Maryland Administrative Code

.14 Record Keeping. The PACE provider shall comply with 42 CFR §460.210.

.15 Reports and Data Collection. A. The PACE provider shall collect and submit to the Department service-specific encounter data by service type in the format and at the frequency designated by the Department and in conformance with the Department's computer coding requirements. …

.16 Confidentiality. A. Subject to the requirements of 42 CFR Part 431 Subpart F, the PACE provider and its contractors may not release or disclose any information concerning a PACE participant to anyone other than the Department except with the written permission of the: (1) PAC…

.17 Financial Solvency. The PACE provider shall comply with 42 CFR §460.80 and 42 CFR §460.208.

.18 Subcontractual Relationships. A. Consistent with this chapter, the PACE provider, in performing its obligations under this chapter and the PACE program agreement, may either engage its own employees and agents or utilize the services of persons, firms, and other entities by m…

.19 Internal Grievance Procedure. The PACE provider shall comply with the grievance procedures described at 42 CFR §460.120—124. Cross References 10.09.44.03E(5) 10.09.44.15F(3)

.20 Third-Party Liability. A. The PACE provider shall identify and collect money owed from responsible third parties liable for the cost of health care services furnished by the PACE provider to its PACE participants. B. Upon request from the Department, the PACE provider shall c…

.21 Payment Rates and Procedures. A. The Department shall: (1) Pay the PACE provider for each PACE participant based on the fixed capitation payment or payments specified in §E of this regulation; and (2) Calculate the capitation payment or payments for the PACE provider using th…

.22 Payment for Emergency Services. A. The PACE provider shall be responsible for prompt payment for all emergency services received by PACE participants. B. If a claim is submitted to the PACE provider within 9 months of the date of service, the PACE provider shall reimburse a h…

.23 Cause for Suspension or Removal and Imposition of Sanctions. A. Cause for suspension or removal and imposition of sanctions under this chapter are set forth in COMAR 10.09.36.08. B. If the Department determines that a provider, any agent or employee of the provider, or any pe…

.24 Appeal Procedures. A. The PACE provider shall comply with 42 CFR §460.122. B. PACE provider appeal procedures under this chapter are set forth in COMAR 10.09.36.09. C. PACE participant appeals are set forth in COMAR 10.01.04. Cross References 10.09.44.04E(1)

.25 Interpretive Regulation. Interpretation of this regulation is subject to COMAR 10.09.36.

.01 Scope. A. This chapter applies to providers organized to deliver mental health case management services to adults. B. The purpose of mental health case management is to assist participants in gaining access to needed medical, mental health, social, educational, and other serv…

.02 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Administrative services organization (ASO)” means the entity with which the Department may contract to provide the services described in COMAR 10.67.08 for the public ment…

.03 Participant Eligibility. A. A recipient is eligible for mental health case management services if the recipient: (1) Is in a federal eligibility category for Maryland Medical Assistance according to COMAR 10.09.24, which governs the determination of eligibility for the Maryla…

.04 Conditions for Mental Health Case Management Provider Participation. A. The local core service agencies shall select mental health case management providers through a competitive procurement process, at least once every 5 years. B. Mental health case management services may b…

.05 Mental Health Case Management Provider Staff. Required Staff. The mental health case management provider shall have staff that is sufficient in numbers and qualifications to provide appropriate services to the participants served and shall include, at a minimum: A. A communit…

.06 Covered Services. A. The Department shall reimburse for the services in §§C—I of this regulation under mental health case management when these services have been documented, pursuant to the requirements in this chapter, as necessary. B. Case management services shall be coor…

.07 Limitations. A. Mental health case management services are advisory in nature. B. A restriction may not be placed on a qualified recipient's option to receive mental health case management services. C. Mental health case management services do not restrict or otherwise affect…

.08 Preauthorization. All covered services under this chapter shall be preauthorized and comply with the requirements of COMAR 10.09.59.08.

.09 Payment Procedures. A. The Program shall reimburse the provider according to the requirements in this chapter and the fees established under COMAR 10.21.25. B. Request for Payment. (1) Requests for payment of mental health case management services shall be submitted by an app…

.10 Recovery and Reimbursement. Recovery and reimbursement are as set forth in COMAR 10.09.36.07.

.11 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.

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

.13 Interpretive Regulation. State regulations are interpreted as 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) “Applicant” means an individual who is applying as a participant in the BI waiver. (2) “Behavior intervention” means services designed to assist individuals who exhibit cha…

.02 Medical Assistance Eligibility. A. Financial eligibility for waiver participants is determined according to the provisions of this regulation and applicable sections of COMAR 10.09.24 Medical Assistance Eligibility, as cited in this section. B. Categorically Needy. An individ…

.03 Participant Eligibility. A. Medical Eligibility for the Waiver. (1) To be medically eligible for the services covered under this chapter, an applicant shall be certified by the Program's utilization control agent to need nursing facility level of care or special hospital leve…

.04 Program Model. A. The program services and supports shall: (1) Maximize the level of functioning of an individual with BI through assistance and support with independent living, self care skills, and social skills in an environment which encourages the participant's ability t…

.05 Conditions for Provider Participation — General. General requirements for participation in the Medical Assistance Program as a provider of BI waiver services are that the provider, with the exception of a medical day care provider, shall: A. Be approved by the BHA as meeting …

.06 Conditions for Provider Participation — Specific. A. Provider of Residential Habilitation or Rehabilitation Services. To provide the services covered under Regulation .07 of this chapter, the provider agency shall: (1) Operate a community-based program of residential habilita…

.07 Covered Services — Residential Habilitation Services. A. The residential habilitation services covered under this regulation shall be provided in a community-based residential facility. B. The covered services shall include: (1) Habilitative services to assist a participant i…

.08 Covered Services — Day Habilitation Services. A. The day habilitation services covered under this regulation shall be provided in a nonresidential setting, separate from the home or facility in which the participant resides. B. The covered services, as defined in this chapter…

.09 Covered Services — Supported Employment Services. A. The supported employment services covered under this regulation shall be provided in nonresidential community settings, separate from the home or facility in which the participant resides. B. The covered services shall: (1)…

.09-1 Covered Services — Individual Support Services. A. Individual support services, as defined in Regulation .01B of this chapter, shall be provided in a participant's own home or their community. B. The service involves the training and development of compensatory strategies a…

.09-2 Covered Services — Medical Day Care Services. A. Covered medical day care services are those set forth in COMAR 10.09.07. B. A unit of service is a minimum of 4 hours present at the medical day care center. Cross References 10.09.46.06E(1)

.10 Conditions for Reimbursement. The Department shall reimburse for services covered under this chapter if the services are: A. Provided to a participant who meets the qualifications for eligibility specified in Regulations .02 and .03 of this chapter; B. Preauthorized in the pa…

.11 Limitations. A. Reimbursement shall be made by the Program only if all of the requirements of this chapter are met. B. Reimbursement may not be made by the Program for a waiver service furnished before: (1) Enrollment of the participant in the waiver; (2) Development of the p…

.12 Payment Procedures. A. Request for Payment. (1) An approved provider, with the exception of a medical day care provider, shall submit requests for payment to BHA or its authorized representative for the services covered under this chapter, according to procedures set forth in…

.13 Recovery and Reimbursement. Recovery and reimbursement under this chapter are as set forth in COMAR 10.09.36.07 and COMAR 10.09.07.09.

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

.15 Appeal Procedures. A. Appeal procedures for applicants and participants are those set forth in COMAR 10.09.24.13 and COMAR 10.01.04. B. Provider appeal procedures under this chapter are set forth in COMAR 10.09.36.09.

.16 Interpretive Regulation. Interpretation of this regulation is subject to COMAR 10.09.36.10.

.01 Definitions. A. In addition to the definitions contained in §B of this regulation, definitions set forth in COMAR 10.09.06.01 are applicable to this chapter. B. Terms Defined. (1) “Charity care” means hospital care for which the costs are not reimbursed through any patient or…

.02 Disproportionate Share Hospitals. A. A Maryland hospital is considered a disproportionate share hospital for purposes of a disproportionate share payment if the hospital's: (1) Medicaid inpatient utilization rate is at least one standard deviation above the mean Medicaid inpa…

.03 Disproportionate Share Payment. A. Free-Standing Acute General, Chronic, or Pediatric/Rehabilitation Hospitals. (1) Except as set forth in §A(2) of this regulation, the disproportionate share payment for disproportionate share hospitals that are free-standing hospitals licens…

.04 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 …