Maryland Administrative Code

.05 Participant Eligibility — Level I — General Care Coordination. The participant as described in Regulation .03A of this chapter shall meet at least two of the following conditions: A. The participant is not linked to behavioral health, health insurance, or medical services; B.…

.06 Participant Eligibility — Level II — Moderate Care Coordination. The participant as described in Regulation .03A of this chapter shall meet three or more of the following conditions: A. The participant is not linked to behavioral health services, health insurance, or medical …

.07 Participant Eligibility — Level III — Intensive Care Coordination. A. The participant shall meet at least one of the following conditions: (1) The participant has been enrolled in the 1915(i) program for 6 months or less; (2) The participant is currently enrolled in Level I o…

.08 Conditions for Provider Participation. A. Selection of CCOs. (1) The local core service agencies shall select child and youth CCOs through a competitive procurement process, at least once every 5 years. (2) Regional CCOs may be procured at the mutual agreement of local core s…

.09 Conditions for Provider Participation — Eligibility. A. General Requirements. To be eligible to be approved as a care coordination organization, an entity shall meet all of the: (1) Conditions for participation as set forth in COMAR 10.09.36.03; and (2) Medical Assistance pro…

.10 Mental Health Case Management Care Coordination Provider Staff. CCOs are required to maintain the following positions: A. Care coordinator supervisor who: (1) Is a mental health professional with a minimum of a Master’s degree and who is licensed and legally authorized to pra…

.11 Covered Services. A. The Department shall reimburse for the care coordination services in this regulation when these services have been documented, pursuant to the requirements of this chapter, as necessary. B. Care coordination services shall be coordinated with, and may not…

.12 Covered Services — Plan of Care. A. The POC shall contain, at minimum: (1) A description of the participant’s strengths and needs; (2) The diagnosis or diagnoses established as evidence of the participant’s eligibility for services under this chapter; (3) The goals of care co…

.13 Covered Services — Child and Family Team Meetings. The CCO shall: A. Coordinate and facilitate the CFT, with CFT meetings convened as often as clinically necessary, but no less than: (1) Within 7 calendar days following a crisis event; (2) For Level I participants, every 6 mo…

.14 Covered Services — Referral and Related Activities. A. The care coordinator shall ensure that the participant or, if the participant is a minor, the minor’s parent or guardian has applied for, has access to, and is receiving the necessary services available to meet the partic…

.15 Covered Services — Monitoring and Follow-Up Activities. A. A CCO shall monitor, as per standards set forth by the Department, the activities and contacts that are considered necessary to ensure the POC is implemented and adequately addresses the participant’s needs, and inclu…

.16 Limitations. A. Care coordination services are facilitative in nature. B. A restriction may not be placed on a qualified recipient’s option to receive mental health case management services. C. Care coordination services do not restrict or otherwise affect: (1) Eligibility fo…

.17 Preauthorization. All covered services under this chapter shall be preauthorized and comply with the requirements of COMAR 10.09.59.08 and COMAR 10.09.89 for services delivered to 1915(i) participants.

.18 Payment Procedures. A. The Program shall reimburse the provider according to the requirements in this chapter and COMAR 10.09.89 for services delivered to 1915(i) participants, and the fees established under COMAR 10.21.25. B. Request for Payment. (1) A provider shall submit …

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

.20 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.

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

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

.01 Purpose and Scope. This chapter establishes requirements for the determination of presumptive eligibility by qualified hospitals effective October 1, 2014.

.02 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Applicant” means an individual who has applied for presumptive eligibility at a participating hospital. (2) “Application” means the presumptive eligibility application. (3…

.03 Requirements. A. A hospital eligible to make presumptive eligibility decisions shall: (1) Participate as a Maryland Medical Assistance Program provider in good standing; and (2) Sign an agreement prepared by the Department. B. The agreement required under §A of this regulatio…

.04 Hospital or Hospital Staff Disqualifications. A. A hospital qualified to make presumptive eligibility decisions shall: (1) Make presumptive eligibility determinations in accordance with established Departmental policies and procedures; and (2) Disqualify individual hospital e…

.05 Criteria. A. An individual, the individual’s guardian, or a representative of the individual with personal knowledge shall apply for presumptive eligibility through a participating hospital. B. An individual, the individual’s guardian, or a representative of the individual wi…

.06 Populations Eligible. Presumptive eligibility may be established for the following eligibility groups: A. Parents and other caretaker relatives whose household income is equal to or less than 133 percent of the federal poverty level; B. Pregnant women whose income is equal to…

.07 Limitations. An individual may not apply for presumptive eligibility in Maryland if the individual: A. Is currently enrolled in the Maryland Medical Assistance Program or Medicare; B. Is an incarcerated inmate in a public institution as defined in COMAR 10.09.24.05-5B; C. Had…

.08 Certification Period. A. Presumptive eligibility begins on the day the hospital determines that the individual is presumptively eligible. B. Presumptive eligibility ends on the earlier of: (1) The day in which the individual is determined eligible for Medical Assistance; or (…

.09 Presumptive Eligibility Appeal Rights. An individual or an organization does not have appeal rights for presumptive eligibility determinations.

.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Acute hospital” means an institution that provides active, short-term medical diagnosis, treatment, and care. (2) “Acute level of care” means care in which a patient is tr…

.02 License Requirements. A. In order to participate in the Program, a provider shall: (1) Be licensed as a hospital by the Department pursuant to Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland; and (2) Obtain other licenses, as set forth in COMAR 10.07.…

.03 Conditions for Participation. A. A provider shall meet all conditions for participation as set forth in COMAR 10.09.36.03. B. To participate in the Program as an acute hospital services provider, the provider shall: (1) Meet the requirements of Title XIX of the Social Securit…

.04 Covered Services. A. The Program covers the services listed in §B of this regulation according to the conditions and requirements indicated. B. The Program covers the following hospital services: (1) Medically necessary emergency services as defined in COMAR 10.09.36.01, incl…

.05 Limitations. The Program does not cover: A. Hospital services, procedures, drugs, or hospital admissions that are investigational or experimental; B. Hospital services denied by Medicare as not medically necessary; C. Inpatient admissions or outpatient visits solely for the a…

.06 Utilization Review. A. Elective Inpatient Preauthorization Reviews. (1) The hospital shall only request preauthorization for inpatient stays when such services: (a) Cannot be provided on an outpatient basis; or (b) Can only be provided in a facility that is licensed as an acu…

.07 Payment Procedures. A. Reimbursement Principles for Acute Hospitals Located in Maryland. (1) The Department will make no direct reimbursement to any State-operated hospital. The Department will claim federal fund recoveries from the U.S. Department of Health and Human Service…

.08 District of Columbia Hospital Reimbursement. A. Inpatient Services Rate Calculation. (1) A hospital in the District of Columbia shall: (a) Bill its usual and customary charges; and (b) Be reimbursed for covered services the lesser of its percentage of charges as calculated in…

.09 Submitting Cost Reports for Freestanding Acute Rehabilitation Hospitals. A. The provider shall submit to the Department or its designee, in the form prescribed, financial and statistical data within 5 months after the end of the provider’s fiscal year unless the Department gr…

.10 Cost Settlement for Freestanding Acute Rehabilitation Hospitals. A. Retrospective Cost Reimbursement for Freestanding Acute Rehabilitation Hospitals. (1) An acute rehabilitation hospital not approved by the Program for reimbursement according to HSCRC rates shall be reimburse…

.11 Recovery and Reimbursement. A. General policies governing recovery and reimbursement procedures applicable to all providers are set forth in COMAR 10.09.36.07. B. If refund of a payment as specified in §A of this regulation is not made, the Department shall reduce its current…

.12 Cause for Suspension or Removal and Imposition of Sanctions. Causes for suspension or removal and imposition of sanctions shall be as set forth in COMAR 10.09.36.08. Cross References 10.09.92.08C(5) 10.09.92.09E 10.09.92.10J

.13 Appeal Procedures. A provider filing an appeal from an administrative decision made in connection with these regulations shall do so according to COMAR 10.09.36.09.

.14 Interpretive Regulation. General policies governing the interpretive regulations 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) “Acute hospital” means an institution that provides active, short-term medical diagnosis, treatment, and care. (2) “Administrative day” means a day of medical services deli…

.02 License Requirements. A. In order to participate in the Program, a provider shall: (1) Be licensed by the Department pursuant to Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, as a hospital; and (2) Obtain any other licenses required by COMAR 10.07.…

.03 Conditions for Participation — General. A. A provider shall meet all conditions for participation as set forth in COMAR 10.09.36.03. B. To participate in the Program as a chronic hospital services provider, the provider shall: (1) Meet the requirements of Title XIX of the Soc…

.04 Specific Conditions for Provider Participation — Brain Injury Community Integration Program. A. To participate in the Program as a provider operating a brain injury community integration program, the provider shall be: (1) Accredited by the Commission on Accreditation of Reha…

.05 Covered Services. A. Chronic hospitals shall provide the following services: (1) Complex respiratory care services; (2) Complex wound care services; (3) Services for participants with multiple co-morbidities, including but not limited to services necessary to care for: (a) Ve…

.06 Limitations. The Program does not cover: A. Services for individuals who are not eligible for Medicaid; B. Services for individuals who are not medically eligible for chronic hospital services; C. Services identified by the Department or its designee as not medically necessar…