Md. Code Regs. 10.67.05.07

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

Section 10.67.05.07 - Access Standards: Clinical and Pharmacy Access

A. Appointments.

(1) New Enrollees: Initial Appointment.

(a) On its receipt and review of the health service needs information of a new enrollee, an MCO shall take appropriate action to ensure that the new enrollee who needs special or immediate health care services, as identified by the health service needs information, receives them in a timely manner.

(b) Unless the new enrollee is assigned to a PCP who was the enrollee's established provider of care immediately before the enrollee's enrollment, and, consistent with any applicable periodicity schedule, the PCP concludes that no immediate initial appointment is necessary:

(i) Unless a shorter time frame otherwise applies, the MCO shall ensure that a new enrollee's initial appointment is scheduled to occur within 90 days of the date of enrollment;

(ii) Unless the PCP confirms that the enrollee has elected to continue prenatal care with her established provider pursuant to COMAR 10.67.67.28C, the MCO shall ensure that an initial prenatal appointment is scheduled to occur within 10 days of the date that the MCO receives the enrollee's completed health risk assessment, or within 10 days of the enrollee's request for an appointment, whichever is sooner;

(iii) If the new enrollee is a person requesting family planning services, the MCO shall ensure that an initial appointment is scheduled to occur within 10 days of the date of the enrollee's request for an appointment; or

(iv) If the new enrollee is identified to be at high risk by the health service needs information form, the MCO shall ensure that an initial appointment is scheduled to occur within 15 business days of the MCO's receipt of the enrollee's completed health risk assessment.

(2) Required Notice to Enrollees of Wellness Services,

(a) An MCO shall notify its enrollees in writing of their due dates for obtaining wellness services, including but not limited to immunizations and examinations, in a timely manner.

(b) An MCO shall perform the notice required in §A(2)(a) of this regulation within 90 days of a new enrollee's enrollment.

(3) Appointment Guidelines.

(a) An MCO shall develop specific guidelines that define how requests for appointments are arranged, which shall include a policy that:

(i) On request, all family members needing appointments will be given appointment times that are approximately concurrent or consecutive, whenever practicable, to facilitate the enrollees' transportation to and from their appointments; and

(ii) When needed, enrollees will be afforded assistance in securing transportation to and from appointments, which shall include, when appropriate, contacting the local transportation grantee agency on behalf of the enrollee for the purpose of securing the enrollee's access to these services.

(b) An MCO shall have 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) When §A(3)(b)(i) of this regulation does not apply, well-child assessments shall be scheduled to be completed within 30 days of the request for an appointment;

(ii) Initial assessments of pregnant and postpartum women and individuals requesting family planning services shall be scheduled to be completed within 10 business days of the request for an appointment;

(iii) Individuals requesting urgent care shall be scheduled to be seen within 48 hours of the request;

(iv) Requests for routine and preventative primary care appointments shall be scheduled to be performed within 30 days of the request;

(v) Requests for routine specialist follow-up appointments shall be scheduled to be performed within 30 days of the initial authorization from the enrollee's primary care provider, or sooner as deemed necessary by the primary care provider, whose office staff shall make the appointment directly with the specialist's office;

(vi) At the discretion of the newborn's PCP, the initial visit for newborns shall be scheduled to be performed within 14 days of discharge from the hospital if no home visit has occurred;

(vii) If a home visit has been provided, the initial visit for newborns shall be scheduled to be performed, at the discretion of the newborn's PCP, within 30 days of discharge from the hospital; and

(viii) Requests for regular optometry, lab, and X-ray appointments shall be scheduled to be performed within 30 days of the request, and within 48 hours of the request for urgent care.

B. An MCO shall respond in a timely manner to its enrollees' needs and requests, as follows:

(1) If the enrollee arrives early or on time for a scheduled appointment, waiting time to be seen for a regular office visit may not exceed 1 hour after the scheduled appointment time;

(2) An MCO representative may not leave an enrollee's telephone call on hold for more than 10 minutes; and

(3) An MCO representative shall respond to patient inquiries as to whether or not to use emergency facilities within 30 minutes.

C. Hours of Access for Clinical Services.

(1) An MCO shall establish, or require its subcontractors to establish, a reasonable schedule of operating hours during which its service delivery sites are open to the MCO's enrollees as follows:

(a) For the MCO's employee and subcontractor providers who are individual practitioners, operating hours shall be at least 20 hours per week and at least 3 days per week;

(b) For subcontractors who have contracted with the MCO as a group practice or facility, the operating hours shall be at least 35 hours per week;

(c) The distribution of the hours of service shall be consistent with enrollee utilization patterns, but is otherwise at the discretion of the MCO or its subcontractor; and

(d) The operating hours may not be less than:

(i) The hours of operation offered to commercial enrollees; or

(ii) The hours of operation offered to Medicaid fee-for-service, if the provider serves only Medicaid enrollees.

(2) Hours of Access for Pharmacy Services.

(a) An MCO shall establish reasonable hours of access to pharmacy services, including weekend and evening hours, which are equivalent to the hours pharmacy services are generally available in the local access area to the public at large.

(b) If the MCO determines that weekend and evening pharmacy hours are not generally available in the local access area, it may request approval from the Department to offer only limited pharmacy hours as specified in §C(2)(c) of this regulation.

(c) To seek approval to offer limited pharmacy hours, an MCO shall make its request for approval to the Department, and shall include the following:

(i) A specification of the geographical areas where the MCO intends to have limited pharmacy hours;

(ii) An explanation of why only limited pharmacy hours are available in these areas; and

(iii) An identification of where its enrollees would have to go to secure prescriptions in the evenings and on weekends.

(d) Except as permitted in §C(2)(e) of this regulation, an MCO shall ensure that an enrollee receives at the time the prescription is dispensed to the enrollee any medically necessary disposable medical supplies or durable medical equipment needed by the enrollee to administer or monitor the enrollee's prescriptions.

(e) An MCO shall ensure that any disposable supplies or durable medical equipment necessary to administer or monitor an enrollee's prescriptions, if not available at the pharmacy at the time of the dispensing of the prescription, is received in a manner so as not to adversely effect the health of the enrollee, but not later than 24 hours.

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

(1) Subject to §D(2) of this regulation, an MCO shall be financially responsible for medically necessary emergency services delivered to its enrollees outside of the MCO's service area.

(2) With the exception of emergency services, an MCO may require authorization before treatment for services delivered to its enrollees outside of the MCO's service area.

(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. The Department may not impose any fines or other sanctions against an MCO for failure to comply with the waiting time standards in §B of this regulation unless there is evidence of a pattern of repeated violations by the MCO.

Md. Code Regs. 10.67.05.07

Regulations .07 recodified from 10.09.66.07 effective 46:22 Md. R. 976, eff. 11/1/2019