PROPOSAL

Maryland Register

Issue Date:  September 28, 2018

Volume 45 • Issue 20 • Page 927-935

 

Title 10

Subtitle 09 MEDICAL CARE PROGRAMS

Notice of Proposed Action

[18-253-P]

The Secretary of Health proposes to:

(1) Amend Regulation .01 under COMAR 10.09.62 Maryland Medicaid Managed Care Program: Definitions;

(2) Amend Regulation .06 under COMAR 10.09.63 Maryland Medicaid Managed Care Program: Eligibility and Enrollment;

(3) Amend Regulation .05 under COMAR 10.09.64 Maryland Medicaid Managed Care Program: MCO Application;

(4) Amend Regulations .05.12, and .15, repeal existing Regulation .19-5, and adopt new Regulation .19-5 under COMAR 10.09.65 Maryland Medicaid Managed Care Program: Managed Care Organizations;

(5) Amend Regulations .04.05.05-1.06.07, and .09 under COMAR 10.09.66 Maryland Medicaid Managed Care Program: Access;

(6) Repeal Regulation .30 under COMAR 10.09.67 Maryland Medicaid Managed Care Program: Benefits;

(7) Amend Regulation .01 under COMAR 10.09.68 Maryland Medicaid Managed Care Program: Program Integrity;

(8) Amend Regulations .01—.03.04, and .05 and adopt new Regulations .02-1 and .03-2 under COMAR 10.09.71 Maryland Medicaid Managed Care Program: MCO Dispute Resolution Procedures;

(9) Repeal Regulations .01—.06 under COMAR 10.09.72 Maryland Medicaid Managed Care Program: Departmental Dispute Resolutions Procedures;

(10) Amend Regulation .01, repeal existing Regulation .02, and adopt new Regulation .02 under COMAR 10.09.73 Maryland Medicaid Managed Care Program: Sanctions;

(11) Amend Regulation .05 under COMAR 10.09.75 Maryland Medicaid Managed Care Program: Corrective Managed Care; and

(12) Amend Regulations .08 under COMAR 10.09.86 Maryland Medicaid Managed Care Program: Independent Review Organization (IRO).

Statement of Purpose

The purpose of this action is to implement regulations to comply with newly adopted federal regulations impacting MCO requirements and oversight (42 CFR Part 438). The new requirements include network adequacy standards and oversight, encounter data requirements, updating the medical loss ratio (MLR) calculation methodology and the MCO’s handling of complaints grievances and appeals.

Comparison to Federal Standards

There is a corresponding federal standard to this proposed action, but the proposed action is not more restrictive or stringent.

Estimate of Economic Impact

The proposed action has no economic impact.

Economic Impact on Small Businesses

The proposed action has minimal or no economic impact on small businesses.

Impact on Individuals with Disabilities

The proposed action has no impact on individuals with disabilities.

Opportunity for Public Comment

Comments may be sent to Michele Phinney, Director, Office of Regulation and Policy Coordination, Maryland Department of Health, 201 West Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499, or email to mdh.regs@maryland.gov, or fax to 410-767-6483. Comments will be accepted through October 29, 2018. A public hearing has not been scheduled.

 

10.09.62 Maryland Medicaid Managed Care Program: Definitions

Authority: Health-General Article, §15-101, Annotated Code of Maryland

.01 Definitions.

A. (text unchanged)

B. Terms Defined.

(1)—(40) (text unchanged)

(40-1) “Credibility adjustment” means an adjustment to the MLR for a partially credible MCO to account for a difference between the actual and target MLRs that may be due to random statistical variation.

(41)—(61) (text unchanged)

(61-1) “Full credibility” means a standard for which the experience of an MCO is determined to be sufficient for the calculation of an MLR with a minimal chance that the difference between the actual and target MLR is not statistically significant.

(62)—(111) (text unchanged)

(111-1) “Medical loss ratio (MLR)” means a formula that measures the ratio of MCO spending on medical and related benefits compared to revenue, to ensure MCOs are spending a sufficient amount of their premium revenue on medical expenses and other high-impact initiatives.

(112)—(119) (text unchanged)

(119-1) “MLR reporting year” means a period of 12 months consistent with the rating period selected by the Department.

(120)—(123-1) (text unchanged)

(123-2) “No credibility” means a standard for which the experience of an MCO is determined to be insufficient for the calculation of an MLR.

(123-3) “Non-claims costs” means expenses for administrative services other than:

(a) Incurred claims;

(b) Expenditures on activities that improve health care quality;

(c) Licensing and regulatory fees; or

(d) Federal and State taxes.

(124)—(126) (text unchanged)

(127) “Ombudsman” or “ombudsman program” has the meaning stated in Health-General Article, §15-101(g), Annotated Code of Maryland[, and is described in COMAR 10.09.72.02].

(128)—(130) (text unchanged)

(130-1) “Partial credibility” means a standard for which the experience of an MCO is determined to be sufficient for the calculation of an MLR but with a non-negligible chance that the difference between the actual and target medical loss ratios is statistically significant.

(131)—(152) (text unchanged)

(153) "Rate adjustment period" has the meaning stated in COMAR [10.09.63.19-4A10.09.65.19-4A.

(153-1)—(182) (text unchanged)

 

10.09.63 Maryland Medicaid Managed Care Program: Eligibility and Enrollment

Authority: Health-General Article, §15-103(b)(3) and (23), Annotated Code of Maryland

.06 Disenrollment.

A.—D. (text unchanged)

[E. At the request of the Department, an MCO shall transmit, with any request for enrollee disenrollment, the MCO's medical and utilization history for the enrollee.]

[F.E. Effective Date of Disenrollment.

(1) Except as specified in [§F(2)—(6)§E(2)—(6) of this regulation, an enrollee's disenrollment is effective on the 10th calendar day after the enrollee selects a new MCO.

(2)(6) (text unchanged)

[G.F. An MCO shall:

(1) [An MCO shall makeMake a good faith effort to give written notice to the Department when enrollees have the right to change MCOs under §A(1)(e) of this regulation 90 days before the effective date of the termination[.];

[(1)(2) [In addition to the notification required in §G of this regulation, the MCO shall provideProvide the Department with a list of the affected enrollees in a format specified by the Department; and

[(2)(3) If applicable, provide the termination survey required under COMAR 10.09.65.17B(4).

[H.G. (text unchanged)

[I.H. At the Department’s discretion, an MCO may be required to reimburse the Department for the costs associated with the mailing of the notifications in [§H§G of this regulation.

 

10.09.64 Maryland Medicaid Managed Care Program: MCO Application

Authority: Health-General Article, §§15-102 and 15-103, Annotated Code of Maryland

.05 Access and Capacity.

A. An MCO applicant shall include in its application the following information or descriptions:

(1)(7) (text unchanged)

(8) Documentation that [enrollees will have access to primary care services, including pharmacy, obstetrics/gynecology and diagnostic laboratory services, within a reasonable distance of their places of residence, demonstrated by showing the availability of these services in:

(a) Urban areas, within a 10-mile radius;

(b) Rural areas, within a 30-mile radius; and

(c) Suburban areas, within a 20-mile radius.the MCO applicant is able to meet the access standards set forth in COMAR 10.09.66 in each service area the MCO applicant plans to enter;

(9) Documentation of any reasons for which they are unable to meet the access requirements of [§A(8) of this regulationCOMAR 10.09.66 in any service area;

(10) For each primary care practice location, a specification of:

(a) (text unchanged)

(b) The staffing at each location, expressed in full-time equivalencies and grouped by medical specialty[, including, but not limited to:

(i) General practice;

(ii) Family practice;

(iii) Internal medicine;

(iv) Pediatrics;

(v) Obstetrics and gynecology; and

(vi) Advanced practice nursing]; and

(11) (text unchanged)

B.—D. (text unchanged)

 

10.09.65 Maryland Medicaid Managed Care Program: Managed Care Organizations

Authority: Health-General Article, §§2-104, 15-102.3, and 15-103; Insurance Article, §§15-112, 15-605, and 15-1008; Annotated Code of Maryland

.05 Special Needs Populations — Children with Special Health Care Needs.

A.—J. (text unchanged)

K. When a child, who is an MCO enrollee, is diagnosed with a special health care need requiring a plan of care which includes specialty services, and that health care need was undiagnosed at the time of enrollment, the parent or guardian of that child may request approval from the MCO for a specific out-of-network specialty provider to provide those services when the MCO does not have a local in-network specialty provider with the same professional training and expertise who is reasonably available and provides the same service and modality, subject to the following provisions:

(1) If the MCO denies the request for an out-of-network provider referral, the child's parent or guardian may initiate the complaint and appeal process set forth at COMAR [10.09.7210.09.71.05;

(2) If at any time the MCO decides to terminate or reduce services provided by the approved out-of-network provider, the child's parent or guardian may initiate the complaint and appeal process set forth at COMAR [10.09.7210.09.71.05;

(3) (text unchanged)

.12 Consumer Advisory Board.

A.—C. (text unchanged)

[D. Pursuant to Regulation .15E(2) of this chapter, the consumer advisory board shall annually report its activities and recommendations to the Secretary.]

.15 Data Collection and Reporting.

A. (text unchanged)

B. Encounter Data.

(1)—(2) (text unchanged)

(3) An MCO shall submit encounter data that identifies the provider who delivers any items or services to enrollees at a frequency and level of detail to be specified by CMS and the Department[.], including, at a minimum:

(a) Enrollee and provider identifying information;

(b) Service, procedure, and diagnoses codes;

(c) Allowed, paid, enrollee responsibility, and third-party liability amounts; and

(d) Service, claims submission, adjudication, and payment dates.

(4)—(5) (text unchanged)

C. (text unchanged)

D. Quarterly Reports. An MCO shall submit to the Department:

(1)—(5) (text unchanged)

(6) Within 10 calendar days after the close of each calendar quarter, in the format specified by the Department, a list of all State fair hearing outcomes during the preceding quarter.

E. (text unchanged)

[F. HEDIS Reporting. By July 1 of each year, an MCO shall submit to the Department a record of its health care delivery and organizational performance during the preceding year measured utilizing the most recent version of the Healthcare Effectiveness Data and Information Set (HEDIS) applicable to the reporting period].

[G.F. (text unchanged)

[H.G. If the MCO exits the HealthChoice Program for any reason, including those listed in COMAR 10.09.63.06A(1)(e) and (f):

(1) (text unchanged)

(2) On receiving the list provided by the MCO, the Department shall provide the list to:

(a) The [enrollment brokerhealth benefits exchange to assist and provide outreach to [recipientsparticipants in selecting an MCO; and

(b) If permitted by State and federal law, the remaining MCOs for [the purpose oflinking [recipientsparticipants with a PCP.

[I.H.[K.J. (text unchanged)

K. Upon request, an MCO whose member has disenrolled shall transfer historical utilization data to the member’s new MCO in the time frame and format specified by the Department.

.19-5 MCO Medical Loss Ratio.

A. By September 15 of the second calendar year following the MLR reporting year, each MCO shall provide to the Department a completed MLR Reporting Template, including the MCO attestation and any additional documentation supporting the MLR reporting template.

B. The MLR experienced for each MCO in an MLR reporting year is the ratio of the numerator, as defined in §D of this regulation, to the denominator, as defined in §E of this regulation.

C. An MLR may be increased by a credibility adjustment, in accordance with §G of this regulation.

D. Components of MLR — Numerator.

(1) The numerator of an MCO's MLR for an MLR reporting year is the sum of the MCO's incurred claims, the MCO's expenditures for activities that improve health care quality, and fraud prevention activities.

(2) Incurred Claims. Incurred claims include the following:

(a) Direct claims that the MCO paid to providers, including under capitated contracts with network providers, for services or supplies covered under the contract and services meeting the requirements of 42 CFR §438.3(e) provided to enrollees;

(b) Unpaid claims liabilities for the MLR reporting year, including claims reported that are in the process of being adjusted or claims incurred but not reported;

(c) Withholds from payments made to network providers;

(d) Claims that are recoverable for anticipated coordination of benefits;

(e) Claims payments recoveries received because of subrogation;

(f) Incurred but not reported claims based on past experience, and modified to reflect current conditions, such as changes in exposure or claim frequency or severity;

(g) Changes in other claims-related reserves; and

(h) Reserves for contingent benefits and the medical claim portion of lawsuits.

(3) An MCO shall deduct the following amounts from incurred claims:

(a) Overpayment recoveries received from network providers; and

(b) Prescription drug rebates received and accrued.

(4) An MCO shall include the following expenditures in incurred claims:

(a) The amount of incentive and bonus payments made, or expected to be made, to network providers; and

(b) The amount of claims payments recovered through fraud reduction efforts, not to exceed the amount of fraud reduction expenses, and excluding activities specified in §D(3) of this regulation;

(5) An MCO may include or deduct the following amounts from incurred claims:

(a) Net payments; or

(b) Receipts related to State-mandated solvency funds;

(6) An MCO shall exclude the following amounts from incurred claims:

(a) Non-claims costs;

(b) Amounts paid to the State as remittance under §I of this regulation; and

(c) Amounts paid to network providers under to 42 CFR §438.6(d).

(7) Non-claims costs as described in §D(6)(a) of this regulation include the following:

(a) Amounts paid to third-party vendors for secondary network savings;

(b) Amounts paid to third-party vendors for network development, administrative fees, claims processing, and utilization management;

(c) Amounts paid, including amounts paid to a provider, for professional or administrative services that do not represent compensation or reimbursement for State plan services or services meeting the definition in 42 CFR §438.3(e) and provided to an enrollee; and

(d) Fines and penalties assessed by regulatory authorities.

(8) Incurred claims paid by one MCO that are later assumed by another MCO shall be reported by the assuming MCO for the entire MLR reporting year, and no incurred claims for that MLR reporting year may be reported by the ceding MCO.

(9) An MCO shall include activities that improve health care quality in one of the following categories:

(a) An MCO activity that meets the requirements of 45 CFR 158.150(b) and is not excluded under 45 CFR 158.150(c);

(b) An MCO activity related to any EQR-related activity as described in 42 CFR §438.358(b) and (c); and

(c) Any MCO expenditure that is related to Health Information Technology and meaningful use, meets the requirements placed on issuers found in 45 CFR 158.151, and is not considered incurred claims.

(10) Excluding expenses for fraud reduction efforts in §D(4)(b) of this regulation, an MCO shall include expenditures on activities related to fraud prevention as adopted for the private market at 45 CFR part 158.

E. Components of MLR — Denominator.

(1) The denominator of an MCO's MLR for an MLR reporting year shall equal the adjusted premium revenue. The adjusted premium revenue is the MCO's premium revenue minus the MCO's federal, State, and local taxes and licensing and regulatory fees and is aggregated in accordance with §F of this regulation.

(2) Premium revenue includes the following for the MLR reporting year:

(a) State capitation payments, developed in accordance with 42 CFR §438.4, to the MCO for all enrollees under a risk contract approved under 42 CFR §438.3(a), excluding payments made under 42 CFR §438.6(d);

(b) State-developed, one-time payments, for specific life events of enrollees;

(c) Other payments to the MCO approved under 42 CFR §438.6(b)(3);

(d) Unpaid cost-sharing amounts that the MCO could have collected from enrollees under the contract, except those amounts the MCO can show it made a reasonable, but unsuccessful, effort to collect;

(e) All changes to unearned premium reserves; and

(f) Net payments or receipts related to risk sharing mechanisms developed in accordance with 42 CFR §438.5 or 42 CFR §438.6.

(3) Federal, State, and Local Taxes and Licensing and Regulatory Fees. Taxes and licensing and regulatory fees for the MLR reporting year include:

(a) Statutory assessments to defray the operating expenses of any State or federal department;

(b) Examination fees in lieu of premium taxes as specified by State law;

(c) Federal taxes and assessments allocated to MCOs excluding federal income taxes on investment income and capital gains and federal employment taxes;

(d) State and local taxes and assessments including:

(i) Any industrywide (or subset) assessments, other than surcharges on specific claims, paid to the State or locality directly;

(ii) Guaranty fund assessments;

(iii) Assessments of State or locality industrial boards or other boards for operating expenses or for benefits to sick employed persons in connection with disability benefit laws or similar taxes levied by states;

(iv) State or locality income, excise, and business taxes other than premium taxes and State employment and similar taxes and assessments; and

(v) State or locality premium taxes plus State or locality taxes based on reserves, if in lieu of premium taxes; and

(e) Payments made by an MCO that are otherwise exempt from federal income taxes, for community benefit expenditures as defined in 45 CFR 158.162(c), limited to the highest of either:

(i) 3 percent of earned premium; or

(ii) The highest premium tax rate in the State for which the report is being submitted, multiplied by an MCO's earned premium in the State.

(4) The total amount of the denominator for an MCO, which is later assumed by another MCO, shall be reported by the assuming MCO for the entire MLR reporting year and no amount under this section for that year may be reported by the ceding MCO.

F. Allocation of Expense.

(1) Each expense shall be included under only one type of expense, unless a portion of the expense fits under the definition of, or criteria for, one type of expense and the remainder fits into a different type of expense, in which case the MCO shall prorate the expense between types of expenses.

(2) An MCO shall report on a pro-rata basis any expenditures that benefit multiple contracts or populations, or contracts other than those being reported.

(3) Methods Used to Allocate Expenses.

(a) An MCO shall base allocation to each category on a generally accepted accounting method that is expected to yield the most accurate results.

(b) An MCO shall apportion shared expenses, including expenses under the terms of a management contract, pro rata to the contract incurring the expense.

(c) The reporting entity shall bear any expenses that relate solely to its operation and may not apportion its operating expenses to other entities.

G. Credibility Adjustment.

(1) An MCO may add a credibility adjustment to a calculated MLR if the MLR reporting year experience has partial credibility.

(2) An MCO shall add the credibility adjustment to the reported MLR calculation before calculating any remittances if required by the State as described in §I of this regulation.

(3) An MCO may not add a credibility adjustment to a calculated MLR if the MLR reporting year experience has full credibility.

(4) If an MCO's experience has no credibility, it is presumed to meet or exceed the MLR calculation standards in this regulation.

(5) MCOs shall use the base credibility factors CMS publishes on an annual basis that are developed according to the methodology in 42 CFR 438.8(h)(4).

 H. Eligibility Groups.

(1) MCOs shall aggregate data for all Medicaid eligibility groups covered under the contract with the Department.

(2) MCOs shall report, and the Department shall calculate, an annual MLR as described in this regulation separately for the childless adult population.

(3) The Department may require separate reporting and a separate MLR calculation for additional populations.

 I. An MCO shall provide a remittance for an MLR reporting year if the MLR for that MLR reporting year does not meet the minimum MLR standard of 85 percent.

J. Newly Contracted MCOs.

(1) The Department may exclude an MCO that is newly contracted with the State from the requirements in this section for the first year of the MCO's operation.

(2) Newly contracted MCOs shall comply with the requirements in this section during the next MLR reporting year in which the MCO is in business with the State, even if the first year was not a full 12 months.

K. If the Department makes a retroactive change to the capitation payments for an MLR reporting year where the report has already been submitted to the Department, the MCO shall recalculate the MLR for all MLR reporting years affected by the change and submit a new report.

L. MCOs shall attest to the accuracy of the calculation of the MLR in accordance with requirements of this section when submitting its report to the Department.

M. Notice and Appeal.

(1) Within 30 days of its receipt of the notice of a remittance being due to the Department, an MCO may appeal the remittance as a sanction pursuant to COMAR 10.09.73.02.

(2) An MCO's appeal does not stay the obligation of the MCO to remit the amount owed to the Department.

 

10.09.66 Maryland Medicaid Managed Care Program: Access

Authority: Health-General Article, §§15-102.1(b)(10) and 15-103(b) Annotated Code of Maryland

.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) (text unchanged)

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

(a) (text unchanged)

(b) The [MCO'sbenefits package, including optional benefits;

(c) [The MCO's accessAccess requirements, which, at a minimum, comply with the requirements of this chapter;

(d) [The MCO's qualityQuality requirements, which shall, at a minimum, comply with the requirements of COMAR 10.09.65.03; [and]

(e) Continuity of care requirements; and

[(e)(f) [The MCO's requirements] 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; [and]

(3)—(4) (text unchanged)

B. (text unchanged)

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

.05 Access Standards: PCPs and MCO’s Provider Network.

A. (text unchanged)

B. Adequacy of Provider Network.

(1)—(5) (text unchanged)

[(6) An MCO’s health care delivery system shall accommodate the cultural and ethnic diversity of the population to be served.]

(6) An MCO shall ensure services are delivered in a culturally competent manner to all enrollees, including enrollees:

(a) With limited English proficiency;

(b) With diverse cultural and ethnic backgrounds; and

(c) Of all genders, sexual orientations, and gender identities.

(7) For enrollees with physical or mental disabilities, an MCO shall ensure its network providers provide:

(a) Physical access;

(b) Reasonable accommodation; and

(c) Accessible equipment.

[(7)(8)—[(8)(9) (text unchanged)

.05-1 Access Standards: Specialty Provider Network.

A. Standards and Regions.

(1) The Department shall review an MCO’s specialty provider network for MCO’s overall network [and for each regionas defined in [§A(4) ofthis regulation.

(2) Overall Network [StandardStandards.

(a) [An MCO shall contract with at least one provider in each of the 14 major specialty areas specified in §A(2)(b) of this regulation.An MCO shall meet either the time or distance standard set forth in Regulation .06A of this chapter for core, major, and pediatric specialties.

[(b) The 14 major specialties are:

(i) Allergy;

(ii) Cardiology;

(iii) Dermatology;

(iv) Endocrinology;

(v) Otolaryngology (ENT);

(vi) Gastroenterology;

(vii) Infectious disease;

(viii) Nephrology;

(ix) Neurology;

(x) Ophthalmology;

(xi) Orthopedics;

(xii) Pulmonology;

(xiii) Surgery; and

(xiv) Urology.]

(b) The 8 core specialties are:

(i) Cardiology;

(ii) Otolaryngology (ENT);

(iii) Gastroenterology;

(iv) Neurology;

(v) Ophthalmology;

(vi) Orthopedics;

(vii) Surgery; and

(viii) Urology.

(c) The 6 major specialties are:

(i) Allergy and immunology;

(ii) Dermatology;

(iii) Endocrinology;

(iv) Infectious disease;

(v) Nephrology; and

(vi) Pulmonology.

(d) The 4 pediatric subspecialties are:

(i) Cardiology;

(ii) Gastroenterology;

(iii) Neurology; and

(iv) Surgery.

[(3) Regional Network Standards.

(a) For each of the specialty care regions listed in §A(4) of this regulation that an MCO serves, an MCO shall contract with at least one provider in each of the eight core specialties specified in §A(3)(b) of this regulation in each region the MCO serves.

(4) Specialty Care Regions. The 40 local areas established by COMAR 10.09.66.06E are grouped into 10 mutually exclusive specialty care regions as follows:

 

Region

Local Access Area

1

Allegany, Garrett, Washington

2

Anne Arundel North, Anne Arundel South, Howard

3

Carroll, Harford East, Harford West, Baltimore County North

4

Baltimore City—SE/Dundalk, Baltimore City—East, Baltimore City—North Central, Baltimore City Northeast, Baltimore County East

5

Baltimore City—Northwest, Baltimore County Northwest, Baltimore City—South, Baltimore City—West, Baltimore County Southwest

6

Montgomery—Silver Spring, Montgomery—Midcounty, Montgomery—North, Frederick

7

Prince George’s Northeast, Prince George’s Northwest, Prince George’s Southeast, Prince George’s Southwest

8

Calvert, Charles, St. Mary’s

9

Caroline, Kent, Queen Anne’s, Talbot, Cecil

10

Dorchester, Somerset, Wicomico, Worcester]

 

B. If the Department determines that an MCO does not meet the requirements specified in [§A(2)(a) or (3)(a)] §A(2)(b)—(d) of this regulation, the MCO may provide additional information to support the adequacy of the MCO's specialty network before any action is taken by the Department.

C. If an MCO fails to meet the requirements established by this regulation, the Department may suspend the automatic assignment to the MCO of recipients who live in the affected [specialty care regionlocal access area. A suspension of automatic assignments may affect the MCO's ability to qualify for the Statewide supplemental payments specified under COMAR 10.09.65.19-3.

.06 Geographical Access.

A. [AnExcept as provided in §C of this regulation, an MCO shall develop and maintain a provider network that [ensures that enrollees have access to the sites at which they receive the following servicesmeets the following time and distance standards:

(1) [Primary care;For adult and pediatric primary care, pharmacy, diagnostic laboratory and x-ray, and gynecology:

(a) In urban areas, within 15 minutes or 10 miles;

(b) In suburban areas, within 30 minutes or 20 miles; and

(c) In rural areas, within 40 minutes or 30 miles;

(2) [Pharmacy;For prenatal care, as defined in §B of this regulation:

(a) In urban areas, within 15 minutes or 10 miles;

(b) In suburban areas, within 30 minutes or 20 miles; and

(c) In rural areas, within 90 minutes or 75 miles;

(3) [OB/GYN; andFor acute inpatient hospitals:

(a) In urban areas, within 20 minutes or 10 miles;

(b) In suburban areas, within 45 minutes or 30 miles; and

(c) In rural areas, within 75 minutes or 60 miles;

(4) [Diagnostic laboratory and X-ray.] For core specialty types, as defined in Regulation .05-1A(2)(b) of this chapter:

(a) In urban areas, within 30 minutes or 15 miles;

(b) In suburban areas, within 60 minutes or 45 miles; and

(c) In rural areas, within 90 minutes or 75 miles;

(5) For major specialty types, as defined in Regulation .05-1A(2)(c) of this chapter:

(a) In urban areas, within 30 minutes or 15 miles;

(b) In suburban areas, within 80 minutes or 60 miles; and

(c) In rural areas, within 110 minutes or 90 miles; and

(6) For pediatric subspecialty types, as defined in Regulation .05-1A(2)(d) of this chapter;

(a) In urban areas, within 30 minutes or 15 miles;

(b) In suburban areas, within 60 minutes or 45 miles; and

(c) In rural areas, within 250 minutes or 200 miles.

[B. Except as provided in §C of this regulation, to meet the geographical access standard established by this regulation, an MCO shall provide the services listed in §A(1)—(4) of this regulation:

(1) In urban areas, within 10 miles of each enrollee's residence;

(2) In rural areas, within 30 miles of each enrollee's residence; and

(3) In suburban areas, within 20 miles of each enrollee’s residence.]

B. Prenatal Care Providers. For the purposes of provider network adequacy, prenatal care providers may include, but are not limited to:

(1) Obstetricians;

(2) Certified nurse midwives; and

(3) Family practitioners who provide prenatal care and perform deliveries.

C. If an MCO can otherwise demonstrate to the Department's satisfaction the adequacy of its provider network notwithstanding its inability to meet the requirements of [§B] §A of this regulation, the Department may, in its discretion, approve the network if special circumstances exist which, considered along with the overall strength of the MCO's network, establish that the Department's approval of the network will enhance recipients' overall access to quality health care services in the area to be served.

D.—E. (text unchanged)

.07 Access Standards: Clinical and Pharmacy Access.

A. Appointments.

(1) (text unchanged)

(2) Required Notice to Enrollees of Wellness Services.

(a)—(b) (text unchanged)

[(c) An MCO's failure to meet the requirements of this subsection shall result in the imposition of sanctions specified in COMAR 10.09.73.]

(3) Appointment Guidelines.

(a) (text unchanged)

(b) An MCO shall [effecthave procedures that result in an interval between the enrollee's request for an appointment and the actual appointment time being consistent with the following standards:

(i)—(viii) (text unchanged)

B.—C. (text unchanged)

D. Clinical Access Outside the MCO's Service Area.

(1)—(2) (text unchanged)

(3) If the MCO’s provider network is unable to provide necessary services, covered under the contract, to an enrollee, the MCO shall adequately and timely cover these services out of network for as long as the MCO’s provider network is unable to provide them.

E. (text unchanged)

.09 Access: Hospitals.

A. An MCO shall comply with the access standards specified in Regulation .06A of this chapter.

B. If an MCO’s service area includes a county that is designated as a medically underserved area and there is only one hospital in the county, the MCO shall include the hospital in its network.

 

10.09.68 Maryland Medicaid Managed Care Program: Program Integrity

Authority: Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland

.01 Requirements to Detect and Prevent Fraud, Waste and Abuse.

A.—K. (text unchanged)

L. Overpayments to Providers and Subcontractors.

(1)—(3) (text unchanged)

(4) The MCO shall have the right to appeal, pursuant to COMAR [10.09.7210.09.73.02, the Department’s recovery of an overpayment.

M. (text unchanged)

N. An MCO shall ensure that all of its network providers are screened, enrolled, and revalidated by the State as Medicaid providers, in accordance with 42 CFR part 455, subparts B and E.

10.09.71 Maryland Medicaid Managed Care Program: MCO Dispute Resolution Procedures

Authority: Health-General Article, §15-103(b)(9)(i)(4) Annotated Code of Maryland

.01 MCO Enrollee Services [Hotline].

An MCO shall:

A. Maintain a member services unit that operates an enrollee [hotlineservices line at least during normal business hours;

B. Operate its enrollee services [hotlineline as a triage device to handle or properly refer enrollees' questions or complaints; and

C. Provide [an enrollee withinformation in the member handbook about how to use the MCO [member services unit andenrollee services [hotlineline to obtain information and assistance.

.02 [Internal] MCO Enrollee Complaint Process [for Enrollees].

A.—B. (text unchanged)

C. An MCO shall [include in thesubmit for Department approval an internal complaint process detailing the procedures for registering and responding to appeals and grievances in a timely fashion, which:

(1) [IncludeIncludes a specific standard for grievance decisions, monitored by the MCO for compliance, directing that:

(a)—(c) (text unchanged)

(2) [IncludeIncludes participation by the provider, if appropriate;

(3) [AllowAllows participation by the ombudsman, if appropriate;

(4) [EnsureEnsures the participation of individuals within the MCO who have the authority to require corrective action;

(5) [Require] Requires documentation of the substance of the grievances and steps taken;

(6) [IncludeIncludes a [protocolprocedure for the aggregation and analysis of appeals and grievance data and use of the data for quality improvement;

[(7) Include a procedure for immediate response to the Department's request of all disputed actions in emergency medical situations;

(8) Include a procedure for notice of all disputed non-emergency medical care actions to the Department within 3 business days of request of the determination to deny;]

[(9)(7) [Include] Includes a documented procedure for reporting:

(a)—(b) (text unchanged)

[(10)] (8) [Include] Includes a documented procedure for written notification of the MCO's determination:

(a) To the enrollee who filed the grievance; and

(b) To those individuals and entities required to be notified of the grievance pursuant to [§C(9)§C(7) of this regulation; [and

(c) To the Department's complaint unit for complaints referred to the MCO by the Department's complaint unit or ombudsman program; and]

[(11)] (9) [EnsureEnsures that decision makers on appeals and grievances:

(a)—(b) (text unchanged)

(c) Are healthcare professionals with clinical expertise in treating the enrollee’s condition or disease, if any of the following apply:

(i) The [grievanceappeal is a denial based on lack of medical necessity;

(ii) (text unchanged)

(iii) The appeal or grievance involves clinical issues; and

(d) (text unchanged)

.02-1 Member Complaints — Time Frames for MCOs to Respond to the Department.

An MCO shall:

A. Acknowledge an enrollee appeal or grievance reported to it by the Department’s complaint resolution unit within 1 business day;

B. Respond to the Department’s request for information regarding disputed nonemergency medical care actions within 3 business days;

C. Provide updates in a time frame specified by the Department;

D. Provide medical records within 5 days of the request; and

E. Provide a corrective action plan upon request and within the time frame specified, but not later than 10 days from the date of the request.

.03 MCO Provider Complaint Process.

A. (text unchanged)

B. An MCO shall include in its provider complaint process at least the following elements:

(1)—(4) (text unchanged)

(5) Procedures for the termination or withdrawal of a provider from the MCO's provider panel, including:

(a) At least 90 days prior notice to the primary care providers in the MCO's provider panel of the MCO's termination of a specialty services provider when the reason for the termination is unrelated to fraud, patient abuse, incompetency, or loss of licensure status; [and]

(b) If possible, at least 90 days prior notice to the primary care providers in the MCO's provider panel of a specialty services provider's withdrawal from the MCO's provider panel; and

(c) Notices to primary care providers informing them of the enrollee’s right to change MCOs as described in COMAR 10.09.63.06A(1)(e).

(6)—(8) (text unchanged)

C. (text unchanged)

.03-2 Provider Complaints — Time Frames for MCOs to Respond to the Department.

An MCO shall:

A. Acknowledge provider grievances within 3 business days;

B. Provide findings to the Department within 5 days; and

C. Provide a corrective action plan to the Department within 10 days from the date of the request.

.04 MCO Actions and Decisions.

A. (text unchanged)

B. Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested:

(1) (text unchanged)

(2) May not be [arbitrarilybased solely on diagnosis, type of illness, or condition.

C.—G. (text unchanged)

.05 MCO Appeal Process for Enrollees.

A. An MCO's appeal process shall:

(1)—(5) (text unchanged)

(6) Provide the case file upon request to the enrollee and the enrollee's representative [with the enrollee's case file], free of charge and sufficiently in advance of the resolution time frame for appeals, which includes:

(a)—(c) (text unchanged)

(7)—(10) (text unchanged)

B. Resolution.

(1) Except for expedited appeals as described in §C, an MCO shall resolve each appeal and provide notice of resolution, as expeditiously as the enrollee’s health condition requires, and unless extended pursuant to §B(2) of this regulation, within 30 days from the day the MCO receives the appeal.

(2)—(6) (text unchanged)

C.—E. (text unchanged)

F. State Fair Hearing.

(1) An enrollee may exercise State fair hearing rights pursuant to the Department’s regulations and State Government Article, §10-201 et seq., Annotated Code of Maryland, subject to the requirements of this regulation.

(2) An enrollee may request a State fair hearing for an MCO appeal resolution after first exhausting the MCO’s appeal process by appealing to the Office of Administrative Hearings using the process specified in COMAR 10.01.04.

(3) An enrollee shall file for a State fair hearing within 120 days from the date the MCO provides on the written notice of appeal resolution.

(4) The parties to an appeal to the Office of Administrative Hearings under this section are the:

(a) MCO;

(b) Enrollee; and

(c) Enrollee’s representative or the personal representative of a deceased enrollee’s estate.

(5) The MCO shall provide documentation regarding medical determinations to enrollees and the Office of Administrative Hearings as required by COMAR 10.01.04 and other applicable law.

(6) The MCO shall continue the enrollee’s benefits pending the outcome of the State fair hearing if all of the following occur:

(a) The enrollee files for continuation of benefits within 10 days of the MCO upholding its action;

(b) The State fair hearing request is filed timely, meaning on or before the later of the following:

(i) 10 days from the date on the MCO’s notice of appeal resolution; or

(ii) The intended effective date of the MCO's proposed action;

(c) The State fair hearing involves the termination, suspension, or reduction of a previously authorized service;

(d) The services were ordered by an authorized provider; and

(e) The authorization period has not expired.

(7) If the MCO continues or reinstates the enrollee's benefits while the State fair hearing is pending, the benefits shall continue until one of the following occurs:

(a) The enrollee withdraws the State fair hearing; or

(b) A State fair hearing decision adverse to the enrollee is issued by the Office of Administrative Hearings.

(8) The final decision of the Office of Administrative Hearings is appealable to the circuit court, and is governed by State Government Article, §10-201 et seq., Annotated Code of Maryland, and the Maryland Rules.

G. The Department may order an MCO to provide a benefit or service based on its evaluation of the MCO’s action.

 

10.09.73 Maryland Medicaid Managed Care Program: Sanctions

Authority: Health-General Article, §15-103(b)(9), Annotated Code of Maryland

.01 Sanction by the Department.

A. If the Department determines, after a sufficient investigation, that an MCO or any agent or employee of the MCO, or any person with an ownership interest in an MCO, or related party of the MCO, has failed to comply with any applicable law, regulation, or contract term, or for other good cause shown, the Department may impose sanctions on the MCO, including but not limited to:

(1)—(3) (text unchanged)

(4) Termination of the [provider agreementcurrent HealthChoice Managed Care Organization Agreement;

(5) Disqualification from future participation in the Maryland Medicaid Managed Care Program; [and]

(6) Orders to provide a benefit or service to enrollees; and

[(6)] (7) (text unchanged)

B. (text unchanged)

[C. Penalties for MCO's Failure to Provide Timely Notice of Wellness Services.

(1) Pursuant to COMAR 10.09.66.07A(2), an MCO is required to provide written notice to its new enrollees, within 90 days of their enrollment, of the due dates of wellness services, including immunizations and examinations.

(2) For failure to achieve at least 90 percent compliance with the notice requirement of COMAR 10.09.66.07A(2), the Department shall reduce the MCO's capitation payment in accordance with the schedule specified in §C(3)(a)—(c) of this regulation.

(3) If an MCO fails to provide the timely notice required by COMAR 10.09.66.07A(2) to at least 90 percent of its new enrollees:

(a) Within 90 days of enrollment, the Department shall effect a 20 percent reduction in the MCO's capitation payment;

(b) Within 180 days of enrollment, the Department shall effect a 30 percent reduction in the MCO's capitation payment; and

(c) Within 270 days of enrollment, the Department shall effect a 50 percent reduction in the MCO's capitation payment.]

.02 Appeal.

A. From the decisions set forth in §B(1)—(8) of this regulation, an MCO may exercise the appeal rights set forth in §C of this regulation.

B. The following Department decisions are appealable by the MCO or MCO applicant:

(1) Denial of an entity’s completed application to become an MCO;

(2) Decision to terminate the MCO's participation in the Maryland Medicaid Managed Care Program;

(3) Decision to impose a fine or other sanction on the MCO as described in Regulation .01 of this chapter;

(4) Order to provide benefits or services to enrollees as described in COMAR 10.09.71.05;

(5) Order that the MCO is impaired or in “hazardous financial condition”;

(6) An adverse decision by the IRO as described in COMAR 10.09.86.08;

(7) The amount of a penalty or incentive as described in COMAR 10.09.65.03;

(8) The denial of a hepatitis C payment as described in COMAR 10.09.65.19;

(9) Overpayments recovered by the Department as described in COMAR 10.09.68.01; and

(10) Remittances to the Department as described in COMAR 10.09.65.19-5.

C. An MCO may appeal a decision listed in §B of this regulation to the Office of Administrative Hearings as specified in COMAR 10.01.03 and COMAR 10.09.36.09.

D. The parties to an appeal to the Office of Administrative Hearings under §C of this regulation are the Department and the MCO. The enrollee is not a party at this hearing.

E. The following sanctions shall take effect immediately and are not subject to stay during the pendency of an appeal:

(1) Any fines imposed;

(2) Orders to provide a benefit or service to enrollees;

(3) Any full or partial withhold of the capitation payment;

(4) Any remittances to the Department as described in COMAR 10.09.65.19-5; or

(5) Any overpayments recovered by the Department as described in COMAR 10.09.68.01.

 

10.09.75 Maryland Medicaid Managed Care Program: Corrective Managed Care

Authority: Health-General Article, §§15-102.1(b)(9) and 15-103, Annotated Code of Maryland

.05 Enrollee Appeal.

A. (text unchanged)

B. Except for the time frame specified in §A of this regulation, an appeal shall be handled as specified in[:

(1)COMAR 10.09.71.05[; and

(2) COMAR 10.09.72.05].

C. (text unchanged)

 

10.09.86 Maryland Medicaid Managed Care Program: Independent Review Organization (IRO)

Authority: Health-General Article, §§2-104(b) and 15-103(b) Annotated Code of Maryland

.08 Appeal.

A. (text unchanged)

B. An MCO that receives an adverse decision from an independent review organization may file an appeal in accordance with COMAR [10.09.72.0610.09.73.02.

ROBERT R. NEALL
Secretary of Health

 

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