Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.23 - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services › Section 10.09.23.07 - Payment Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. Request for
				  payment of services shall be submitted in accordance with COMAR 10.09.36.04.
B. Billing time limitations for
				  claims submitted pursuant to this chapter as set forth in COMAR 10.09.36.06.
C. Rates for services provided by
				  chiropractors, speech therapists, occupational therapists, and nutritionists
				  covered under this chapter are included in the Early Periodic, Screening,
				  Diagnosis, and Treatment (EPSDT) Provider Manual.
D. Reimbursement of Medically Monitored
				  Intensive Inpatient Treatment Services Provided in an Intermediate Care
				  Facility.
(1) The Department may not directly
				  reimburse any State-operated intermediate care facility for participants. The
				  Department shall claim federal fund recoveries from the Department of Health
				  and Human Services for services to federally eligible Title XIX patients in
				  these intermediate care facilities.
(2) The Department shall pay the intermediate
				  care facility the lesser of:
(a) The
				  provider's customary charge unless the service is free to individuals not
				  covered by Medicaid; or
(b) The
				  provider's per diem costs for covered services according to the principles
				  established under Title XVIII of the Social Security Act, up to a maximum of
				  $400 per day.
(3) The
				  maximum payment in §D(2)(b) of this regulation will be updated annually by
				  the Centers for Medicare and Medicaid Service's published federal fiscal year
				  market basket increase percentage relating to hospitals excluded from the
				  prospective payment system.
(4)
				  Submitting Cost Reports.
(a) Facilities
				  reimbursed according to Medicare standards and principles for retrospective
				  cost reimbursement as described in
				  42 CFR §
													413.40, as amended, shall submit to the
				  Department or its designee, in the form prescribed, financial and statistical
				  data within 3 months after the end of the provider's fiscal year unless the
				  Department grants the provider an extension or the provider discontinues
				  participation in the Program. If reports are not received within 3 months and
				  the Department has not granted an extension, the Department shall withhold from
				  the provider a maximum of 10 percent of the current interim payment for the
				  calendar month in which the report is due and any subsequent calendar month
				  until the report has been submitted. There may not be a refund or adjustment
				  for withholding in cost settlement.
(b) If a provider discontinues participation,
				  financial and statistical data shall be submitted to the Department within 45
				  days after the effective date of termination.
(c) The Department may grant an extension if:
(i) The provider makes a written request
				  setting forth the specific reasons for the request; and
(ii) The Department determines, taking into
				  consideration the totality of the circumstances, that the request is
				  reasonable.
(d) If a
				  report is not submitted by the last day of the 6th month after the end of the
				  provider's fiscal year, and the provider has not received an extension, the
				  Department, in addition to withholding percentages of payment pursuant to
				  §D(3)(a) of this regulation, may impose one or more sanctions as provided
				  for in Regulation .09 of this chapter.
(e) If a report is not submitted by the last
				  day of the 6th month after the end of the provider's fiscal year, or a report
				  is submitted but the provider cannot furnish proper documentation to verify
				  costs, the Department, if applicable, shall make final cost settlement for that
				  fiscal year at a certain percentage of the last final per diem rates for which
				  the Department has verified costs for that facility, provided that the rates
				  established may not exceed the maximum per diem rates in effect when the
				  facility's costs were last settled.
(f) For purposes of §D(3)(a)-(e) of this
				  regulation, reports are considered received when the submitted reports are
				  completed according to instructions issued by the Department.
(5) Participant's Contribution.
(a) The local department of social services
				  or the State-operated facility's fiscal agent shall determine the amount the
				  participant has available to pay toward the cost of medical or remedial care
				  for inpatient services, and so inform the provider.
(b) The provider shall collect from the
				  participant that amount as shown available on the designated form.
(c) The provider may not collect a total
				  amount, including the participant's resource and the Department's payment,
				  which exceeds the provider's rate established by the Department.
(d) The provider shall show to the Department
				  sums collected from the participant.