Issue Date: December 13, 2013
Volume 40 • Issue 25 • Pages 2078—2086
DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Subtitle 09 MEDICAL CARE PROGRAMS
10.09.84 Community First Choice
Authority: Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland
Notice of Proposed Action
The Secretary of Health and Mental Hygiene proposes to adopt Regulations .01—.29 under a new chapter, COMAR 10.09.84 Community First Choice.
Statement of Purpose
The purpose of this action is to implement a program covering personal assistance services, emergency back-up systems, transition services, and items that substitute for human assistance, for Medicaid-eligible individuals who require an institutional level of care.
Comparison to Federal Standards
There is a corresponding federal standard to this proposed action, but the proposed action is not more restrictive or stringent.
Estimate of Economic Impact
I. Summary of Economic Impact. Funding for Community First Choice (CFC) services in the Fiscal Year 2014 budget for the period January 1 through June 30, 2014 totals $68,598,000, including $8,231,000 in enhanced federal matching funds.
II. Types of Economic Impact.
A. On issuing agency:
B. On other State agencies:
C. On local governments:
D. On regulated industries or trade groups:
E. On other industries or trade groups:
F. Direct and indirect effects on public:
III. Assumptions. (Identified by Impact Letter and Number from Section II.)
A. The State’s 6-month appropriation for services that will be covered through the CFC program during the period January 1 through June 30, 2014, is $68,598,000 (total funds). Under the federal authority for this program, the State will claim 6% enhanced federal matching funds for these services, i.e., 56% rather than the usual 50% match. This will generate approximately $8,231,000 additional federal revenue. The State’s General Fund appropriation of $30,183,000 is unchanged.
C. Local health departments will provide nurse monitoring for CFC participants who are enrolled in a waiver program, individuals who are receiving CFC services who would otherwise be receiving only State Plan personal care services, and State Plan personal care enrollees who are not eligible for CFC. It is projected that this will total 9,909 participants, averaging 7.52 hours of service during the 6-month period, with a payment rate of $79.36 per hour, for a total of $5,917,000. Compared with the $3,013,000 they would be receiving for State Plan personal care recipients under the current monthly rate methodology, this represents an increase of $2,904,000.
D. Enhanced federal funding in the amount of $5,327,000 will pay for additional services for State Plan personal care recipients who will become eligible for CFC services.
Economic Impact on Small Businesses
The proposed action has a meaningful economic impact on small business. An analysis of this economic impact follows. Providers of many of the services covered under this program are small businesses that will benefit from the expanded coverage that will be available to individuals who are eligible for Medicaid under the State Plan.
Impact on Individuals with Disabilities
The proposed action has an impact on individuals with disabilities as follows:
The proposal establishes a new program that will expand coverage of personal assistance and related support services under the State Plan. It also creates increased opportunities for participants to self-direct their services.
Opportunity for Public Comment
Comments may be sent to Michele Phinney, Director, Office of Regulation and Policy Coordination, Department of Health and Mental Hygiene, 201 West 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 January 13, 2014. A public hearing has not been scheduled.
A. 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:
(1) Are eligible for Medicaid under:
(a) A home and community-based services waiver; or
(b) The State Plan; and
(2) Have been determined to require an institutional level of care.
B. Community First Choice is designed as a system of personal assistance that:
(1) Supports participants’ ability to direct their own services;
(2) Supports participants in the home with personal assistance and other services; and
(3) Establishes adequate rates for provider reimbursement.
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 changing clothes;
(d) 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; and
(e) Toileting, including:
(i) Bladder and bowel requirements;
(ii) Routines associated with the achievement or maintenance of continence; and
(iii) Incontinence care.
(2) “Applicant” means an individual who is applying to participate in the Program and receive services under this chapter.
(3) “Assistance” means that another person:
(a) Physically performs the activity for the participant;
(b) Physically helps the participant to perform the activity;
(c) Is present while the participant performs the activity; or
(d) Cues or encourages the participant to perform the activity.
(4) “Case management services” means services which assist an applicant or a participant in gaining access to waiver and other covered Medicaid services.
(5) “Case manager” means a person performing case management services under a waiver program and acting in the role of the supports planner.
(6) “Certified medication technician (CMT)” means an individual, regardless of title, who:
(a) Completes a 20-hour course in medication administration approved by the Maryland Board of Nursing;
(b) Is certified by the board under COMAR 10.39.04; and
(c) Performs medication administration tasks delegated by a nurse monitor in accordance with COMAR 10.27.11.
(7) “Certified nursing assistant (CNA)” means an individual, regardless of title, who:
(a) Is certified by the Maryland Board of Nursing under COMAR 10.39.01; and
(b) Routinely performs delegated nursing tasks delegated by a nurse in accordance with COMAR 10.27.11.
(8) “Community First Choice” means the Medicaid home and community-based services program implemented under this chapter in accordance with the application and any amendments to it submitted by the Department and approved by the Secretary of Health and Human Services, which authorizes the provision of certain home and community-based services under the Maryland Medical Assistance Program.
(9) “Community setting” is the area, district, locality, neighborhood, or vicinity where a group of people live.
(a) A community setting 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 include:
(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 10.22.03; or
(vi) Other institutions.
(10) “Conflict of interest” means a real or seeming incompatibility between one’s private interests and one’s public or fiduciary duties.
(11) “Delegated nursing functions” means nursing services provided to a participant by an enrolled personal assistance provider under the supervision of a registered nurse in accordance with COMAR 10.27.11 or nurse practitioner in accordance with COMAR 10.27.07.
(12) “Department” means the Maryland Department of Health and Mental Hygiene, or its authorized agent acting on behalf of the Department.
(13) “Family member” means a legally responsible relative, including:
(a) A spouse;
(b) A parent of a minor dependent child; or
(c) An individual who has full and unrestricted powers of guardianship.
(14) “Fiscal intermediary” means an agency that is under contract with the Department to provide fiscal intermediary services that provides certain services performed on behalf of the Department or the participant, or both, such as:
(a) Employer-related payroll functions, such as State and federal tax withholding, withholding of union dues, and Social Security withholding; and
(b) Verification of eligible services and providers to be reimbursed by the Program, including preauthorizations in some instances.
(15) “Home” means the participant’s place of residence in a community setting.
(16) “Individual’s representative” means a parent, family member, guardian, advocate, or other authorized representative of an individual.
(17) “Institution” means an establishment that furnishes, in single or multiple facilities, food, shelter, and some treatment or services to four or more individuals unrelated to the proprietor.
(18) “Instrumental activities of daily living (IADLs)” 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.
(19) “Local health department” means the local agency which, in accordance with COMAR 10.09.30 and this chapter:
(a) Assesses applicants;
(b) Reassesses participants at least every 12 months, or upon a significant change of health status;
(c) Participates on a multidisciplinary team to develop an applicant’s plan of care; and
(d) Participates on a multidisciplinary team to review, and revise as necessary, a participant’s plan of care at least every 12 months.
(20) “Medicaid” means the Maryland Medical Assistance Program, administered by the State of Maryland under Title XIX of the Social Security Act, which provides comprehensive medical and other health-related care for categorically eligible and medically needy participants.
(21) “Medically necessary” means that the service or benefit is:
(a) Directly related to diagnostic, preventive, 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.
(22) “Nurse” means an individual who is currently licensed to practice nursing in the State under COMAR 10.27.
(23) “Nurse monitor” means a registered nurse who assesses participants and evaluates the delivery of care.
(24) “Nursing facility” means a facility which is participating in the Maryland Medical Assistance Program as a nursing facility pursuant to COMAR 10.09.10.
(25) “Participant” means an individual who:
(a) Has been determined to meet the qualifications for participation in Community First Choice as specified in Regulation .04 of this chapter; and
(b) Is enrolled with the Department to receive Medicaid services.
(26) “Participant-employed” means a person employed by the participant who will render personal assistance services and meets requirements of Regulation .06 of this chapter.
(27) “Person-centered” means that the plan reflects what is important to the individual, what is important for his or her health and welfare, and developed with input from the individual and the individual’s representative when applicable.
(28) “Personal assistance provider agency” means a public or private agency that:
(a) Employs or contracts with personal assistance providers; and
(b) Has been enrolled by the Program as a provider of personal assistance services.
(29) Personal Assistance Services.
(a) “Personal assistance services” means assistance specific to the functional needs of a participant with a chronic illness, medical condition, or disability and includes assistance with activities of daily living and instrumental activities of daily living.
(b) “Personal assistance services” includes the performance of some delegated nursing functions.
(30) “Plan of service” means the written person-centered support plan developed by the applicant or participant with support from the supports planner and the individual’s representative, when applicable.
(31) “Preauthorization” means an approval required from the Department or its designee before services can be rendered.
(32) “Program” means the Medical Assistance Program.
(33) “Provider” has the same meaning as defined in COMAR 10.09.36.
(34) “Provider agreement” means a contract between the Department and the provider for rendering the services under this chapter.
(35) “Quality plan” means the plan developed by the Department to address quality assurance and oversight.
(36) “Recommended plan of care” means the recommended service plan developed by a nurse after a face-to-face assessment of an applicant or participant.
(37) “Self-direct” means a consumer-controlled method of selecting and providing services and supports that allows the individual maximum control of the home and community-based personal assistance services and supports, with the individual acting as the employer of record with necessary supports to perform that function, or the individual having a significant and meaningful role in the management of a provider of service when services are provided by an agency.
(38) “Supports planner” means an individual who coordinates services, including:
(a) Supporting development of a person-centered plan of service;
(b) Interacting with third parties on behalf of, or in conjunction with, the applicant or participant; and
(c) The responsibility for ensuring an accurate plan of service is provided to the Department.
(39) “Telephonic timekeeping system” means a system developed by the Department that certain providers are required to use to accurately time stamp the start and finish of services provided to a participant.
.03 Requirements for Provider Licensing or Certification.
A. 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) Licensed vocational nurses;
(5) Certified medication technicians;
(6) Certified nursing assistants;
(7) Occupational therapists;
(8) Physical therapists;
(9) Speech pathologists;
(10) Nutritionists; and
B. 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) Medical Assistance personal assistance provider under COMAR 10.09.20;
(4) A personal assistance provider who renders personal assistance services in his or her home under COMAR 10.07.14; and
(5) Nursing Referral Service Agency under COMAR 10.07.07.
.04 Participant Eligibility.
A. To be eligible for participation, a participant shall be determined by the Department to:
(1) Require the level of care provided in a hospital, nursing facility, or an intermediate care facility for individuals with intellectual disabilities; and
(2) Be eligible for the Maryland Medical Assistance Program under an eligibility group defined in COMAR 10.09.24.
B. To be eligible for participation, a participant must have an active plan of service. The plan of service shall:
(1) Be based on:
(a) The assessment and recommended plan of care; and
(b) Consultation from the applicant or participant;
(2) Address the applicant’s or participant’s needs;
(3) Specify the items and services needed to safely support the participant in the community, including:
(a) A plan for receiving personal assistance services in case of an emergency; and
(b) Specific requests for items or services that substitute for human assistance;
(4) Specify the name of the personal assistance provider or agency providing personal assistance services; and
(5) Include the signature of the participant, the individual’s representative if applicable, the supports planner, and the personal assistance provider listed within the plan of service.
C. A participant’s eligibility for services shall be re-evaluated by the Department every 12 months, or more frequently if needed due to a significant change in the participant’s condition or needs.
D. Participant eligibility shall be terminated if the participant:
(1) No longer meets the required level of care;
(2) No longer resides at home;
(3) Is without personal assistance services for 30 days;
(4) Voluntarily chooses, or the participant’s legal representative chooses on the participant’s behalf, to disenroll from the Program;
(5) Moves to another state;
(6) Is an inpatient for 30 consecutive days or more in an institutional setting, including but not limited to a chronic hospital or nursing facility; or
.05 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 policy by:
(a) Reporting incidents and complaints within 24 hours of knowledge of the event;
(b) Submitting a written report within 7 calendar days on a form designated by the Department; and
(c) Notifying the local department of social services immediately if the provider has a reason to believe that the participant has been subjected to abuse, neglect, self-neglect, or exploitation, in accordance with COMAR 07.02.16;
(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 from the participant or a participant’s representative when applicable;
(8) Submit a transition plan to the case manager or supports planner and participant or participant’s representative when applicable when suspending or terminating services;
(9) Demonstrate substantial, sustained compliance with the requirements of this chapter for at least 24 months after a cited deficiency which presented serious danger to participants’ health and safety;
(10) Verify Medicaid eligibility at the beginning of each month that services will be rendered; and
(11) Not be a Medicaid provider or principal of a Medicaid provider that has overpayments that remain due to the Department.
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) Been suspended or removed from participating as a Medicaid provider under COMAR 10.09.20;
(3) Undergone the imposition of sanctions under COMAR 10.09.36.08;
(4) Been subject to disciplinary action, including actions by the licensing board or any provider or principal of any provider agency;
(5) Been cited by a State agency for deficiencies which affect participants’ health and safety; or
(6) 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.
.06 Specific Conditions for Provider Participation — Personal Assistance Services.
A. To participate in the Program as a consumer-employed provider of personal assistance services under this chapter, unless otherwise exempted under §E of this regulation, a personal assistance provider shall:
(1) Be at least 18 years old;
(2) Be legally eligible for employment rendering personal assistance services in the State;
(3) Be able to communicate, read, write, and follow directions in English;
(4) Be currently certified by an organization recognized by the Board of Nursing to provide training in the following areas:
(a) Cardiopulmonary resuscitation; and
(b) Basic first aid;
(5) Accept instruction and training on the personal assistance services required in the participant’s plan of service from the following:
(a) The participant;
(b) The nurse monitor;
(c) The supports planner;
(d) A treating physician;
(e) Other involved professionals; and
(f) A Department representative;
(6) Be selected by the participant;
(7) Submit to a pre-employment criminal background investigation for which the prospective provider shall:
(a) Submit an application for a criminal history record check to the Criminal Justice Information System Office, Department of Public Safety and Correctional Services; and
(b) Direct the Department of Public Safety and Correctional Services to send the criminal history report to the Department;
(8) Agree to use a telephonic timekeeping system to:
(a) Document time; and
(b) Submit claims for payment.
(9) Understand and carry out the participant’s plan of service;
(10) If performing delegated nursing functions, be supervised by a nurse monitor in accordance with COMAR 10.27.11; and
(11) Before rendering services to any participant, be determined by the nurse monitor to be competent to perform any delegated nursing tasks.
B. To participate in the Program as a consumer-employed provider of personal assistance services a personal assistance provider may not:
(1) Be the participant’s family member;
(2) Have been convicted of, received a probation before judgment for, or entered a plea of nolo contendere to, a felony or any crime involving moral turpitude or theft, or have any other criminal history that indicates behavior which is potentially harmful to participants; or
(3) Be cited on the Board of Nursing Alert or any other registries with a determination of abuse, misappropriation of property, financial exploitation, or neglect.
C. An agency that provides personal assistance services shall:
(1) Employ individuals to provide personal assistance services who meet the conditions of §§A and B of this regulation;
(2) Employ a registered nurse who may delegate nursing tasks to a CNA or CMT in accordance with COMAR 10.27.09 and 10.27.11;
(3) Either provide services directly through their employees or arrange for the provision of services under the direction of the individual receiving services;
(4) Allow participants to have a significant role in the selection and dismissal of the providers of their choice, for the delivery of their specific care, and for the services and supports identified in their person-centered service plan;
(5) Be licensed as a:
(a) Residential Service Agency under COMAR 10.07.05;
(b) Home Health Agency under COMAR 10.07.10; or
(c) Nursing Referral Service Agency under COMAR 10.07.07;
(6) 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;
(7) Include in the notice to the Department the method for informing participants and representatives of its intent to close, change ownership, change location, or sell its business;
(8) Include in the notice to the Department, and inform participants and representatives, of the transition plan developed by the agency to ensure continuity of services to participants;
(9) 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 services; and
(10) Submit a Medicaid provider application to the Department if the new owner chooses to participate in the Program.
D. A consumer-employed or agency-employed provider of personal assistance services who performs delegated nursing services in accordance with COMAR 10.27.11 shall:
(1) If required to administer medications in accordance with the plan of service, be a certified medications technician; and
(2) If performing other delegated nursing functions, also be a certified nursing assistant.
(1) Subject to approval by the Department, consumer-employed providers of personal assistance services may be exempted from the qualifications of §§A(2), (4), (5), (8), and B(2) of this regulation, if:
(a) The exemption is made at the request of the participant that the provider serves; and
(b) The exemption request is submitted in a format designated by the Department.
(2) Providers that have been exempted from any qualification may only serve the participant or participants who have requested the exemption.
(3) The Department may:
(a) Grant conditional exemptions; and
(b) Revoke exemptions for cause.
F. If requested by the agency or applicant to provide personal assistance services the Department may waive the provisions of §B(2) of this regulation if the agency or applicant demonstrates that:
(1) The conviction, probation before judgment, or a plea of nolo contendere to a felony or any crime involving moral turpitude or theft was entered more than 10 years before the date of the provider application; and
(2) The criminal history does not indicate behavior that is potentially harmful to participants.
.07 Specific Conditions for Provider Participation — Supports Planning Services.
To participate in the Program as a supports planning provider under Regulation .15 of this chapter, a provider shall:
A. Be identified by the Department through a solicitation process and agree to be monitored by the Department; or
B. Be the Area Agency on Aging enrolled to provide case management services under COMAR 10.09.54.
.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 accordance with §B of this regulation;
B. Have demonstrated experience with the skill being taught; and
C. Be willing to meet at the participant’s home to provide services.
.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 which sells, rents, installs, services, or operates the device or service;
B. Provide or arrange for any installation, maintenance, training, or monitoring required for the device or system;
C. Ensure that any response center is:
(1) Responsible for monitoring and responding to a notification of an emergency by the system; and
(2) Adequately staffed 24 hours a day, 7 days a week by properly trained staff; and
D. Submit reports to the Department regarding activation and participant use no less than monthly or at a greater frequency as requested by the Department.
.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 Department;
(2) Provide or arrange for any installation, maintenance, training, or monitoring required for the proper operation of the device or system, if applicable; and
(3) Receive a referral from the participant, participant’s case manager, or supports planner, based on services preauthorized in the plan of service.
B. To participate in the Program as a provider of home-delivered meals, the provider shall:
(1) Use a cooking facility or food preparation site that has a food service license issued by the local health department, in accordance with COMAR 10.15.03, or an appropriate license from the state in which the site is located; and
(2) Be approved for each licensing renewal based on inspections performed by State sanitarians in accordance with COMAR 10.15.03, or by the licensing authority in the state in which the site is located.
C. To participate in the Program as a provider of assistive devices, equipment, or technology services, the provider shall be one of the following entities:
(1) A Program provider of disposable medical supplies and durable medical equipment under COMAR 10.09.12; or
(2) The store, vendor, organization, or company which sells or rents the equipment or system, subject to Department approval.
.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 group employing a licensed occupational therapist;
B. Receive a referral from the participant’s supports planner, based on services preauthorized in the plan of service; and
C. Document the provider’s findings and recommendations on a form approved by the Program.
.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 and Medicaid Services in accordance with §1915(b)(4) of the Social Security Act;
B. Employ or contract with registered nurses who hold a current professional license to practice in Maryland;
C. Agree to accept all referrals from the Department; and
D. Agree to be monitored by the Department.
.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 pre-approved by the Department in the participant’s plan of service, billed in accordance with the payment procedures in Regulation .24 of this chapter, and documented as necessary to prevent institutionalization.
.14 Covered Services — Personal Assistance.
A. Definition. “Unit of service” means a 15-minute increment of service that is 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 services when provided by a personal assistance provider:
(1) Assistance with activities of daily living;
(2) Delegated nursing functions if this assistance is:
(a) Specified in the participant’s plan of service; and
(b) Rendered in accordance with the Maryland Nurse Practice Act, COMAR 10.27.11, and other requirements of the Maryland Board of Nursing;
(3) Assistance with tasks requiring judgment to protect a participant from harm or neglect;
(4) Assistance with or completion of instrumental activities of daily living, provided in conjunction with the services covered under §B(1)—(3) of this regulation; and
(5) Assistance with the participant’s self-administration of medications, or administration of medications or other remedies, when ordered by a physician.
C. Personal assistance services may not include:
(1) Services rendered to anyone other than the participant or primarily for the benefit of anyone other than the participant;
(2) The cost of food or meals prepared in or delivered to the home or otherwise received in the community; or
(3) Housekeeping services, other than those incidental to services covered under §B of this regulation.
.15 Covered Services — Supports Planning.
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. 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 services; and
(4) Allow participant’s to exercise as much control as desired to select, train, supervise, schedule, determine duties, and dismiss the personal assistance provider.
C. Supports planning services include time spent by a qualified provider conducting any of the following activities:
(1) Assisting the participant in developing a person-centered plan of service in consultation with the applicant or participant and any individual requested by the participant.
(2) Assisting the participant with referral, 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;
(3) Monitoring the provision of services to determine if services are received in accordance with the plan of services;
(4) Using information technology systems developed by the Department;
(5) Coordinating with the fiscal intermediary to assist in managing budgeted resources;
(6) Providing guidance and support to help individuals self-direct their services; and
(7) Verifying the participant’s eligibility and at the beginning of each month that personal assistance services will be rendered.
.16 Covered Services — Consumer Training.
A. Definition. “Unit of service” means 15 minutes of service rendered by a qualified provider to a participant, not including the time spent by the provider:
(1) Planning, preparing, or setting up the training; or
(2) Following up after the training.
B. 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.
C. The topics covered by consumer training shall be:
(1) Targeted to the individualized needs of the participant receiving the training; and
(2) Sensitive of the educational background, culture, and general environment of the participant receiving the training.
.17 Covered Services — Personal Emergency Response Systems.
A. Definition. “Unit of service” means any of the following coverages related to a device, system, or piece of equipment covered under §B of this regulation:
(1) Purchase and installation;
(2) Monthly cost of a covered system or rented device or equipment, including monitoring, maintenance, and repair.
B. A personal emergency response system is an electronic device or system which enables a participant to secure help in an emergency and may include but is not limited to:
(1) A device connected to the participant’s telephone or other device and programmed to signal, upon activation of a help button, a response center with properly trained staff on duty 24 hours a day, 7 days a week;
(2) A portable help button to allow for the participant’s mobility; and
(3) A motion detector when necessary for the participant’s safety.
.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.
B. Each item or service shall:
(1) Be preauthorized in the participant’s plan of service as necessary to:
(a) Prevent the participant’s institutionalization or hospitalization; and
(b) Ensure the participant’s health, safety, and independence;
(2) Specifically relate to ADLs or IADLs within the approved plan of service;
(3) Comply with policies and procedure guidance defined by the Department;
(4) Meet necessary standards of manufacture, design, usage, and installation, if applicable;
(5) Be provided in accordance with applicable State and local building codes and pass required inspections, if applicable; and
(6) Not be prescribed primarily to provide comfort or convenience.
C. Each item or service shall be confirmed by the Program as not covered for the participant by:
(1) Medicaid under the State Plan as durable medical equipment or pharmacy services under COMAR 10.09.03, 10.09.12, or 10.09.67;
(2) Medicare; or
(3) Any other third-party payer.
D. Excluded from coverage under this regulation are adaptations or improvements to the home which:
(1) Are of general maintenance, such as carpeting, roof repair, and central air conditioning;
(2) Are not of direct medical or remedial benefit to the participant;
(3) Add to the home’s total square footage; or
(4) Modify the exterior of the home, other than the provision of ramps.
.19 Covered Services — Environmental Assessments.
A. Definition. “Unit of service” means the completion of an on-site environmental assessment of a home or residence where the participant lives or will live as a participant.
B. An environmental assessment may not be provided before the effective date of the participant’s eligibility for services.
C. The service may be recommended by a multidisciplinary team in the plan of service for a participant when an environmental assessment is considered necessary to:
(1) Ensure the health and safety of a participant with special environmental needs; and
(2) Obtain additional professional advice from an occupational therapist about the:
(a) Physical structure of a participant’s home or residence; and
(b) Functional or mental limitations or disabilities of a participant as they relate to the environment.
D. Included in the environmental assessment, as necessary, may be:
(1) An evaluation of the presence and likely progression of a disability or a chronic illness or condition in a participant;
(2) Environmental factors in the facility or home;
(3) The participant’s ability to perform activities of daily living;
(4) The participant’s strength, range of motion, and endurance; and
(5) The participant’s need for assistive devices and equipment.
E. Based on an inspection of the home and interviews with the participant and any individual requested by the participant, the provider shall complete a form, to be reviewed by the supports planner, which details the provider’s findings and recommendations, especially relating to a participant’s need for services.
.20 Covered Services — Nurse Monitoring.
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. The program covers the following services when provided by a nurse monitor:
(1) Developing provider instructions for personal assistance;
(2) Instructing the individual providing personal assistance services concerning the services required under the participant’s provider instructions, and about conditions which should be brought to the attention of the supports planner, nurse monitor, or personal physician;
(3) Availability to give instruction and to answer questions;
(4) Complying with the Department’s reportable events policy; and
(5) Maintaining an up-to-date client profile in an electronic database designated by the Department.
C. The Program covers nurse monitoring services according to the following schedule:
(1) Contact with the participant for the purpose of reviewing participant status at a minimum of every 6 months with at least one in-person home or workplace visit every 12 months; and
(2) Additional nurse monitoring services in accordance with COMAR 10.27.09 and 10.27.11 at a frequency established in conjunction with the participant, and the representative when applicable, based on the participant’s medical condition or clinical status.
D. Home and Workplace Visits.
(1) The nurse monitoring provider shall use the home or workplace visit for the following purposes:
(a) To assess the participant’s condition;
(b) To delegate nursing tasks to a CNA or CMT in accordance with COMAR 10.27.09 and 10.27.11;
(c) To assess the quality of personal assistance services;
(d) To provide instruction and training to the individual providing personal assistance services; and
(e) To determine the need for discharge from personal assistance services or referral to other services.
(2) The nurse monitor shall assess the quality of personal assistance services by:
(a) Reviewing the provider instructions;
(b) Observing the interactions and relationship between the participant and the individual providing personal assistance services;
(c) Observing the performance of the individual providing personal assistance services; and
(d) Evaluating the performance of individuals to whom nursing tasks have been delegated.
.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 provider-owned residence to a home or community-based residence.
B. Transition services may include all or some of the following:
(1) Security deposits;
(2) Essential furnishings and moving expenses;
(3) Set-up fees or deposits for utility services; and
(4) Other health and safety assurances.
C. Transition services may not include recreational items including, but not limited to:
(2) Cable television access; or
(3) Gaming systems.
.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 in order to:
(1) Prevent the applicant’s or participant’s admission to an institution;
(2) Safely transition the applicant or participant from an institution, such as a nursing facility, into the community; or
(3) 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; and
E. Is provided by a Medicaid provider who meets the conditions for participation under this chapter.
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 safety.
B. The Department shall establish a budget for personal assistance services that may be included in the participant’s plan of services, based upon each participant’s assessment of need.
C. The Program does not cover the following services:
(1) Service primarily for the purpose of housekeeping or unrelated to the participant’s activities of daily living, such as:
(a) Cleaning of floor and furniture in areas not occupied by the participant;
(b) Laundry other than that incidental to services for the participant; and
(c) Shopping for groceries or household items unless in the company of the participant;
(2) Services provided by providers not approved for participation by the Department;
(3) Expenses incurred while escorting participants:
(a) To obtain medical diagnosis or treatment;
(b) To or from the participant’s workplace; or
(c) For participation in social or community activities;
(4) Expenses related to room and board for either the participant or the personal assistance provider.
A. Request for Payment — Personal Assistance Services. To receive payment as a provider of personal assistance services under Regulation .14 of this chapter, a provider shall use the telephonic timekeeping system approved by the Department to:
(1) Document time; and
(2) Submit claims.
B. Request for Payment — All Other Covered Services. To receive payment as a provider of services covered under Regulations .15—.21 of this chapter, a provider shall submit claims in accordance with procedures outlined in the Department’s billing manual.
C. Billing time limitations are set forth in COMAR 10.09.36.06.
(1) Payments for services rendered to a participant shall be made:
(a) Directly to a qualified provider; or
(b) Through a fiscal intermediary who shall:
(i) Verify that expenditures are allowable according to a participant’s plan of service and budget; and
(ii) Deduct fees and taxes as appropriate;
(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.
.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 COMAR 10.09.36.09.
.28 Appeal Procedures — Applicants and Participants.
Appeal procedures for applicants and participants are those set forth in:
A. COMAR 10.09.24.13; and
.29 Interpretive Regulation.
Interpretive regulatory requirements shall be as set forth in COMAR 10.09.36.10.
JOSHUA M. SHARFSTEIN, M.D.
Secretary of Health and Mental Hygiene