reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.41 - Employed Individuals with Disabilities › Section 10.09.41.06 - Time Standards

Current through Register Vol. 51, No. 14, July 12, 2024
A. Time
				  Standards for the Department.
(1) Disability
				  Determined by Social Security Administration. With respect to an application
				  submitted by an individual determined to be disabled as provided in Regulation
				  .03B(3)(b) of this chapter, unless the time standard is extended pursuant to
				  §D of this regulation, the Department shall, not later than 30 days from
				  the application date:
(a) Complete its
				  determination or redetermination of eligibility, subject to any premium payment
				  required by Regulation .07 of this chapter, and issue a written notice that
				  satisfies the requirements of Regulation .08B of this chapter; or
(b) Determine that it cannot complete its
				  eligibility determination without additional information or verifications, and
				  issue a written notice that informs the applicant or recipient of:
(i) The information and verifications
				  required to determine or redetermine eligibility; and
(ii) The due dates for the Department's
				  eligibility determination and for the applicant's or recipient's provision of
				  the additional information and verifications requested by the
				  Department.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.41 - Employed Individuals with Disabilities › Section 10.09.41.08 - Determination, Notice, and Certification Period

Current through Register Vol. 51, No. 14, July 12, 2024
A. Department's Determination. Based on the
				  information presented, the Department shall determine whether an applicant or
				  recipient is or is not eligible for the EID coverage group under this
				  chapter.
B. Finding of Eligibility
				  or Continuing Eligibility.
(1) Notice of
				  Initial Eligibility. If the Department determines that an applicant is
				  eligible, subject to the requirements of Regulation .07A of this chapter, for
				  the EID coverage group, the Department shall issue to the applicant written
				  notice that includes:
(a) A statement of the
				  finding of eligibility, as applicable, indicating the beginning and ending
				  dates of coverage, in accordance with §E of this regulation; and
(b) Notice of the right to request a hearing
				  pursuant to Regulation .13 of this chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.41 - Employed Individuals with Disabilities › Section 10.09.41.09 - Posteligibility Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Department's Responsibility. If it makes a determination as described in
				  Regulation .08A of this chapter, the Department shall:
(1) Inform the applicant or recipient of the
				  applicant's or recipient's legal rights and obligations; and
(2) Provide to the applicant or recipient
				  written notice of the findings, rights, and obligations as specified in COMAR
				  10.09.24.12A(2) and
				  (4) and Regulation .08B or C of this
				  chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.41 - Employed Individuals with Disabilities › Section 10.09.41.10 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except
				  as provided in §§B and C of this regulation, a recipient in the EID
				  coverage group is covered for medically necessary services required by the
				  recipient, if the services are:
(1) Furnished
				  by a provider who, with respect to the services rendered, is approved by the
				  Department to participate in the Medical Assistance Program;
(2) Covered under the State Plan;
(3) Not covered under ESI or any other health
				  insurance coverage besides Medical Assistance; and
(4) Not the subject of any third party
				  liability.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.41 - Employed Individuals with Disabilities › Section 10.09.41.11 - Conditions of Participation and Reimbursement

Current through Register Vol. 51, No. 14, July 12, 2024
The requirements for provider participation and
					 reimbursement for services furnished to Medical Assistance recipients in the
					 EID coverage group are governed by the same authorities that apply to services
					 furnished to Medical Assistance recipients in other coverage groups,
					 including:
A. General Medical
				  Assistance Provider Participation Criteria, as specified in COMAR 10.09.36;
				  and
B. Service-specific provisions
				  included within regulations applicable to individual service
				  categories.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.41 - Employed Individuals with Disabilities › Section 10.09.41.12 - Fraud, Liens, Recovery, and Reimbursement

Current through Register Vol. 51, No. 14, July 12, 2024
A. The provisions of COMAR
				  10.09.24.14A
				  concerning fraud apply to this chapter.
B. The Department shall make a claim against
				  income or resources, or both, of a recipient for benefits correctly paid, or to
				  be paid, under the circumstances specified in COMAR
				  10.09.24.15A
				  -1.
C. The Department may impose a lien on the
				  property of a recipient under the circumstances specified in COMAR
				  10.09.24.15A
				  -2(1).
D. The Department shall seek recovery of
				  Medical Assistance benefits correctly paid as provided in COMAR
				  10.09.24.15A
				  -3.
E. The Department shall accept reimbursement
				  if voluntarily offered by a current or former recipient or by someone acting on
				  behalf of the current or former recipient.
F. Extended Benefits Pending a Hearing
				  Decision.
(1) The Department shall refer for
				  reimbursement consideration all cases in which:
(a) A recipient received extended benefits
				  pending a hearing and decision by the hearing officer; and
(b) The hearing officer affirmed the decision
				  of the Department that was the subject of the appeal.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.41 - Employed Individuals with Disabilities › Section 10.09.41.13 - Hearings

Current through Register Vol. 51, No. 14, July 12, 2024
A. An EID applicant
				  or recipient shall have the hearing rights specified in COMAR 10.01.04, subject
				  to the qualification set forth in §B of this regulation.
B. To apply the terms of COMAR 10.01.04 to
				  the hearing rights of an EID applicant or recipient, substitute "the
				  Department" for references therein to the "local department of social
				  services".
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.42 - Free-Standing Medicare-Certified Ambulatory Surgical Centers › Section 10.09.42.01 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter,
				  the following terms have the meanings indicated.
B. Terms Defined.
(1) "Covered surgical procedures" means those
				  surgical and other medical procedures which meet the criteria specified in
				  42 CFR Part 416, Subpart F,
				  §
												416.166(a) and (b),
				  and which are published by the Centers for Medicare and Medicaid Services (CMS)
				  in the Federal Register.
(2)
				  "Dental Benefits Administrator (DBA)" means an entity that administers the
				  dental program for the Department of Health and Mental Hygiene.
(3) "Dental services" means emergency,
				  preventive, or therapeutic services for oral diseases which are administered by
				  or under the general supervision of a dentist in the practice of the
				  profession.
(4) "Department" means
				  the Department as defined in COMAR
				  10.09.36.01A.
(5) "Free-standing Ambulatory
				  Surgery Center (ASC)" means an entity capable of providing ambulatory surgical
				  services, which is not located in a hospital setting, and which is
				  Medicare-certified to furnish ambulatory surgical services.
(6) "Hospital" means any institution which
				  falls within the jurisdiction of Health-General Article, Title 19, Subtitle 3,
				  Annotated Code of Maryland, and is licensed pursuant to COMAR
				  10.07.01.
(7) "Medical Assistance
				  Program" means the Medical Assistance Program as defined in COMAR
				  10.09.36.01A.
(8) "Medicare" means Medicare as
				  defined in COMAR
				  10.09.36.01A.
(9) "Medicare-certified facility"
				  means a facility which:
(a) Is certified for
				  Medicare by the regional office of the Centers for Medicare and Medicaid
				  Services (CMS) to furnish ambulatory surgical services directly to
				  patients;
(b) Has an agreement with
				  (CMS) under Medicare to participate as an ASC; and
(c) Meets the conditions set forth by (CMS)
				  in 42 CFR Part 416, Subparts B, C, and F, § 416.163.
(10) "Patient" means a recipient awaiting or
				  undergoing health care or treatment.
(11) "Physician" means an individual legally
				  licensed to practice medicine in the state in which the physician's practice is
				  located.
(12) "Podiatrist" means a
				  Doctor of Podiatry (D.P.M.) who is licensed to practice podiatry by the Board
				  or by the state in which the service is rendered.
(13) "Program" means Program as defined in
				  COMAR 10.09.36.
(14) "Provider"
				  means a free-standing ambulatory surgical center which, through appropriate
				  agreement with the Department, has been identified as a Program provider by the
				  issuance of a provider account number.
(15) "Recipient" means recipient as defined
				  in COMAR 10.09.36.01A.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.42 - Free-Standing Medicare-Certified Ambulatory Surgical Centers › Section 10.09.42.02 - License Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  License requirements under this chapter are referenced in COMAR
				  10.09.36.02A.
B. The provider shall ensure that
				  all X-ray and other radiological equipment 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 meets the
				  standards established by COMAR 26.12.01 and COMAR 26.12.02 or other applicable
				  standards established by the state in which the service is provided.
C. The provider shall ensure that Clinical
				  Laboratory Improvement Amendments (CLIA) certification exists for all clinical
				  laboratory services performed, and:
(1) If
				  located in Maryland, comply with requirements of Health-General Article, Title
				  17, Subtitles 2 and 3, Annotated Code of Maryland, and either COMAR 10.10.01 or
				  10.10.06, as applicable; or
(2) If
				  located out-of-State, comply with other applicable standards established by the
				  state or locality in which the service is provided.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.42 - Free-Standing Medicare-Certified Ambulatory Surgical Centers › Section 10.09.42.03 - 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
				  meet all conditions for participation as set forth in COMAR
				  10.09.36.03 and 42 CFR, Part 416,
				  Subpart B.
B. Specific
				  requirements for participation in the Program are that the provider shall meet
				  all specific conditions for participation as set forth in 42 CFR, Part 416,
				  Subpart C, to include the following:
(1) Be
				  approved by Medicare to furnish ambulatory surgical services to patients and
				  maintain documentation of certification by the Department of Health and Human
				  Services and the Centers for Medicare and Medicaid Services;
(2) Have clearly defined, written, patient
				  care policies;
(3) Maintain
				  adequate documentation of each recipient visit as part of the plan of care,
				  which at a minimum, shall include:
(a) Date of
				  service;
(b) Recipient's reason for
				  visit;
(c) A brief description of
				  service provided, and
(d) A legible
				  signature and printed or typed name of the professional providing care, with
				  the appropriate title;
(4) Have written, effective procedures for
				  infection control which are known to all levels of staff as specified in COMAR
				  10.06.01;
(5) Be approved by the
				  state in which the service is provided, except where a Certificate of Need is
				  not required;
(6) Provide for
				  in-house Program evaluation and clinical record review which assess use of
				  services for appropriateness in meeting a recipient's needs;
(7) Refer laboratory testing only to
				  independent medical laboratory providers.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.42 - Free-Standing Medicare-Certified Ambulatory Surgical Centers › Section 10.09.42.04 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
The Program covers the following:
A. Medically necessary facility services
				  rendered to recipients in a free-standing Medicare-certified ambulatory
				  surgical center;
B. Diagnostic,
				  curative, palliative, or rehabilitative services, when clearly related to the
				  recipient's individual needs;
C.
				  Surgical procedures which meet the standards described in
				  42 CFR Part 416, Subpart D,
				  §
											416.65, and as published by the
				  Centers for Medicare and Medicaid Services; and
D. Dental services that have been
				  pre-authorized by the Dental Benefits Administrator (DBA).
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.42 - Free-Standing Medicare-Certified Ambulatory Surgical Centers › Section 10.09.42.05 - 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. Services denied by Medicare as not
				  medically justified;
E. Separate
				  billing of services which are included in the composite Medicare rate for an
				  ambulatory surgical center;
F.
				  Surgical procedures which:
(1) Generally
				  result in extensive blood loss;
(2)
				  Require major or prolonged invasion of body cavities;
(3) Directly involve major blood
				  vessels;
(4) Are generally
				  emergency or life-threatening in nature;
(5) Commonly require systemic thrombolytic
				  therapy;
(6) Are designated as
				  requiring inpatient care (overnight);
(7) Can only be reported using a CPT unlisted
				  surgical procedure code; or
(8) Are
				  otherwise excluded under 42
				  CFR §
												411.15(a) -(h) and
				  (j)-(s);
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.42 - Free-Standing Medicare-Certified Ambulatory Surgical Centers › Section 10.09.42.06 - Payment Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  Program reimburses a facility fee when the free-standing Medicare certified
				  ambulatory surgery center provides a covered surgical procedure, in accordance
				  with 42 CFR §
											416.166 to an eligible Medicaid recipient.
				  Reimbursement for the facility fee includes, but is not limited to the
				  following:
(1) Nursing, technician, and
				  related services;
(2) Use of the
				  facility;
(3) Drugs, biologicals,
				  surgical dressings, supplies, splints, casts, and appliances, and any equipment
				  directly related to the provision of surgical procedures;
(4) Administrative costs;
(5) Materials including supplies and
				  equipment for the administration and monitoring of anesthesia;
(6) Radiology services for which separate
				  payment is not allowed and other diagnostic tests or interpretive services that
				  are integral to a surgical procedure;
(7) Supervision of the services of a nurse
				  anesthetist by the operating surgeon;
(8) Ancillary items and services that are
				  integral to a covered surgical procedure as defined in
				  42 CFR §
												416.166; and
(9) Any laboratory testing performed under a
				  Clinical Laboratory Improvement Amendment of 1988 (CLIA) certificate of waiver.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.42 - Free-Standing Medicare-Certified Ambulatory Surgical Centers › Section 10.09.42.07 - Recovery and Reimbursement

Current through Register Vol. 51, No. 14, July 12, 2024
Recovery and reimbursement under this chapter are set forth
					 in COMAR 10.09.36.07A.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.42 - Free-Standing Medicare-Certified Ambulatory Surgical Centers › Section 10.09.42.08 - Cause for Suspension or Removal and Imposition of Sanctions

Current through Register Vol. 51, No. 14, July 12, 2024
Causes for suspension or removal and imposition of
					 sanctions under this chapter are set forth in COMAR
					 10.09.36.08A.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.42 - Free-Standing Medicare-Certified Ambulatory Surgical Centers › Section 10.09.42.09 - Appeal Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
Appeal procedures under this chapter are set forth in COMAR
					 10.09.36.09A.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.42 - Free-Standing Medicare-Certified Ambulatory Surgical Centers › Section 10.09.42.10 - Interpretive Regulation

Current through Register Vol. 51, No. 14, July 12, 2024
Interpretive regulations under this chapter are set forth
					 in COMAR 10.09.36.10A.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.01 - Purpose and Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter governs the determination of eligibility and
					 the conditions of participation for MCHP Premium.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.02 - 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" means a child:
(a) Whose representative has submitted a
				  written application for the Maryland Children's Health Program to the local
				  health department or the local department of social services;
(b) Who has been determined ineligible for
				  MCHP;
(c) Whose representative
				  indicated on the application form an interest in participating in MCHP Premium;
				  and
(d) Whose family income is more
				  than 200 percent but not more than 300 percent of the federal poverty
				  level.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.03 - Coverage Groups

Current through Register Vol. 51, No. 14, July 12, 2024
MCHP Premium covers children younger than 19 years old
					 whose family income is above 200 percent but at or below 300 percent of the
					 FPL.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.04 - Application

Current through Register Vol. 51, No. 14, July 12, 2024
A. Who Determines
				  Eligibility.
(1) The LHD and the LDSS shall
				  determine eligibility for MCHP.
(2)
				  The Department shall determine eligibility for MCHP Premium.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.05 - Nonfinancial Eligibility Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Citizenship. In order to be eligible for
				  full benefits under MCHP Premium, an applicant shall be one of the following:
(1) A citizen of the United States;
(2) A person residing in the United States
				  who is:
(a) A qualified alien as defined under
				  Regulation .02B of this chapter;
(b) An honorably discharged veteran of the
				  armed forces of the United States;
(c) An alien on active duty in the armed
				  forces of the United States; or
(d)
				  The spouse, including a surviving spouse who has not remarried, or unmarried
				  dependent child of an honorably discharged veteran of or alien on active duty
				  in the armed forces of the United States;
(3) An individual residing in the United
				  States who is:
(a) An alien who has been
				  granted asylum under § 208 of the Immigration and Nationality
				  Act;
(b) A refugee admitted into
				  the United States under § 207 of the Immigration and Nationality
				  Act;
(c) An alien whose deportation
				  has been withheld under § 243(h) of the Immigration and Nationality
				  Act;
(d) A Cuban or Haitian
				  entrant;
(e) An alien admitted to
				  the country for permanent residence as an Amerasian immigrant under Title II of
				  the Foreign Operations, Export Financing and Related Programs Appropriations
				  Act of 1989;
(f) A legal permanent
				  resident who first entered the country under another exempt category, that is,
				  as a refugee, asylee, Cuban or Haitian entrant, trafficking victim, or alien
				  whose deportation was being withheld, and who later converted to legal
				  permanent resident status;
(g) A
				  victim of a severe form of trafficking who has been subjected to:
(i) Sex trafficking, if the act is induced by
				  force, fraud, or coercion, or if the individual induced to perform the act is
				  younger than 18 years old; or
(ii)
				  Involuntary servitude;
(h) An honorably discharged veteran of the
				  armed forces of the United States;
(i) An alien on active duty in the armed
				  forces of the United States; or
(j)
				  A spouse, including a surviving spouse who has not remarried, or unmarried
				  dependent child of an honorably discharged veteran or alien on active duty in
				  the armed forces of the United States; or
(4) An individual residing in the United
				  States who is a qualified alien 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 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.06 - Consideration of Family Income

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  representative shall report the income of each family member. When there is
				  evidence of regular expenditures that are inconsistent with reported income,
				  the representative shall offer an explanation to reconcile the
				  inconsistency.
B. Determining
				  Countable Family Income.
(1) In determining
				  an applicant's financial eligibility for MCHP Premium, the applicant's family
				  income shall be considered for the applicable period under
				  consideration.
(2) Family income
				  shall consist of the income of the applicant and the following family members,
				  if living with the applicant:
(a) The
				  applicant's parent or parents; and
(b) At the option of the applicant's
				  representative, any of the applicant's siblings.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.07 - Consideration of Family Income: Earned and Unearned Income

Current through Register Vol. 51, No. 14, July 12, 2024
The requirements relating to consideration of family earned
					 and unearned income under COMAR
					 10.09.11.08B
					 apply to this chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.08 - Consideration of Family Income: Income Disregards

Current through Register Vol. 51, No. 14, July 12, 2024
The requirements relating to income disregards under COMAR
					 10.09.11.09B
					 apply to this chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.09 - Determining Financial Eligibility

Current through Register Vol. 51, No. 14, July 12, 2024
Current and New Enrollees. An applicant is financially
					 eligible for MCHP Premium if, for the period under consideration, the
					 applicant's countable net family income as determined under Regulation .08 of
					 this chapter, is greater than 200 percent but not greater than 300 percent of
					 the federal poverty level for a family size equal to the size of the
					 applicant's family.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.10 - Certification Periods

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  certification period begins the first day of the month in which the eligible
				  child is enrolled in a MCO.
B.
				  Duration of Certification Period.
(1) The
				  initial certification period, or the certification period beginning after a
				  period of ineligibility for MCHP Premium, shall end not later than 1 year from
				  the beginning month of certification for MCHP Premium.
(2) Notwithstanding §B(1) of this
				  regulation, the certification period may be shortened:
(a) If a determination of ineligibility is
				  made; or
(b) At the request of the
				  representative.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.11 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
A child enrolled in MCHP Premium is eligible for all health
					 benefits included in the Maryland Medicaid Managed Care Program, as set forth
					 in COMAR 10.09.67, the school-based health centers program as set forth in
					 COMAR 10.09.68, and the rare and expensive case management.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.12 - Program Participation Requirements - Enrollment

Current through Register Vol. 51, No. 14, July 12, 2024
A. An eligible individual who is enrolled in
				  MCHP Premium shall be covered through a Maryland Medicaid Managed Care
				  MCO.
B. Timely Enrollment.
(1) The Department or its designee shall
				  contact the representative to affirm the representative's willingness to pay a
				  family contribution amount for coverage of the eligible individual.
(2) If the representative is not willing to
				  pay a family contribution amount, or if the Department or its designee is not
				  able to contact the representative within 30 days of the application date, the
				  Department shall close the case.
(3) The representative shall:
(a) Send to the Department or its designee
				  the first month's family contribution within 30 days of receiving notice of
				  eligibility for MCHP Premium, or the case will be closed; and
(b) Complete and submit to the Department's
				  enrollment broker a MCO selection and enrollment form for each eligible
				  child.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.13 - Program Participation Requirements - Family Contribution

Current through Register Vol. 51, No. 14, July 12, 2024
A. Family
				  Contribution Required. As a requirement of enrollment and participation in MCHP
				  Premium, the representative of an eligible individual shall agree to pay the
				  following annual family contribution:
(1) For
				  an eligible individual whose family income is above 200 percent but at or below
				  250 percent of the FPL, an amount equal to 2 percent of the annual income of a
				  family of two at 200 percent of the FPL; and
(2) For an eligible individual whose family
				  income is above 250 percent, but at or below 300 percent of the FPL, an amount
				  equal to 2 percent of the annual income of a family of two at 250 percent of
				  the FPL.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.14 - Program Participation Requirements - Change in Status

Current through Register Vol. 51, No. 14, July 12, 2024
A. The representative shall report any change
				  in family status or composition of the eligible individual's family within 10
				  days of the change.
B. Change in
				  family status includes increase or decrease in the number of family members
				  through birth, death, marriage, adoption, separation, divorce, or the voluntary
				  or involuntary removal of a family member from residence with the
				  family.
C. The representative shall
				  complete a MCHP application and file it with the LHD or LDSS in the appropriate
				  jurisdiction to apply for coverage under MCHP Premium for a child added to the
				  family, including a newborn child, unless the newborn child's mother was
				  eligible for Medicaid when the child was born.
D. For all changes except addition of a
				  child, the Department shall evaluate the effect of the change on continued
				  eligibility for MCHP Premium and notify the representative of its determination
				  within 60 days of the report of the change.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.15 - Post-Eligibility Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Notice
				  of Eligibility Determination. The Department shall inform the representative of
				  the applicant's legal rights and obligations and give the representative
				  written notification of the following:
(1)
				  For eligible persons:
(a) A finding of
				  eligibility;
(b) The period of
				  coverage; and
(c) The right to
				  request a hearing; and
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.16 - 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 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.17 - Fraud, Abuse, and Penalty

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  The requirements relating to fraud and recipient abuse under COMAR
				  10.09.24.14B
				  apply to this chapter.
B. A person
				  convicted of fraud under this chapter is subject to penalties as described in
				  Criminal Law Article, §§
										8-516 and
				  8-517, Annotated Code of
				  Maryland.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.18 - Adjustments and Recoveries

Current through Register Vol. 51, No. 14, July 12, 2024
In all cases where MCHP Premium benefits have been
					 incorrectly paid, the Department shall seek recovery pursuant to COMAR
					 10.09.24.15B.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.43 - Maryland Children's Health Program (MCHP) Premium › Section 10.09.43.19 - 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 for MCHP Premium 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 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.01 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter,
				  the following terms have the meanings indicated.
B. Terms Defined.
(1) "Community spouse" means an individual
				  who:
(a) Lives in the community outside a
				  long-term care facility;
(b) Is not
				  determined to meet the criteria for participation for:
(i) PACE under this chapter; or
(ii) A waiver under § 1915(c) of the
				  Social Security Act; and
(c) Is married to an institutionalized
				  spouse.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.02 - Application for Qualification as a PACE Provider

Current through Register Vol. 51, No. 14, July 12, 2024
An applicant for participation in the Program as a PACE
					 provider shall submit to the Department and CMS a complete PACE application
					 that describes how the entity meets all requirements in 42 CFR 460 et
					 seq.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.03 - PACE provider

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  PACE provider shall comply with:
(1) 42 CFR
				  460 et seq.;
(2) This
				  chapter;
(3) The provider agreement
				  signed with the Department;
(4)
				  COMAR 10.09.36;
(5) Standards in
				  P.L.
				  101-330, Americans with Disabilities Act of 1990,
				  42 U.S.C. §
												12101 et seq.;
(6) Any other applicable regulations,
				  transmittals, and guidelines issued by the Department that are in effect;
				  and
(7) All other requirements of
				  applicable federal and State law.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.04 - Term of the Provider Agreement

Current through Register Vol. 51, No. 14, July 12, 2024
A. The duration or term of the agreement
				  between the Department and the PACE provider is specified in the provider
				  agreement.
B. The provider
				  agreement shall provide for automatic amendment, renegotiation, or termination,
				  or all of the above, of the provider agreement by either party if any part of
				  the provider agreement's provider benefit package is changed under the State
				  Plan.
C. Termination.
(1) The Department may terminate immediately
				  the provider agreement upon notification:
(a)
				  By the U. S. Department of Health and Human Services, that it is withdrawing
				  federal financial participation in all or part of the cost of the PACE benefit
				  package;
(b) By the Department of
				  Budget and Management, of the unavailability of sufficient State funds for the
				  PACE benefit package; or
(c) That
				  the owners or managers of the PACE provider, or other persons with substantial
				  provider agreement relationships with the PACE provider, have been convicted of
				  certain crimes or received certain sanctions as specified in § 1128 of the
				  Social Security Act.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.05 - Participant Eligibility

Current through Register Vol. 51, No. 14, July 12, 2024
A. An
				  eligible person shall:
(1) Reside in the PACE
				  approved service area upon enrollment;
(2) Be 55 years old or older;
(3) Be able to be maintained in a
				  community-based setting with the assistance of PACE at the time of enrollment
				  without jeopardizing the participant's health or others' health or
				  safety;
(4) Be determined by the
				  Department to need the level of care required under the State Plan for coverage
				  of nursing facility services for longer than 4 months; and
(5) Be willing to abide by the provision that
				  requires participants to receive all health and long-term care services
				  exclusively from the PACE provider and its contracted or referred
				  providers.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.06 - Participant Enrollment

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  Department shall enroll eligible persons who have chosen to enroll in the PACE
				  provider.
B. The PACE provider
				  shall enter into an enrollment agreement with a qualified recipient on the form
				  approved by the Department.
C. The
				  PACE provider shall enroll eligible recipients in the order in which they
				  apply, and may not discriminate on the basis of health status in its
				  enrollment, re-enrollment, or disenrollment procedures.
D. Signature on Enrollment Forms.
(1) Except as indicated under §D(2) of
				  this regulation, a recipient 55 years old or older shall sign and submit the
				  enrollment form;
(2) A legal
				  guardian or legal representative shall sign enrollment forms for eligible
				  persons determined to be incapacitated or incompetent to sign the
				  form.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.07 - Termination of Participant's Enrollment

Current through Register Vol. 51, No. 14, July 12, 2024
A. Termination of a participant's enrollment
				  may be initiated by the:
(1) PACE
				  provider;
(2) Department;
(3) Participant; or
(4) Participant's legal guardian or legal
				  representative.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.08 - Participant Rights

Current through Register Vol. 51, No. 14, July 12, 2024
The PACE provider shall ensure notification and protection
					 of the rights of enrollees according to
					 42 CFR §
											460.110 and
					 42 CFR §
											460.112.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.09 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except
				  as limited or expanded by the PACE benefit package specified in the PACE
				  program agreement, the PACE provider shall directly provide, arrange, purchase,
				  or otherwise make available, as medically necessary and appropriate, the
				  services specified in the State Plan and the PACE benefit package.
B. The PACE benefit package for all
				  participants, regardless of the source of payment, shall include the following:
(1) All Medicaid-covered services, as
				  specified in the State Plan;
(2)
				  Multidisciplinary assessment and treatment planning;
(3) Social work services;
(4) Nutritional counseling;
(5) Recreational therapy;
(6) Certain meals;
(7) Medical specialty services;
(8) Prosthetics, orthotics, corrective vision
				  devices, such as eyeglasses and lenses, hearing aids, dentures, and repair and
				  maintenance of these items;
(9)
				  Assisted living; and
(10) Other
				  services determined necessary by the multidisciplinary team to improve and
				  maintain the participant's overall health status.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.10 - Limitations on Coverage

Current through Register Vol. 51, No. 14, July 12, 2024
Limitations on coverage are as specified in the PACE
					 program agreement and 42 CFR
					 §
											460.96.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.11 - Authorization Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
The PACE provider shall obtain approval by the Department
					 before any changes in the following:
A. Service contract agreements;
B. PACE provider benefit package;
C. PACE provider's service area;
D. PACE provider's enrollment
				  limit;
E. PACE provider agreement;
				  or
F. PACE provider
				  structure.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.12 - Marketing and Information

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  PACE provider agreement shall specify the methods by which the PACE provider
				  will assure the Department that its marketing plans, procedures, and materials
				  are accurate and do not mislead, confuse, or defraud the Department or
				  potential participants.
B. The PACE
				  provider's marketing plan and all marketing procedures and materials require
				  approval by the Department before implementation and utilization.
C. The PACE provider may not participate in:
(1) Activities described in
				  42 CFR §
												460.82(e); or
(2) Face-to-face or telephone contact with a
				  recipient, or otherwise soliciting a recipient who is not a participant of the
				  PACE provider, unless authorized by the Department or initiated by the
				  recipient.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.13 - Quality Assurance and Improvement Systems

Current through Register Vol. 51, No. 14, July 12, 2024
A. The PACE provider shall comply with 42 CFR
				  Part 460, Subpart H (Quality Assessment and Performance Improvement).
B. The PACE provider shall comply with
				  requirements designated by the Department.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.14 - Record Keeping

Current through Register Vol. 51, No. 14, July 12, 2024
The PACE provider shall comply with
					 42 CFR §
											460.210.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.15 - Reports and Data Collection

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  The PACE provider shall collect and submit to the Department service-specific
				  encounter data by service type in the format and at the frequency designated by
				  the Department and in conformance with the Department's computer coding
				  requirements.
B. The PACE provider
				  shall prepare and submit to the Department reports related to third-party
				  liability as required by Regulation .20 of this chapter.
C. The PACE provider shall immediately notify
				  the Department if it has knowledge of a participant's death.
D. The PACE provider shall have an effective
				  procedure for reporting to the Department the following information:
(1) Patterns of utilization;
(2) Health status of participants;
				  and
(3) Appeals and grievances made
				  by participants.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.16 - Confidentiality

Current through Register Vol. 51, No. 14, July 12, 2024
A. Subject to the
				  requirements of 42 CFR Part 431 Subpart F, the PACE provider and its
				  contractors may not release or disclose any information concerning a
				  participant to anyone other than the Department except with the written
				  permission of the:
(1) Participant;
				  or
(2) Participant's attorney,
				  legal representative, or legal guardian.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.44 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 10.09.44.17 - Financial Solvency

Current through Register Vol. 51, No. 14, July 12, 2024
The PACE provider shall comply with
					 42 CFR §
											460.80 and
					 42 CFR §
											460.208.