(a) Basic requirement.—(1) General rule. Except as specified in paragraphs (a)(2) and (a)(3) of this section, the State must ensure that MCOs and PHPs comply with the requirements of this section.

(2) PHP exception. For PHPs, the State determines, based on the scope of the entity's services, and on the way the State has organized the delivery of managed care services, whether a particular PHP is required—

(i) To perform the initial and ongoing screenings and assessments specified in paragraphs (d) and (e) of this section; and

(ii) To meet the primary care requirement of paragraph (h)(1) of this section.

(3) Exception for MCOs that serve dually eligible enrollees. (i) For an MCO that serves enrollees who are also enrolled in a Medicare+Choice plan and also receive Medicare benefits, the State determines to what extent that MCO must meet the initial screening, assessment, and treatment planning provisions of paragraphs (d), (e), and (f) of this section.

(ii) The State bases its determination on the services it requires the MCO to furnish to dually eligible enrollees.

(b) State responsibility to identify enrollees with special health care needs. The State must implement mechanisms to identify to the MCO and PHP, upon enrollment, the following groups:

(1) Enrollees at risk of having special health care needs, including—

(i) Children and adults who are receiving SSI benefits;

(ii) Children in Title IV-E foster care;

(iii) Enrollees over the age of 65; and

(iv) Enrollees in relevant, State-established, risk-adjusted, higher-cost payment categories.

(v) Any other category of recipients identified by CMS.

(2) Children under the age of 2.

(3) Other enrollees known by the State to be pregnant or to have special health care needs.

(c) Requirements for MCOs and PHPs. The State must ensure—

(1) That each MCO, and each PHP for which the State determines it is appropriate in accordance with paragraphs (a)(2) and (a)(3) of this section, meets the requirements of paragraphs (d), (e), and (h)(1) of this section; and

(2) That each MCO and each PHP meets the requirements of paragraphs (f), (g), and (h)(2) through (h)(6) of this section.

(d) Initial screening and assessment. Each MCO and each PHP must make a best effort attempt to meet the following standards:

(1) For enrollees identified under paragraph (b)(1) of this section,

(i) Performs enrollee screening within 30 days of receiving the identification; and

(ii) For any enrollee the screening identifies as being pregnant or having special health care needs, performs a comprehensive health assessment as expeditiously as the enrollee's health requires, but no later than 30 days from the date of identification.

(2) For enrollees identified under paragraphs (b)(2) and (b)(3) of this section, or who identify themselves as being pregnant or having special health care needs, performs a comprehensive health assessment as expeditiously as the enrollee's health requires, but no later than 30 days from the date of identification.

(3) For all other enrollees—

(i) Performs screening within 90 days from the date of enrollment; and

(ii) For any enrollee the screening identifies as being pregnant or having special health care needs, performs the comprehensive health assessment as expeditiously as the enrollee's health requires but no later than 30 days from the date of identification.

(e) On-going screening and assessment. Each MCO and each PHP must implement mechanisms to—

(1) Identify enrollees who develop special health care needs after they enroll in the MCO or PHP; and

(2) Perform comprehensive health assessments as expeditiously as the enrollee's health requires, but no later than 30 days from the date of identification.

(f) Treatment plans. For pregnant women and for enrollees determined to have special health care needs, each MCO and each PHP implements a treatment plan that—

(1) Is appropriate to the conditions and needs identified and assessed under paragraphs (d) and (e) of this section;

(2) Is for a specific period of time and is updated periodically;

(3) Specifies a standing referral or an adequate number of direct access visits to specialists;

(4) Ensures adequate coordination of care among providers;

(5) Is developed with enrollee participation; and

(6) Ensures periodic reassessment of each enrollee as his or her health condition requires.

(g) Use of health care professionals. Each MCO and each PHP uses appropriate health care professionals to—

(1) Perform any comprehensive health assessments required by this section; and

(2) Develop, implement, and update any treatment plans required by this section.

(h) Primary care and coordination program. Each MCO and each PHP must implement a coordination program that meets State requirements and achieves the following:

(1) Ensures that each enrollee has an ongoing source of primary care appropriate to his or her needs and a person or entity formally designated as primarily responsible for coordinating the health care services furnished to the enrollee.

(2) Coordinates the services the MCO or PHP furnishes to the enrollee with the services the enrollee receives from any other MCOs and PHPs;

(3) Shares with other MCOs and PHPs serving the enrollee the results of its screenings and assessments of the enrollee so that those activities need not be duplicated.

(4) Ensures that in the process of coordinating care, each enrollee's privacy is protected consistent with the confidentiality requirements in § 438.224.

(5) Ensures that each provider maintains health records that meet professional standards and that there is appropriate and confidential sharing of information among providers.

(6) Has in effect procedures to address factors (such as a lack of transportation) that may hinder enrollee adherence to prescribed treatments or regimens.

(7) Ensures that its providers have the information necessary for effective and continuous patient care and quality improvement, consistent with the confidentiality and accuracy requirements of § 438.224 and the information system requirements of § 438.242.