Md. Code Regs. 10.67.04.20

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.04.20 - MCO Payment for Self-Referred, Emergency, Physician, and Hospital Services

A. MCO Payment for Self-Referred Services.

(1) For undisputed claims that are submitted to the MCO within 6 months of the date of service, an MCO shall reimburse out-of-plan providers within 30 days for eligible services performed upon an enrollee who has self-referred:

(a) To a school-based health clinic pursuant to COMAR 10.67.67.28B, for services described in COMAR 10.67.68;

(b) For family planning services, pursuant to COMAR 10.67.67.28A;

(c) For an initial medical examination for an enrollee who is a child in State-supervised care, pursuant to Regulation .13F of this chapter;

(d) For one annual diagnostic and evaluation service visit for an enrollee diagnosed with human immunodeficiency virus or acquired immune deficiency syndrome (HIV/AIDS) pursuant to COMAR 10.67.67.28E;

(e) For obstetric and gynecologic care provided to a pregnant woman, under the circumstances described in COMAR 10.67.67.28C; and

(f) For an initial medical examination of a newborn when the:

(i) Examination is performed in a hospital by an on-call physician; and

(ii) MCO failed to provide for the service before the newborn's discharge from the hospital.

(2) An MCO shall reimburse out-of-plan providers to whom enrollees have self-referred for school-based services as described in COMAR 10.67.68.03 and family planning services including office visits (CPT codes 99201-99205 and 99211-99215), preventive medicine office visits (CPT codes 99383-99386 and 99393-99396), and all FDA-approved contraceptive devices, methods and supplies, at the established Medicaid rates.

(3) An MCO shall reimburse out-of-plan providers to whom enrollees have self-referred for an initial examination for a child in State-supervised care utilizing the Medicaid payment schedule for the following procedure codes:

CPT code	Service Description
Initial Comprehensive Preventive Medicine (New Patient)
99381	Infant (younger than 1 year old)
99382	Early childhood (1-4 years old)
99383	Late childhood (5-11 years old)
99384	Adolescent (12-17 years old)
Periodic Comprehensive or Preventive Services (Established Patient)
99391	Infant (younger than 1 year old)
99392	Early childhood (1-4 years old)
99393	Late childhood (5-11 years old)
99394	Adolescent (12-17 years old)

(4) An MCO shall reimburse out-of-plan providers rendering pregnancy-related services, as described in COMAR 10.67.06.28, at the Medicaid rate.

(5) An MCO shall reimburse out-of-plan providers performing the DES for HIV/AIDS at the Medicaid rate.

(6) An MCO may require enrollees to utilize in-plan providers for pharmacy and laboratory services ordered by out-of-plan providers of self-referral services, except as provided in §A(7) of this regulation.

(7) An MCO shall reimburse out-of-plan providers at the Medicaid rate for medically necessary pharmacy and laboratory services when the pharmacy or laboratory service is provided:

(a) In connection with a self-referred service specified in §A(1) of this regulation; and

(b) On-site by the out-of-plan provider at the same location that the self-referred service specified in §A(1) of this regulation was delivered to the MCO's enrollee.

(8) An MCO shall reimburse out-of-plan providers for renal dialysis services in a Medicare-certified facility, at least the Medicaid rate, regardless of whether or not the MCO's preauthorization was secured.

(9) An MCO shall reimburse out-of-plan providers under the circumstances described in COMAR 10.67.67.28G at a rate not less than the fee-for-service Medicaid rate for an initial medical examination of a newborn when the mother's MCO fails to provide for the service before the newborn is discharged from the hospital.

(10) An MCO shall reimburse out-of-plan providers at the Medicaid fee-for-service rate for the substance abuse services described in COMAR 10.67.67.28.

(11) An MCO shall reimburse out-of-plan doulas at the Medicaid fee-for-service rate for services performed during the prenatal, labor and delivery, and postpartum periods of pregnancy as described in COMAR 10.67.06.28 through December 31, 2025.

B. MCO Payment for Emergency Services Provided at a Hospital. An MCO shall reimburse a hospital emergency facility and provider, which is not required to obtain prior authorization or approval for payment from an MCO in order to obtain reimbursement under this regulation, for:

(1) Health care services that meet the definition of emergency services in Health-General Article, §19-701, Annotated Code of Maryland;

(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 MCO authorized, referred, or otherwise instructed the enrollee to use the emergency facility and the medically necessary services are related to the emergency condition; 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 MCO fails to provide 24-hour access to a physician.

C. MCO Payment to an Out-of-Network Federally Qualified Health Center for Services Immediately Required Due to an Unforeseen Illness, Injury, or Condition.

(1) Effective October 1, 2010, an MCO shall reimburse an out-of-network federally qualified health center (FQHC) for services provided to an enrollee that are immediately required due to an unforeseen illness, injury, or condition if:

(a) The FQHC participates in the Medical Assistance Program;

(b) The FQHC does not have a contract with the MCO;

(c) The services are immediately required due to the enrollee's unforeseen illness, injury, or condition;

(d) The emergent services are provided on site at the FQHC; and

(e) The FQHC has, before rendering services, verified with the enrollee's primary care provider that the enrollee cannot be seen within a reasonable amount of time based on the severity of the enrollee's condition.

(2) An MCO may require that the FQHC provide documentation that the FQHC has obtained the verification required under §C(1)(e) of this regulation. An MCO is not required to reimburse an out-of-network FQHC for emergent services provided to an enrollee if the FQHC fails to provide the documentation.

(3) An MCO may require that the FQHC provide documentation that services were required for the reasons identified under §C(1)(c) of this regulation. An MCO is not required to reimburse an out-of-network FQHC for emergent services provided to an enrollee if the FQHC fails to provide the documentation.

(4) The rate at which the MCO shall reimburse an out-of-network FQHC for services provided under §C(1) of this regulation shall be the rate identified in COMAR 10.67.65.21.

(5) For any reimbursement paid by an MCO under §C of this regulation, the Program shall pay the MCO the difference between the rates identified in COMAR 10.67.65.21 and COMAR 10.67.08.05-1.

D. MCO Payment for Provider Services.

(1) An MCO shall pass on to providers any MCO rate adjustment that is specified by the Department for a fee increase.

(2) For inpatient services performed in hospitals, an MCO shall pay all providers, regardless of the provider's contracting status, at least the Medicaid fee-for-service rate.

(3) The MCO may not be required to pay providers more than the Medicaid fee-for-service rate.

E. Payment for Hospital Services.

(1) An MCO shall reimburse Maryland hospital providers on the basis of rates approved by the Maryland Health Services Cost Review Commission (HSCRC).

(2) An MCO shall reimburse hospital administrative days at the Medicaid fee-for-service rate.

(3) Upon the direction of the Department, an MCO shall reduce payments by 20 percent to a hospital located in a contiguous state or in the District of Columbia for services rendered to its enrollees, if the hospital has failed to supply appropriate discharge data to the Health Services Cost Review Commission.

Md. Code Regs. 10.67.04.20

Regulations .20 recodified from 10.09.65.20 effective 46:22 Md. R. 976, eff. 11/1/2019; amended effective 51:12 Md. R. 620, eff. 6/24/2024.