Issue Date: January 24, 2014
Volume 41 • Issue 2 • Pages 120—127
DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Subtitle 09 MEDICAL CARE PROGRAMS
Notice of Proposed Action
The Secretary of Health and Mental Hygiene proposes to:
(1) Repeal existing Regulations .01—.37 and adopt new Regulations .01—.27 under COMAR 10.09.54 Home and Community-Based Options Waiver; and
(2) Repeal in their entirety existing Regulations .01—.34 under COMAR 10.09.55 Living at Home Waiver Program.
Statement of Purpose
The purpose of this action is to remove services that will be covered under a new State Plan program, COMAR 10.09.84 Community First Choice, and to implement the Home and Community-Based Options Waiver to include all remaining services and cover all participants previously eligible for services under the Home/Community Based Services Waiver for Older Adults and the Living at Home Waiver Program under a single program. The proposed action is to be effective January 6, 2014.
Comparison to Federal Standards
There is no corresponding federal standard to this proposed action.
Estimate of Economic Impact
The proposed action has no economic impact.
Economic Impact on Small Businesses
The proposed action has minimal or no economic impact on small businesses.
Impact on Individuals with Disabilities
The proposed action has an impact on individuals with disabilities as follows:
The proposed action will help to ensure that individuals with disabilities continue to receive waiver services from qualified providers.
Opportunity for Public Comment
Comments may be sent to Michele A. Phinney, Director, Office of Regulation and Policy Coordination, Department of Health and Mental Hygiene, 201 W. Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499 (TTY 800-735-2258), or email to firstname.lastname@example.org, or fax to 410-767-6483. Comments will be accepted through February 24, 2014. A public hearing has not been scheduled.
10.09.54 [Home/Community Based Services Waiver for Older Adults] Home and Community-Based Options Waiver
Authority: Health-General Article, §§2-104(b), 15-103, 15-105, and 15-132, Annotated Code of Maryland
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:
(a) Bathing and completing personal hygiene routines;
(b) Dressing and changing clothes;
(d) Toileting, including:
(i) Bladder and bowel requirements;
(ii) Routines associated with the achievement or maintenance of continence; and
(iii) Incontinence care;
(e) Mobility, including:
(i) Transferring from a bed, chair, or other structure;
(ii) Moving, turning, and positioning the body while in bed or in a wheelchair; and
(iii) Moving about indoors or outdoors.
(2) "Area agency" has the meaning stated in Human Services Article, §10-101(b), Annotated Code of Maryland.
(3) "Assisted living services provider" means a provider licensed by the Department in accordance with COMAR 10.07.14.
(4) "Case management" means services which assist an applicant or a participant in gaining access to the waiver services covered under this chapter, as well as to other services under the Medical Assistance Program.
(5) "Case manager" means an individual performing case management services under a waiver program.
(6) Community Setting.
(a) “Community setting” means the area, district, locality, neighborhood, or vicinity where a group of people live which provides participants with opportunities to:
(i) Seek employment and work in competitive integrated settings;
(ii) Engage in community life;
(iii) Control personal resources; and
(iv) Receive services.
(b) "Community setting" does not mean:
(ii) Nursing facilities;
(iii) Institutions for mental diseases;
(iv) Intermediate care facilities for individuals with intellectual disabilities;
(v) Community-based residential facilities for individuals with intellectual or developmental disabilities licensed under COMAR 10.22.02;
(vii) Residential treatment centers; or
(viii) Any establishment that furnishes food, shelter, and some treatment or services to four or more persons unrelated to the proprietor.
(7) "Department" means the Maryland Department of Health and Mental Hygiene, or its authorized agent acting on behalf of the Department.
(8) "Family member" means an adult who:
(a) Lives with or provides care to the participant; and
(b) Is not paid to provide the care.
(9) “Home” means the participant's place of residence in a community setting.
(10) “Home and Community-Based Options Waiver” means the program implemented under this chapter in accordance with the document for this waiver and any amendments to it submitted by the Department and approved by the Secretary of Health and Human Services, which authorizes the waiver of certain specified statutory requirements limiting coverage for home and community-based services under the Maryland Medical Assistance Program.
(11) “Instrumental activities of daily living” means tasks or activities that include, but are not limited to:
(a) Preparing meals;
(b) Performing light chores that are incidental to the personal assistance services provided to the participant;
(c) Shopping for groceries;
(d) Nutritional planning;
(e) Traveling as needed;
(f) Managing finances and handling money;
(g) Using the telephone or other appropriate means of communication;
(h) Reading; and
(i) Planning and making decisions.
(12) "Maryland Department of Aging" has the meaning stated in Human Services Article, Title 10, Annotated Code of Maryland.
(13) "Medicaid" means the Medical Assistance Program.
(14) "Medical Assistance Program" means the Program administered by Maryland under Title XIX of the Social Security Act, which provides comprehensive medical and other health-related care for categorically eligible and medically needy recipients.
(15) "Medical day care" means a program of medically supervised, health-related services provided in an ambulatory setting to medically handicapped adults who, due to their degree of impairment, need health maintenance and restorative services supportive to their community living in accordance with COMAR 10.09.07.
(16) "Medically necessary" means that the service or benefit is:
(a) Directly related to diagnostic, preventative, curative, ameliorative, palliative or rehabilitative treatment of an illness, injury, disability, or health condition;
(b) Consistent with current accepted standards of good medical practice;
(c) The most cost efficient service that can be provided without sacrificing effectiveness or access to care; and
(d) Not primarily for the convenience of the participant, the participant’s family, or the provider.
(17) "Nursing facility" means a facility which is participating in the Maryland Medical Assistance Program as a nursing facility pursuant to COMAR 10.09.10.
(18) "Participant" means an individual who:
(a) Has been determined to meet the qualifications for participation in the waiver as specified in Regulation .03 of this chapter; and
(b) Is enrolled with the Department to receive Medicaid services.
(19) “Person-centered” means that the plan reflects what is important to the individual, what is important for his or her health and welfare, and is developed with input from the individual and the individual’s representative when applicable.
(20) "Plan of service" means the written, person-centered support plan developed by the applicant or participant with support from the case manager and the individual’s representative, when applicable.
(21) “Principal” means a person who:
(a) Has a direct or indirect ownership or control interest of 5 percent or more in the provider;
(b) Is an officer, director, agent, or managing employee of the entity; or
(c) Was described in §B(20)(a) of this regulation, but is no longer so described because of a transfer of ownership or control interest to an immediate family member or a member of the household of the person who continues to maintain an interest described in §B(20)(a) of this regulation.
(22) “Program” means the Medical Assistance Program.
(23) "Provider" has the same meaning stated in COMAR 10.09.36.
(24) "Provider agreement" means a contract between the Department and the provider for rendering the services under this chapter.
(25) "Recipient" means an individual who is certified by the Department as eligible for, and is receiving, Medical Assistance benefits.
(26) "Reportable event " means an allegation of, or an actual occurrence of, an incident that may pose an immediate or serious risk, or has potential to adversely affect the physical or mental health, safety, or well-being of a waiver applicant or participant, or complaints regarding administrative service or quality of care issues.
(27) "Room and board" means rent or mortgage, utilities, maintenance, furnishings, and food, which are provided in or associated with an individual's place of residence.
(28) "State Plan" means a comprehensive, written commitment by a State Medicaid agency, submitted under §1902(a) of the Social Security Act, to administer or supervise the administration of the Medical Assistance Program in accordance with federal requirements.
(29) "Waiver applicant" means an individual who is applying for participation in the waiver, to receive the services covered under this chapter.
(30) "Waiver" means the Home and Community-Based Options Waiver as implemented through this chapter.
.02 Licensing and Certification Requirements.
A. Assisted living services providers shall be licensed by the Department in accordance with COMAR 10.07.14.
B. The following health professionals providing services under this chapter shall be licensed to practice in the jurisdiction in which services are rendered:
(2) Registered nurses;
(3) Licensed practical nurses;
(4) Occupational therapists;
(5) Physical therapists;
(8) Social workers; and
C. The following shall be appropriately licensed, certified, or approved by the Department to provide services under this chapter:
(1) Licensed home health agency under COMAR 10.09.04;
(2) Certified residential services agency under COMAR 10.07.05;
(3) Nursing facility under COMAR 10.07.02; and
(4) Medical day care center under COMAR 10.09.07.
.03 Participant Eligibility.
A. General Requirements.
(1) To be eligible for participation, an individual shall be determined by the Department to meet the conditions of §§B—E of this regulation.
(2) Eligibility for waiver services shall be reevaluated every 12 months or more frequently if needed due to a significant change in the participant’s condition, needs, or financial status.
B. Technical Eligibility. To be eligible for services covered under this chapter, an applicant or participant shall be determined by the Department to meet the technical eligibility criteria if the individual:
(1) Has been determined by the Department to need a nursing facility level of care;
(2) Is at least 18 years old;
(3) Is not simultaneously enrolled for services covered under:
(a) Another Medicaid waiver program under the authority of §1915(c) of the Social Security Act; or
(b) The Program of All-Inclusive Care for the Elderly (PACE);
(4) Has an active plan of service that:
(a) Is based on:
(i) The assessment and recommended plan of care; and
(ii) Consultation with the applicant or participant;
(b) Addresses the applicant’s or participant’s needs;
(c) Specifies the names of service providers;
(d) Is cost neutral, which is determined by adding annualized costs of services covered under this chapter and any other State Plan services which are not covered for nursing facility residents, and ensuring that the resulting amount is not more than 125 percent of the Program's average per capita-annualized-net payments for nursing facility services. Any assessed participant contributions will not be considered in determining cost neutrality; and
(e) Includes the signature of the participant, the individual’s representative if applicable, and the case manager listed within the plan of service;
(5) Is offered the choice between waiver services and nursing facility services;
(6) Chooses to receive waiver services;
(7) Resides in a home, as defined under Regulation .02B of this chapter; and
(8) Uses at least one waiver service within a 12-month period.
C. Medical Assistance Eligibility.
(1) An individual is not eligible to receive waiver services during a penalty period imposed under COMAR 10.09.24.08-1 or 10.09.24.08-2 due to disposal of assets.
(2) All provisions of COMAR 10.09.24 which are applicable to aged, blind, or disabled institutionalized persons are applicable to waiver applicants and participants, with the following exceptions:
(a) COMAR 10.09.24.04J(1)—(3);
(b) COMAR 10.09.24.06B(2)(a)(ii);
(c) COMAR 10.09.24.08G;
(d) COMAR 10.09.24.10C;
(e) COMAR 10.09.24.10D(4) — (6);
(f) COMAR 10.09.24.10-1C(3)(a); and
(g) COMAR 10.09.24.15A-2(2).
D. Cost of Care.
(1) For a participant whose home is an assisted living facility, the Department shall reduce its monthly payment for assisted living services by the amount remaining after deducting from the individual's total nonexcluded monthly income the following amounts in the following order:
(a) A personal needs allowance, consisting of the amount established in accordance with COMAR 10.09.24.10D(2)(c) and the assisted living provider's charge, not exceeding $420 per month, for room and board;
(b) A spousal or family maintenance allowance, or both, if applicable, in accordance with COMAR 10.09.24.10-1C(3)(b) and (c); and
(c) Incurred medical expenses in accordance with COMAR 10.09.24.10D(2)(f)—(h).
(2) The Department shall determine the amount of available income to be paid by a participant towards the cost of assisted living services.
(3) The participant shall pay the amount of available income for the participant’s cost of care, and the assisted living provider’s monthly charge for room and board, directly to the assisted living services provider.
E. Waiver Eligibility. Based on the criteria established in §§A—C of this regulation an applicant's eligibility for services under this chapter shall be established by the Department based on the following policies for the effective date of waiver eligibility:
(1) No retroactive eligibility; and
(2) Waiver eligibility may not begin before the latest of the following five dates:
(a) Waiver application date;
(b) Effective date of medical certification for the waiver's institutional level of care;
(c) Date that the applicant's written waiver plan of service is established, which shall include at least one waiver service and may be a provisional plan for not more than the first 60 days of waiver enrollment;
(d) Date that the applicant or representative signed a form designated by the Department to indicate the choice of waiver services as an alternative to institutionalization; and
(e) Date of the applicant's discharge from institutionalization in a long term care facility, if applicable.
F. Annual Cap and Registry for Waiver Participation.
(1) The Department shall establish an annual cap, approved by the federal Centers for Medicare and Medicaid Services (CMS), for the number of unduplicated individuals who may receive the services covered under this chapter, based on available State and federal funding.
(2) Eligible individuals shall be enrolled in the waiver on a first-come, first-served basis until the annual cap on waiver participation is reached.
(3) Once the annual cap on waiver participation is reached:
(a) A registry list shall be established for individuals interested in applying for waiver services;
(b) Individuals on the registry shall have an opportunity to apply for the waiver in accordance with procedures established by the Department; and
(c) The Department and CMS may authorize increasing the waiver cap if the Department determines that sufficient Program funds are available to reimburse the services recommended in the individual's plan of service and the participant's other Program services for the remainder of the State fiscal year.
(5) Individuals in nursing facilities who are receiving Medicaid services for at least 30 days may apply directly for the waiver without being put on the registry list.
G. Termination of Participation.
(1) A participant shall be terminated from participation in the waiver if the participant:
(a) No longer meets the eligibility requirements specified in §§B—E of this regulation;
(b) Voluntarily chooses, or the participant’s authorized representative chooses on the participant’s behalf, to disenroll from the waiver program;
(c) Moves to another state;
(d) Is an inpatient for 30 consecutive days or more in a hospital or nursing facility; or
(2) If an individual is terminated from the waiver, the same individual may re-enter the waiver during the same waiver year, or within 90 days of termination contingent on waiver capacity, provided that the individual meets all of the eligibility requirements of the waiver.
.04 Conditions for Provider Participation—General Requirements.
A. To participate as a provider of a service covered under this chapter a provider shall:
(1) Meet all of the conditions for participation as a Maryland Medical Assistance Program provider as set forth in COMAR 10.09.36, except as otherwise specified in this chapter;
(2) Verify the qualifications of all individuals who render services on the provider’s behalf, and provide a copy of the current license or credentials upon request;
(3) Implement the reporting and follow-up of incidents and complaints in accordance with the Department’s established reportable events policy;
(4) Agree to cooperate with required inspections, reviews, and audits by authorized governmental representatives;
(5) Agree to provide services, and to subsequently bill the Department in accordance with the reimbursement methodology specified in this chapter for only those services covered under this chapter which have been:
(a) Pre-approved in the participant's plan of service;
(b) Provided in a manner consistent with the participant's plan of service; and
(c) Identified in the provider agreement as within the scope of the provider's Medicaid participation;
(6) Agree to maintain and have available written documentation of services, including dates and hours of services provided to participants, for a period of 6 years, in a manner approved by the Department;
(7) Agree not to suspend, terminate, increase, or reduce services for an individual without authorization from the Department and with consultation and agreement by the participant or a participant’s representative when applicable;
(8) Submit a transition plan to the case manager and participant or participant’s representative when applicable when suspending or terminating services;
(9) Verify Medicaid eligibility at the beginning of each month that services will be rendered;
(10) Not be a Medicaid provider or principal of a Medicaid provider that has overpayments that remain due to the Department;
(11) Notify the Department in writing at least 45 days in advance of any:
(a) Voluntary closure;
(b) Change of ownership;
(c) Change of location;
(d) Sale of the business;
(e) Change in the name under which the provider is doing business; or
(f) Change in provider tax identification number;
(12) Include in the notice to the Department regarding any change of status under §A(11) of this regulation, the method for informing waiver participants and representatives of its intent to close, change ownership, change location, or sell its business;
(13) Apply for a new license if applicable, whenever ownership is to be transferred from the person or organization named on the license to another person or organization in time to assure continuity of waiver services; and
(14) Submit a Medicaid provider application to the Department if the new owner chooses to participate in the waiver program.
B. To participate as a provider of a service covered under this chapter, a provider or its principals may not, within the past 24 months, have:
(1) Had a license or certificate suspended or revoked as a health care provider, health care facility, or provider of direct care services;
(2) Undergone the imposition of sanctions under COMAR 10.09.36.08;
(3) Been subject to disciplinary action, including actions by the licensing board, that indicate behavior which is potentially harmful to participants;
(4) Been cited by a State agency for deficiencies which affect participants’ health and safety; or
(5) Experienced a termination of a Medicaid provider agreement or been barred from work or participation by a public or private agency due to:
(a) Failure to meet contractual obligations; or
(b) Fraudulent billing practices.
C. A provider who renders health-related services to participants shall agree to:
(1) Periodically indicate the condition of a participant in accordance with the procedures and forms designated by the Department; and
(2) Share and discuss the documented information at the request of the participant.
.05 Specific Conditions for Provider Participation—Assisted Living.
A. To participate in the program as a provider of assisted living services under this chapter a provider shall:
(1) Be licensed by the Department at the time that services are rendered, in accordance with COMAR 10.07.14, to provide assisted living services;
(2) Be or employ a manager who is qualified as:
(a) A licensed physician;
(b) A licensed registered nurse;
(c) A licensed practical nurse; or
(d) An individual with at least 3 years’ experience in direct patient care in a private home, certified home, or health-related facility;
(3) Employ an alternate assisted living manager who meets the requirements as specified in §A(2) of this regulation.
(4) Have at least one staff person per eight residents on duty at all times during daytime hours, and have a staff-to-resident ratio at night which is adequate to provide the required services and maintain the facility in a safe and orderly condition, with additional staffing if required by the Department depending on residents' functional levels;
(5) Participate in training on the waiver billing process and other waiver requirements, as specified by the Department;
(6) Have the appropriate insurance coverage to cover the provider and its employees and vehicles if the provider chooses to transport participants to medical, social, recreational, and other services;
(7) Cooperate with other service providers and quality assurance monitors by:
(a) Facilitating on-site visits of authorized quality assurance monitors to review compliance with waiver and regulatory requirements;
(b) Facilitating a case manager's on-site visits to the facility, which shall occur at least quarterly, to review the facility, regulatory compliance, service provision, and participants' status and needs;
(c) Communicating with a participant's case manager concerning the participant's status, needs, and service provision;
(d) Informing the case manager within 1 working day of any significant change in the participant's status and service needs;
(e) Facilitating, as necessary and appropriate, the delivery of authorized waiver and State Plan services in the plan of service; and
(f) Facilitating waiver participant's relocation to comparable housing, if necessary, including transfer of all personal belongings and financial arrangements; and
(8) Submit claims consistent with the provisions of Regulation .22 of this chapter.
B. Bed Reservations. If bed reservations are offered to participants who are absent from an assisted living facility, the bed reservations policy shall:
(1) Be provided to all residents and, where appropriate, the resident's representative, at admission;
(2) Be fairly and consistently applied to all residents;
(3) Specify that the bed reservation service is not a Medicaid covered service;
(4) Clearly state that it is the resident's decision whether to reserve the bed; and
(5) Specify that the charges to participants for bed reservation days may not exceed the full Medicaid waiver per diem rate.
C. An assisted living provider may limit waiver participation to a designated unit or units only if approved by Department and the facility resident agreement contains the following provisions:
(1) The facility's participation in the Program is limited to one or more designated units and, in order to access Medicaid waiver benefits, the resident shall reside in a designated unit;
(2) A resident of a designated unit has a right to apply for the waiver at any time and access waiver benefits without restrictions by the provider when the resident is found eligible by the Program; and
(3) A resident not in a designated unit who is otherwise eligible or seeking eligibility for the waiver shall be given first consideration and, with all other factors equal, first priority in admission to a vacant bed in a designated unit.
.06 Specific Conditions for Provider Participation—Behavior Consultation.
To participate in the program as a provider of behavior consultation services under this chapter a provider shall:
(1) A health services agency that:
(a) Employs a qualified individual or individuals to render behavior consultation services; and
(b) Assures supervision of the individual rendering behavior consultation services by a licensed mental health professional or by a bachelor's level nurse with 4 years of experience or with an appropriate graduate degree; or
(2) An individual who is:
(a) Qualified to render behavior consultation services; and
(b) Licensed to practice independently;
B. Assure that the individual who renders behavior consultation services:
(1) Is a licensed:
(a) Registered nurse;
(b) Psychologist; or
(c) Clinical social worker; and
(a) Direct experience working with adults with behavioral problems; and
(b) Demonstrated ability to perform assessments; and
C. Assure response within 24 hours to a referral from a participant's case manager for behavior consultation services.
.07 Specific Conditions for Provider Participation—Senior Center Plus.
To participate in the program as a provider of Senior Center Plus services under this chapter a provider shall:
A. Be approved and monitored by the Maryland Department of Aging as a nutrition service provider;
B. Meet all local and State requirements to operate as a nutrition site, which include but are not limited to inspection and approval of the facility by the local fire marshal, periodic fire drills, and inspection and approval by the local sanitarian to assure compliance with health department requirements for food service facilities;
C. Assure that the facility provides an accessible environment, in compliance with the Americans with Disabilities Act (ADA), 28 CFR Part 36;
D. Maintain adequate records on participants, including progress notes and outcomes;
E. Provide at least one staff person per eight clients, with additional staffing if required by the Maryland Department of Aging depending on participants' functional levels;
F. Employ as the center's manager or in another staff position an individual who:
(1) Is a licensed health professional or a licensed social worker;
(2) Has at least 3 years’ experience in direct patient care at an adult day care center, nursing facility, or health-related facility; and
(3) Participates in training specified and approved by the Maryland Department of Aging;
G. Provide Senior Center Plus services to participants at least 4 hours a day, 1 or more days a week on a regularly scheduled basis, in an out-of-home, outpatient setting;
H. Serve at least one nutritional meal per day that:
(1) Is prepared in a licensed food service establishment;
(2) Meets at least 1/3 of the daily recommended dietary allowance; and
(3) Does not constitute a full nutritional regimen of three meals per day;
I. Serve snacks, as desired by the participants, when the day program exceeds 6 hours; and
J. Have menus reviewed and approved quarterly by a registered dietitian for nutritional adequacy.
.08 Specific Conditions for Provider Participation—Family Training.
To participate in the Program as a provider of family training under this chapter a provider shall:
A. Be a self-employed trainer or an agency that employs qualified trainers in accordance with §§B—D of this regulation;
B. Have demonstrated experience with the skill being taught;
C. Be willing to meet at the participant's home to provide services; and
D. Employ licensed registered nurses, occupational therapists, physical therapists, or social workers who are appropriately experienced and licensed to provide the needed training.
.09 Specific Conditions for Provider Participation—Dietitian and Nutritionist Services.
To participate in the program as a provider of dietitian and nutritionist services under this chapter a provider shall be a:
A. Dietitian or nutritionist who is licensed in accordance with COMAR 10.56.01 and Health Occupations Article, Title 5, Annotated Code of Maryland; or
B. Professional group or agency which employs an individual who is licensed in accordance with §A of this regulation.
.10 Specific Conditions for Provider Participation—Medical Day Care Services.
To participate in the program as a provider of medical day care services under this chapter a provider shall:
A. Meet the licensure requirements as provided in COMAR 10.12.04; and
B. Meet the requirements of COMAR 10.09.07.
.11 Specific Conditions for Provider Participation—Case Management Services.
To participate in the program as a provider of case management services under this chapter a provider shall:
A. Be an area agency or other entity designated by the Department through a process approved by the Centers for Medicare and Medicaid Services in accordance with §1915(b)(4) of the Social Security Act; and
B. Agree to be monitored by the Department.
.12 Covered Services—General.
The Program shall reimburse for the services specified in Regulations .13—.19 of this chapter when, pursuant to the requirements of this chapter, these services have been pre-approved by the Department in the participant’s plan of service, and billed in accordance with the payment procedures in Regulation .22 of this chapter.
.13 Covered Services—Assisted Living Services.
A. Definition. "Unit of service" means a day of service.
B. Assisted living services shall include the provision of:
(1) A structured, supportive environment in a home-like setting;
(2) Personal assistance and chore services including:
(a) Assisting the participant, as necessary, with performing activities of daily living and instrumental activities of daily living, including cuing the participant to perform these activities;
(b) Routine housekeeping, laundry, household care, and chore services needed to maintain the facility as a clean, sanitary, and safe environment; and
(c) Menu planning, food shopping, and meal preparation and serving;
(3) Basic personal hygiene supplies, including but not limited to:
(b) Bathroom tissue;
(c) Paper towels;
(e) Toothbrush; and
(4) 24-hour supervision of participants to assure health and safety;
(5) Assistance with medication administration, in accordance with COMAR 10.27.11 and COMAR 10.07.14;
(6) Recreational and social activities of a nontherapeutic and nonhabilitative nature which are confined to the assisted living facility and are for the purpose of socialization;
(7) Reminding the participant of medical appointments;
(8) Assistance with transportation arrangements to needed services;
(9) Conferring with the participant's case manager about the participant's status and service needs, as necessary;
(10) Assisting the participant in accessing needed medical or mental health services in emergency situations; and
(11) Other services specified for assisted living programs in COMAR 10.07.14.
C. The living environment and service provision shall reflect participants' individualized needs and preferences.
D. Assisted living services reimbursed under this chapter may not include room and board.
.14 Covered Services—Behavior Consultation Services.
A. Definition. "Unit of service" means an hour of service that is approved in the plan of service and rendered to a participant by a qualified provider, not including:
(1) The time spent on related activities before or after the home visit; or
(2) The provider's time spent on any supervisory or consultative services provided to the renderer of services.
B. A provider may bill for the length of a home visit to a participant, upon completion of the services specified in §D of this regulation.
C. Behavior consultation services may be preauthorized by a participant's plan of service when:
(1) A participant or the participant’s representative request the service due to an identified behavioral issue; or
(2) The participant’s behavior is:
(a) Potentially dangerous to the participant's or another person's health and functioning; or
(b) Placing the participant at risk of institutionalization due to health and safety concerns.
D. Behavior consultation services include a:
(1) Home visit by an individual qualified to render services to:
(a) Evaluate a participant's behavior;
(b) Assess the situation;
(c) Determine the contributing factors; and
(d) Recommend interventions and treatments;
(2) Written report with the results of the provider’s assessment and recommendations to be reviewed by the participant, the participant’s representative and family when applicable, and the participant’s case manager and caregivers, which may include an assisted living provider; and
(3) Verbal review of the report with the participant, the participant’s representative and family when applicable, and the participant’s case manager and caregivers, which may include an assisted living provider, to discuss:
(a) The report's findings and recommendations; and
(b) A course of action, including any related needed medical interventions.
.15 Covered Services—Senior Center Plus.
A. Definition. "Unit of service" means a day of attendance by a participant for at least 4 hours, not including transportation to and from the center.
B. Senior Center Plus services include a program of structured group recreational activities, supervised care, assistance with activities of daily living and instrumental activities of daily living, and enhanced socialization provided in an out-of-home, outpatient setting. Social and recreational activities designed for elderly, disabled individuals, as well as one nutritious meal shall be available at the center.
C. This program is designed to promote the participants' optimal functioning and to have a positive impact on the participants' orientation and cognitive ability.
D. A provider may choose to provide transportation to and from the site of the Senior Center Plus services. These transportation services may:
(1) Not be included in the provider's daily rate negotiated with the Maryland Department of Aging; and
(2) Be reimbursed through some other funding source for transportation services.
E. This service does not cover:
(2) Direct health care; or
(3) A full regimen of three meals per day.
.16 Covered Services—Family Training.
A. Definition. "Unit of service" means an hour of service that is approved in the plan of service and rendered to a family member by a qualified provider, not including the time spent planning, preparing, setting up or following up after the training.
B. The training and counseling services may not include services rendered:
(1) On a group basis or in a classroom setting; or
(2) To a family member of a participant residing in a licensed assisted living facility.
C. The topics covered by the training and counseling services shall be:
(1) Targeted to the individualized needs of the family member receiving the training, as related to the participant's needs;
(2) Sensitive to the educational background, culture, and general environment of the participant or family member receiving the training; and
(3) Specified in the plan of service as necessary to:
(a) Ensure the participant's health and safety; and
(b) Prevent the participant's institutionalization.
D. The training and counseling services may include:
(1) Instruction on treatment regimens and dementia;
(2) Use of equipment specified in the plan of service;
(3) Other issues; or
(4) Follow-up training as authorized.
.17 Covered Services—Dietitian and Nutritionist Services.
A. Definition. "Unit of service" means an hour of service that is approved in the plan of service and rendered to a participant by a qualified provider.
B. Dietitian and nutritionist services shall include:
(1) The provision of nutrition care plan outcomes and approaches;
(2) Nutrition care planning, nutrition assessment, and dietetic instruction; and
(3) Services within the scope of practice of the nutritionist's or dietitian's license, as defined by:
(a) Health Occupations Article, Title V, Annotated Code of Maryland; and
(b) Regulations under COMAR 10.56 for the Board of Dietetic Practice.
C. Dietitian and nutritionist services may not include services rendered:
(1) On a group basis or in a classroom setting; or
(2) To participants residing in a licensed assisted living facility.
D. The services shall be:
(1) Covered if the participant's medical condition requires the judgment, knowledge, and skills of a licensed nutritionist or licensed dietitian;
(2) Targeted to the individualized needs of the participant, rather than being of general interest;
(3) Sensitive to the educational background, culture, religion, eating habits and preferences, and general environment of the participant; and
(4) Specified in the participant's plan of service as necessary to:
(a) Ensure the participant's health and safety; and
(b) Prevent the participant's institutionalization or hospitalization.
.18 Covered Services—Medical Day Care Services.
A. Definition. "Unit of service" means a day of care in which the participant is certified present at the medical day care center a minimum of 4 hours.
B. Medical day care services shall be provided in accordance with COMAR 10.09.07.
.19 Covered Services—Case Management Services.
A. Definition. "Unit of service" means a 15-minute increment of service that is approved by the Department and rendered to a participant by a qualified provider.
B. Case management services shall be targeted to address the individualized needs of the participant and be sensitive to the educational background, culture, and general environment of the participant.
C. Case management services include time spent by a qualified provider conducting any of the following activities:
(1) Assisting with the initial or annual waiver eligibility process;
(2) Assisting with the application and supporting the individual in maintaining all public and private benefits, resources, and entitlements;
(3) Conducting an assessment of needs, and developing a person-centered plan of service, to include all services needed to live safely in the community;
(4) Assisting the participant with referrals, access, and coordination of services, both Medicaid and non-Medicaid, to address the participant’s needs including, but not limited to:
(a) Behavioral health;
(b) Educational services;
(c) Disposable medical supplies and durable medical equipment;
(e) Medical services; and
(f) Social services;
(5) Monitoring the provision of services to determine if services are received in accordance with the plan of services;
(6) Facilitating referrals to other programs if the individual is denied waiver services; and
(7) Using information technology systems developed by the Department.
.20 Conditions for Reimbursement.
The Program shall reimburse for the services specified in Regulations .13—.19 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 in order to:
(1) Prevent the applicant’s or participant’s admission to an institution; or
(2) Assure the health and safety of an applicant or participant in the community;
B. Has been pre-approved by the Department in the participant’s plan of service;
C. Is provided to an enrolled participant;
D. Is medically necessary;
E. Is provided by a Medicaid provider who meets the conditions for participation under this chapter; and
F. Is cost-neutral for the Program, which is determined by adding annualized costs of services covered under this chapter and any other State Plan services which are not covered for nursing facility residents, and ensuring that the resulting amount is not more than:
(1) 125 percent of the Program's average per capita-annualized-net payments for nursing facility services for a waiver participant in accordance with the provisions of Regulation .03B(4)(d) of this chapter; and
(2) In the aggregate for all waiver participants, 100 percent of the Program’s average per capita-annualized-net payments for nursing facility services.
A. Reimbursement may be made by the Program only when the requirements of this chapter are met.
B. The Program may not reimburse the following combinations of services for a participant for the same date of service:
(1) Senior Center Plus and Medical Day Care under this chapter; or
(2) Assisted living services under this chapter and personal assistance services under COMAR 10.09.20 or COMAR 10.09.84.
.22 Payment Procedures.
A. Request for Payment. To receive payment as a provider of services covered under Regulations .13—.19 of this chapter, a provider shall submit claims in accordance with procedures outlined in the Department’s billing manual.
B. Billing time limitations for the services covered under this chapter are set forth in COMAR 10.09.36.06.
(1) Payments shall be made directly to a qualified provider.
(2) Providers shall be paid the lesser of:
(a) Their usual and customary charge to the general public; or
(b) The rate established according to the fee schedule published by the Department.
(1) The Department shall publish a fee schedule for services covered under this chapter which shall be publicly available and updated at least annually or upon any changes made by the Department.
(2) The Program’s rates as specified in the Department’s fee schedule shall increase on July 1 of each year, subject to the limitations of the State budget, by the lesser of:
(a) 2.5 percent; or
(b) The percentage of the annual increase in the March Consumer Price Index for All Urban Consumers, all items component, Washington-Baltimore, from U.S. Department of Labor, Bureau of Labor Statistics.
.23 Recovery and Reimbursement.
Recovery and reimbursement are as set forth in COMAR 10.09.36.07.
.24 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.
.25 Appeal Procedures.
Appeal procedures are those set forth in COMAR 10.09.36.09.
.26 Interpretive Regulation.
State regulations are interpreted as set forth in COMAR 10.09.36.10.
.27 Implementation Date.
This chapter shall be implemented January 6, 2014.
JOSHUA M. SHARFSTEIN, M.D.
Secretary of Health and Mental Hygiene