Maryland Administrative Code

.14 Fraud. A. “Medicaid fraud” means: (1) Knowingly and willfully making or causing to be made any false statement or representation of a material fact in any application for any benefit or payment under a State plan established by Title XIX of the Social Security Act of 1939; (2…

.14-1 Recipient Abuse. A. Forms of Abuse. Recipient abuse exists when: (1) A recipient utilizes an inappropriate type of provider for care; (2) A recipient utilizes an appropriate type of provider at an inappropriate frequency for care; (3) A recipient utilizes an appropriate pro…

.15 Liens, Adjustments, and Recoveries. A. Definitions. In this regulation, the following terms have the meanings indicated: (1) “Dependent” means a: (a) Child of the decedent, or the decedent's descendants; (b) Sibling, including half or step, of the decedent; or (c) Parent of t…

.16 Interpretive Regulation. Except if 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 be…

.17 Information from and Liability of Health Insurance Carriers. A. A carrier shall: (1) Provide, at the request of the Department, information about individuals who are eligible for benefits under the Program or are Program recipients so that the Department may determine: (a) Wh…

.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Child's family” means those individuals with whom a participant resides, who are responsible for the participant, and who are the primary nurturing caregivers. (2) “Depart…

.02 Licensure and Certification. A. Providers shall meet the requirements of COMAR 13A.06.07. B. Providers shall meet all the requirements of the jurisdiction in which they operate.

.03 Conditions for Participation. Providers shall meet all requirements for participation in the Program stated in COMAR 10.09.36.03 and COMAR 13A.06.07. Cross References 10.09.25.01B(18)

.04 Covered Services. A. The Program covers the services listed in §B of this regulation when the services are provided to a child: (1) Eligible for services under IDEA; (2) Who is an eligible Medicaid recipient; (3) Who was transported to or from a Medicaid-covered service under…

.05 Limitations. A. To participate in the Program as a provider of transportation services under IDEA, a provider shall be a local education agency, a local lead agency, a State-operated education agency, or State-supported education agency. B. Providers shall only bill the Progr…

.06 Payment Procedures. A. Request for Payment. (1) An enrolled provider shall submit a request for payment of services rendered and completed under this chapter according to procedures established by the Department. The Department reserves the right to return to the provider, be…

.07 Recovery and Reimbursement. Recovery and reimbursement is as set forth in COMAR 10.09.36.07.

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

.09 Appeal Procedures. Appeal procedures are those set forth in COMAR 10.09.36.09.

.10 Interpretive Regulation. Interpretive regulations are those 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) “Alternative living unit” means a residence that: (a) Provides residential services for individuals who, because of developmental disabilities, require specialized living a…

.02 Licensing Requirements. A. Providers of residential habilitation services shall be licensed pursuant to COMAR 10.22.03 or 10.22.14. B. Providers of day habilitation or supported employment services shall be licensed pursuant to COMAR 10.22.12 or 10.22.13. C. Providers of serv…

.03 Conditions for Participation. A. General requirements for participation in the Medical Assistance Program are that the providers: (1) Meet all conditions for participation specified in COMAR 10.09.36, except as otherwise specified in this regulation; (2) Meet the licensure re…

.04 Covered Services for Services Coordination. The Department shall reimburse for services coordination which shall include the following: A. Convening the interdisciplinary team and conducting the team meeting for the development and revision of the ISP; B. Assisting the waiver…

.05 Covered Services for Residential Habilitation. A. The Department shall reimburse residential habilitation services providers for those services listed below, exclusive of room and board. These regulations do not limit payments, within the fiscal guidelines of the Department, …

.06 Covered Services for Day Habilitation. A. Day habilitation services shall be provided that are required and recommended in the waiver participant's IHP by licensed day habilitation programs and shall include the services listed in Regulation .05 of this chapter and in §B—D of…

.07 Covered Services for Environmental Modifications. A. Environmental modifications shall be provided on a limited, one-time-only basis to the extent necessary to enable waiver participants with physical infirmities or disabilities to live safely in community homes as an alterna…

.08 Covered Services for Respite Care. A. Respite care may only be provided to waiver participants who receive residential habilitation or residential option services in their home or in an individual family care home. B. When respite care is received in a: (1) State residential …

.08-1 Covered Services for Supported Employment. A. Supported employment services are available to waiver participants: (1) Who previously resided in a State residential center or nursing facility; (2) For whom competitive employment at or above the minimum wage is unlikely; and …

.08-2 Covered Services for Residential Option Services. A. Residential option services are available as an alternative to residential habilitation for those waiver participants who: (1) Have followed DDA's application procedures according to COMAR 10.22.11; (2) Are determined by …

.08-3 Assistive Technology and Adaptive Equipment. A. This technology and equipment includes the assistive technology and adaptive equipment necessary to enable a waiver participant to live in the community and to participate in community activities, when this technology and equi…

.08-4 Covered Services for Intensive Behavior Management. Services shall be provided in accordance with COMAR 10.22.10. Cross References 10.09.26.13D(1)(i)(ii) 10.09.26.13D(3)(a)(ii)

.08-5 Covered Services for Medical Day Care. A. Unit of service means a day of care in which the participant is certified present at the medical day care center for a minimum of 4 hours. B. Medical day care services shall be provided in accordance with COMAR 10.09.07. C. Medical …

.09 Conditions for Reimbursement. The Department shall reimburse for services in Regulations .04—.08-5 of this chapter when they are: A. Provided to waiver participants; B. With the exception of medical day care services, contained in the waiver participant's plan of care, approv…

.10 Limitations. A. These regulations do not cover the following services: (1) Services available to waiver participants through programs funded under the Rehabilitation Act of 1973, §110, Public Law 94-142, or Education of the Handicapped Act, §602(16) and (17); (2) Services whi…

.11 Participant Eligibility. A. Waiver participants shall meet the eligibility conditions of §B of this regulation, as well as Regulation .12 of this chapter. B. To be eligible for services under the Home and Community Based Services Waiver for the Developmentally Disabled, a per…

.12 Medical Assistance Eligibility. A. Definitions. In this regulation, the following terms have the meanings indicated: (1) “Aged” means a person who is 65 years old or older. (2) “Blind” means having a condition in which a person is certified by an ophthalmologist as having eit…

.13 Payment Procedures. A. Request for Payment. (1) All requests for payment of services rendered shall be submitted according to procedures established by the Department. Payment requests which are not properly prepared or submitted may not be processed, but shall be returned un…

.14 Recovery and Reimbursement. Recovery and reimbursement are as specified in COMAR 10.09.36.

.15 Cause for Suspension or Removal and Imposition of Sanctions. Cause for suspension or removal and imposition of sanctions is as specified in COMAR 10.09.36.

.16 Appeal Procedures. A. Appeal procedures for providers are as specified in COMAR 10.09.36. B. Persons filing appeals contending that they were not informed of their choice of services or that they were denied the service of their choice may file an appeal requesting a fair hea…

.17 Interpretive Regulation. State regulations shall be interpreted as specified in COMAR 10.09.36.

.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Certified nursing assistant” means an individual who: (a) Is certified by the Maryland Board of Nursing; and (b) Performs nursing tasks delegated by a registered nurse or …

.02 Licensing Requirements. Providers shall meet all licensing requirements specified in COMAR 10.09.36.

.03 Conditions for Participation. A. General requirements for participation in the Medical Assistance Program are that providers shall meet all conditions for participation specified in COMAR 10.09.36. B. Specific requirements for participation in the Program as a provider of hom…

.04 Covered Services. A. The Program reimburses for home care services which include the following: (1) Shift nursing services provided by a licensed registered nurse or a licensed practical nurse if: (a) The complexity of the service or the condition of a participant requires th…

.05 Participant Eligibility. A. Requirements. Model waiver participants shall meets the financial eligibility requirements under §B, C, or D of this regulation and the nonfinancial requirements of §§E and F of this regulation. B. Categorically needy eligibility recipients of supp…

.06 Payment Procedures. A. Payment procedures as set forth in COMAR 10.09.36 apply. B. Payments. (1) Payments shall be made directly to a qualified provider. (2) Providers shall be paid the lesser of: (a) The provider's customary charge to the general public unless the service is…

.07 Recovery and Reimbursement. Recovery and reimbursement shall be as specified in COMAR 10.09.36.

.08 Cause for Suspension or Removal and Imposition of Sanctions. Cause for suspension or removal and imposition of sanctions shall be as specified in COMAR 10.09.36.

.09 Appeal Procedures. Appeal procedures shall be as specified in COMAR 10.09.36.

.10 Interpretive Regulation. State regulations shall be interpreted as specified in COMAR 10.09.36.