Maryland Administrative Code

.21 Cost Reporting. A. The provider shall include, for purposes of cost finding, direct and indirect costs applicable to recipient care. B. The provider shall specifically identify, in the cost report, costs associated with related organizations. C. The provider shall maintain ad…

.22 Desk Reviews and Field Verification. 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…

.23 Third Party Liability Reviews and Audits of Nursing Facilities. A. Quarterly Reports of Credit Balances. A provider shall report the credit balances of the nursing facility to the Department on a quarterly basis. B. Third Party Liability Review. The Department shall conduct a…

.24 MDS Validation and Ventilator Care Validation. 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…

.25 New Nursing Facilities, Replacement Facilities, and Change of Ownership. A. The Department shall establish rates for new nursing facilities, replacement facilities, and nursing facilities with a change of ownership as outlined in §§B—D of this regulation. B. New Nursing Facil…

.26 Selected Costs — Allowable. 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 aver…

.27 Selected Costs — Not Allowable. The following costs are not allowable in establishing prospective rates: A. Costs not adequately documented; B. Costs for chaplaincy training and other religious training programs; C. Bad debts incurred by private pay or Medicare patients or th…

.28 Recipient's Resource. A. The Department of Human Services will determine the application of a recipient's resource to the cost of medical or remedial care pursuant to COMAR 10.09.24. B. The provider shall collect a recipient's resource available for medical or remedial care, …

.29 Recipient's Personal Needs Fund. A. If a provider administers a recipient's personal needs fund, it shall administer the fund according to guidelines established by the Department. B. Upon request during normal business hours, a provider shall make available for verification …

.30 Reimbursement Classes. A. The reimbursement classes for the Administrative and Routine cost center are as follows: (1) Facilities in the Baltimore metropolitan region consisting of the following counties: (a) Anne Arundel; (b) Baltimore; (c) Carroll; (d) Harford; and (e) Howa…

.31 Nursing Service Personnel and Procedures. A. Personnel Types and Category Groupings. Selected Personnel Types Personnel Categories Director of nursing (RN or LPN) Directors of nursing (DON) Assistant director of nursing (RN or LPN) RN charge nurse Registered nurses (RN) RN st…

.32 Recovery and Reimbursement. A. If the recipient has insurance or other coverage, or if any other person is obligated, either legally or contractually, to pay for or to reimburse the recipient for any service covered by this chapter, the provider shall seek payment from that s…

.33 Cause for Suspension or Removal and Imposition of Sanctions. A. If the Department determines that a provider, any agent or employee of the provider, or any person with an ownership interest in the provider has failed to comply with applicable federal or State laws or regulati…

.34 Appeal Procedures. A. Except as provided for in §B of this regulation, providers filing appeals from administrative decisions made in connection with these regulations shall do so according to COMAR 10.09.36.09. B. Nursing Home Appeal Board. (1) Appeals regarding rate calcula…

.35 Interpretive Regulation. Except when the language of a specific regulation indicates an intent by the Department to provide reimbursement for covered services to Program recipients without regard to the availability of federal financial participation, State regulations shall …

.01 Purpose and Scope. A. This chapter governs the determination of eligibility for the Maryland Children's Health Program with an income standard based on the modified adjusted gross income methodology specified in the Affordable Care Act of 2010, effective January 1, 2014. B. E…

.02 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Affordable Care Act” means the Patient Protection and Affordable Care Act of 2010 (Pub.L.111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (…

.03 Coverage Groups. Eligibility may be established for the Maryland Children's Health Program for children younger than 19 years old whose household income is equal to or less than 200 percent of the federal poverty level.

.04 Application. A. The Department or its designee shall determine eligibility for children. B. The Department or its designee shall give oral, written, or electronic information about the Maryland Children’s Health Program such as: (1) Requirements for eligibility; (2) Available…

.05 Application: Additional Requirements. A. Social Security Number. (1) As a condition of eligibility, an applicant shall furnish to the Department or its designee a Social Security number for the applicant. If the applicant cannot furnish a Social Security number, the applicant…

.06 Nonfinancial Eligibility Requirements. A. Citizenship. In order to be eligible for full benefits under the Maryland Children's Health Program, an individual shall meet the federal requirements for Medical Assistance eligibility as a citizen or qualified alien, as specified at…

.07 Consideration of Household Income. A. The applicant shall report the income of any family member, except for the income of a member that does not file a federal tax return and is not claimed as a federal tax dependent. B. Determining Countable Household Income. (1) In determi…

.08 Consideration of Family Income: Earned and Unearned Income — Repealed.

.09 Consideration of Family Income: Income Disregards — Repealed.

.10 Determining Financial Eligibility. An applicant is financially eligible for the Maryland Children's Health Program if, for the period under consideration, the applicant's countable household income as determined under Regulation .07 of this chapter does not exceed 200 percent…

.11 Certification Periods. A. For a newborn, certification begins on the day the child is born to an eligible woman and ends on the last day of the month of the child's 1st birthday. B. For an eligible child, certification begins on the first day of the month of application, or u…

.12 Covered Services. A. A child certified for the Program is entitled to all health benefits through the Maryland Medicaid Managed Care Program. B. In the case of an alien who is eligible for benefits under COMAR 10.09.24.05D(4)(b), covered services are limited to those that are…

.13 Post-Eligibility Requirements. A. Notice of Eligibility Determination. The Department or its designee shall inform an applicant of the applicant's legal rights and obligations and give the applicant written or electronic notification of the following: (1) For eligible individ…

.14 Hearings. The requirements relating to hearings under COMAR 10.01.04 apply to this chapter.

.15 Fraud and Abuse. The requirements relating to fraud and abuse under COMAR 10.09.24.14 apply to this chapter.

.16 Adjustments and Recoveries. The requirements relating to adjustments and recoveries under COMAR 10.09.24.15, with the exception of COMAR 10.09.24.15A(1) and (2), apply to this chapter.

.17 Interpretive Regulation. State regulations shall be interpreted in conformity with applicable federal statutes and regulations, except if the language of a specific regulation indicates an intent by the Department to provide reimbursement for covered services to Program recip…

.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Customary charge” means the uniform amount that the provider charges in the majority of cases for a specific supply or piece of equipment, excluding token charges for char…

.02 License Requirements. Providers of services shall meet the licensing requirements as set forth in COMAR 10.09.36.02.

.03 Conditions for Participation. To participate in the Program, the provider: A. Effective January 1, 2018, shall be in an approved status with Medicare; B. Effective April 1, 2012 through December 31, 2017, shall, unless exempt from Medicare accreditation requirements: (1) Be a…

.04 Covered Services. A. The following medically necessary items are covered when ordered by an individual who is enrolled as a provider in the Program on the date of service: (1) Disposable medical supplies; (2) Durable medical equipment; (3) Repairs to purchased durable medical…

.05 Limitations. The Program does not cover: A. Incontinency pants and disposable underpads unless the following conditions are met: (1) The incontinence supplies are medically necessary for medical conditions associated with prolonged urinary or bowel incontinence; (2) For pull-…

.06 Prepayment Authorization Requirements. A. Prepayment authorization is required for: (1) Disposable medical supplies with a charge exceeding $500, except as specified in §B(1) and (4) of this regulation and durable medical equipment on the approved list of items as individual …

.07 Payment Procedures. A. Payment procedures shall be as set forth in COMAR 10.09.36.04. B. The provider’s billed charges to the Program may not exceed the provider’s customary charge. If the item is free to individuals not covered by Medicaid: (1) The provider: (a) May charge t…

.08 Recovery and Reimbursement. Recovery and reimbursement shall be as set forth in COMAR 10.09.36.07.

.09 Cause for Suspension or Removal and Imposition of Sanctions. Cause for suspension or removal and imposition of sanctions shall be as set forth in COMAR 10.09.36.08.

.10 Appeal Procedures. Appeal procedures shall be as set forth in COMAR 10.09.36.09.

.11 Interpretive Regulation. State Regulations shall be interpreted as set forth in COMAR 10.09.36.10.

.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Department” has the meaning stated in COMAR 10.09.36. (2) “Medical Assistance Program” has the meaning stated in COMAR 10.09.36. (3) “Medical Care Programs” has the meanin…

.02 Licensing Requirements. Providers shall meet all licensing requirements as set forth in COMAR 10.09.36.

.03 Conditions for Participation. To participate in the Program, the provider shall: A. Comply with the conditions for participation as set forth in COMAR 10.09.36; B. Be approved as a provider of ambulance services by Medicare.

.04 Covered Services. The program covers copayment and deductible payments for Medicare-approved services to Maryland Medical Assistance recipients.