Maryland Administrative Code

.07 Recovery and Reimbursement. Recovery and reimbursement are 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. 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. State regulations shall be interpreted in conformity with COMAR 10.09.36.10.

.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) Active Treatment. (a) “Active treatment” means, according to 42 CFR §483.440(a), a continuous active treatment program which includes aggressive, consistent implementation …

.02 Participant Eligibility. A. Medical Eligibility for the Autism Waiver. (1) To be medically eligible for the services covered under the chapter, an applicant shall be certified by the licensed psychologist, licensed social worker, licensed clinical professional counselor, cert…

.03 Care Planning Process. A. Multidisciplinary Team. (1) A multidisciplinary team shall be convened by the local school system or local lead agency in accordance with COMAR 10.09.52 to: (a) Assess or reassess an applicant's or participant's need and eligibility for Autism Waiver…

.04 Conditions for Participation — General. To provide Autism Waiver services, the provider: A. Shall be approved in accordance with the requirements specified in this chapter; B. Shall have a provider agreement in effect, signed with the Program; C. Shall meet all the conditions…

.05 Specific Conditions for Participation — Residential Habilitation Services. To provide the services covered under Regulation .11 of this chapter, the provider agency shall: A. Provide services in a facility that meets the following requirements: (1) Complies with regulations g…

.06 Specific Conditions for Participation — Intensive Individual Support Services. To provide the service covered under Regulation .15 of this chapter, the provider shall: A. Have at least 3 years of experience in providing habilitation services to children with autism; B. Employ…

.06-1 Specific Conditions for Participation — Therapeutic Integration Services. To provide one or more of the services covered under Regulation .14 of this chapter, the provider shall: A. Have at least 3 years of experience in providing habilitation services to children with auti…

.06-2 Specific Conditions for Participation — Intensive Therapeutic Integration Services. To provide one or more of the services covered under Regulation .14-1 of this chapter, the provider shall: A. Meet all the conditions of Regulation .06-1 of this chapter; and B. Have an on-s…

.07 Specific Conditions for Participation — Respite Care. A. The respite care provider shall have adequate liability insurance and be appropriately bonded. B. A professional who provides respite care services or supervises a direct care worker rendering the services shall be: (1)…

.08 Specific Conditions for Participation — Family Consultation. A. To provide the services covered under Regulation .17 of this chapter, a consultant shall be: (1) Certified in accordance with COMAR 13A.12.01 as a psychologist, special educator, or speech therapist; (2) Licensed…

.09 Specific Conditions for Participation — Environmental Accessibility Adaptations. To provide the services covered under Regulation .18 of this chapter, the provider shall: A. Be the store, vendor, contractor, or builder from which the adaptation is purchased; B. Be able to ins…

.10 Specific Conditions for Participation — Adult Life Planning Services. A. To provide the services covered under Regulation .19 of this chapter, the provider shall: (1) Be an individual with a bachelor’s degree; and (2) Have 3 years of full-time experience serving adults with a…

.11 Covered Services — Residential Habilitation Services. A. The Program under this regulation does not cover the following: (1) Any Medicaid State Plan services which are provided by medical professionals employed by or under contract with the residential habilitation provider; …

.12 Repealed.

.13 Repealed.

.14 Covered Services — Therapeutic Integration Services. A. Therapeutic integration services under this regulation: (1) Are provided at a nonresidential setting separate from the home or facility where the participant lives; (2) Focus on expressive therapies and therapeutic recre…

.14-1 Covered Services — Intensive Therapeutic Integration Services. A. Intensive therapeutic integration services under this regulation: (1) Are provided at a nonresidential setting separate from the home or facility where the participant lives; (2) Shall have an on-site direct …

.15 Covered Services — Intensive Individual Support Services. A. Intensive individual support services: (1) Are intensive, one-on-one interventions with the participant provided by a direct care worker; (2) May be received by the participant on a long-term basis; (3) Are authoriz…

.16 Covered Services — Respite Care. A. Respite care: (1) Shall consist of one-on-one interventions with the participant; (2) Shall be rendered by a qualified: (a) Professional who meets the qualifications in Regulation .07B of this chapter; or (b) Direct care worker who is super…

.17 Covered Services — Family Consultation. A. Family consultation shall be provided as specified in the family consultation plan, and: (1) Shall be based on family-oriented goals to benefit the participant; (2) Shall be provided to one family at a time; (3) May not include advoc…

.18 Covered Services — Environmental Accessibility Adaptations. A. Environmental accessibility adaptations are those physical adaptations to the participant's home, which are reasonable and medically necessary to: (1) Prevent the participant's institutionalization; (2) Assure: (a…

.19 Covered Services — Adult Life Planning Services. A. Adult life planning services shall be provided as specified in the adult life planning treatment plan. B. Adult life planning services shall: (1) Result in the participant's transition from Autism Waiver services to comparab…

.20 Conditions for Reimbursement. The Department shall reimburse for services under this chapter when the services are: A. Provided to a participant who meets the qualifications for eligibility specified in Regulation .02 of this chapter; B. Preauthorized in the participant's pla…

.21 Limitations. A. Reimbursement may be made by the Program only when all of the requirements of this chapter are met. B. Residential habilitation services may not be reimbursed for the same date of service as intensive individual support services, therapeutic integration servic…

.22 Payment Procedures. A. Request for Payment. (1) An approved provider shall submit requests for payment for the services covered under this chapter according to the procedures set forth in COMAR 10.09.36.04 or otherwise established by the Program. (2) The provider shall: (a) B…

.23 Recovery and Reimbursement. Recovery and reimbursement are set forth in COMAR 10.09.36.07 and include, but are not limited to: A. Providing waiver services without a valid required license or appropriate credentials as required; B. Employing staff or consultants that do not m…

.24 Cause for Suspension or Removal and Imposition of Sanctions. A. Cause for suspension or removal and imposition of sanctions is set forth in COMAR 10.09.36.08. B. In addition to the sanctions specified at COMAR 10.09.36.08, the Department may limit: (1) The number of participa…

.25 Appeal Procedures for Providers. Appeal procedures for providers are those set forth in COMAR 10.09.36.09.

.26 Appeal Procedures for Applicants and Participants. Appeal procedures for applicants and participants are those set forth in COMAR 10.09.24.13 and 10.01.04.

.27 Interpretive Regulation. State regulations are 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) “Applicant” means an entity which submits an application to become a partially capitated provider. (2) “Capitation payment” means the sum of money paid by the Program on be…

.02 Application for Qualification as a Partially Capitated Provider. A. An applicant shall demonstrate to the satisfaction of the Department that it has the managerial, financial, clinical, and administrative capability to carry out the duties required by these regulations. B. An…

.03 Conditions of Participation. A. A PCP shall meet the general conditions for participation as set forth in COMAR 10.09.36.03. B. In addition, the PCP shall: (1) Ensure that all of its employees, subcontractors, and employees of its subcontractors are appropriately licensed in …

.04 Covered Services. Providers may be capitated for one of the following packages of services subject to the approval of the Department: A. Inpatient hospital services, as long as the applicant, if regulated by the Health Services Cost Review Commission, has received permission …

.05 Enrollment and Termination of Enrollment. A. The Department shall determine the boundaries of the geographic area that a PCP may serve. The Department shall limit enrollment in a PCP to recipients who live in that area. B. The PCP is responsible for the enrollment of recipien…

.06 Marketing. A. The PCP shall specify in its provider agreement the methods by which the PCP will assure the Department that its marketing plans, procedures, and materials are accurate and do not mislead, confuse, or defraud the Department or recipients. B. The Department shall…

.07 Quality Assurance. A PCP shall maintain an internal quality assurance system based on written policies, standards, and procedures that is in accordance with accepted medical practices and professional standards and that includes, at a minimum, the following: A. A comprehensiv…

.08 Record Keeping and Reports. A. The PCP shall have an effective procedure for reporting to the Department the following information: (1) The cost of operations; (2) Patterns of utilization; (3) The health status of enrollees; (4) Information demonstrating that the PCP has a fi…

.09 Confidentiality. Subject to the requirements of 42 CFR 431F (1994), the PCP and its subcontractors may not release or disclose any information concerning an enrollee except with the written permission of the: A. Department; B. Enrollee; or C. Enrollee's attorney, legal repres…

.10 Financial Solvency. A. The PCP shall include in its provider agreement a clause that the PCP will hold harmless both the Department and its enrollees from any liability for payment for the legal obligations of the PCP. B. The PCP shall give the Department access to the PCP's …

.11 Subcontracts. A. The PCP shall ensure that the following provisions are contained in all subcontracts: (1) A description of the services to be provided by the subcontractor; (2) A description of other activities to be performed by the subcontractor; (3) Providing for release …

.12 Internal Grievance Procedure. A. The PCP shall have an internal grievance procedure which has been preapproved by the Department. The PCP shall provide a copy of its internal grievance procedures to all enrollees. B. The internal grievance procedure may: (1) Provide for the p…

.13 Payment Procedure. A. The Department shall pay a PCP a per capita capitation payment for capitated services. B. The Department shall calculate the capitation payment as a percentage of the cost to the Program of providing the same services on a fee-for-service basis to an act…