(a) (1) The Secretary shall administer the Maryland Medical Assistance
Program.
(2) The Program:
(i) Subject to the limitations of the State budget, shall provide
medical and other health care services for indigent individuals or medically indigent
individuals or both;
(ii) Shall provide, subject to the limitations of the State budget,
comprehensive medical, dental, and other health care services, including services
provided in accordance with § 15-141.5 of this subtitle, for all eligible pregnant
women whose family income is at or below 250 percent of the poverty level for the
duration of the pregnancy and for 1 year immediately following the end of the
woman's pregnancy, as permitted by the federal law;
(iii) Shall provide, subject to the limitations of the State budget,
comprehensive medical and other health care services for all eligible children
currently under the age of 1 whose family income falls below 185 percent of the
poverty level, as permitted by federal law;
(iv) Beginning on January 1, 2012, shall provide, subject to the
limitations of the State budget, family planning services to all women whose family
income is at or below 200 percent of the poverty level, as permitted by federal law;
(v) Shall provide, subject to the limitations of the State budget,
comprehensive medical and other health care services for all children from the age of
1 year up through and including the age of 5 years whose family income falls below
133 percent of the poverty level, as permitted by the federal law;
(vi) Beginning on January 1, 2014, shall provide, subject to the
limitations of the State budget, comprehensive medical care and other health care
services for all children who are at least 6 years of age but are under 19 years of age
whose family income falls below 133 percent of the poverty level, as permitted by
federal law;
(vii) Shall provide, subject to the limitations of the State budget,
comprehensive medical care and other health care services for all legal immigrants
who meet Program eligibility standards and who arrived in the United States before
August 22, 1996, the effective date of the federal Personal Responsibility and Work
Opportunity Reconciliation Act, as permitted by federal law;
(viii) Shall provide, subject to the limitations of the State budget
and any other requirements imposed by the State, comprehensive medical care and
other health care services for all legal immigrant children under the age of 18 years
and pregnant women who meet Program eligibility standards and who arrived in the
United States on or after August 22, 1996, the effective date of the federal Personal
Responsibility and Work Opportunity Reconciliation Act;
(ix) Beginning on January 1, 2014, shall provide, subject to the
limitations of the State budget, and as permitted by federal law, medical care and
other health care services for adults whose annual household income is at or below
133 percent of the poverty level;
(x) Subject to the limitations of the State budget, and as
permitted by federal law:
1. Shall provide comprehensive medical care, dental
care, and other health care services for former foster care adolescents who, on their
18th birthday, were in foster care under the responsibility of the State and are not
otherwise eligible for Program benefits; and
2. May provide comprehensive medical care, dental
care, and other health care services for former foster care adolescents who, on their
18th birthday, were in foster care under the responsibility of any other state or the
District of Columbia;
(xi) May include bedside nursing care for eligible Program
recipients;
(xii) Shall provide services in accordance with funding
restrictions included in the annual State budget bill;
(xiii) 1. Beginning on January 1, 2019, may provide, subject
to the limitations of the State budget, and as permitted by federal law, dental services
for adults whose annual household income is at or below 133 percent of the poverty
level; and
2. Beginning on January 1, 2023, shall provide, subject
to the limitations of the State budget, and as permitted by federal law, dental services
for adults, including diagnostic, preventive, restorative, and periodontal services,
whose annual household income is at or below 133 percent of the federal poverty level;
(xiv) Shall provide, subject to the limitations of the State budget,
medically appropriate drugs that are approved by the United States Food and Drug
Administration for the treatment of hepatitis C, regardless of the fibrosis score, and
that are determined to be medically necessary;
(xv) Shall provide, subject to the limitations of the State budget,
health care services appropriately delivered through telehealth to a patient in
accordance with § 15-141.2 of this subtitle;
(xvi) Beginning on January 1, 2021, shall provide, subject to the
limitations of the State budget and § 15-855(b)(2) of the Insurance Article, and as
permitted by federal law, services for pediatric autoimmune neuropsychiatric
disorders associated with streptococcal infections and pediatric acute onset
neuropsychiatric syndrome, including the use of intravenous immunoglobulin
therapy, for eligible Program recipients, if pediatric autoimmune neuropsychiatric
disorders associated with streptococcal infections and pediatric acute onset
neuropsychiatric syndrome are coded for billing and diagnosis purposes in accordance
with § 15-855(d) of the Insurance Article;
(xvii) Beginning on January 1, 2022, may not include, subject to
federal approval and limitations of the State budget, a frequency limitation on
covered dental prophylaxis care or oral health exams that requires the dental
prophylaxis care or oral health exams to be provided at an interval greater than 120
days within a plan year;
(xviii) Shall provide, subject to the limitations of the State budget,
comprehensive medical care and other health care services to noncitizen pregnant
women who would be eligible for the Program but for their immigration status and
to their children up to the age of 1 year;
(xix) Shall provide coverage of abortion care services to Program
recipients in the manner described in § 15-857(b)(1)(ii) and (2) of the Insurance
Article;
(xx) Beginning on July 1, 2023, shall provide, subject to federal
approval and limitations of the State budget, community violence prevention services
in accordance with § 15-141.3 of this subtitle;
(xxi) Beginning on January 1, 2023, shall provide, subject to the
limitations of the State budget, and as permitted by federal law, coverage for self-
measured blood pressure monitoring for all Program recipients diagnosed with
uncontrolled high blood pressure, including:
1. The provision of validated home blood pressure
monitors; and
2. Reimbursement of health care provider and other
staff time used for patient training, transmission of blood pressure data,
interpretation of blood pressure readings and reporting, and the delivery of co-
interventions, including educational materials or classes, behavioral change
management, and medication management;
(xxii) Beginning on January 1, 2024, shall provide gender-
affirming treatment in accordance with § 15-151 of this subtitle;
(xxiii) Beginning on July 1, 2025, shall provide, subject to the
limitations of the State budget, and as permitted by federal law, coverage for
biomarker testing in accordance with § 15-859 of the Insurance Article;
(xxiv) Beginning on January 1, 2025, shall provide coverage for
prostheses in accordance with § 15-844 of the Insurance Article;
(xxv) Beginning on January 1, 2026, shall provide, subject to the
limitations of the State budget, and as permitted by federal law, coverage for self-
measured blood pressure monitoring for eligible Program recipients in accordance
with § 15-141.6 of this subtitle;
(xxvi) Beginning on January 1, 2026, shall provide coverage for a
transfer to a special pediatric hospital in accordance with § 15-861 of the Insurance
Article;
(xxvii) Beginning on January 1, 2026, if providing coverage for the
delivery of anesthesia, shall provide coverage for the delivery of anesthesia in
accordance with § 15-862 of the Insurance Article; and
(xxviii) Beginning on January 1, 2026, shall provide calcium
score testing in accordance with § 15-863 of the Insurance Article; and
(3) Subject to restrictions in federal law or waivers, the Department
may:
(i) Impose cost-sharing on Program recipients; and
(ii) For adults who do not meet requirements for a federal
category of eligibility for Medicaid:
1. Cap enrollment; and
2. Limit the benefit package.
(4) Subject to the limitations of the State budget, the Department
shall implement the provisions of Title II of the federal Patient Protection and
Affordable Care Act, as amended by the federal Health Care and Education
Reconciliation Act of 2010, to include:
(i) Parents and caretaker relatives who have a dependent
child living in the parents' or caretaker relatives' home; and
(ii) Adults who do not meet requirements, such as age,
disability, or parent or caretaker relative of a dependent child, for a federal category
of eligibility for Medicaid and who are not enrolled in the federal Medicare program,
as enacted by Title XVII of the Social Security Act.
(5) On or before January 1, 2025, subject to the limitations of the
State budget, and as permitted by federal law, the Department:
(i) Shall establish an Express Lane Eligibility Program to
enroll individuals in the Maryland Medical Assistance Program and Maryland
Children's Health Program based on eligibility findings by the Supplemental
Nutrition Assistance Program;
(ii) May not consider any other income or eligibility
requirements;
(iii) To the extent that a waiver is needed to maximize the
number of State residents who may qualify for the Express Lane Eligibility Program,
shall apply to the Centers for Medicare and Medicaid Services for one or more waivers
under § 1115 of the federal Social Security Act to implement the Express Lane
Eligibility Program; and
(iv) Shall make all reasonable efforts to expedite enrollment of
eligible individuals in the Express Lane Eligibility Program, provided that the
Department may propose or implement the use of Express Lane Eligibility for
renewals before proposing or implementing the use of Express Lane Eligibility for
initial enrollment.
(b) (1) As permitted by federal law or waiver, the Secretary may
establish a program under which Program recipients are required to enroll in
managed care organizations.
(2) (i) The benefits required by the program developed under
paragraph (1) of this subsection shall be adopted by regulation and shall be
equivalent to the benefit level required by the Maryland Medical Assistance Program
on January 1, 1996.
(ii) Subject to the limitations of the State budget and as
permitted by federal law or waiver, the Department shall provide reimbursement for
medically necessary and appropriate inpatient, intermediate care, and halfway house
substance abuse treatment services for substance abusing enrollees 21 years of age
or older who are recipients of temporary cash assistance under the Family
Investment Program.
(iii) Each managed care organization participating in the
program developed under paragraph (1) of this subsection shall provide or arrange
for the provision of the benefits described in subparagraph (ii) of this paragraph.
(iv) Nothing in this paragraph may be construed to prohibit a
managed care organization from offering additional benefits, if the managed care
organization is not receiving capitation payments based on the provision of the
additional benefits.
(v) Notwithstanding subparagraph (i) of this paragraph, the
benefits required by the program developed under paragraph (1) of this subsection
shall include dental services for pregnant women.
(3) Subject to the limitations of the State budget and as permitted by
federal law or waiver, the program developed under paragraph (1) of this subsection
and the program developed under § 15-301 of this title may provide guaranteed
eligibility for each enrollee for up to 6 months, unless an enrollee obtains health
insurance through another source.
(4) (i) The Secretary may exclude specific populations or services
from the program developed under paragraph (1) of this subsection.
(ii) For any populations or services excluded under this
paragraph, the Secretary may authorize a managed care organization, to provide the
services or provide for the population, including authorization of a separate dental
managed care organization or a managed care organization to provide services to
Program recipients with special needs.
(5) (i) Except for a service excluded by the Secretary under
paragraph (4) of this subsection, each managed care organization shall provide all
the benefits required by regulations adopted under paragraph (2) of this subsection.
(ii) For a population or service excluded by the Secretary under
paragraph (4) of this subsection, the Secretary may authorize a managed care
organization to provide only for that population or provide only that service.
(iii) A managed care organization may subcontract specified
required services to a health care provider that is licensed or authorized to provide
those services.
(6) Except for the Program of All-inclusive Care for the Elderly
("PACE") Program, the Secretary may not include the long-term care population or
long-term care services in the program developed under paragraph (1) of this
subsection.
(7) The program developed under paragraph (1) of this subsection
shall ensure that enrollees have access to a pharmacy that:
(i) Is licensed in the State; and
(ii) Is within a reasonable distance from the enrollee's
residence.
(8) For cause, the Department may disenroll enrollees from a
managed care organization and enroll them in another managed care organization.
(9) Each managed care organization shall:
(i) Have a quality assurance program in effect which is subject
to the approval of the Department and which, at a minimum:
1. Complies with any health care quality improvement
system developed by the Centers for Medicare and Medicaid Services;
2. Complies with the quality requirements of
applicable State licensure laws and regulations;
3. Complies with practice guidelines and protocols
specified by the Department;
4. Provides for an enrollee grievance system, including
an enrollee hotline;
5. Provides a provider grievance system;
6. Provides for enrollee and provider satisfaction
surveys, to be taken at least annually;
7. Provides for a consumer advisory board to receive
regular input from enrollees;
8. Provides for an annual consumer advisory board
report to be submitted to the Secretary; and
9. Complies with specific quality, access, data, and
performance measurements adopted by the Department for treating enrollees with
special needs;
(ii) Submit to the Department:
1. Service-specific data by service type in a format to
be established by the Department;
2. Utilization and outcome reports, such as the Health
Plan Employer Data and Information Set (HEDIS), as directed by the Department;
and
3. At least semiannually, aggregate data that includes:
A. The number of enrollees provided with substance
abuse treatment services; and
B. The amount of money spent on substance abuse
treatment;
(iii) Promote timely access to and continuity of health care
services for enrollees;
(iv) Demonstrate organizational capacity to provide special
programs, including outreach, case management, and home visiting, tailored to meet
the individual needs of all enrollees;
(v) Provide assistance to enrollees in securing necessary
health care services;
(vi) Provide or assure alcohol and drug abuse treatment for
substance abusing pregnant women and all other enrollees of managed care
organizations who require these services;
(vii) Educate enrollees on health care prevention and good
health habits;
(viii) Assure necessary provider capacity in all geographic areas
under contract;
(ix) Be accountable and hold its subcontractors accountable for
standards established by the Department and, upon failure to meet those standards,
be subject to one or more of the following penalties:
1. Fines;
2. Suspension of further enrollments;
3. Withholding of all or part of the capitation payment;
4. Termination of the contract;
5. Disqualification from future participation in the
Program; and
6. Any other penalties that may be imposed by the
Department;
(x) Subject to applicable federal and State law, include
incentives for enrollees to comply with provisions of the managed care organization;
(xi) Provide or arrange to provide primary mental health
services;
(xii) Provide or arrange to provide all Medicaid-covered
services required to comply with State statutes and regulations mandating health
and mental health services for children in State supervised care:
1. According to standards set by the Department; and
2. Locally, to the extent the services are available
locally;
(xiii) Submit to the Department aggregate information from the
quality assurance program, including complaints and resolutions from the enrollee
and provider grievance systems, the enrollee hotline, and enrollee satisfaction
surveys;
(xiv) Maintain as part of the enrollee's medical record the
following information:
1. The basic health risk assessment conducted on
enrollment;
2. Any information the managed care organization
receives that results from an assessment of the enrollee conducted for the purpose of
any early intervention, evaluation, planning, or case management program;
3. Information from the local department of social
services regarding any other service or benefit the enrollee receives, including
assistance or benefits from a program administered by the Department of Human
Services under the Human Services Article; and
4. Any information the managed care organization
receives from a school-based clinic, a core services agency, a local health department,
or any other person that has provided health services to the enrollee;
(xv) Upon provision of information specified by the Department
under paragraph (19) of this subsection, pay school-based clinics for services provided
to the managed care organization's enrollees;
(xvi) In coordination with participating dentists, enrollees, and
families of enrollees, develop a process to arrange to provide dental therapeutic
treatment to individuals under 21 years of age that requires:
1. A participating dentist to notify a managed care
organization when an enrollee is in need of therapeutic treatment and the dentist is
unable to provide the treatment;
2. A managed care organization to provide the enrollee
or the family of the enrollee with a list of participating providers who offer therapeutic
dental services; and
3. A managed care organization to notify the enrollee
or the family of the enrollee that the managed care organization will provide further
assistance if the enrollee has difficulty obtaining an appointment with a provider of
therapeutic dental services;
(xvii) Provide the advance directive information sheet developed
under § 5-615 of this article:
1. To all enrollees at the time of initial enrollment and
in the managed care organization's enrollee publications;
2. If the managed care organization maintains a
website, on the managed care organization's website; and
3. At the request of an enrollee; and
(xviii) If a managed care organization maintains a website, after
the tab on the State-designated health information exchange website required under
§ 19-145(b)(2)(iv) of this article is developed, provide a link to the webpage that is
accessed through the tab.
(10) The Department shall adopt regulations that assure that
managed care organizations employ appropriate personnel to:
(i) Assure that individuals with special needs obtain needed
services; and
(ii) Coordinate those services.
(11) (i) A managed care organization shall reimburse a hospital
emergency facility and provider for:
1. Health care services that meet the definition of
emergency services in § 19-701 of this article;
2. Medical screening services rendered to meet the
requirements of the federal Emergency Medical Treatment and Active Labor Act;
3. Medically necessary services if the managed care
organization authorized, referred, or otherwise allowed the enrollee to use the
emergency facility and the medically necessary services are related to the condition
for which the enrollee was allowed to use the emergency facility; and
4. Medically necessary services that relate to the
condition presented and that are provided by the provider in the emergency facility
to the enrollee if the managed care organization fails to provide 24-hour access to a
physician as required by the Department.
(ii) A provider may not be required to obtain prior
authorization or approval for payment from a managed care organization in order to
obtain reimbursement under this paragraph.
(12) (i) Each managed care organization shall notify each enrollee
when the enrollee should obtain an immunization, examination, or other wellness
service.
(ii) Each managed care organization shall:
1. Maintain evidence of compliance with paragraph (9)
of this subsection; and
2. Provide to the Department, upon initial application
to provide health care services to enrollees and on an annual basis thereafter,
evidence of compliance with paragraph (9) of this subsection, including submission of
a written plan.
(iii) A managed care organization that does not comply with
subparagraph (i) of this paragraph for at least 90% of its new enrollees:
1. Within 90 days of their enrollment may not receive
more than 80% of its capitation payments;
2. Within 180 days of their enrollment may not receive
more than 70% of its capitation payments; and
3. Within 270 days of their enrollment may not receive
more than 50% of its capitation payments.
(iv) If a managed care organization does not comply with the
requirements of paragraph (9) of this subsection, the Department may contract with
any community-based health organization that the Department determines is willing
and able to perform comprehensive outreach services to enrollees.
(v) In addition to the provisions of subparagraph (iv) of this
paragraph, if a managed care organization does not comply with the requirements of
paragraph (9) of this subsection or fails to provide evidence of compliance to the
Department under subparagraph (ii) of this paragraph, the Department may:
1. Impose a fine on the managed care organization
which shall be deposited in the HealthChoice Performance Incentive Fund
established under § 15-103.3 of this subtitle;
2. Suspend further enrollment into the managed care
organization;
3. Withhold all or part of the capitation rate from the
managed care organization;
4. Terminate the provider agreement; or
5. Disqualify the managed care organization from
future participation in the Maryland Medicaid Managed Care Program.
(13) The Department shall:
(i) Establish and maintain an ombudsman program and a
locally accessible enrollee hotline;
(ii) Perform focused medical reviews of managed care
organizations that include reviews of how the managed care organizations are
providing health care services to special populations;
(iii) Provide timely feedback to each managed care organization
on its compliance with the Department's quality and access system;
(iv) Establish and maintain within the Department a process
for handling provider complaints about managed care organizations; and
(v) Adopt regulations relating to appeals by managed care
organizations of penalties imposed by the Department, including regulations
providing for an appeal to the Office of Administrative Hearings.
(14) (i) Except as provided in subparagraph (iii) of this paragraph,
the Department shall delegate responsibility for maintaining the ombudsman
program for a county to that county's local health department on the request of the
local health department.
(ii) A local health department may not subcontract the
ombudsman program.
(iii) Before the Department delegates responsibility to a local
health department to maintain the ombudsman program for a county, a local health
department that is also a Medicaid provider must receive the approval of the
Secretary and the local governing body.
(15) A managed care organization may not:
(i) Without authorization by the Department, enroll an
individual who at the time is a Program recipient; or
(ii) Have face-to-face or telephone contact, or otherwise solicit
with an individual who at the time is a Program recipient before the Program
recipient enrolls in the managed care organization unless:
1. Authorized by the Department; or
2. The Program recipient initiates contact.
(16) (i) The Department shall be responsible for enrolling Program
recipients into managed care organizations.
(ii) The Department may contract with an entity to perform
the enrollment function.
(iii) The Department or its enrollment contractor shall
administer a health risk assessment developed by the Department to ensure that
individuals who need special or immediate health care services will receive the
services on a timely basis.
(iv) The Department or its enrollment contractor:
1. May administer the health risk assessment only
after the Program recipient has chosen a managed care organization; and
2. Shall forward the results of the health risk
assessment to the managed care organization chosen by the Program recipient within
5 business days.
(17) For a managed care organization with which the Secretary
contracts to provide services to Program recipients under this subsection, the
Secretary shall establish a mechanism to initially assure that each historic provider
that meets the Department's quality standards has the opportunity to continue to
serve Program recipients as a subcontractor of at least one managed care
organization.
(18) (i) The Department shall make capitation payments to each
managed care organization as provided in this paragraph.
(ii) In consultation with the Insurance Commissioner, the
Secretary shall:
1. Set capitation payments at a level that is actuarially
adjusted to the benefits provided; and
2. Actuarially adjust the capitation payments to reflect
the relative risk assumed by the managed care organization.
(iii) In actuarially adjusting capitation payments under
subparagraph (ii)2 of this paragraph, the Secretary, in consultation with the
Insurance Commissioner, shall take into account, to the extent allowed under federal
law, the expenses incurred by the managed care organization applicable to the
business of providing care to enrolled individuals.
(19) (i) School-based clinics and managed care organizations shall
collaborate to provide continuity of care to enrollees.
(ii) School-based clinics shall be defined by the Department in
consultation with the State Department of Education.
(iii) Each managed care organization shall require a school-
based clinic to provide to the managed care organization certain information, as
specified by the Department, about an encounter with an enrollee of the managed
care organization prior to paying the school-based clinic.
(iv) Upon receipt of information specified by the Department,
the managed care organization shall pay, at Medicaid-established rates, school-
based clinics for covered services provided to enrollees of the managed care
organization.
(v) The Department shall work with managed care
organizations and school-based clinics to develop collaboration standards, guidelines,
and a process to assure that the services provided are covered and medically
appropriate and that the process provides for timely notification among the parties.
(vi) Each managed care organization shall maintain records of
all health care services:
1. Provided to its enrollees by school-based clinics; and
2. For which the managed care organization has been
billed.
(20) The Department shall establish standards for the timely delivery
of services to enrollees.
(21) (i) The Department shall establish a delivery system for
specialty mental health services for enrollees of managed care organizations.
(ii) The Behavioral Health Administration shall:
1. Design and monitor the delivery system;
2. Establish performance standards for providers in
the delivery system; and
3. Establish procedures to ensure appropriate and
timely referrals from managed care organizations to the delivery system that include:
A. Specification of the diagnoses and conditions eligible
for referral to the delivery system;
B. Training and clinical guidance in appropriate use of
the delivery system for managed care organization primary care providers;
C. Preauthorization by the utilization review agent of
the delivery system; and
D. Penalties for a pattern of improper referrals.
(iii) The Department shall collaborate with managed care
organizations to develop standards and guidelines for the provision of specialty
mental health services.
(iv) The delivery system shall:
1. Provide all specialty mental health services needed
by enrollees;
2. For enrollees who are dually diagnosed, coordinate
the provision of substance use disorder services provided by the managed care
organizations of the enrollees;
3. Consist of a network of qualified mental health
professionals from all core disciplines;
4. Include linkages with other public service systems;
and
5. Comply with quality assurance, enrollee input, data
collection, and other requirements specified by the Department in regulation.
(v) The Department may contract with a managed care
organization for delivery of specialty mental health services if the managed care
organization meets the performance standards adopted by the Department in
regulations.
(vi) The provisions of § 15-1005 of the Insurance Article apply
to the delivery system for specialty mental health services established under this
paragraph and administered by an administrative services organization.
(vii) The Department and the Behavioral Health
Administration shall ensure that the delivery system has an adequate network of
providers available to provide substance use disorder treatment for children under
the age of 18 years.
(22) The Department shall include a definition of medical necessity in
its quality and access standards.
(23) (i) The Department shall adopt regulations relating to
enrollment, disenrollment, and enrollee appeals.
(ii) Program recipients shall have the right to choose:
1. The managed care organization with which they are
enrolled; and
2. The primary care provider to whom they are
assigned within the managed care organization.
(iii) If a recipient is disenrolled and reenrolls within 120 days
of the recipient's disenrollment, the Department shall:
1. Assign the recipient to the managed care
organization in which the recipient previously was enrolled; and
2. Require the managed care organization to assign the
recipient to the primary care provider of record at the time of the recipient's
disenrollment.
(iv) Whenever a recipient has to select a new managed care
organization because the recipient's managed care organization has departed from
the HealthChoice Program, the departing managed care organization:
1. Shall provide a written notice to the recipient 60
days before departing from the Program;
2. Shall include in the notice the name and provider
number of the primary care provider assigned to the recipient and the telephone
number of the enrollment broker; and
3. Within 30 days after departing from the Program,
shall provide the Department with a list of enrollees and the name of each enrollee's
primary care provider.
(v) On receiving the list provided by the managed care
organization, the Department shall provide the list to:
1. The enrollment broker to assist and provide
outreach to recipients in selecting a managed care organization; and
2. The remaining managed care organizations for the
purpose of linking recipients with a primary care provider in accordance with federal
law and regulation.
(vi) Subject to subsection (f)(4) and (5) of this section, an
enrollee may disenroll from a managed care organization:
1. Without cause in the month following the
anniversary date of the enrollee's enrollment; and
2. For cause, at any time as determined by the
Secretary.
(24) The Department or its subcontractor, to the extent feasible in its
marketing or enrollment programs, shall hire individuals receiving assistance under
the program of Aid to Families with Dependent Children established under Title IV,
Part A, of the Social Security Act, or the successor to the program.
(25) The Department shall disenroll an enrollee who is a child in
State-supervised care if the child is transferred to an area outside of the territory of
the managed care organization.
(26) The Secretary shall adopt regulations to implement the
provisions of this section.
(27) (i) 1. The Department shall establish the Maryland
Medicaid Advisory Committee, composed of no more than 25 members.
2. The majority of the members of the Committee shall
be enrollees or enrollee advocates.
3. At least five members of the Committee shall be
enrollees representative of the entire Medicaid population.
(ii) The Committee members shall include:
1. At least five current or former enrollees or the
parents or guardians of current or former enrollees;
2. Providers who are familiar with the medical needs
of low-income population groups, including board-certified physicians;
3. Hospital representatives;
4. At least five but not more than 10 advocates for the
Medicaid population, including representatives of special needs populations, such as:
A. Children with special needs;
B. Individuals with physical disabilities;
C. Individuals with developmental disabilities;
D. Individuals with mental illness;
E. Individuals with brain injuries;
F. Medicaid and Medicare dual eligibles;
G. Individuals who are homeless or have experienced
homelessness;
H. Individuals enrolled in home- and community-
based services waivers;
I. Elderly individuals;
J. Low-income individuals and individuals receiving
benefits through the Temporary Assistance for Needy Families Program; and
K. Individuals receiving substance abuse treatment
services;
5. Two members of the Finance Committee of the
Senate of Maryland, appointed by the President of the Senate; and
6. Three members of the Maryland House of Delegates,
appointed by the Speaker of the House.
(iii) A designee of each of the following shall serve as an ex-
officio member of the Committee:
1. The Secretary of Human Services;
2. The Executive Director of the Maryland Health Care
Commission; and
3. The Maryland Association of County Health
Officers.
(iv) In addition to any duties imposed by federal law and
regulation, the Committee shall:
1. Advise the Secretary on the implementation,
operation, and evaluation of managed care programs under this section;
2. Review and make recommendations on the
regulations developed to implement managed care programs under this section;
3. Review and make recommendations on the
standards used in contracts between the Department and managed care
organizations;
4. Review and make recommendations on the
Department's oversight of quality assurance standards;
5. Review data collected by the Department from
managed care organizations participating in the Program and data collected by the
Maryland Health Care Commission;
6. Promote the dissemination of managed care
organization performance information, including loss ratios, to enrollees in a manner
that facilitates quality comparisons and uses layman's language;
7. Assist the Department in evaluating the enrollment
process; and
8. Review reports of the ombudsmen.
(v) Except as specified in subparagraphs (ii) and (iii) of this
paragraph, the members of the Maryland Medicaid Advisory Committee shall be
appointed by the Secretary and serve for a 4-year term.
(vi) In making appointments to the Committee, the Secretary
shall provide for continuity and rotation.
(vii) In appointing consumer members to the Committee, the
Secretary shall seek recommendations from:
1. The State Protection and Advocacy System
Organization;
2. The Statewide Independent Living Council;
3. The Developmental Disabilities Council;
4. The Department of Disabilities;
5. The Department of Aging;
6. Consumer advocacy organizations; and
7. The public.
(viii) The Secretary shall appoint the chair of the Committee.
(ix) The Secretary shall appoint nonvoting members from
managed care organizations who may participate in Committee meetings, unless the
Committee meets in closed session as provided in § 3-305 of the General Provisions
Article.
(x) The Department shall provide staff for the Committee.
(xi) The Committee shall determine the times and places of its
meetings.
(xii) 1. The chair of the Committee and the staff for the
Committee shall provide the agenda, minutes, and any written materials to be
presented or discussed at a meeting to the members of the Committee at least 5 days
prior to the meeting.
2. The agenda, minutes, and written materials shall be
provided to members of the Committee in a manner and format that reasonably
accommodates the specific needs of the member.
(xiii) 1. Except as provided in subsubparagraph 2 of this
subparagraph, a member of the Committee:
A. May not receive compensation; but
B. Is entitled to reimbursement for expenses under the
Standard State Travel Regulations, as provided in the State budget.
2. A member of the Committee who is an enrollee is
entitled to reimbursement for:
A. Expenses for personal and dependent care incurred
during the meeting and during travel time to and from the meeting;
B. Expenses for cognitive supports related to the
meeting; and
C. Appropriate transportation to and from the meeting.
3. On request, the Department shall provide for a
dedicated Department staff person:
A. To review meeting materials with enrollee members
in advance of a meeting by telephone or in person; and
B. To provide referrals to advocacy organizations.
(28) (i) The Department shall ensure that payments for services
provided by a hospital located in a contiguous state or in the District of Columbia to
an enrollee under the Program shall be reduced by 20% if the hospital fails to submit
discharge data on all Maryland patients receiving care in the hospital to the Health
Services Cost Review Commission in a form and manner the Commission specifies.
(ii) Subparagraph (i) of this paragraph does not apply to a
hospital that presently provides discharge data to the public in a form the Health
Services Cost Review Commission determines is satisfactory.
(29) A managed care organization shall provide coverage for hearing
loss screenings of newborns provided by a hospital before discharge.
(30) (i) The Department shall provide enrollees and health care
providers with an accurate directory or other listing of all available providers:
1. In written form, made available upon request; and
2. On an Internet database.
(ii) The Department shall update the Internet database at
least every 30 days.
(iii) The written directory shall include a conspicuous reference
to the Internet database.
(31) Paragraph (9)(xvii) of this subsection may not be construed to
require a managed care organization to:
(i) Assist an enrollee in drafting an electronic advance care
planning document;
(ii) Store electronic advance care planning documents; or
(iii) Access advance care planning documents.
(32) A managed care organization may not apply a prior authorization
requirement for a prescription drug used as postexposure prophylaxis for the
prevention of HIV if the prescription drug is prescribed for use in accordance with
Centers for Disease Control and Prevention guidelines.
(33) The Secretary shall adopt regulations for pharmacy benefits
managers that contract with managed care organizations that establish
requirements for conducting audits of pharmacies or pharmacists that are:
(i) To the extent practicable, substantively similar to the
audit provisions under § 15-1629 of the Insurance Article; and
(ii) Consistent with federal law.
(c) (1) (i) In this subsection the following words have the meanings
indicated.
(ii) "Certified nurse practitioner" means a registered nurse
who is licensed in this State, has completed a nurse practitioner program approved
by the State Board of Nursing, and has passed an examination approved by that
Board.
(iii) "Nurse anesthetist" means a registered nurse who is:
1. Certified under the Health Occupations Article to
practice nurse anesthesia; and
2. Certified by the Council on Certification or the
Council on Recertification of Nurse Anesthetists.
(iv) "Nurse midwife" means a registered nurse who is licensed
in this State and has been certified by the American College of Nurse-Midwives as a
nurse midwife.
(v) "Optometrist" has the meaning stated in § 11-101 of the
Health Occupations Article.
(2) The Secretary may contract for the provision of care under the
Program to eligible Program recipients.
(3) The Secretary may contract with insurance companies or
nonprofit health service plans or with individuals, associations, partnerships,
incorporated or unincorporated groups of physicians, chiropractors, dentists,
podiatrists, optometrists, pharmacists, hospitals, nursing homes, nurses, including
nurse anesthetists, nurse midwives and certified nurse practitioners, opticians, and
other health practitioners who are licensed or certified in this State and perform
services on the prescription or referral of a physician.
(4) For the purposes of this section, the nurse midwife need not be
under the supervision of a physician.
(5) Except as otherwise provided by law, a contract that the
Secretary makes under this subsection shall continue unless terminated under the
terms of the contract by the Program or by the provider.
(d) As permitted by federal law or waiver, the Secretary may administer the
Medicare Option Prescription Drug Program, established under § 15-124.3 of this
subtitle, as part of the Maryland Medical Assistance Program.
(e) By regulation, the Department shall adopt a methodology to ensure that
federally qualified health centers are paid reasonable cost-based reimbursement that
is consistent with federal law.
(f) (1) The Department shall establish mechanisms for:
(i) Identifying a Program recipient's primary care provider at
the time of enrollment into a managed care program; and
(ii) Maintaining continuity of care with the primary care
provider if:
1. The provider has a contract with a managed care
organization or a contracted medical group of a managed care organization to provide
primary care services; and
2. The recipient desires to continue care with the
provider.
(2) If a Program recipient enrolls in a managed care organization and
requests assignment to a particular primary care provider who has a contract with
the managed care organization or a contracted group of the managed care
organization, the managed care organization shall assign the recipient to the primary
care provider.
(3) A Program recipient may request a change of primary care
providers within the same managed care organization at any time and, if the primary
care provider has a contract with the managed care organization or a contracted
group of the managed care organization, the managed care organization shall honor
the request.
(4) In accordance with the federal Health Care Financing
Administration's guidelines, a Program recipient may elect to disenroll from a
managed care organization if the managed care organization terminates its contract
with the Department.
(5) A Program recipient may disenroll from a managed care
organization to maintain continuity of care with a primary care provider if:
(i) The contract between the primary care provider and the
managed care organization or contracted group of the managed care organization
terminates because:
1. The managed care organization or contracted group
of the managed care organization terminates the provider's contract for a reason
other than quality of care or the provider's failure to comply with contractual
requirements related to quality assurance activities;
2. A. The managed care organization or contracted
group of the managed care organization reduces the primary care provider's capitated
or applicable fee for services rates;
B. The reduction in rates is greater than the actual
change in rates or capitation paid to the managed care organization by the
Department; and
C. The provider and the managed care organization or
contracted group of the managed care organization are unable to negotiate a mutually
acceptable rate; or
3. The provider contract between the provider and the
managed care organization is terminated because the managed care organization is
acquired by another entity; and
(ii) 1. The Program recipient desires to continue to receive
care from the primary care provider;
2. The provider contracts with at least one other
managed care organization or contracted group of a managed care organization; and
3. The enrollee notifies the Department or the
Department's designee of the enrollee's intention within 90 days after the contract
termination.
(6) The Department shall provide timely notification to the affected
managed care organization of an enrollee's intention to disenroll under the provisions
of paragraph (5) of this subsection.‹ Prev All Maryland sections Next ›
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