of whether the provider's office or facility has accommodations for physical disabilities, including offices, exam room or rooms and equipment;
(ix)
An indication of whether or not the provider is accepting new patients;
(x)
An indication of the age range of patients accepted or whether there is no age limit; and
(xi)
If applicable, how access to the provider is otherwise limited.
(2)
Upon request by an enrollee, an MCO shall furnish a paper copy of the provider directory.
D.
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.
E.
The Department may consider the information listed in §§B and C of this regulation to be provided if the MCO:
(1)
Mails a printed copy of the information to the enrollee's mailing address;
(2)
Provides the information by email after obtaining the enrollee's agreement to receive the information by email;
(3)
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
(4)
Provides the information by any other method that can reasonably be expected to result in the enrollee receiving that information.
F.
An MCO shall update its online provider directory no later than 30 days after the MCO receives updated provider information.
G.
An MCO shall update its paper directory:
(1)
Monthly if the MCO does not have a mobile-enabled electronic directory; or
(2)
Quarterly if the MCO has a mobile-enabled electronic directory.
H.
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.
Regulation .03 Access Standards: Outreach.LinkCopy Citation
A.
An MCO is responsible for delivering needed health care services even when the enrollee is difficult to reach or misses appointments.
B.
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.
C.
Adults.
(1)
An MCO shall, before referring the enrollee to the local health department, make documented attempts to ensure that follow-up appointments are scheduled in accordance with the enrollee's treatment plan by attempting a variety of contact methods, which may include:
(a)
Written correspondence;
(b)
Telephone contact; and
(c)
Face-to-face contact.
(2)
If the enrollee, due to impaired cognitive ability or psychosocial problems such as homelessness or other conditions, can be expected to have difficulty understanding the importance of treatment instructions or difficulty navigating the health care system, the MCO shall, after exhausting its best efforts to contact and bring into care the enrollee in accordance with §C(1) of this regulation, make, or ensure that the enrollee's provider makes, a written referral to the local health department for its assistance within 10 business days of whichever first occurs:
(a)
The third consecutive missed appointment; or
(b)
The MCO or the enrollee's provider identifies the enrollee's repeated noncompliance with a regimen of care.
D.
Child Younger than 2 Years Old Needing EPSDT Screening Services.
(1)
An MCO shall ensure that appointments are scheduled in accordance with the EPSDT periodicity schedule or within 30 days of the MCO's receipt of the health risk assessment, whichever is less.
(2)
If the enrollee fails to keep the appointment, the MCO shall ensure that a second appointment is scheduled within 30 days.
(3)
If the enrollee misses the second appointment, a third appointment shall be scheduled within 30 days.
(4)
For each scheduled appointment, the MCO shall:
(a)
Provide written notice to the enrollee's parent, guardian, or caretaker of the appointment dates; and
(b)
Attempt to notify the enrollee's parent, guardian, or caretaker of the appointment dates by telephone.
(5)
If the enrollee misses the second appointment in a row, after the MCO has made the notification attempts required by §C(1) of this regulation, the MCO shall, within 10 business days, make, or ensure that the enrollee's provider makes, a written referral to the local health department for its assistance in bringing the enrollee into care.
(6)
After referral to the local health department, the MCO shall continue to work collaboratively with the local health department to bring the enrollee into care until the enrollee comes back into compliance with the EPSDT periodicity schedule.
E.
Child Younger than 21 Years Old Needing Follow-up Treatment.
(1)
An MCO shall ensure that an appointment for follow-up care is scheduled at a time interval appropriate to the enrollee's diagnosed condition.
(2)
If the enrollee fails to keep the appointment, the MCO shall reschedule the appointment for the enrollee to be seen within 30 days.
(3)
For each scheduled appointment, the MCO shall:
(a)
Provide written notice to the enrollee, or to the enrollee's parent, guardian, or caretaker, as appropriate, of the appointment dates by mail; and
(b)
Attempt to notify the enrollee, or the enrollee's parent, guardian, or caretaker, as appropriate, of the appointment dates by telephone.
(4)
If the enrollee misses the second consecutive follow-up appointment after the MCO has made the notification attempts required by §C(1) of this regulation, the MCO shall, within 10 business days, make, or ensure that the enrollee's provider makes, a written referral to the local health department for its assistance in bringing the enrollee into care.
(5)
After referral to the local health department, the MCO shall work collaboratively with the local health department to bring the enrollee into care.
F.
Pregnant or Postpartum Woman Needing Prenatal or Postpartum Care.
(1)
Initial Visit. An MCO shall schedule an initial visit for the pregnant or postpartum enrollee to be seen within 10 days of her request for an appointment. If she fails to appear for the appointment, the MCO shall reschedule in a timely manner appropriate to her medical condition.
(2)
Follow-Up Appointments. After the enrollee has completed an initial visit that includes a comprehensive history, physical exam, and completion of the Maryland Prenatal Risk Assessment, the MCO shall ensure that appointments are scheduled for the enrollee in compliance with the periodicity schedule of the ACOG guidelines. If the enrollee fails to appear for a scheduled appointment, the MCO shall ensure that the appointment is rescheduled for the enrollee to be seen within 10 days.
(3)
For each scheduled appointment, the MCO shall:
(a)
Provide written notice to the enrollee of the appointment dates; and
(b)
Attempt to notify the enrollee of the appointment dates by telephone.
(4)
After making the attempts specified in §F(3) of this regulation, if the MCO is unable to bring the enrollee into care within 30 days of the first missed appointment, the MCO shall, within 10 days of the last missed appointment, make, or ensure that the enrollee's provider makes, a written referral to the local health department for its assistance in bringing the enrollee into care.
(5)
After referral to the local health department, the MCO shall work collaboratively with the local health department to bring the patient into care, until the enrollee comes back in compliance with the ACOG periodicity schedule.
Regulation .04 Access Standards: Information for Providers.LinkCopy Citation
A.
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:
(1)
Before distribution, file a copy of its manual with the Department for review;
(2)
Include in its manual the information necessary to facilitate the providers’ full compliance with federal and State Medicaid requirements, including information on:
(a)
Medicaid statutes and regulations;
(b)
The benefits package, including optional benefits;
(c)
Access requirements, which, at a minimum, comply with the requirements of this chapter;
(d)
Quality requirements, which shall, at a minimum, comply with the requirements of COMAR 10.67.04.03;
(e)
Continuity of care requirements;
(f)
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
(g)
The MCO’s practice guidelines as described in 42 CFR §438.236.
(3)
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:
(a)
Preventive health services;
(b)
Primary acute medical care;
(c)
Chronic medical care;
(d)
Consultation, referral, and follow-up in areas including medical specialties and child dental care;
(e)
Referral for ancillary and support-related services including but not limited to:
(i)
Drug therapies;
(ii)
Diagnostic tests;
(iii)
Medical supplies;
(iv)
Durable medical equipment; and
(v)
Case management when appropriate for complex conditions;
(f)
24-hour per day, 7-day per week provider coverage for medically necessary services;
(g)
Maintenance of a medical record, including records of referral arrangements and outcomes of those referrals; and
(h)
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
(4)
Inform the providers of the following enrollee appeal, grievance, and fair hearing procedures and time frames:
(a)
The enrollee's right to a State fair hearing, how to obtain a hearing, and representation rules at a hearing;
(b)
The enrollee's right to file appeals and grievances, and the enrollee's requirements and time frames for filing;
(c)
The availability of assistance in filing;
(d)
The toll-free numbers to file verbal appeals and grievances;
(e)
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
(f)
The provider's right to appeal, on the enrollee's behalf, the failure of the MCO to cover a service.
B.
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:
(1)
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
(2)
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.
C.
An MCO shall provide to each PCP an updated list of the PCP’s assigned enrollees monthly.
Regulation .05 Access Standards: PCPs and MCO's Provider Network.LinkCopy Citation
A.
Primary Care Provider (PCP).
(1)
An MCO shall assign each enrollee to a primary care provider who is:
(a)
Chosen by the enrollee from the MCO's panel of qualified providers; or
(b)
Chosen by the MCO from its panel of qualified providers if the enrollee has failed to choose a PCP.
(2)
An enrollee may request a change of PCP at any time if the PCP is within the recipient's current MCO's panel of providers.
(3)
With respect to enrollees younger than 21 years old, an MCO shall assign the enrollee to a PCP who is certified by the EPSDT program, unless the enrollee or the enrollee's parent, guardian, or caretaker, as appropriate, specifically requests assignment to a PCP who is not EPSDT-certified.
(4)
If the enrollee’s parent, guardian, or caretaker, as appropriate, chooses a non-EPSDT certified PCP in accordance to §A(3) of this regulation, within 30 days of enrollment, the MCO shall:
(a)
Notify the parent, guardian, or caretaker, by letter, that a non-EPSDT certified PCP has been chosen; and
(b)
Include in the notification an explanation of the:
(i)
EPSDT preventive screening services to which an enrollee is entitled according to the EPSDT periodicity schedule;
(ii)
Importance of accessing the EPSDT preventive screening services; and
(iii)
Process for requesting a change to an EPSDT-certified PCP to obtain preventive screening services.
(5)
An MCO may include, as appropriate, any of the following practitioners to serve as the primary care provider for an enrollee:
(a)
General practitioner;
(b)
Family practitioner;
(c)
Internist;
(d)
Pediatrician;
(e)
OB/GYN;
(f)
Physician assistant;
(g)
Certified nurse midwife;
(h)
Nurse practitioner certified in any of the following areas of specialization:
(i)
Adult;
(ii)
Pediatric;
(iii)
Geriatric;
(iv)
OB/GYN;
(v)
School nurse; or
(vi)
Family; and
(i)
A physician practicing in a specialty area other than those enumerated in §A(5)(b)—(e) of this regulation.
(6)
The enrollee's designated primary care provider (PCP) is the enrollee's primary coordinator of care.
(7)
For female enrollees, if the enrollee's PCP is not a women's health specialist, the MCO shall provide direct access, without the need for a referral, to a women's health specialist within the MCO's network for covered services necessary to provide women's routine and preventive health care services.
B.
Adequacy of Provider Network.
(1)
An MCO shall develop and maintain a complete network of adult and pediatric primary care, specialty care, ancillary service, vision, pharmacy, home health, and any other providers adequate to deliver the full scope of benefits as required by this chapter and COMAR 10.67.06.
(2)
An MCO shall clearly define and specify referral requirements to specialty and other providers.
(3)
An MCO shall require the PCP to maintain records of referral arrangements, and the feedback and outcomes of those referrals, within each enrollee's medical records.
(4)
An MCO shall maintain a list of its proposed and existing subcontracts with health care providers who are necessary to fulfill the MCO's service delivery obligations.
(5)
An MCO shall provide a list of its subcontractor providers to the Department.
(6)
An MCO shall ensure services are delivered in a culturally competent manner to all enrollees, including enrollees:
(a)
With limited English proficiency;
(b)
With diverse cultural and ethnic backgrounds; and
(c)
Of all genders, sexual orientations, and gender identities.
(7)
For enrollees with physical or mental disabilities, an MCO shall ensure its network providers provide:
(a)
Physical access;
(b)
Reasonable accommodation; and
(c)
Accessible equipment.
(8)
Capacity.
(a)
MCOs shall ensure adequate capacity and services, in compliance with 42 CFR §438.206(b)(1)(i), as amended.
(b)
The Department shall assess the MCO's provider network and determine its capacity to serve waiver-eligible recipients in each local access area in its service area.
(c)
Unless the MCO can establish to the Department's satisfaction the adequacy of a higher ratio, the Department shall determine the MCO's capacity with respect to any local access area by assuming that in-plan individual practitioners, based on full-time equivalency, will be assigned no more than the number of enrollees that is consistent with a 200:1 ratio of enrollee to practitioner in the local access area.
(d)
The Department may not approve an enrollee-to-PCP ratio that is higher than 2,000:1.
(9)
To ensure compliance with the timely access requirements in Regulation .07 of this chapter, an MCO shall:
(a)
Establish mechanisms to ensure that network providers comply with access requirements;
(b)
Monitor regularly to determine compliance; and
(c)
Take corrective action if there is a failure to comply.
Regulation .05-1 Access Standards: Specialty Provider Network.LinkCopy Citation
A.
Standards and Regions.
(1)
The Department shall review an MCOs specialty provider network for MCOs overall network as defined in this regulation.
(2)
Overall Network Standards.
(a)
An MCO shall meet either the time or distance standard set forth in Regulation .06A of this chapter for core, major, and pediatric specialties.
(b)
The nine core specialties are:
(i)
Cardiology;
(ii)
Otolaryngology (ENT);
(iii)
Gastroenterology;
(iv)
Neurology;
(v)
Oncology;
(vi)
Ophthalmology;
(vii)
Orthopedics;
(viii)
Surgery; and
(ix)
Urology.
(c)
The 6 major specialties are:
(i)
Allergy and immunology;
(ii)
Dermatology;
(iii)
Endocrinology;
(iv)
Infectious disease;
(v)
Nephrology; and
(vi)
Pulmonology.
(d)
The 4 pediatric subspecialties are:
(i)
Cardiology;
(ii)
Gastroenterology;
(iii)
Neurology; and
(iv)
Surgery.
B.
If the Department determines that an MCO does not meet the requirements specified in §A(2)(b)(d) of this regulation, the MCO may provide additional information to support the adequacy of the MCO's specialty network before any action is taken by the Department.
C.
If an MCO fails to meet the requirements established by this regulation, the Department may suspend the automatic assignment to the MCO of recipients who live in the affected local access area.
Regulation .06 Geographical Access.LinkCopy Citation
A.
Except as provided in §C of this regulation, an MCO shall develop and maintain a provider network that meets the following time and distance standards:
(1)
For adult and pediatric primary care, pharmacy, diagnostic laboratory and x-ray, and gynecology:
(a)
In urban areas, within 15 minutes or 10 miles;
(b)
In suburban areas, within 30 minutes or 20 miles; and
(c)
In rural areas, within 40 minutes or 30 miles;
(2)
For prenatal care, as defined in §B of this regulation:
(a)
In urban areas, within 15 minutes or 10 miles;
(b)
In suburban areas, within 30 minutes or 20 miles; and
(c)
In rural areas, within 90 minutes or 75 miles;
(3)
For acute inpatient hospitals:
(a)
In urban areas, within 20 minutes or 10 miles;
(b)
In suburban areas, within 45 minutes or 30 miles; and
(c)
In rural areas, within 75 minutes or 60 miles;
(4)
For core specialty types, as defined in Regulation .05-1A(2)(b) of this chapter:
(a)
In urban areas, within 30 minutes or 15 miles;
(b)
In suburban areas, within 60 minutes or 45 miles; and
(c)
In rural areas, within 90 minutes or 75 miles;
(5)
For major specialty types, as defined in Regulation .05-1A(2)(c) of this chapter:
(a)
In urban areas, within 30 minutes or 15 miles;
(b)
In suburban areas, within 80 minutes or 60 miles; and
(c)
In rural areas, within 110 minutes or 90 miles; and
(6)
For pediatric subspecialty types, as defined in Regulation .05-1A(2)(d) of this chapter:
(a)
In urban areas, within 30 minutes or 15 miles;
(b)
In suburban areas, within 80 minutes or 60 miles; and
(c)
In rural areas, within 250 minutes or 200 miles.
B.
Prenatal Care Providers. For the purposes of provider network adequacy, prenatal care providers may include, but are not limited to:
(1)
Obstetricians;
(2)
Certified nurse midwives; and
(3)
Family practitioners who provide prenatal care and perform deliveries.
C.
If an MCO can otherwise demonstrate to the Department's satisfaction the adequacy of its provider network notwithstanding its inability to meet the requirements of §A of this regulation, the Department may, in its discretion, approve the network if special circumstances exist which, considered along with the overall strength of the MCO's network, establish that the Department's approval of the network will enhance recipients' overall access to quality health care services in the area to be served.
D.
Geographical Access: Local Access Areas.
E.
For purposes of this regulation:
(1)
Urban enrollment area includes Baltimore City;
(2)
Rural enrollment counties include:
(a)
Allegany;
(b)
Calvert;
(c)
Caroline;
(d)
Cecil;
(e)
Charles;
(f)
Dorchester;
(g)
Frederick;
(h)
Garrett;
(i)
Kent;
(j)
Queen Anne's;
(k)
Saint Mary's;
(l)
Somerset;
(m)
Talbot;
(n)
Washington;
(o)
Wicomico; and
(p)
Worcester; and
(3)
Suburban enrollment counties include:
(a)
Baltimore County;
(b)
Anne Arundel;
(c)
Carroll;
(d)
Harford;
(e)
Howard;
(f)
Montgomery; and
(g)
Prince George’s.
Regulation .07 Access Standards: Clinical and Pharmacy Access.LinkCopy Citation
A.
Appointments.
(1)
New Enrollees: Initial Appointment.
(a)
On its receipt and review of the health service needs information of a new enrollee, an MCO shall take appropriate action to ensure that the new enrollee who needs special or immediate health care services, as identified by the health service needs information, receives them in a timely manner.
(b)
Unless the new enrollee is assigned to a PCP who was the enrollee’s established provider of care immediately before the enrollee’s enrollment, and, consistent with any applicable periodicity schedule, the PCP concludes that no immediate initial appointment is necessary:
(i)
Unless a shorter time frame otherwise applies, the MCO shall ensure that a new enrollee's initial appointment is scheduled to occur within 90 days of the date of enrollment;
(ii)
Unless the PCP confirms that the enrollee has elected to continue prenatal care with her established provider pursuant to COMAR 10.67.06.28C, the MCO shall ensure that an initial prenatal appointment is scheduled to occur within 10 days of the date that the MCO receives the enrollee's completed health risk assessment, or within 10 days of the enrollee's request for an appointment, whichever is sooner;
(iii)
If the new enrollee is a person requesting family planning services, the MCO shall ensure that an initial appointment is scheduled to occur within 10 days of the date of the enrollee's request for an appointment; or
(iv)
If the new enrollee is identified to be at high risk by the health service needs information form, the MCO shall ensure that an initial appointment is scheduled to occur within 15 business days of the MCO’s receipt of the enrollee’s completed health risk assessment.
(2)
Required Notice to Enrollees of Wellness Services.
(a)
An MCO shall notify its enrollees in writing of their due dates for obtaining wellness services, including but not limited to immunizations and examinations, in a timely manner.
(b)
An MCO shall perform the notice required in §A(2)(a) of this regulation within 90 days of a new enrollee's enrollment.
(3)
Appointment Guidelines.
(a)
An MCO shall develop specific guidelines that define how requests for appointments are arranged, which shall include a policy that:
(i)
On request, all family members needing appointments will be given appointment times that are approximately concurrent or consecutive, whenever practicable, to facilitate the enrollees' transportation to and from their appointments; and
(ii)
When needed, enrollees will be afforded assistance in securing transportation to and from appointments, which shall include, when appropriate, contacting the local transportation grantee agency on behalf of the enrollee for the purpose of securing the enrollee's access to these services.
(b)
An MCO shall have procedures that result in an interval between the enrollee's request for an appointment and the actual appointment time being consistent with the following standards:
(i)
When §A(3)(b)(i) of this regulation does not apply, well-child assessments shall be scheduled to be completed within 30 days of the request for an appointment;
(ii)
Initial assessments of pregnant and postpartum women and individuals requesting family planning services shall be scheduled to be completed within 10 business days of the request for an appointment;
(iii)
Individuals requesting urgent care shall be scheduled to be seen within 48 hours of the request;
(iv)
Requests for routine and preventative primary care appointments shall be scheduled to be performed within 30 days of the request;
(v)
Requests for routine specialist follow-up appointments shall be scheduled to be performed within 30 days of the initial authorization from the enrollee's primary care provider, or sooner as deemed necessary by the primary care provider, whose office staff shall make the appointment directly with the specialist's office;
(vi)
At the discretion of the newborn's PCP, the initial visit for newborns shall be scheduled to be performed within 14 days of discharge from the hospital if no home visit has occurred;
(vii)
If a home visit has been provided, the initial visit for newborns shall be scheduled to be performed, at the discretion of the newborn's PCP, within 30 days of discharge from the hospital; and
(viii)
Requests for regular optometry, lab, and X-ray appointments shall be scheduled to be performed within 30 days of the request, and within 48 hours of the request for urgent care.
B.
An MCO shall respond in a timely manner to its enrollees' needs and requests, as follows:
(1)
If the enrollee arrives early or on time for a scheduled appointment, waiting time to be seen for a regular office visit may not exceed 1 hour after the scheduled appointment time;
(2)
An MCO representative may not leave an enrollee's telephone call on hold for more than 10 minutes; and
(3)
An MCO representative shall respond to patient inquiries as to whether or not to use emergency facilities within 30 minutes.
C.
Hours of Access for Clinical Services.
(1)
An MCO shall establish, or require its subcontractors to establish, a reasonable schedule of operating hours during which its service delivery sites are open to the MCO's enrollees as follows:
(a)
For the MCO's employee and subcontractor providers who are individual practitioners, operating hours shall be at least 20 hours per week and at least 3 days per week;
(b)
For subcontractors who have contracted with the MCO as a group practice or facility, the operating hours shall be at least 35 hours per week;
(c)
The distribution of the hours of service shall be consistent with enrollee utilization patterns, but is otherwise at the discretion of the MCO or its subcontractor; and
(d)
The operating hours may not be less than:
(i)
The hours of operation offered to commercial enrollees; or
(ii)
The hours of operation offered to Medicaid fee-for-service, if the provider serves only Medicaid enrollees.
(2)
Hours of Access for Pharmacy Services.
(a)
An MCO shall establish reasonable hours of access to pharmacy services, including weekend and evening hours, which are equivalent to the hours pharmacy services are generally available in the local access area to the public at large.
(b)
If the MCO determines that weekend and evening pharmacy hours are not generally available in the local access area, it may request approval from the Department to offer only limited pharmacy hours as specified in §C(2)(c) of this regulation.
(c)
To seek approval to offer limited pharmacy hours, an MCO shall make its request for approval to the Department, and shall include the following:
(i)
A specification of the geographical areas where the MCO intends to have limited pharmacy hours;
(ii)
An explanation of why only limited pharmacy hours are available in these areas; and
(iii)
An identification of where its enrollees would have to go to secure prescriptions in the evenings and on weekends.
(d)
Except as permitted in §C(2)(e) of this regulation, an MCO shall ensure that an enrollee receives at the time the prescription is dispensed to the enrollee any medically necessary disposable medical supplies or durable medical equipment needed by the enrollee to administer or monitor the enrollee's prescriptions.
(e)
An MCO shall ensure that any disposable supplies or durable medical equipment necessary to administer or monitor an enrollee's prescriptions, if not available at the pharmacy at the time of the dispensing of the prescription, is received in a manner so as not to adversely affect the health of the enrollee, but not later than 24 hours.
D.
Clinical Access Outside the MCO's Service Area.
(1)
Subject to §D(2) of this regulation, an MCO shall be financially responsible for medically necessary emergency services delivered to its enrollees outside of the MCO's service area.
(2)
With the exception of emergency services, an MCO may require authorization before treatment for services delivered to its enrollees outside of the MCO's service area.
(3)
If the MCO’s provider network is unable to provide necessary services, covered under the contract, to an enrollee, the MCO shall adequately and timely cover these services out of network for as long as the MCO’s provider network is unable to provide them.
E.
The Department may not impose any fines or other sanctions against an MCO for failure to comply with the waiting time standards in §B of this regulation unless there is evidence of a pattern of repeated violations by the MCO.
Regulation .08 Emergency Services Access.LinkCopy Citation
A.
An MCO shall develop and maintain policies and procedures for the adequate provision of emergency services for all its enrollees, including:
(1)
Instituting and monitoring a system for responding to enrollees' emergency medical conditions, with provisions for immediate attention to and appropriate disposition of emergency calls; and
(2)
Informing and educating its enrollees in the procedures to be followed in the event of an emergency, whether within or outside of the MCO's service area.
B.
An MCO shall provide medically necessary emergency services 24 hours per day, 7 days per week.
C.
An MCO shall maintain an emergency telephone service, with a physician on call, for the purpose of rendering medical advice and authorizing care at other facilities when use of the MCO's own facilities is impractical.
D.
An MCO may provide emergency services access through adequate and appropriate triage assessments performed by qualified medical professionals.
E.
An MCO shall utilize the trauma triage and transfer protocols established through the Maryland Institute for Emergency Medical Services Systems (MIEMSS) as the basis for directing the severely injured enrollee to the most appropriate level designated trauma center.
F.
An MCO shall reimburse, within 30 days of invoice, the undisputed claims of hospital emergency facilities and providers for the following services provided to the MCO's enrollees:
(1)
Emergency services, as defined in COMAR 10.67.01.01B;
(2)
Medical screening services based on the federal Emergency Medical Treatment and Active Labor Act (EMTALA);
(3)
If the MCO authorized, referred, or otherwise instructed the enrollee to use the emergency facility, medically necessary services that are related to the emergency condition, including poststabilization services; and
(4)
If the MCO fails to provide 24 hour access to a physician, medically necessary services that relate to the condition presented and that are provided by the provider in an emergency facility to the enrollee.
G.
Poststabilization Services. The MCO may not require preapproval of, and is financially responsible for, poststabilization services obtained in or outside of the MCO's network and administered to maintain, improve, or resolve the enrollee's stabilized condition if:
(1)
The MCO does not respond to a request for a preapproval within 1 hour;
(2)
The MCO cannot be contacted; or
(3)
The MCO representative and the treating physician cannot reach an agreement concerning the enrollee's care, and an MCO physician is not available for consultation, in which case:
(a)
The MCO shall give the treating physician the opportunity to consult with an MCO physician; and
(b)
The treating physician may continue care of the patient until a plan is reached or one of the following criteria is met:
(i)
An MCO physician with privileges at the treating hospital assumes responsibility for the enrollee's care;
(ii)
An MCO physician assumes responsibility for the enrollee's care through transfer;
(iii)
An MCO representative and the treating physician reach an agreement concerning the enrollee's care; or
(iv)
The enrollee is discharged.
H.
An MCO may require that any continuing care be obtained from the MCO's providers or from providers approved by the MCO when the following conditions are satisfied:
(1)
The enrollee's medical condition is appropriately stabilized and permits transferring responsibility for the enrollee's care, without medically harmful consequences, to these providers; and
(2)
The transfer is consistent with the requirements of the federal Emergency Medical Treatment and Active Labor Act (EMTALA).
Regulation .09 Access: Hospitals.LinkCopy Citation
A.
An MCO shall comply with the access standards specified in Regulation .06A of this chapter.
B.
If an MCO’s service area includes a county that is designated as a medically underserved area and there is only one hospital in the county, the MCO shall include the hospital in its network.
Chapter annotations
Authority: Health-General Article, §§2-104, 15-102.1(b)(10), 15-102.3 and 15-103; Insurance Article §§15-112, 15-605, and 15-1008; Annotated Code of Maryland
History: Effective date:
History: Regulations .01—.08 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)
History: Regulation .01 amended effective February 26, 2018 (45:4 Md. R. 205)
History: Regulation .01A 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); November 7, 2016 (43:22 Md. R. 1221)
History: Regulation .01B amended effective June 30, 2008 (35:13 Md. R. 1180)
History: Regulation .02 amended effective February 18, 2002 (29:3 Md. R. 220); June 30, 2008 (35:13 Md. R. 1180); February 16, 2015 (42:3 Md. R. 316); February 26, 2018 (45:4 Md. R. 205)
History: Regulation .02B, C amended effective August 29, 2016 (43:17 Md. R. 955)
History: Regulations .03 and .04 amended as an emergency provision effective July 1, 1997 (24:16 Md. R. 1151); emergency status expired December 31, 1997
History: Regulation .03 amended effective February 9, 1998 (25:3 Md. R. 144); February 2, 2004 (31:2 Md. R. 82)
History: Regulation .03D 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)
History: Regulation .04 amended effective February 9, 1998 (25:3 Md. R. 144)
History: Regulation .04A amended effective November 6, 2006 (33:22 Md. R. 1732)
History: Regulation .04A 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)
History: Regulation .04A amended effective April 19, 2010 (37:8 Md. R. 615); February 16, 2015 (42:3 Md. R. 316)
History: Regulation .04A, B amended effective June 30, 2008 (35:13 Md. R. 1180)
History: Regulation .04A, C amended effective December 31, 2018 (45:26 Md. R. 1244)
History: Regulation .04C amended effective December 24, 2012 (39:25 Md. R. 1613)
History: Regulation .05 amended effective April 10, 2006 (33:7 Md. R. 668); June 30, 2008 (35:13 Md. R. 1180)
History: Regulation .05A amended effective June 25, 2001 (28:12 Md. R. 1109)
History: Regulation .05A 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)
History: Regulation .05A amended effective February 16, 2015 (42:3 Md. R. 316); February 1, 2016 (42:23 Md. R. 1434)
History: Regulation .05B amended effective April 19, 2010 (37:8 Md. R. 615); February 6, 2012 (39:2 Md. R. 141) August 29, 2016 (43:17 Md. R. 955); December 31, 2018 (45:26 Md. R. 1244)
History: Regulation .05-1 adopted effective February 2, 2004 (31:2 Md. R. 82)
History: Regulation .05-1 amended effective December 31, 2018 (45:26 Md. R. 1244)
History: Regulation .06 amended effective April 28, 2014 (41:8 Md. R. 471); December 31, 2018 (45:26 Md. R. 1244)
History: Regulation .06A amended effective April 19, 2010 (37:8 Md. R. 615)
History: Regulation .06B amended effective February 6, 2012 (39:2 Md. R. 141)
History: Regulation .06E 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)
History: Regulation .06E amended effective April 9, 2007 (34:7 Md. R. 698); November 5, 2007 (34:22 Md. R. 1977)
History: Regulation .07A amended effective February 2, 2004 (31:2 Md. R. 82); April 19, 2010 (37:8 Md. R. 615); February 6, 2012 (39:2 Md. R. 141); October 28, 2013 (40:21 Md. R. 1775); February 16, 2015 (42:3 Md. R. 316)
History: Regulation .07A, D amended effective December 31, 2018 (45:26 Md. R. 1244)
History: Regulation .07B, C 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)
History: Regulation .07B, D amended effective November 6, 2006 (33:22 Md. R. 1732)
History: Regulation .07B, C amended effective June 30, 2008 (35:13 Md. R. 1180)
History: Regulation .08 amended effective June 30, 2008 (35:13 Md. R. 1180)
History: Regulation .08B, F amended effective November 6, 2006 (33:22 Md. R. 1732)
History: Regulation .09 adopted effective March 14, 2016 (43:5 Md. R. 385)
History: Regulation .09 amended effective December 31, 2018 (45:26 Md. R. 1244)
History: Chapter transferred from COMAR 10.09.66 effective November 1, 2019 (46:22 Md. R. 977)
History: Regulation .01B amended effective June 13, 2022 (49:12 Md. R. 641)
History: Regulation .02C amended effective June 24, 2024 (51:12 Md. R. 620)
History: Regulation .02G amended effective June 13, 2022 (49:12 Md. R. 641)
History: Regulation .04A amended effective June 13, 2022 (49:12 Md. R. 641)
History: Regulation .05-1A amended effective April 28, 2025 (52:8 Md. R. 359)
History: Regulation .05-1C amended effective October 18, 2021 (48:21 Md. R. 889); April 28, 2025 (52:8 Md. R. 359)