Md. Code Regs. 10.67.06.28

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

Section 10.67.06.28 - Benefits - Self-Referral Services

A. An MCO shall be financially responsible for reimbursing, in accordance with COMAR 10.67.04.20, an out-of-plan provider chosen by the participant for the following services:

(1) Family planning services specified in COMAR 10.67.65.20A(2), (6), and (7);

(2) Services performed by school-based health centers (SBHCs), as provided in COMAR 10.67.76;

(3) Pregnancy-related services for women who are pregnant and, at the time of initial enrollment, have received prenatal care during their current pregnancy from an out-of-plan provider, and this pre-enrollment care consists of at least the following:

(1) A full prenatal examination;

(2) A risk assessment; and

(3) Appropriate laboratory services;

(4) Initial medical examination for children in State custody when performed by an EPSDT certified provider;

(5) One annual diagnostic and evaluation service (DES) visit for any enrollee diagnosed with HIV/AIDS, which the MCO is responsible for facilitating on the enrollee's behalf;

(6) Renal dialysis services performed in a Medicare-certified facility;

(7) Initial medical examination of a newborn when the:

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

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

(8) Emergency services as described in COMAR 10.67.05.08B ;

(9) Prenatal, intrapartum, and postpartum services performed at a free-standing birth center located in Maryland or a contiguous state; and

(10) Doula services, through December 31, 2025.

B. An MCO shall pay undisputed claims of the SBHC for services provided to its participants within 30 days of the MCO's receipt of the invoice.

C. An MCO shall provide SBHCs in its service area with the current information needed to facilitate communication between the SBHC, PCP, and the MCO regarding care provided to the MCO's participant, and to effect reimbursement by the MCO, including:

(1) Information concerning the MCO's policies and procedures regarding the provision of pharmacy and laboratory services;

(2) Instructions for submitting claims; and

(3) Contact information, including names and phone numbers of the following individuals:

(a) The MCO representative who serves as an SBHCs contact person for coordination of care; and

(b) The student-participant's PCP.

Md. Code Regs. 10.67.06.28

Regulations .28 recodified from 10.09.67.28 effective 46:22 Md. R. 976, eff. 11/1/2019; amended effective 51:12 Md. R. 620, eff. 6/24/2024.