​PROPOSAL

Maryland Register

Issue Date:  February 1, 2019

Volume 46 • Issue 3 • Page 138-144

Title 10 
MARYLAND DEPARTMENT OF HEALTH

Subtitle 52 PREVENTIVE MEDICINE

10.52.08 Maryland HIV Prevention Case Management Program

Authority: Health-General Article, §§2-104(b) and (j), 2-105(a), and 
18-102(a), Annotated Code of Maryland

Notice of Proposed Action

[19-032-P]

The Secretary of Health proposes to adopt new Regulations .01—.16 under a new chapter, COMAR 10.52.08 Maryland HIV Prevention Case Management Program.

Statement of Purpose

The purpose of this action is to establish regulations for the Maryland HIV Prevention Case Management Program (Prevention Program), which provides prevention and wraparound services for individuals at elevated risk for acquiring HIV. These regulations include recipient eligibility criteria for the Prevention Program. Regulations for eligibility criteria are required by Ch. 46 (S.B. 91), Acts of 2016, Public Health — State-Identified HIV Priorities in order to use rebates received by the Maryland Department of Health (the Department) from the Maryland AIDS Drug Assistance Program (MADAP) to fund the Prevention Program.

This proposal further establishes regulations for the Prevention Program related to:

(1) Program funding;

(2) Application for funding from the Department;

(3) Navigation program design and operation;

(4) Recipient screening, care plan, application, and enrollment into the program;

(5) Covered services;

(6) Recovery of payments;

(7) Fraud;

(8) Confidentiality;

(9) Availability of funding and program termination;

(10) Changes in eligibility and enrollment;

(11) Reconsideration and appeal;

(12) Payment procedures; and

(13) Cause for suspension or removal, and imposition of sanctions.

Comparison to Federal Standards

There is no corresponding federal standard to this proposed action.

Estimate of Economic Impact

I. Summary of Economic Impact. This proposal will have an economic impact on the Department and local health departments or community-based organizations if a local health department or a community-based organization applies to establish a program to provide HIV prevention and wraparound services funded by the Department. Local health departments and community-based organizations that are approved will receive funding from the Department to provide these services. Because these programs are not yet established, and the Department does not know how many local health departments or community-based organizations will apply, the economic impact is indeterminable. In addition, the cost to establish programs may vary across jurisdictions as costs of services provided will vary widely. MADAP drug rebate funds will be used. The cost of this program will be dependent on the number of approved grant applications, but is not expected to exceed $2,000,000 annually.

 

	Revenue (R+/R-)
II. Types of Economic Impact.	Expenditure (E+/E-)	Magnitude
A. On issuing agency:	(E+)	Up to $2,000,000
B. On other State agencies:	NONE
C. On local governments:	(R+)	Indeterminable
	Benefit (+) Cost (-)	Magnitude
D. On regulated industries or trade groups:	NONE
E. On other industries or trade groups:	NONE
F. Direct and indirect effects on public:	(+)	Indeterminable
III. Assumptions. (Identified by Impact Letter and Number from Section II.)
A. Through the Maryland HIV Prevention Case Management Program, the Department will provide grant funding to local health departments and community-based organizations to provide HIV prevention and wraparound services. This funding will come from the Department, so there will be an increase in expenditures. Because the Department does not know how many organizations will apply and be approved for funding or how much funding will be needed, this impact is indeterminable, but is not expected to exceed $2,000,000 annually.
C. Local health departments may apply for grant funding to provide HIV prevention and wraparound services. If local health departments apply for and receive funding, these regulations will result in a positive economic impact on local health departments. Because the Department does not know how many local health departments will apply for funding or how much funding will be needed, this impact is indeterminable.
F. Through the establishment of the Maryland HIV Prevention Case Management Program, individuals at elevated risk for acquiring HIV will be able to access HIV prevention and wraparound services. These services will benefit these individuals and may include financial assistance. Because the Department does not know how many individuals will participate in the program or how much financial assistance will be needed, this impact in indeterminable.

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 Jake Whitaker, Acting Director, Office of Regulation and Policy Coordination, Maryland Department of Health, 201 West 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 March 4, 2019. A public hearing has not been scheduled.

.01 Purpose.

The purpose of the Maryland HIV Prevention Case Management Program is to:

A. Provide community-based prevention services for individuals at elevated risk for acquiring human immunodeficiency syndrome (HIV) including:

(1) Routine testing;

(2) Risk reduction counseling; and

(3) Pre-exposure prophylaxis (PrEP); and

B. Address the needs of recipients that would otherwise present barriers to accessing prevention services including:

(1) Housing;

(2) Transportation;

(3) Food;

(4) Vocational assistance; and

(5)  Health care needs including:

(a) Primary health care services; and

(b) Behavioral health care services.

.02 Definitions.

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) “Acquired immunodeficiency syndrome (AIDS)” means the medical condition caused by the human immunodeficiency virus.

(2) Agent.

(a) “Agent” means an individual who assists an applicant in submitting an application for prevention services and is employed by an organization that has received funding from the Department under the Maryland HIV Prevention Case Management Program.

(b) “Agent” includes:

(i) A prevention navigator;

(ii) A case manager;

(iii) A licensed social worker;

(iv) A registered nurse; and

(v) Any other related professional who assists an individual in submitting an application to a grantee.

(3) “Annual recertification form” means the form approved by the Department on which a recipient provides information to the Department to verify eligibility for the Prevention Program at the end of each enrollment period.

(4) “Antiretroviral therapy (ART)” means multiple anti-retroviral medications that are prescribed to slow or stop the replication of HIV in the body.

(5) “Applicant” means an individual on whose behalf an application has been submitted to a grantee for services under the Maryland HIV Prevention Case Management Program and whose eligibility status is not yet determined.

(6) “Care plan” means an outline of a recipient’s engagement with a case manager including the:

(a) Services needed by the recipient;

(b) Progress toward meeting those needs; and

(c) Responsibilities of the case manager and recipient toward meeting those goals or needs.

(7) “Case management services” means the assignment of a recipient’s case to a case manager for ongoing assessment and coordination of the various services needed to engage in the Maryland HIV Prevention Case Management Program.

(8) “Community-based organization (CBO)” means a public or private organization that:

(a) Is representative of a community or significant segments of a community; and

(b) Provides educational, health, or social services to individuals in the community.

(9) “Department” means the Maryland Department of Health.

(10) “Engaged” means actively enrolled in services with the case manager including:

(a) Meeting in-person at least quarterly with a case manager; and

(b) Keeping in contact with a case manager by phone, email, or messaging application at least once per month.

(11) “Enrollment period” means the period of time a recipient may receive Maryland HIV Prevention Case Management Program benefits.

(12) “Grantee” means an organization that:

(a) Receives funding from the Maryland Prevention Case Management Program;

(b) Employs at least one agent; and

(c) Provides:

(i) At least one covered service; and

(ii) Financial assistance for the client to engage in covered services offered outside the organization.

(13) “Gross income” means the income derived from sources provided in Regulation .06B of this chapter before any deductions.

(14) “Human immunodeficiency virus (HIV)” means the virus that causes AIDS.

(15) Identity Documents.

(a) “Identity documents” means documents that are used by a recipient to prove identity to access:

(i) Medical services;

(ii) Social services;

(iii) Housing;

(iv) Employment; or

(v) Other services.

(b) “Identity document” includes a:

(i) Social Security card;

(ii) Birth certificate;

(iii) Driver’s license; and

(iv) State identification card.

(16) “LGBTQIA+” means lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other genders and sexual identities.

(17) “Navigation program” means a program established according to Regulations .04 and .05 of this chapter by a grantee that is approved by the Department to provide HIV prevention services to a recipient or to pay for HIV prevention services for a recipient using Prevention Program funds.

(18) “nPEP” means non-occupational Post-Exposure Prophylaxis, which is prescribing ART or other U.S. Food and Drug Administration-approved medications for someone who is currently HIV-negative and at increased risk for HIV acquisition due to a non-work-related known or suspected exposure to HIV that occurred in the preceding 72 hours.

(19) Payor.

(a) “Payor” means an organization that pays for medical, social, or other services as part of the Maryland HIV Prevention Case Management Program.

(b) “Payor” includes a:

(i) Public insurance plan;

(ii) Private insurance plan;

(iii) Foundation or other source of grant funding; and

(iv) Pharmaceutical patient assistance program or foundation pharmaceutical assistance program.

(20) “PrEP” means HIV pre-exposure prophylaxis, which is prescribing ART or other U.S. Food and Drug Administration-approved medications for the prevention of HIV to an individual who is HIV-negative and at increased risk of acquiring HIV due to sexual contact or sharing of injection drug equipment with an individual living with HIV or of unknown HIV status.

(21) “Prevention navigator” means an individual employed by a grantee who:

(a) Assists an applicant or recipient in:

(i) Assessing needs;

(ii) Applying for services; and

(iii) Following up on referrals; and

(b) Provides services to recipients including:

(i) Health education;

(ii) Health literacy support; and

(iii) Prevention counseling.

(22) “Prevention Program” means the Maryland HIV Prevention Case Management Program.

(23) “Recipient” means an individual who is enrolled in Prevention Program services.

(24) “Resident” means an individual:

(a) Who lives in Maryland voluntarily with the intention of making the State the individual’s home and not for a temporary purpose; and

(b) For whom any temporary absence from the State is coupled with an intent to return so as not to interrupt the continuity of residence.

(25) “Sexually transmitted infection (STI)” means an infection passed from one person to another person through sexual contact.

(26) “Visit” means an appointment at the office of a service provider, between the recipient and a case manager, prevention navigator, health care provider, or other professional that is billable by health insurance.

.03 Program Funding.

A. The Department may provide funding to a CBO or a local health department approved to establish and operate a navigation program.

B. Funding may cover:

(1) Case management services provided by an agent at a local health department or CBO;

(2) The estimated cost for a local health department or CBO to directly provide covered services to recipients; and

(3) The estimated cost for a local health department or CBO to provide payments to external organizations for covered services provided to program recipients.

C. A local health department or a CBO that is approved to operate a navagation program:

(1) May apply to the Department for grant funding to cover case management and services each State fiscal year; and

(2) Shall include in the application for grant funding community input and feedback to identify community needs and estimate costs for services for each funding period.

.04 Application for Funding from the Department.

A. A CBO or local health department that applies to receive funding from the Department to establish a navigation program:

(1) Shall submit an application to the Department that includes:

(a) Responses to all applicable questions; and

(b) Any supporting documentation indicated on the application;

(2) May voluntarily withdraw an application at any time; and

(3) May submit a new application at any time.

B. The Department shall:

(1) Request additional information or changes to the application if necessary; and

(2) Respond in writing to the applicant within 60 calendar days indicating the disposition of the application and explanation of the decision.

C. The Department shall:

(1) Review the application; and

(2) Either:

(a) Approve the application if the:

(i) Application is complete; and

(ii) The navigation program meets the requirements of Regulation .05 of this chapter; or

(b) Disapprove the application if the:

(i) Application does not provide sufficient information or documentation on the program; or

(ii) Navigation program does not meet the requirements of Regulation .05 of this chapter.

D. A CBO or local health department whose application is disapproved may appeal the decision to the Director of the Infectious Disease Prevention and Health Services Bureau in the Department by submitting the request in writing within 30 calendar days of the date postmarked on the notice of disapproval.

E. If a CBO or local health department submits an appeal, the Director of the Infectious Disease Prevention and Health Services Bureau shall within 60 days:

(1) Grant or deny the appeal; and

(2) Respond in writing to the CBO or local health department:

(a) Indicating whether the appeal has been granted or denied; and

(b) Providing an explanation of the decision.

.05 Navigation Program Design and Operation.

The grantee approved to operate a navigation program:

A. Shall ensure that all navigaton program staff have:

(1) Appropriate levels of expertise in working with individuals who are members of vulnerable populations such as people of color, members of the LGBTQIA+ community, and people who use drugs;

(2) Knowledge of harm reduction strategies; and

(3) Skills in implementing harm reduction strategies;

B. Shall ensure that all program staff receive training approved by the Department to work with vulnerable populations and to provide referrals to:

(1) Community services;

(2) Counseling; and

(3) Preventative education;

C. Shall ensure that all program staff demonstrate sensitivity to participant differences including:

(1) Cultural;

(2) Behavioral; and

(3) Values;

D. Shall ensure that information collected to identify program participants is kept confidential according to:

(1) Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and

(2) The Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. §§1320d et seq., as amended, the HITECH Act, 42 U.S.C. §§17932, et seq., as amended, and 45 CFR Parts 160 and 164, as amended, and their implementing regulations; and

E. May not discriminate against participants based on factors including but not limited to:

(1) Culture;

(2) Language;

(3) Ability;

(4) Socioeconomic status;

(5) Sexual orientation;

(6) Gender identity;

(7) Age;

(8) Religion;

(9) Race; and

(10) Ethnicity.

.06 Recipient Eligbility for Program Services.

A. To be eligible for prevention program benefits, an individual shall meet the following criteria:

(1) Be a resident;

(2) Have one of the following factors for increased risk of acquisition of HIV:

(a) A recently diagnosed STI;

(b) A partner known to be living with HIV, if the partner:

(i) Is not prescribed ART; or

(ii) Takes ART inconsistently;

(c) Sharing of injection drug equipment;

(d) Be a member of one of the following populations:

(i) Individuals identifying as a gay, bisexual, or same-gender-loving man;

(ii) Individuals identifying as transgender; or

(iii) Individuals engaging in commercial sex work; or

(e) Be sexually active with no or inconsistent use of condoms in a zip code with:

(i) Increased prevalence or incidence of HIV; or

(ii) Low viral suppression among people living with HIV;

(3) Have a projected gross income that is less than or equal to 138 percent of the Federal Poverty Level Guidelines, as updated annually in the Federal Register by the U.S. Department of Health and Human Services under authority of 42 U.S.C. §9902(2); and

(4) Not be eligible to enroll with or be enrolled with another payor that covers all services provided by the Prevention Program.

B. Gross Income.

(1) Gross income includes income derived from:

(a) Wages and salaries, including tips;

(b) Net income from self-employment or business;

(c) Unemployment compensation;

(d) Social Security payments, including disability payments;

(e) Alimony;

(f) Retirement or pension;

(g) Investments, including dividends or interest;

(h) Rental income; and

(i) Other taxable income, such as prizes, awards, and gambling winnings.

(2) Gross income does not include income derived from:

(a) Child support;

(b) Gifts;

(c) Supplemental Social Security income;

(d) Veterans’ disability payments;

(e) Workers’ compensation; and

(f) Proceeds from loans, such as student loans, home equity loans, or bank loans.

C. The Prevention Program shall be the payor of last resort for a recipient.

.07 Recipient Screening, Care Plan, Application, and Enrollment into the Program.

A. Screening.

(1) The agent shall complete a needs assessment and a sexual health screening for the applicant or recipient during each visit.

(2) The needs assessed shall include but are not limited to:

(a) Housing;

(b) Access to food;

(c) Employment;

(d) Job readiness;

(e) Educational or vocational needs;

(f) Behavioral health;

(g) Medical needs;

(h) Transportation;

(i) Linguistic needs;

(j) Legal needs; and

(k) Health education and literacy.

(3) A sexual health screening shall include sexual health counseling.

(4) If a recipient is enrolled in a Prevention Program that includes PrEP, the recipient shall meet with a health care provider with prescribing capability on a quarterly basis to complete recommended laboratory tests.

B. Care Plan. The agent shall:

(1) Develop a care plan based on the assessment and screening completed per §A of this regulation; and

(2) Update the care plan during each visit to track progress or identify new needs.

C. Application.

(1) The agent shall assist the client in completing an application on the form designated by the Department that includes:

(a) Responses to all applicable questions; and

(b) A copy of the requested verification documentation, including proof of residence and gross income.

(2) The agent or the applicant may voluntarily withdraw the application at any time without prejudice.

(3) The agent shall submit the application to the grantee for review and approval.

(4) The grantee shall:

(a) Approve the application if the:

(i) The application is complete;

(ii) The applicant is determined to be eligible; and

(iii) All necessary verification documents are included with the application; or

(b) Disapprove the application if the:

(i) Application is incomplete; or

(ii) Applicant fails to provide sufficient information or documentation to determine eligibility.

(5) After a determination has been made in accordance with §C(4) of this regulation, the grantee shall contact the applicant with the status of the application.

D. Enrollment.

(1) A recipient shall be enrolled in the Prevention Program beginning the first day of the month in which the approved application was received.

(2) Prevention Program benefits for the recipient shall be discontinued automatically after 12 months from the date of enrollment if the client does not complete an annual recertification form, or sooner should program funding from the Department be exhausted.

(3) A recipient:

(a) Shall be notified in writing by the agent and grantee 30 days prior to the termination of benefits; and

(b) Subject to application approval and availability of funds, may complete an annual recertification form to receive continuing benefits.

E. Engagement.

(1) To receive Prevention Program benefits, a recipient shall remain engaged with the agent.

(2) If the recipient does not remain engaged with the agent, the recipient may be disenrolled from the Prevention Program.

(3) If a recipient is disenrolled from the Prevention Program due to lack of engagement, the recipient may reapply for Prevention Program services.

.08 Covered Services.

A. If a recipient is enrolled with a payor that provides some of the services provided by the Prevention Program, the Prevention Program shall be billed only for services not covered by the payor.

B. The grantee:

(1) May provide covered program services directly; and

(2) May refer recipients to an outside organization and pay for the services on behalf of the recipient.

C. The agent employed by the grantee shall obtain and keep on file documentation of costs and receipt of payment for services paid for under §B(2) of this regulation. 

D. Prevention Program services covered by a grantee shall include:

(1) Medical services including:

(a) Office visits;

(b) Laboratory services;

(c) Vaccinations;

(d) PrEP or nPEP medications provided to a recipient; and

(e) Durable medical equipment not covered by insurance or another funding source;

(2) Behavioral health services identified in the recipient’s care plan including:

(a) Mental health therapy;

(b) Psychiatric services; and

(c)  Substance use disorder services;

(3) HIV prevention services identified in the recipient’s care plan including:

(a) Testing;

(b) Harm reduction counseling;

(c) Health education;

(d) Risk reduction counseling; and

(e) Navigation, outreach, and case management to improve adherence to PrEP;

(4) If the recipient is able to afford ongoing rental housing payments based on net income, one-time financial assistance for housing that is equal to the recipient’s share of the costs for 1 month’s rent payment required to:

(a) Obtain rental housing; or

(b) If the recipient is under threat of eviction, maintain rental housing;

(5) Financial assistance for up to 12 months of:

(a) Transitional housing;

(b) Emergency housing; or

(c) Rapid rehousing; 

(6) One-time financial assistance not exceeding $1,000 for utility arrears to prevent a utility shut-off;

(7) Emergency food assistance paid via grocery store gift cards;

(8) If other financial aid sources have been exhausted, one-time financial assistance for education including:

(a) Adult literacy course tuition, fees, and books;

(b) Adult basic education course tuition, fees, and books;

(c) GED preparatory class tuition, fees, and books;

(d) GED exam fees;

(e) Tuition for a driver’s license preparation course to enable the recipient to obtain a driver’s license for the purposes of employment as driver for a taxi, rideshare, or delivery company;

(f) Tuition, fees, and materials for a single career preparation course;

(g) Tuition, fees, and materials for completing a career preparation certificate program up to 20 credits or 800 hours at the community college in the recipient’s county of residence; and

(h) Tuition, fees, and materials for completing a career preparation certificate program above 20 credits or 800 hours, subject to approval by the Department and availability of funds;

(9) Job-readiness services, including:

(a) Education on:

(i) Interviewing skills;

(ii) Resume writing; and

(iii) Job searching;

(b) Resume proofreading and editing;

(c) Mock interviews and feedback; and

(d) Provision of donated interview attire;

(10) Child care services needed for the recipient to receive services identified in the recipient’s care plan;

(11) Transportation assistance for the recipient to receive services identified in the recipient’s care plan including but not limited to:

(a) Public transit assistance; and

(b) A voucher for a taxi or car service;

(12) Provided that the services are not available directly from the service provider and the service provider is not required by law to provide the services, linguistic services needed for the recipient to receive medical or social services identified in the recipient’s care plan;

(13) Legal services including:

(a) Assistance with paperwork and fees required for identification to obtain employment, medical care, or other services identified in the recipient’s care plan;

(b) Assistance for a transgender recipient seeking to change the name or gender marker on identity documents; and

(c) Assistance with expungement services to help improve the ability of the recipient to obtain employment or access to educational programs;

(14) Recovery services needed as a result of sexual assault, intimate partner violence, or interpersonal violence of which the recipient was a victim;

(15) Financial literacy education and tax filing education or assistance; and

(16) If private health or dental insurance is necessary for the recipient to receive services identified in the recipient’s care plan, financial assistance for health or dental insurance premiums to purchase a plan on Maryland Health Connection.

.09 Recovery of Payments.

A. If benefits have been incorrectly paid or another payor has been identified, the Department shall seek recovery of the amount of those payments.

B. A grantee shall inform the Department if benefits have been incorrectly paid or another payor has been identified.

.10 Fraud.

A. The Department shall pursue cases of suspected misrepresentation or fraud pursuant to Criminal Law Article, §8-503, Annotated Code of Maryland, or any other applicable statutory provision.

B. A grantee shall inform the Department of suspected misrepresentation or fraud that may be pursued under the Criminal Law Article, §8-503, Annotated Code of Maryland, or any other applicable statutory provision.

.11 Confidentiality.

Except when otherwise authorized by law, the agent of an applicant, the agent of a recipient, the grantee, and the Department:

A. Shall keep all applicant and recipient personal information confidential;

B. May not disclose personal information kept on an applicant or recipient without written consent of the:

(1) Applicant;

(2) Recipient;

(3) Applicant’s parent or legal guardian; or

(4) Recipient’s parent or legal guardian;

C. Shall comply with the laws and regulations concerning the privacy and security of protected health information under:

(1) Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and

(2) The Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. §§1320d et seq., as amended, the HITECH Act, 42 U.S.C. §§17932, et seq., as amended, and 45 CFR Parts 160 and 164, as amended, and their implementing regulations; and

D. Shall ensure that all interactive video technology-assisted communication comply with HIPAA patient privacy and security regulations.

.12 Availability of Funding and Program Termination.

A. If sufficient monies are not available to fund the Prevention Program, the Department shall take the action necessary to eliminate a deficit which may include program termination or restricting eligibility for the program.

B. If the program is terminated, the Department shall continue to provide benefits for each currently enrolled recipient through the earlier of:

(1) The end of the recipient’s 12-month enrollment period; or

(2) 6 months from the date of program termination.

.13 Changes in Eligibility and Disenrollment.

A. A recipient shall notify the agent or Department within 60 business days of a change in:

(1) Availability of third-party or insurance payment for covered services;

(2) Gross income; or

(3) Address.

B. If the agent or Department determines that a change reported in §A of this regulation results in the recipient no longer qualifying for Prevention Program services, the agent or the Department shall disenroll the recipient.

C. The notice of disenrollment shall:

(1) Be mailed to the recipient at least 15 business days before the effective date of disenrollment;

(2) Include an explanation of the action;

(3) Cite the section of regulations supporting the action; and

(4) Explain the right of the recipient to request reconsideration or an appeal of the decision.

D. If the recipient is determined to be ineligible before the end of the current enrollment period because of a change in residency, medical, or financial eligibility criteria, the disenrollment shall be the earlier of:

(1) The date on which the recipient’s current enrollment ends; or

(2) The first day of the month that is at least 15 calendar days after the date of the notice of ineligibility for benefits.

.14 Reconsideration and Appeal.

A. An applicant or recipient who has been notified by the Department or grantee of ineligibility for or disenrollment from Prevention Program benefits may request reconsideration of the decision by submitting a letter of reconsideration with additional supporting documentation or information to the agent or Department within 30 business days of the notification.

B. If an applicant or recipient submits a letter of reconsideration within 30 days of notification of ineligibility or disenrollment from the Prevention Program for reconsideration, the grantee or Department shall:

(1) Review all additional supporting documentation provided by the applicant or recipient within 10 business days of the grantee or Department’s receipt of the request for reconsideration; and

(2) Issue a final decision in writing to the applicant or recipient.

C. An applicant or recipient may appeal the reconsideration decision by requesting in writing a hearing with the Office of Administrative Hearings.

D. The Office of Administrative Hearings shall:

(1) Conduct a hearing according to the procedures set forth in COMAR 28.02.01;

(2) Hold a hearing to review the decision within 45 days of the postmarked date on the letter requesting a hearing; and

(3) Issue a decision in writing to the applicant or recipient.

.15 Payment Procedures.

A. The grantee shall:

(1) Pay for covered services directly to the vendor on behalf of the recipient; and

(2) Report amounts paid for services in the expenditure reports required by the Department.

B. The agent shall obtain documentation of payments due to outside organizations and receipt of payment made on behalf of the recipient.

C. Payment for services, other than gift cards for the purchase of food, may not be provided directly to the recipient.

D. If the recipient has an insurance plan that covers any of the services provided by the Prevention Program, the grantee or Department shall pay the service provider the balance remaining after the insurance plan pays for services.

.16 Cause for Suspension or Removal, and Imposition of Sanctions.

A. If the Department determines that a service provider or service provider’s employee, or both, has failed to comply with federal or State laws and regulations or has engaged in fraud or abuse, the Department may:

(1) Suspend the service provider from receiving payments from Prevention Program funds;

(2) Withhold payment to the service provider; or

(3) Permanently ban the service provider from receiving funds from the Prevention Program and bar future payments to the service provider.

B. If a service provider or the service provider’s employee is barred from Medicaid or Medicare, the Department shall bar the service provider or service provider’s employee.

C. A service provider that is barred or suspended from receiving payments according to this regulation shall notify a recipient that the provider is no longer able to accept payment from the Prevention Program and that the recipient may:

(1) Find a new provider through the recipient’s agent or the Department; or

(2) Pay for services directly to continue with the service provider.

ROBERT R. NEALL
Secretary of Health

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