Maryland Administrative Code

.46 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) “Department” means the Maryland Department of Health, the single State agency designated to administer the Maryland Medical Assistance Program under Title XIX of the Social…

.02 License Requirements. In order to participate in the Program, the provider shall: A. Meet all requirements as set forth in COMAR 10.09.36.02; and B. Ensure that Clinical Laboratory Improvement Amendments (CLIA) certification exists for all clinical laboratory services perform…

.03 Conditions for Participation. A. To participate in the Program, a provider shall meet all conditions for participation as set forth in COMAR 10.09.36.03. B. Specific requirements for participation with the Department as a provider-based outpatient oncology facility require th…

.04 Covered Services. The Program covers the following services when medically necessary: A. Radiation therapy; B. Chemotherapy; C. IV Infusion; D. Blood transfusions; E. Medical supplies; F. Drugs; and G. Bone marrow biopsies.

.05 Limitations. The following services are not covered: A. Any service or treatment that is not medically necessary; B. Experimental or investigational services; C. Services that are specifically included as part of another service; and D. Professional fees provided by physician…

.06 Payment Procedures. A. General policies for payment procedures that are applicable to all providers are set forth in COMAR 10.09.36.04. B. Specific Payment Procedures for a Provider-Based Outpatient Oncology Facility. (1) The provider shall submit a request for payment on the…

.07 Recovery and Reimbursement. A. If the recipient has insurance, or if any other person is obligated either legally or contractually to pay for or to reimburse for any service covered by this chapter, the provider shall seek payment from that source first. If an insurance carri…

.08 Cause for Suspension or Removal and Imposition of Sanctions. General policies governing cause for suspension or removal and imposing sanctions that are applicable to all providers are set forth in COMAR 10.09.36.08.

.09 Appeal Procedures. General policies governing appeal procedures that are applicable to all providers are set forth in COMAR 10.09.36.09.

.10 Interpretive Regulation. General policies governing the interpretive regulations that are applicable to all providers are 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) “Claim” means a demand for payment, whether or not the right is reduced to judgment, liquidated, unliquidated, fixed, contingent, matured, unmatured, disputed, undisputed, …

.02 Program’s Right of Subrogation. A. The Department may not pay medical claims that are payable by a third party. B. The Department is assigned any and all rights to payments by any third party that result from medical care received by the recipient, together with the rights of…

.03 Recipient Responsibility. A. A recipient shall cooperate with and assist the Department in identifying and providing information concerning third parties who may be liable to pay for care and services received by the recipient under the Program. B. A recipient is required to …

.04 Notice to the Department. A. An attorney representing a recipient in a cause of action that gives rise to the Department’s right of subrogation under Regulation .02 of this chapter shall notify the Program’s Division of Recoveries and Financial Services in writing before: (1)…

.05 Judgment, Award, or Settlement of a Medical Assistance Claim. A. Except as provided in §§B—E of this regulation, a third party shall have no further liability if it settles or compromises a dispute in good faith and without knowledge that the individual is a recipient of Prog…

.06 Program Claim. A. In a case where the Department is subrogated to the rights of the recipient, the Department has a claim to the proceeds of the recovery from the persons liable, whether the proceeds of the recovery are by way of judgment, settlement, or otherwise and shall, …

.07 Conflict with Federal Requirements. If any provision of this chapter related to subrogation, assignment, or lien conflicts with federal law concerning the Program or receipt of federal funds to finance the Program, the provision does not apply to the extent of the conflict.

.01 Purpose. The purpose of Community First Choice is to provide certain home and community-based services and supports, as an alternative to institutional placements, to individuals who have been determined to require an institutional level of care.

.02 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Activities of daily living (ADLs)” means tasks or activities that include, but are not limited to: (a) Bathing and completing personal hygiene routines; (b) Dressing and c…

.03 Requirements for Provider Licensing or Certification. The following health professionals providing services under this chapter shall be licensed to practice in the jurisdiction in which services are rendered: A. Physicians; B. Registered nurses; C. Licensed practical nurses; …

.04 Participant Eligibility. A. To participate in the Program, a participant shall: (1) Be determined by the Department to need the level of care provided in a hospital, nursing facility, an intermediate care facility for individuals with intellectual disabilities, an institution…

.05 Conditions for Provider Participation — General Requirements. A. To participate as a provider of a service covered under this chapter, a provider: (1) Shall meet all of the conditions for participation as a Medicaid provider as set forth in COMAR 10.09.36, except as otherwise…

.06 Specific Conditions for Provider Participation — Personal Assistance. A. Personal assistance service providers shall: (1) Be licensed as a Residential Service Agency under COMAR 10.07.05 to provide Level Two or Level Three home care services; (2) Employ a registered nurse who…

.07 Specific Conditions for Provider Participation — Supports Planning. To participate in the Program as a supports planning provider under Regulation .15 of this chapter, a provider shall: A. Agree to be monitored by the Department; and B. Be: (1) Identified by the Department th…

.08 Specific Conditions for Provider Participation — Consumer Training. To participate in the Program as a provider of consumer training under Regulation .16 of this chapter, a provider shall: A. Be a self-employed trainer or an agency that employs qualified trainers in accordanc…

.09 Specific Conditions for Provider Participation — Personal Emergency Response Systems. To participate in the Program as a provider of personal emergency response systems under Regulation .17 of this chapter, a provider shall: A. Be the store, vendor, organization, or company w…

.10 Specific Conditions for Provider Participation — Items or Services that Substitute for Human Assistance. A. To participate in the program as a provider of items or services that substitute for human assistance, the provider shall: (1) Be approved and monitored by the Departme…

.11 Specific Conditions for Provider Participation — Environmental Assessments. To participate in the Program as a provider of environmental assessments under Regulation .19 of this chapter, the provider shall: A. Be a licensed occupational therapist, or an agency or professional…

.12 Specific Conditions for Provider Participation — Nurse Monitoring. To participate in the Program as a nurse monitoring provider under Regulation .20 of this chapter, a provider shall: A. Be designated by the Department through a process approved by the Centers for Medicare an…

.13 Covered Services — General. The Program shall reimburse for the services specified in Regulations .14—.21 of this chapter, when, pursuant to the requirements of this chapter, these services have been preauthorized by the Department in the participant’s plan of service, billed…

.14 Covered Services — Personal Assistance. A. The Program covers personal assistance services that are approved in the plan of service and rendered to a participant by a qualified provider in the participant’s home or a community setting. B. The Program covers the following serv…

.15 Covered Services — Supports Planning. A. Supports planning services shall: (1) Address the individualized needs of the participant; (2) Be sensitive to the educational background, culture, and general environment of the participant; (3) Support the participant to self-direct …

.16 Covered Services — Consumer Training. A. Consumer training includes instruction and skill building in such areas including, but not limited to, acquisition, maintenance, and enhancement of skills necessary for the participant to accomplish ADLs and IADLs. B. The topics covere…

.17 Covered Services — Personal Emergency Response Systems. A. The Program covers the following related to a device, system, or piece of equipment described under §B of this regulation: (1) Purchase and installation; (2) Monthly cost of a covered system or rented device or equipm…

.18 Covered Services — Items or Services that Substitute for Human Assistance. A. The program covers items or services that increase a participant’s independence or substitute for human assistance, to the extent that expenditures would otherwise be made for the human assistance. …

.19 Covered Services — Environmental Assessments and Adaptations. A. The Program covers an on-site environmental assessment and adaptations of a home or residence where the participant lives or will live as a participant. B. An environmental assessment or adaptation may not be pr…

.20 Covered Services — Nurse Monitoring. A. The program covers the following services when provided by a nurse monitor: (1) Being available to give instruction and to answer questions; (2) Complying with the Department’s reportable events policy; and (3) Maintaining an up-to-date…

.21 Covered Services § Transition Services. A. Definition. “Transition service” means a service that is: (1) Not otherwise available under the Program; (2) Approved in the plan of service; and (3) Rendered to assist the participant in transitioning from an institution or a provid…

.22 Conditions for Reimbursement. The Program shall reimburse for the services specified in Regulations .14—.21 of this chapter, if provided in accordance with the requirements of this chapter and if the service: A. Is recommended on the participant’s plan of service as necessary…

.23 Limitations. A. Reimbursement for Personal Emergency Response System is limited to participants who: (1) Live alone; or (2) Have no regular caregiver for extended parts of the day and would otherwise require extensive routine supervision to ensure the participant’s health and…

.24 Payment Procedures. A. Request for Payment — Personal Assistance. To receive payment as a personal assistance provider agency under Regulation .14 of this chapter, a provider and its workers shall use the telephonic timekeeping system approved by the Department to: (1) Docume…

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

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

.27 Appeal Procedures — Providers. Appeal procedures shall be as set forth in: A. COMAR 10.09.36.09; and B. COMAR 10.01.03.

.28 Appeal Procedures — Applicants and Participants. Appeal procedures for applicants and participants are those set forth in: A. COMAR 10.09.24.13; and B. COMAR 10.01.04.

.29 Interpretive Regulation. Interpretive regulatory requirements shall be as set forth in COMAR 10.09.36.10.