Sec. 10.67.12.02. Corrective Managed Care Plan

A. An MCO’s corrective managed care plan:

(1) Shall cover enrollee abuse of medical assistance pharmacy benefits; and

(2) May cover enrollee abuse of nonpharmacy medical assistance benefits.

B. For all benefit abuse covered by an MCO’s corrective managed care plan, the plan shall:

(1) Use the criteria as described in Regulation .01B of this regulation to determine if enrollees have abused benefits;

(2) Provide for a medical review of the alleged abuse consistent with §C of this regulation;

(3) Provide that an enrollee found to have abused benefits will be enrolled in the program for 24 months;

(4) Provide that an enrollee who has been enrolled in a 24 month plan and is subsequently found to have abused MCO benefits shall be enrolled in the plan for an additional 36 months;

(5) Provide for the MCO to select any participating provider in the MCO that meets the requirements of COMAR 10.67.05.05A to serve as the enrollee’s primary care, specialty care, and pharmacy providers for enrollees in corrective managed care, as appropriate to the type of benefit the enrollee has been found to have abused;

(6) Require an enrollee to obtain prescribed drugs only from a single designated pharmacy provider, which may be any pharmacy or any single branch of a pharmacy chain that participates in the MCO and meets the requirements of COMAR 10.67.05.06B and .07C(2) unless the prescription is:

(a) Pursuant to an emergency department visit;

(b) Pursuant to hospital inpatient treatment; or

(c) A specialty drug as defined in COMAR 10.67.06.04;

(7) Provide enrollees determined to have abused benefits the ability to suggest primary care, specialty care, or pharmacy providers;

(8) Require the MCO to accept the enrollee’s suggestion referenced in §B(7) of this regulation unless the MCO determines that the recipient’s choice of provider would not serve the enrollee’s best interest in achieving appropriate use of the health care systems and benefits available through the MCO;

(9) Provide an enrollee determined to have abused benefits 20 days from the date of the notice to present additional documentation to explain the facts that serve as the basis for the MCO’s determination of benefit abuse, consistent with §D of this regulation;

(10) Provide for the designation of a new primary care, specialty care, or pharmacy provider if the enrollee moves out of the service area of the current primary care or pharmacy provider;

(11) Provide for prompt reporting to the Department the name of any enrollee enrolled in the MCO’s program, the duration of enrollment, or any change in the duration of enrollment; and

(12) Be submitted to the Department for review and approval:

(a) Within 60 days of the effective date of this regulation; and

(b) Before the implementation of any modification.

C. The medical review required in §B(2) of this regulation shall:

(1) Be performed by a medical reviewer who is a licensed health care professional;

(2) Consider all information that is relevant and available to the MCO, including but not limited to MCO payment records and information secured from any interviews conducted; and

(3) Where appropriate, consider records obtained from other sources, including:

(a) Providers of medical services;

(b) Statistical reports;

(c) Outside complaints;

(d) Referrals from other agencies; or

(e) Any other appropriate sources.

D. If an enrollee provides additional information pursuant to §B(9) of this regulation within 20 days:

(1) The effective date of the enrollment provided in the notice shall be tolled pending the MCO’s review of the additional information;

(2) The MCO shall consider whether the additional information changes the MCO’s determination regarding the appropriateness of the enrollee’s enrollment in corrective managed care;

(3) The MCO shall notify the enrollee of its decision whether the MCO is affirming or reversing its determination to enroll the enrollee in corrective managed care; and

(4) If the MCO confirms its determination to enroll the enrollee in corrective managed care, the notice shall:

(a) Identify the effective date and duration of that enrollment; and

(b) Include an explanation of the enrollee’s right to appeal the determination as described in Regulation .05 of this chapter.

E. An MCO’s corrective managed care plan may include a process for re-considering, at any interval of time, a decision to enroll an enrollee in the MCO’s corrective managed care plan, if the process entitles the enrollee to appeal the decision pursuant to Regulation .05 of this chapter at the same interval of time.