PROPOSAL
Maryland Register
Issue Date: December 23, 2016
Volume 43 • Issue 26 • Pages 1464—1487
Title 10
DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Subtitle 09 MEDICAL CARE PROGRAMS
Notice of Proposed Action
[16-332-P]
The Secretary of Health and Mental Hygiene proposes to:
(1) Repeal Regulations .01—.18 under COMAR 10.09.06 Hospital Services;
(2) Adopt new Regulations .01—.14 under a new chapter, COMAR 10.09.92 Acute Hospitals;
(3) Adopt new Regulations .01—.16 under a new chapter, COMAR 10.09.93 Chronic Hospitals;
(4) Adopt new Regulations .01—.13 under a new chapter, COMAR 10.09.94 Special Pediatric Hospitals; and
(5) Adopt new Regulations .01—.13 under a new chapter, COMAR 10.09.95 Special Psychiatric Hospitals.
Statement of Purpose
The purpose of this action is to replace in its entirety the Hospital Services chapter and create separate chapters for Acute, Chronic, Special Pediatric and Special Psychiatric Hospitals, respectively.
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 no impact on individuals with disabilities.
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 dhmh.regs@maryland.gov, or fax to 410-767-6483. Comments will be accepted through January 23, 2017. A public hearing has not been scheduled.
Authority: Health-General Article, §§2-104(b), 15-102.8, 15-103, and 15-105, Annotated Code of Maryland
.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 treated:
(a) For a brief but severe episode of illness, for conditions that are the result of disease or trauma; and
(b) During recovery from surgery.
(3) “Acute rehabilitation hospital” means an institution devoted to therapy that is designed to facilitate the process of recovery from illness or injury for patients with various neurological, muscular-skeletal, orthopedic, and other medical conditions following stabilization of acute medical issues.
(4) “Administrative day” means a day of medical services delivered to a participant who no longer requires an acute level of care.
(5) “Administrative services organization (ASO)” means an organization with which the Department contracts to assist in the management and operation of the Maryland Public Behavioral Health System.
(6) “Admission” means the formal acceptance by a hospital of a participant who is to be provided with room, board, and medically necessary services in an area of the hospital where patients stay at least overnight.
(7) “Ancillary services” means diagnostic and therapeutic services, including but not limited to radiology, laboratory tests, pharmacy, and physical therapy services, provided exclusive of room and board.
(8) “Concurrent review” means a periodic reauthorization of continued medical eligibility for the level of services provided in an acute hospital which allows for close monitoring of the participant’s progress, treatment goals, and objectives during an inpatient hospitalization.
(9) “Date of service” means:
(a) For inpatient hospitalizations, the date of admission into an acute hospital up to, but not including, the date of discharge;
(b) For outpatient services, the date services are rendered in the outpatient department of the hospital;
(c) For emergency services, the date or dates the services are rendered in the emergency department of an acute hospital; or
(d) For observation services, the date or dates the services are rendered in an acute hospital.
(10) “Department” means the Maryland Department of Health and Mental Hygiene, which is the single State agency designated to administer the Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.
(11) “Designee” means any entity designated to act on behalf of the Department.
(12) “Diagnosis-related group” means a participant classification system adopted by the U.S. Department of Health and Human Services, in which each hospital discharge case is assigned a category based on the primary diagnosis, secondary diagnoses (if any), procedures performed, age, sex, and discharge status of the participant.
(13) “Electronic signature” means a secure electronic identification of an individual who authorizes an electronic record or transaction.
(14) “Emergency department” means the area in a hospital that is designed, staffed, and equipped to provide prompt treatment to individuals requiring immediate medical care for acute illness, trauma, and other medical conditions.
(15) “Emergency services” means any health care service provided to evaluate and treat any medical condition where immediate, unscheduled medical care is required.
(16) “Emergent condition” means a disease, illness, or injury characterized by sudden onset and symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in:
(a) Placing the participant’s health or, with respect to a pregnant woman, the health of the woman or unborn child in serious jeopardy;
(b) Serious impairment of bodily functions; or
(c) Serious dysfunction of any bodily organ or part.
(17) “Freestanding medical facility” means a facility:
(a) In which medical and health services are provided;
(b) That is physically separate from a hospital or hospital grounds; and
(c) That is an administrative part of a hospital or related institution.
(18) “Health Services Cost Review Commission (HSCRC)” means the independent organization within the Department of Health and Mental Hygiene which is responsible for reviewing and approving rates for hospitals pursuant to Health-General Article, Title 19, Subtitle 2, Annotated Code of Maryland.
(19) “Maryland Medical Assistance Program” means the program of comprehensive medical and other health-related care for indigent and medically indigent individuals.
(20) “Medically necessary” means that the service or benefit is:
(a) Directly related to diagnostic, preventative, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;
(b) Consistent with 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, family, or provider.
(21) “Medicare” means the medical insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq.
(22) “Nonqualified alien” means a foreign-born resident who:
(a) Is not a naturalized U.S. citizen; and
(b) Is eligible for federal Medical Assistance coverage of only emergency medical services, as specified under COMAR 10.09.24.05-2A.
(23) “Observation services” means the medically necessary services used to assess the participant’s outpatient condition to determine the need for possible admission to an inpatient acute care setting.
(24) “Organ” means a part of an organism that is typically self-contained and has a specific vital function, such as a heart or liver.
(25) “Out-of-State hospital” means any hospital outside of Maryland, except for hospitals located in the District of Columbia.
(26) “Outpatient services” means nonemergency services provided to the participant on the hospital campus that do not require hospital admission.
(27) “Participant” means an individual who is enrolled with the Department to receive Medical Assistance services.
(28) “Patient” means an individual awaiting or undergoing health care or treatment.
(29) “Preauthorization” means the approval required from the Department or its designee before a service can be rendered by the provider and reimbursed.
(30) “Preoperative day” means an inpatient day in an acute hospital before:
(a) Surgery for a participant who is being admitted for surgery; or
(b) A surgical procedure when the participant was admitted for a nonsurgical procedure but the need for surgery arose during that stay.
(31) “Program” means the Maryland Medical Assistance Program.
(32) “Prospective payment system” means a predetermined amount of reimbursement per day for inpatient hospital services.
(33) “Provider” means an acute hospital which, through agreement with the Department, has been identified as a Program provider by the issuance of a provider number.
(34) “Retrospective review” means the process of determining medical necessity of an inpatient admission after the participant has been discharged from the hospital.
(35) “Specialty behavioral health” means services as defined in COMAR 10.09.70.02D and F.
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 10.07.01.
B. The provider shall ensure that Clinical Laboratory Improvement Amendments (CLIA) certification exists for all clinical laboratory services performed, and:
(a) Health-General Article, Title 17, Subtitles 2 and 3, Annotated Code of Maryland; and
(b) COMAR 10.10.01; or
(2) If located out-of-State, comply with:
(a) All applicable standards established by the state or locality in which the service is provided; and
(b) The requirements of COMAR 10.09.09.02.
.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 Security Act for participation as a hospital, as issued by the Department of Health and Human Services;
(2) Directly provide or make available through contractual arrangements or transfer agreements, medically necessary covered services;
(3) Accept payment by the Program as payment in full for the covered service;
(4) Make available to the Department or its designee the participant’s medical record for review and certification of medical necessity for admission and continuation of stay;
(5) Maintain documentation of each contact with the participant as part of the complete medical record, which, at a minimum, includes:
(a) Date of service;
(b) The participant’s chief medical complaint or reason for visit;
(c) A description of the services provided, including:
(i) Progress notes;
(ii) Imaging studies;
(iii) Laboratory results;
(iv) Medication administration records; and
(v) Discharge summary; and
(d) A signature, electronic or handwritten, along with the printed or typed name of the individual providing care, with the appropriate title; and
(6) If the hospital provider is the only hospital within the county, participate with each participating HealthChoice Managed Care Organization in the county.
C. If an out-of-State or District of Columbia hospital, the hospital shall:
(1) Unless a waiver has been granted by the Secretary of Health and Human Services, have in effect a utilization review plan applicable to all participants who receive Medical Assistance under Title XVII of the Social Security Act which meets the requirements of §1861(k) of the Social Security Act; and
(2) Comply with applicable regulations of this chapter and COMAR 10.09.36.
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, including triage, related ancillary services, and when necessary, observation stays of a participant who presents to a hospital emergency department;
(2) Medically necessary services performed in an outpatient department of a hospital;
(3) Medically necessary services performed at a freestanding medical facility;
(4) Medically necessary inpatient hospital services meeting the following criteria:
(a) Inpatient days, including preoperative days, determined to be medically necessary by the Department or its designee;
(b) Admissions from an emergency department resulting in a medically necessary inpatient stay; and
(c) Elective admissions that the Department or its designee determines to be medically necessary;
(5) Inpatient stays determined to be medically necessary due to an emergent condition by the Department or its designee for a nonqualified alien;
(6) Administrative days determined to be necessary by the Department or its designee; and
(7) Medically necessary services performed in an acute rehabilitation hospital when the participant meets the following criteria at the time of admission:
(a) Requires active and ongoing therapeutic intervention of multiple therapy disciplines, one of which shall be physical or occupational therapy;
(b) Requires and can reasonably be expected to actively participate in, and benefit from, the therapy, which generally consists of:
(i) At least 3 hours of therapy a day, at least 5 days a week; or
(ii) In well-documented cases, at least 15 hours of intensive rehabilitation therapy within a 7 day consecutive period;
(c) Is sufficiently stable to be able to actively participate in the therapy program; and
(d) Requires supervision by a licensed physician, who has specialized training and experience in inpatient rehabilitation, which includes:
(i) Conducting face-to-face visits with the patient at least 3 days a week to assess the patient both medically and functionally; and
(ii) Modifying the course of treatment as needed to maximize the participant’s capacity to benefit from the rehabilitation process.
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 administration of injections, unless medical necessity and the participant’s inability to take appropriate oral medications is documented in the participant’s medical record;
D. Elective inpatient admissions without preauthorization;
E. Elective inpatient admissions from the emergency department for dialysis services that are the result of problems occurring with placement in a freestanding dialysis facility;
F. Outpatient visits for one or more of the following:
(1) Prescription drug or food supplement pick up;
(2) Collection of specimens for laboratory procedures;
(3) Recording of an electrocardiogram;
(4) Ascertaining the participant’s weight; and
(5) Administration of vaccines;
G. Interpretation of laboratory tests or panels;
H. Autopsies;
I. Weight control medications;
J. Care provided to a well newborn beyond the:
(1) Length of the mother’s stay for a normal obstetrical or uncomplicated caesarean section delivery; or
(2) First 4 days of the newborn’s life when the mother remains in the hospital due to other circumstances;
K. Telephones, televisions, or personal comfort items or services;
L. Duplicate care or services;
M. Elective admissions to hospitals outside of Maryland, except the District of Columbia, unless the Department or its designee determines that comparable services are not available in Maryland;
N. Inpatient and outpatient diagnostic and laboratory services not ordered by the attending physician or other practitioner;
O. Inpatient days provided in excess of the days approved by the Department or its designee;
P. Hospital laboratory tests which are coverable under COMAR 10.09.09, unless the specimen is obtained in the hospital for a participant receiving inpatient, outpatient, emergency department, or observation services; and
Q. Hospital services provided outside of the United States.
.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 acute hospital.
(2) The hospital shall obtain preauthorization for elective inpatient admissions from the Department or its designee, before the participant is admitted, by providing the following information including, but not limited to:
(a) Participant’s medical history and physical;
(b) Doctor’s progress notes; and
(c) Sufficient clinical information or documentation that supports the medical necessity of the acute inpatient admission.
B. Concurrent Reviews.
(1) As long as the participant remains hospitalized, the Department or its designee shall perform concurrent reviews based on the participant’s diagnosis and medical condition.
(2) For emergency inpatient admissions that exceed more than 24 hours, the concurrent review process shall be initiated by the hospital within the first 48 hours of the admission, or by the next business day.
(3) For elective inpatient admissions, the hospital shall initiate the concurrent review process before the termination of days previously certified by the Department or its designee.
(4) The hospital shall forward sufficient clinical documentation to the Department or its designee that supports the need for continuing acute care. Documentation submitted shall include, but is not limited to:
(a) Current medical health status;
(b) Treatment received to date; and
(c) A proposed treatment plan for the continued stay.
C. Retrospective Reviews.
(1) The hospital shall request that the Department or its designee perform a retrospective review of an inpatient admission after the participant is discharged, to determine the medical necessity of the admission and stay.
(2) The hospital shall provide the following to the Department or its designee when requesting a retrospective review following discharge from an acute hospital. Documentation submitted shall include, but is not limited to:
(a) The participant’s complete medical record;
(b) The principal, secondary, and tertiary diagnoses; and
(c) All surgical procedure codes.
D. Reviews for Nonqualified Aliens. The Department or its designee reviews the admission and discharge summary of an emergency inpatient admission for a nonqualified alien to determine whether the inpatient hospital stay meets the emergent condition criteria as defined in COMAR 10.09.24.05-2A.
E. Reviews for Behavioral Health. The hospital shall contact the behavioral health ASO to request an authorization for all inpatient admissions that are described in COMAR 10.09.70.02D and F.
.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 Services for services to participants in State-operated hospitals.
(2) Acute hospitals located in Maryland that participate in the Program, shall charge the rates approved by the HSCRC and be reimbursed 94 percent pursuant to COMAR 10.37.10, except for administrative days.
(3) If the Program discontinues using rates which have been approved by HSCRC, the Program shall reimburse providers:
(a) According to Medicare standards and principles for retrospective cost reimbursement described in 42 CFR §413; or
(b) On the basis of charges if less than reasonable cost.
(4) The Department may not reimburse for the services of a hospital’s salaried or contractual physicians as a separate line item. Charges for these services should be included in the room and board rate or the appropriate ancillary service only, when HSCRC has included these salaries in the hospital’s costs.
(5) The Program shall reimburse room and board charges from the day of admission up to, but not including, the date of discharge from the hospital.
(6) The provider shall submit a request for payment according to procedures established by the Department.
(7) The Program reserves the right to return to the provider any invoice that is not properly completed.
(8) Payments on Medicare claims are authorized if:
(a) The provider accepts Medicare assignment;
(b) Medicare makes a direct payment to the provider;
(c) Medicare determined that services are medically necessary;
(d) The services are covered by the Program; and
(e) Initial billing is made directly to Medicare according to Medicare guidelines.
(9) The Department shall make a supplemental payment on Medicare claims as follows:
(a) Deductible and co-insurance shall be paid in accordance with the limits of this regulation; and
(b) Hospitals shall be paid subject to the HSCRC discounts, except in the case of a participant receiving hospital services in an out-of-State facility, in which case the deductible and co-insurance shall be paid in full.
(10) The provider shall not bill the Department or participant for:
(a) Completion of forms and reports;
(b) Broken or missed appointments;
(c) Services rendered by mail, telephone, or otherwise not in person, with the exception of telehealth services in accordance with COMAR 10.09.49; and
(d) Providing a copy of a participant’s medical record, when requested by another licensed provider on behalf of the participant.
(11) Billing time limitations are set forth in COMAR 10.09.36.06.
(12) Freestanding medical facilities are reimbursed by the Department at the rate set for the freestanding facility by HSCRC.
B. Reimbursement Principles for Out-of-State Hospitals.
(1) For hospitals outside of Maryland, excluding the District of Columbia, claims reflecting dates of service on or after October 1, 2009, shall be reimbursed at a rate that is 100 percent of the amount reimbursable by the host state’s Title XIX agency or the amount of the hospital’s actual charges in total, whichever is less.
(2) Out-of-State providers are responsible for reimbursing the Department or its designee for overpayments, in accordance with COMAR 10.09.36.07.
C. Reimbursement Principles for Administrative Days.
(1) The hospital shall be paid for administrative days that are requested at the time of retrospective review and that are authorized by the Department or its designee after review of the:
(a) Clinical documentation;
(b) Discharge plan indicating that the hospital was seeking placement for the participant on the administrative days requested; and
(c) Documentation that was submitted to the Department on the authorized form that shows placement activity occurred on each day claimed as an administrative day.
(2) To be paid for administrative days, for participants who are not ventilator dependent, the reimbursement amount shall be an estimated Statewide average of the Program nursing home payment rate as determined by the Department.
(3) A hospital is not eligible for administrative day reimbursement if the days have already been billed as acute days.
D. Reimbursement Principles for Freestanding Acute Rehabilitation Hospitals. For freestanding acute rehabilitation hospitals not approved by the Program for reimbursement according to HSCRC rates, the Department shall reimburse these hospitals using a prospective payment system.
.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 §A(2) of this regulation or its charges.
(2) The percentage of charges in §A(1) of this regulation is the product of the following:
(a) The cost-to-charges percentage using only those costs of the hospital reported in the hospital’s most recent cost report as determined by the Program or its designee;
(b) The lesser of 100 percent or the cost-to-charge projection percentage which is:
(i) The hospital’s cost-to-charge ratio in its most recent cost report trended by its cost-to-charge ratio in the 2 prior years’ cost reports or, if 3 years of data are not available, the hospital’s cost-to-charge ratio in its most recent cost report divided by its cost-to-charge ratio in the prior year’s cost report; and
(ii) Applied from the midpoint of the report period used to develop the cost-to-charges percentage in §A(2)(a) of this regulation, to the midpoint of the prospective payment period;
(c) The percentage of the hospital’s costs which are efficiently and economically incurred as adjusted to reflect labor market differences between District of Columbia hospitals and Maryland hospitals; and
(d) The uncompensated care factor which is equal to:
(i) For pediatric hospitals with average lengths of stay less than 18 days, one plus two and a half times the quotient of the hospital’s uncompensated care divided by gross revenue; or
(ii) For all other hospitals, one plus the quotient of the hospital’s uncompensated care divided by gross revenue.
(3) Effective for dates of service starting July 1, 2012, and forward, the rate calculated for FY 2012 in accordance with §A(2) of this regulation shall be increased by 9 percent.
(4) A hospital in the District of Columbia shall be reimbursed for administrative days in accordance with Regulation .07C of this chapter.
(5) Efficiently and economically incurred District of Columbia hospitals’ costs are those costs which are:
(a) Less than or equal to the adjusted costs for the same all-participant, refined-diagnosis-related groups in Maryland hospitals;
(b) For hospitals with average lengths of stay of 18 days or more:
(i) Less than or equal to the adjusted cost for the same diagnosis-related groups in Maryland hospitals; and
(ii) Categorized into the following two age groups: younger than 18 years old, and 18 years old or older;
(c) Exclusive of:
(i) Maryland case charges greater than $500,000; and
(ii) District of Columbia hospital case charges greater than $500,000 times the ratio of the average charge of the District of Columbia hospital case divided by the average charge of the Maryland hospital case; and
(d) Derived from hospital costs as specified in this subsection.
(6) Maryland hospital costs are the hospitals’ charges reduced by the hospital-specific ratio of operating costs to gross charges as determined by the Program or designee.
(7) There may not be a year-end cost settlement.
B. Outpatient Services.
(1) A hospital located 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 §B(2) of this regulation or its charges.
(2) The percentage of charges in §B(1) of this regulation is the product of:
(a) The cost-to-charges percentage using only those costs of the hospital reported in the hospital’s most recent cost report as determined by the Program or its designee; and
(b) The lesser of 100 percent or the cost-to-charge projection percentage which is:
(i) The hospital’s cost-to-charge ratio in its most recent cost report trended by its cost-to-charge ratio in the 2 prior years’ cost reports or, if 3 years of data are not available, the hospital’s cost-to-charge ratio in its most recent cost report divided by its cost-to-charge ratio in the prior year’s cost report; and
(ii) Applied from the midpoint of the report period used to develop the cost-to-charges percentage in §B(2)(a) of this regulation, to the midpoint of the prospective payment period.
(3) Effective for dates of service starting July 1, 2012, and forward, the rates calculated for FY 2012 in accordance with §B(2) of this regulation shall be increased by 9 percent.
(4) The analysis shall be performed by the Program or its designee.
(5) There may not be a year-end cost settlement.
(6) Outpatient reimbursement rates are implemented in conjunction with, and are applicable to, the same dates of service as inpatient rates.
C. Submitting Cost Reports.
(1) 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 grants the provider an extension or the provider discontinues participation in the Program.
(2) When reports are not received within 5 months and an extension has not been granted:
(a) For hospitals reimbursed in accordance with this regulation, the Program shall reduce the inpatient percentage of payment for that hospital by 5 percentage points, starting the calendar month after the calendar month in which the report is due, which will remain in effect until the report has been submitted, and there will be no refund; or
(b) For hospitals reimbursed according to Medicare standards and principles for retrospective cost reimbursement as described in 42 CFR §413, the Department shall:
(i) Withhold from the provider a maximum of 5 percent of the current monthly interim payment starting the calendar month after the calendar month in which the report is due and any subsequent calendar months until the report has been submitted; and
(ii) Refund withholdings at cost settlement.
(3) If a provider discontinues participation in the Program, financial and statistical data shall be submitted to the Department within 45 days after the effective date of termination.
(4) The Program shall grant an extension for submission of cost reports:
(a) Upon written request by the provider, setting forth the specific reasons for the request, if the Department determines, taking into consideration the totality of the circumstances, that the request is reasonable; or
(b) Concurrent with any extension granted to the hospital by Medicare, but not to exceed 60 days from the due date of cost reports.
(5) In addition to a reduction in payment percentage or withholding a percentage of interim payment pursuant to §C(2) of this regulation, when a report is not submitted by the last day of the 6th month after the end of the provider’s fiscal year and the provider has not received an extension, the Department may impose one or more sanctions as provided for in Regulation .12 of this chapter.
(6) When a report is not submitted by the last day of the 6th month after the end of the provider’s fiscal year or a report is submitted but the provider cannot furnish proper documentation to verify costs, the Department shall, if applicable, make final cost settlement for that fiscal year at a certain percentage of the last final per diem rates for which the Department has verified costs for that facility, provided that the rates established will not exceed the maximum per diem rates in effect when the facility’s costs were last settled.
(7) For purposes of §C(1)—(6) of this regulation, reports are considered received when the submitted reports are completed according to instructions issued by the Department or its designee.
(8) When a report is received after imposing a reduction as specified in §C(2)(a) of this regulation, the rate of reimbursement calculated using the latest cost report information shall be implemented starting with the 1st day of the 4th full calendar month after the month in which the report was received by the Program.
.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 grants the provider an extension or the provider discontinues participation in the Program.
B. For hospitals who do not submit reports within 5 months, for whom an extension has not been granted, and who are reimbursed according to Medicare standards and principles for retrospective cost reimbursement as described in 42 CFR §413, the Department shall:
(1) Withhold from the provider a maximum of 5 percent of the current monthly interim payment starting the calendar month after the calendar month in which the report is due and any subsequent calendar months until the report has been submitted; and
(2) Refund withholdings at cost settlement.
C. If a provider discontinues participation, financial and statistical data shall be submitted to the Department within 45 days after the effective date of termination.
D. The Program shall grant an extension for submission of cost reports:
(1) Upon written request by the provider, setting forth the specific reasons for the request, if the Department determines, taking into consideration the totality of the circumstances, that the request is reasonable; or
(2) Concurrent with any extension granted to the hospital by Medicare, but not to exceed 60 days from the due date of cost reports.
E. In addition to a reduction in payment percentage or withholding a percentage of interim payment pursuant to §B of this regulation, when a report is not submitted by the last day of the 6th month after the end of the provider’s fiscal year and the provider has not received an extension, the Department may impose one or more sanctions as provided for in Regulation .12 of this chapter.
F. When a report is not submitted by the last day of the 6th month after the end of the provider’s fiscal year or a report is submitted but the provider cannot furnish proper documentation to verify costs, the Department shall, if applicable, make final cost settlement for that fiscal year at a certain percentage of the last final per diem rates for which the Department has verified costs for that facility, provided that the rates established will not exceed the maximum per diem rates in effect when the facility’s costs were last settled.
G. For purposes of §§A—F of this regulation, reports are considered received when the submitted reports are completed according to instructions issued by the Department or its designee.
.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 reimbursed according to Medicare standards and principles for retrospective cost reimbursement described in 42 CFR §413, or on the basis of charges if less than reasonable cost.
(2) In calculating retrospective cost reimbursement rates, the Department or its designee will deduct from the designated costs or group of costs those restricted contributions which are designated by the donor for paying certain provider operating costs, or groups of costs, or costs of specific groups of participants.
(3) When the cost, or group or groups of costs designated, cover services rendered to all participants, including Medical Assistance participants, operating costs applicable to all participants shall be reduced by the amount of the restricted grants, gifts, or income from endowments, thus resulting in a reduction of allowable costs.
(4) Final settlement for services in the provider’s fiscal year shall be determined based on Medicare retrospective cost principles found in 42 CFR §413, adjusted for Medicaid allowable costs. Allowable costs specific to the Program shall be limited to a base year cost per discharge increased by the applicable federal rate of increase times the number of Program discharges for that fiscal year.
(5) Base Year. For purposes of determining limits on the increase of cost, in accordance with Medicare regulations, the base year shall be:
(a) For an existing provider, the first year of entering into the Program or the first year separate rates for the unit or units of service or services are approved; or
(b) For a new provider, the 12-month period immediately before the provider was initially subject to target rate increases.
(6) Initial Interim Rates. In order to establish an initial interim rate, the provider shall submit to the Department or its designee, before the beginning of the first billing period, the following:
(a) A detailed cost build-up, consistent with Medicare principles and cost finding, that supports the requested rate;
(b) A current, projected, and prior year’s charge rate schedule;
(c) Finalized prior year’s Medicare cost reports and the most current submission;
(d) A detailed revenue schedule; and
(e) Audited financial statements.
(7) The provider shall supply the Department or its designee the assurances necessary to establish that its customary charges to participants liable for payment on a charge basis exceed the allowable cost for these services.
(8) Initial Interim Rates for Newly Established Services or Providers.
(a) The provider shall submit to the Department or its designee, a detailed cost build-up, consistent with Medicare principles and cost finding that supports the requested rate that follows.
(b) The Department will compare the rate with a compatible facility and determine a reasonable rate that does not exceed the projected charges.
(9) Revision of Interim Rates.
(a) The provider may request an interim rate revision if the actual and projected costs exceed the interim rate by 10 percent.
(b) The provider shall furnish the Department or its designee with appropriate documentation showing the reason for the increase and other necessary comparisons.
(c) The Department will lower the provider’s interim rate to closely approximate the final allowable reasonable cost based on the results of the prior year’s review.
(d) The provider may request no more than one interim rate revision during the provider’s fiscal year.
(10) Cost Settlement. The provider shall submit to the Department or its designee:
(a) A Medicaid cost report based on actual data using the cost reporting forms used by Medicare for retrospective cost reimbursement;
(b) A copy of its Maryland Medical Assistance log;
(c) Cost reports that are sufficient in detail to support a separate cost finding for designated Maryland Medical Assistance unique cost centers; and
(d) A finalized Medicare cost report for the cost reporting year.
(11) Final Program costs shall be Maryland Medical Assistance specific.
(12) Tentative cost settlements may not be performed on a routine basis. However, the Program reserves the right to calculate tentative settlements in limited cases, when appropriate, as determined by the Department.
(13) The Department will base final settlement on the results of the finalized Medicare cost reports.
B. The Department or its designee shall notify each provider participating in the Program of the results of the final settlement under §A(10)—(13) of this regulation.
C. Within 60 days after the provider receives the notification described in §B of this regulation, the Department shall pay the amount due to the provider regardless of whether the provider files an appeal.
D. The provider may request review of the settlement under §A(10)—(13) of this regulation by filing written notice with the Program’s Appeal Board within 30 days after receipt of the notification of the results of the settlement from the Department or its designee.
E. The Appeal Board shall be composed of the following:
(1) A representative of the hospital industry who is:
(a) Knowledgeable in Medicare and Medicaid reimbursement principles; and
(b) Appointed by the Secretary of the Department;
(2) An individual who:
(a) Is employed by the State;
(b) Is knowledgeable in Medicare and Medicaid reimbursement principles;
(c) Did not participate in the verification of costs; and
(d) Is appointed by the Secretary of the Department; and
(3) A third member selected by the first two members of the Appeal Board.
F. When the Appeal Board reviews an appeal from a provider in which an Appeal Board member is employed or in which the member has a financial or personal interest, the Secretary of the Department shall designate an alternate for the member.
G. If the provider elects not to appeal to the Appeal Board:
(1) The provider shall pay the amount due within 60 days after the notification described in §B of this regulation;
(2) The provider may request a longer payment schedule within 60 days after the provider receives notification of the amount due the Program, the Department may establish, after consultation with the provider, a longer payment schedule; and
(3) The Department shall establish a longer payment schedule if, in the Department’s judgment based on sufficient documentation submitted by the provider, failure to grant a longer payment schedule would:
(a) Result in financial hardship to the provider; or
(b) Have an adverse effect on the quality of participant care furnished by the facility.
H. If the provider elects to appeal to the Appeal Board, the following provisions apply:
(1) Within 30 days after a provider’s filing of an appeal of the Department or its designee’s determination that the provider owes money to the Program, the Department or its designee shall:
(a) Recalculate the amount due to the Program based on the verification, exclusive of the amount in controversy which is subject to the appeal; and
(b) Notify the provider of that amount;
(2) In order to enable the Department or its designee to perform this recalculation, the provider shall indicate the specific adjustment and the specific amount being appealed;
(3) Subject to the provisions of §H(4) of this regulation, payment for the amount due the Program, if any, after the recalculation, shall be made within 60 days after the provider receives notification of the recalculation; and
(4) If a provider requests a longer payment schedule within 60 days after the provider receives notification of the recalculation, the Department may establish, after consultation with the provider, a longer payment schedule in accordance with §G(3) of this regulation.
I. Appeal Board Findings.
(1) After the Department receives the findings of the Appeal Board, the Department shall:
(a) Determine the amount that is due either to the Program or to the provider; and
(b) Notify the provider of that amount.
(2) The portion of the amount in controversy that is paid is subject to an award of interest that is:
(a) Calculated from the date the appeal was filed through the date of payment; and
(b) Based on the 6-month Treasury Bill rate in effect on the date the appeal was filed.
(3) Interest paid to a provider under §I(2) of this regulation is not subject to any offset or other reduction against otherwise allowable costs.
(4) If the provider accepted the determination made under §I(1) of this regulation, within 60 days after the provider receives the notification under §I(1) of this regulation, the Program shall pay the amount the Department determined is due the provider, if any.
(5) Subject to §I(6) of this regulation, within 60 days after the provider receives the notification, the provider shall pay the amount due the Program, if any.
(6) If a provider requests a longer payment schedule within 30 days after the provider receives notification of the amount due the Program, the Department may establish, after consultation with the provider, a longer payment schedule in accordance with §G(3) of this regulation.
J. After expiration of the 60-day payment period, or longer payment schedule established by the Department as described in §§G—I of this regulation, and in addition to the sanctions provided in Regulation .12 of this chapter, the Department may recover the unpaid balance by withholding the amount due from the interim payment which would otherwise be payable to the provider.
K. The Department or a provider aggrieved by a reimbursement decision of the Appeal Board may appeal the decision of the Appeal Board as the final decision for judicial review under the Administrative Procedure Act, State Government Article, §10-222, Annotated Code of Maryland.
L. If the provider or the Department appeals the final decision of the Appeal Board, the provider or the Department shall place any money due from the provider or from the Program in an interest-bearing escrow account. The money due shall include the interest, based on the rate in §I(2)(b) of this regulation, calculated from the date of the administrative appeal through the date of opening the escrow account. The money shall remain in escrow until a final decision has been rendered. Upon a final determination of the dispute, the appropriate person administering the escrow account shall distribute the money in that account, including any interest accrued, in conformity with the final determination.
M. The provider may file an appeal of the results of the settlement with the Medicare Appeal Board as a substitute for the Department’s Appeal Board, and the decision rendered by the Medicare Appeal Board will be accepted by the Department as binding.
.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 payment to the provider by the amount of the duplicate payment, overpayment, or third-party payment.
.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.
.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.
General policies governing the interpretive regulations applicable to all providers are set forth in COMAR 10.09.36.10.
Authority: Health-General Article, §§2-104(b), 15-102.8, 15-103, and 15-105, Annotated Code of Maryland
.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 delivered to a participant who no longer requires the level of care that the provider is licensed to deliver.
(3) “Admission” means the formal acceptance by a hospital of a participant who is to be provided with room, board, and medically necessary services in an area of the hospital where individuals stay at least overnight.
(4) “Ancillary services” means diagnostic and therapeutic services including but not limited to radiology, laboratory tests, pharmacy, and physical therapy services, provided exclusive of room and board.
(5) “Appropriate facility” means:
(a) A facility located within a 25-mile radius of the participant’s residence; or
(b) If acceptable to the participant, a more distant facility, which is licensed and certified to render the participant’s required level of care, except when the only facility or facilities that provide the level of care and specialized services required by the participant exceed that distance.
(6) “Brain injury” means an injury or insult to the brain that occurs after birth and is not related to congenital or degenerative disease, which results in cognitive, physical, behavioral, or emotional disability that is documented in the medical record.
(7) “Brain injury community integration program” means a program located on the campus of a licensed chronic hospital and approved by the Department to treat individuals with primary diagnoses of brain injury resulting in functional limitations and disability, who need services designed to transition to home or a community-based program of services and supports.
(8) Chronic Hospital.
(a) “Chronic hospital” means an institution licensed by the Department of Health and Mental Hygiene in accordance with COMAR 10.07.01.03B, which provides services to patients with complex medical needs who do not require hospitalization in an acute hospital, but whose treatment needs exceed the capabilities of a nursing facility.
(b) “Chronic hospital” does not mean a long-term care hospital, as defined at 42 CFR §412.23(e).
(9) “Concurrent review” means a periodic reauthorization of continued medical eligibility for the level of services provided by a chronic hospital which allows for close monitoring of the participant’s progress, treatment goals, and objectives, performed during an inpatient hospitalization.
(10) “Date of service” means:
(a) For inpatient hospitalizations, the date of admission into a chronic hospital up to, but not including, the date of discharge; or
(b) For outpatient services, the date services are rendered in the outpatient department of the hospital.
(11) “Department” means the Maryland Department of Health and Mental Hygiene, which is the single State agency designated to administer the Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.
(12) “Designee” means any entity designated to act on behalf of the Department.
(13) “Electronic signature” means a secure electronic identification of an individual who authorizes an electronic record or transaction.
(14) “Health Services Cost Review Commission (HSCRC)” means the independent organization within the Department of Health and Mental Hygiene which is responsible for reviewing and approving rates for hospitals pursuant to Health-General Article, Title 19, Subtitle 2, Annotated Code of Maryland.
(15) “Interdisciplinary team” means a physician-led multidisciplinary clinical team consisting of, at a minimum:
(a) The participant or an individual of the participant’s choice;
(b) A physician;
(c) A registered nurse;
(d) A social worker;
(e) The participant’s case manager; and
(g) Any other clinical professional indicated by an individual’s specific needs, including but not limited to:
(i) A psychologist;
(ii) A behavioral analyst;
(iii) A dietitian or nutritionist; and
(iv) Licensed therapists in other disciplines.
(16) “Level of care” means an assessment that an individual needs the level of services provided in a special psychiatric hospital.
(17) “Medical Assistance Program” means the program of comprehensive medical and other health-related care for indigent and medically indigent persons.
(18) “Medically necessary” means that the service or benefit is:
(a) Directly related to diagnostic, preventative, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;
(b) Consistent with 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, family, or provider.
(19) “Medicare” means the medical insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq.
(20) “Neuro-behavioral” means the discipline within medical rehabilitation that focuses on behavioral impairments seen in association with brain injury resulting from trauma, hypoxia, or ischemia.
(21) “Out-of-State hospital” means any hospital outside of Maryland, except for hospitals located in the District of Columbia.
(22) “Outpatient services” means services provided to the participant on the hospital campus that do not require hospital admission.
(23) “Participant” means an individual who is enrolled with the Department to receive Medical Assistance services.
(24) “Program” means the Maryland Medical Assistance Program.
(25) “Provider” means a chronic hospital which, through agreement with the Department, has been identified as a Program provider by the issuance of a provider number.
.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 10.07.01.
B. The provider shall ensure that Clinical Laboratory Improvement Amendments (CLIA) certification exists for all clinical laboratory services performed, and:
(1) If located in Maryland, comply with requirements of:
(a) Health-General Article, Title 17, Subtitles 2 and 3, Annotated Code of Maryland; and
(b) COMAR 10.10.01; or
(2) If located out-of-State, comply with other applicable standards established by the state or locality in which the service is provided and with the requirements of COMAR 10.09.09.02.
C. The provider shall obtain accreditation by the Commission on Accreditation of Rehabilitation Facilities if it provides neuro-behavioral rehabilitation or brain injury services.
.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 Social Security Act for participation as a hospital, as issued by the U.S. Department of Health and Human Services;
(2) 24 hours per day, 7 days per week, meet the following staffing requirements:
(a) On-call or on-site physician services;
(b) On-site registered nurses;
(c) On-site respiratory therapist services; and
(d) On-site advanced cardiac life support services;
(3) Directly provide or make available through contractual arrangements or transfer agreements, medically necessary covered services;
(4) Accept payment by the Program as payment in full for the covered service;
(5) Make available to the Department or its designee the participant’s medical record for review and certification of medical necessity for admission and continuation of stay; and
(6) Maintain documentation of each contact with the participant as part of the complete medical record, which, at a minimum, includes:
(a) Date of service;
(b) The participant’s chief medical complaint or reason for admission;
(c) A description of the services provided, including:
(i) Progress notes;
(ii) Imaging studies;
(iii) Laboratory results;
(iv) Medication administration records; and
(v) Discharge summary; and
(d) A signature, electronic or handwritten, along with the printed or typed name of the individual providing care, with the appropriate title.
.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 Rehabilitation Facilities; and
(2) Approved by the Department to provide the Program.
B. Staff Requirements. In addition to the requirements in Regulation .03 of this chapter, a brain injury community integration program shall meet staffing requirements, as approved by the Program, necessary to provide the neuro-behavioral management programming set forth in Regulation .05D of this chapter.
C. At least annually, in a form specified by the Program, a provider operating a brain injury community integration program shall report on the individuals admitted to and participating in the program, including:
(1) Length of stay;
(2) Discharge setting; and
(3) Any other data specified by the Program.
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) Ventilator-assisted individuals who have been ventilator dependent for less than 6 months and who need further medical stabilization or are candidates for weaning from ventilator assistance;
(b) Tracheostomy participants who require suctioning more frequently than every 2 hours or are candidates for decannulation;
(c) More than two extensive stage IV decubiti which require daily intensive treatment that is not available in a nursing facility; or
(d) Extensive post-operative or post-traumatic care with multiple drains or extensive dressing change or therapies beyond the capabilities of a nursing facility;
(4) For participants admitted for intensive rehabilitation services, at least two sessions, 5 days per week, of physical therapy, occupational therapy, or speech therapy focused on language pathology; and
(5) Ancillary services.
B. Treatment Plan.
(1) Within 24 hours of a participant’s admission, a physician shall perform a documented face-to-face evaluation of the participant and begin developing an individualized treatment plan designed to meet the participant’s assessed needs.
(2) By the 7th day of a participant’s admission, an interdisciplinary team shall establish a written, individualized treatment plan for the participant, which shall include, at a minimum:
(a) Diagnoses;
(b) Treatment goals;
(c) Frequency of interventions for each type of service ordered;
(d) Duration of treatment of each type of service ordered; and
(e) Prognosis.
(3) The physician-led interdisciplinary team shall update the individualized treatment plan weekly until discharge.
C. The Program covers outpatient hospital services provided by a chronic hospital when the services are:
(1) Medically necessary; and
(2) Provided to individuals who are eligible for Medical Assistance and who are not current inpatients at the chronic hospital, except when payment for certain outpatient services provided to a participant on the date of inpatient admission or within 3 calendar days before the date of an inpatient admission are bundled, in accordance with 42 CFR §412.2(c)(5).
D. The program covers the following brain injury community integration program services:
(1) Neuro-behavioral management programming, which includes, but is not limited to:
(a) Assessment of maladaptive behaviors using valid and reliable behavioral measurement tools;
(b) Pharmacologic intervention provided to manage maladaptive behaviors related to brain injury;
(c) Neuro-behavioral programming created, implemented, overseen, and revised as needed;
(d) Incorporation of neuro-behavioral programming into therapy and care for participants in the community integration program; and
(e) Referral to a neuro-psychiatrist, as needed, if a neuro-psychiatrist is not a member of the facility staff;
(2) Cognitive skills adaptation and compensation programming, including:
(a) Specific programming dedicated to cognitive skills adaptation and compensation; and
(b) Incorporation of cognitive compensatory strategies into community integration program participant’s interdisciplinary team treatment;
(3) Community re-entry programming, including specific programming dedicated to social or pragmatic skills, leisure skills, and life skills; and
(4) According to the participant’s needs:
(a) The services of a psychiatrist or psychiatric nurse;
(b) Services and supports related to substance use disorders and other addictions;
(c) Speech therapy, which includes but is not limited to:
(i) Cognitive skills;
(ii) Communication skills;
(iii) Swallowing ability; and
(iv) Linguistic programming that assists the patient to connect the meaning of words to their context;
(d) Occupational therapy, which includes but is not limited to:
(i) Instrumental activities of daily living; and
(ii) Community re-entry activities;
(e) Physical therapy, which includes but is not limited to:
(i) Ambulation; and
(ii) Motor planning and coordination;
(f) Dietary services, which includes but is not limited to nutritional needs assessment and monitoring; and
(g) Case management, which includes but is not limited to:
(i) Treatment planning; and
(ii) Discharge planning.
E. The Program covers administrative days approved by the Department or its designee according to the conditions set forth in Regulation .08C of this chapter.
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 necessary;
D. Hospital services, procedures, drugs, or hospital admissions that are investigational or experimental;
E. Duplicated care or services;
F. Interpretation of laboratory tests or panels;
G. Inpatient and outpatient diagnostic and laboratory services not ordered by the attending physician or other practitioner involved in the participant’s care; or
H. Telephones, televisions, or personal comfort items or services.
.07 Medical Eligibility.
A. General Requirements.
(1) An admission to a chronic hospital is medically necessary for a participant whose:
(a) Medical condition is not stabilized subsequent to a course of treatment at an acute hospital, or whose deteriorating medical condition resulted in a readmission to an acute hospital from a nursing facility or community setting; and
(b) Service and care needs require active and continuing medical treatment at an intensity and frequency not provided in a nursing facility, as defined in COMAR 10.09.10.01B, such as:
(i) 24-hour availability of a physician, physician assistant, or nurse practitioner, and associated nursing staff; and
(ii) Active and continuing medical treatment by a physician at least three times per week as documented in the medical record, physician orders, and physician progress notes.
(2) An admission to a chronic hospital is medically necessary for a participant who needs intensive rehabilitation services other than those provided in a special rehabilitation hospital.
(3) A participant who may not be able to fully participate in a chronic hospital rehabilitation program may be admitted for a brief trial period of inpatient care after review by the Department or its designee and approval by the Program. If no progress on rehabilitative goals occurs, the participant shall be discharged to a lower level of care.
B. Medical Criteria for Brain Injury Community Integration Programs. In order to be preauthorized by the Program for services in a brain injury community integration program, a participant:
(1) Shall have a primary diagnosis of brain injury;
(2) Shall be at low risk of potential medical instability;
(3) May not require acute inpatient physical rehabilitation services;
(4) Shall require an intensive neuro-behavioral or neuro-cognitive rehabilitation program at a chronic level of care as described in §A of this regulation in order to:
(a) Address pervasive and persisting maladaptive behaviors, or behavioral health risk factors, that preclude a safe discharge to the community or to a less restrictive setting; and
(b) Relearn basic living and adaptive skills;
(5) Shall have potential for achievement of specific functional outcomes with the potential of improving functional ability so that discharge to a less restrictive setting is a reasonable goal;
(6) Shall need rehabilitative programming, which may include:
(a) Recreation therapy;
(b) Speech language pathology;
(c) Occupational therapy;
(d) Physical therapy; and
(e) Neuro-psychology;
(7) Shall require at least two contacts daily within the rehabilitative programming that address the neuro-behavioral or neuro-cognitive needs of the participant;
(8) Shall require active and continued clinical treatment by a physician who is experienced in neuro-rehabilitation and in psychopharmacology for a minimum of three contacts per week;
(9) Shall require a structured and integrated environment of care that provides on-going behavioral programming designed to reduce maladaptive behaviors that are reinforced by clinical support and administrative staff;
(10) Shall make progress toward the achievement of specified functional outcomes; and
(11) Shall have the ability to participate in the required number of therapy sessions.
.08 Utilization Review.
A. Admission and Prior Approval.
(1) For participants and individuals who have applied for Medical Assistance, the provider shall request a determination from the Department or its designee at the time of admission, or at the time of application for Medical Assistance, that the individual meets the medical eligibility criteria set forth in Regulation .07A of this chapter.
(2) For a participant to be preauthorized for services in a brain injury community integration program, the provider shall request a determination from the Department or its designee that the participant meets the criteria set forth in Regulation .07B of this chapter.
(3) If the provider obtains the determination set forth in §A(1) or (2) of this regulation after admission, the eligibility determination shall be effective on the date that the determination was requested.
B. Concurrent Review.
(1) On a monthly basis, the provider shall notify the Department or its designee of all persons who have:
(a) Received an initial determination of medical eligibility for chronic hospital services;
(b) Been determined to continue to meet medical eligibility criteria for chronic hospital services;
(c) Been discharged; or
(d) Been determined to no longer be medically eligible.
(2) Concurrent review shall be conducted as long as the participant remains hospitalized, based on the participant’s diagnosis and condition, to ensure the medical necessity of the participant’s inpatient stay, at the following intervals:
(a) After an initially authorized 30-day stay, or at the end of the expected length of stay identified at admission, whichever comes first; and
(b) Every 14 days following the initial concurrent review, including clinical updates, on a form determined by the Department or its designee.
(3) The Department or its designee may conduct on-site reviews.
C. Administrative Days.
(1) To be paid for administrative days, the provider shall document, in a form designated by the Department, information which satisfies the conditions listed below:
(a) The participant who was initially eligible has been determined to no longer require chronic hospital services, and the provider has:
(i) Received a determination from the Department or its designee that the participant requires the level of service provided by a nursing facility but an appropriate facility is not available;
(ii) Established a plan for discharge during the period of administrative days, is actively pursuing placement at an appropriate level of care for the participant, and has documented this activity in the participant’s record; and
(iii) Submitted documentation to the Department or its designee that placement activity was conducted no fewer than 3 days per week during the period for which payment is requested for administrative days; or
(b) The participant is no longer medically eligible to receive chronic hospital services but cannot be moved, and the following conditions are met:
(i) The medical reason the participant cannot be moved is documented by the attending physician in the participant’s medical record;
(ii) The attending physician reevaluates the medical cause of the participant’s inability to be moved at least once every 7 days; and
(iii) The provider documents the active treatments used to resolve the medical cause of the participant’s inability to be moved;
(2) To receive reimbursement for administrative days, the provider shall document that it has met the conditions of §C(1) of this regulation, at least every 14 days.
(3) Documentation shall be submitted to the Department or its designee no later than 3 business days following the end of the 14-day period.
.09 Payment Procedures.
A. Reimbursement of Maryland Chronic Hospitals.
(1) In-State chronic hospitals shall be reimbursed according to:
(a) Rates approved by the HSCRC pursuant to COMAR 10.37.03; or
(b) The administrative day rate as follows:
(i) For a participant who is not ventilator-dependent, payment for approved administrative days shall be the estimated Statewide average Medicaid nursing facility payment rate as determined by the Department; and
(ii) For a participant who is ventilator-dependent, payment for approved administrative days shall be the estimated average Medicaid nursing facility payment rate for ventilator-dependent residents as determined by the Department.
(2) State-operated chronic hospitals shall be reimbursed according to Regulation .10 of this chapter. The Department shall make no direct reimbursement to any State-operated chronic hospital.
B. Reimbursement of Out-of-State Hospitals.
(1) The Department shall reimburse an out-of-State hospital that provides a level of service equivalent to that provided at a chronic hospital only if:
(a) The proposed admission is first reviewed by the Department or its designee and the out-of-State placement is determined medically necessary according to Regulation .07A of this chapter;
(b) The hospital possesses the same certifications and accreditations as the Program requires for a comparable level of services and specific program in a Maryland chronic hospital; and
(c) The hospital meets one of the following conditions:
(i) The hospital proposes to provide a service or specific treatment that the participant cannot obtain in a Maryland chronic hospital; or
(ii) The hospital is located geographically closer to the established residence of the participant than a Maryland chronic hospital.
(2) The Department shall reimburse an out-of-State hospital at the lesser of:
(a) The average rate established by the HSCRC for an equivalent cost center for a Maryland chronic hospital; or
(b) The rate charged by the out-of-State hospital pursuant to 42 CFR Part 412, Subpart O.
.10 Cost Reporting—State-Operated Chronic 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 grants the provider an extension or the provider discontinues participation in the Program.
B. For hospitals who do not submit reports within 5 months, for whom an extension has not been granted, and who are reimbursed according to Medicare standards and principles for retrospective cost reimbursement as described in 42 CFR §413, the Department shall:
(1) Withhold from the provider a maximum of 5 percent of the current monthly interim payment starting the calendar month after the calendar month in which the report is due and any subsequent calendar months until the report has been submitted; and
(2) Refund withholdings at cost settlement.
C. If a provider discontinues participation, financial and statistical data shall be submitted to the Department within 45 days after the effective date of termination.
D. The Program shall grant an extension for submission of cost reports:
(1) Upon written request by the provider, setting forth the specific reasons for the request, if the Department determines, taking into consideration the totality of the circumstances, that the request is reasonable; or
(2) Concurrent with any extension granted to the hospital by Medicare, but not to exceed 60 days from the due date of cost reports.
E. In addition to a reduction in payment percentage or withholding a percentage of interim payment pursuant to §B of this regulation, when a report is not submitted by the last day of the 6th month after the end of the provider’s fiscal year and the provider has not received an extension, the Department may impose one or more sanctions as provided for in Regulation .14 of this chapter.
F. When a report is not submitted by the last day of the 6th month after the end of the provider’s fiscal year or a report is submitted but the provider cannot furnish proper documentation to verify costs, the Department shall, if applicable, make final cost settlement for that fiscal year at a certain percentage of the last final per diem rates for which the Department has verified costs for that facility, provided that the rates established will not exceed the maximum per diem rates in effect when the facility’s costs were last settled.
G. For purposes of §§A—F of this regulation, reports are considered received when the submitted reports are completed according to instructions issued by the Department or its designee.
.11 Cost Settlement — State-operated Chronic Hospitals.
A. Final settlement for services in the provider’s fiscal year shall be determined based on Medicare retrospective cost principles found at 42 CFR §413, adjusted for Program allowable costs. Allowable costs specific to the Program shall be limited to a base year cost per discharge increased by the applicable federal rate of increase times the number of Program discharges for that fiscal year.
B. Base Year. For purposes of determining limits on the increase of cost, in accordance with Medicare regulations, the base year for an existing provider shall be the first year of entering into the Program or the first year separate rates for the unit or units of service or services are approved.
C. The provider shall supply the Department or its designee the assurances necessary to establish that its customary charges to participants liable for payment exceed the allowable cost for these services.
D. Revision of Interim Rates. The provider may request an interim rate revision should the actual and projected cost exceed the interim rate by 10 percent. The provider shall furnish the Department or its designee with appropriate schedules showing the reason for the increase and any other information supporting the request. The Department will lower the provider’s interim rate to closely approximate the final allowable reasonable cost based on the results of the prior year’s review. The provider may request not more than two interim rate revisions during the accounting year.
E. Cost Settlement. The provider shall submit to the Department or its designee a Medicaid cost report based on actual data using the cost reporting forms used by Medicare for retrospective cost reimbursement. The provider shall also submit a copy of its Maryland Medical Assistance log. The submitted cost report shall be in sufficient detail to support a separate cost finding for designated Maryland Medical Assistance unique cost centers. Tentative cost settlements may not be performed on a routine basis. However, the Program reserves the right to calculate tentative settlements in limited cases, when appropriate, as determined by the Department. The provider shall furnish the Department or its designee with a finalized Medicare cost report for the cost reporting year. The Department will base final settlement on the results of the finalized Medicare cost reports.
.12 Cost Settlement for State-operated Chronic Hospitals — Payments and Appeals.
A. The Department or its designee shall notify each provider participating in the Program of the results of the final settlement under Regulation .11 of this chapter.
B. Within 60 days after the provider receives the notification described in §A of this regulation, the Department shall pay the amount due to the provider regardless of whether the provider files an appeal.
C. The provider may request review of the settlement under Regulation .11 of this chapter by filing written notice with the Program’s Appeal Board within 30 days after receipt of the notification of the results of the settlement from the Department or its designee.
D. The Appeal Board shall be composed of the following:
(1) A representative of the hospital industry who is:
(a) Knowledgeable in Medicare and Medicaid reimbursement principles; and
(b) Appointed by the Secretary of the Department;
(2) A person who:
(a) Is employed by the State;
(b) Is knowledgeable in Medicare and Medicaid reimbursement principles;
(c) Did not participate in the verification of costs; and
(d) Is appointed by the Secretary of the Department; and
(3) A third member selected by the first two members of the Appeal Board.
E. When the Appeal Board reviews an appeal from a provider in which an Appeal Board member is employed or in which the member has a financial or personal interest, the Secretary of the Department shall designate an alternate for the member.
F. If the provider elects not to appeal to the Appeal Board:
(1) The provider shall pay the amount due within 60 days after the notification described in §A of this regulation;
(2) If the provider requests a longer payment schedule within 60 days after the provider receives notification of the amount due the Program, the Department may establish, after consultation with the provider, a longer payment schedule; and
(3) The Department shall establish a longer payment schedule if, in the Department’s judgment based on sufficient documentation submitted by the provider, failure to grant a longer payment schedule would:
(a) Result in financial hardship to the provider; or
(b) Have an adverse effect on the quality of participant care furnished by the facility.
G. If the provider elects to appeal to the Appeal Board, the following provisions apply:
(1) Within 30 days after a provider appeals a determination by the Department or its designee that the provider owes money to the Program, the Department or its designee shall:
(a) Recalculate the amount due to the Program based on the verification, exclusive of the amount in controversy which is subject to the appeal; and
(b) Notify the provider of that amount;
(2) In order to enable the Department or its designee to perform this recalculation, the provider shall indicate the specific adjustment and the specific amount being appealed;
(3) Subject to the provisions of §G(4) of this regulation, payment for the amount due the Program, if any, after the recalculation, shall be made within 60 days after the provider receives notification of the recalculation; and
(4) If a provider requests a longer payment schedule within 60 days after the provider receives notification of the recalculation, the Department may establish, after consultation with the provider, a longer payment schedule in accordance with §F(3) of this regulation.
H. Appeal Board Findings.
(1) After the Department receives the findings of the Appeal Board, the Department shall:
(a) Determine the amount that is due either to the Program or to the provider; and
(b) Notify the provider of that amount.
(2) The portion of the amount in controversy that is paid is subject to an award of interest that is:
(a) Calculated from the date the appeal was filed through the date of payment; and
(b) Based on the 6-month Treasury Bill rate in effect on the date the appeal was filed.
(3) Interest paid to a provider under §H(2) of this regulation is not subject to any offset or other reduction against otherwise allowable costs.
(4) If the provider accepted the determination made under §H(1) of this regulation, within 60 days after the provider receives the notification under §H(1) of this regulation, the Program shall pay the amount the Department determined is due the provider, if any.
(5) Subject to §H(6) of this regulation, within 60 days after the provider receives the notification, the provider shall pay the amount due the Program, if any.
(6) If a provider requests a longer payment schedule within 30 days after the provider receives notification of the amount due the Program, the Department may establish, after consultation with the provider, a longer payment schedule in accordance with §F(3) of this regulation.
I. After expiration of the 60-day payment period, or longer payment schedule established by the Department as described in §§F—H of this regulation, and in addition to the sanctions provided in Regulation .14 of this chapter, the Department may recover the unpaid balance by withholding the amount due from the interim payment which would otherwise be payable to the provider.
J. The Department or a provider aggrieved by a reimbursement decision of the Appeal Board may appeal the decision of the Appeal Board as the final decision for judicial review under the Administrative Procedure Act, State Government Article, §10-222, Annotated Code of Maryland.
K. If the provider or the Department appeals the final decision of the Appeal Board, the provider or the Department shall place any money due from the provider or from the Program in an interest-bearing escrow account. The money due shall include the interest, based on the rate in §H(2)(b) of this regulation, calculated from the date of the administrative appeal through the date of opening the escrow account. The money shall remain in escrow until a final decision has been rendered. Upon a final determination of the dispute, the appropriate person administering the escrow account shall distribute the money in that account, including any interest accrued, in conformity with the final determination.
L. The provider may file an appeal of the results of the settlement with the Medicare Appeal Board as a substitute for the Department’s Appeal Board, and the decision rendered by the Medicare Appeal Board will be accepted by the Department as binding.
.13 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 payment to the provider by the amount of the duplicate payment, overpayment, or third-party payment.
.14 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.
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.
.16 Interpretive Regulation.
General policies governing the interpretive regulations applicable to all providers are set forth in COMAR 10.09.36.10.
10.09.94 Special Pediatric Hospitals
Authority: Health-General Article, §§2-104(b), 15-102.8, 15-103, and 15-105, Annotated Code of Maryland
.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 delivered to a participant who no longer requires the level of care that the provider is licensed to deliver.
(3) “Admission” means the formal acceptance by a hospital of a participant who is to be provided with room, board, and medically necessary services in an area of the hospital where patients stay at least overnight.
(4) “Ancillary services” means diagnostic and therapeutic services including but not limited to radiology, laboratory tests, pharmacy, and physical therapy services, provided exclusive of room and board.
(5) “Appropriate facility” means:
(a) A facility located within a 25-mile radius of the participant’s residence; or
(b) If acceptable to the participant, a more distant facility, which is licensed and certified to render the participant’s required level of care, except when the only facility or facilities that provide the level of care and specialized services required by the participant exceed that distance.
(6) “Concurrent review” means a periodic reauthorization of continued medical eligibility for the level of services provided by a special pediatric hospital, which allows for close monitoring of the participant’s progress, treatment goals, and objectives, performed during an inpatient hospitalization.
(7) “Date of service” means:
(a) For inpatient hospitalizations, the date of admission into a special pediatric hospital up to, but not including, the date of discharge; or
(b) For outpatient services, the date services are rendered in the outpatient department of the hospital.
(8) “Department” means the Maryland Department of Health and Mental Hygiene, which is the single State agency designated to administer the Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.
(9) “Designee” means any entity designated to act on behalf of the Department.
(10) “Diagnosis-related group” means a participant classification system adopted by the U.S. Department of Health and Human Services, in which each hospital discharge case is assigned a category based on the primary diagnosis, secondary diagnoses, if any, procedures performed, and age, sex, and discharge status of the participant.
(11) “Electronic signature” means a secure electronic identification of an individual who authorizes an electronic record or transaction.
(12) “Health Services Cost Review Commission (HSCRC)” means the independent organization within the Department of Health and Mental Hygiene which is responsible for reviewing and approving rates for hospitals pursuant to Health-General Article, Title 19, Subtitle 2, Annotated Code of Maryland.
(13) “Level of care” means an assessment that an individual needs the level of services provided in a special psychiatric hospital.
(14) “Maryland Medical Assistance Program” means the program of comprehensive medical and other health-related care for indigent and medically indigent persons.
(15) “Medically necessary” means that the service or benefit is:
(a) Directly related to diagnostic, preventative, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;
(b) Consistent with 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, family, or provider.
(16) “Medicare” means the medical insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq.
(17) “Out-of-State hospital” means any hospital outside of Maryland, except for hospitals located in the District of Columbia.
(18) “Outpatient services” means services provided to the participant on the hospital campus that do not require hospital admission.
(19) “Participant” means an individual who is enrolled with the Department to receive Medical Assistance services.
(20) “Plan of treatment” means a written plan developed by a participant’s consulting physician and other appropriate clinicians, which is provided to the Department on request and includes:
(a) Diagnosis;
(b) Treatment goals;
(c) Specific procedures planned for the participant, including surgeries;
(d) Duration of treatment of each type of service ordered;
(e) Expected length of stay; and
(f) Any other appropriate information, including caregiver education and discharge plan.
(21) “Program” means the Maryland Medical Assistance Program.
(22) “Prospective payment system” means a predetermined amount of reimbursement per day for inpatient hospital services.
(23) “Provider” means a special pediatric hospital which, through agreement with the Department, has been identified as a Program provider by the issuance of a provider number.
(24) Special Pediatric Hospital.
(a) “Special pediatric hospital” means a facility licensed by the Office of Health Care Quality as a special hospital that provides nonacute medical, rehabilitation, therapy, and palliative services to children and adolescents younger than 22 years old.
(b) “Special pediatric hospital” includes an out-of-State or District of Columbia hospital identified by the Program as:
(i) A facility that provides nonacute medical, rehabilitation, therapy, and palliative services to children and adolescents younger than 22 years old; and
(ii) A facility that provides nonacute medical, rehabilitation, and therapy services to individuals ages 2 through 22 with co-occurring medical and behavioral conditions.
.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 other licenses, as set forth in COMAR 10.07.01.
B. The provider shall ensure that Clinical Laboratory Improvement Amendments (CLIA) certification exists for all clinical laboratory services performed, and:
(1) If located in Maryland, comply with requirements of:
(a) Health-General Article, Title 17, Subtitles 2 and 3, Annotated Code of Maryland; and
(b) COMAR 10.10.01; or
(2) If located out-of-State, comply with other applicable standards established by the state or locality in which the service is provided and with the requirements of COMAR 10.09.09.02.
.03 Conditions for Participation.
A. A provider shall meet all conditions for participation as set forth in COMAR 10.09.36.
B. To participate in the Program as a special pediatric hospital services provider, the provider shall:
(1) Meet the requirements of Title XIX of the Social Security Act for participation as a hospital, as issued by the U.S. Department of Health and Human Services;
(2) Directly provide, or make available through contractual arrangements or transfer agreements, medically necessary covered services;
(3) Accept payment by the Program as payment in full for the covered services;
(4) Make available to the Department or its designee the participant’s medical record for review and certification of medical necessity for admission and continuation of stay; and
(5) Maintain documentation of each contact with the participant as part of the complete medical record, which, at a minimum, includes:
(a) Date of service;
(b) The participant’s chief medical complaint or reason for admission or outpatient visit;
(c) A description of the services provided, including:
(i) Progress notes;
(ii) Imaging studies;
(iii) Laboratory results;
(iv) Medication administration records; and
(v) Discharge summary; and
(d) A signature, electronic or handwritten, along with the printed or typed name of the individual providing care, with the appropriate title.
C. If an out-of-State or District of Columbia hospital, the hospital shall:
(1) Have in effect a utilization review plan applicable to all participants who receive Medical Assistance under Title XIX of the Social Security Act which meets the requirements of §1861(k) of the Social Security Act unless a waiver has been granted by the Secretary of Health and Human Services; and
(2) Allow HealthChoice managed care organizations to pay no more and no less than the reimbursement rates established in Regulation .07 of this chapter unless the parties mutually agree to an alternative arrangement in a contract either on or after July 1, 2011.
.04 Covered Services.
A. The Program covers the following inpatient services at special pediatric hospitals:
(1) A hospital admission determined to be medically necessary for a participant who is stable enough for transfer to a post-acute setting and requires medical or rehabilitative services that:
(a) Cannot be provided at a lower level of care; and
(b) Meets the medical eligibility criteria under Regulation .06 of this chapter;
(2) Administrative days for the length of time certified by the Department or its designee;
(3) Inpatient admissions for intensive occupational therapy, physical therapy, or speech therapy on a regimen which is less than 3 hours per day, 5 days per week, when these services are provided in a unit that is accredited by the Commission on Accreditation of Rehabilitation Facilities to provide rehabilitation services; and
(4) Ancillary services.
B. The Program covers the following outpatient hospital services:
(1) Medically necessary services for the provision of diagnostic, curative, palliative, or rehabilitative treatment; and
(2) For a participant younger than 21 years old, physical therapy, occupational therapy, speech therapy, and audiology services if:
(a) The therapy provider develops a written plan of treatment in collaboration with the participant’s primary care physician and the participant or the parent or guardian of the participant;
(b) The service is provided according to the plan of treatment; and
(c) The services provider sends an update of the plan of treatment to the participant’s primary care physician every 90 days.
.05 Limitations.
The Program does not cover:
A. Investigational or experimental hospital services, procedures, or drugs;
B. Inpatient admissions or outpatient visits solely for the administration of injections, unless medical necessity and the participant’s inability to take appropriate oral medications is documented in the participant’s medical record;
C. Outpatient visits intended to accomplish one or more of the following:
(1) Prescription drug or food supplement pick-up;
(2) Collection of specimens for laboratory procedures;
(3) Recording of an electrocardiogram; or
(4) Ascertaining the participant’s weight;
D. Interpretation of laboratory tests or panels;
E. Autopsies;
F. Immunizations required for travel outside the continental United States;
G. Leaves of absence beyond the period of the census check of the same day;
H. Day care;
I. Psychological evaluations and treatments except when:
(1) Ordered by a physician, and the medical necessity is documented in the participant’s medical record; or
(2) Performed as mental health service, as part of the plan of treatment;
J. Duplicated care or services;
K. Elective admissions to hospitals outside of Maryland and the District of Columbia unless the Department or its designee determines that comparable services are not available in Maryland, except under certain conditions where child participants are in foster care, or are for other reasons placed outside the State and are covered under certain criteria, as determined by the Department or its designee;
L. Inpatient and outpatient diagnostic services not specifically ordered by the attending physician or other responsible practitioner;
M. Inpatient days or services provided in excess of the days approved by the Department or its designee;
N. Hospital laboratory tests which are coverable under COMAR 10.09.09.04, if the specimen is not obtained in the hospital;
O. Hospital services provided outside of the United States;
P. The completion of forms and reports;
Q. Broken or missed appointments;
R. Professional services rendered by mail or telephone; or
S. Telephones, televisions, or personal comfort items or services.
.06 Utilization Review.
A. The Department or its designee shall conduct utilization review to determine that special pediatric hospital admissions and outpatient services are authorized only when medically necessary.
B. Review Procedure.
(1) For all admissions, the special pediatric hospital shall provide:
(a) The elements of a participant’s medical record specified by the Department or its designee for preadmission review, and request to certify the participant’s admission; and
(b) Sufficient clinical information or documentation to the Department or its designee that supports the need for admission to a special pediatric hospital including, but not limited to:
(i) Current medical health status;
(ii) Treatment received to date;
(iii) Proposed treatment plan for requested admission; and
(iv) Expected length of stay.
(2) Admission for inpatient services may be authorized only when these services cannot be provided:
(a) On an outpatient basis; or
(b) In a facility that is licensed to provide a more appropriate level of care to the participant.
(3) Concurrent review shall be conducted as long as the participant remains hospitalized, based on the participant’s diagnosis and condition, to ensure the medical necessity of the participant’s inpatient stay, at the following intervals:
(a) After an initially authorized 14-day stay, or at the end of the expected length of stay identified at admission, whichever comes first; and
(b) Every 14 days following the initial concurrent review, in a form and including clinical documentation as specified by the Department or its designee.
(4) The Department or its designee may conduct on-site reviews after an initially authorized period of 30 days, and every 30 days thereafter until discharge.
(5) An elective inpatient hospital admission requires preadmission authorization by the Department or its designee.
C. Administrative Days.
(1) To be paid for administrative days, the provider shall document, in a form designated by the Department, information which satisfies the conditions listed below:
(a) The participant has been determined to no longer require special pediatric hospital services, and the provider has:
(i) Received a determination from the Department or its designee that the participant requires the level of service provided in a lower-acuity facility, but an appropriate facility is not available;
(ii) Established a plan for discharge during the period of administrative days, is actively pursuing placement at an appropriate level of care for the participant, and has documented this activity in the participant’s record; and
(iii) Submitted documentation to the Department or its designee that placement activity was conducted no fewer than 3 days per week during the period for which payment is requested for administrative days; or
(b) The participant is no longer medically eligible to receive special pediatric hospital services but cannot be moved, and the following conditions are met:
(i) The medical reason the participant cannot be moved is documented by the attending physician in the participant’s medical record;
(ii) The attending physician reevaluates the medical cause of the participant’s inability to be moved at least once every 7 days; and
(iii) The provider documents the active treatments used to resolve the medical cause of the participant’s inability to be moved;
(2) To receive reimbursement for administrative days, the provider shall document that it has met the conditions of §C(1) of this regulation, at least every 14 days.
(3) Documentation shall be submitted to the Department or its designee no later than 3 business days following the end of the 14-day period.
.07 Payment Procedures.
A. HSCRC Reimbursement Principles.
(1) Except for hospitals reimbursed under the provisions of §B of this regulation and except for administrative days, hospitals located in Maryland that participate in the Program shall charge and be reimbursed according to rates approved by the HSCRC pursuant to COMAR 10.37.03.
(2) If the Program discontinues using rates which have been approved by HSCRC, the Program shall reimburse a provider:
(a) According to Medicare standards and principles for retrospective cost reimbursement described in 42 CFR §413; or
(b) On the basis of charges if less than reasonable cost.
(3) The Department may not reimburse for the services of a hospital’s salaried or contractual physicians as a separate line item.
B. Annual Market Basket Reimbursement Principles.
(1) Except as specified in §B(2)—(5) of this regulation, a special pediatric hospital not approved by the Program for reimbursement according to HSCRC rates shall be reimbursed according to Medicare standards and principles for retrospective cost reimbursement described in 42 CFR §413, or on the basis of charges if less than reasonable cost. In calculating retrospective cost reimbursement rates, the Department or its designee will deduct from the designated costs or group of costs those restricted contributions which are designated by the donor for paying certain provider operating costs, or groups of costs, or costs of specific groups of participants. When the cost, or group or groups of costs designated, cover services rendered to all participants, including Medical Assistance participants, operating costs applicable to all participants shall be reduced by the amount of the restricted grants, gifts, or income from endowments, thus resulting in a reduction of allowable costs.
(2) For days of service on or after July 1, 2006, in special pediatric hospitals with pediatric rehabilitation beds in Maryland not approved by the Program for reimbursement according to HSCRC rates, the Department shall reimburse these hospitals using a prospective payment system consisting of per diem rates based on service categories audited and adjusted in the provider’s fiscal year 2004 cost report. The base per diem rates shall be:
(a) Annually adjusted by the factor indicated in the Centers for Medicare and Medicaid Services Annual Market Basket Update Factor for the Long Term Care Hospital Prospective Payment System; and
(b) Determined by allocating Medicaid inpatient costs into service categories as follows:
(i) Rehabilitation categories — $1,486.58;
(ii) Feeding categories — $2,213.98;
(iii) Severe behavior categories — $2,544.66; and
(iv) Other categories — $1,126.69.
(3) For new services established after July 1, 2006, in special pediatric hospitals with pediatric rehabilitation beds in Maryland not approved by the Program for reimbursement according to HSCRC rates, the Program shall pay at an initial rate that is set as an interim rate at the Medicaid weighted average rate of all existing inpatient per diem rates. After the first full year, actual cost data shall be used to prospectively set the new service rate.
(4) For days of service on or after July 1, 2006, in special pediatric hospitals with pediatric rehabilitation beds in Maryland not approved by the Program for reimbursement according to HSCRC rates, the Department shall reimburse hospital based outpatient services on a prospective basis that shall be adjusted annually by the difference between the:
(a) Medicaid weighted average charge increase; and
(b) Centers for Medicare and Medicaid Services Outpatient Prospective Payment System Market Basket Update Factor.
(5) For outpatient services in §B(4) of this regulation, the revenue shall be maintained at the fiscal year 2011 level beginning July 1, 2011.
C. Out-of-State Hospitals Reimbursement Principles.
(1) An out-of-State hospital, except a hospital located in the District of Columbia, shall be reimbursed the lesser of its charges or the amount reimbursable by the host state’s Title XIX agency. The hospital shall be reimbursed for administrative days in accordance with Regulation .09E of this chapter.
(2) For outpatient services, an out-of-State hospital, except a hospital located in the District of Columbia, shall be reimbursed the lesser of its charges or the amount reimbursable by the host state’s Title XIX agency.
.08 District of Columbia Hospital Reimbursement.
A. Inpatient Services Base 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 §A(2) of this regulation or its charges.
(2) The percentage of charges in §A(1) of this regulation is the product of the following:
(a) The cost-to-charges percentage using only those costs of the hospital reported in the hospital’s most recent cost report as determined by the Program or its designee;
(b) The lesser of 100 percent or the cost-to-charge projection percentage which is:
(i) The hospital’s cost-to-charge ratio in its most recent cost report trended by its cost-to-charge ratio in the 2 prior years’ cost reports or, if 3 years of data are not available, the hospital’s cost-to-charge ratio in its most recent cost report divided by its cost-to-charge ratio in the prior year’s cost report; and
(ii) Applied from the midpoint of the report period used to develop the cost-to-charges percentage in §A(2)(a) of this regulation, to the midpoint of the prospective payment period;
(c) The percentage of the hospital’s costs which are efficiently and economically incurred as determined in accordance with §A(6) of this regulation; and
(d) The uncompensated care factor, which is equal to one plus the quotient of the hospital’s uncompensated care divided by gross revenue.
(3) Effective for dates of service starting July 1, 2012, and forward, the rate calculated for FY 2012 in accordance with §A(2) of this regulation shall be increased by 9 percent.
(4) A hospital in the District of Columbia shall be reimbursed for administrative days in accordance with Regulation .08C of this chapter.
(5) Efficiently and economically incurred District of Columbia hospitals’ costs are costs which are:
(a) Less than or equal to the adjusted costs for the same all participant refined-diagnosis related groups in Maryland hospitals;
(b) For hospitals with average lengths of stay of 18 days or more:
(i) Less than or equal to the adjusted cost for the same diagnosis-related groups in Maryland hospitals; and
(ii) Categorized into the following two age groups: younger than 18 years old, and 18 years old or older;
(c) Exclusive of:
(i) Maryland case charges greater than $500,000; and
(ii) District of Columbia hospital case charges greater than $500,000 times the ratio of the average charge of the District of Columbia hospital case divided by the average charge of the Maryland hospital case; and
(d) Derived from hospital costs as specified in this subsection.
(6) Maryland hospital costs are the hospitals’ charges reduced by the hospital specific ratio of operating costs to gross charges as determined by the Program or designee.
(7) There may not be a year-end cost settlement.
(8) For hospitals located in the District of Columbia that are not acute children’s hospitals, the reimbursement amount described in §A(1) of this regulation will be reduced by 2 percent.
B. Outpatient Services.
(1) A hospital located 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 §B(2) of this regulation or its charges.
(2) The percentage of charges in §B(1) of this regulation is the product of:
(a) The cost-to-charges percentage using only those costs of the hospital reported in the hospital’s most recent cost report as determined by the Program or its designee; and
(b) The lesser of 100 percent or the cost-to-charge projection percentage which is:
(i) The hospital’s cost-to-charge ratio in its most recent cost report trended by its cost-to-charge ratio in the 2 prior years’ cost reports or, if 3 years of data are not available, the hospital’s cost-to-charge ratio in its most recent cost report divided by its cost-to-charge ratio in the prior year’s cost report; and
(ii) Applied from the midpoint of the report period used to develop the cost-to-charges percentage in §B(2)(a) of this regulation, to the midpoint of the prospective payment period.
(3) Effective for dates of service starting July 1, 2012, and forward, the rates calculated for FY 2012 in accordance with §B(2) of this regulation shall be increased by 9 percent.
(4) The analysis shall be performed by the Program or its designee.
(5) There may not be a year-end cost settlement.
(6) Outpatient reimbursement rates are implemented in conjunction with, and are applicable to, the same dates of service as inpatient rates.
C. Cost Reporting.
(1) A special pediatric hospital provider reimbursed according to this regulation 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 grants the provider an extension or the provider discontinues participation in the Program.
(2) When reports are not received within 5 months and an extension has not been granted:
(a) For hospitals reimbursed in accordance with Regulation .08 of this chapter, the Program shall reduce the inpatient percentage of payment for that hospital by 5 percentage points, starting the calendar month after the calendar month in which the report is due, which will remain in effect until the report has been submitted, and there will be no refund; or
(b) For a hospital reimbursed according to Medicare standards and principles for retrospective cost reimbursement as described in 42 CFR §413, the Department shall:
(i) Withhold from the provider a maximum of 5 percent of the current monthly interim payment starting the calendar month after the calendar month in which the report is due and any subsequent calendar months until the report has been submitted; and
(ii) Refund withholdings at cost settlement.
(3) If a provider discontinues participation in the Program, financial and statistical data shall be submitted to the Department within 45 days after the effective date of termination.
(4) The Program may grant an extension for submission of cost reports:
(a) Upon written request by the provider, setting forth the specific reasons for the request, if the Department determines, taking into consideration the totality of the circumstances, that the request is reasonable; or
(b) Concurrent with any extension granted to the hospital by Medicare, but not to exceed 60 days from the due date of cost reports.
(5) When a report is not submitted by the last day of the 6th month after the end of the provider’s fiscal year, and the provider has not received an extension, the Department may impose, in addition to a reduction in payment percentage or withholding a percentage of interim payment pursuant to §C(2) of this regulation, one or more sanctions as provided for in Regulation .11 of this chapter.
(6) When a report is not submitted by the last day of the sixth month after the end of the provider’s fiscal year or a report is submitted but the provider cannot furnish proper documentation to verify costs, the Department shall, if applicable, make final cost settlement for that fiscal year at a certain percentage of the last final per diem rates for which the Department has verified costs for that facility, provided that the rates established will not exceed the maximum per diem rates in effect when the facility’s costs were last settled.
(7) For purposes of §C(1)—(6) of this regulation, reports are considered received when the submitted reports are completed according to instructions issued by the Department or its designee.
(8) When a report is received after imposing a reduction as specified in §C(2)(a) of this regulation, the rate of reimbursement calculated using this cost report information shall be implemented starting the 1st day of the 4th full calendar month after the month in which the report was received by the Program.
.09 Billing and Reimbursement Principles.
A. The Program shall pay room and board charges for the day of admission, and may not pay room and board charges for the day of discharge from the hospital.
B. The provider shall submit a request for payment according to procedures designated by the Department.
C. Payments of Medicare Claims.
(1) Payment of Medicare claims is authorized if:
(a) The provider accepts Medicare assignment;
(b) Medicare makes direct payment to the provider;
(c) Medicare determined that services were medically necessary;
(d) The services are covered by the Program; and
(e) Initial billing is made directly to Medicare according to Medicare guidelines.
(2) Payment of a deductible and co-insurance related to Medicare claims shall be paid subject to the HSCRC discounts, except in the case of a participant receiving hospital services in an out-of-State facility, in which case deductible and co-insurance shall be paid in full.
D. Out-of-State Hospital Reimbursement.
(1) The Program shall reimburse hospitals outside of Maryland, excluding the District of Columbia, at a rate that is 100 percent of the amount reimbursable by the host state’s Title XIX agency or the amount of the hospital’s actual charges in total, whichever is less.
(2) Out-of-State providers are responsible for reimbursing the Department for overpayments, in accordance with Regulation .10 of this chapter.
E. Payment for Administrative Days.
(1) The provider shall document, on forms designated by the Department, information that satisfies the conditions stated in Regulation .06C of this chapter.
(2) The provider shall:
(a) Receive determination from the Department or its designee that the participant no longer requires the level of care that the special pediatric hospital is licensed to provide;
(b) Receive determination from the Department or its designee that the participant requires services at a lower level of acuity, and a bed in an appropriate facility is not available; and
(c) Notify the Department or its designee of discharge planning before the termination of the need for inpatient hospitalization at the level the facility is licensed to provide, and obtained a level of care determination from the agent.
F. During the period of administrative days, the Department or its designee shall review the documentation in increments of not more than 14 days.
G. For participants who are not ventilator-dependent, payment for approved administrative days shall be the lesser of:
(1) An estimated Statewide average Medicaid nursing home payment rate as determined by the Department; or
(2) If the hospital has a unit which is a skilled nursing facility, the allowable costs in effect under Medicare or extended services provided to participants of the unit.
H. The Department will make no direct payment to the participant.
I. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.06.
J. The Department reserves the right to return to the provider, before payment, all invoices not properly completed.
K. Noncompliance with the Program’s requirements as determined by the Department or its designee shall result in nonpayment of the claim.
L. Payment on claims to a hospital located in the District of Columbia shall be reduced by a quarterly claims processing fee of 6 percent.
.10 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 payment to the provider by the amount of the duplicate payment, overpayment, or third-party payment.
.11 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.
.12 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.
.13 Interpretive Regulation.
General policies governing the interpretive regulations that are applicable to providers are set forth in COMAR 10.09.36.10.
10.09.95 Special Psychiatric Hospitals
Authority: Health-General Article, §§2-104(b), 15-102.8, 15-103, and 15-105, Annotated Code of Maryland
.01 Definitions.
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) “Administrative day” means a day of medical services delivered to a participant who no longer requires the level of care which the provider is licensed to deliver and is awaiting placement in a nursing home or residential care facility.
(2) “Admission” means the formal acceptance by a specialty psychiatric hospital of a patient who is to be provided with room, board, and medically necessary services in an area of the hospital where patients stay at least overnight.
(3) “Ancillary services” means diagnostic and therapeutic services, provided exclusive of room and board, including but not limited to:
(a) Radiology;
(b) Laboratory tests;
(c) Pharmacy services; and
(d) Physical therapy services.
(4) “Appropriate facility” means:
(a) A facility located within a 25-mile radius of the participant’s residence; or
(b) If acceptable to the participant, a more distant facility, which is licensed and certified to render the participant’s required level of care, except when the only facility or facilities that provide the level of care and specialized services required by the participant exceed that distance.
(5) “Concurrent review” means a periodic reauthorization of continued eligibility for the level of services provided by a special psychiatric hospital which allows for close monitoring of the participant’s progress, treatment goals, and objectives during an inpatient hospitalization.
(6) “Date of service” means:
(a) For inpatient hospitalizations, the date of admission into a special psychiatric hospital up to, but not including, the date of discharge;
(b) For outpatient services, the date services are rendered in the outpatient department of the special psychiatric hospital; and
(c) For observation services, the date or dates the services are rendered in a special psychiatric hospital, which are ordered by a medical staff practitioner to determine the need for inpatient admission.
(7) “Department” means the State Department of Health and Mental Hygiene, which is the single State agency designated to administer the Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.
(8) “Designee” means any entity designated to act on behalf of the Department.
(9) “Electronic signature” means a secure electronic identification of an individual who authorizes an electronic record or transaction.
(10) “Emergent condition” means a disease, illness, or injury characterized by sudden onset and symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in:
(a) Placing the participant’s health or, with respect to a pregnant woman, the health of the woman or unborn child in serious jeopardy;
(b) Serious impairment of bodily functions; or
(c) Serious dysfunction of any bodily organ or part.
(11) “Health Services Cost Review Commission (HSCRC)” means the independent organization within the Department of Health and Mental Hygiene which is responsible for reviewing and approving rates for hospitals pursuant to Health-General Article, Title 19, Subtitle 2, Annotated Code of Maryland.
(12) “Level of care” means an assessment that an individual needs the level of services provided in a special psychiatric hospital.
(13) “Maryland Medical Assistance Program” means the program of comprehensive medical and other health-related care for indigent and medically indigent persons.
(14) “Medicaid” means the Maryland Medical Assistance Program.
(15) “Medically necessary” means that the service or benefit is:
(a) Directly related to diagnostic, preventative, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;
(b) Consistent with 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, family, or provider.
(16) “Medicare” means the medical insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq.
(17) “Mental health services” means those services described in COMAR 10.09.59.06 rendered to treat the diagnoses set forth in COMAR 10.09.70.02.
(18) “Nonqualified alien” means a foreign-born resident who:
(a) Is not a naturalized U.S. citizen; and
(b) Is eligible for federal Medical Assistance coverage of only emergency medical services, as specified under COMAR 10.09.24.05-2A.
(19) “Observation services” means the medically necessary diagnostic services used to assess the participant’s outpatient condition to determine the need for possible admission to an inpatient special psychiatric care setting.
(20) “Organ” means a part of an organism that is typically self-contained and has a specific vital function, such as a heart or liver.
(21) “Out-of-State hospital” means any hospital outside of Maryland, except for hospitals located in the District of Columbia.
(22) “Outpatient services” means services provided to the participant on the hospital campus that do not require hospital admission.
(23) “Partial hospitalization” means outpatient, intensive, nonresidential psychiatric treatment, which is an alternative to inpatient acute general hospitalization, for any part of a 24-hour day for a minimum of 4 consecutive hours per day.
(24) “Participant” means a person who is certified as eligible for and is receiving Medical Assistance benefits.
(25) “Patient” means an individual awaiting or undergoing health care or treatment.
(26) “Plan of treatment” means a written plan, developed to address the referred problem or problems, which includes:
(a) Diagnosis;
(b) Treatment goals;
(c) Frequency of visits for each type of service ordered;
(d) Duration of treatment of each type of service ordered;
(e) Prognosis; and
(f) Other appropriate items.
(27) “Preauthorization” means the approval required from the Department or its designee before a service can be rendered by the provider and reimbursed.
(28) “Program” means the Maryland Medical Assistance Program.
(29) “Provider” means a special psychiatric hospital which through agreement with the Department has been identified as a Program provider by the issuance of a provider number.
(30) “Retrospective review” means the process of determining medical necessity of an inpatient admission after the participant has been discharged from the hospital.
(31) “Special psychiatric hospital” means an institution that:
(a) Provides short-term services for psychiatric illnesses in a hospital setting with facilities, medical staff, and all necessary personnel to provide diagnosis, care, and treatment;
(b) Falls within the jurisdiction of Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland; and
(c) Is licensed pursuant to COMAR 10.07.01 or other applicable standards established by the state in which the service is provided.
.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 specialty psychiatric hospital; and
(2) Obtain other licenses, as set forth in COMAR 10.07.01.
B. A provider shall ensure that Clinical Laboratory Improvement Amendments (CLIA) certification exists for all clinical laboratory services performed, and:
(1) If located in Maryland, comply with requirements of:
(a) Health-General Article, Title 17, Subtitles 2 and 3, Annotated Code of Maryland; and
(b) COMAR 10.10.01; or
(2) If located out-of-State, comply with other applicable standards established by the state or locality in which the service is provided and with the requirements of COMAR 10.09.09.02.
.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 a special psychiatric hospital services provider, the provider shall:
(1) Meet the requirements of Title XIX of the Social Security Act for participation as a hospital, as issued by the Department of Health and Human Services;
(2) Meet the following staffing requirements 24 hours per day, 7 days per week:
(a) On-call or on-site physician services including psychiatric physicians;
(b) On-site registered nurses;
(c) On-site advanced cardiac life support services;
(3) If licensed to provide inpatient psychiatric services for individuals younger than 21 years old:
(a) Meet the requirements for participation as defined in 42 CFR §440.160; and
(b) Provide acute psychiatric services as defined in 42 CFR Part 441, Subpart D;
(4) Directly provide or make available through contractual arrangements or transfer agreements, medically necessary covered services;
(5) Accept payment by the Program as payment in full for the covered service;
(6) Make available to the Department or its designee the participant’s medical record for review and certification of medical necessity for admission and continuation of stay;
(7) Maintain documentation of each contact with the participant as part of the medical record, which, at a minimum, includes:
(a) Date of service;
(b) A plan of treatment as defined in Regulation .01B of this chapter;
(c) The participant’s chief medical complaint or reason for visit;
(d) A description of the services provided, including:
(i) Progress notes;
(ii) Imaging studies;
(iii) Laboratory results;
(iv) Medication administration records; and
(v) Discharge summary; and
(e) A signature, electronic or handwritten, along with the printed or typed name of the individual providing care, with the appropriate title;
(8) Submit to the Department or its designee within 5 months of the close of the hospital’s fiscal year, as required by the Department, a hospital cost report for outpatient services which are subject to cost settlement in accordance with Regulation .11 of this chapter;
C. If an out-of-State or District of Columbia hospital, the special psychiatric hospital shall:
(1) Unless a waiver has been granted by the Secretary of Health and Human Services, have in effect a utilization review plan applicable to all participants who receive Medical Assistance under Title XVII of the Social Security Act which meets the requirements of §1861(k) of the Social Security Act; and
(2) Comply with applicable regulations of this chapter and COMAR 10.09.36.
.04 Covered Services.
A. The Program covers the following inpatient special psychiatric hospital services:
(1) Medically necessary services for the number of days, per admission, including days certified by the Department or its designee;
(2) Medically necessary mental health services authorized in accordance with COMAR 10.09.59.08 and as set forth in Regulation .05B(4) of this chapter;
(3) Medically necessary services when these services are:
(a) Necessary for the provision of diagnostic, curative, palliative, or rehabilitative treatment; and
(b) Described in the participant’s medical record in sufficient detail to support the invoices submitted for services.
(4) Administrative days for the length of time certified by the Department or its designee;
(5) Leaves of absence for therapeutic reasons or extenuating circumstances up to 12 hours per day, if the participant returns the same day, before the census check; and
(6) Observation services.
B. The Program covers partial hospitalization when the hospital has:
(1) Written approval from the Office of Licensing and Certification Programs to be a provider of partial hospitalization in accordance with COMAR 10.21.02;
(2) A certificate of need from the Maryland Health Resources Planning Commission, if required, to be a provider of partial hospitalization; and
(3) Obtained preauthorization in accordance with COMAR 10.09.59.08.
.05 Limitations.
A. There are limitations placed on the coverage of some special psychiatric hospital inpatient and outpatient services.
B. The Program does not cover:
(1) Special psychiatric hospital services, procedures, drugs or admissions that are investigational or experimental;
(2) Services identified by the Department or its designee as not medically necessary;
(3) Elective inpatient admissions without preauthorization;
(4) Inpatient admissions or outpatient visits solely for the administration of injections, unless medical necessity and the participant’s inability to take appropriate oral medications is documented in the participant’s medical record;
(5) Inpatient mental health services for an individual between 21 and 64 in a special psychiatric hospital of more than 16 beds that primarily engages in providing mental health services for an individual who is not waiver-eligible, as defined in COMAR 10.09.62.01, except when receiving mental health services in the special psychiatric hospital immediately before the participant reached 21 years old, in which case the services may be continued until the earlier of the following:
(a) The date the participant no longer requires the services; or
(b) The date the participant reaches 22 years old;
(6) Outpatient visits for one or more of the following:
(a) Prescription drug or food supplement pick up;
(b) Collection of specimens for laboratory procedures;
(c) Recording of an electrocardiogram;
(d) Ascertaining the participant’s weight; and
(e) Administration of vaccines;
(7) Leaves of absence beyond the period of the census check of the same day;
(8) Psychological evaluations and treatments except when:
(a) Ordered by a physician, and the medical necessity is documented in the participant’s medical record; or
(b) Performed as mental health services as part of an approved treatment plan;
(9) Telephones, televisions, or personal comfort items or services;
(10) Duplicated care or service as indicated by more than one charge for the same stay or more than one room accommodation for the same time, for example, a charge for an inpatient day and observation room charge;
(11) Administrative days for participants pending discharge to home or nonmedical institutions;
(12) Inpatient and outpatient diagnostic and laboratory services not ordered by the attending physician or other practitioner;
(13) Inpatient days provided in excess of the days approved by the Department or its designee;
(14) Hospital laboratory tests which are coverable under COMAR 10.09.09, unless the specimen is obtained in the hospital;
(15) Admissions to special psychiatric hospitals, unless the participant is diagnosed with any one of the specialty mental health codes listed in COMAR 10.09.70.02 or unless the Department or its designee grants a special exception based on the complexity of the situation at admission; or
(16) Elective admissions to hospitals outside of Maryland, except the District of Columbia, unless the Department or its designee determines that comparable services are not available in Maryland.
.06 Utilization Review Requirements.
A. Elective Inpatient Preauthorization Reviews.
(1) The special psychiatric 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 a special psychiatric hospital.
(2) The special psychiatric hospital shall obtain preauthorization for elective inpatient admissions from the Department or its designee, before the participant is admitted, by providing the following information including, but not limited to:
(a) Participant’s medical history and physical;
(b) Doctor’s progress notes; and
(c) Sufficient clinical information or documentation that supports the medical necessity of the inpatient admission.
B. Concurrent Review Process.
(1) The concurrent review process shall be initiated by the hospital.
(2) If the participant remains hospitalized, additional days shall be certified by the Department or its designee before the termination of the previously certified days.
(3) The special psychiatric hospital shall forward sufficient clinical information or documentation to the Department or its designee that supports the need for continuing care. Information submitted shall include:
(a) Current health status;
(b) Treatment received to date;
(c) Proposed treatment plan for continued stay; and
(d) Discharge planning.
C. Retrospective Reviews.
(1) The special psychiatric hospital shall request that the Department or its designee perform a retrospective review of an inpatient admission after the participant is discharged, to determine the medical necessity of the admission.
(2) The special psychiatric hospital shall provide the following to the Department or its designee when requesting a retrospective review following discharge from a special psychiatric hospital. Documentation submitted shall include, but is not limited to:
(a) The participant’s complete medical record;
(b) The principal, secondary, and tertiary diagnoses; and
(c) All relevant procedure codes.
D. Reviews for Nonqualified Aliens. The Department or its designee reviews the admission and discharge summary of an emergency inpatient admission for a nonqualified alien to determine whether the inpatient special psychiatric hospital stay meets the emergent condition criteria as defined in COMAR 10.09.24.05-2A.
.07 Payment Procedures.
A. Reimbursement Principles.
(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 Services for services to participants in State-operated hospitals.
(2) The Department shall compare the current rates with the projected upper payment limit for inpatient days of service on or after July 1, 2012, in freestanding private psychiatric hospitals in Maryland whose rates for commercial providers are set by the HSCRC.
(3) If the rates do not exceed the projected upper payment limit calculated by the Department, the Department shall reimburse these hospitals using a rate of 94 percent of the current rates for services set by the HSCRC for each hospital’s commercial providers in the fiscal year the prospective payments are made.
(4) If the rates do exceed the projected upper payment limit calculated by the Department, the per diem payments to each such hospital shall be decreased by the same proportion that the projected upper payment limit is exceeded.
(5) If the Program discontinues using rates which have been approved by HSCRC, the Program shall reimburse providers:
(a) According to Medicare standards and principles for retrospective cost reimbursement described in 42 CFR §413; or
(b) On the basis of charges if less than reasonable cost.
(6) The Department may not reimburse for the services of a hospital’s salaried or contractual physicians as a separate line item. When HSCRC has included these salaries in the hospital’s costs, charges for these services shall be included in the room and board rate or the appropriate ancillary service only.
(7) Payment advances other than those made in accordance with HSCRC regulations may not be made routinely.
(8) Inpatient and outpatient services in out-of-State or District of Columbia special psychiatric and outpatient services in in-State special psychiatric hospitals are cost-settled on an annual basis according to §B of this regulation.
B. Retrospective Cost Reimbursement.
(1) Except as specified in §A of this regulation, a special psychiatric hospital not approved by the Program for reimbursement according to HSCRC rates shall be reimbursed:
(a) According to Medicare standards and principles for retrospective cost reimbursement described in 42 CFR §413; or
(b) On the basis of charges, if less than reasonable cost.
(2) In calculating retrospective cost reimbursement rates, the Department or its designee will deduct from the designated costs or group of costs those restricted contributions which are designated by the donor for paying certain provider operating costs, groups of costs, or costs of specific groups of participants. When the cost, or group or groups of costs designated, cover services rendered to all participants, including Medical Assistance participants, operating costs applicable to all participants shall be reduced by the amount of the restricted grants, gifts, or income from endowments thus resulting in a reduction of allowable costs.
(3) Final settlement for services in the provider’s fiscal year shall be determined based on Medicare retrospective cost principles found at 42 CFR §413, adjusted for Medicaid allowable costs. Allowable costs specific to the Program shall be limited to a base-year cost per discharge increased by the applicable federal rate of increase times the number of Program discharges for that fiscal year.
(4) Base Year. For purposes of determining limits on the increase of cost, in accordance with Medicare regulations, the base year shall be:
(a) For an existing provider, the first year of entering into the Program or the first year separate rates for the unit or units of service or services are approved; and
(b) For a new provider, or all of these, the 12-month period immediately before the provider was initially subjected to target rate increases.
(5) Initial Interim Rates. In order to establish an initial interim rate, the provider shall submit to the Department or its designee, before the beginning of the first billing period, at least 90 days before the beginning of billing for services, the following:
(a) A detailed cost build-up, consistent with Medicare principles and cost finding, that supports the requested rate;
(b) A current, projected, and prior year’s charge rate schedule;
(c) Finalized prior year’s Medicare cost reports and the most current submission;
(d) A detailed revenue schedule; and
(e) Audited financial statements.
(6) The provider shall supply the Department or its designee the assurances necessary to establish that its customary charges to participants liable for payment on a charge basis exceed the allowable cost for these services.
(7) Initial Interim Rates for Newly Established Services or Providers.
(a) The provider shall submit to the Department or its designee, a detailed cost build-up, consistent with Medicare principles and cost finding, that supports the requested rate that follows Medicare principles and cost finding.
(b) The Department will compare the rate with a compatible facility and determine a reasonable rate that does not exceed the projected charges.
(8) Revision of Interim Rates.
(a) The provider may request an interim rate revision should the actual and projected cost exceed the interim rate by 10 percent.
(b) The provider shall furnish the Department or its designee with appropriate schedules showing the reason for the increase and other any other information that supports the rate increase.
(c) The Department will lower the provider’s interim rate to approximate the final allowable reasonable cost based on the results of the prior year’s review.
(d) The provider may request not more than two interim rate revisions during the accounting year.
(9) Cost Settlement.
(a) The provider shall submit to the Department or its designee:
(i) A Medicaid cost report based on actual data using the cost reporting forms used by Medicare for retrospective cost reimbursement;
(ii) A copy of the provider’s Program log; and
(iii) A finalized Medicare cost report for the cost reporting year.
(b) The final Program cost report shall be sufficiently detailed to support a separate cost finding for Maryland Medical Assistance unique cost centers. The provider shall also submit a copy of its Maryland Medical Assistance log. The submitted cost report shall be in sufficient detail to support a separate cost finding for designated Maryland Medical Assistance unique cost centers.
(c) Tentative cost settlements may not be performed on a routine basis. However, the Program may, when it determines appropriate, calculate tentative settlements. The provider shall furnish the Department or its designee with a finalized Medicare cost report for the cost reporting year.
(d) The Department will base final settlement on the results of the finalized Medicare cost reports.
C. The Program shall reimburse room and board charges for the day of admission, but may not reimburse room and board charges for the day of discharge from the hospital.
D. The provider shall submit request for payment according to procedures established by the Department.
E. Payments on Medicare claims are authorized if:
(1) The provider accepts Medicare assignment;
(2) Medicare makes direct payment to the provider;
(3) Medicare determined the services were medically necessary;
(4) The services are covered by the Program; and
(5) Initial billing is made directly to Medicare according to Medicare guidelines.
F. Payment on Medicare claims is subject to the following provisions:
(1) Deductible and co-insurance, according to the limits of §E of this regulation, shall be paid subject to the HSCRC discounts, except in the case of a participant receiving hospital services in an out-of-State facility, in which case deductible and co-insurance shall be paid in full; or
(2) Services not covered by Medicare, but by the Program, if medically justified according to §E of this regulation.
G. Administrative Days.
(1) To be paid for administrative days, the special psychiatric hospital shall document, on forms designated by the Department, information demonstrating that the participant who was initially eligible has been determined to no longer require special psychiatric hospital services and the provider has:
(a) Received a determination from the Department or its designee that the participant requires the level of service provided in a lower-acuity facility, but an appropriate facility is not available;
(b) Established a plan for discharge during the period of administrative days, is actively pursuing placement at an appropriate level of care for the participant, and has documented this activity in the participant’s record;
(c) Maintained documentation in the participant’s medical record that placement activity was conducted no fewer than 3 days per week during the period for which payment is requested for administrative days; and
(d) Notified the local agency responsible for development of the discharge treatment and education plan of the potential placement, if the participant is at risk of a residential treatment center placement on admission;
(2) If the participant requires the level of care provided by a residential treatment center and a bed in a residential treatment center is not available, in order to be paid for administrative days, the special psychiatric hospital shall document that it timely notified local coordinating councils and any other local agency, as appropriate, of the necessity to continue inpatient psychiatric service at a residential treatment center before the termination of the need for inpatient psychiatric hospitalization;
(3) If the participant is at an inappropriate level of care but cannot be moved, in order to be paid for administrative days, the special psychiatric hospital shall:
(a) Provide the attending physician’s declaration that, because of physical or emotional problems, the participant is unable to be moved;
(b) Document in the participant’s medical record the attending physician’s reasons why the participant cannot be moved; and
(c) Document the attending physician’s reevaluation of the participant’s inability to be moved in the participant’s record at least every 14 days in special psychiatric hospital.
H. Payment for approved administrative days for a special psychiatric hospital seeking placement of a participant to a residential treatment center shall be the average residential treatment center rate issued pursuant to COMAR 10.09.29.13B.
I. The Department may not reimburse a special psychiatric hospital for administrative days if:
(1) The special psychiatric hospital bills the Program for days of care for which the hospital is licensed to provide; or
(2) The Program or the Program’s designee determines the participant no longer requires the level of care for the days requested.
J. The Department may not make direct payment to the participant.
K. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.06.
L. The Department reserves the right to return to the provider, before payment, all invoices not properly completed.
M. Noncompliance with the Program’s requirements as determined by the Department or its designee shall result in nonpayment of the claim.
.08 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 payment to the provider by the amount of the duplicate payment, overpayment, or third-party payment.
.09 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.
.10 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.
.11 Submitting Cost Reports.
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 grants the provider an extension or the provider discontinues participation in the Program.
B. For hospitals who do not submit reports within 5 months, for whom an extension has not been granted, and who are reimbursed according to Medicare standards and principles for retrospective cost reimbursement as described in 42 CFR §413, the Department shall:
(1) Withhold from the provider a maximum of 5 percent of the current monthly interim payment starting the calendar month after the calendar month in which the report is due and any subsequent calendar months until the report has been submitted; and
(2) Refund withholdings at cost settlement.
C. If a provider discontinues participation, financial and statistical data shall be submitted to the Department within 45 days after the effective date of termination.
D. The Program shall grant an extension for submission of cost reports:
(1) Upon written request by the provider, setting forth the specific reasons for the request, if the Department determines, taking into consideration the totality of the circumstances, that the request is reasonable; or
(2) Concurrent with any extension granted to the special psychiatric hospital by Medicare, but not to exceed 60 days from the due date of cost reports.
E. In addition to a reduction in payment percentage or withholding a percentage of interim payment pursuant to §B of this regulation, when a report is not submitted by the last day of the 6th month after the end of the provider’s fiscal year and the provider has not received an extension, the Department may impose one or more sanctions as provided for in Regulation .09 of this chapter.
F. When a report is not submitted by the last day of the 6th month after the end of the provider’s fiscal year or a report is submitted but the provider cannot furnish proper documentation to verify costs, the Department shall, if applicable, make final cost settlement for that fiscal year at a certain percentage of the last final per diem rates for which the Department has verified costs for that facility, provided that the rates established will not exceed the maximum per diem rates in effect when the facility’s costs were last settled.
G. For purposes of §§A—F of this regulation, reports are considered received when the submitted reports are completed according to instructions issued by the Department or its designee.
.12 Cost Settlement.
A. The Department or its designee shall notify each provider participating in the Program of the results of the final settlement under Regulation .07 of this chapter.
B. Within 60 days after the provider receives the notification described in §A of this regulation, the Department shall pay the amount due to the provider regardless of whether the provider files an appeal.
C. The provider may request review of the settlement under Regulation .07 of this chapter by filing written notice with the Program’s Appeal Board within 30 days after receipt of the notification of the results of the settlement from the Department or its designee.
D. The Appeal Board shall be composed of the following:
(1) A representative of the hospital industry who is:
(a) Knowledgeable in Medicare and Medicaid reimbursement principles; and
(b) Appointed by the Secretary of the Department;
(2) An individual who:
(a) Is employed by the State;
(b) Is knowledgeable in Medicare and Medicaid reimbursement principles;
(c) Did not participate in the verification of costs; and
(d) Is appointed by the Secretary of the Department; and
(3) A third member selected by the first two members of the Appeal Board.
E. When the Appeal Board reviews an appeal from a provider in which an Appeal Board member is employed or in which the member has a financial or personal interest, the Secretary of the Department shall designate an alternate for the member.
F. If the provider elects not to appeal to the Appeal Board, the provider shall:
(1) Pay the amount due within 60 days after the notification described in §A of this regulation; or
(2) Request a longer payment schedule within 60 days after the provider receives notification of the amount due to the Program.
G. After consultation with the provider, the Department may establish a longer payment schedule if it determines, based on sufficient documentation submitted by the provider, that failure to grant a longer payment schedule would:
(1) Result in financial hardship to the provider; or
(2) Have an adverse effect on the quality of participant care furnished by the facility.
H. If the provider elects to appeal to the Appeal Board, the following provisions apply:
(1) Within 30 days after the filing of an appeal by a provider that the Department or its designee determined owes money to the Program, the Department or its designee shall:
(a) Recalculate the amount due to the Program based on the verification, exclusive of the amount in controversy which is subject to the appeal; and
(b) Notify the provider of that amount;
(2) In order to enable the Department or its designee to perform this recalculation, the provider shall indicate the specific adjustment and the specific amount being appealed;
(3) Subject to the provisions of §H(4) of this regulation, payment for the amount due the Program, if any, after the recalculation, shall be made within 60 days after the provider receives notification of the recalculation; and
(4) If a provider requests a longer payment schedule within 60 days after the provider receives notification of the recalculation, the Department may establish, after consultation with the provider, a longer payment schedule in accordance with §G of this regulation.
I. Appeal Board Findings.
(1) After the Department receives the findings of the Appeal Board, the Department shall:
(a) Determine the amount that is due either to the Program or to the provider; and
(b) Notify the provider of that amount.
(2) The portion of the amount in controversy that is paid is subject to an award of interest that is:
(a) Calculated from the date the appeal was filed through the date of payment; and
(b) Based on the 6-month Treasury Bill rate in effect on the date the appeal was filed.
(3) Interest paid to a provider under §I(2) of this regulation is not subject to any offset or other reduction against otherwise allowable costs.
(4) If the provider accepted the determination made under §I(1) of this regulation, within 60 days after the provider receives the notification under §I(1) of this regulation, the Program shall pay the amount the Department determined is due the provider, if any.
(5) Subject to §I(6) of this regulation, within 60 days after the provider receives the notification, the provider shall pay the amount due the Program, if any.
(6) If a provider requests a longer payment schedule within 30 days after the provider receives notification of the amount due the Program, the Department may establish, after consultation with the provider, a longer payment schedule in accordance with §G of this regulation.
J. After expiration of the 60-day payment period, or longer payment schedule established by the Department as described in §§F—I of this regulation, and in addition to the sanctions provided in Regulation .09 of this chapter, the Department may recover the unpaid balance by withholding the amount due from the interim payment which would otherwise be payable to the provider.
K. The Department or a provider aggrieved by a reimbursement decision of the Appeal Board may appeal the Appeal Board’s decision as the final agency decision under the Administrative Procedure Act, State Government Article, §10-222, Annotated Code of Maryland.
L. If the provider or the Department appeals a final decision of the Appeal Board, the provider or the Department shall place any money due from the provider or from the Program in an interest-bearing escrow account. The money due shall include the interest, based on the rate in §I(2)(b) of this regulation, calculated from the date of the administrative appeal through the date of opening the escrow account. The money shall remain in escrow until a final decision has been rendered. Upon a final determination of the dispute, the appropriate person administering the escrow account shall distribute the money in that account, including any interest accrued, in conformity with the final determination.
M. The provider may file an appeal of the results of the settlement with the Medicare Appeal Board as a substitute for the Department’s Appeal Board, and the decision rendered by the Medicare Appeal Board will be accepted by the Department as binding.
.13 Interpretive Regulation.
General policies governing the interpretive regulations applicable to all providers are set forth in COMAR 10.09.36.10.
VAN T. MITCHELL
Secretary of Health and Mental Hygiene
