Md. Code Regs. 10.09.57.03

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.57.03 - Conditions of Participation

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.

Md. Code Regs. 10.09.57.03

Regulations .03 adopted as an emergency provision effective June 14, 1995 (22:14 Md. R. 1051); adopted permanently effective October 23, 1995 (22:21 Md. R. 1616)