Sec. 10.67.05.04. Access Standards: Information for Providers

A. An MCO shall develop and make available either electronically or by hard copy to all of its PCP and specialty care providers a Medicaid requirements manual, including periodic updates as appropriate, and shall:

(1) Before distribution, file a copy of its manual with the Department for review;

(2) Include in its manual the information necessary to facilitate the providers' full compliance with federal and State Medicaid requirements, including information on:

(a) Medicaid statutes and regulations;

(b) The benefits package, including optional benefits;

(c) Access requirements, which, at a minimum, comply with the requirements of this chapter;

(d) Quality requirements, which shall, at a minimum, comply with the requirements of COMAR 10.67.04.03;

(e) Continuity of care requirements; and

(f) Requirements for referral to specialist, ancillary, and other providers as necessary to provide the full range of medically necessary services that are covered by the Maryland Medicaid Managed Care Program;

(3) Inform the MCO’s primary and specialty care providers of their responsibility to provide or arrange for medically necessary accessible health care services that are continuous, comprehensive, and coordinated for each enrollee, including:

(a) Preventive health services;

(b) Primary acute medical care;

(c) Chronic medical care;

(d) Consultation, referral, and follow-up in areas including medical specialties and child dental care;

(e) Referral for ancillary and support-related services including but not limited to:

(i) Drug therapies;

(ii) Diagnostic tests;

(iii) Medical supplies;

(iv) Durable medical equipment; and

(v) Case management when appropriate for complex conditions;

(f) 24-hour per day, 7-day per week provider coverage for medically necessary services;

(g) Maintenance of a medical record, including records of referral arrangements and outcomes of those referrals; and

(h) Detection of mental health problems or substance use disorder during routine or follow-up screening, to be treated either through the MCO or referred to the behavioral health ASO for services; and

(4) Inform the providers of the following enrollee appeal, grievance, and fair hearing procedures and time frames:

(a) The enrollee's right to a State fair hearing, how to obtain a hearing, and representation rules at a hearing;

(b) The enrollee's right to file appeals and grievances, and the enrollee's requirements and time frames for filing;

(c) The availability of assistance in filing;

(d) The toll-free numbers to file verbal appeals and grievances;

(e) The enrollee's right to request continuation of benefits during an appeal or State fair hearing filing, and that if the MCO action is upheld in a hearing, the enrollee may be liable for the cost of any continued benefits; and

(f) The provider's right to appeal, on the enrollee's behalf, the failure of the MCO to cover a service.

B. An MCO shall ensure that its PCP and specialty care providers receive adequate information regarding the Medicaid Program to facilitate full compliance with all federal and State Medicaid requirements. The MCO shall:

(1) Ensure that each PCP and specialty care provider receives, at the time they enter into a contract, a copy of the MCO's Medicaid requirements manual, and any other pertinent information; and

(2) Provide each PCP and specialty care provider, on an ongoing basis as appropriate, with periodic updates of the materials required to be provided under §B(1) of this regulation.

C. An MCO shall provide to each PCP an updated list of the PCP’s assigned enrollees monthly.