reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.17-1 - Selected Costs - Not Allowable for Payments for Services Provided Effective January 1, 2015

Current through Register Vol. 51, No. 14, July 12, 2024
The following costs are not allowable in establishing
					 prospective rates:
A. Costs not
				  adequately documented;
B. Costs for
				  chaplaincy training and other religious training programs;
C. Bad debts incurred by private pay or
				  Medicare patients or third-party payers and bad debts resulting from denied
				  costs of the Program;
D. Recipient
				  resources certified as available for medical and remedial care by the
				  Department of Human Resources which are uncollected;
E. Advertising expenses, except those
				  necessary for personnel recruitment;
F. Stockholder costs incurred primarily for
				  the benefit of stockholders or other investors, including the costs of
				  stockholders' annual reports and newsletters, annual meetings, mailing of
				  proxies, stock transfer agent fees, stock exchange registration fees,
				  stockbroker and investment analysis, stock issuance costs, and accounting and
				  legal fees for consolidating statements for Securities and Exchange Commission
				  purposes;
G. Any contributions,
				  whether charitable or not, to any individual or organization;
H. Public relations expenses;
I. Costs of maintaining a recipient in a
				  private room which exceeds costs of a semiprivate room;
J. Cost of depreciable assets and minor
				  equipment useful for a lifetime of at least 2 years, with a historical cost of
				  at least $500 or an aggregate historical cost of at least $500 if they are
				  purchased in a quantity of like or similar items;
K. Civil money penalties, fines, and all
				  costs associated with sanctions, including receivership, initiated by the
				  Department or any other local, State, or federal government agency;
L. Interest paid by a provider under
				  Regulations .14J(2) or .30E(5) of this chapter;
M. Administrator compensation for any owner,
				  or relative of the owner, in excess of the limits established based on the
				  results of the 2001 nonowner administrator compensation survey, trended forward
				  based on the percentage of the annual increase or decrease in the All Items
				  category of the Consumer Price Index for All Urban Consumers (CPI-U), as
				  follows:
(1) For facilities with 1-74 beds,
				  the median compensation from that group;
(2) For facilities with 75-199 beds, the
				  median compensation from that group; and
(3) For facilities with 200 or more beds, the
				  median compensation from all facilities with 200 or more beds;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.18 - Pay-for-Performance - Scoring Data Review

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Department shall report scores for
				  pay-for-performance quality measures in Regulation .15 of this chapter, on or
				  about July 1 of each year, based on data compiled during the prior fiscal
				  year.
B. A facility shall have 30
				  days from the date of the report to review and comment on performance
				  data.
C. If the Department
				  determines that there are any errors in transcription of the data provided to
				  the Department, or calculation of scores, ranks, or payment amounts, all
				  facilities shall be rescored and revised scores shall be distributed. A final
				  30-day review period shall be allowed if the rescoring results in significant
				  modifications.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.19 - Pay-for-Performance - Payment Distribution

Current through Register Vol. 51, No. 14, July 12, 2024
A. Beginning
				  State fiscal year 2021, and each year thereafter, 1 percent of the budget
				  allocation for nursing facility services shall be distributed based on
				  pay-for-performance scores.
B.
				  Eighty-five percent of the amount identified in §A of this regulation
				  shall be distributed to the highest scoring facilities, representing 40 percent
				  of the eligible days of care, in accordance with the methodology described in
				  Regulation .16 of this chapter.
C.
				  Funds shall be distributed among the facilities identified in §B of this
				  regulation, based on the facility's relative score, such that the
				  highest-scoring facility shall receive twice the amount per day as the
				  lowest-scoring facility receiving payment.
D. Fifteen percent of the amount identified
				  in §A of this regulation shall be distributed to the facilities that
				  qualify for payment for improvement in accordance with Regulation .17 of this
				  chapter.
E. Funds shall be
				  distributed among the facilities included in §D of this regulation, based
				  on a facility's relative point increase from the prior fiscal year, such that
				  the facility with the greatest point increase shall receive twice the amount
				  per day as the facility with the smallest point increase.
F. A facility shall receive a lump-sum
				  payment based on the per diem amount determined in accordance with §C or E
				  of this regulation, multiplied by the facility's Medicaid days of care in the
				  facility's most recent cost report, not to exceed 1 year.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.20 - Payment Procedures - Out-of-State Facilities

Current through Register Vol. 51, No. 14, July 12, 2024
A. Out-of-State nursing facilities that are
				  not special rehabilitation nursing facilities and do not meet the exception to
				  cost reporting requirements set forth in Regulation .21M of this chapter shall
				  be reimbursed at a rate that is the lesser of:
(1) The average Statewide quarterly rate
				  identified by Regulation .07 of this chapter for in-State nursing facilities
				  minus the quality assessment; and
(2) The out-of-State facility's Medicaid per
				  diem rate provided by the state in which the facility is located, or, if the
				  state provides the facility with more than one Medicaid per diem rate, the
				  facility's lowest per diem rate.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.21 - Cost Reporting

Current through Register Vol. 51, No. 14, July 12, 2024
A. The provider
				  shall include, for purposes of cost finding, direct and indirect costs
				  applicable to recipient care.
B.
				  The provider shall specifically identify, in the cost report, costs associated
				  with related organizations.
C. The
				  provider shall maintain adequate financial records and statistical data
				  according to generally accepted accounting principles and procedures. This
				  system of accounts will provide as a minimum:
(1) Maintenance of a chronological cash
				  receipts and disbursements journal in sufficient detail to show the exact
				  nature of the receipts and disbursements;
(2) Proper reference to supporting invoice,
				  voucher, or other form of original evidence;
(3) Maintenance of an appropriate time
				  reporting system for all personnel and proper payroll authorizations and
				  vouchers;
(4) Provision for payment
				  by check (when financial transactions involve numerous small expenditures, an
				  imprest petty cash fund may be established, provided adequate supporting
				  vouchers are maintained);
(5)
				  Maintenance of records on all assets capitalized and depreciation on the
				  assets;
(6) Maintenance of
				  appropriate records of patient days by level of care;
(7) Maintenance of records on an accrual
				  basis;
(8) Maintenance of a daily
				  midnight bed census by recipient name in a form prescribed by the Department
				  (use of the prescribed form may be waived by the Department or its designee
				  where a provider demonstrates the ability to maintain a superior system of
				  census information); and
(9)
				  Maintenance of other records as required by the Department.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.22 - Desk Reviews and Field Verification

Current through Register Vol. 51, No. 14, July 12, 2024
A. Desk
				  Reviews.
(1) The Department or its designee
				  may conduct a desk review of the costs before establishing the Administrative
				  and Routine and Other Patient Care prices and Nursing Service rates.
(2) The Department or its designee shall
				  notify each provider participating in the Program if any adjustments resulted
				  from the desk review.
(3) Desk
				  review adjustments shall be used in the computation of any future rate for the
				  facility or the facility's future owner that is based on the reported or desk
				  reviewed costs, until the rate is rebased.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.23 - Third Party Liability Reviews and Audits of Nursing Facilities

Current through Register Vol. 51, No. 14, July 12, 2024
A. Quarterly
				  Reports of Credit Balances. A provider shall report the credit balances of the
				  nursing facility to the Department on a quarterly basis.
B. Third Party Liability Review. The
				  Department shall conduct a third party liability review of the reports of the
				  credit balances provider under §A of this regulation.
C. Third Party Liability Audit of Random
				  Sample. The Department or its designee may conduct a third party liability
				  audit of a random sample of the reports of credit balances reviewed under
				  §B of this regulation.
D.
				  Third Party Liability Audit of Noncompliant Nursing Facility.
(1) Subject to §D(2) of this regulation,
				  the Department or its designee may conduct a third party liability audit of a
				  nursing facility that is found to be noncompliant under §B of this
				  regulation.
(2) In conducting the
				  third party liability audit, the Department or its designee may only review the
				  financial information of the nursing facility for the 2-year period immediately
				  before the first day of the audit period in which the nursing facility was
				  found to be noncompliant.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.24 - MDS Validation and Ventilator Care Validation

Current through Register Vol. 51, No. 14, July 12, 2024
A. MDS Validation.
(1) In order to validate that the Nursing
				  Service rate is supported by medical record documentation, accurately coded and
				  submitted, the Department shall conduct periodic MDS validation reviews, which
				  shall:
(a) Compare the MDS assessment coding
				  with the corresponding medical record documentation to determine unsupported
				  MDS assessments;
(b) Determine the
				  completeness, timeliness, and accuracy of resident MDS assessments identified
				  on the resident roster; and
(c)
				  Determine the completeness and accuracy of the resident payment source listed
				  on the resident roster.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.26 - Selected Costs - Allowable

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Recreational Services. The allowable costs of recreational services of a
				  facility shall be based on an hourly or salary rate, not on a fee-for-service
				  basis.
B. Over-the-Counter Drugs.
				  The cost of over-the-counter drugs is not to exceed the average wholesale price
				  plus 50 percent, or the usual selling price, whichever is lower.
C. Leave of Absence. The Department shall pay
				  the sum of the rates identified in Regulations .09-.11 of this chapter, less
				  patient resources for the cost of reserving beds for recipients for therapeutic
				  home visits or participation in State-approved therapeutic or rehabilitative
				  programs, subject to the following conditions:
(1) The recipient's plan of care provides for
				  the absence;
(2) The leave of
				  absence does not exceed 18 days during any calendar year;
(3) The recipient's attending physician shall
				  complete the physician's authorization form not more than 30 days before the
				  recipient's anticipated leave of absence; and
(4) The facility submits the physician's
				  authorization form to the Department with the facility's invoice, which covers
				  the month in which the leave of absence occurred.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.27 - Selected Costs - Not Allowable

Current through Register Vol. 51, No. 14, July 12, 2024
The following costs are not allowable in establishing
					 prospective rates:
A. Costs not
				  adequately documented;
B. Costs for
				  chaplaincy training and other religious training programs;
C. Bad debts incurred by private pay or
				  Medicare patients or third-party payers and bad debts resulting from denied
				  costs of the Program;
D. Recipient
				  resources certified as available for medical and remedial care by the
				  Department of Human Resources which are uncollected;
E. Advertising expenses, except those
				  necessary for personnel recruitment;
F. Stockholder costs incurred primarily for
				  the benefit of stockholders or other investors, including the costs of
				  stockholders' annual reports and newsletters, annual meetings, mailing of
				  proxies, stock transfer agent fees, stock exchange registration fees,
				  stockbroker and investment analysis, stock issuance costs, and accounting and
				  legal fees for consolidating statements for Securities and Exchange Commission
				  purposes;
G. Any contributions,
				  whether charitable or not, to any individual or organization;
H. Public relations expenses;
I. Costs of maintaining a recipient in a
				  private room which exceeds costs of a semiprivate room;
J. Cost of depreciable assets and minor
				  equipment useful for a lifetime of at least 2 years, with a historical cost of
				  at least $500 or an aggregate historical cost of at least $500 if they are
				  purchased in a quantity of like or similar items;
K. Civil money penalties, fines, and all
				  costs associated with sanctions, including receivership, initiated by the
				  Department or any other local, State, or federal government agency;
L. Interest paid by a provider under
				  Regulation .23E(5) of this chapter;
M. Administrator compensation for any owner,
				  or relative of the owner, in excess of the limits established based on the
				  results of the 2001 nonowner administrator compensation survey, trended forward
				  based on the percentage of the annual increase or decrease in the All Items
				  category of the Consumer Price Index for All Urban Consumers (CPI-U), as
				  follows:
(1) For facilities with 1-74 beds,
				  the median compensation from that group;
(2) For facilities with 75-199 beds, the
				  median compensation from that group; and
(3) For facilities with 200 or more beds, the
				  median compensation from all facilities with 200 or more beds;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.28 - Recipient's Resource

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  Department of Human Resources will determine the application of a recipient's
				  resource to the cost of medical or remedial care pursuant to COMAR
				  10.09.24.
B. The provider shall
				  collect a recipient's resource available for medical or remedial care, as
				  certified by the Department of Human Resources.
C. The total of a recipient's available
				  resource for medical or remedial care and the Department's payment may not
				  exceed the provider's per diem rate.
D. The provider shall show sums collected
				  from a recipient's available resource as patient revenue.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.29 - Recipient's Personal Needs Fund

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  If a provider administers a recipient's personal needs fund, it shall
				  administer the fund according to guidelines established by the
				  Department.
B. Upon request during
				  normal business hours, a provider shall make available for verification by the
				  Department or its designee the records of all transactions involving
				  recipient's personal needs funds.
C. A provider may not use a recipient's
				  personal needs fund for care or services which are either allowable as part of
				  the per diem cost or otherwise covered by the Medical Assistance
				  Program.
D. Upon request during
				  normal business hours, 7 days a week, for a minimum of 3 hours each day, a
				  provider shall allow a recipient to withdraw or otherwise use his personal
				  needs fund.
E. A provider may not
				  use a recipient's personal needs fund for care or services not requested or not
				  provided. A recipient's personal needs fund may not be used to retire a
				  pre-existing debt.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.30 - Reimbursement Classes

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  reimbursement classes for the Administrative and Routine cost center are as
				  follows:
(1) Facilities in the Baltimore
				  metropolitan region consisting of the following counties:
(a) Anne Arundel,
(b) Baltimore,
(c) Carroll,
(d) Harford, and
(e) Howard;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.31 - Nursing Service Personnel and Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. Personnel Types and Category Groupings.
Selected Personnel Types
Personnel Categories
Director of nursing (RN or LPN)
Directors of nursing (DON)
Assistant director of nursing (RN or LPN)
RN charge nurse
Registered nurses (RN)
RN staff nurse
RN relief nurse
Registry RN charge nurse
Registry RN staff nurse
LPN charge nurse
Licensed practical nurses (LPN)
LPN staff nurse
LPN relief nurse
Registry LPN charge nurse
Registry LPN staff nurse
Graduate nurse
Nurse aide
Nurse aides (NA)
Nurse aide relief
Registry nurse aide
Ward clerk
Certified medication aide
Certified medication aide (CMA)
B. Minimum Data Set
				  Resource Utilization Groups Hourly Weights.
RUG-IV 48
Total Hours
ES3
6.17733333
ES2
5.04483333
ESI
5.69500000
RAE
5.17450000
RAD
4.70150000
RAC
3.86266667
RAB
3.07583333
RAA
2.28500000
HE2
5.43733333
HE1
4.49366667
HD2
5.00533333
HD1
3.99700000
HC2
4.26566667
HC1
3.84616667
HB2
5.30500000
HB1
3.02300000
LE2
4.89816667
LEI
4.01933333
LD2
4.31583333
LD1
3.35383333
LC2
3.32883333
LCI
3.36916667
LB2
4.07566667
LB1
2.91083333
CE2
4.28650000
CE1
3.86816667
CD2
4.46816667
CD1
3.80533333
CC2
3.02250000
CC1
2.98650000
CB2
2.83283333
CB1
2.68883333
CA2
1.87200000
CA1
1.75983333
BB2
2.49116667
BB1
2.46466667
BA2
2.12716667
BA1
1.65100000
PE2
3.84716667
PE1
3.81933333
PD2
3.74566667
PD1
3.46050000
PC2
2.68133333
PCI
2.90283333
PB2
2.74100000
PB1
2.00416667
PA2
1.07683333
PA1
1.34950000
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.32 - 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 any service 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.
C. If the recipient is eligible for benefits
				  from another payment source and elects to forfeit those benefits, the Program
				  may reduce payment by the value of the benefits forfeited.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.33 - 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, 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
				  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;
(5) Denial of payment for new Medicaid
				  admissions.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.34 - Appeal Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except
				  as provided for in §B of this regulation, providers filing appeals from
				  administrative decisions made in connection with these regulations shall do so
				  according to [State Government Article, Title 10, Subtitle 2, and
				  Health-General Article, §2-201 "2-207, Annotated Code of Maryland] COMAR
				  10.09.36.09C.
B. Nursing Home Appeal Board.
(1) Appeals regarding rate calculations or
				  cost report adjustments which cannot be resolved administratively go to the
				  Nursing Home Appeal Board.
(2) The
				  Appeal Board shall be composed of the following members:
(a) A representative of the nursing home
				  industry who is:
(i) Knowledgeable in
				  Medicare and Medicaid reimbursement principles; and
(ii) Appointed by the Secretary;
(b) An individual who:
(i) Is employed by the State;
(ii) Knowledgeable in Medicare and Medicaid
				  reimbursement principles;
(iii) Did
				  not directly participate in the field verification or desk review;
				  and
(iv) Is appointed by the
				  Secretary; and
(c) A
				  third member selected by the first two members of the Board.
(3) When the Board is reviewing an
				  appeal from a provider in which a Board member is employed or in which he has a
				  financial or personal interest, the Secretary shall designate an alternate for
				  that member.
(4) If the provider
				  elects to appeal to the Appeal Board and the Appeal Board finds in favor of the
				  provider, the Department shall initiate a claims adjustment settlement for the
				  impacted service dates within 60 days after the notification of the
				  findings.
(5) The Department or any
				  provider aggrieved by a reimbursement decision of the Appeal Board may not
				  appeal to the Board of Review but may take a direct judicial appeal. The appeal
				  shall be made as provided for judicial review of final decisions in the
				  Administrative Procedure Act,§10-222, State Government Article, Annotated
				  Code of Maryland.
(6) An appeal
				  shall be filed in accordance with COMAR 10.01.09.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.35 - 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 10.09.11 - Maryland Children's Health Program › Section 10.09.11.01 - Purpose and Scope

Current through Register Vol. 51, No. 14, July 12, 2024
A. This
				  chapter governs the determination of eligibility for the Maryland Children's
				  Health Program.
B. Eligibility for
				  the Maryland Children's Health Program may be established for:
(1) Women of any age during pregnancy and
				  during the postpartum period whose income is equal to or less than 250 percent
				  of the federal poverty level; and
(2) Children younger than 19 years old whose
				  family income is equal to or less than 200 percent of the federal poverty
				  level.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.02 - 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.
(a) "Applicant" means an individual whose
				  written application for the Maryland Children's Health Program has been
				  submitted to the local health department or the local department of social
				  services but has not received final action.
(b) "Applicant" includes an individual whose
				  application is submitted through a representative.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.03 - Coverage Groups

Current through Register Vol. 51, No. 14, July 12, 2024
The following individuals may be determined eligible for
					 the Maryland Children's Health Program:
A. Pregnant and postpartum women of any age
				  whose family income is equal to or less than 250 percent of the federal poverty
				  level; and
B. Children younger than
				  19 years old and whose family income is equal to or less than 200 percent of
				  the federal poverty level.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.04 - Application

Current through Register Vol. 51, No. 14, July 12, 2024
A. The local health
				  department or the local department of social services shall determine
				  eligibility for pregnant women and children.
B. The local health department or the local
				  department of social services shall give oral or written information about the
				  eligibility requirements, coverage, scope, and related services of the Maryland
				  Children's Health Program, and an individual's rights and obligations under the
				  Program, to any individual requesting this information.
C. The local health department or the local
				  department of social services shall make the application form available without
				  delay to an individual requesting one.
D. A resident temporarily absent from the
				  State but intending to return may apply for assistance by mail to the local
				  health department or the local department of social services in the
				  jurisdiction in which the resident's home is located. The individual shall
				  demonstrate the individual's continued residency in the State and shall meet
				  all technical and financial requirements in order to be determined
				  eligible.
E. Application Filing and
				  Signature Requirements.
(1) An individual who
				  wishes to apply for the Maryland Children's Health Program under this chapter
				  shall submit a written and signed application form to the local health
				  department or the local department of social services in the jurisdiction in
				  which the individual's residence is located. An applicant is responsible for
				  completing the application but may be assisted in the completion by an
				  individual of the applicant's choice.
(2) For the purpose of establishing only the
				  date of application, the applicant, or a person acting on behalf of the
				  applicant, shall sign the application form.
(3) For the purpose of establishing
				  eligibility of a pregnant or postpartum woman of any age, the applicant shall
				  sign the application form.
(4) For
				  the purpose of establishing eligibility of a child applicant who is neither
				  pregnant nor postpartum, a parent or stepparent living with the child shall
				  complete and sign the application form. If the child does not live with a
				  parent, an authorized representative who is 21 years old or older shall
				  complete and sign the application form.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.05 - Application: Additional Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Social Security Number.
(1) As a condition of eligibility, an
				  applicant shall furnish to the local health department or the local department
				  of social services a Social Security number for the applicant. If the applicant
				  cannot furnish a Social Security number, the applicant shall apply for a
				  number. Assistance may not be denied, delayed, or discontinued pending the
				  issuance or verification of the number if the applicant complies with this
				  subsection.
(2) Eligibility may not
				  be established until the applicant:
(a)
				  Furnishes a Social Security number; or
(b) Requests the assignment of the number
				  through the Social Security Administration.
(3) Failure to provide the required Social
				  Security number shall result in ineligibility for the applicant.
(4) If an applicant lacks the resources to
				  meet the requirements of this regulation, the local health department or the
				  local department of social services shall assist the applicant in obtaining the
				  necessary documents, and any costs incurred by the local department shall be
				  paid for out of administrative funds.
(5) If the application indicates that a
				  Social Security number was issued previously, the local health department or
				  the local department of social services shall request validation of the number
				  by the Social Security Administration.
(6) Individuals described under Regulation
				  .06A(2) of this chapter who are applying for limited benefits to treat an
				  emergency medical condition are not subject to the requirements in
				  §A(1)-(4) of this regulation.
(7) The requirements described under
				  §A(1)-(5) of this regulation are not applicable to members of the
				  applicant's family.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.06 - Nonfinancial Eligibility Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Citizenship. In order to be eligible for
				  full benefits under the Maryland Children's Health Program, an individual shall
				  meet the federal requirements for Medical Assistance eligibility as a citizen
				  or qualified alien, as specified at COMAR
				  10.09.24.05C.
B. Residency. In order to be
				  eligible for benefits under this chapter, an individual shall be a resident of
				  Maryland, in accordance with the requirements at COMAR
				  10.09.24.05C
				  -3.
C. Pregnancy. In order to be eligible for
				  benefits under this chapter, a woman shall be pregnant or be within the
				  postpartum period.
D. Age. In order
				  to be eligible for benefits under this chapter, a child shall be younger than
				  19 years old.
E. Inmate of a Public
				  Institution. In order to receive benefits under this chapter, an individual may
				  not be an inmate of a public institution, as specified at COMAR
				  10.09.24.05C
				  -5B.
F. Institution for Mental Diseases. In order
				  to be eligible for benefits under this chapter, an individual between 21 and 64
				  years old or a child applying under Title XXI of the Social Security Act may
				  not be a patient in an institution for mental diseases, unless such individuals
				  are eligible in accordance with COMAR
				  10.09.24.05C
				  -5C.
G. No Private Health Insurance. In order to
				  be eligible for benefits under Title XXI of the Social Security Act, an
				  individual may not be covered by an employer-sponsored health benefit plan or
				  have been voluntarily terminated from an employer-sponsored health benefit plan
				  within 6 months before the application date for benefits under this
				  chapter.
H. An alien who fails to
				  meet the requirements under §A of this regulation, but meets all other
				  nonfinancial and financial factors of eligibility under this chapter, may be
				  determined eligible for coverage under COMAR
				  10.09.24.05C
				  -2.
I. Documentation of Citizenship and Identity.
(1) An applicant or recipient shall be
				  required as a condition of eligibility to provide documentary evidence of
				  identity as well as citizenship or nationality, to the Department's
				  satisfaction, based on federal requirements, if the individual is:
(a) Declared to be a citizen or national of
				  the United States; and
(b) Being
				  determined for:
(i) Initial eligibility based
				  on an application filed on or after September 1, 2006; or
(ii) Continuing eligibility based on a
				  redetermination with an end date on or after September 30, 2006.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.07 - Consideration of Family Income

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  applicant shall report the income of each family member. When there is evidence
				  of regular expenditures which are inconsistent with reported income, the
				  applicant shall offer an explanation to reconcile the inconsistency.
B. Determining Countable Net Family Income.
(1) In determining an applicant's financial
				  eligibility for the Maryland Children's Health Program, the applicant's family
				  income is considered for the applicable period under consideration.
(2) For the pregnant or postpartum applicant,
				  family income shall consist of the income of the pregnant or postpartum woman
				  and of the following family members when living with the applicant:
(a) Spouse; and
(b) The applicant's children younger than 21
				  years old.
(3) For the
				  child applicant who is neither pregnant nor postpartum, family income shall
				  consist of the income of the child applicant and the following family members
				  when living with the child applicant:
(a) The
				  child applicant's parents; and
(b)
				  At the option of the child applicant's parents, any of the child applicant's
				  siblings.
(4) For the
				  married child applicant who is neither pregnant nor postpartum, family income
				  shall consist of the income of the married child applicant and the married
				  child applicant's spouse.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.08 - Consideration of Family Income:Earned and Unearned Income

Current through Register Vol. 51, No. 14, July 12, 2024
A. Earned income includes the following:
(1) Wages, including sick or severance
				  pay;
(2) Commissions and
				  fees;
(3) Salaries and
				  tips;
(4) Profit from
				  self-employment income, as described in Regulation .09A(3)(a) of this
				  chapter;
(5) Income earned by a
				  migrant worker; and
(6) The Earned
				  Income Tax Credit (EITC).
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.09 - Consideration of Family Income: Income Disregards

Current through Register Vol. 51, No. 14, July 12, 2024
A. Income Disregards. The following
				  disregards shall be deducted from countable gross family income:
(1) $90 monthly for each employed family
				  member whether working full-time or part-time;
(2) The amount of child care expenses paid to
				  an individual who is not a legally responsible relative, not to exceed:
(a) $200 monthly per child if the parent or
				  parents are employed at least 100 hours per month; or
(b) $100 monthly per child if the parent or
				  parents are employed less than 100 hours per month; and
(3) A disregard of one-half of the gross
				  income amount for the following types of income:
(a) Profit from self-employment income,
				  unless an applicant or recipient can document a cost to produce in excess of
				  the disregard of one-half of gross income; and
(b) Profit from rental property income and
				  other income-producing property.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.10 - Determining Financial Eligibility

Current through Register Vol. 51, No. 14, July 12, 2024
An applicant is financially eligible for the Maryland
					 Children's Health Program if, for the period under consideration, the
					 applicant's countable net family income as determined under Regulation .07 of
					 this chapter does not exceed:
A. 200
				  percent of the federal poverty level for a family size equal to the size of the
				  family for child applicants younger than 19 years old; and
B. 250 percent of the federal poverty level
				  for a family size equal to the size of the family for pregnant and postpartum
				  women applicants.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.11 - Certification Periods

Current through Register Vol. 51, No. 14, July 12, 2024
A. For an
				  eligible woman, certification begins on the first day of the month of
				  application and ends on the last day of the second month after the pregnancy
				  ends.
B. For a newborn,
				  certification begins on the day the child is born to an eligible woman and ends
				  on the last day of the month of the child's 1st birthday.
C. For an eligible child, certification
				  begins on the first day of the month of application, or up to 3 months before
				  the month of application, if medical expenses were incurred during the earlier
				  months, and continues until the day the child is determined
				  ineligible.
D. A pregnant woman
				  eligible for health benefits under this chapter continues to be eligible for
				  benefits without regard to any change in income of the family of which she is a
				  member until the end of the second month after the pregnancy ends.
E. A child who, on the day the child becomes
				  19 years old, is receiving acute inpatient services under this chapter and who,
				  but for attaining that age, would remain eligible for Medical Assistance
				  benefits, shall continue to receive benefits until the end of the stay for
				  which acute inpatient services are furnished.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.12 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. A woman
				  certified for the Program, whether pregnant or within the postpartum period, is
				  entitled to all health benefits for which federal financial participation is
				  available, and shall receive her benefits through the Maryland Medicaid Managed
				  Care Program.
B. A child certified
				  for the Program is entitled to all health benefits through the Maryland
				  Medicaid Managed Care Program.
C.
				  In the case of an alien who is eligible for benefits under Regulation .06A(2)
				  of this chapter, covered services are limited to those that are necessary for
				  the treatment of an emergency medical condition, as defined under Regulation
				  .02B of this chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.13 - Post-Eligibility Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Notice
				  of Eligibility Determination. The local health department or the local
				  department of social services shall inform an applicant of the applicant's
				  legal rights and obligations and give the applicant written notification of the
				  following:
(1) For eligible persons:
(a) A finding of eligibility,
(b) The beginning and ending dates for
				  coverage, and
(c) The right to
				  request a hearing;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.14 - Hearings

Current through Register Vol. 51, No. 14, July 12, 2024
The requirements relating to hearings under COMAR
					 10.09.24.13B
					 apply to this chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.15 - 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
					 apply to this chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.16 - Adjustments and Recoveries

Current through Register Vol. 51, No. 14, July 12, 2024
The requirements relating to adjustments and recoveries
					 under COMAR
					 10.09.24.15B,
					 with the exception of COMAR
					 10.09.24.15A(1) and
					 (2), apply to this chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.11 - Maryland Children's Health Program › Section 10.09.11.17 - Interpretive Regulation

Current through Register Vol. 51, No. 14, July 12, 2024
State regulations shall be interpreted in conformity with
					 applicable federal statutes and regulations, except if 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.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.12 - Disposable Medical Supplies and Durable Medical Equipment › Section 10.09.12.02 - License Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
Providers of services shall meet the licensing requirements
					 as set forth in COMAR
					 10.09.36.02A.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.12 - Disposable Medical Supplies and Durable Medical Equipment › Section 10.09.12.03 - Conditions for Participation

Current through Register Vol. 51, No. 14, July 12, 2024
To participate in the Program, the provider:
A. Effective January 1, 2018, shall be in an
				  approved status with Medicare;
B.
				  Effective April 1, 2012 through December 31, 2017, shall, unless exempt from
				  Medicare accreditation requirements:
(1) Be
				  accredited by a Medicare-approved accreditation organization;
(2) Provide documentation of:
(a) Accreditation; or
(b) Having submitted an application for
				  accreditation; and
(3)
				  Be accredited or terminated from the Program;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.12 - Disposable Medical Supplies and Durable Medical Equipment › Section 10.09.12.04 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  following medically necessary items are covered when ordered by an individual
				  who is enrolled as a provider in the Program on the date of service:
(1) Disposable medical supplies;
(2) Durable medical equipment;
(3) Repairs to purchased durable medical
				  equipment;
(4) All disposable
				  medical supplies and durable medical equipment for home kidney dialysis
				  purchased or rented for Medical Assistance recipients;
(5) Prosthetic devices which include:
(a) Artificial eyes;
(b) Breast prostheses, including surgical
				  brassiere; and
(c) Upper and lower
				  extremity, full and partial, to include stump cover or harnesses where
				  necessary.
(6)
				  Replacement of prostheses;
(7)
				  Individually form-fitted support stockings, leg or arm, including all fitting,
				  dispensing, and follow-up care, for recipients for whom these supports are
				  medically necessary, not to exceed two at one time, three times in a 12-month
				  period for recipients 21 years old or older;
(8) Evaluation for equipment that was
				  subsequently provided through the Department's recycling program as described
				  in Regulation .07O of this chapter;
(9) Speech generating, augmentative, and
				  alternative communication devices for recipients enrolled under fee-for-service
				  or a Managed Care Organization; and
(10) Enteral nutritional products given by
				  nasogastric, jejunostomy, or gastrostomy tube in the home.