reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.08 - Freestanding Clinics › Section 10.09.08.14 - Interpretive Regulation

Current through Register Vol. 51, No. 14, July 12, 2024
State regulations shall be interpreted in conformity with
					 COMAR 10.09.36.10.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.09 - Medical Laboratories › Section 10.09.09.02 - License Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  provider shall meet all license requirements as set forth in COMAR
				  10.09.36.02D.
B. Medical laboratories are
				  required to ensure that Clinical Laboratory Improvement Amendments (CLIA)
				  certification exists for all clinical laboratory services performed.
C. Medical laboratories located in Maryland
				  shall be in compliance with COMAR 10.10.01.
D. Out-of-State Laboratories.
(1) Laboratories with representation or
				  specimen pick-up in Maryland shall be in compliance with the applicable
				  standards of the state and locality in which the laboratory is located and
				  ensure that CLIA certification exists for all clinical laboratory services
				  performed, and that requirements of applicable sections of COMAR 10.10.01 are
				  met.
(2) Laboratories without
				  representation or specimen pick-up in Maryland shall be in compliance with the
				  applicable standards of the state and locality in which the laboratory is
				  located and ensure that CLIA certification exists for all clinical laboratory
				  services performed.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.09 - Medical Laboratories › Section 10.09.09.03 - 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, except that a
				  signature on the services order specified in COMAR
				  10.09.36.03A(19)
				  is not required.
B. Specific
				  requirements for participation in the Program as a medical laboratory include
				  all of the following:
(1) Be in compliance
				  with all applicable license, certification, environmental, legal, and
				  professional requirements to perform the clinical laboratory services
				  offered;
(2) Maintain records
				  adequate to substantiate the ordering, performance, and reporting of clinical
				  laboratory services performed or referred;
(3) Agree to seek reimbursement from the
				  Program only for services set forth in Regulation .04 of this chapter when
				  provided to eligible participants;
(4) Agree to refrain from billing
				  participants for noncovered services set forth in Regulation .05 of this
				  chapter; and
(5) Agree to abide by
				  all provisions set forth in Regulation .07 of this chapter when seeking
				  reimbursement from the Program.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.09 - Medical Laboratories › Section 10.09.09.04 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
The Program covers the following services:
A. Medically necessary laboratory services,
				  when the services are:
(1) Rendered to
				  participants in a physician's office, hospital, freestanding clinic, or medical
				  laboratory;
(2) Provided according
				  to the laws and regulations of the state and locality in which they are
				  rendered;
(3) Rendered pursuant to
				  a properly completed order or standing order;
(4) Adequately documented in the provider's
				  files;
(5) Clinical and diagnostic
				  services for which certification by the Centers for Medicare and Medicaid
				  Services (CMS) under CLIA exists, if required; and
(6) Ordered by an individual who is enrolled
				  as a provider in the Program with an active status on the date of
				  service;
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.09 - Medical Laboratories › Section 10.09.09.05 - Limitations

Current through Register Vol. 51, No. 14, July 12, 2024
The following are not covered:
A. Services for which the medical laboratory
				  provider cannot supply a properly completed order or standing order identifying
				  the individual practitioner who ordered the laboratory services;
B. Services not adequately documented in the
				  participant's medical records;
C.
				  Services denied by Medicare as not medically necessary;
D. Clinical laboratory services, for which
				  certification by HCFA under CLIA is required, when these services are performed
				  by laboratories that are not certified to perform those services;
E. Procedures that the provider knows or
				  should know are investigational or experimental in nature;
F. Services included by the Program as part
				  of the charge made by an inpatient facility, hospital outpatient department,
				  freestanding clinic, or other Program-recognized entity;
G. Medical laboratory services related to
				  autopsies;
H. Medical laboratory
				  services for which there was insufficient quantity of specimen, improper
				  specimen handling, or other circumstances that would render the results
				  unreliable; and
I. Laboratory
				  services ordered by an:
(1) Individual who is
				  not enrolled as a provider in the Program with an active status on the date of
				  service; and
(2) Entity, facility,
				  or another provider that is not an individual.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.09 - Medical Laboratories › Section 10.09.09.06 - Preauthorization Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Preauthorization is required for any service identified as needing
				  preauthorization in the current laboratory fee schedule, in accordance with
				  Regulation .07D of this chapter.
B.
				  The provider shall submit the request for preauthorization according to the
				  procedures established by, and in the form designated by, the
				  Department.
C. Preauthorization is
				  issued when:
(1) Program procedures are met;
				  and
(2) The provider submits to the
				  Department adequate documentation demonstrating that the service to be
				  preauthorized is medically necessary.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.09 - Medical Laboratories › Section 10.09.09.07 - Payment Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. General
				  policies for payment procedures that are applicable to all providers are set
				  forth in COMAR
				  10.09.36.04A.
B. Medical laboratory providers
				  shall identify the individual who ordered the laboratory services by recording
				  the individual practitioner's National Provider Identifier (NPI) number on the
				  claim.
C. Unless the service is
				  free to individuals not covered by Medicaid, the provider shall charge the
				  Program the lesser of.
(1) The provider's
				  customary charge to the general public; or
(2) The provider's customary charge to other
				  third-party payers.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.09 - Medical Laboratories › Section 10.09.09.08 - Recovery and Reimbursement

Current through Register Vol. 51, No. 14, July 12, 2024
General policies for recovery and reimbursement that are
					 applicable to all providers 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 10.09.09 - Medical Laboratories › Section 10.09.09.09 - Cause for Suspension or Removal and Imposition of Sanctions

Current through Register Vol. 51, No. 14, July 12, 2024
General policies governing cause for suspension or removal
					 and imposing sanctions that are applicable to all providers 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 10.09.09 - Medical Laboratories › Section 10.09.09.10 - Appeal Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
General policies governing appeal procedures that are
					 applicable to all providers 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 10.09.09 - Medical Laboratories › Section 10.09.09.11 - Interpretive Regulation

Current through Register Vol. 51, No. 14, July 12, 2024
General policies governing the interpretive regulations
					 that are applicable to all providers 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 10.09.10 - Nursing Facility Services › Section 10.09.10.02 - License Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
In order to participate in the Program, a provider shall be
					 licensed by the Department, pursuant to Health-General Article, §19-301 et
					 seq., Annotated Code of Maryland, and COMAR 10.07.02, and shall obtain other
					 licenses, as may be required by applicable State and local
					 laws.
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 10.09.10.04 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
The Program covers routine care and the following supplies,
					 equipment, and services when appropriate to meet the needs of the
					 recipient:
A. Those described in the
				  Department of Health and Human Services regulations entitled "Requirements for
				  Long Term Care Facilities", 42 CFR Part 483, Subpart B (1996), subject to
				  limitations in Regulation .05 of this chapter.
B. Over-the-counter drugs.
C. Bed reservations for recipients who are on
				  a leave of absence to visit with friends or relatives or to participate in
				  State-approved therapeutic or rehabilitative programs for a maximum of 18 days
				  in any calendar year and without any limitation on the number of days per
				  visit.
D. Repealed.
E. Administrative days approved by the
				  Department or its designee according to the conditions set forth in Regulation
				  .26D of this chapter.
F.
				  Specialized rehabilitative therapy services which meet the conditions listed
				  below:
(1) Physical Therapy. Physical therapy
				  services for Medical Assistance Program purposes are those services furnished
				  to a recipient which meet all of the following conditions:
(a) The services are directly and
				  specifically related to a plan of care designed by the physician after any
				  needed consultation with the qualified physical therapist;
(b) The services are of such a level of
				  complexity and sophistication or the condition of the recipient needs the
				  judgment, knowledge, or skills of a qualified physical therapist;
The services are performed by or under the supervision of a
					 qualified physical therapist;
(d) The services are provided with the
				  expectation, based on the assessment made by the physician of the recipient's
				  restorative potential after any needed consultation with the qualified physical
				  therapist, that the recipient will improve significantly in a reasonable, and
				  generally predictable, period of time;
(e) The services are considered under
				  accepted standards of medical practice to be a specific and effective treatment
				  for the recipient's condition; and
(f) The services are reasonable and necessary
				  to the treatment of the recipient's condition.
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 10.09.10.05 - Limitations

Current through Register Vol. 51, No. 14, July 12, 2024
The following are not covered:
A. Services by an out-of-State nursing
				  facility unless the Department and the nursing facility execute a provider
				  agreement;
B. Audiology
				  services;
C.
										 Services reimbursed under Title XVIII of the Social Security Act;
				  and
D. Services for which payment
				  is made directly to a provider other than the nursing facility.
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 10.09.10.06 - Preauthorization Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  Department of Human Services shall certify the recipient for financial
				  eligibility, and the Department or its designee shall certify the recipient as
				  requiring nursing facility services, except as provided in Regulation .26D of
				  this chapter.
B. The Department or
				  its designee will certify as requiring nursing facility services only those
				  financially eligible recipients requiring nursing facility services as defined
				  in Regulation .01B of this chapter.
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 10.09.10.07 - Prospective Rates

Current through Register Vol. 51, No. 14, July 12, 2024
A. A provider
				  shall be paid the prospective rate for nursing facility services as defined in
				  Regulation .01B of this chapter plus the Nursing Facility Quality Assessment
				  add-on identified in Regulation .11E of this chapter.
B. When necessary, each facility's per diem
				  rate shall be reduced by the same percentage to maintain compliance with the
				  Medicare upper payment limit requirement.
C. Power wheelchairs and bariatric beds are
				  not included in the prospective rate, but may be preauthorized for payment in
				  accordance with COMAR 10.09.12.
D.
				  Support Surfaces.
(1) Support surfaces are
				  not included in the prospective rate.
(2) A provider shall be paid a per diem rate
				  for providing appropriate specialized support surfaces to patients with
				  pressure ulcers or in recovery from myocutaneous flap or graft surgery for a
				  pressure ulcer.
(3) A Class A
				  support surface is a mattress replacement which has been approved as a Group 2
				  Pressure Reducing Support Surface by the Medical Policy of the Medicare Durable
				  Medical Equipment Regional Carrier. A Class A support surface shall be
				  reimbursed per day at the Medicare Durable Medical Equipment Regional Carrier
				  Maryland monthly fee cap, in effect at the beginning of the State fiscal year,
				  for HCPCS Code E0277 multiplied by 12 and then divided by the number of days in
				  the State fiscal year.
(4) A Class
				  B support surface is an air fluidized bed which has been approved as a Group 3
				  Pressure Reducing Support Surface by the Medical Policy of the Medicare Durable
				  Medical Equipment Regional Carrier. A Class B support surface shall be
				  reimbursed per day at the Medicare Durable Medical Equipment Regional Carrier
				  Maryland monthly fee cap, in effect at the beginning of the State fiscal year,
				  for HCPCS Code E0194 multiplied by 12 and then divided by the number of days in
				  the State fiscal 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 10.09.10.07-1 - Interim Working Capital Fund

Current through Register Vol. 51, No. 14, July 12, 2024
A. A provider may request an allotment from
				  the Interim Working Capital Fund if the facility for which an allotment is
				  requested has not had any of the following deficiencies cited in any survey
				  conducted by the Office of Health Care Quality during the calendar year
				  preceding the calculation of the allotment, using the scope and severity matrix
				  found in the Centers for Medicare and Medicaid Services State Operations Manual
				  for Survey and Certification, Part 7, § 7400E:
(1) Two or more "G" level deficiencies;
				  or
(2) One or more "H" or higher
				  level deficiencies.
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 10.09.10.07-2 - Prospective Rates Effective January 1, 2015

Current through Register Vol. 51, No. 14, July 12, 2024
A. For dates of service from January 1, 2015
				  through December 31, 2016, a 2012 final per diem rate shall be determined based
				  on the following from each nursing facility's cost report ending in 2012 and
				  shall be adjusted by the nursing facility budget changes implemented from the
				  settled 2012 rate through and including December 31, 2016:
(1) The Administrative and Routine final per
				  diem rate identified under Regulation .08B of this chapter;
(2) The Other Patient Care final per diem
				  rate identified under Regulation .09B of this chapter;
(3) The kosher kitchen add-ons identified
				  under Regulations .08H and .09H of this chapter;
(4) The total amount of therapy payments
				  identified under Regulation .09-1 of this chapter divided by the total Medicaid
				  days excluding hospital bed hold days for the cost reporting period;
(5) The Capital component calculated as:
(a) Capital payments identified under
				  Regulation .10 of this chapter, less the Nursing Facility Quality Assessment
				  expense; and
(b) Divided by the
				  total Medicaid days excluding hospital bed hold days; and
(6) The Nursing payments identified under
				  Regulation .11C of this chapter divided by the total Medicaid days less
				  Hospital Bed Hold Days and Therapeutic Leave Days.
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 10.09.10.08 - Interim Working Capital Fund

Current through Register Vol. 51, No. 14, July 12, 2024
A. A provider
				  may request an allotment from the Interim Working Capital Fund if the facility
				  for which an allotment is requested has not had any of the following
				  deficiencies cited in any survey conducted by the Office of Health Care Quality
				  during the calendar year preceding the calculation of the allotment, using the
				  scope and severity matrix found in the Centers for Medicare and Medicaid
				  Services State Operations Manual for Survey and Certification, Part 7,
				  §7400E:
(1) Two or more "G" level
				  deficiencies; or
(2) One or more
				  "H" or higher level deficiencies.
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 10.09.10.08-1 - Rate Calculation - Administrative and Routine Costs for Rates Effective January 1, 2015

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  Administrative and Routine cost center includes:
(1) Administrative expenses;
(2) Medical records expenses;
(3) Training expenses;
(4) Dietary;
(5) Laundry;
(6) Housekeeping;
(7) Operation and maintenance; and
(8) Capitalized organization and start-up
				  costs.
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 10.09.10.09 - Rate Calculation - Administrative and Routine Costs

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  Administrative and Routine cost center includes:
(1) Administrative expenses;
(2) Medical records expenses;
(3) Training expenses;
(4) Dietary;
(5) Laundry;
(6) Housekeeping;
(7) Operation and maintenance; and
(8) Capitalized organization and start-up
				  costs.
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 10.09.10.09-1 - Rate Calculation - Therapy Services for Rates Effective on or Before December 31, 2014

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Reimbursement for therapy services which meet the conditions as stated in
				  Regulation .04F of this chapter is outlined in §§B-C of this
				  regulation.
B. Physical,
				  Occupational, and Speech Therapy Services.
(1)
				  Physical, occupational, and speech therapy services will be reimbursed in
				  15-minute increments with a maximum per diem duration of 1 hour.
(2) Reimbursement rates for each type of
				  therapy shall be calculated as a percent of an hourly rate comprised of two
				  components from the Medicare Therapy Services Guidelines and a per diem supply
				  cost. The hourly rate shall be the sum of:
(a) The adjusted hourly salary equivalent
				  amount effective for the period corresponding to the State fiscal year from the
				  Medicare guidelines;
(b) One-sixth
				  of the total travel allowance for the period corresponding to the State fiscal
				  year from the Medicare guidelines; and
(c) A supply allowance established at $0.30
				  for the period October 1, 1999, through June 30, 2000, and indexed in
				  subsequent years based on the Consumer Price Index for All Urban Consumers
				  (CPI-U), nonprescription medical equipment and supplies component, from U.S.
				  Department of Labor, Bureau of Labor Statistics, CPI Detailed Report, Table
				  4.
(3) Reimbursement
				  rates shall be established at 25 percent of the hourly rate for a 15-minute
				  therapy session, 50 percent of the hourly rate for a 30-minute therapy session,
				  75 percent of the hourly rate for a 45-minute therapy session, and 100 percent
				  of the hourly rate for a 60-minute therapy session.
(4) Providers shall be reimbursed based upon
				  the Medicare Therapy Services Guidelines established for the geographic area in
				  which the provider is located.
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 10.09.10.09-2 - Rate Calculation - Other Patient Care Costs for Rates Effective January 1, 2015

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Other
				  Patient Care cost center includes:
(1)
				  Medical director administrative expenses;
(2) Pharmacy;
(3) Recreational activities;
(4) Patient care consultant
				  services;
(5) Food cost
				  (unprepared);
(6) Social services;
				  and
(7) Religious
				  services.
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 10.09.10.10 - Rate Calculation - Other Patient Care Costs

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Other Patient Care cost center
				  includes:
(1) Medical director administrative
				  expenses;
(2) Pharmacy;
(3) Recreational activities;
(4) Patient care consultant
				  services;
(5) Food cost
				  (unprepared);
(6) Social services;
				  and
(7) Religious
				  services.
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 10.09.10.10-1 - Rate Calculation - Capital Costs for Rates Effective January 1, 2015

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Capital cost
				  center includes:
(1) Real estate taxes;
				  and
(2) Fair rental
				  value.
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 10.09.10.11 - Rate Calculation - Capital Costs

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Capital cost center includes:
(1) Real estate taxes; and
(2) Fair rental value.
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 10.09.10.11-1 - Pay-for-Performance - Eligibility

Current through Register Vol. 51, No. 14, July 12, 2024
In order to be eligible to receive funds through the
					 pay-for-performance program under the provisions of Regulations .11-2-.11-6 of
					 this chapter:
A. The provider shall be
				  subject to quality assessment under COMAR 10.01.20; and
B. During the 1 year period ending March 31
				  of the prior State fiscal year, the provider may not have been:
(1) Identified by the federal Centers for
				  Medicare and Medicaid Services as a special focus facility;
(2) Denied payment for new admissions by the
				  Department; or
(3) Identified by
				  the Department as delivering substandard quality of care.
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 10.09.10.11-2 - Pay-for-Performance - Quality Measures

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Providers shall receive a composite score based on the following:
(1) Staffing levels and staff stability, as
				  described in §§B and C of this regulation, shall comprise 40 percent
				  of each facility's score;
(2)
				  Maryland Health Care Commission Nursing Facility Family Survey, as described in
				  §D of this regulation, shall comprise 40 percent of each facility's
				  score;
(3) Minimum Data Set
				  Clinical Quality Indicators, as described in §E of this regulation, shall
				  comprise 16 percent of each facility's score;
(4) Employment of an infection control
				  coordinator, as described in §F of this regulation, shall comprise 2
				  percent of each facility's score; and
(5) Staff immunization survey, as described
				  in §G of this regulation, shall comprise 2 percent of each facility's
				  score.
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 10.09.10.11-3 - Pay-for-Performance - Scoring Methodology

Current through Register Vol. 51, No. 14, July 12, 2024
A. Facilities that are eligible for
				  pay-for-performance under Regulation .11-1 of this chapter shall receive a
				  score for each quality measure described in Regulation .11-2 of this
				  chapter.
B. For the quality
				  measures described in Regulation .11-2B"E of this chapter, a facility is ranked
				  and awarded points as follows:
(1) The highest
				  ranked facility receives 100 percent of the points available;
(2) The median score, weighted by total days
				  of care, receives 50 percent of the points available;
(3) Zero points would be received by any
				  facility whose raw score is below the median by an amount equal to or greater
				  than the difference between the highest score and the median score;
				  and
(4) All other facilities will
				  receive points proportionate to where the score falls within the range between
				  the highest and zero.
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 10.09.10.11-4 - Pay-for-Performance - Payment for Improvement

Current through Register Vol. 51, No. 14, July 12, 2024
A. In order to be eligible for improvement
				  payment, a facility:
(1) Shall meet the
				  eligibility criteria specified in Regulation .11-1 of this chapter;
(2) Shall be eligible and receive a composite
				  score during the current fiscal year and the prior fiscal year; and
(3) May not be receiving a payment based upon
				  its score as described in Regulation .11-6C of this chapter.
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 10.09.10.11-5 - 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 .11-2 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 10.09.10.11-6 - Pay-for-Performance - Payment Distribution

Current through Register Vol. 51, No. 14, July 12, 2024
A. During State fiscal year 2011, 0.2445
				  percent of the budget allocation for nursing facility services shall be
				  distributed based on pay-for-performance scores.
B. Beginning State fiscal year 2012, and each
				  year thereafter, 0.5 percent of the budget allocation for nursing facility
				  services shall be distributed based on pay-for-performance scores.
C. Eighty-five percent of the amount
				  identified in §A or B of this regulation shall be distributed to the
				  highest scoring facilities, representing 35 percent of the eligible days of
				  care, in accordance with the methodology described in Regulation .11-3 of this
				  chapter.
D. Funds shall be
				  distributed among the facilities identified in §C 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.
E. Fifteen percent of the
				  amount identified in §A or B of this regulation shall be distributed to
				  the facilities that qualify for payment for improvement in accordance with
				  Regulation .11-4 of this chapter.
F. Funds shall be distributed among the
				  facilities included in §E 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.
G. A facility shall receive a lump-sum
				  payment based on the per diem amount determined in accordance with §D or F
				  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 10.09.10.11-7 - Rate Calculation - Nursing Service Costs for Rates Effective January 1, 2015

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Nursing
				  Service cost center includes all nursing expenses related to the direct
				  provision of patient care.
B. The
				  Department shall initially establish Nursing Service prices for the rate period
				  January 1, 2015, through June 30, 2015, and thereafter rebase the Nursing
				  Service prices between every 2 and 4 rate years. Prices may be rebased more
				  frequently if the Department determines that there is an error in the data or
				  in the calculation that results in a substantial difference in payment, or if a
				  significant change in provider behavior or costs has resulted in payment that
				  is inequitable across providers. The Department shall rebase based on the
				  following steps:
(1) The indexed costs shall
				  be calculated as set forth in Regulation .08-1B(1)-(3) of this
				  chapter;
(2) Each cost report's
				  indexed Nursing Service costs shall be divided by the actual days of nursing
				  care to arrive at the indexed Nursing Service cost per diem;
(3) The indexed Nursing Service cost per diem
				  shall be normalized to the Statewide average case mix index by multiplying the
				  indexed Nursing Service cost per diem by the facility's normalization ratio
				  calculated as the Statewide average case mix index divided by the cost report
				  period case mix index rounded to four decimals which creates the Normalized
				  Nursing Cost per diem;
(4) For each
				  reimbursement class, each cost report's Medicaid resident days shall be used in
				  the array of cost per diems identified in §B(3) of this regulation to
				  calculate the Medicaid day weighted median using the method established in
				  Regulation .08-1B(5) of this chapter;
(5) The final price for Nursing Service costs
				  for each reimbursement class is calculated as the geographic regional Medicaid
				  day weighted median Nursing Service cost multiplied by 1.0825; and
(6) For years between periods when the prices
				  are rebased, the final price for Nursing Service costs shall be adjusted as set
				  forth in Regulation .08-1D of this chapter.
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 10.09.10.11-8 - Ventilator Care Nursing Facilities Effective January 1, 2015

Current through Register Vol. 51, No. 14, July 12, 2024
Nursing facilities with licensed nursing facility beds,
					 which have been determined by the Department to meet the standards for
					 ventilator care under COMAR 10.07.02, shall be reimbursed as follows:
A. Services for residents receiving
				  ventilator care shall be reimbursed as follows:
(1) The Nursing Service rate identified in
				  Regulation .11-7 of this chapter shall be calculated with a facility average
				  Medicaid case mix index that includes only residents receiving ventilator care;
				  and
(2) An amount of $280 shall be
				  added to the total prospective 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 10.09.10.12 - Rate Calculation - Nursing Service Costs

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Nursing Service cost center includes
				  all nursing expenses related to the direct provision of patient care.
B. The Department shall initially establish
				  Nursing Service prices for the rate period January 1, 2015, through June 30,
				  2015, and thereafter rebase the Nursing Service prices between every 2 and 4
				  rate years. Prices may be rebased more frequently if the Department determines
				  that there is an error in the data or in the calculation that results in a
				  substantial difference in payment, or if a significant change in provider
				  behavior or costs has resulted in payment that is inequitable across providers.
				  The Department shall rebase based on the following steps:
(1) The indexed costs shall be calculated as
				  set forth in Regulation .09B(1)-(3) of this chapter;
(2) Each cost report's indexed Nursing
				  Service costs shall be divided by the actual days of nursing care to arrive at
				  the indexed Nursing Service cost per diem;
(3) The indexed Nursing Service cost per diem
				  shall be normalized to the Statewide average case mix index by multiplying the
				  indexed Nursing Service cost per diem by the facility's normalization ratio
				  calculated as the Statewide average case mix index divided by the cost report
				  period case mix index rounded to four decimals which creates the Normalized
				  Nursing Cost per diem;
(4) For each
				  reimbursement class, each cost report's Medicaid resident days shall be used in
				  the array of cost per diems identified in §B(3) of this regulation to
				  calculate the Medicaid day weighted median using the method established in
				  Regulation .09B(5) of this chapter;
(5) The final price for Nursing Service costs
				  for each reimbursement class is calculated as the geographic regional Medicaid
				  day weighted median Nursing Service cost multiplied by 1.0825; and
(6) For years between periods when the prices
				  are rebased, the final price for Nursing Service costs shall be adjusted as set
				  forth in Regulation .09D of this chapter.
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 10.09.10.12-1 - Payment Procedures - Out-of-State Facilities for Rates Effective January 1, 2015

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 .13N of this chapter shall be reimbursed at a rate that is the
				  lesser of:
(1) The average Statewide
				  quarterly rate identified by Regulation .07-2 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 10.09.10.13 - Ventilator Care Nursing Facilities

Current through Register Vol. 51, No. 14, July 12, 2024
Nursing facilities with licensed nursing facility beds,
					 which have been determined by the Department to meet the standards for
					 ventilator care under COMAR 10.07.02, shall be reimbursed as follows:
A. Services for residents receiving
				  ventilator care shall be reimbursed as follows:
(1) The Nursing Service rate identified in
				  Regulation .12 of this chapter shall be calculated with a facility average
				  Medicaid case mix index that includes only residents receiving ventilator care;
				  and
(2) An amount of $285 shall be
				  added to the total prospective 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 10.09.10.14 - Pay-for-Performance - Eligibility

Current through Register Vol. 51, No. 14, July 12, 2024
In order to be eligible to receive funds through the
					 pay-for-performance program under the provisions of Regulations .15-.19 of this
					 chapter:
A. The provider shall be
				  subject to quality assessment under COMAR 10.01.20; and
B. During the 1 year period ending March 31
				  of the prior State fiscal year, the provider may not have been:
(1) Identified by the federal Centers for
				  Medicare and Medicaid Services as a special focus facility;
(2) Denied payment for new admissions by the
				  Department; or
(3) Identified by
				  the Department as delivering substandard quality of care.
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 10.09.10.14-1 - Desk Reviews and Field Verification for Rates Effective January 1, 2015

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 10.09.10.14-2 - MDS Validation and Ventilator Care Validation for Rates Effective January 1, 2015

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 10.09.10.15 - Pay-for-Performance - Quality Measures

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Providers shall receive a composite score based on the following:
(1) Staffing levels, as described in §B
				  of this regulation, shall comprise 20 percent of each facility's
				  score;
(2) Staffing stability, as
				  described in §C of this regulation, shall comprise 15 percent of each
				  facility's score;
(3) Maryland
				  Health Care Commission Nursing Facility Family Survey, as described in §D
				  of this regulation, shall comprise 30 percent of each facility's
				  score;
(4) Minimum Data Set
				  Clinical Quality Indicators, as described in §E of this regulation, shall
				  comprise 30 percent of each facility's score;
(5) Staff immunization survey, as described
				  in §F of this regulation, shall comprise 5 percent of each facility's
				  score.
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 10.09.10.16 - Pay-for-Performance - Scoring Methodology

Current through Register Vol. 51, No. 14, July 12, 2024
A. Facilities that are eligible for
				  pay-for-performance under Regulation .14 of this chapter shall receive a score
				  for each quality measure described in Regulation .15 of this chapter.
B. For the quality measures described in
				  Regulation .15B-E of this chapter, a facility is ranked and awarded points as
				  follows:
(1) The highest ranked facility
				  receives 100 percent of the points available;
(2) The median score, weighted by total days
				  of care, receives 50 percent of the points available;
(3) Zero points would be received by any
				  facility whose raw score is below the median by an amount equal to or greater
				  than the difference between the highest score and the median score;
				  and
(4) All other facilities will
				  receive points proportionate to where the score falls within the range between
				  the highest and zero.
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 10.09.10.16-1 - Selected Costs - Allowable for Payments for Services Provided Effective January 1, 2015

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 .08-1, .09-2 and .10-1 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 10.09.10.17 - Pay-for-Performance - Payment for Improvement

Current through Register Vol. 51, No. 14, July 12, 2024
A. In order to be eligible for improvement
				  payment, a facility:
(1) Shall meet the
				  eligibility criteria specified in Regulation .14 of this chapter;
(2) Shall be eligible and receive a composite
				  score during the current fiscal year and the prior fiscal year; and
(3) May not be receiving a payment based upon
				  its score as described in Regulation .19C of this chapter.