Maryland Administrative Code

.04 Application. A. The Department or its designee shall determine eligibility for a targeted low-income child and a birthing parent. B. The Department or its designee shall give oral, written, or electronic information about the separate CHIP Program and CHIP Health Services Ini…

.05 Application — Additional Requirements. A. Third-Party Liability. (1) A participant shall notify the Department or its designee within 10 working days when medical treatment has been provided as a result of a motor vehicle accident or other occurrence in which a third party mi…

.06 Nonfinancial Eligibility Requirements. A. Individuals qualifying for coverage under this section are not required to provide a Social Security number or meet satisfactory immigration status. B. Residency. To be eligible for benefits under this chapter, an individual shall be …

.07 Consideration of Household Income. A. The applicant shall report the income of any family member, except for the income of a member that does not file a federal tax return and is not claimed as a federal tax dependent. B. Determining Countable Household Income. (1) In determi…

.08 Determining Financial Eligibility. An applicant is financially eligible for the separate CHIP Program or the CHIP Health Services Initiative if, for the period under consideration, the applicant’s countable household income as determined under Regulation .07 of this chapter d…

.09 Certification Periods. A. For a targeted low-income child, certification for the separate CHIP Program begins: (1) On the first day of the month of application, no earlier than conception, and continues until the last day of the month in which the pregnancy ends; or (2) For r…

.10 Covered Services. A. A targeted low-income child certified for the separate CHIP Program is entitled to all health benefits through the Maryland Medicaid Managed Care Program. B. A birthing parent certified for the CHIP Health Services Initiative is entitled to all health ben…

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

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

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

.14 Adjustments and Recoveries. The requirements relating to adjustments and recoveries under COMAR 10.09.24.15, except for COMAR 10.09.24.15A(1) and (2), apply to this chapter.

.15 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 to Program parti…

.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Certified violence prevention professional” means a prevention professional who meets the requirements of Regulation .02 of this chapter. (2) “Community violence” means in…

.02 Certification Requirements. A. An individual rendering services under this chapter shall complete an accredited training and certification program for certified violence prevention professionals, approved by the Department. B. An accredited training and certification program …

.03 Conditions for Participation. A. General requirements for participation in the Program are that a provider shall: (1) Meet all conditions for participation as set forth in COMAR 10.09.36.03; and (2) If rendering services via telehealth, comply with COMAR 10.09.49 and any sub …

.04 Covered Services. A. Effective July 1, 2023, the Department shall reimburse for community violence prevention services as described in §B of this regulation when these services: (1) Are medically necessary; and (2) Rendered to a participant who: (a) Has been exposed to commun…

.05 Limitations. Under this chapter, the Program does not cover services: A. Following an episode of intimate partner violence or domestic violence; B. Delivered by a provider that is not affiliated with a trauma PARC, level I, or level II licensed short-term general hospital or …

.06 Payment Procedures. A. General policies governing payment procedures that are applicable to all providers are set forth in COMAR 10.09.36.04. B. The provider shall charge the Program the provider’s customary charge to the general public for similar services. If the service is…

.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Behavioral health care manager” means a nurse, clinical social worker, or psychologist working under the oversight and direction of the physician or other primary care pro…

.02 Conditions for Participation. A. A provider shall meet all conditions for participation as set forth in COMAR 10.09.36.03. B. A provider may not knowingly employ or contract with a person, partnership, or corporation which the Program has disqualified from providing or supply…

.03 Covered Services. The Program covers the following medically necessary services rendered to participants under the Collaborative Care Model: A. Care coordination and management; B. Regular, systematic monitoring and treatment using a validated clinical rating scale; C. Regula…

.04 Eligibility for Services. Eligibility for services under the Collaborative Care Model is limited to participants with a behavioral health diagnosis that is clinically appropriate for the primary care setting for which there is a validated tool to monitor symptoms and quantify…

.05 Limitations. Under this chapter, the Program does not cover the following: A. Services not specified in Regulation .03 of this chapter; B. Services not medically necessary; C. Services prohibited by the Maryland Nurse Practice Act or by the State Board of Nursing; D. Advanced…

.06 Payment Procedures. A. The provider shall submit the request for payment of services rendered according to procedures established by the Program and in the form designated by the Program. B. The Program reserves the right to return to the provider, before payment, all claims …

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

.08 Causes for Suspension or Removal and Imposition of Sanctions. Causes for suspension or removal and imposition of sanctions are 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.

.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Assistance in Community Integration Services (ACIS)” means the ACIS program, a health related social needs benefit for qualified individuals, which is implemented in accor…

.02 Conditions for Participation. A. A provider shall meet all conditions for participation as set forth in COMAR 10.09.36.03. B. A lead entity shall: (1) Have been awarded participant spaces for ACIS by the Program; and (2) Be a member of its local Continuum of Care Program.

.03 Eligibility for Services. Eligibility for ACIS services under this chapter is limited to individuals who meet the following health and housing criteria: A. The individual is a participant that uses Maryland Medical Assistance; B. The individual meets at least one of the follo…

.04 Covered Services. A. The Program shall cover the following ACIS services: (1) Compliance activities; and (2) Housing and tenancy-based case management services when three or more services, as specified in §B of this regulation, are delivered per month per participant. B. Hous…

.05 Limitations. A. Under this chapter, the Program does not cover the following: (1) Services provided to or for the primary benefit of individuals other than the participant; (2) Services rendered but not appropriately documented; and (3) Room and board. B. Providers may not bi…

.06 Payment Procedures. A. General policies governing payment procedures that are applicable to all providers are set forth in COMAR 10.09.36.04. B. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.06. C. Payments for services…

.07 Recovery and Reimbursement. Recovery and reimbursement regulations 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 are 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. Interpretive regulatory requirements shall be as set forth in COMAR 10.09.36.10.

.01 Purpose. A. The purpose of the Rare and Expensive Case Management (REM) program is to provide case management services and subspecialty care for Maryland Medicaid Managed Care Program eligible individuals with rare and expensive conditions. B. The program is designed to provi…

.02 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Activities of daily living” means tasks or activities that include but are not limited to bathing, feeding, toileting, dressing, and ambulation. (2) “Business day” means a…

.03 REM Eligibility. A. An individual is eligible to participate in the REM program if the individual: (1) Is eligible for Maryland Medicaid Managed Care as specified in COMAR 10.67.02.01; (2) Has one or more of the diagnoses specified in Regulation .17 of this chapter; and (3) E…

.04 Participant Enrollment and Disenrollment. A. Anyone may refer an individual into the REM program including, but not limited to a: (1) Family member; (2) Physician; (3) Discharge planner; (4) Hospital; (5) Clinic; (6) Social worker; and (7) Managed care organization (MCO). B. …

.05 Benefits. A REM participant is eligible for the following: A. Fee-for-service Medical Assistance benefits available to a Medical Assistance participant not enrolled in an MCO; B. Services described in Regulations .10 and .11 of this chapter when determined medically necessary…

.06 Requirements for Provider Qualification. A. A case manager providing case management under this chapter shall be: (1) An RN; or (2) A social worker. B. The following professionals providing services under this chapter to REM participants shall be licensed, certified, or other…

.07 Conditions for Participation — General Requirements. A provider rendering services pursuant to this chapter shall: A. Meet the applicable conditions for participation set forth in COMAR 10.09.36; B. Meet the provider qualification requirements specified in Regulation .06 of t…

.08 Specific Conditions for Provider Participation. A. Case Management Providers. To participate in the Program, a case management provider shall meet the conditions set forth in Regulations .06 and .07 of this chapter. B. Chiropractic Service Providers. To participate in the Pro…

.09 Covered Services — General Requirements. For participants in the REM program, the Program covers and shall reimburse for services specified in Regulations .10 and .11 of this chapter when these services are: A. Medically necessary; B. Prescribed by a: (1) Physician; (2) Physi…

.10 Covered Services. A. Chiropractic services are covered for REM participants when: (1) Services are provided to a REM participant who is 21 years old or older; (2) Services are provided by a physician or chiropractor; (3) The qualifying REM diagnosis or related illness shows d…