Sec. 10.67.05.03. Access Standards: Outreach

A. An MCO is responsible for delivering needed health care services even when the enrollee is difficult to reach or misses appointments.

B. The assistance of local health departments in contacting and bringing into care enrollees who are difficult to reach or miss appointments is available for the specific categories of enrollees identified in this regulation, but only after the MCO has made documented attempts to contact and bring into care an enrollee who is difficult to reach or misses appointments before seeking the assistance of the local health department.

C. Adults.

(1) An MCO shall, before referring the enrollee to the local health department, make documented attempts to ensure that follow-up appointments are scheduled in accordance with the enrollee's treatment plan by attempting a variety of contact methods, which may include:

(a) Written correspondence;

(b) Telephone contact; and

(c) Face-to-face contact.

(2) If the enrollee, due to impaired cognitive ability or psychosocial problems such as homelessness or other conditions, can be expected to have difficulty understanding the importance of treatment instructions or difficulty navigating the health care system, the MCO shall, after exhausting its best efforts to contact and bring into care the enrollee in accordance with §C(1) of this regulation, make, or ensure that the enrollee's provider makes, a written referral to the local health department for its assistance within 10 business days of whichever first occurs:

(a) The third consecutive missed appointment; or

(b) The MCO or the enrollee's provider identifies the enrollee's repeated noncompliance with a regimen of care.

D. Child Younger than 2 Years Old Needing EPSDT Screening Services.

(1) An MCO shall ensure that appointments are scheduled in accordance with the EPSDT periodicity schedule or within 30 days of the MCO's receipt of the health risk assessment, whichever is less.

(2) If the enrollee fails to keep the appointment, the MCO shall ensure that a second appointment is scheduled within 30 days.

(3) If the enrollee misses the second appointment, a third appointment shall be scheduled within 30 days.

(4) For each scheduled appointment, the MCO shall:

(a) Provide written notice to the enrollee's parent, guardian, or caretaker of the appointment dates; and

(b) Attempt to notify the enrollee's parent, guardian, or caretaker of the appointment dates by telephone.

(5) If the enrollee misses the second appointment in a row, after the MCO has made the notification attempts required by §C(1) of this regulation, the MCO shall, within 10 business days, make, or ensure that the enrollee's provider makes, a written referral to the local health department for its assistance in bringing the enrollee into care.

(6) After referral to the local health department, the MCO shall continue to work collaboratively with the local health department to bring the enrollee into care until the enrollee comes back into compliance with the EPSDT periodicity schedule.

E. Child Younger than 21 Years Old Needing Follow-up Treatment.

(1) An MCO shall ensure that an appointment for follow-up care is scheduled at a time interval appropriate to the enrollee's diagnosed condition.

(2) If the enrollee fails to keep the appointment, the MCO shall reschedule the appointment for the enrollee to be seen within 30 days.

(3) For each scheduled appointment, the MCO shall:

(a) Provide written notice to the enrollee, or to the enrollee's parent, guardian, or caretaker, as appropriate, of the appointment dates by mail; and

(b) Attempt to notify the enrollee, or the enrollee's parent, guardian, or caretaker, as appropriate, of the appointment dates by telephone.

(4) If the enrollee misses the second consecutive follow-up appointment after the MCO has made the notification attempts required by §C(1) of this regulation, the MCO shall, within 10 business days, make, or ensure that the enrollee's provider makes, a written referral to the local health department for its assistance in bringing the enrollee into care.

(5) After referral to the local health department, the MCO shall work collaboratively with the local health department to bring the enrollee into care.

F. Pregnant or Postpartum Woman Needing Prenatal or Postpartum Care.

(1) Initial Visit. An MCO shall schedule an initial visit for the pregnant or postpartum enrollee to be seen within 10 days of her request for an appointment. If she fails to appear for the appointment, the MCO shall reschedule in a timely manner appropriate to her medical condition.

(2) Follow-Up Appointments. After the enrollee has completed an initial visit that includes a comprehensive history, physical exam, and completion of the Maryland Prenatal Risk Assessment, the MCO shall ensure that appointments are scheduled for the enrollee in compliance with the periodicity schedule of the ACOG guidelines. If the enrollee fails to appear for a scheduled appointment, the MCO shall ensure that the appointment is rescheduled for the enrollee to be seen within 10 days.

(3) For each scheduled appointment, the MCO shall:

(a) Provide written notice to the enrollee of the appointment dates; and

(b) Attempt to notify the enrollee of the appointment dates by telephone.

(4) After making the attempts specified in §F(3) of this regulation, if the MCO is unable to bring the enrollee into care within 30 days of the first missed appointment, the MCO shall, within 10 days of the last missed appointment, make, or ensure that the enrollee's provider makes, a written referral to the local health department for its assistance in bringing the enrollee into care.

(5) After referral to the local health department, the MCO shall work collaboratively with the local health department to bring the patient into care, until the enrollee comes back in compliance with the ACOG periodicity schedule.