PARRIS N. GLENDENING, Governor

Ch. 352

(II) FOR CALENDAR YEAR 1997, IF THE MANAGED CARE
ORGANIZATION'S LOSS RATIO IS LESS THAN 80% OR ITS EXPENSE RATIO IS GREATER
THAN 20%, THE DEPARTMENT SHALL ADJUST THE PAYMENTS MADE TO THE
MANAGED CARE ORGANIZATION, UNLESS THE DEPARTMENT GRANTS A WAIVER
FROM THESE REQUIREMENTS.

(III) FOR CALENDAR YEAR 1998 AND AFTER, IF THE MANAGED
CARE ORGANIZATION'S LOSS RATIO IS LESS THAN 85% OR ITS EXPENSE RATIO IS
GREATER THAN 15%, THE DEPARTMENT SHALL ADJUST THE PAYMENTS MADE TO
THE MANAGED CARE ORGANIZATION, UNLESS THE DEPARTMENT GRANTS A
WAIVER FROM THESE REQUIREMENTS.

(16) (I) THE DEPARTMENT SHALL MAKE CAPITATION PAYMENTS TO EACH
MANAGED CARE ORGANIZATION AS PROVIDED IN THIS PARAGRAPH.

(II) IN CONSULTATION WITH THE INSURANCE COMMISSIONER THE
SECRETARY SHALL:

1.        SET CAPITATION PAYMENTS AT A LEVEL THAT IS
ACTUARIALLY ADJUSTED TO THE BENEFITS PROVIDED; AND

2.        ACTUARIALLY ADJUST THE CAPITATION PAYMENTS TO
REFLECT THE RELATIVE RISK ASSUMED BY THE MANAGED CARE ORGANIZATION.

(13) (17) (I) SCHOOL-BASED CLINICS AND MANAGED CARE
ORGANIZATIONS SHALL COLLABORATE TO PROVIDE CONTINUITY OF CARE TO
ENROLLEES.

(II) SCHOOL-BASED CLINICS SHALL BE DEFINED BY THE
DEPARTMENT IN CONSULTATION WITH THE STATE DEPARTMENT OF EDUCATION.

(III) A EACH MANAGED CARE ORGANIZATION SHALL REQUIRE A
SCHOOL-BASED CLINIC TO PROVIDE TO THE MANAGED CARE ORGANIZATION
CERTAIN INFORMATION, AS SPECIFIED BY THE DEPARTMENT, ABOUT AN
ENCOUNTER WITH AN ENROLLEE OF THE MANAGED CARE ORGANIZATION PRIOR
TO PAYING THE SCHOOL-BASED CLINIC AT MEDICAID-ESTABLISHED RATES.

(IV) A MANAGED CARE ORGANIZATION SHALL MAINTAIN A
RECORD OF ALL SERVICES FOR WHICH IT HAS BEEN BILLED THAT HAVE BEEN
PROVIDED TO AN ENROLLEE BY A SCHOOL-BASED CLINIC.

(IV)    UPON RECEIPT OF INFORMATION SPECIFIED BY THE
DEPARTMENT THE MANAGED CARE ORGANIZATION SHALL PAY, AT
MEDICAID-ESTABLISHED RATES, SCHOOL-BASED CLINICS FOR COVERED SERVICES
PROVIDED TO ENROLLEES OF THE MANAGED CARE ORGANIZATION

(V)     THE DEPARTMENT SHALL WORK WITH MANAGED CARE
ORGANIZATIONS AND SCHOOL-BASED CLINICS TO DEVELOP COLLABORATION
STANDARDS, GUIDELINES, AND A PROCESS TO ASSURE THAT THE SERVICES
PROVIDED ARE COVERED AND MEDICALLY APPROPRIATE AND THAT THE PROCESS
PROVIDES FOR TIMELY NOTIFICATION AMONG THE PARTIES.

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