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    Maryland Register

    Issue Date:  September 14, 2018

    Volume 45 • Issue 19 • Pages 872—876



    Title 10 


    Notice of Proposed Action


    The Secretary of Health proposes to:

    (1) Amend Regulations .02—.04.08.09, and .11 under COMAR 10.09.37 Family Planning Program Eligibility; and

    (2) Amend Regulations .01—.07 under COMAR 10.09.58 Family Planning Program.

    Statement of Purpose

    The purpose of this action is to:

    (1) Expand family planning eligibility by increasing the income limits and eliminating gender and age requirements for those who are able to receive benefits, in accordance with Senate Bill 774 Maryland Medical Assistance Program—Family Planning Services, 2018, Health and Government Operations;

    (2) Update definitions for consistency with other chapters;

    (3) Remove redundant references to X-ray equipment requirements;

    (4) Add language to specify which provider types may provide services under the Family Planning Program; and

    (5) Clarify laboratory tests and pharmaceutical supplies covered under the limited benefit family planning program by removing certain services that are not medically necessary for family planning.

    Comparison to Federal Standards

    There is no corresponding federal standard to this proposed action.

    Estimate of Economic Impact

    I. Summary of Economic Impact. Medicaid expenditures are expected to increase by $193,152 in fiscal 2019 in order to expand the Medicaid Family Planning Waiver Program to include woman and men of all ages with incomes up to 250 percent FPG.



    Revenue (R+/R-)


    II. Types of Economic Impact.






    A. On issuing agency:



    B. On other State agencies:


    C. On local governments:




    Benefit (+)
    Cost (-)




    D. On regulated industries or trade groups:



    E. On other industries or trade groups:


    F. Direct and indirect effects on public:


    III. Assumptions. (Identified by Impact Letter and Number from Section II.)

    A. and D. Assumptions are as follows:

    • An estimated 3,201 men and women with incomes below 200 percent FPG enroll in the program due to the lifting of age and gender restrictions.

    • An estimated 5,871 men and women with incomes between 200 percent FPG and 250 percent FPG enroll in the program due to the lifting of age and gender restrictions and an increase in income eligibility.

    • The annual service cost per enrollee is $32 (as this is based on serving women, the actual annual service cost may differ to serve both men and women).

    • Medicaid incurs $48,000 in contractor costs for the vendor that maintains the separate eligibility system for the program.

    • As contractor costs are based on the number of enrollees, to the extent participation is greater, costs increase by $24,000 for each additional 5,000 enrollees.

    • Expansion of the program begins January 1, 2019.

    • The federal matching rate is 90 percent for family planning services and 50 percent for contractor costs.

    • The proposed regulations will use $38,515 general funds and $154,637 federal funds.

    Economic Impact on Small Businesses

    The proposed action has a meaningful economic impact on small business. An analysis of this economic impact follows.

    The proposed action may have a meaningful economic impact on small businesses that provide family planning services because an estimated, additional 9,072 individuals may enroll in the program in and seek services from 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, Maryland Department of Health, 201 W. Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499 (TTY 800-735-2258), or email to mdh.regs@maryland.gov, or fax to 410-767-6483. Comments will be accepted through October 15, 2018. A public hearing has not been scheduled.


    10.09.37 Family Planning Program Eligibility

    Authority: Health-General Article, §§2-104(b) [and] 15-103(a), and 15-140, Annotated Code of Maryland

    .02 Definitions.

    A. (text unchanged)

    B. Terms Defined.

    (1) Applicant.

    (a) 'Applicant' means [a womanan individual whose written, signed application for the Family Planning Program has been submitted to the Department but has not received final action.

    (b) “Applicant” includes a non-pregnant [womanindividual whose application is submitted through an authorized representative.

    (2)—(4) (text unchanged)

    (5) “Authorized representative” means a spouse, legal guardian, parent, individual with power of attorney, relative or other individual designated in writing to the Department, authorized concerning the applicant’s or [recipient’sparticipant’s eligibility under this chapter to:

    (a) Act on an applicant’s or [recipient’sparticipant’s behalf; and

    (b) (text unchanged)

    (6) “Continuing eligibility” means a [recipient’s] participant’s eligibility for a subsequent certification period after the current certification period, based on the Department’s redetermination of eligibility with respect to [a woman] an individual who is enrolled in Family Planning on the application date.

    (7)—(10) (text unchanged)

    (11) Earned Income.

    (a) “Earned Income” means payment received by an individual in cash or in-kind as a result of employment, including self-employment.

    (b) (text unchanged)

    (12) (text unchanged)

    (13) 'Family Planning Program” means the program established in Health–General Article, §15-103 et seq., Annotated Code of Maryland to provide services related to contraceptive care to [womenindividuals who meet the eligibility requirements specified in Regulation .03 of this chapter.

    (14) (text unchanged)

    (15) “Household [size]” [means:] means sharing a common household.

    [(a) The applicant;

    (b) The spouse who resides with the applicant; and

    (c) Any children younger than 19 years old who resides with the applicant.]

    (16) “Income” means any property or service received by a person in cash or in-kind which can be applied directly, or by sale or conversion, to meet basic needs for food, shelter, and medical expenses.

    [(16)(17) (text unchanged)

    (18) 'In-kind income' means support or benefits in the form of food or shelter, or both, received by a person.

    [(17)(19)—[(19)(21) (text unchanged)

    [(22) 'Recipient' means a woman who is certified as eligible for the Family Planning Program.]

    (22) “Participant” means an individual who is certified as eligible for the Family Planning Program.

    [(20)(23)[(21)(24) (text unchanged)

    [(23)(25) “Redetermination” means a determination regarding the [continuing] eligibility of a [recipient] participant.

    [(24)(26) (text unchanged)

    [(25)] (27) 'Unearned income' means all income which does not meet the definition of earned income [as defined in §B of this regulation].

    .03 Eligibility for Family Planning Program Coverage.

    A. In order to be determined eligible for benefits under the Family Planning Program, an applicant:

    (1) Shall:

    (a) Have a household income that does not exceed [200250 percent of the federal poverty level; and

    (b) Meet the following requirements:

    (i)—(ii) (text unchanged)

    (iii) Residency requirements in COMAR[; and].

    [(c) Be under 51 years of age; and]

    (2) (text unchanged)

    B. An applicant whose income does not exceed [200] 250 percent of the federal poverty level and is determined eligible for pregnancy or postpartum coverage under COMAR 10.09.24 shall be:

    (1)—(2) (text unchanged)

    .04 Application.

    A. The Department shall:

    (1) (text unchanged)

    (2) Give oral or written information about the eligibility requirements, coverage, scope and related services of the Family Planning Program, and [a woman’s] an individual’s rights and obligations under the Family Planning Program, to any individual requesting this information;

    (3) Give [a womanan individual requesting Family Planning Program coverage the opportunity to apply; and

    (4) Make the application available to the individual without delay[;].

    B. (text unchanged)

    C. [A womanAn individual who wishes to apply for the Family Planning Program under this chapter shall submit a written, signed application form to the Department. An applicant shall be responsible for completing the application but may be assisted by another individual of the applicant’s choice.

    D. (text unchanged)

    E. [A womanAn individual who applies for the Family Planning Program may voluntarily withdraw that application; however the application form will remain the property of the Department.

    F. (text unchanged)

    G. Extension of Time Limitations.

    (1) The Department may approve an extension of the time limitation specified in §E of this regulation if:

    (a) The applicant or authorized representative is actively attempting to establish the applicant’s or [recipient’s] participant’s eligibility but has been unable to provide the required information or verification through no fault of the applicant, [recipientparticipant, or authorized representative; or

    (b) (text unchanged)

    (2) The Department shall document the reason for the extension in the applicant’s or [recipient’sparticipant’s case record.

    (3) (text unchanged)

    H.—K. (text unchanged)

    L. A [recipientparticipant shall cooperate with the Department in completing a form designated by the Department to report pertinent information and in collecting available health insurance benefits and other third-party payments.

    .08 Determining Financial Eligibility.

    An applicant is financially eligible for the Family Planning Program if the applicant's countable net family income as determined under Regulations .05, .06, and .07 of this chapter does not exceed [200250 percent of the federal poverty level.

    .09 Certification Periods.

    A. For a [recipientparticipant, certification for initial eligibility begins not sooner than the first day of the month of application.

    B. A [recipient’sparticipant’s eligibility under Regulation .03 of this chapter will end as of the:

    (1)—(2) (text unchanged)

    (3) Date the Department receives notice of permanent sterilization of a [recipient] participant;

    [(4) End of the month in which the recipient becomes age 51;]

    [(5)] (4) Beginning of the month in which the [recipient] participant is enrolled in [Medicaid] Medicare; or

    [(6)] (5) Date a [recipient] participant becomes an inmate in a public institution.

    .11 Post–Eligibility Requirements.

    A. The Department shall inform the applicant of the applicant’s legal rights and obligations and give the applicant written notification of the following:

    (1) For an eligible [womanindividual:

    (a)—(c) (text unchanged)

    (2) For an ineligible [womanindividual:

    (a)—(d) (text unchanged)

    B. [RecipientParticipant Responsibility.

    (1) A [recipientparticipant shall notify the Department within 10 business days of changes affecting the [recipient’s] participant’s eligibility.

    (2) A [recipientparticipant shall limit use of the Family Planning card to the [womanindividual whose name appears on the card.

    (3) When written notice of cancellation is received, a [recipientparticipant shall discontinue use of the Family Planning card on the first day of ineligibility.

    (4) (text unchanged)

    (5) A [recipientparticipant shall cooperate with the State’s Medical Assistance quality control review process, including verification of information pertinent to the determination of eligibility.

    (6) If the [recipientparticipant refuses to cooperate, the [recipient’sparticipant’s coverage shall end subject to the regulation governing timely and adequate notice under COMAR

    [(6)] (7) If the [recipientparticipant refuses to cooperate, the [recipient’sparticipant’s coverage shall end subject to the regulation governing timely and adequate notice under COMAR 10.01.04.

    C. Unscheduled Redeterminations.

    (1) The Department shall promptly make an unscheduled redetermination when:

    (a) The [woman’sparticipant’s circumstance suggests future changes which may affect eligibility before the due date of a scheduled redetermination;

    (b) Relevant facts or changes in circumstances are reported by the [recipientparticipant or an authorized representative; or

    (c) (text unchanged)

    (2) The Department shall notify the [recipientparticipant that a redetermination shall establish continuing eligibility.

    (3) (text unchanged)

    (4) The Department shall notify the [recipientparticipant of the required information and verifications needed to determine eligibility and the time standards in acting in the redetermination process.

    (5) (text unchanged)

    (6) Eligibility Decisions.

    (a) [Recipients] Participants who are determined eligible for the remainder of the certification period shall be sent a notice in accordance with §A(1) of this regulation.

    (b) [Recipients] Participants determined ineligible for the remainder of the certification period because of a change in circumstances or failure to establish eligibility following a change in circumstances, shall be sent a notice in accordance with §A(2) of this regulation.

    (7) [A womanAn individual may reapply after cancellation of current eligibility, at which time a new period under consideration shall be established.

    D. Scheduled Redeterminations.

    (1) The Department shall make a scheduled redetermination of [a woman’sa participant’s eligibility once every 12 months.

    (2) The Department shall notify the [recipientparticipant that a redetermination shall establish continuing eligibility.

    (3)—(4) (text unchanged)

    (5) The new period shall be related to the date the application is received but may not include months in which the [womanparticipant was entitled to coverage under the current certification period.

    (6) A [recipientparticipant shall be treated the same as an applicant at the time of scheduled redetermination.

    (7)—(9) (text unchanged)


    10.09.58 Family Planning Program

    Authority: Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland

    .01 Purpose and Scope.

    A. (text unchanged)

    B. Eligibility shall be established [for women] according to COMAR 10.09.37.

    .02 Definitions.

    A. (text unchanged)

    B. Terms Defined.

    (1) ['Certified nurse practitioner' means a licensed registered nurse who:

    (a) By reason of certification under COMAR 10.27.07, may practice in Maryland as a nurse practitioner under the terms of those regulations; or

    (b) Qualifies as a nurse practitioner in the state in which services are provided.] “Advanced practice nurse” means an individual who meets the requirements in COMAR 10.09.01.

    (2)—(11) (text unchanged)

    (12) “Participant” means an individual who is certified as eligible for the Family Planning Program as described in COMAR 10.09.37.

    [(12)(13) (text unchanged)

    (14) “Physician assistant” means an individual who meets the requirements in COMAR 10.09.55.

    [(14)(15)[(16)(17) (text unchanged)

    [(17) 'Recipient' means a woman who is certified as eligible for the Program according to COMAR 10.09.37.]

    .03 Licensure Requirements.

    A. [A certified nurse practitionerAn advanced practice nurse shall[:

    (1) Be licensed to practice registered nursing in Maryland and be certified as a nurse practitioner by the Board of Nursing; or

    (2) Meet the nurse practitioner regulatory requirements of the state in which services are providedbe licensed to practice as described in COMAR 10.09.01.

    B. A doctor of medicine or osteopath shall be licensed and legally authorized to practice medicine in the state in which the service is delivered as described in COMAR 10.09.02.

    C. A physician assistant must be licensed to practice as described in COMAR 10.09.55.

    [C.D.—[E.F. (text unchanged)

    [F. The provider shall ensure that all X-ray and other radiological equipment is maintained and inspected in compliance with the requirements of Environment Article, Title 8, Subtitle 3, Annotated Code of Maryland (Maryland Radiation Act), and meets the standards established by COMAR 26.12.01 and 26.12.02, or other applicable standards established by the state in which the service is provided.]

    .04 Conditions of Participation.

    A. Providers shall be enrolled as Medical Assistance Program providers and shall meet the requirements for participation in the Maryland Medical Assistance Program as set forth in COMAR, as well as the requirements for participation as set forth in the COMAR chapter defining the provider and covered service being rendered.

    B. [If required by the state in which services are provided, certified nurse practitioners shall have a written agreement with a licensed physician.Services covered in Regulation .05A—C of this chapter shall be provided by:

    (1) A physician;

    (2) An advance practice nurse; or

    (3) A physician assistant.

    [C. Services are rendered in accordance with recognized standards established for family planning by the American College of Obstetricians and Gynecologists.]

    [D.] C. (text unchanged)

    .05 Covered Services.

    The following services are covered under this chapter:

    A. Office medical visits [and hospital outpatient department visits] for the primary purpose of providing age and sex appropriate family planning [purposes] services, which include:

    (1) [Complete initial and annual physical examination including auscultation of heart and lungs;] Focused history, physical exam, and laboratory testing necessary to evaluate and manage the participant’s choice of chemical, mechanical, or other method to prevent conception;

    [(2) Pelvic examination, including bimanual and speculum, and Pap smears annually, unless clinical indication for more frequent examination exists;

    (3) Breast examination;

    (4) Rectal examination, if indicated;]

    [(5)(2)[(7)] (4) (text unchanged)

    B.—C. (text unchanged)

    D. The following laboratory tests:

    (1)—(3) (text unchanged)

    [(4) Serologic tests for syphilis;

    (5) Gonorrhea and chlamydia screening and culture;

    (6) Tests for human immunodeficiency viruses;

    (7) Herpes culture;]

    (4) Appropriate laboratory tests to screen for sexually transmitted infections;

    [(8)] (5) (text unchanged)

    [(9)(6) Rubella titer of females without documentation of prior rubella immunization; and

    [(10)(7) (text unchanged)

    [(11) Blood glucose; and

    (12) Glucose tolerance tests;]

    E. Pharmaceutical supplies and devices:

    (1) (text unchanged)

    (2) To treat sexually transmitted infections when diagnosed during the course of an office visit, as outlined in §A of this regulation, which are covered under COMAR except treatment for[;]:

    (a) Human immunodeficiency virus; and

    (b) Hepatitis.

     F.—G.. (text unchanged)

    .06 Limitations.

    A. (text unchanged)

    B. Limitations for [certified nurse practitioner] advanced practice nurse services covered under this chapter are those set forth in COMAR

    C.—F. (text unchanged)

    G. Limitations for acute hospital services covered under this chapter are those set forth in COMAR [10.09.06]

    H. Limitations for physician assistant services covered under this chapter are those set forth in COMAR

    I. Limitations for ambulatory surgery centers covered under this chapter are those set forth in COMAR

    .07 Payment Procedures.

    A.—B. (text unchanged)

    C. Payment procedures for [certified nurse practitioners] advanced practice nurses are those set forth in COMAR

    D.—E. (text unchanged)

    F. [For dates of service on or after January 1, 2012, paymentPayment procedures for clinic services delivered in local health departments, family planning clinics, and other free-standing clinics are those set forth in COMAR

    G.—H. (text unchanged)

    I. Payment procedures for acute hospital services are those set forth in COMAR []

    J. Payment procedures for physician assistant services are those set forth in COMAR

    K. Payment procedures for ambulatory surgery centers are those set forth in COMAR

    Secretary of Health