reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.56 - Home and Community-Based Services Waiver for Children with Autism Spectrum Disorder › Section 10.09.56.22 - Payment Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. Request for
				  Payment.
(1) An approved provider shall submit
				  requests for payment for the services covered under this chapter according to
				  the procedures set forth in COMAR
				  10.09.36.04B or
				  otherwise established by the Program.
(2) The provider shall:
(a) Bill the Program in accordance with the
				  payment methodology specified in §§D and E of this
				  regulation;
(b) Accept payment from
				  the Program as payment in full for the services covered under this chapter and
				  make no additional charge to the participant or any other party for these
				  services; and
(c) Submit a request
				  for payment in a manner approved by the Program, which includes the:
(i) Date or dates of service;
(ii) Participant's name and Medicaid
				  number;
(iii) Provider's name,
				  location, and Program identification number;
(iv) Type, procedure code or codes, and unit
				  or units of covered services provided; and
(v) Amount of reimbursement
				  requested.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.56 - Home and Community-Based Services Waiver for Children with Autism Spectrum Disorder › Section 10.09.56.23 - Recovery and Reimbursement

Current through Register Vol. 51, No. 14, July 12, 2024
Recovery and reimbursement are set forth in COMAR
					 10.09.36.07B and
					 include, but are not limited to:
A.
				  Providing waiver services without a valid required license or appropriate
				  credentials as required;
B.
				  Employing staff or consultants that do not meet conditions for participation in
				  accordance with Regulation .04 of this chapter to provide services to waiver
				  participants;
C. Lacking adequate
				  documentation of services that were billed to the Program;
D. Submitting claims for services not
				  authorized in the participant's plan of care; and
E. Providing services that are not in
				  accordance with the requirements of this chapter and other applicable
				  regulations and law.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.56 - Home and Community-Based Services Waiver for Children with Autism Spectrum Disorder › Section 10.09.56.24 - Cause for Suspension or Removal and Imposition of Sanctions

Current through Register Vol. 51, No. 14, July 12, 2024
A. Cause for
				  suspension or removal and imposition of sanctions is set forth in COMAR
				  10.09.36.08B.
B. In addition to the sanctions
				  specified at COMAR
				  10.09.36.08B, the
				  Department may limit:
(1) The number of
				  participants served by the provider; and
(2) The number and type of services
				  provided.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.56 - Home and Community-Based Services Waiver for Children with Autism Spectrum Disorder › Section 10.09.56.25 - Appeal Procedures for Providers

Current through Register Vol. 51, No. 14, July 12, 2024
Appeal procedures for providers are those set forth in
					 COMAR 10.09.36.09B.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.56 - Home and Community-Based Services Waiver for Children with Autism Spectrum Disorder › Section 10.09.56.26 - Appeal Procedures for Applicants and Participants

Current through Register Vol. 51, No. 14, July 12, 2024
Appeal procedures for applicants and participants are those
					 set forth in COMAR
					 10.09.24.13B and
					 10.01.04.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.56 - Home and Community-Based Services Waiver for Children with Autism Spectrum Disorder › Section 10.09.56.27 - Interpretive Regulation

Current through Register Vol. 51, No. 14, July 12, 2024
State regulations are interpreted as set forth in COMAR
					 10.09.36.10B.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.01 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter,
				  the following terms have the meanings indicated.
B. Terms Defined.
(1) "Applicant" means an entity which submits
				  an application to become a partially capitated provider.
(2) "Capitation payment" means the sum of
				  money paid by the Program on behalf of an enrollee on a regular periodic per
				  capita basis for capitated services.
(3) "Capitated services" means a service
				  provided by a PCP or one of its subcontractors for which the Department has
				  agreed to pay a capitation payment to the PCP.
(4) "Department" means the Department of
				  Health and Mental Hygiene, the single State agency designated to administer the
				  Maryland Medical Assistance Program under Title XIX of the Social Security Act,
				  42 U.S.C. §
												1396 et seq.
(5) "Enrollee" means a recipient who has
				  entered into an agreement to receive certain Medical Assistance services from
				  or through a PCP.
(6) "Medical
				  Assistance Program" has the meaning stated in COMAR
				  10.09.36.01B.
(7) "Partially capitated provider
				  (PCP)" means a public or private legal entity which is organized for the
				  purpose of providing or arranging for the provision of medical and
				  health-related services which meets the conditions for participation in
				  Regulations .02 and .03 of this chapter for enrollment and which is eligible to
				  enter into a contract with the Department to receive a capitated payment for a
				  limited number of services.
(8)
				  "Program" means the Maryland Medical Assistance Program as defined in COMAR
				  10.09.36.01B.
(9) "Provider" means a partially
				  capitated provider.
(10) "Provider
				  agreement" means the agreement between the Department and the partially
				  capitated provider which specifies the terms of the relationship between the
				  Department and the provider, and includes the amount of the capitation payment
				  and the specific services to be provided for the capitation payment.
(11) "Recipient" has the meaning stated in
				  COMAR 10.09.36.01B.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.02 - Application for Qualification as a Partially Capitated Provider

Current through Register Vol. 51, No. 14, July 12, 2024
A. An applicant
				  shall demonstrate to the satisfaction of the Department that it has the
				  managerial, financial, clinical, and administrative capability to carry out the
				  duties required by these regulations.
B. An applicant shall submit the following
				  documents to the Department along with a completed application form:
(1) A narrative of the applicant's overall
				  plan for providing and arranging for the provision of high quality services to
				  enrollees efficiently, effectively, and economically;
(2) A description of the organization and
				  staff responsible for delivering health care and a copy of the applicant's
				  organizational documents;
(3) An
				  annualized pro forma budget and financial plan for the operation of the
				  organization or, at the Department's option, of the appropriate unit within the
				  organization responsible for the operation for delivery of services pursuant to
				  this regulation for the first 3 years of its anticipated operations which
				  demonstrates its financial viability based on reasonable assumptions;
(4) An annualized cash flow chart;
(5) A statement of policy and procedures for
				  accounting, methods of reimbursing subcontractors, and payment of emergency and
				  out-of-area claims;
(6) Balance
				  sheets;
(7) Any other financial
				  information the Program requires;
(8) Full and complete information at all
				  times as to the identity of each person or corporation with an ownership or
				  control interest in the PCP and of any subcontractor in which the applicant has
				  a 5 percent or more ownership interest;
(9) A detailed description of the applicant's
				  quality assurance plan which demonstrates compliance with Regulation .07 of
				  this chapter;
(10) A description of
				  a system for the receipt and prompt adjudication of complaints and grievances
				  by enrollees which complies with Regulation .12 of this chapter;
(11) A description of the process by which
				  data about services provided will be collected;
(12) Copies of all of the applicant's
				  contracts with subcontractors;
(13)
				  A description of the boundaries of the geographic area or area the applicant
				  wishes to serve; and
(14) A copy of
				  the applicant's marketing plan.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.03 - Conditions of Participation

Current through Register Vol. 51, No. 14, July 12, 2024
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.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.04 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
Providers may be capitated for one of the following
					 packages of services subject to the approval of the Department:
A. Inpatient hospital services, as long as
				  the applicant, if regulated by the Health Services Cost Review Commission, has
				  received permission from that agency to receive capitation payments;
B. Mental health services, including but not
				  limited to, psychiatric inpatient treatment and community mental health
				  outpatient services;
C. Not more
				  than two of the following services or groups of services:
(1) Outpatient hospital services,
(2) Physician services,
(3) Laboratory and X-ray services,
(4) Nursing facility services, EPSDT, and
				  family planning services, and
(5)
				  Home health services;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.05 - Enrollment and Termination of Enrollment

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Department shall determine the
				  boundaries of the geographic area that a PCP may serve. The Department shall
				  limit enrollment in a PCP to recipients who live in that area.
B. The PCP is responsible for the enrollment
				  of recipients who have chosen to enroll in the PCP.
C. The PCP shall enter into an enrollment
				  contract with a recipient on the form approved by the Department.
D. The PCP shall enroll eligible recipients
				  in the order in which the eligible recipients apply and may not discriminate on
				  the basis of health status in its enrollment, re-enrollment, or disenrollment
				  procedures.
E. Termination of
				  enrollment may be initiated by the enrollee, the enrollee's parent, guardian,
				  or legal representative, by the PCP, or by the Department.
F. The Department shall approve all
				  terminations of enrollment.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.06 - Marketing

Current through Register Vol. 51, No. 14, July 12, 2024
A. The PCP shall
				  specify in its provider agreement the methods by which the PCP will assure the
				  Department that its marketing plans, procedures, and materials are accurate and
				  do not mislead, confuse, or defraud the Department or recipients.
B. The Department shall preapprove all
				  marketing plans, procedures, and materials.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.07 - Quality Assurance

Current through Register Vol. 51, No. 14, July 12, 2024
A PCP shall maintain an internal quality assurance system
					 based on written policies, standards, and procedures that is in accordance with
					 accepted medical practices and professional standards and that includes, at a
					 minimum, the following:
A. A
				  comprehensive quality assurance plan which:
(1) Addresses both the quality of clinical
				  care and nonclinical aspects of service such as accessibility, coordination,
				  and continuity of care,
(2)
				  Provides for review by physicians and other health professionals of the process
				  followed in the provision of health services,
(3) Provides feedback to health professionals
				  and PCP staff regarding performance and patient results,
(4) Objectively and systematically monitors
				  and evaluates the quality and appropriateness of care to enrollees through
				  quality of care studies and related activities, and
(5) Provides for continuous performance of
				  the activities, including tracking of issues over time;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.08 - Record Keeping and Reports

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  The PCP shall have an effective procedure for reporting to the Department the
				  following information:
(1) The cost of
				  operations;
(2) Patterns of
				  utilization;
(3) The health status
				  of enrollees;
(4) Information
				  demonstrating that the PCP has a fiscally sound operation; and
(5) Complaints and grievances made by
				  enrollees.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.09 - Confidentiality

Current through Register Vol. 51, No. 14, July 12, 2024
Subject to the requirements of 42 CFR 431 F(1994), the PCP
					 and its subcontractors may not release or disclose any information concerning
					 an enrollee except with the written permission of the:
A. Department;
B. Enrollee; or
C. Enrollee's attorney, legal representative,
				  or guardian.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.10 - Financial Solvency

Current through Register Vol. 51, No. 14, July 12, 2024
A. The PCP
				  shall include in its provider agreement a clause that the PCP will hold
				  harmless both the Department and its enrollees from any liability for payment
				  for the legal obligations of the PCP.
B. The PCP shall give the Department access
				  to the PCP's financial records at reasonable intervals in order to monitor the
				  PCP's financial solvency.
C. The
				  PCP shall file annual audited financial statements with the Department. A PCP
				  in operation for less than 1 year shall file an interim statement.
D. The provider agreement shall provide for
				  the continuation of benefits to all enrollees for the duration of the contract
				  period for which payment has been made.
E. The PCP shall have a financially sound
				  operation as demonstrated by:
(1) A positive
				  net worth; and
(2) Sufficient cash
				  and adequate liquidity, as determined by the Department, to meet the PCP's
				  obligations as they become due.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.11 - Subcontracts

Current through Register Vol. 51, No. 14, July 12, 2024
A. The PCP shall
				  ensure that the following provisions are contained in all subcontracts:
(1) A description of the services to be
				  provided by the subcontractor;
(2)
				  A description of other activities to be performed by the
				  subcontractor;
(3) Providing for
				  release to the PCP of any information necessary for the PCP to perform any of
				  its obligations under its contract with the Department, including but not
				  limited to compliance with the reporting and quality assurance requirements of
				  this chapter;
(4) That the
				  facilities and records of the subcontractor shall be open to inspection by the
				  PCP and the Department and that medical records or copies of medical records
				  will be transferred to the PCP upon request upon termination of the
				  subcontractor;
(5) That a
				  termination of the subcontract may not be effective without 30 days prior
				  written notice to the Department;
(6) That the subcontractor shall look solely
				  to the PCP for compensation for services provided to recipients;
(7) The subcontractor shall cooperate with
				  the PCP in implementing the PCP's quality assurance program; and
(8) Such other provisions as the Department
				  may reasonably require, taking into consideration the nature of the services to
				  be provided and the requirements of this contract.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.12 - Internal Grievance Procedure

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  The PCP shall have an internal grievance procedure which has been preapproved
				  by the Department. The PCP shall provide a copy of its internal grievance
				  procedures to all enrollees.
B. The
				  internal grievance procedure may:
(1) Provide
				  for the prompt resolution of any complaints of enrollees or their
				  representatives;
(2) Assure the
				  participation of individuals with the authority to require corrective action;
				  and
(3) Require that a written
				  record be made of all grievances and complaints by enrollees, and the responses
				  taken by the PCP.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.13 - Payment Procedure

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  Department shall pay a PCP a per capita capitation payment for capitated
				  services.
B. The Department shall
				  calculate the capitation payment as a percentage of the cost to the Program of
				  providing the same services on a fee-for-service basis to an actuarially
				  equivalent non-enrolled group.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.14 - Recovery and Reimbursement

Current through Register Vol. 51, No. 14, July 12, 2024
Recovery and reimbursement under this chapter are as set
					 forth in COMAR
					 10.09.36.07B.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.15 - Cause for Suspension or Removal and Imposition of Sanctions

Current through Register Vol. 51, No. 14, July 12, 2024
Causes for suspension or removal and imposition of
					 sanctions under this chapter are as set forth in COMAR
					 10.09.36.08B.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.16 - Appeal Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
Appeal procedures under this chapter are as set forth in
					 COMAR 10.09.36.09B.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.57 - Partially Capitated Programs › Section 10.09.57.17 - Interpretive Regulation

Current through Register Vol. 51, No. 14, July 12, 2024
Interpretation of this regulation is subject to COMAR
					 10.09.36.10B.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.58 - Family Planning Program › Section 10.09.58.01 - Purpose and Scope

Current through Register Vol. 51, No. 14, July 12, 2024
A. This
				  chapter governs the coverage of services for the Medical Assistance Family
				  Planning Program.
B. Eligibility
				  shall be established according to COMAR 10.09.37.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.58 - Family Planning Program › Section 10.09.58.03 - Licensure Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. An
				  advanced practice nurse shall
be licensed to practice as described in COMAR 10.09.01.
B. A doctor of medicine or osteopath shall be
				  licensed and legally authorized to practice medicine in the state in which the
				  service is delivered as described in COMAR 10.09.02.
C. A physician assistant must be licensed to
				  practice as described in COMAR 10.09.55.
D. Medical laboratories shall ensure that
				  Clinical Laboratory Improvement Amendments (CLIA) certification exists for all
				  clinical laboratory services performed, and, if located:
(1) In Maryland or out-of-State with
				  representation or specimen pick-up in Maryland, comply with the requirements of
				  Health-General Article, §§17-202, 17-212, and 17-214.1, Annotated
				  Code of Maryland, and COMAR 10.10.01; or
(2) Out-of-State without representation or
				  specimen pick-up in Maryland, comply with other applicable standards
				  established by the state and locality in which the services are
				  provided.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.58 - Family Planning Program › Section 10.09.58.04 - Conditions of Participation

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Providers shall be enrolled as Medical Assistance Program providers and shall
				  meet the requirements for participation in the Maryland Medical Assistance
				  Program as set forth in COMAR
				  10.09.36.03, as well as the
				  requirements for participation as set forth in the COMAR chapter defining the
				  provider and covered service being rendered.
B.
										 Services covered
				  in Regulation .05A-C of this chapter shall be provided by:
(1) A physician;
(2) An advance practice nurse; or
(3) A physician assistant.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.58 - Family Planning Program › Section 10.09.58.05 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
The following services are covered under this
					 chapter:
A. Office medical visits for
				  the primary purpose of providing age and sex appropriate family planning
				  services, which include:
(1) Focused history,
				  physical exam, and laboratory testing necessary to evaluate and manage the
				  participant's choice of chemical, mechanical, or other method to prevent
				  conception;
(2)
				  Basic education regarding human sexuality and reproduction;
(3) Advice and counseling regarding all
				  family planning methods, including natural family planning measures and
				  sterilization procedures, the availability and effectiveness of methods,
				  procedures involved in each, and untoward effects and potential complications
				  of each method; and
(4) Referral
				  mechanism and documented referral for all patients demonstrating illness,
				  disease, or pregnancy;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.58 - Family Planning Program › Section 10.09.58.06 - Limitations

Current through Register Vol. 51, No. 14, July 12, 2024
A. The following
				  services are not covered:
(1) Services not
				  medically necessary;
(2)
				  Therapeutic abortion;
(3)
				  Transportation services;
(4) EPSDT
				  services;
(5) Services delivered in
				  an in-patient hospital setting or ambulatory surgical center other than:
(a) Permanent sterilizations; and
(b) A hysterosalpingogram following the
				  Essure procedure;
(6)
				  Infertility services, including reversal of sterilization; and
(7) Any service not listed in Regulation .05
				  of this chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.58 - Family Planning Program › Section 10.09.58.07 - Payment Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. Payment
				  procedures are those set forth in COMAR
				  10.09.36.04B.
B. Billing time limitations are
				  those set forth in COMAR
				  10.09.36.06B.
C. Payment procedures for advanced
				  practice nurses are those set forth in COMAR 10.09.01.06.
D. Payment procedures for physician services
				  in the office or home are those set forth in COMAR
				  10.09.02.07B.
E. Payment procedures for clinic
				  services delivered in federally qualified health centers are those set forth in
				  COMAR 10.09.08.05B.
F. Payment procedures for clinic
				  services delivered in local health departments, family planning clinics, and
				  other free-standing clinics are those set forth in COMAR 10.09.02.07.
G. Payment procedures for pharmacy
				  services are those set forth in COMAR
				  10.09.03.07B.
H. Payment procedures for medical
				  laboratory services are those set forth in COMAR
				  10.09.09.07B.
I. Payment procedures for acute
				  hospital services are those set forth in COMAR 10.09.92.07.
J. Payment procedures for physician assistant
				  services are those set forth in COMAR 10.09.55.06.
K. Payment procedures for ambulatory surgery
				  centers are those set forth in COMAR 10.09.42.06.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.58 - Family Planning Program › Section 10.09.58.08 - Recovery and Reimbursement

Current through Register Vol. 51, No. 14, July 12, 2024
Recovery and reimbursement are as set forth in COMAR
					 10.09.36.07B.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.58 - Family Planning Program › Section 10.09.58.09 - Cause for Suspension or Removal and Imposition of Sanctions

Current through Register Vol. 51, No. 14, July 12, 2024
Cause for suspension or removal and imposition of sanctions
					 are as set forth in COMAR
					 10.09.36.08B.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.58 - Family Planning Program › Section 10.09.58.10 - Appeal Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
The requirements related to appeal procedures under COMAR
					 10.09.36 and 10.09.37 apply to this chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.58 - Family Planning Program › Section 10.09.58.11 - Fraud and Abuse

Current through Register Vol. 51, No. 14, July 12, 2024
The requirements relating to fraud and abuse under COMAR
					 10.09.24.14B
					 shall apply to this chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.58 - Family Planning Program › Section 10.09.58.12 - Interpretive Regulation

Current through Register Vol. 51, No. 14, July 12, 2024
State regulations are interpreted as set forth in COMAR
					 10.09.36.10B.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.59 - Specialty Mental Health Services › Section 10.09.59.02 - License Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
To participate in the Program, a provider shall meet the
					 license requirements stated in COMAR 10.09.36.02.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.59 - Specialty Mental Health Services › Section 10.09.59.03 - General Conditions for Provider Participation

Current through Register Vol. 51, No. 14, July 12, 2024
To participate in the Program, a provider shall:
A. Meet the conditions for provider
				  participation in the Medical Assistance Program as set forth in COMAR
				  10.09.36.03;
B. Meet the conditions for licensure and
				  practice as set forth in COMAR 10.63.01, 10.63.02, and 10.63.06;
C. Have clearly defined and written patient
				  care policies; and
D. Maintain,
				  either manually or electronically, adequate documentation of each contact with
				  a participant as part of the medical record, which, at a minimum, meets the
				  following requirements:
(1) Includes the date
				  of service with service start and end times;
(2) Includes the participant's primary
				  behavioral health complaint or reason for the visit;
(3) Includes a brief description of the
				  service provided, including progress notes;
(4) Includes an official e-Signature, or a
				  legible signature, along with the printed or typed name of the individual
				  providing care, with the appropriate title;
(5) Is made available to the following as
				  requested:
(a) The Department;
(b) The ASO;
(c) The Core Service Agency;
(d) The Office of Inspector General;
				  and
(e) The Office of the Attorney
				  General Medicaid Fraud Control Unit; and
(6) Is consistent with the medical records
				  confidentiality and disclosure requirements of:
(a) Maryland Confidentiality of Medical
				  Records Act, Health-General Article, Title 4, Subtitle 3, Annotated Code of
				  Maryland; and
(b) Relevant federal
				  statutes and regulations, including the Health Insurance Portability and
				  Accountability Act, 42
				  U.S.C. §
													1320D et seq., and implementing
				  regulations at 45 CFR Parts 160 and 164.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.59 - Specialty Mental Health Services › Section 10.09.59.04 - Provider Requirements for Participation

Current through Register Vol. 51, No. 14, July 12, 2024
A. Individual Practitioner Providers. To
				  participate in the Program as an individual practitioner of specialty mental
				  health services, the provider shall:
(1) Be
				  licensed and legally authorized to practice independently by the appropriate
				  Board to practice in the state in which the service is rendered; and
(2) Demonstrate, by training and experience,
				  the competency to provide mental health services as one of the following:
(a) A licensed certified social
				  worker-clinical;
(b) A nurse
				  psychotherapist (APRN-PHM);
(c) A
				  pediatric nurse practitioner with a PMHS;
(d) A nurse practitioner-psychiatric
				  (CRNP-PMH);
(e) A physician who
				  demonstrates the competency to provide specialty mental health services;
(f) A licensed certified counselor
				  which includes:
(i) A licensed professional
				  counselor;
(ii) A licensed marriage
				  and family therapist;
(iii) A
				  licensed counselor-alcohol and drug; or
(iv) A licensed clinical professional art
				  therapist;
(g) A
				  psychiatrist certified by the American Board of Psychiatry and Neurology or
				  possessing the minimum educational and training requirements to take the Board
				  of Psychiatry and Neurology examination for certification in psychiatry;
				  or
(h) A
				  psychologist.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.59 - Specialty Mental Health Services › Section 10.09.59.05 - Eligibility

Current through Register Vol. 51, No. 14, July 12, 2024
A. A participant is
				  eligible for specialty mental health services if:
B. Individuals are eligible for Psychiatric
				  Rehabilitation Programs for adults if the individual:
(1) Has been referred for psychiatric
				  rehabilitation program services by a licensed mental health professional who:
(a) Is enrolled as a provider in the Program
				  with an active status on the date of service;
(b)Facilitates an informed choice of
				  psychiatric rehabilitation program providers; and
(c) Currently provides inpatient, residential
				  treatment center, or outpatient mental health services to the
				  individual;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.59 - Specialty Mental Health Services › Section 10.09.59.06 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
The ASO shall reimburse the following specialty mental
					 health services rendered to participants when authorized by the ASO:
A. Medically necessary specialty mental
				  health services delivered by providers listed in Regulation .04 of this
				  chapter, for which the primary diagnosis is listed in COMAR
				  10.09.70.02I or
				  J;
B. Telehealth services as
				  defined in COMAR 10.09.49; and
C.
				  Presumptive drug tests and definitive drug tests, when ordered by a specialty
				  mental health provider, with a behavioral health primary diagnosis listed in
				  COMAR 10.09.70.021 or J on the claim.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.59 - Specialty Mental Health Services › Section 10.09.59.07 - Limitations

Current through Register Vol. 51, No. 14, July 12, 2024
The Program does not cover the following:
A. Services not delivered in compliance with
				  the COMAR references listed in Regulations .04 and .05 of this chapter;
B. Services not medically
				  necessary;
C. Investigational or
				  experimental drugs and procedures;
D. Specialty mental health services for
				  participants in an institution for mental disease as defined in
				  42 CFR §
											435.1009 unless the service is delivered
				  through the Medicaid Emergency Psychiatric Demonstration;
E. Specialty mental health visits solely for
				  the purpose of:
(1) Prescribing
				  medication;
(2) Administering
				  medication;
(3) Drug or supply
				  pick-up;
(4) Collecting laboratory
				  specimens;
(5) Interpreting
				  laboratory tests or panels; or
(6)
				  Administering injections, unless the following are documented in the
				  participant's medical record:
(a) Medical
				  necessity; and
(b) The
				  participant's inability to take appropriate oral medications;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.59 - Specialty Mental Health Services › Section 10.09.59.08 - Authorization Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  ASO shall establish a process, through a utilization review system, for
				  authorization of specialty mental health services.
B. The ASO shall authorize services that are:
(1) Medically necessary;
(2) Of a type, frequency, and duration that
				  are consistent with expected results and cost-effective; and
(3) Delivered in a manner consistent with
				  this chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.59 - Specialty Mental Health Services › Section 10.09.59.09 - Payment Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. Payment
				  procedures shall be followed as specified in COMAR 10.09.36.04.
B. A provider shall deliver and document
				  services in accordance with Department regulations in order to receive
				  reimbursement.
C. Unless the care
				  is free to other patients, a provider shall bill the Program its usual and
				  customary charge to the general public.
D. The Department shall authorize
				  supplemental payment on Medicare claims only if:
(1) The provider accepts Medicare
				  assignments;
(2) Medicare makes
				  direct payment to the provider;
(3) Medicare has determined that the services
				  are medically necessary;
(4) The
				  services are covered by the Program; and
(5) Initial billing is made directly to
				  Medicare according to Medicare guidelines.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.59 - Specialty Mental Health Services › Section 10.09.59.10 - Recovery and Reimbursement

Current through Register Vol. 51, No. 14, July 12, 2024
Recovery and reimbursement are as set forth in COMAR
					 10.09.36.07
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.59 - Specialty Mental Health Services › Section 10.09.59.11 - Cause for Suspension or Removal and Imposition of Sanctions

Current through Register Vol. 51, No. 14, July 12, 2024
Cause for suspension or removal and imposition of sanctions
					 are as set forth in COMAR 10.09.36.08.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.59 - Specialty Mental Health Services › Section 10.09.59.12 - Appeal Procedures for Providers

Current through Register Vol. 51, No. 14, July 12, 2024
Appeal procedures for providers are as set forth in COMAR
					 10.09.36.09.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.59 - Specialty Mental Health Services › Section 10.09.59.13 - Appeal Rights - Denial of Services

Current through Register Vol. 51, No. 14, July 12, 2024
Appeal procedures for applicants and participants are as
					 set forth in COMAR 10.01.03 and 10.01.04
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.59 - Specialty Mental Health Services › Section 10.09.59.14 - Interpretive Regulation

Current through Register Vol. 51, No. 14, July 12, 2024
State regulations are interpreted as set forth in COMAR
					 10.09.36.10.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.60 - Senior Prescription Drug Assistance Program › Section 10.09.60.01 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter,
				  the following terms have the meanings indicated.
B. Terms Defined.
(1) "Administrator" means the third party
				  that contracts with the Department to administer the Program.
(2) "Annual household income" has the meaning
				  stated in Regulation .02B of this chapter.
(3) "Department" means the Maryland
				  Department of Health and Mental Hygiene.
(4) "Eligible individual" means an individual
				  who meets the criteria set forth in Regulation .02A of this chapter:
(5) "Enrollee" means an individual enrolled
				  in the Senior Prescription Drug Assistance Program.
(6) "Household member"
				  means:
(a) An eligible individual;
(b) The spouse of an eligible individual if
				  the spouse resides in the same residence as the eligible individual;
				  and
(c) An individual who:
(i) Is related to an eligible individual by
				  blood, marriage, or adoption;
(ii)
				  Resides in the same residence as the eligible individual; and
(iii) Is dependent on the eligible individual
				  or the spouse of the eligible individual for at least one-half of the
				  individual's support.
(7)
				  "Prescription drug plan sponsor" means a nongovernmental entity that is
				  certified by the Centers for Medicare and Medicaid Services as meeting the
				  requirements of the Medicare Prescription Drug, Improvement, and Modernization
				  Act of 2003 for offering in the State:
(a) A
				  Medicare Part D prescription drug plan; or
(b) A Medicare Advantage Plan that provides
				  prescription drug benefits.
(8) "Program" means
				  the Senior Prescription Drug Assistance Program established under
				  Health-General Article, Title 15, Subtitle 10, Annotated Code of
				  Maryland.
(9) "Program Fund" means the Fund established under
				  Insurance Article, §
											15-1004, Annotated Code of
				  Maryland.
(10) "Reasonable administrative expenses" means
				  administrative expenses including, but not limited to, marketing, advertising,
				  mailing, printing, and fully allocated costs for administration of the
				  Program.
(11) Support and Maintenance Furnished in-Kind.
(a) "Support and maintenance furnished
				  in-kind" means any food or shelter that is:
(i) Given to an eligible individual or the
				  spouse of an eligible individual without cost; or
(ii) Received by an eligible individual or
				  the spouse of an eligible individual because another person has paid the
				  cost.
(b) "Support and
				  maintenance in-kind" includes the provision of room, rent, garbage collection
				  services, mortgage payments, real property tax payments, and heating fuel, gas,
				  electricity, water, and sewage payments.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.60 - Senior Prescription Drug Assistance Program › Section 10.09.60.02 - Eligibility, Enrollment, and Disenrollment

Current through Register Vol. 51, No. 14, July 12, 2024
A. To be eligible for enrollment in the
				  Program, an individual shall:
(1) Be a
				  resident of Maryland;
(2) Be a
				  Medicare beneficiary enrolled in the Medicare Part D Voluntary Prescription
				  Drug Benefit Program or a Medicare Advantage Plan that provides Part D
				  coverage;
(3) Have an annual
				  household income, as described in §B of this regulation, at or below 300
				  percent of the Federal Poverty Guidelines that apply to the individual based on
				  the number of household members of the individual;
(4) Not be enrolled in a health benefit plan,
				  other than a Medicare Part D prescription drug plan or a Medicare Advantage
				  Plan, that provides prescription drug benefits at the time the individual
				  applies for enrollment in the Program; and
(5) Not be eligible for a full federal
				  low-income subsidy under 42
				  CFR §
												423.772.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.60 - Senior Prescription Drug Assistance Program › Section 10.09.60.03 - Outreach Program

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  Department shall develop and implement an outreach program targeted at eligible
				  individuals.
B. The Department
				  shall publicize the existence and eligibility requirements of the Program
				  through the following entities:
(1) The
				  Department of Aging;
(2) Local
				  health departments;
(3) Continuing
				  care retirement communities;
(4)
				  Places of worship;
(5) Civic
				  organizations;
(6) Community
				  pharmacies; and
(7) Any other
				  entity that the Department determines is appropriate.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.60 - Senior Prescription Drug Assistance Program › Section 10.09.60.04 - Administrator

Current through Register Vol. 51, No. 14, July 12, 2024
A. Administrator
				  Contract. The Administrator and the Department shall execute an Administrator
				  contract specifying the terms under which the Administrator shall operate the
				  Program, including but not limited to an agreement by the Administrator to:
(1) Provide the prescription drug benefit
				  subsidies described in Regulation .06 of this chapter;
(2) Submit a detailed quarterly financial
				  accounting of the Program, including the identification of all revenue and cost
				  items to the Department,
(3)
				  Develop and implement a marketing plan designed to notify eligible individuals
				  throughout the State of the existence and eligibility criteria for the Program;
				  and
(4) Collect and submit to the
				  Department, data regarding the costs for program enrollees.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.60 - Senior Prescription Drug Assistance Program › Section 10.09.60.05 - Program Description Booklet

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  The Administrator shall develop a Program description booklet.
B. The Program description booklet is subject
				  to approval by the Department.
C.
				  The Program description booklet shall describe the essential features of the
				  Program including:
(1) Eligibility
				  requirements;
(2) A listing of
				  available prescription drug plans and details of the prescription drug
				  plans;
(3) Termination
				  provisions;
(4) Appeal
				  procedures;
(5) Other Program
				  guidelines; and
(6) All other
				  terms, conditions, and limitations of the Program.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.60 - Senior Prescription Drug Assistance Program › Section 10.09.60.06 - Prescription Drug Benefit Subsidy

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Program shall:
(1) Provide a prescription drug benefit
				  subsidy, as determined by the Department, that may pay all or some of the
				  deductibles, coinsurance payments, premiums, and copayments under the federal
				  Medicare Part D Pharmaceutical Assistance Program for enrollees of the Program;
				  and
(2) Provide the subsidy to the
				  maximum number of individuals eligible for enrollment in the Program, subject
				  to the money available in the Program Fund.