Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 2
Subtitle 09 - MEDICAL CARE PROGRAMS
Chapter 10.09.57 - Partially Capitated Programs
Section 10.09.57.03 - Conditions of Participation
Universal Citation: MD Code Reg 10.09.57.03
Current through Register Vol. 51, No. 19, September 20, 2024
A. A PCP shall meet the general conditions for participation as set forth in COMAR 10.09.36.03B.
B. In addition, the PCP shall:
(1) Ensure that all of its employees,
subcontractors, and employees of its subcontractors are appropriately licensed
in the jurisdiction in which they are practicing;
(2) Enter into and maintain contractual
arrangements necessary to meet the medical and health needs of enrollees for
which it is receiving a capitation payment, except for emergency treatment and
out-of-area referrals;
(3) Accept
all Medical Assistance recipients who qualify for the PCP's services who select
the PCP and who reside in the PCP's designated geographic area;
(4) Allow each enrollee to choose his or her
health professionals within the PCP to the extent possible and
appropriate;
(5) Comply with the
requirements of Regulations .05-----.12 of this chapter;
(6) Monitor the quality of the services its
subcontractors render to its enrollees;
(7) Be accessible 24 hours a day to enrollees
unless the Program waives this requirement in the provider agreement;
(8) Agree to provide services to enrollees as
promptly as appropriate;
(9) Have a
marketing plan which has been approved by the Department and conduct marketing
activities in accordance with that plan; and
(10) Meet all other applicable requirements
of federal and State law.
C. In accordance with 42 CFR § 434.26(b)(4), an applicant who does not come within one of the exceptions specified in 24 CFR § 434.26(b) shall request from the Department a waiver of 42 CFR § 434.26(a), which provides that Medicaid recipients and Medicare beneficiaries may constitute not more than 75 percent of the enrollees of a health maintenance organization or prepaid capitation plan. The Department shall pursue a waiver for good cause.
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