Sec. 10.67.04.05. Special Needs Populations — Children with Special Health Care Needs

A. An MCO shall meet the standards set forth in this regulation for treating children with special health care needs.

B. The Department shall maintain a record of the complaints received through the Department's enrollee and provider hotlines which involve the denial of care for children and review these complaint logs as part of its quality assurance system.

C. An MCO shall demonstrate that its therapies provider network is adequate by demonstrating its:

(1) Providers' pediatric specialties;

(2) Collaboration with schools that provide IEP or IFSP services to its enrollees, where available; and

(3) Provision of family-focused services and development of family-focused plans of care.

D. An MCO shall provide case management services to children with special health care needs as appropriate. For complex cases involving multiple medical interventions or social services, or both, a multidisciplinary team shall be used to review and develop the plan of care for special health care needs children.

E. An MCO shall provide coordinated care for special health care needs children in State-supervised care.

F. An MCO shall refer child victims of alleged abuse, neglect, or sexual offense to an appropriate provider capable of:

(1) Determining if the alleged abuse, neglect, or sexual offense occurred;

(2) Determining if medical intervention is needed; and

(3) Ensuring the preservation of evidence.

G. An MCO shall ensure coordination with the Department’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program.

H. An MCO shall establish protocols for effecting medically necessary service referrals to specialty care providers for children with special health care needs.

I. The service referrals referenced in §H of this regulation shall:

(1) Include services intended to improve or preserve the continuing health and quality of life for children with special health care needs, regardless of the ability of the services to effect permanent cure; and

(2) Be made when the child is:

(a) Identified as being at risk of a developmental delay by the developmental screen required by EPSDT;

(b) Experiencing a delay of 25 percent or more in any developmental area as measured by appropriate diagnostic instruments and procedures;

(c) Manifesting atypical development or behavior; or

(d) Diagnosed with a physical or mental condition that has a high probability of resulting in developmental delay.

J. An MCO shall provide durable medical equipment to a special needs child in a timely manner.

K. When a child, who is an MCO enrollee, is diagnosed with a special health care need requiring a plan of care which includes specialty services, and that health care need was undiagnosed at the time of enrollment, the parent or guardian of that child may request approval from the MCO for a specific out-of-network specialty provider to provide those services when the MCO does not have a local in-network specialty provider with the same professional training and expertise who is reasonably available and provides the same service and modality, subject to the following provisions:

(1) If the MCO denies the request for an out-of-network provider referral, the child's parent or guardian may initiate the complaint and appeal process set forth at COMAR 10.67.09.05;

(2) If at any time the MCO decides to terminate or reduce services provided by the approved out-of-network provider, the child's parent or guardian may initiate the complaint and appeal process set forth at COMAR 10.67.09.05;

(3) The MCO shall continue to cover the services of the out-of-network provider during the course of the appeal until such time as the Office of Administrative Hearings issues its decision.