PROPOSAL
Maryland Register
Issue Date: July 20, 2018
Volume 45 • Issue 15 • Pages 733 - 735
Title 10
MARYLAND DEPARTMENT OF HEALTH
Notice of Proposed Action
[18-180-P]
The Secretary of Health proposes to:
(1) Amend Regulations .01 and .02 under COMAR 10.01.04 Fair Hearing Appeals Under the Maryland State Medical Assistance Program;
(2) Amend Regulations .02 and .05 under COMAR 10.09.63 Maryland Medicaid Managed Care Program: Eligibility and Enrollment;
(3) Amend Regulations .19, .20, and .27 and adopt new Regulations .26-4 and .26-5 under COMAR 10.09.67 Maryland Medicaid Managed Care Program: Benefits; and
(4) Amend Regulation .03 under COMAR 10.09.70 Maryland Medicaid Managed Care Program: Non-Capitated Covered Services.
Statement of Purpose
The purpose of this action is to:
(1) Correct the time frame and conditions under which an enrollee can request a State fair hearing;
(2) Update eligibility regulations to coincide with current business practices;
(3) Require that enrollees applying through the Maryland Health Exchange choose an MCO at time of application or be automatically assigned to an MCO;
(4) Require MCOs to cover a single dispensing supply of up to 12 months for prescription contraceptives; and
(5) Require MCOs to cover audiology for adults and children and remote patient monitoring.
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
I. Summary of Economic Impact. The proposed action will save the Department a total of $4,000,000 because it moves Medicaid participants from fee-for-service Medicaid coverage to MCO coverage.
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Revenue (R+/R-) |
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II. Types of Economic Impact. |
Expenditure
(E+/E-) |
Magnitude |
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A. On issuing agency: |
(E-) |
$4,000,000 |
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B. On other State agencies: |
NONE |
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C. On local governments: |
NONE |
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Benefit (+)
Cost (-) |
Magnitude |
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D. On regulated industries or trade groups: |
NONE |
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E. On other industries or trade groups: |
NONE |
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F. Direct and indirect effects on public: |
NONE |
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III. Assumptions. (Identified by Impact Letter and Number from Section II.) |
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A. The cost savings (i.e., $4,000,000 in total funds; $2,000,000 in general funds) reflect the impact of moving Medicaid fee-for-service participants to MCOs, which saves the Department money due to the fixed per-person cost paid to MCOs. |
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 W. Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499 (TTY 800-735-2258), or email to mdh.regs@maryland.gov, or fax to 410-767-6483. Comments will be accepted through August 20, 2018. A public hearing has not been scheduled.
Subtitle 01 PROCEDURES
10.01.04 Fair Hearing Appeals Under the Maryland State Medical Assistance Program
Authority: Health-General Article, §2-104, Annotated Code of Maryland
.01 Definitions.
A. (text unchanged)
B. Terms Defined.
(1) (text unchanged)
(2) “Action by an MCO” means:
(a) Denial or limited authorization of a requested service, including [the type or level of service;]:
(i) The type or level of service;
(ii) Requirements for medical necessity;
(iii) Appropriateness;
(iv) Setting; or
(v) Effectiveness of a covered benefit;
(b)—(c) (text unchanged)
(d) Failure to provide services in a timely manner; [or]
(e) Failure to act within the required time frames[.]; or
(f) The denial of an enrollee’s request to dispute a financial liability, including:
(i) Cost sharing;
(ii) Copayments;
(iii) Premiums;
(iv) Deductibles;
(v) Coinsurance; or
(vi) Other enrollee financial liabilities.
(3)—(14) (text unchanged)
.02 Opportunity for a Fair Hearing.
A. An opportunity for a fair hearing shall be granted if:
(1)—(7) (text unchanged)
(8) A Program [recipient] participant in an MCO is appealing an action by an MCO and the appeal has been filed within [90] 120 days from the date specified in the notice from the MCO as required by COMAR 10.09.71.05.
[B. Alternative Processes for Program Recipient Enrolled in an MCO.
(1) A Program recipient in an MCO may exercise appeal rights as specified in Regulation .04 of this chapter and COMAR 10.09.71.05 without first exhausting the MCO complaint and appeal procedures specified in COMAR 10.09.71.
(2) A Program recipient in an MCO who receives an adverse decision following the MCO appeals process set forth in COMAR 10.09.71.05 may request a fair hearing within 10 days of the date of the adverse decision according to COMAR 10.09.71.05 and Regulation .04 of this chapter.]
[C.] B. (text unchanged)
Subtitle 09 MEDICAL CARE PROGRAMS
10.09.63 Maryland Medicaid Managed Care Program: Eligibility and Enrollment
Authority: Health-General Article, §15-103(b)(16) and (23), Annotated Code of Maryland
.02 Enrollment.
A. The Department shall [provide to waiver-eligible individuals] make available through its website and upon request provide a paper copy of the following:
(1)—(4) (text unchanged)
B. Only the Department, or its designee, is authorized to enroll individuals into MCOs.
[C. Individuals who are new waiver-eligible recipients shall be enrolled in an MCO within 1 month of the Department's receipt of notice of the individual's Medical Assistance eligibility.
D. Upon determination of Maryland Medicaid Managed Care Program eligibility, the Department shall enroll eligible individuals into an MCO by:
(1) Mail;
(2) Telephone;
(3) Face-to-face meeting, if requested;
(4) Face-to-face meeting in the recipient’s home, if medically necessary; or
(5) Online.]
C. A participant found eligible for Maryland Medicaid under 42 U.S.C §1902(a)(10)A(i) shall be assigned to:
(1) The MCO the participant chooses at the time of application; or
(2) If the participant does not choose, an MCO with available capacity that is accepting new participants in the participant’s service area.
D. Except for a participant found eligible as described in §C of this regulation, a participant, including a child in foster care or kinship care, shall:
(1) Have 28 days from the day the Department mails its eligibility notification in which to select an MCO; or
(2) Be assigned to an MCO with available capacity that is accepting new participants in the participant’s service area.
E. All Managed Care Program eligible family members who live in the same household shall be assigned to the same MCO.
[E.] F. [Children] Newborns.
(1)—(3) (text unchanged)
[(4) The following children shall be automatically enrolled in the MCO of the adoptive parent unless the parent notifies the Department otherwise:
(a) A child who has been legally adopted;
(b) A child who is the subject of a petition for adoption who has been placed in the enrollee's home with the expectation that the placement will be permanent, and for whom a temporary custody order has been issued by a court of competent jurisdiction pending finalization of the child's adoption by the enrollee; or
(c) A child who is the subject of a petition by a licensed adoption agency for the termination of parental rights, and who has been placed in the enrollee's home by the licensed adoption agency with the expectation that the placement will be permanent and that the child will be legally adopted by the enrollee.
F. Recipient Selection of an MCO.
(1) Except as provided in §F2 of this regulation, a recipient shall have 21 days from the day the Department mails its eligibility notification in which to select an MCO.
(2) A recipient who is a child in foster care or kinship care shall have 60 days from the date the Department mails its eligibility notification in which to select an MCO.
(3) A recipient may select an MCO that does not serve the recipient's local access area, upon the approval of the Department and the MCO.
(4) Upon the request of the recipient or the recipient's representative, the Department shall arrange for a face-to-face meeting with a representative of the Department or its enrollment agent in order to assist a recipient in selecting an MCO.
G. Except as specified in COMAR 10.09.24.04F(3), a recipient who desires to be enrolled in a particular MCO shall personally authorize, either orally or in writing, enrollment into that MCO.
H. Automatic Assignment Criteria.
(1) Children in Foster and Kinship Care. An eligible recipient who is a child in foster care or kinship care, and who fails to elect an MCO within 60 days of the Department's mailing of eligibility notification shall be assigned to an MCO with available capacity that accepts new enrollees in accordance with the procedures specified in §H(2) of this regulation.
(2) Except as provided in §H(1) of this regulation, an eligible recipient who fails to elect an MCO within 21 days of the Department's mailing of eligibility notification shall be assigned to an MCO with available capacity that accepts new enrollees as follows:
(a) Unless inconsistent with assigning household members to the same MCO pursuant to §H(2)(b) of this regulation, the Department shall randomly assign the recipient to any MCO in the local access area; or
(b) The Department shall, in addition to assigning the recipient to an MCO pursuant to §H(2)(a) of this regulation, assign to the same MCO all the recipient's family members who:
(i) Are simultaneously eligible for enrollment in the Maryland Medicaid Managed Care Program; and
(ii) Live in the same household as the recipient.]
[I.] G. Effective Date of Enrollment. Enrollment in an MCO shall be effective at 12:01 a.m.[, local time,] on the 10th calendar day beginning with the day on which the Department notifies the MCO of the enrollment.
H. Upon the approval of the Department and the MCO, a participant may select an MCO that does not serve the participant’s service area.
[J. Recipient Notification of MCO Enrollment. Within 10 days of notice from the Department or its enrollment agent that a recipient has been enrolled in its organization, an MCO shall notify the recipient of the assignment.
K. An MCO shall furnish to the Department and its enrollment agent on a monthly basis an updated list of the providers in the MCO's network, indicating practices that are accepting new patients.]
[L] I. The [enrollment broker] Department or its designee shall submit the enrollee's choice of PCP to the enrollee's selected MCO at the time of enrollment.
.05 Reassignment.
A.—D. (text unchanged)
E. A Program [recipient] participant who has been disenrolled from an MCO because the Department terminated the MCO's contract shall be assigned to another MCO subject to Regulation [.02H] .02D of this chapter.
10.09.67 Maryland Medicaid Managed Care Program: Benefits
Authority: Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland
.19 Benefits — Family Planning Services.
A.—C. (text unchanged)
D. An MCO shall provide coverage for a single dispensing of a supply of prescription contraceptives for a [6-month] 12-month period.
[E. The requirement in §D of this regulation does not apply to the first 2-month supply of prescription contraceptives dispensed to a member under:
(1) The initial prescription for the contraceptives; or
(2) Any subsequent prescription for a contraceptive that is different than the last contraceptive dispensed.]
.20 Benefits — EPSDT Services.
A. (text unchanged)
B. The health care services described in §A(3) of this regulation shall include, at a minimum, all services described in this chapter, and the following:
(1)—(2) (text unchanged)
[(3) Audiology services, as listed in the Maryland Medical Assistance Audiology Procedure Code and Fee Schedule, according to COMAR 10.09.51.04A(4);]
[(4)] (3) Private duty nursing services including:
(a) (text unchanged)
(b) On-going private duty nursing services delivered by a licensed practical nurse or a registered nurse; and
[(5)] (4) Durable medical equipment[; and
(6) All fees associated with cochlear implant surgery except for the device].
C. (text unchanged)
.26-4 Audiology.
An MCO shall provide enrollees medically necessary audiology services as described in COMAR 10.09.51, including:
A. Hearing aids;
B. Cochlear implants;
C. Auditory osseointegrated devices; and
D. Related services.
.26-5 Remote Patient Monitoring.
An MCO shall provide its enrollees medically necessary remote patient monitoring services as described in COMAR 10.09.96.
.27 Benefits — Limitations.
A. The benefits or services not required to be provided by an MCO are as follows:
(1)—(21) (text unchanged)
[(22) The purchase, examination, or fitting of hearing aids and supplies, and tinnitus maskers for adults 21 years old or older;
(23) Cochlear implant devices for adults 21 years old or older;]
[(24)] (22)—[(25] (23) (text unchanged)
B. (text unchanged)
10.09.70 Maryland Medicaid Managed Care Program: Non-Capitated Covered Services
Authority: Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland
.03 [Non Behavioral] Nonbehavioral Health Fee-For-Service Benefits.
An MCO may not be required to provide any of the following benefits or services that are reimbursed directly by the Department:
A.—F. (text unchanged)
[G. Audiology services including the purchase, examination, or fitting of hearing aids and supplies, and tinnitus masker for enrollees younger than 21 years old;
H. Cochlear implant devices for enrollees younger than 21 years old;]
[I.] G. Physical therapy, speech therapy, and occupational therapy[, and audiology] services when:
(1)—(2) (text unchanged)
[J.] H.—[P.] N. (text unchanged)
ROBERT R. NEALL
Secretary of Health
