Sec. 10.09.90.09. Conditions for Provider Participation — Eligibility

A. General Requirements. To be eligible to be approved as a care coordination organization, an entity shall meet all of the:

(1) Conditions for participation as set forth in COMAR 10.09.36.03; and

(2) Medical Assistance provisions listed in COMAR designated for their provider type.

B. Specific Requirements. A CCO:

(1) May not place restrictions on the qualified recipient’s right to elect to or decline to:

(a) Receive care coordination as authorized by the Department; and

(b) Choose a care coordinator, as approved by the Department, and other care providers;

(2) Shall employ appropriately qualified individuals as care coordinators, and care coordinator supervisors with relevant work experience, including experience with the populations of focus, including but not limited to:

(a) Youth younger than 18 years old with a serious emotional disturbance or co-occurring disorder; and

(b) Young adults with a serious emotional disturbance or co-occurring disorder;

(3) Shall assign care coordinators to the participant and family;

(4) Shall schedule a face-to-face meeting with the participant and family within 72 hours of notification of the participant’s enrollment in Care Coordination services;

(5) Shall convene the first CFT meeting within 30 calendar days of notification of enrollment to begin developing the POC;

(6) Shall collect information gathered during the application process including results from the physical examination, psychosocial and psychiatric screening, assessments, evaluations, and information from the CFT, participant, and family, and the identified supports to be incorporated as a part of POC development process;

(7) For 1915(i) participants:

(a) Shall arrange for the participant and family to meet with peer support partners within 30 calendar days of notification of enrollment to allow the participant and family the opportunity to determine the role of peer support in the development and implementation of the POC; and

(b) Shall arrange for the participant and family to meet with the intensive in-home service (IIHS) to develop the initial crisis plan within 1 week of enrollment in the 1915(i);

(8) Shall assure that:

(a) A participant’s initial assessment is completed within 10 calendar days after the participant has been authorized by Department and determined eligible for, and has elected to receive, care coordination services; and

(b) An initial POC is completed within 15 calendar days after completion of the initial assessment;

(9) Shall maintain an electronic health record for each participant which includes all of the following:

(a) An initial referral and intake form with identifying information, including, but not limited to, the individual’s name and Medicaid identification number;

(b) A written agreement for services signed by the participant or the participant’s legally authorized representative and by the participant’s care coordinator;

(c) An assessment as specified in Regulation .07of this chapter; and

(d) A POC as specified in Regulation .07D-E of this chapter;

(10) Shall have formal written policies and procedures, approved by the Department, or the Department’s designee, which specifically address the provision of care coordination to participants in accordance with the requirements of this chapter;

(11) Shall be available to participants and, as appropriate, their families or, if the participant is a minor, the minor’s parent or guardian, for 24 hours a day, 7 calendar days a week, in order to refer:

(a) Participants to needed services and supports; and

(b) In the case of a behavioral health emergency, participants to behavioral health treatment and evaluation services in order to divert the participant’s admission to a higher level of care;

(12) Shall document in the participant’s care coordination records if the participant declines care coordination services or if a service is terminated because it was not working;

(13) May not provide other services to participants unless the Department approves how conflict of interest standards would be safely addressed.

(14) Shall be knowledgeable of the eligibility requirements and application procedures of federal, State, and local government assistance programs that are applicable to participants;

(15) Shall maintain information on current resources for behavioral health, medical, social, financial assistance, vocational, educational, housing, and other support services including informal community resources;

(16) Shall safeguard the confidentiality of the participant’s records in accordance with State and federal laws and regulations governing confidentiality;

(17) Shall comply with the Department’s fiscal and program reporting requirements and submit reports to the Department in the manner specified by the Department;

(18) Shall provide services in a manner consistent with the best interest of recipients and may not restrict an individual’s access to other services;

(19) Shall assure the amount, duration, and scope of the care coordination activities are documented in a participant’s POC, which includes care coordination activities before discharge and after discharge when transitioning from an institution, to facilitate a successful transition into the community; and

(20) Shall commit to coordinating with all agencies involved in the participant’s POC.