Md. Code Regs. 10.67.06.01 - Required Benefits Package - In General

A. Except for non-covered services set forth in Regulation .27 of this chapter and the non-capitated services described in COMAR 10.67.70, an MCO shall provide its enrollees with a benefits package that includes the covered services specified in this chapter when these services are deemed to be medically necessary including services covered under the Maryland Medicaid State Plan in the amount, duration, and scope set forth in the State Plan and in accordance with 42 CFR § 440.230.

B. An MCO shall ensure that the services provided are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished.

C. An MCO is not required to provide non-covered services even when the service is medically necessary.

D. Any limitations set forth in this chapter on covered services are not applicable to services required by enrollees who are younger than 21 years old when it is shown that the services are medically necessary to correct or lessen health problems detected or suspected by EPSDT screening services, as described in Regulation .20 of this chapter.

E. An MCO may place appropriate limits on a service on the basis of criteria applied under the State plan, such as medical necessity.

F. Cost Sharing and Prohibitions.

(1) Except for the following, an MCO may not charge its enrollees any copayments, premiums, or cost sharing:

(a) Up to a $3 copayment for brand-name drugs;

(b) Up to a $1 copayment for generic drugs;

(c) Any other charge up to fee-for-service limits as approved by the Department.

(2) An MCO may not:

(a) Deny services to an individual who is eligible for services because of the individual's inability to pay the cost sharing;

(b) Restrict its enrollees' access to needed drugs and related pharmaceutical products by requiring that enrollees use mail-order pharmacy providers; or

(c) Arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the enrollee.

G. An MCO shall ensure that all health care services provided under this chapter are performed, to the extent required by law, by an appropriate health care provider who is licensed, certified, or otherwise legally authorized to practice or deliver the services in the state in which the service is provided.

G. H. An MCO shall provide for a second opinion from a qualified health care professional within the network, or, if necessary, arrange for the enrollee to obtain one outside the MCO network.

Notes

Md. Code Regs. 10.67.06.01

Regulations .01 recodified from 10.09.67.01 effective 46:22 Md. R. 976, eff. 11/1/2019