Maryland Administrative Code

.04 Covered Services. A. The Program covers medically necessary services described in §B of this regulation, rendered to participants in a free-standing dialysis facility, when these services are: (1) Performed by a physician or by one of the following: (a) A physician assistant;…

.05 Limitations. 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. Drugs and supplies which are acquired at no cost; E. Injection…

.06 Payment Procedures. A. Reimbursement Principles. (1) Reimbursement by the Program is for services described in Regulation .04B of this chapter provided at a free-standing dialysis facility which has been approved for Medicare by the Division of Survey and Certification of CMS…

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

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

.09 Appeal Procedures. Providers filing appeals from administrative decisions made in connection with these regulations shall do so according to COMAR 10.09.36.09.

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

.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “American Academy of Pediatric Dentists” means the membership organization representing the specialty of pediatric dentistry. (2) “Department” means the Maryland Department…

.01-1 Incorporation by Reference. The Audiology, Physical Therapy, and Early Periodic, Screening, Diagnosis, and Treatment (EPSDT) Provider Manual (Maryland Medical Assistance Program, Effective January 1, 2022) is incorporated by reference.

.02 Provider Qualifications. A. EPSDT screening and treatment providers shall meet all of the licensure and certification requirements specified in this or any other applicable chapter of COMAR, statute, or policy for the service that the provider renders. B. In order for the Pro…

.03 Conditions for Participation. A. In order to receive payments as a Medicaid provider, providers shall meet the following general requirements: (1) All conditions for participation set forth in COMAR 10.09.36; (2) If delivering services via telehealth, comply with COMAR 10.09.…

.04 Covered Services. A. The Program covers all medically necessary care, including all health care services to identify and correct physical and mental problems that are covered in the State Plan, or that are allowable under the federal Medicaid program as described in §1905(a) …

.05 Limitations. A. Any Program limits on services or treatments identified in this regulation are not applicable for individuals younger than 21 years old if it is shown that the treatments or services are medically necessary to correct or ameliorate identified or suspected heal…

.06 Preauthorization. Preauthorization is required for: A. Certain audiology and hearing aid services, as specified in COMAR 10.09.51.06; B. Certain dental services, as specified in COMAR 10.09.05.06; C. Certain vision services, as specified in COMAR 10.09.14.06; D. Private duty …

.07 Payment Procedures. A. Request for payment of services shall be submitted in accordance with COMAR 10.09.36.04. B. Billing time limitations for claims submitted pursuant to this chapter as set forth in COMAR 10.09.36.06. C. Rates for services provided by chiropractors, speech…

.08 Recovery and Reimbursement. A. Regardless of whether the participant has other third-party insurance coverage, EPSDT screening providers shall bill the Program directly for the following components of an EPSDT screen: (1) Comprehensive unclothed physical examinations; (2) Imm…

.09 Cause for Suspension or Removal and Imposition of Sanctions. A. Cause for suspension or removal and impositions of sanctions are as set forth in COMAR 10.09.36.08. B. If during a quality assessment, the Department staff determines that the provider does not meet the standards…

.10 Appeal Procedures. Appeal procedures are as set forth in COMAR 10.09.36.09.

.11 Interpretive Regulations. State regulations are interpreted as set forth in COMAR 10.09.36.10.

.01 Purpose and Scope. A. This chapter governs the determination of eligibility for the Maryland Medical Assistance Program. B. Eligibility may be established for the following coverage groups: (1) The MAGI coverage groups whose income standard is based on the modified adjusted g…

.02 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Aged” means a person who is 65 years old or older. (2) “Aid to the Permanently and Totally Disabled” means a former category of public assistance mandated under Title XIV …

.02-1 MAGI 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…

.03 Coverage Groups. A. The following individuals, including recipients of Temporary Cash Assistance, may be determined eligible for the MAGI coverage groups: (1) Parents and other caretaker relatives whose household income is equal to or less than 123 percent of the federal pove…

.03-1 Coverage Group for Women with Breast or Cervical Cancer — Purpose, Definitions, and Eligibility Criteria. A. Purpose. (1) The purpose of Regulations .03-1 and .03-2 of this chapter is to exercise the State's option under Title XIX of the Social Security Act to create a new …

.03-2 Coverage Group for Women with Breast or Cervical Cancer — Eligibility, Determination, and Covered Services Process. A. Screening. A woman is considered to have received screening services if the: (1) NBCCEDP funded all or part of the woman's screening services; or (2) NBCCE…

.03-3 Medicare Savings Program Coverage. A. Non-Financial and Resource Eligibility for the Medicare Savings Programs. In order to be eligible for the Medicare savings program under §§E—H of this regulation, an individual: (1) May not be enrolled in Medical Assistance or the Maryl…

.03-4 Medicare Buy-In Coverage for Medical Assistance Recipients. A. If a recipient, who is determined federally eligible and enrolled in Medical Assistance or the Maryland Children’s Health Program according to the requirements of this chapter or COMAR 10.09.11, is entitled to h…

.04 Application — General Requirements. A. The Department or its designee shall determine initial (retroactive and current) and continuing eligibility. B. The Department or its designee shall give oral, written, or electronic information about the Medical Assistance Program such …

.04-1 Specific Application Requirements for MAGI Exempt Coverage Groups. A. All of the requirements of Regulation .04 of this chapter shall apply with the exceptions stated in this chapter. B. Application Filing and Signature Requirements. (1) An individual who wishes to apply fo…

.05 Nonfinancial Eligibility Requirements — Citizenship. A. Eligibility. To be eligible for federal coverage of full Medical Assistance benefits, an individual shall be: (1) A citizen of the United States, including: (a) An individual who was born in: (i) One of the 50 states; (i…

.05-1 Documentation of Citizenship and Identity. A. An applicant or recipient shall be required as a condition of eligibility to provide documentary evidence of identity as well as citizenship or nationality, to the Department's satisfaction, based on federal requirements, if the…

.05-2 Nonfinancial Eligibility Requirements — Emergency Medical Services for Ineligible or Illegal Aliens. A. An alien shall be eligible for federal Medical Assistance coverage of emergency medical services, as specified under §§B and C of this regulation, if the alien is determi…

.05-3 Nonfinancial Eligibility Requirements — Residency. A. To be eligible for the Maryland Medical Assistance Program, an applicant or recipient shall be a Maryland resident. B. An individual is a Maryland resident if the individual resides in Maryland with the intent of remaini…

.05-4 Nonfinancial Criteria for MAGI Exempt Coverage Groups. A. Blindness. (1) To be eligible for Medical Assistance as a blind individual, an applicant or a recipient shall be blind as defined at Regulation .02 of this chapter. (2) Procedure for Determination of Blindness. (a) I…

.05-5 Nonfinancial Eligibility Requirements — Institutions. A. Inmate of a Public Institution. (1) To be eligible for Medical Assistance, an applicant or recipient may not be incarcerated as an inmate of a public institution. (2) Inmate Status. (a) An individual is considered inc…

.06 MAGI Exempt Assistance Unit. A. Purpose and Scope. This regulation establishes who shall be a member of an assistance unit, who may be excluded from an assistance unit, who will have separate eligibility determinations, and whose income and resources will be considered in det…

.06-1 MAGI Household Unit. A. Purpose and Scope. (1) This regulation establishes who shall be a member of the MAGI household and who will be excluded from the MAGI household. (2) The regulation applies to applicants and recipients of coverage groups described under Regulation .03…

.07 Consideration of Income. A. This regulation contains the rules for considering earned and unearned income of: (1) Members of the MAGI household unit and those individuals whose income is considered pursuant to Regulation .06-1 of this chapter in determining financial eligibil…

.08 Consideration of Resources for MAGI Exempt Coverage Groups. A. This regulation contains the rules for considering resources of members of the MAGI exempt assistance unit and those individuals whose income and resources are considered pursuant to Regulation .06 of this chapter…

.08-1 Disposal of Assets for Less Than Fair Market Value. A. Definitions. In this regulation, the following terms have the meanings indicated: (1) “Assets” means all income and resources of an individual and of an individual's spouse, including any income or resources which the i…

.08-2 Treatment of Trust Amounts. A. For the purpose of this regulation, “trust” has the meaning defined under Regulation .08-1A of this chapter. B. Treatment of Trusts Established after August 10, 1993. (1) In determining eligibility for Medical Assistance for any period under c…

.08-3 Resource Consideration of Entrance Fees for Continuing Care Retirement Communities. A. Treatment of Entrance Fees before January 1, 2006. For Medical Assistance applications or requests for spousal resource assessments filed before January 1, 2006, the entrance fee shall be…

.08-4 Resource Consideration of Long-Term Care Partnership Policies. A. This regulation establishes the rules for applicants and recipients who: (1) Own a long-term care (LTC) partnership policy; and (2) Meet all factors of Medicaid eligibility in accordance with MAGI Exempt cove…

.09 Determining Financial Eligibility for Noninstitutionalized Individuals. A. Basis. (1) Financial eligibility is determined on the basis of the countable net income and resources of members of the MAGI exempt assistance unit and those individuals whose income and resource are c…

.10 Determining Financial Eligibility for Institutionalized Persons. A. Scope. (1) This section applies to persons who are institutionalized throughout a calendar month. (2) Institutional status is presumed to begin on the first day of the first full calendar month in which the p…

.10-1 Treatment of Income and Resources of Certain Institutionalized Spouses. A. Basis. (1) Except as this regulation specifically provides, the provisions of this regulation may not affect: (a) The determination of what constitutes income or resources; (b) The methodology and st…

.10-2 Substantial Home Equity and Exclusion of Long-Term Care Coverage. A. Subject to §E of this regulation, an institutionalized individual is not covered by Medical Assistance for long-term care services in a nursing facility, medical institution with a level of care equivalent…