Maryland Administrative Code

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

.01 Purpose and Scope. A. This chapter governs the coverage of services for the Medical Assistance Family Planning Program. B. Eligibility shall be established according to COMAR 10.09.37.

.02 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Advanced practice nurse” means an individual who meets the requirements in COMAR 10.09.01. (2) “Department” means the Maryland Department of Health as defined in COMAR 10.…

.03 Licensure Requirements. A. An advanced practice nurse shall be licensed to practice as described in COMAR 10.09.01. B. A doctor of medicine or osteopath shall be licensed and legally authorized to practice medicine in the state in which the service is delivered as described i…

.04 Conditions of Participation. A. Providers shall be enrolled as Medical Assistance Program providers and shall meet the requirements for participation in the Maryland Medical Assistance Program as set forth in COMAR 10.09.36.03, as well as the requirements for participation as…

.05 Covered Services. The following services are covered under this chapter: A. Office medical visits for the primary purpose of providing age and sex appropriate family planning services, which include: (1) Focused history, physical exam, and laboratory testing necessary to eval…

.06 Limitations. A. The following services are not covered: (1) Services not medically necessary; (2) Transportation services; (3) EPSDT services; (4) Services delivered in an in-patient hospital setting or ambulatory surgical center other than: (a) Permanent sterilizations; and …

.07 Payment Procedures. A. Payment procedures are those set forth in COMAR 10.09.36.04. B. Billing time limitations are those set forth in COMAR 10.09.36.06. C. Payment procedures for advanced practice nurses are those set forth in COMAR 10.09.01.06. D. Payment procedures for phy…

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

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

.10 Appeal Procedures. The requirements related to appeal procedures under COMAR 10.09.36 and 10.09.37 apply to this chapter.

.11 Fraud and Abuse. The requirements relating to fraud and abuse under COMAR 10.09.24.14 shall apply to this chapter.

.12 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) “Administrative services organization (ASO)” means the contractor procured by the State to provide the Department with administrative support services to operate the Maryla…

.02 License Requirements. To participate in the Program, a provider shall meet the license requirements stated in COMAR 10.09.36.02.

.03 General Conditions for Provider Participation. To participate in the Program, a provider shall: A. Meet the conditions for provider participation in the Medical Assistance Program as set forth in COMAR 10.09.36.03; B. Meet the conditions for licensure and practice as set fort…

.04 Provider Requirements for Participation. A. Individual Practitioner Providers. To participate in the Program as an individual practitioner of specialty mental health services, the provider shall: (1) Be licensed and legally authorized to practice independently by the appropri…

.05 Eligibility. A. A participant is eligible for specialty mental health services if: (1) The individual meets the Department’s medical necessity criteria; and (2) The service is appropriate to the specific provider type or community-based mental health provider listed in Regula…

.06 Covered Services. A. The ASO shall reimburse the following specialty mental health services rendered to participants when authorized by the ASO: (1) Medically necessary specialty mental health services delivered by providers listed in Regulation .04 of this chapter, for which…

.07 Limitations. The Program does not cover the following: A. Services not delivered in compliance with the COMAR references listed in Regulations .04 and .05 of this chapter; B. Services not medically necessary; C. Investigational or experimental drugs and procedures; D. Special…

.08 Authorization Requirements. A. The ASO shall establish a process, through a utilization review system, for authorization of specialty mental health services. B. The ASO shall authorize services that are: (1) Medically necessary; (2) Of a type, frequency, and duration that are…

.09 Payment Procedures. A. Payment procedures shall be followed as specified in COMAR 10.09.36.04. B. A provider shall deliver and document services in accordance with Department regulations in order to receive reimbursement. C. Unless the care is free to other patients, a provid…

.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 are as set forth in COMAR 10.09.36.08.

.12 Appeal Procedures for Providers. Appeal procedures for providers are as set forth in COMAR 10.09.36.09.

.13 Appeal Rights — Denial of Services. Appeal procedures for applicants and participants are as set forth in COMAR 10.01.03 and 10.01.04.

.14 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) “Administrator” means the third party that contracts with the Department to administer the Program. (2) “Annual household income” has the meaning stated in Regulation .02B …

.02 Eligibility, Enrollment, and Disenrollment. A. To be eligible for enrollment in the Program, an individual shall: (1) Be a resident of Maryland; (2) Be a Medicare beneficiary enrolled in the Medicare Part D Voluntary Prescription Drug Benefit Program or a Medicare Advantage P…

.03 Outreach Program. A. The Department shall develop and implement an outreach program targeted at eligible individuals. B. The Department shall publicize the existence and eligibility requirements of the Program through the following entities: (1) The Department of Aging; (2) L…

.04 Administrator. A. Administrator Contract. The Administrator and the Department shall execute an Administrator contract specifying the terms under which the Administrator shall operate the Program, including but not limited to an agreement by the Administrator to: (1) Provide …

.05 Program Description Booklet. A. The Administrator shall develop a Program description booklet. B. The Program description booklet is subject to approval by the Department. C. The Program description booklet shall describe the essential features of the Program including: (1) E…

.06 Prescription Drug Benefit Subsidy. A. The Program shall: (1) Provide a prescription drug benefit subsidy, as determined by the Department, that may pay all or some of the deductibles, coinsurance payments, premiums, and copayments under the federal Medicare Part D Pharmaceuti…

.07 Contracts with Prescription Drug Plan Sponsors. A. The Department may enter into contracts with prescription drug plan sponsors who have been approved by the Centers for Medicare and Medicaid Services to offer Medicare Part D plans in the State. B. A prescription drug plan sp…

.08 Program Fund. A. The Program Fund shall include: (1) Interest and investment income attributable to the Program Fund; and (2) Money deposited to the account by a nonprofit health service plan in accordance with §C of this regulation. B. On or before April 1, 2003 and quarterl…

.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Adult Evaluation and Review Services (AERS)” means an entity within the local health department which, in accordance with the waiver, this chapter, and COMAR 10.09.30, ass…

.02 Medical Assistance Eligibility. A. Categorically Needy. An individual is eligible for waiver services as categorically needy if the individual is receiving Medical Assistance as a: (1) Recipient of Supplemental Security Income (SSI); (2) Member of a low income family with chi…

.03 Participant Eligibility. A. Medical Eligibility. (1) To be eligible for the services covered under COMAR 10.09.07, a waiver applicant or participant shall be certified by the Department or its designee as needing nursing facility services, pursuant to COMAR 10.09.10. (2) The …

.04 Waiver Eligibility. A. Based on the criteria established in Regulations .02 and .03 of this chapter, an applicant's eligibility for services under this chapter shall be established by the Department, and waiver eligibility may not begin before the latest of the following five…

.05 Annual Cap and Registry for Waiver Participation. A. For each State fiscal year beginning on July 1, the Department shall establish a cap, approved by CMS, for the number of unduplicated individuals who may receive the services covered under this chapter, based on available S…

.06 Conditions for Provider Participation. A. Conditions for provider participation are those set forth in COMAR 10.09.07. B. Providers shall maintain a service plan for each participant that includes: (1) Name, address, and telephone number of the participant; (2) Medical Assist…

.07 Covered Services. Covered services are those set forth in COMAR 10.09.07.

.08 Limitations. Limitations are those set forth in COMAR 10.09.07.

.09 Payment Procedures. Payment procedures are those set forth in COMAR 10.09.07.

.10 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.

.11 Cause for Suspension or Removal and Imposition of Sanctions. A. Cause for suspension or removal and imposition of sanctions for providers shall be in accordance with COMAR 10.09.36. B. If the Department determines that a provider has failed to accurately assess the rehabilita…

.12 Interpretive Regulation. State regulations are interpreted as set forth in COMAR 10.09.36.10.