Maryland Administrative Code

.06 Time Standards. 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 standar…

.07 Premium. A. Submission of Premium. (1) Unless an exception under §A(2) of this regulation applies or a timely claim of hardship is raised pursuant to §C of this regulation, an applicant or recipient shall, as a condition of eligibility for the EID coverage group, pay the prem…

.08 Determination, Notice, and Certification Period. 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 …

.09 Posteligibility Requirements. 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) Provi…

.10 Covered Services. 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, i…

.11 Conditions of Participation and Reimbursement. 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 Assi…

.12 Fraud, Liens, Recovery, and Reimbursement. A. The provisions of COMAR 10.09.24.14 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 circumstan…

.13 Hearings. 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 “t…

.01 Definitions. 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 wh…

.02 License Requirements. A. License requirements under this chapter are referenced in COMAR 10.09.36.02. 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, En…

.03 Conditions for Participation. 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 …

.04 Covered Services. 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 r…

.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. Services denied by Medicare as not medically justified; E. Sep…

.06 Payment Procedures. 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 inc…

.07 Recovery and Reimbursement. Recovery and reimbursement under this chapter are set forth in COMAR 10.09.36.07.

.08 Cause for Suspension or Removal and Imposition of Sanctions. Causes for suspension or removal and imposition of sanctions under this chapter are set forth in COMAR 10.09.36.08.

.09 Appeal Procedures. Appeal procedures under this chapter are set forth in COMAR 10.09.36.09.

.10 Interpretive Regulation. Interpretive regulations under this chapter are set forth in COMAR 10.09.36.10.

.01 Purpose and Scope. This chapter governs the determination of eligibility and the conditions of participation for MCHP Premium with an income standard based on the modified adjusted gross income methodology specified in the Affordable Care Act of 2010, effective January 1, 201…

.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 MCHP Premium Program for children younger than 19 years old whose household income is above 200 percent but at or below 300 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 MCHP Premium such as: (1) Requirements for eligibility; (2) Available services; (3) An individu…

.05 Nonfinancial Eligibility Requirements. 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 def…

.06 Consideration of Family Income. A. The applicant shall report the income of each family member, except for the income of members that do not file a federal tax return and are not claimed as a federal tax dependent. B. Determining Countable Household Income. (1) In determining…

.07 Consideration of Family Income: Earned and Unearned Income — Repealed. Cross References 10.09.43.02B(11)

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

.09 Determining Financial Eligibility. Current and New Enrollees. An applicant is financially eligible for MCHP Premium if, for the period under consideration, the applicant's countable household income as determined under Regulation .06 of this chapter, is greater than 200 perce…

.10 Certification Periods. 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 ineligibil…

.11 Covered Services. 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 ca…

.12 Program Participation Requirements — Enrollment. A. An eligible individual who is enrolled in MCHP Premium shall be covered through a Maryland Medicaid Managed Care MCO. B. Timely Enrollment. The representative shall: (1) Send to the Department or its designee the first month…

.13 Program Participation Requirements — Family Contribution. 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 el…

.14 Program Participation Requirements — Change in Status. A. The applicant shall report any change in family status or family composition within 10 days of the change. B. Change in family status includes increase or decrease in the number of family members through birth, death, …

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

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

.17 Fraud, Abuse, and Penalty. A. The requirements relating to fraud and recipient abuse under COMAR 10.09.24.14 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 Cod…

.18 Adjustments and Recoveries. In all cases where MCHP Premium benefits have been incorrectly paid, the Department shall seek recovery pursuant to COMAR 10.09.24.15.

.19 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 for MCHP Premium…

.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Amount that would otherwise have been paid (AWOP)” means the amount the Program expects to have paid for services for a PACE participant under the State Plan had the parti…

.02 Application for Qualification as a PACE Provider. 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.

.03 PACE Provider. A. The PACE provider shall comply with: (1) 42 CFR 460 et seq.; (2) This chapter; (3) The Medicaid provider agreement and the PACE Organization Provider Agreement signed with the Department; (4) COMAR 10.09.36; (5) Standards in P.L. 101-330, Americans with Disa…

.04 Term of the PACE Organization Provider Agreement. A. The duration or term of the agreement between the Department and the PACE provider is specified in the PACE Organization Provider Agreement. B. The PACE Organization Provider Agreement shall provide for automatic amendment,…

.05 PACE Participant Eligibility. 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 jeopa…

.06 Pace Participant Enrollment. 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 an eligible participant on the form approved by the Department. C. The PACE provider…

.07 Termination of PACE Participant's Enrollment. A. Termination of a PACE participant's enrollment may be initiated by the: (1) PACE provider; (2) Department; (3) PACE participant; or (4) PACE participant’s legal guardian or legal representative. B. All enrollment terminations r…

.08 PACE Participant Rights. The PACE provider shall ensure notification and protection of the rights of enrollees according to 42 CFR §460.110 and 42 CFR §460.112.

.09 Covered Services. 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 …

.10 Limitations on Coverage. Limitations on coverage are as specified in the PACE program agreement and 42 CFR §460.96.