<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".28" citation="COMAR 10.67.06.28" title_num="10" subtitle_num="67" chapter_num="06" heading="Benefits — Self-Referral Services.">
  <paragraph num="A.">
    <text>An MCO shall be financially responsible for reimbursing, in accordance with COMAR 10.67.04.20, an out-of-plan provider chosen by the participant for the following services:</text>
    <paragraph num="(1)">
      <text>Family planning services specified in COMAR 10.67.04.20A(2), (6), and (7);</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Services performed by school-based health centers (SBHCs), as provided in COMAR 10.09.76;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Pregnancy-related services for women who are pregnant and, at the time of initial enrollment, have received prenatal care during their current pregnancy from an out-of-plan provider, and this pre-enrollment care consists of at least the following:</text>
      <paragraph num="(a)">
        <text>A full prenatal examination;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A risk assessment; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Appropriate laboratory services;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Initial medical examination for children in State custody when performed by an EPSDT certified provider;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>One annual diagnostic and evaluation service (DES) visit for any enrollee diagnosed with HIV/AIDS, which the MCO is responsible for facilitating on the enrollee's behalf;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Renal dialysis services performed in a Medicare-certified facility;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Initial medical examination of a newborn when the:</text>
      <paragraph num="(a)">
        <text>Examination is performed in a hospital by an on-call physician; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>MCO failed to provide for the service before the newborn's discharge from the hospital;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(8)">
      <text>Emergency services as described in COMAR 10.67.05.08B;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Prenatal, intrapartum, and postpartum services performed at a free-standing birth center located in Maryland or a contiguous state; and</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Doula services, through December 31, 2025.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>An MCO shall pay undisputed claims of the SBHC for services provided to its participants within 30 days of the MCO's receipt of the invoice.</text>
  </paragraph>
  <paragraph num="C.">
    <text>An MCO shall provide SBHCs in its service area with the current information needed to facilitate communication between the SBHC, PCP, and the MCO regarding care provided to the MCO's participant, and to effect reimbursement by the MCO, including:</text>
    <paragraph num="(1)">
      <text>Information concerning the MCO's policies and procedures regarding the provision of pharmacy and laboratory services;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Instructions for submitting claims; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Contact information, including names and phone numbers of the following individuals:</text>
      <paragraph num="(a)">
        <text>The MCO representative who serves as an SBHC's contact person for coordination of care; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The student-participant's PCP.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>