reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.03 - Pharmacy Services › Section 10.09.03.08 - Recovery and Reimbursement

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  If the recipient has insurance or other coverage, or if any other person is
				  obligated, either legally or contractually, to pay for, or to reimburse the
				  recipient for services covered by this chapter, the provider shall seek payment
				  from that source first. If an insurance carrier rejects the claim or pays less
				  than the amount allowed by the Medical Assistance Program, the provider may
				  submit a claim to the Program. The provider shall submit a copy of the
				  insurance carrier's notice or remittance advice with his invoice. If payment is
				  made by both the Program and the insurance or other source for the same
				  service, the provider shall refund to the Department, within 60 days of
				  receipt, the amount paid by the Program, or the insurance or third-party
				  source, whichever is less.
B. The
				  provider shall reimburse the Department for any overpayment.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.03 - Pharmacy Services › Section 10.09.03.09 - Cause for Suspension or Removal and Imposition of Sanctions

Current through Register Vol. 51, No. 14, July 12, 2024
A. If the
				  Department determines that a provider, pharmacist, any agent or employee of the
				  provider, or any person with an ownership interest in the provider has failed
				  to comply with applicable federal or State laws or regulations, the Department
				  may initiate one or more of the following actions against the responsible
				  party:
(1) Suspension from Program;
(2) Withholding of payment by the
				  Program;
(3) Removal from the
				  Program;
(4) Disqualification from
				  future participation in the Program, either as a provider or as a person
				  providing services for which Program payment will be claimed.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.03 - Pharmacy Services › Section 10.09.03.10 - Appeal Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
Providers filing appeals from administrative decisions made
					 in connection with these regulations shall do so according to COMAR
					 10.09.36.09B.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.03 - Pharmacy Services › Section 10.09.03.11 - Interpretive Regulation

Current through Register Vol. 51, No. 14, July 12, 2024
Except when the language of a specific regulation indicates
					 an intent by the Department to provide reimbursement for covered services to
					 Program recipients without regard to the availability of federal financial
					 participation, State regulations shall be interpreted in conformity with
					 applicable federal statutes and regulations.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.03 - Pharmacy Services › Section 10.09.03.12 - Preferred Drug Program

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  Department may establish a Pharmacy and Therapeutics Committee
				  (Committee).
B. The Committee shall
				  consist of the following 12 members:
(1) Five
				  members of the Committee shall be Maryland licensed pharmacists residing in the
				  State, including a pharmacist with expertise with mental health
				  drugs;
(2) Five members of the
				  Committee shall be Maryland licensed physicians residing in the State,
				  including a psychiatrist; and
(3)
				  Two members of the Committee shall be consumer representatives residing in the
				  State.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.04 - Home Health Services › Section 10.09.04.02 - License Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A home health agency shall be licensed pursuant to
					 Health-General Article, §§19-401 "19-408, Annotated Code of Maryland,
					 or shall be part of a hospital or related institution licensed pursuant to
					 Health-General Article, §§19-301 "19-359, Annotated Code of Maryland,
					 or shall be legally authorized to provide home health services in the
					 jurisdiction in which the service is provided.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.04 - Home Health Services › Section 10.09.04.03 - Conditions for Participation

Current through Register Vol. 51, No. 14, July 12, 2024
A. To be a
				  provider, a home health agency shall be a participating home health agency
				  under Medicare.
B. To participate
				  in the Program, the home health agency shall:
(1) Apply for participation in the Program
				  using the form designated by the Department;
(2) Be approved for participation by the
				  Department;
(3) Have in effect a
				  provider agreement with the Department;
(4) Accept payment by the Department as
				  payment in full for covered services rendered and make no additional charge to
				  any person for covered services;
(5) Provide verification to the Department,
				  in the manner prescribed by the Department, of all changes in the provider's
				  charges within 10 days of the occurrence of the changes;
(6) Maintain all patient care, medical
				  supply, timesheets, official agency recipient or witness signature records, and
				  billing records for a minimum of 6 years after completion of an audit by the
				  Department and make them available, upon request, to the appropriate State and
				  federal personnel or their designees during office hours;
(7) Secure from the participant's physician,
				  physician assistant, certified nurse midwife, or certified nurse practitioner a
				  written plan of treatment which relates the items and services to the
				  participant's medical condition;
(8) Maintain a participant's plan of care
				  based on the physician's, physician assistant's, certified nurse midwife's or
				  certified nurse practitioner's plan of treatment for the participant;
(9) Provide services without regard to race,
				  color, age, sex, national origin, marital status, or physical or mental
				  handicap;
(10) Verify the
				  participant's eligibility;
(11)
				  Place no restriction on a participant's right to select his choice of providers
				  under this subtitle;
(12) Agree
				  that if the Program denies payment or requests repayment on the basis that an
				  otherwise covered service was not medically necessary, the provider may not
				  seek payment for that service from the participant;
(13) Agree that if the Program denies payment
				  due to late billing, the provider may not seek payment from the
				  participant;
(14) Provide services
				  in person unless expressly authorized by the Department to render services via
				  telehealth; and
(15) If not
				  rendering services in person, comply with COMAR 10.09.49 and any subregulatory
				  guidance issued by the Department.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.04 - Home Health Services › Section 10.09.04.04 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Program
				  covers the services listed in §§B and C of this regulation when the
				  services are:
(1) Provided upon the written
				  order of a physician, physician assistant, certified nurse midwife, or
				  certified nurse practitioner;
(2)
				  Furnished under the current plan of treatment;
(3) Ordered by an individual who is enrolled
				  as a provider in the Program with an active status on the date of
				  service;
(4) Consistent with the
				  current diagnosis and treatment of the participant's condition;
(5) In accordance with accepted standards of
				  medical practice;
(6) Required by
				  the medical condition rather than the convenience or preference of the
				  participant;
(7) Considered under
				  accepted standards of medical practice to be a specific and effective treatment
				  for the participant's condition;
(8) Required on a part-time, intermittent
				  basis;
(9) Rendered in the
				  participant's home, or other setting when normal life activities take the
				  participant outside the home, by an approved provider;
(10) Received by the participant as
				  documented by the participant's signature or the signature of the participant's
				  witness on the home health agency's official forms; and
(11) Adequately described in the signed and
				  dated progress notes.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.04 - Home Health Services › Section 10.09.04.05 - Limitations

Current through Register Vol. 51, No. 14, July 12, 2024
The Program does not cover the following:
A. Nonskilled services rendered by licensed
				  nurses, physical therapists, occupational therapists and speech
				  pathologists;
B. Services and
				  medical supplies that are not medically necessary and appropriate;
C. Durable medical equipment except as
				  covered under COMAR 10.09.12;
D.
				  Services primarily for the purpose of housekeeping, including but not limited
				  to:
(1) Cleaning of floor and
				  furniture;
(2) Laundry;
				  and
(3) Shopping;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.04 - Home Health Services › Section 10.09.04.06 - Preauthorization Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Preauthorization is required for:
(1) More
				  than one visit per type of service per day;
(2) Any service or combination of services
				  specified in Regulation .04 of this chapter and rendered during any 30-day
				  period for which the provider anticipates payments from the program in excess
				  of the Medicaid average nursing facility rate;
(3) Four or more hours of care per day
				  whether the 4-hour limit is reached in one visit or in several visits in one
				  day; and
(4) Any instances in which
				  home health aide services without skilled nursing services are
				  provided.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.04 - Home Health Services › Section 10.09.04.07 - Payment Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. The provider
				  shall submit his request for payment on the form designated by the
				  Department.
B. To receive payment
				  for services under Regulation .04 of this chapter, a provider and its workers
				  shall use the Electronic Visit Verification method and data management system
				  approved by the Department to document time and submit claims in accordance
				  with COMAR
				  10.09.36.03-2.
C. The provider shall submit requests for
				  payment for supplies on the same invoice which requests payment for the visit
				  during which the supplies were used.
D. The Department reserves the right to
				  return to the provider, before payment, all invoices not properly
				  completed.
E. Payment Rates.
(1) The provider shall be paid the lesser of:
(a) The provider's customary charge to the
				  general public unless the service is free to individuals not covered by
				  Medicaid; or
(b) The rate in
				  accordance with the Department's fee schedule.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.04 - Home Health Services › Section 10.09.04.08 - Recovery and Reimbursement

Current through Register Vol. 51, No. 14, July 12, 2024
Recovery and reimbursement regulations are set forth in
					 COMAR 10.09.36.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.04 - Home Health Services › Section 10.09.04.09 - 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 set forth in COMAR 10.09.36.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.04 - Home Health Services › Section 10.09.04.10 - Appeal Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
Appeal procedures are set forth in COMAR
					 10.09.36.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.04 - Home Health Services › Section 10.09.04.11 - Interpretive Rule

Current through Register Vol. 51, No. 14, July 12, 2024
State regulations are interpreted as set forth in COMAR
					 10.09.36.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.05 - Dental Services › Section 10.09.05.02 - License Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  provider shall meet all license requirements as set forth in COMAR
				  10.09.36.02B.
B. A dentist shall be licensed and
				  legally authorized to practice dentistry in the state in which service is
				  provided.
C. All dentists and
				  dental hygienists working for a mobile dental unit shall be currently licensed
				  and registered with the Maryland Board of Dental Examiners.
D. The driver of the mobile dental unit:
(1) Shall possess a valid operator's license
				  appropriate for the type of vehicle that is driven;
(2) May not have violations related to the
				  operation of a motor vehicle in the last 3 years; and
(3) May not have any violations involving
				  alcohol or other illegal substances related to the operation of a motor vehicle
				  in the last 10 years.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.05 - Dental Services › Section 10.09.05.03 - Provider Qualifications and Conditions for Participation

Current through Register Vol. 51, No. 14, July 12, 2024
A. General
				  requirements for participation in the Program are that a provider shall:
(1) Comply with requirements set forth in
				  COMAR 10.09.36; and
(2) If
				  delivering services via telehealth, comply with COMAR 10.09.49 and any
				  subregulatory guidance issued by the Department.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.05 - Dental Services › Section 10.09.05.04 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  Program covers medically necessary dental services for participants younger
				  than 21 years old and eligible former foster care participants younger than 26
				  years old, including but not limited to the following:
(1) Emergency, preventive, diagnostic, and
				  treatment services;
(2) Semiannual
				  cleaning, fluoride treatment and examination;
(3) Pit and fissure sealants for the occlusal
				  surfaces of posterior permanent teeth that are without decay;
(4) Orthodontic care for conditions which:
(a) Have adjusted case scores of at least 15
				  points on the Handicapping Labio-Lingual Deviations Index (HLD) Table No. 4;
				  and
(b) Cause dysfunction due to a
				  handicapping malocclusion that is supported by comprehensive pretreatment
				  orthodontic records, which include at a minimum:
(i) Cephalometric head film with
				  analysis;
(ii) Panoramic or full
				  series periapical radiographs;
(iii) Extra-oral and intra-oral
				  photographs;
(iv) Clinical summary
				  with diagnosis;
(v) HLD score
				  sheets from attending orthodontist; and
(vi) Treatment plan;
(5) Consultations for participants
				  who meet the requirements of §A(1), (2), (3), or (4) of this
				  regulation;
(6) Drugs dispensed or
				  injectable drugs administered by the dentist within the limitations of COMAR
				  10.09.03;
(7) Oral Health
				  assessment by an EPSDT certified provider, and if determined medically
				  necessary, the application of fluoride varnish for children 9 months old
				  through 5 years old;
(8) General
				  anesthesia during dental procedures, when it is medically necessary;
				  and
(9) Fluoride varnish.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.05 - Dental Services › Section 10.09.05.06 - Preauthorization Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Preauthorization is issued when:
(1) Program
				  procedures are met;
(2) Program
				  limitations are met;
(3) The
				  provider submits to the Department, adequate documentation demonstrating that
				  the service to be preauthorized is medically necessary; and
(4) The participant is eligible for the
				  service.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.05 - Dental Services › Section 10.09.05.07 - Payment Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. To
				  obtain compensation from the Department for covered services, the provider
				  shall submit a request for payment on the form designated by the Department
				  with the following data or attachments:
(1)
				  If applicable, the preauthorization number shall be inserted in the designated
				  appropriate field on the invoice claim form;
(2) If applicable, pathology reports shall be
				  attached to the claim form; and
(3)
				  If applicable, comprehensive narratives shall be attached to the claim form for
				  those services that are "By Report".
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.05 - Dental Services › Section 10.09.05.08 - Recovery and Reimbursement

Current through Register Vol. 51, No. 14, July 12, 2024
A. If
				  the participant has insurance or other coverage, or if any other person is
				  obligated, either legally or contractually, to pay for or to reimburse the
				  participant for services covered by this chapter, the provider shall seek
				  payment from that source first. If an insurance carrier rejects the claim or
				  pays less than the amount allowed by the Medical Assistance Program, the
				  provider may submit a claim to the Program. The provider shall submit a copy of
				  the insurance carrier's notice or remittance advice with his invoice. If
				  payment is made by both the Program and the insurance or other source for the
				  same service, the provider shall refund to the Department, within 60 days of
				  receipt, the amount paid by the Program, or the insurance or other source,
				  whichever is less.
B. The provider
				  shall reimburse the Department for any overpayment.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.05 - Dental Services › Section 10.09.05.09 - Cause for Suspension or Removal and Imposition of Sanctions

Current through Register Vol. 51, No. 14, July 12, 2024
A. If the
				  Department determines that a provider, dentist, any agent or employee of the
				  provider, or any person with an ownership interest in the provider has failed
				  to comply with applicable federal or State laws or regulations, the Department
				  may initiate one or more of the following actions against the responsible
				  party:
(1) Suspension from the
				  Program;
(2) Withholding of payment
				  by the Department;
(3) Removal from
				  the Program;
(4) Disqualification
				  from future participation in the Program, either as a provider or as a person
				  providing services for which Program payment will be claimed.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.05 - Dental Services › Section 10.09.05.10 - Appeal Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Providers may exercise appeal rights pursuant to State Government Article,
				  Title 10, Subtitle 2, Annotated Code of Maryland.
B. Appeals shall be filed within 30 days of
				  receipt of notice of administrative decisions.
C. The provider may appeal a decision to the
				  Office of Administrative Hearings as specified in COMAR
				  10.09.36.09F.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.05 - Dental Services › Section 10.09.05.11 - Interpretive Regulation

Current through Register Vol. 51, No. 14, July 12, 2024
Except when the language of a specific regulation indicates
					 an attempt by the Department to provide reimbursement for covered services to
					 Program participants without regard to the availability of federal financial
					 participation, State regulations shall be interpreted in conformity with
					 applicable federal statutes and regulations.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.06 - Adult Residential Substance Use Disorder Services › Section 10.09.06.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter governs residential substance use disorder
					 services for adults, effective July 1, 2017.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.06 - Adult Residential Substance Use Disorder Services › Section 10.09.06.03 - Licensure Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
To participate in the Program, a provider shall:
A. Meet the license requirements stated in
				  COMAR 10.09.36.02 and, after April 1,
				  2018, COMAR
				  10.63.01.05;
B. Be accredited by a Maryland-approved
				  accrediting body; and
C. Be licensed
				  by the Behavioral Health Administration (BHA) for each level of care.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.06 - Adult Residential Substance Use Disorder Services › Section 10.09.06.04 - Conditions for Participation

Current through Register Vol. 51, No. 14, July 12, 2024
A. General
				  requirements for participation in the Program are that a provider shall:
(1) Comply with requirements set forth in
				  COMAR 10.09.36; and
(2) If
				  delivering services via telehealth, comply with COMAR 10.09.49 and any
				  subregulatory guidance issued by the Department.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.06 - Adult Residential Substance Use Disorder Services › Section 10.09.06.05 - Participant Eligibility and Referral

Current through Register Vol. 51, No. 14, July 12, 2024
A participant is eligible for substance use disorder
					 services under this chapter if the participant:
A. Is enrolled in the Program and is not
				  enrolled in Medicare on the day a service is rendered;
B. Meets the Department's medical necessity
				  criteria based on the ASAM placement criteria for each level of care;
				  and
C. Is 18 years old or older and
				  is not receiving care from a provider under COMAR 10.09.23.04.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.06 - Adult Residential Substance Use Disorder Services › Section 10.09.06.06 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. A
				  residential, low intensity level 3.1 provider shall provide:
(1) Therapeutic substance use disorder
				  services for a minimum of 5 hours per week; and
(2) Services in a structured environment in
				  combination with low-intensity treatment and ancillary services to support and
				  promote recovery.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.06 - Adult Residential Substance Use Disorder Services › Section 10.09.06.07 - Limitations

Current through Register Vol. 51, No. 14, July 12, 2024
The Program does not cover the following in a residential
					 substance use disorder treatment facility for adults:
A. Services not medically
				  necessary;
B. ASAM Level 2 services
				  by any provider;
C. Except for
				  services rendered to individuals in a residential, low-intensity program, ASAM
				  Level 1 services by any provider;
D. Services not specified in Regulation .06
				  of this chapter;
E. Services beyond
				  the provider's scope of practice;
F. Investigational and experimental drugs and
				  procedures;
G. Services rendered
				  but not appropriately documented; and
H. Services not preauthorized as required in
				  Regulation .08 of this chapter.
I.
				  Additional services rendered via telehealth when telehealth services comprise
				  more than 50 percent of a participant's weekly clinical
				  services.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.06 - Adult Residential Substance Use Disorder Services › Section 10.09.06.08 - Authorization Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  provider shall obtain authorization from the ASO to provide residential
				  substance use disorder services outlined in Regulation .06 of this
				  chapter.
B. The ASO agent shall
				  authorize services that are:
(1) Medically
				  necessary for the applicable level of service as outlined by ASAM criteria for
				  admission; and
(2) Of a type,
				  frequency, and duration that are consistent with expected results and
				  cost-effectiveness.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.06 - Adult Residential Substance Use Disorder Services › Section 10.09.06.09 - Payment Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. General
				  policies governing payment procedures that are applicable to all providers are
				  set forth in COMAR 10.09.36.04.
B.
				  Billing time limitations for claims submitted under this chapter are set forth
				  in COMAR 10.09.36.06.
C. For dates
				  of services from January 1, 2021 through June 30, 2022, rates for the services
				  outlined in this chapter shall be as follows:
(1) For ASAM Level 3.1, the provider shall
				  receive $94.70 per diem;
(2) For
				  ASAM Level 3.3, the provider shall receive $211.05 per diem;
(3) For ASAM Level 3.5, the provider shall
				  receive $211.05 per diem;
(4) For
				  ASAM Level 3.7, the provider shall receive $324.92 per diem; and
(5) For ASAM Level 3.7-WM, the provider shall
				  receive $395.12 per diem.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.06 - Adult Residential Substance Use Disorder Services › Section 10.09.06.10 - Cause for Suspension or Removal and Imposition of Sanctions

Current through Register Vol. 51, No. 14, July 12, 2024
Recovery and reimbursement shall be 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 10.09.06 - Adult Residential Substance Use Disorder Services › Section 10.09.06.11 - 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 shall be 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 10.09.06 - Adult Residential Substance Use Disorder Services › Section 10.09.06.12 - Appeals Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
Appeals procedures shall be as set forth in accordance with
					 COMAR 10.09.36.09.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.07 - Medical Day Care Services › Section 10.09.07.02 - Licensing Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
The provider shall be licensed under COMAR
					 10.12.04.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.07 - Medical Day Care Services › Section 10.09.07.03 - Conditions for Participation

Current through Register Vol. 51, No. 14, July 12, 2024
Requirements for providing medical day care services are
					 that the providers shall:
A. Meet the
				  licensure requirements as provided in Regulation .02 of this chapter;
B. Meet the requirements of COMAR
				  10.09.36;
C. Be open to
				  participants at least 6 hours a day, 5 days a week, and post hours of
				  operation;
D. Verify the licenses
				  and credentials for all professionals employed by or contracting with the
				  medical day care center;
E. Provide
				  or arrange for the provision of any covered service, as specified in Regulation
				  .05 of this chapter, or any other service which is required by a plan of
				  care;
F. Demonstrate to the
				  satisfaction of the Program that a need exists for medical day care in the
				  service area and that the provider has the necessary expertise to deliver the
				  service;
G. Have policies and
				  procedures as required under COMAR 10.12.04;
H. Maintain medical records for each
				  participant which shall include, as a minimum, the following:
(1) An application for admission;
(2) The medical day care center's plan of
				  care as required under §M(3)-(4) of this regulation;
(3) The current home and community based
				  services waiver service plan or the approved medical day care preauthorization
				  form for the participant;
(4)
				  Medical orders for all services rendered which may include, but is not limited
				  to, the:
(a) Type and duration of
				  service;
(b) Frequency of service;
				  and
(c) Dosage and frequency of
				  medications when prescribed;
(5) The medical history, chronic illnesses,
				  principal and significant diagnoses, prognoses, prescribed medications, special
				  diets, allergies, and assessments of the recipient's physical and mental status
				  specifying the general types of activities the recipient can and cannot
				  do;
(6) The documentation of daily
				  nursing observations for the first 5 days of attendance, and monthly after the
				  first 5 days of attendance; and
(7)
				  The initial social history, ADCAPS assessment, and, when needed, social service
				  and activity progress notes;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.07 - Medical Day Care Services › Section 10.09.07.04 - Staffing Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  medical day care center shall have adequate staffing capability to monitor the
				  participants at all times. The composition of the staff depends in part on the
				  needs of the participants and on the number of participants the medical day
				  care center serves. At a minimum, the medical day care center shall meet the
				  requirements of COMAR 10.12.04.14.
B. The medical day care center shall also
				  have:
(1) A full-time or part-time licensed
				  social worker, who has at least 1 year of experience providing services to
				  adults in a health care setting; and
(2) A full-time, part-time, or contractual
				  medical director who:
(a) Has 1 year of
				  experience in the care of impaired adults; and
(b) May function as the primary care provider
				  for those participants who do not have a primary care provider, consult with
				  staff regarding a participant's condition and medical needs, and assist with
				  the development of the medical day care center's health care
				  policies.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.07 - Medical Day Care Services › Section 10.09.07.05 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  Program reimburses for a day of care which includes the following services:
(1) Health care services supervised by the
				  director, medical director, or health director, which emphasize primary
				  prevention, early diagnosis and treatment, rehabilitation and continuity of
				  care, including the following:
(a)
				  Participation in the development of the individual participant's plan of
				  care;
(b) Participation in the
				  determination of the participant's medical, psychosocial, and functional
				  status;
(c) Consultation with the
				  participant's primary care provider, and
(d) Consultation with staff regarding a
				  participant's condition and health care needs;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.07 - Medical Day Care Services › Section 10.09.07.06 - Limitations

Current through Register Vol. 51, No. 14, July 12, 2024
A. Medical day care
				  services are not covered for:
(1) Individuals
				  who do not meet the definition of "participant" in Regulation .01B of this
				  chapter; and
(2) Individuals
				  younger than 16 years old.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.07 - Medical Day Care Services › Section 10.09.07.07 - Authorization Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
The provider is entitled to reimbursement from the Program
					 when:
A. The participant is enrolled
				  in a home and community based services waiver; and
B. The service is specified in the
				  participant's home and community based services waiver service plan.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.07 - Medical Day Care Services › Section 10.09.07.08 - Payment Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. Requests for
				  Payment.
(1) All requests for payment of
				  services rendered shall be submitted in accordance with COMAR
				  10.09.36.
(2) Billing time
				  limitations for claims submitted pursuant to this chapter are set forth in
				  COMAR 10.09.36.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.07 - Medical Day Care Services › Section 10.09.07.09 - Recovery and Reimbursement

Current through Register Vol. 51, No. 14, July 12, 2024
Recovery and reimbursement shall be in accordance with
					 COMAR 10.09.36.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.07 - Medical Day Care Services › Section 10.09.07.10 - 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
					 shall be in accordance with COMAR 10.09.36.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.07 - Medical Day Care Services › Section 10.09.07.11 - Appeal Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
Appeal procedures shall be in accordance with COMAR
					 10.09.36.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.07 - Medical Day Care Services › Section 10.09.07.12 - Interpretive Regulation

Current through Register Vol. 51, No. 14, July 12, 2024
State regulations shall be interpreted in accordance with
					 COMAR 10.09.36.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.08 - Freestanding Clinics › Section 10.09.08.02 - License Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. The provider
				  shall meet all license requirements as set forth in COMAR 10.09.36.02.
B. A physician or osteopath
				  providing services in a freestanding clinic shall be licensed and legally
				  authorized to practice medicine in the state in which the service is
				  provided.
C. The provider shall
				  ensure that all X-ray and other radiological equipment:
(1) Is maintained and inspected in compliance
				  with the requirements of the Maryland Radiation Act, Environment Article, Title
				  8, Subtitle 3, Annotated Code of Maryland; and
(2) Meets the standards established by COMAR
				  26.12.01-26.12.03, or other applicable standards established by the state in
				  which the service is provided.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.08 - Freestanding Clinics › Section 10.09.08.03 - Conditions for Participation

Current through Register Vol. 51, No. 14, July 12, 2024
A. General
				  requirements for participation in the Program are that a provider shall:
(1) Meet all the conditions for participation
				  as set forth in COMAR 10.09.36; and
(2) If delivering services via telehealth,
				  comply with COMAR 10.09.49 and any subregulatory guidance issued by the
				  Department.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.08 - Freestanding Clinics › Section 10.09.08.04 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Program
				  covers the services listed in §§B-E of this regulation according to
				  the conditions and requirements indicated.
B. Medically Necessary Services. The program
				  covers medically necessary services as described in §§C, D, and E of
				  this regulation and in Regulation .05 of this chapter, rendered to participants
				  by a freestanding clinic, when these services are performed by a physician or
				  by:
(1) A registered nurse, a psychologist,
				  or a social worker, provided that the individual performs the service within
				  the scope of the individual's license or certification for the purpose of
				  assisting in the provision of physicians' services;
(2) A nurse midwife, a nurse practitioner, a
				  licensed practical nurse, or a registered physician's assistant, provided that
				  the individual performs the services within the scope of the individual's
				  license or certification; or
(3) An
				  addictions counselor who meets the requirements in accordance with COMAR
				  10.58.07.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.08 - Freestanding Clinics › Section 10.09.08.05 - Federally Qualified Health Center Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. To
				  participate as a federally qualified health center, the provider shall meet the
				  requirements of Regulations .03 and .04B of this chapter and shall:
(1) Meet the conditions for coverage in
				  accordance with 42 CFR § 491, Subpart A;
(2) Be enrolled in the EPSDT/Healthy Kids
				  Program as provided in COMAR 10.09.23 and provide EPSDT/Healthy Kids services
				  to participants who are eligible to receive them;
(3) Supply the Department with financial and
				  other information as requested;
(4)
				  Meet one of the following conditions:
(a)
				  Meet all of the requirements for receiving a grant under §329, 330, or 340
				  of the Public Health Service Act,
				  42 U.S.C. §
													254(c), as determined by the
				  Secretary of the United States Department of Health and Human Services, and in
				  accordance with 42 CFR
				  §
													405.2401;
(b) Receive a waiver from the Secretary of
				  the United States Department of Health and Human Services of one or more of the
				  requirements for receiving a grant pursuant to §329, 330, or 340 of the
				  Public Health Service Act; or
(c)
				  Be an outpatient health program or facility operated by a tribe or tribal
				  organization under the Indian Self-Determination Act or by an Urban Indian
				  organization receiving funds under Title V of the Indian Health Care
				  Improvement Act;
(5)
				  Comply with the requirements contained in COMAR 10.09.59 if delivering mental
				  health services and COMAR 10.09.80 when providing substance use disorder
				  services; and
(6) Comply with the
				  requirements contained in COMAR 10.09.05, if rendering dental
				  services.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.08 - Freestanding Clinics › Section 10.09.08.06 - Limitations

Current through Register Vol. 51, No. 14, July 12, 2024
The Program does not cover the following:
A. Services not specified in Regulation .04
				  of this chapter;
B. Services not
				  medically necessary;
C.
				  Investigational and experimental drugs and procedures;
D. Procedures solely for cosmetic
				  purposes;
E. Services denied by
				  Medicare as not medically justified;
F. Freestanding clinic services for inpatient
				  participants in State-operated facilities serving individuals with intellectual
				  disabilities;
G. Freestanding clinic
				  services provided to hospital inpatients;
H. Freestanding clinic visits when patients
				  are referred to hospital outpatient departments or emergency rooms for services
				  ordinarily provided in freestanding clinics covered by this chapter;
I. Freestanding clinic visits solely for the
				  purpose of one or more of the following:
(1)
				  Prescription drugs or collection of laboratory specimens, unless otherwise
				  allowed;
(2) Certification or
				  recertification of food supplements;
(3) Performing laboratory tests required only
				  for certification or recertification of food supplement programs;
(4) Nutritional assessments in the absence of
				  diagnosis of nutritional disorders, unless EPSDT or primary health services are
				  provided at the same time;
(5)
				  Ascertaining the patient's weight;
(6) Interpretation of laboratory tests or
				  panels; and
(7) Measurement of
				  blood pressure;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.08 - Freestanding Clinics › Section 10.09.08.07 - Freestanding Clinic Reimbursement Methodology

Current through Register Vol. 51, No. 14, July 12, 2024
A. Reimbursement for Family Planning Clinics.
				  The Department shall pay the family planning clinic the lesser of the
				  provider's customary charge or the provider's acquisition cost, but no more
				  than the maximum reimbursement allowed for similar procedures or services
				  required in COMAR
				  10.09.02.07D. f
				  the service is free to individuals not covered by Medicaid:
(1) The provider:
(a) May charge the Program; and
(b) Shall be reimbursed in accordance with
				  COMAR 10.09.02.07D;
				  and
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.08 - Freestanding Clinics › Section 10.09.08.08 - Reimbursement Methodology for FQHC Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. Federally qualified health centers shall
				  be reimbursed for covered services once the provider is in compliance with all
				  federal and State requirements.
B.
				  The only well-child visits that are eligible for Program reimbursement are
				  those that are billed as EPSDT screens.
C. Payment of Allowable Costs.
(1) Federally qualified health centers shall
				  be paid 100 percent of the FQHC's allowable costs, subject to the limitations
				  contained in §§D-G of this regulation, that are related to the
				  provision of covered services.
(2)
				  Allowable costs will be determined in accordance with Medicare principles of
				  cost reimbursement as contained in
				  42 CFR
				  413.5, unless otherwise specified in this
				  chapter.
(3) Providers' allowable
				  costs are subject to audit and verification by the Department or its
				  designee.
(4) Costs not adequately
				  documented, return on equity, bad debts incurred by private pay, Medicare
				  patients, or third-party payers, and bad debts resulting from denied costs of
				  the Program are not allowable in establishing reimbursement rates.
(5) Services covered under § 1915(g) of
				  Title XIX of the Social Security Act, which are called targeted case management
				  services, and the costs associated with these services, are excluded when
				  establishing reimbursement rates.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.08 - Freestanding Clinics › Section 10.09.08.09 - Preauthorization Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  following procedures or services require preauthorization:
(1) Vision care according to COMAR
				  10.09.14.06 and COMAR
				  10.09.23;
(2) Mental health
				  services which shall comply with the requirements of COMAR 10.09.59;
(3) Substance use disorder services which
				  shall comply with the requirements of COMAR 10.09.80; and
(4) Dental services which shall comply with
				  the requirements of COMAR 10.09.05.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.08 - Freestanding Clinics › Section 10.09.08.10 - Payment Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. The provider
				  shall submit a completed request for payment in the format designated by the
				  Department with any required documentation.
B. The Program reserves the right to return
				  to the provider, before payment, all invoices not properly completed with a
				  diagnosis, procedure code, and description of the services provided.
C. The provider shall bill the Program the
				  provider's customary charge to the general public for similar services. If the
				  service is free to individuals not covered by Medicaid:
(1) The provider:
(a) May charge the Program; and
(b) Shall be reimbursed in accordance with
				  COMAR 10.09.02.07D;
				  and
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.08 - Freestanding Clinics › Section 10.09.08.11 - 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 10.09.08 - Freestanding Clinics › Section 10.09.08.12 - 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 10.09.08 - Freestanding Clinics › Section 10.09.08.13 - Appeal Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
Providers filing appeals from administrative decisions made
					 in connection with this chapter shall do so according to COMAR 10.09.36.09.