Sec. 10.67.04.10. Special Needs Populations — Individuals with HIV/AIDS

A. An MCO shall meet the standards set forth in this regulation for treating individuals with HIV/AIDS.

B. HIV/AIDS Specialist.

(1) An MCO shall allow an enrollee with HIV/AIDS to choose an HIV/AIDS specialist for treatment and coordination of primary and specialty care.

(2) To qualify as an HIV/AIDS specialist, a health care provider shall be board certified in the field of infectious diseases by a member board of the American Board of Medical Specialties or:

(a) Hold a current, valid, unrevoked, and unsuspended Maryland license or certification as a:

(i) Doctor of medicine;

(ii) Doctor of osteopathy;

(iii) Nurse practitioner; or

(iv) Physician's assistant being supervised by a medical doctor;

(b) Have provided direct, continuous, ongoing care for at least 20 patients with HIV over the past 2 years; and

(c) Have completed one of the following requirements:

(i) If a medical doctor, certified physician's assistant being supervised by a medical doctor, or doctor of osteopathy, at least 30 hours of HIV-related continuing medical education category I credits over the past 2 years;

(ii) If a nurse practitioner, at least 30 hours of HIV-related continuing education units over the past 2 years;

(iii) If a medical doctor, certified physician's assistant being supervised by a medical doctor, doctor of osteopathy, or a nurse practitioner, an accredited training program over the past year; or

(iv) If a medical doctor, certified physician's assistant being supervised by a medical doctor, doctor of osteopathy, or a nurse practitioner, has completed the American Academy of HIV Medicine (AAHIVM) credentialing examination.

C. AIDS Case Management Services.

(1) An MCO shall ensure that an enrollee with HIV/AIDS receives case management services that:

(a) Link the enrollee with the full range of available benefits;

(b) Link the enrollee with any additional needed services including:

(i) Mental health services;

(ii) Substance abuse services;

(iii) Medical services;

(iv) Social services;

(v) Financial services;

(vi) Counseling services;

(vii) Educational services;

(viii) Housing services; and

(ix) Other required support services;

(c) Ensure timely and coordinated access to medically necessary levels of care that support continuity of care across the continuum of service providers;

(d) Are performed by licensed physicians, physician assistants, advanced practice nurses, registered nurses, social workers, or other individuals who are appropriately trained, experienced, and supervised by a licensed practitioner; and

(e) Include, but are not limited to:

(i) Initial and ongoing assessment of the enrollee's needs and personal support systems, including the MCO offering an enrollee one face-to-face meeting during the initial assessment and documenting the enrollee's acceptance or declination of the face to face meeting;

(ii) Development of a comprehensive, individualized service plan, using a multidisciplinary approach;

(iii) Coordination of the services required to implement the plan;

(iv) Periodic reevaluation and adaptation of the plan as necessary over the life of the enrollee;

(v) Development of an outreach system for the enrollee and family by which the case manager and primary care provider track services received, clinical outcomes, and the need for additional follow-up; and

(vi) Serving as an effective enrollee advocate to resolve differences between the enrollee and providers of care pertaining to the course or content of therapeutic interventions.

(2) An enrollee diagnosed with HIV/AIDS shall be offered case management services by the MCO at any time after diagnosis. An enrollee who has previously refused these services may request case management from the MCO at any time.

D. Diagnostic Evaluation Service (DES) Assessment.

(1) An MCO shall offer a diagnostic evaluation service (DES) assessment annually and document the enrollee's acceptance or declination.

(2) The DES shall consist of a comprehensive medical and psychosocial assessment.

(3) A DES provider shall use assessment and care plan forms used by the Department for adult and pediatric assessments.

(4) An individual shall select a DES provider from an approved list of sites, and may select a DES provider which is not part of the individual's MCO if so desired.

(5) An MCO and other qualified institutions may become DES providers as provided in COMAR 10.09.32.03C.

E. An individual with HIV/AIDS who has a substance use disorder shall be referred to the behavioral health ASO for substance abuse treatment within 24 hours of request.

F. Clinical Trials.

(1) An MCO may refer enrollees who are individuals with HIV/AIDS to facilities or organizations that can provide the enrollees' access to clinical trials.

(2) An MCO shall provide enrollees with HIV/AIDS access to clinical trials in accordance with COMAR 10.67.06.26-1.