Ch. 4

2004 LAWS OF MARYLAND

(4)      THE SECRETARY SHALL INCLUDE A DEFINITION OF "MEDICAL
NECESSITY" IN ITS QUALITY AND ACCESS STANDARDS.

(5)      NOTHING IN THE COMMUNITY CHOICE PROGRAM MAY PRECLUDE A
NURSING HOME FROM UTILIZING AN INSTITUTIONAL PHARMACY OF ITS OWN
CHOICE FOR THE PROVISION OF INSTITUTIONAL PHARMACY SERVICES AND
BENEFITS FOR WAIVER ENROLLEES IN THE NURSING HOME.

(E)     COMMUNITY CHOICE PROGRAM RECIPIENTS SERVED BY THE PROGRAM
DEVELOPED UNDER THIS SECTION SHALL BE ALLOWED TO CHOOSE AMONG AT
LEAST TWO COMMUNITY CARE ORGANIZATIONS THAT HAVE DEMONSTRATED A
NETWORK CAPACITY SUFFICIENT TO MEET THE NEEDS OF THE POPULATION.

(F)     (1) ON AN ANNUAL BASIS OR FOR CAUSE, AN ENROLLEE MAY CHOOSE
TO DISENROLL FROM A COMMUNITY CARE ORGANIZATION AND ENROLL IN ANOTHER
COMMUNITY CARE ORGANIZATION.

(2)      EACH ENROLLEE RECEIVING SERVICES IN A NURSING HOME, AN
ASSISTED LIVING FACILITY, OR AN ADULT DAY CARE FACILITY, A PSYCHIATRIC
REHABILITATION PROGRAM, OR A RESIDENTIAL REHABILITATION PROGRAM SHALL
HAVE THE OPTION OF REMAINING IN THE NURSING HOME, ASSISTED LIVING
FACILITY, OR ADULT DAY CARE FACILITY, PSYCHIATRIC REHABILITATION PROGRAM,
OR RESIDENTIAL REHABILITATION PROGRAM.

(3)      AN ENROLLEE OF THE PROGRAM WHO QUALIFIES FOR NURSING
LEVEL CARE MAY CHOOSE TO RECEIVE SERVICES IN A NURSING HOME OR IN THE
COMMUNITY, IF THE COMMUNITY PLACEMENT IS COST-EFFECTIVE.

(4)      THE COMMUNITY CHOICE PROGRAM SHALL ENSURE THAT ALL
ENROLLEES IN THE PROGRAM MAINTAIN ACCESS TO PHARMACY BENEFITS,
INCLUDING ALL CLASSES OF DRUGS, THAT ARE COMPARABLE TO THE BENEFITS
PROVIDED IN THE MEDICAL ASSISTANCE PROGRAM.

(G)     (1) EACH COMMUNITY CARE ORGANIZATION SHALL PROVIDE FOR THE
BENEFITS DESCRIBED IN SUBSECTION (D) OF THIS SECTION.

(2)      THIS SECTION MAY NOT BE CONSTRUED TO PREVENT A COMMUNITY
CARE ORGANIZATION FROM PROVIDING ADDITIONAL BENEFITS THAT ARE NOT
COVERED BY A CAPITATED RATE.

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

(II)     THE SECRETARY SHALL SET CAPITATION PAYMENTS AT A
LEVEL THAT IS ACTUARIALLY ADJUSTED FOR THE BENEFITS PROVIDED.

(III)   THE SECRETARY SHALL ADJUST CAPITATION PAYMENTS TO
REFLECT THE RELATIVE RISK ASSUMED BY THE COMMUNITY CARE ORGANIZATION.

(H) THE DEPARTMENT SHALL REQUIRE COMMUNITY CARE ORGANIZATIONS
TO BE CERTIFIED TO ACCEPT CAPITATED PAYMENTS FROM THE FEDERAL MEDICARE
PROGRAM FOR INDIVIDUALS WHO ARE DUALLY ELIGIBLE.

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