Sec. 10.67.05.02. Access Standards: Enrollee Handbook and Provider Directory

A. An MCO shall inform and educate its enrollees about:

(1) Basic information about the MCO;

(2) The availability of health care services and how to access them;

(3) The definitions of managed care terminology in accordance with 42 CFR 438.10(c)(4)(i); and

(4) Enrollee's rights and responsibilities in the MCO, and that the exercise of those rights does not adversely affect the way the MCO, its providers, or the Department treats the enrollee.

B. An MCO shall, at the time of enrollment, and anytime upon request, furnish each enrollee with a copy of the MCO’s enrollee handbook that includes all language in the template provided by the Department and the following current information:

(1) The enrollee's rights and responsibilities in the MCO as described in 42 CFR §438.100(b)(1), as amended;

(2) Information on how to access urgent care and emergency care services, including:

(a) What constitutes an emergency medical condition and emergency services;

(b) The following facts:

(i) Prior authorization is not required for these services; and

(ii) The enrollee has a right to use any hospital or other setting for emergency care;

(3) The services included in the MCO's benefits package, including optional benefits provided by the MCO;

(4) How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided;

(5) The amount, duration, and scope of benefits available in sufficient detail to ensure that enrollees understand the benefits to which they are entitled;

(6) The availability of behavioral health services that are not included in the MCO’s benefits package, and how to access these services;

(7) Information on the availability of self-referral services as well as any restrictions on the enrollee’s freedom of choice among network providers;

(8) Information about how enrollees may obtain benefits from out-of-network providers;

(9) Any policies and procedures necessary to facilitate accessing needed services in compliance with the Maryland Medicaid Managed Care Program, including any requirements for service authorizations or referrals for specialty care and for other benefits not furnished by the enrollee’s primary care provider;

(10) Information about the availability of EPSDT, prenatal care, family planning, and other wellness services, including education programs;

(11) A statement that the MCO cannot require an enrollee to obtain a referral before choosing a family planning provider;

(12) The process of selecting and changing the enrollee’s primary care provider;

(13) A description of any benefits the MCO offers in addition to those required by the Maryland Medicaid Managed Care Program, including applicable terms and conditions for accessing those benefits;

(14) Information on how to access auxiliary aids and services, including additional information in alternative formats or languages;

(15) The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees, including:

(a) A description of each unit and number;

(b) An explanation of how the phone numbers can be used to obtain information and assistance; and

(c) An explanation of the MCO’s internal grievance procedure.

(16) Information regarding the importance of scheduling and maintaining appointments for preventive services;

(17) If applicable, a list of services that are not covered by the MCO because of moral or religious objections, and a statement that informs the enrollee that the State will provide information on how and where to obtain these services;

(18) The rule pertaining to poststabilization care services, as set forth in Regulation .08G of this chapter;

(19) Appeal, grievance, and fair hearing procedures and time frames that include the following:

(a) The right to a State fair hearing, including the method for obtaining a hearing and the rules that govern representation at the hearing;

(b) The right to file appeals and grievances;

(c) The requirements and time frames for filing an appeal or grievance;

(d) The availability of assistance in the filing process;

(e) The toll-free numbers that the enrollee may use to file an appeal or grievance by phone;

(f) The fact that, if requested by the enrollee, the benefits will continue if the enrollee files an appeal or a request for a State fair hearing within the time frames specified for filing; and

(g) That the enrollee may be required to pay the cost of the services furnished while the appeal is pending, if the final decision is adverse to the enrollee;

(20) Any appeal rights the State chooses to make available to providers;

(21) Advanced directives as set forth in 42 CFR §438.3(j)(1), as amended;

(22) Information on how to report suspected fraud or abuse;

(23) Additional information that is available upon request, including the following:

(a) Information on the structure and operation of the MCO; and

(b) Physician incentive plans.

(24) Information on how to access or obtain the MCO’s provider directory.

C. Provider Directory.

(1) An MCO shall provide enrollees with information regarding their provider networks including:

(a) Its primary care service locations;

(b) A listing of the MCO’s hospital providers, of both inpatient and outpatient services, in the enrollee’s county, their addresses, and services provided;

(c) A listing of the MCO’s pharmacy providers in the enrollee’s county and their addresses; and

(d) A listing of the individual practitioners who are the MCO’s primary and specialty care providers in the enrollee’s county, grouped by medical specialty, giving:

(i) Name;

(ii) Address;

(iii) Practice location or locations;

(iv) Telephone number or numbers;

(v) Website URL, as appropriate;

(vi) Any group affiliation, as appropriate;

(vii) Cultural and linguistic capabilities, including languages offered by the provider or a skilled medical interpreter at the provider’s offices, American Sign Language interpretation, and whether the provider has completed cultural competence training;

(viii) An indication of whether the provider’s office or facility has accommodations for physical disabilities, including offices, exam room or rooms and equipment;

(ix) An indication of whether or not the provider is accepting new patients;

(x) An indication of the age range of patients accepted or whether there is no age limit; and

(xi) If applicable, how access to the provider is otherwise limited.

(2) Upon request by an enrollee, an MCO shall furnish a paper copy of the provider directory.

D. An MCO shall notify all enrollees of their right to request and obtain the information listed in §§B and C of this regulation at least once a year.

E. The Department may consider the information listed in §§B and C of this regulation to be provided if the MCO:

(1) Mails a printed copy of the information to the enrollee’s mailing address;

(2) Provides the information by email after obtaining the enrollee’s agreement to receive the information by email;

(3) Posts the information on the MCO’s website and advises the enrollee in paper or electronic form that the information is available on the internet and includes the applicable internet address, provided that enrollees with disabilities who cannot access this information online are provided auxiliary aids and services upon request at no cost; or

(4) Provides the information by any other method that can reasonably be expected to result in the enrollee receiving that information.

F. An MCO shall update its online provider directory no later than 30 days after the MCO receives updated provider information.

G. An MCO shall update its paper directory on a monthly basis.

H. An MCO shall make provider directories available on its website in a machine-readable file and format as specified by the Secretary for the U.S. Department of Health and Human Services.