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<regulation prefix="Regulation" num=".01" citation="COMAR 10.67.06.01" title_num="10" subtitle_num="67" chapter_num="06" heading="Required Benefits Package — In General.">
  <paragraph num="A.">
    <text>Except for non-covered services set forth in Regulation .27 of this chapter and the non-capitated services described in COMAR 10.67.08, an MCO shall provide its enrollees with a benefits package that includes the covered services specified in this chapter when these services are deemed to be medically necessary including services covered under the Maryland Medicaid State Plan in the amount, duration, and scope set forth in the State Plan and in accordance with 42 CFR §440.230.</text>
  </paragraph>
  <paragraph num="B.">
    <text>An MCO shall ensure that the services provided are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished.</text>
  </paragraph>
  <paragraph num="C.">
    <text>An MCO is not required to provide non-covered services even when the service is medically necessary.</text>
  </paragraph>
  <paragraph num="D.">
    <text>Any limitations set forth in this chapter on covered services are not applicable to services required by enrollees who are younger than 21 years old when it is shown that the services are medically necessary to correct or lessen health problems detected or suspected by EPSDT screening services, as described in Regulation .20 of this chapter.</text>
  </paragraph>
  <paragraph num="E.">
    <text>An MCO may place appropriate limits on a service on the basis of criteria applied under the State plan, such as medical necessity.</text>
  </paragraph>
  <paragraph num="F.">
    <text>Cost Sharing and Prohibitions.</text>
    <paragraph num="(1)">
      <text>Except for the following, an MCO may not charge its enrollees any copayments, premiums, or cost sharing:</text>
      <paragraph num="(a)">
        <text>Up to a $3 copayment for brand-name drugs;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Up to a $1 copayment for generic drugs;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Any other charge up to fee-for-service limits as approved by the Department.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>An MCO may not:</text>
      <paragraph num="(a)">
        <text>Deny services to an individual who is eligible for services because of the individual's inability to pay the cost sharing;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Impose copayments for the following:</text>
        <paragraph num="(i)">
          <text>Family planning services and supplies;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Individuals younger than 21 years old;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Pregnant women;</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>Institutionalized individuals who are inpatients in long-term care facilities or other institutions; and</text>
        </paragraph>
        <paragraph num="(v)">
          <text>Emergency services.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(c)">
        <text>Arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the enrollee.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>An MCO shall ensure that all health care services provided under this chapter are performed, to the extent required by law, by an appropriate health care provider who is licensed, certified, or otherwise legally authorized to practice or deliver the services in the state in which the service is provided.</text>
  </paragraph>
  <paragraph num="H.">
    <text>An MCO shall provide for a second opinion from a qualified health care professional within the network, or, if necessary, arrange for the enrollee to obtain one outside the MCO network.</text>
  </paragraph>
</regulation>