# COMAR Title 10 — Maryland Department of Health

## Subtitle 02 — Division of Reimbursements

### Chapter 01 — Charges for Services Provided Through the Maryland Department of Health

**Authority:** Health-General Article, §§16-201—16-407, Annotated Code of Maryland

**Administrative History:** Effective date: January 6, 1976 (3:4 Md. R. 215)

**Administrative History:** Promulgated as emergency provision April 14, 1976 (3:11 Md. R. 586)

**Administrative History:** Regulations .01—.07 amended effective July 21, 1976 (3:15 Md. R. 791)

**Administrative History:** Regulation .02 amended effective May 5, 1986 (13:9 Md. R. 1027)

**Administrative History:** Regulation .04 amended as an emergency provision effective March 18, 1985 (12:7 Md. R. 693); adopted permanently effective June 3, 1985 (12:11 Md. R. 1047)

**Administrative History:** Regulation .04 amended as an emergency provision effective November 14, 1985 (12:25 Md. R. 2468); adopted permanently effective April 6, 1986 (13:7 Md. R. 795)

**Administrative History:** Regulation .04 amended effective May 5, 1986 (13:9 Md. R. 1027)

**Administrative History:** Regulation .04A amended effective March 23, 1987 (14:6 Md. R. 714); June 27, 1988 (15:13 Md. R. 1552); April 1, 1991 (18:6 Md. R. 685)

**Administrative History:** Regulations .05A and .07A amended effective May 5, 1986 (13:9 Md. R. 1027)

**Administrative History:** Chapter revised as an emergency provision effective July 1, 1995 (22:15 Md. R. 1112); revised permanently effective October 9, 1995 (22:20 Md. R. 1543)

**Administrative History:** Regulation .03 amended as an emergency provision effective June 29, 1996 (23:15 Md. R. 1080); amended permanently effective November 4, 1996 (23:22 Md. R. 1496)

**Administrative History:** Regulation .03D amended as an emergency provision effective November 14, 1997 (24:25 Md. R. 1717); amended permanently effective February 23, 1998 (25:4 Md. R. 243)

**Administrative History:** Regulation .03D amended as an emergency provision effective September 14, 1998 (25:21 Md. R. 1571); amended permanently effective December 28, 1998 (25:26 Md. R. 1923)

**Administrative History:** Chapter revised as an emergency provision effective December 1, 2000 (27:25 Md. R. 2277); revised permanently effective March 19, 2001 (28:05 Md. R. 551)

**Administrative History:** Chapter revised effective August 17, 2015 (42:15 Md. R. 1055)

**Administrative History:** Regulation .04B amended effective February 27, 2017 (44:4 Md. R. 252)

#### Regulation .01 Purpose.

*COMAR 10.02.01.01*

It is the intent of this chapter that:

A. The cost of care of a recipient of services be determined in accordance with the charges for health services set under this chapter;

B. There be a single or, if appropriate, bundled charge for each health service rendered to an individual, including an individual in a group session or family group session; and

C. The methods for determining full costs be uniform among all units.

#### Regulation .02 Scope.

*COMAR 10.02.01.02*

This chapter applies to:

A. All inpatient facilities operated by the Department;

B. All local health departments' programs funded by the Department;

C. All private or public alcohol and drug abuse providers funded by the Behavioral Health Administration;

D. Adult day care funded by the Office of Health Services; and

E. Family planning services funded by the Prevention and Health Promotion Administration.

#### Regulation .03 Definitions.

*COMAR 10.02.01.03*

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

B. Terms Defined.

  (1) “Charge” means the dollar amount set or approved by the Secretary for each clinic visit, day of care, hour, procedure, or other unit of service, as specified in the Schedule of Charges, which is the single rate to be charged all recipients of service, estates, third-party payers and insurers, or chargeable persons.

  (2) “Chargeable person” means:

    (a) Any responsible relative of a recipient of services;

    (b) Except for a recipient of services, any other person who is legally responsible for the cost of care of the individual; and

    (c) Any person who maintains a policy of health insurance under which a recipient of services is insured.

  (3) “CPT” means a Current Procedural Terminology listing descriptive terms and identifying codes for reporting clinical services and procedures.

  (4) “Daily per capita inpatient cost of care” means the cost of providing a day of care at a State-operated inpatient facility.

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

  (6) “Division” means the Cost Accounting and Reimbursement Division of the Department.

  (7) Federal Indirect Cost.

    (a) “Federal indirect cost” means the cost the federal government recognizes as the costs of operating an inpatient facility that are not directly attributable to the operation of the inpatient facility.

    (b) “Federal indirect cost” includes costs which benefit the Department as a whole and the inpatient facility indirectly, but cannot be readily identified with the inpatient facility without disproportionate effort.

  (8) “Fee” means the charge or that part of the charge after an ability-to-pay determination or the elimination of disallowed costs by any third-party payer or insurer.

  (9) “Health service” means any service for which a charge is established that is provided to any person, client, or resident in or by a unit of the Department, political subdivision, or grantee which is deemed appropriate by that unit to the care and treatment of an individual under its care or enrolled in its program.

  (10) “Local health department” means a governmental agency that:

    (a) Is funded wholly or partly by the Department;

    (b) Assumes legal and financial responsibility and accountability both for funds awarded by the Department and for the provision of health services; and

    (c) Operates under the general direction of a health officer who is duly appointed by and reports to the Secretary pursuant to Health-General Article, Title 3, Subtitle 3, Annotated Code of Maryland.

  (11) “Medical Assistance ” means the Maryland Medical Assistance Program, which is administered by the State and pays the medical bills of certain needy and low-income individuals pursuant to Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland, and 42 U.S.C. Chapter 7, Subchapter XIX.

  (12) “Non-inpatient related costs” means costs at a State-operated facility which do not relate to the delivery of inpatient care.

  (13) “Out-of-network services” means health services that are provided to a recipient of services which are not subject to payment at a negotiated rate under an agreement between the provider and a public or private third-party payer or insurer for the recipient of services.

  (14) “Private provider” means:

    (a) All private or non-local health department alcohol and drug abuse service providers funded by the Behavioral Health Administration;

    (b) Adult day care service providers funded by the Office of Health Services; and

    (c) Family planning service providers funded by the Prevention and Health Promotion Administration.

  (15) “Provider” means a facility operated by:

    (a) The Department;

    (b) A local health department; or

    (c) A private provider.

  (16) Recipient of Services.

    (a) “Recipient of services” means an individual who receives care, maintenance, treatment, or support from a facility, clinic, local health department, program, or other entity that is operated or funded wholly or partly by the Department.

    (b) “Recipient of services” includes, but is not limited to an individual:

      (i) In a public facility under Health-General Article, Title 10, Annotated Code of Maryland;

      (ii) In a facility or Veterans' Administration hospital for comprehensive evaluation under Health-General Article, Title 7, Annotated Code of Maryland;

      (iii) In a residential public facility or a facility from which this State obtains residential care under Health-General Article, Title 7, Annotated Code of Maryland; and

      (iv) To whom juvenile screening or treatment services are provided under Human Services Article, §9-227(b)(1)(ii), Annotated Code of Maryland.

  (17) “Responsible relative” means one or more of the following who are legally responsible for the cost of care of a recipient of services:

    (a) The spouse of the recipient of services;

    (b) A parent of the recipient of services who is a minor; and

    (c) An adult child of the recipient of services.

  (18) “Schedule of charges” means a list of charges for health services as determined pursuant to instructions provided by the Division and this chapter, and set or approved by the Secretary.

  (19) “Secretary” means the Secretary of Health.

  (20) “Shared costs” means costs arising out of shared functions between two State-operated inpatient facilities.

  (21) Statewide and Departmental Overhead.

    (a) “Statewide and departmental overhead” means those costs incurred by the State and allocated to the facility which benefit the State-operated inpatient facility's operation as a whole, but are not related to the delivery of direct patient care.

    (b) “Statewide and departmental overhead” includes costs that are usually incurred for a common purpose benefiting the State-operated inpatient facility which are not readily identified with the State-operated inpatient facility without disproportionate effort, such as Statewide accounting, purchasing, and personnel functions.

  (22) “Third-party payer disallowance” means the difference between the charge and the payment amount authorized by an agreement between a provider and a public or private third-party payer or insurer.

#### Regulation .04 Setting of Charges for Local Health Departments.

*COMAR 10.02.01.04*

A. The Secretary shall approve a Schedule of Charges for each local health department containing the CPT-based charges for health services provided by the local health department which remain in effect until changed as provided in this chapter.

B. CPT-Based Charge.

  (1) Each health service for which payment is sought shall be assigned an applicable CPT code.

  (2) Approved Method for Determining CPT-Based Charges.

    (a) The CPT-based charge for each health service shall be equivalent to 150 percent of the Medicare participating provider fee allowance for the corresponding CPT code in the most recent Medicare Physician’s Fee Schedule for Maryland or the Washington, DC, suburbs, as appropriate, which is updated annually in the Federal Register by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, in accordance with 42 U.S.C. §1395w-4.

    (b) For any health service performed by a local health department for which a rate is not assigned in the applicable Medicare Physicians Fee Schedule, the CPT-based charge shall be equivalent to 150 percent of the Maryland Medical Assistance participating provider fee allowance for the corresponding CPT code in the Professional Services Provider Manual and Fee Schedule, as published by the Department and incorporated by reference in COMAR 10.09.02.07D.

    (c) For any health service performed by a local health department for which a rate is not assigned on the applicable Medicare Physicians Fee Schedule or in the Professional Services Provider Manual and Fee Schedule, the CPT-based charge shall be equivalent to the average hourly rate of the employees providing the service to the recipients of services, calculated based upon current fiscal year salaries and fringe benefits, multiplied by the projected time of service with recipient of services, plus 20 percent for indirect costs.

C. Revisions and modifications to a Schedule of Charges shall be made and approved by the Secretary pursuant to instructions issued by the Division, provided that the Schedule of Charges for each local health department is updated and approved by the Secretary at least annually.

D. Each approved Schedule of Charges, with all revisions and modifications, shall be retained by the Division and also be prominently posted at each location of the local health department where health services are provided.

#### Regulation .05 Setting of Charges for State-Operated Inpatient Facilities.

*COMAR 10.02.01.05*

A. Inpatient Charge.

  (1) For each fiscal year, a daily per capita inpatient cost of care for a State-operated inpatient facility shall be determined by:

    (a) Utilizing the legislatively approved budget for the inpatient facility;

    (b) Adding the federal indirect cost and Statewide and departmental overhead, less shared cost, for the applicable fiscal year; and

    (c) Dividing the amount determined in §A(1)(b), of this regulation, by the average daily population of the facility for the applicable fiscal year to arrive at the daily per capita inpatient cost of care for the facility.

  (2) The per diem inpatient charge shall equal the daily per capita inpatient cost of care as determined in §A(1)(c) of this regulation.

  (3) The per diem inpatient charge shall be set forth in the Schedule of Charges.

B. Medicare-Eligible Patient Charge.

  (1) For each fiscal year, a Medicare daily per capita inpatient cost of care for a State-operated inpatient facility shall be determined by:

    (a) Utilizing the legislatively approved budget for the inpatient facility, minus the cost of physician and ancillary services for the inpatient facility;

    (b) Adding the federal indirect cost and Statewide and departmental overhead, less shared cost, for the applicable fiscal year; and

    (c) Dividing the amount determined in §B(1)(b), of this regulation, by the average daily population of the facility for the applicable fiscal year to arrive at the Medicare daily per capita inpatient cost of care for the facility.

  (2) The per diem Medicare-eligible inpatient charge shall equal the Medicare daily per capita inpatient cost of care as determined in §B(1)(c) of this regulation.

  (3) The per diem Medicare-eligible inpatient charge shall be set forth in the Schedule of Charges.

C. Physician Charge.

  (1) For each fiscal year, a charge of physician services provided at a Medicare-eligible State-operated inpatient facility shall be determined by utilizing the most recent Facility Medicare Physicians fee schedule for Maryland or Washington, D.C., suburbs as appropriate, which is updated annually in the Federal Register by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, pursuant to 42 U.S.C §1395w-4.

  (2) The physician charge shall be set forth in the Schedule of Charges.

D. Ancillary Charge.

  (1) For each fiscal year, a charge for ancillary services provided at a Medicare-eligible State-operated inpatient facility shall be determined by utilizing the most recent Facility Medicare Physicians fee schedule for Maryland or Washington, D.C., suburbs as appropriate, which is updated annually in the Federal Register by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, pursuant to 42 U.S.C §1395w-4.

  (2) The ancillary charge shall be set forth in the Schedule of Charges.

E. Charges for State-operated inpatient facilities shall be based on the best estimate of costs, including all appropriate indirect costs, according to generally accepted cost accounting practice. State-operated inpatient facilities, in support of the proposed Schedule of Charges, shall report the estimate of costs in the form required by the Secretary. When the dollar amount is set by statute, the Schedule of Charges shall specify that amount.

F. Revisions and modifications to the approved Schedule of Charges to reflect changes in charges or the addition of new services shall be made when recommended by the Division and approved by the Secretary.

G. The approved Schedule of Charges, with all revisions and modifications, shall be retained in the Office of the Secretary and also be available for public inspection in the Superintendent's office of the State-operated inpatient facility.

#### Regulation .06 Setting of Charges for Private Providers.

*COMAR 10.02.01.06*

A. A private provider shall submit annually, to the Division, a cost report and proposed recommended Schedule of Charges, pursuant to instructions provided by the Division.

B. At least annually, the Secretary shall approve a Schedule of Charges recommended for each private provider containing the per service charges for each private provider which remain in effect until changed as provided in this chapter.

C. Per Service Charge. A charge for each service provided shall be determined for each private provider by:

  (1) Calculating the actual cost for each type of service provided;

  (2) Adjusting the actual cost determined in §C(1) of this regulation for depreciation and inflation, less equipment cost; and

  (3) Dividing the amount determined in §C(2) of this regulation by the actual units of service provided.

D. If a private provider's service charges are established by the Health Services Cost Review Commission (HSCRC), the requirements of §C of this regulation, do not apply.

E. A private provider's proposed service charges shall be based on the best estimate of costs, according to generally accepted cost accounting practices, including all appropriate indirect costs. Private providers, in support of their proposed Schedule of Charges shall report their estimates pursuant to instructions provided by the Division. When specific service charges are set by statute, the Secretary shall approve these service charges consistent with the statute.

F. Revisions and modifications to the approved Schedule of Charges to reflect changes in cost estimates or the addition or deletion of services for a private provider shall be made when recommended by the Division and approved by the Secretary.

G. The approved Schedule of Charges for a private provider, with all revisions and modifications, shall be retained in the Division and also be prominently posted at each location of the private provider where services are provided.

#### Regulation .07 Setting of Charges for Laboratories Administration.

*COMAR 10.02.01.07*

A. The Laboratories Administration shall submit annually, to the Division, a cost report and proposed recommended Schedule of Charges, pursuant to instructions provided by the Division.

B. At least annually, the Secretary shall approve a Schedule of Charges recommended for each type of laboratory service which remains in effect until changed as provided in this chapter.

C. Charge for a Laboratory Service. A laboratory service charge shall be determined by:

  (1) Calculating the total cost of a type of laboratory test which may include, but is not limited to, salary and fringe benefits of staff dedicated to the type of laboratory service, and reagents, supplies, and equipment used in the type of laboratory service;

  (2) Calculating the total number of units of each type of laboratory test performed; and

  (3) Dividing the total cost of a type of laboratory test, as determined in §C(1) of this regulation, by the total number of units of each laboratory service, as determined in §C(2) of this regulation.

D. Revisions and modifications to the approved Schedule of Charges for the Laboratories Administration shall be made when recommended by the Division, and approved by the Secretary, to reflect changes in cost estimates or the addition of new laboratory services.

E. The approved Schedule of Charges for the Laboratories Administration, with all revisions and modifications, shall be retained in the Office of the Secretary and also be posted prominently in the administrative offices of the Laboratories Administration.

F. Notwithstanding the procedure for determining a laboratory service charge set forth in §C of this regulation, the Secretary may adjust the Schedule of Charges if deemed to be in the best interest of public health.

#### Regulation .08 Determination of Ability to Pay and Fees to be Collected.

*COMAR 10.02.01.08*

A. For inpatient care rendered in facilities operated by the Department, fees shall be established in conformity with applicable statutory requirements and regulations issued by the Secretary. The following apply:

  (1) The total cost of care of each recipient of services is, in the first instance, the responsibility of the recipient of services and also the chargeable person as provided in Health-General Article, §16-102(b), Annotated Code of Maryland. Any uncollectible costs for services provided to the recipient shall become the responsibility of the State.

  (2) In accordance with the provisions of Health-General Article, §16-101 et seq., Annotated Code of Maryland, recipients of services and other chargeable persons shall be jointly and severally liable for payment of inpatient charges as set forth in the Schedule of Charges adopted by the Secretary pursuant to Regulation .05 of this chapter. The Department will bill all recipients of services and chargeable persons on the basis of their available financial resources including insurance and third-party payers, up to but not exceeding the full per capita daily charge for services.

B. Outpatient and Community Based Services.

  (1) For all other services, including outpatient and other community based services, the provisions of this section apply.

  (2) All recipients of services and chargeable persons shall be liable for payment of the charges as set forth in the Schedule of Charges, subject to the following:

    (a) For uninsured recipients of services, a waiver or reduction of charges may be granted on a case-by-case basis, following an individual determination of financial need of a recipient of services or chargeable person, based upon criteria set forth by the Secretary pursuant to §B(4) of this regulation; and

    (b) For insured, in-network recipients of services, liability for payment will be reduced to account for any contractually agreed upon third-party payer disallowance.

  (3) The Secretary shall issue and revise annually an ability-to-pay method and schedule for use in making an individualized determination of financial need of a recipient of services or chargeable person. The difference between the charge for the services rendered and the fee derived from this schedule shall be an ability-to-pay allowance.

  (4) All local health departments and other providers shall use the uniform method of determining ability to pay as set forth by the Secretary.

  (5) In those instances where only a portion of a provider's programs are subject to these regulations and a method of determining ability to pay different from that set forth by the Secretary is used, the different method may be used if approved by the Secretary.

  (6) Any errors, omissions, or false statements or documents used in the determination of ability to pay or billing of any amounts due, may result in a redetermination of ability to pay and billing of any amounts due.

#### Regulation .09 Billing and Collection of Charges and Fees.

*COMAR 10.02.01.09*

A. Billings and collections for care rendered in State operated inpatient facilities shall be calculated by the Department in accordance with the following procedures:

  (1) The Department shall conduct a financial investigation of a recipient of services or chargeable persons' ability-to-pay in accordance with the requirements of COMAR 10.04.02.03 and COMAR 10.04.02.04;

  (2) Based on the foregoing investigation, the Department shall prepare a Notice of Rate Establishment Form setting forth that portion of those charges for which the recipient of services or chargeable person shall be responsible;

  (3) Upon receipt of the Notice of Rate Establishment, a recipient of services or chargeable person may, within 10 days, request the Division to conduct an informal review of the billing in accordance with COMAR 10.02.03.04, or may note an appeal from the billing in accordance with COMAR 10.02.03.05, or both.

B. The Secretary may require each local health department and other provider to submit for approval or modification a plan for billing and collection of charges, fees, and insurance benefits.

C. This plan shall set forth:

  (1) The procedures to be followed in applying the ability-to-pay determination method and schedule;

  (2) The methods to be used for collecting the charges, fees, and insurance benefits;

  (3) The methods for receiving and accounting for all sums of money collected;

  (4) The procedure to be followed in making a reasonable effort to collect unpaid amounts due; and

  (5) The procedure to write off unpaid amounts due, as appropriate.

#### Regulation .10 Distribution and Application of Amounts Collected.

*COMAR 10.02.01.10*

A. All payments made under the provisions of this subtitle for services rendered through facilities and programs of the Department shall be made to and collected by the Department, and shall be accounted for and deposited into the General Funds of the State Treasury by the Department.

B. Local health departments and other providers shall report all funds collected as revenues which are to be treated in accordance with Department or federal grant guidelines or other agreements and contracts under which their programs are funded.

#### Regulation .11 Records and Reports Required.

*COMAR 10.02.01.11*

A. An individual financial record for each recipient of services or chargeable person shall be maintained, which shall contain relevant financial information including:

  (1) The ability-to-pay determination, including, when available, applicable documents appropriate to the verification of assets, income, expenses, allowances and exemptions;

  (2) The types and dates of services rendered and the approved charges, the amounts and dates of collections;

  (3) An indication of the recipient of services eligibility for any federal program providing funding for the services rendered;

  (4) A signed authorization to release medical information and assignment of third-party benefits;

  (5) Any other information as may be required by the Secretary from time to time.

B. Financial records of fees assessed and collected shall include:

  (1) Copies of prenumbered receipts;

  (2) Cash receipts report;

  (3) Records of deposits; and

  (4) Other records necessary for proper audit trail.

C. The Secretary may waive any of the requirements of this section where appropriate upon written requests supported by reasons and justifications.

### Chapter 02 — Abandonment or Abuse of Responsible Relatives by Recipients of Care

**Authority:** Health-General Article, §16-203, Annotated Code of Maryland

**Administrative History:** Effective date: July 1, 1971

**Administrative History:** Regulations .01, .02B, and .03A amended effective May 5, 1986 (13:9 Md. R. 1028)

**Administrative History:** Regulation .03C repealed effective May 5, 1986 (13:9 Md. R. 1028)

**Administrative History:** Chapter repealed effective June 27, 1988 (15:13 Md. R. 1552)

**Administrative History:** Regulations .01—.03 under a new chapter, Abandonment or Abuse of Responsible Relatives by Recipients of Care, adopted effective June 27, 1988 (15:13 Md. R. 1552)

**Administrative History:** Regulation .01 amended effective January 17, 2005 (32:1 Md. R. 27)

#### Regulation .01 Definitions.

*COMAR 10.02.02.01*

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

B. Terms Defined.

  (1) “Abandonment” means wrongful and continuous absence by a:

    (a) Spouse from the home for a period of 18 months or longer, immediately before the recipient of services' hospitalization; or

    (b) Parent coupled with failure to support a child, or children, for a period of 18 months or more during the child's or children's minority.

  (2) “Abuse” or “physical abuse” means:

    (a) The sustaining of physical injury;

    (b) Cruel or inhumane treatment;

    (c) A malicious act or treatment; or

    (d) Harm, or threatened harm, to the health or welfare of the individual.

  (3) “Crime of violence” means:

    (a) Abduction;

    (b) Arson;

    (c) Burglary;

    (d) Daytime housebreaking;

    (e) Kidnapping;

    (f) Manslaughter, except involuntary manslaughter;

    (g) Assault in the first degree;

    (h) Murder;

    (i) Rape;

    (j) Robbery;

    (k) Robbery with a deadly weapon;

    (l) Sexual offense in the first degree;

    (m) Sexual offense in the second degree;

    (n) Use of a handgun in the commission of a felony or other crime of violence;

    (o) An attempt to commit any one of the following offenses:

      (i) Assault with intent to murder;

      (ii) Assault with intent to rape;

      (iii) Assault with intent to rob;

      (iv) Assault with intent to commit a sexual offense in the first degree; and

      (v) Assault with intent to commit a sexual offense in the second degree.

  (4) “Minority” means the period of time when a child is 17 years old or younger.

  (5) “Recipient of services”:

    (a) Means an individual who receives care, maintenance, treatment, or support in a facility or program that is operated or funded wholly or partly by the Department;

    (b) Includes, but is not limited to, an individual in a:

      (i) Public facility under the Maryland Mental Law, Health-General Article, Title 10, Annotated Code of Maryland;

      (ii) Facility or Veteran's Administration hospital for comprehensive evaluation under Health-General Article, Title 7, Annotated Code of Maryland;

      (iii) Residential, public facility, or a facility from which the State obtains residential care under the Maryland Developmental Disabilities Law, Health-General Article, Title 7, Annotated Code of Maryland; and

      (iv) Facility operated by the Office of Chronic and Rehabilitation Facilities.

  (6) “Responsible relative” means the:

    (a) Spouse of a recipient of services;

    (b) Parents of a recipient of services who is a minor; and

    (c) Children of a recipient of services.

  (7) “Sexual abuse”:

    (a) Means an act that involves sexual molestation or exploitation of a person by another person;

    (b) Includes, but is not limited to:

      (i) Incest, rape, or sexual offenses in any degree,

      (ii) Sodomy, and

      (iii) Unnatural or perverted sexual practices.

#### Regulation .02 Scope.

*COMAR 10.02.02.02*

It is the policy of the Maryland Department of Health, in accordance with:

A. Health-General Article, §16-203(a)(3), Annotated Code of Maryland, to excuse a legally responsible relative from contributing to the cost of in-patient care of a recipient of services if that legally responsible relative has been abandoned by the recipient of services;

B. Health-General Article, §16-203(a)(4), Annotated Code of Maryland, to excuse all legally responsible relatives from contributing to the cost of in-patient care of a recipient of services if that recipient of services has committed any of the following actions in relation to any legally responsible relative:

  (1) Abuse or physical abuse;

  (2) Crime of violence; or

  (3) Sexual abuse.

#### Regulation .03 Burden of Proof.

*COMAR 10.02.02.03*

A. A responsible relative claiming to have been abused, sexually abused, abandoned, or subjected to a crime of violence by the recipient of services shall have the burden of establishing to the satisfaction of the Department by a preponderance of the evidence that the legally responsible relative was abandoned, abused, sexually abused, or subjected to a crime of violence by the recipient of services.

B. Acceptable evidence for abuse and crimes of violence includes, but is not limited to:

  (1) Police reports; or

  (2) Medical records, or medical statements prepared by a physician, physician's assistant, or nurse.

C. Acceptable evidence for abandonment includes, but is not limited to, affidavits from disinterested parties of the facts surrounding the abandonment.

### Chapter 03 — Appeal Hearings to the Division of Reimbursements

**Authority:** Health-General Article, §2-207, Annotated Code of Maryland

**Administrative History:** Effective date: July 1, 1971

**Administrative History:** Regulation .01 amended effective June 28, 1999 (26:13 Md. R. 1019)

**Administrative History:** Regulations .01, .02C, and .03A amended effective May 5, 1986 (13:9 Md. R. 1028)

**Administrative History:** Regulation .01B amended effective March 14, 2016 (43:5 Md. R. 385)

**Administrative History:** Regulation .03-1 adopted effective May 5, 1986 (13:9 Md. R. 1028)

**Administrative History:** Regulation .04B, C amended effective June 28, 1999 (26:13 Md. R. 1019)

**Administrative History:** Regulation .06B amended effective May 5, 1986 (13:9 Md. R. 1028); June 28, 1999 (26:13 Md. R. 1019)

**Administrative History:** Regulation .06C amended effective May 5, 1986 (13:9 Md. R. 1028)

**Administrative History:** Regulation .08A, C amended effective June 28, 1999 (26:13 Md. R. 1019)

#### Regulation .01 Definitions.

*COMAR 10.02.03.01*

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

B. Terms Defined.

  (1) “Administrative law judge” means an individual appointed by the Chief Administrative Law Judge under State Government Article, §9-1604, Annotated Code of Maryland, or designated by the Chief Administrative Law Judge under State Government Article, §9-1607, Annotated Code of Maryland.

  (2) “Appellant” means any individual who requests an appeal hearing for the reasons specified in Regulation .02, of this chapter.

  (3) “Chargeable person” means any responsible relative and, except for a recipient of services, any other person who is legally responsible in an individual or representative capacity for the care of the individual.

  (4) “Division” means the Division of Reimbursements of the Maryland Department of Health.

  (5) Recipient of Services.

    (a) “Recipient of services” means an individual who receives care, maintenance, treatment, or support in a facility or program that is operated or funded wholly or partly by the Department.

    (b) “Recipient of services” includes, but is not limited to an individual:

      (i) In a public facility under Health-General Article, Title 10, Annotated Code of Maryland;

      (ii) In a facility or Veterans Administration hospital for comprehensive evaluation under the Health-General Article, Title 7, Annotated Code of Maryland;

      (iii) In a residential, public facility or a facility from which this State obtains residential care under Health-General Article, Title 7, Annotated Code of Maryland; and

      (iv) In a facility operated under Public Health Services.

  (6) “Responsible relative” means the:

    (a) Spouse of a recipient of services;

    (b) Parents of a recipient of services who is a minor; and

    (c) Children of a recipient of services.

#### Regulation .02 Opportunity for an Appeal Hearing.

*COMAR 10.02.03.02*

An opportunity for an appeal hearing shall be granted when:

A. A rate is established (or increased) against an individual in an amount which is deemed by the individual to be arbitrary and excessive in accordance with the individual's financial circumstances;

B. An individual is aggrieved by any division policy, action, or inaction:

  (1) Which affects the charges established or manner of billing; or

  (2) Results in an increase in the rates established;

C. In the judgment of a recipient of services, responsible relative, or other chargeable person, he or she is adversely affected by any other Division policy, action, or inaction.

#### Regulation .03 Notification of Right to Request an Appeal Hearing.

*COMAR 10.02.03.03*

A. Whenever the Division conducts an investigation of an individual's financial resources and issues a notice of rate establishment for services rendered to a recipient of services in accordance with COMAR 10.02.01.05, the Division shall provide written notification to the individual of his or her right to seek an informal review or an appeal, or both, from the rates established by the Division.

B. The notification specified in §A of this regulation shall:

  (1) Advise the individual of the matters which are the proper subject of an appeal hearing as provided in Regulation .02, of this chapter;

  (2) Advise the individual of his right to be represented by a lawyer or other person of his choice during the entire hearing process;

  (3) Advise the individual that he may present witnesses and documents in his behalf at the hearing.

#### Regulation .03-1 Request for a Rate Review.

*COMAR 10.02.03.03-1*

A. If a recipient of services or other chargeable person submits a written request that the Division review the notice of rate establishment, the financial agent for the Division shall:

  (1) Review the notice of rate establishment to determine the accuracy of the charges established;

  (2) Review all pertinent information presented by the individual to determine if any adjustments in the billing are appropriate under these regulations;

  (3) Provide the individual with a final billing statement which indicates both the:

    (a) Division's position with regard to any written claims for a reduction in the rate established by the Division which are submitted by the individual to the financial agent; and

    (b) Final rates established by the Division for services rendered to a recipient of services.

B. The recipient of services or chargeable person shall have such rights as are set forth in Regulation .05, of this chapter, to request an appeal hearing regarding the Division's informal rate review and the charges for services established by it. In order to note an appeal from the charges established pursuant to the informal rate review, the recipient of services or chargeable person shall follow the procedures as set forth in Regulation .05, of this chapter.

#### Regulation .04 Request for an Appeal Hearing.

*COMAR 10.02.03.04*

A. Any individual, either himself or through a representative, may request an appeal hearing by giving a clear statement, in writing, to any financial agent of the Division that he desires an opportunity to present for review any matter which is the proper subject of an appeal hearing as provided in Regulation .02. This statement shall be forwarded immediately to the Chief of Reimbursements. When the Division receives a request for a hearing, it shall assist the appellant in submitting and processing the request.

B. The Division shall promptly acknowledge any request for an appeal hearing and shall thereafter set forth in writing the date, time, and place of the appeal hearing, after consulting with the Office of Administrative Hearings. The acknowledgement shall include the information specified in Regulation .03B of this chapter.

C. If any party notifies the Division that the time designated by the Division is not convenient to the party, and requests a different time for the hearing, the Office of Administrative Hearings shall designate another time convenient to the parties if it deems that the party has sufficient reason for requesting the change.

D. A request for an appeal hearing may not be granted unless it is made within 30 days of the receipt of the notification specified in Regulation .03A of this chapter or, if Regulation .03A does not apply, within 30 days following the conclusion of the action or inaction which is the subject of the appeal.

E. The Division may dismiss a request for an appeal hearing when it has been withdrawn in writing by the appellant or his representative, or abandoned. An appellant shall be deemed to have abandoned his request if he does not appear for the hearing on the established date.

#### Regulation .05 Pre-Hearing Procedures.

*COMAR 10.02.03.05*

The appellant and the Division may request the names of all witnesses that the other party intends to call at the hearing.

#### Regulation .06 Hearing Procedures.

*COMAR 10.02.03.06*

A. The appellant and the Division shall have the opportunity to present witnesses, documentary evidence, and oral and written argument, and to cross-examine all adverse witnesses.

B. If the appellant wishes to call as witnesses any of the Division's current employees, or former employees who reside within the State, whose action or inaction is being contested by the appellant or whose testimony is, in the judgment of the appellant, relevant to the issues under consideration, the Office of Administrative Hearings shall require their presence at the hearing. If the appellant has knowledge of the names or other identifying descriptions of the employees before the hearing, the appellant shall supply the Office of Administrative Hearings with the names or other identifying descriptions at least 5 days before the hearing. Subpoenas may be issued under COMAR 28.02.02.11.

C. If the Division introduces, as evidence, documents from the case record, special investigation file, or other sources, the appellant shall have the opportunity to examine persons who prepared the documents and to examine the case record or special investigation file for the purpose of discovering information favorable to his case. If these persons are no longer employees of the Division, the appellant shall be permitted to examine a Division representative familiar with the documents and applicable Division policies.

#### Regulation .07 The Record.

*COMAR 10.02.03.07*

A. A recording of the hearing shall be made. A copy of the recording shall be supplied to the appellant whenever the appellant takes a further appeal. The recording, together with all exhibits and papers admitted into evidence, shall constitute the exclusive record for decision. Nonrecorded or confidential information which the appellant does not have an opportunity to hear or see may not be made a part of the hearing record.

B. The recording and copies of all exhibits and papers shall remain in the custody of the hearing officer for a period not to exceed 2 years, or until all litigation involving the decision is terminated.

#### Regulation .08 Findings, Conclusions and Decisions.

*COMAR 10.02.03.08*

A. The administrative law judge shall prepare a written summary of findings and conclusions, based exclusively on the record, and shall make a recommendation based on those findings and conclusions. The summary of findings and conclusions shall state the policies, regulations, or laws upon which the decision is based.

B. A copy of the findings, conclusions and decisions shall be forwarded to the appellant or his representatives no later than 60 days after the date of the hearing.

C. The recommendation of the administrative law judge, after approval by the Secretary of Health, shall be final and binding upon the Division and shall be implemented immediately unless otherwise specifically indicated in the decision. When the hearing decision is favorable to the appellant, or when the Division grants the relief the appellant requests before the hearing decision, the Division, where applicable, shall authorize corrected billing or other relief retroactive to the date the incorrect action was taken.

D. The decision, if not favorable to the appellant, may be appealed to the Board of Review as provided by law in Health-General Article, §2-207, Annotated Code of Maryland.

E. Subsequent appeals, as provided by law, may be taken by the appellant.

### Chapter 04 — Schedule of Charges for Providers of the Alcohol and Drug Abuse Administration

*Repealed*

**Administrative History:** Effective date: October 7, 1985 (12:20 Md. R. 1926)

**Administrative History:** Regulation .02B amended effective October 29, 1990 (17:21 Md. R. 2528)

**Administrative History:** Regulation .03A amended effective December 15, 1986 (13:25 Md. R. 2658); December 28, 1987 (14:26 Md. R. 2746); September 4, 1989 (16:17 Md. R. 1885); October 29, 1990 (17:21 Md. R. 2528); August 3, 1992 (19:15 Md. R. 1390)

**Administrative History:** Regulation .03B amended effective September 4, 1989 (16:17 Md. R. 1885); October 29, 1990 (17:21 Md. R. 2528)

**Administrative History:** Chapter repealed as an emergency provision effective December 1, 2000 (27:25 Md. R. 2277); repealed permanently effective March 19, 2001 (28:05 Md. R. 551)

### Chapter 05 — Schedules of Charges for Providers of the Drug Abuse Administration

*Repealed*

**Administrative History:** Effective date: October 7, 1985 (12:20 Md. R. 1926)

**Administrative History:** Regulation .03A amended effective December 15, 1986 (13:25 Md. R. 2658); December 28, 1987 (14:26 Md. R. 2746)

**Administrative History:** Chapter repealed effective September 4, 1989 (16:17 Md. R. 1885)

### Chapter 06 — Schedules of Charges for Health Facilities Operated by or Funded in Whole or in Part by the Laboratories Administration

*Repealed*

**Administrative History:** Effective date: October 7, 1985 (12:20 Md. R. 1926)

**Administrative History:** Regulation .03A amended effective December 15, 1986 (13:25 Md. R. 2658)

**Administrative History:** Chapter repealed as an emergency provision effective December 1, 2000 (27:25 Md. R. 2277): repealed permanently effective March 19, 2001 (28:05 Md. R. 551)

### Chapter 07 — Schedule of Charges for Health Facilities Operated by or Funded in Whole or in Part by the Community and Public Health Administration

*Repealed*

**Administrative History:** Effective date: October 7, 1985 (12:20 Md. R. 1926)

**Administrative History:** Regulation .01 amended effective October 29, 1990 (17:21 Md. R. 2528)

**Administrative History:** Regulation .02B amended effective October 29, 1990 (17:21 Md. R. 2528)

**Administrative History:** Regulation .03 amended effective April 3, 1989 (16:6 Md. R. 727)

**Administrative History:** Regulation .03 amended as an emergency provision effective July 1, 1991 (18:14 Md. R. 1604); amended permanently effective September 30, 1991 (18:19 Md. R. 2099)

**Administrative History:** Regulation .03A amended effective August 10, 1987 (14:16 Md. R. 1773); October 29, 1990 (17:21 Md. R. 2528)

**Administrative History:** Regulation .03B amended effective October 29, 1990 (17:21 Md. R. 2528)

**Administrative History:** Regulation .03B amended as an emergency provision effective July 1, 1992 (19:14 Md. R. 1311); emergency status extended at 19:20 Md. R. 1812; emergency status expired February 1, 1993

**Administrative History:** Regulation .03B amended effective February 2, 1993 (19:26 Md. R. 2287); October 11, 1993 (20:20 Md. R. 1571)

**Administrative History:** Regulation .03B amended as an emergency provision effective July 1, 1993 (20:14 Md. R. 1164)

**Administrative History:** Regulation .03B amended as an emergency provision effective July 1, 1994 (21:13 Md. R. 1152); emergency status expired August 9, 1994 (21:18 Md. R. 1506)

**Administrative History:** Regulation .03B amended as an emergency provision effective August 10, 1994 (21:18 Md. R. 1505); amended permanently effective November 20, 1994 (21:23 Md. R. 1933)

**Administrative History:** Regulation .03B amended as an emergency provision effective July 1, 1995 (22:15 Md. R. 1113); amended permanently effective October 9, 1995 (22:20 Md. R. 1543)

**Administrative History:** Regulation .03B amended as an emergency provision effective July 1, 1996 (23:14 Md. R. 1006); amended permanently effective October 7, 1996 (23:20 Md. R. 1422)

**Administrative History:** Regulation .03 amended and new Regulations .04—.27 adopted as an emergency provision effective August 22, 1997 (24:19 Md. R. 1335); adopted permanently effective November 17, 1997 (24:23 Md. R. 1611)

**Administrative History:** Chapter repealed as an emergency provision effective December 1, 2000 (27:25 Md. R. 2277); repealed permanently effective March 19, 2001 (28:05 Md. R. 551)

### Chapter 08 — Schedule of Charges for Providers of the Mental Hygiene Administration

*Repealed*

**Administrative History:** Effective date: October 7, 1985 (12:20 Md. R. 1927)

**Administrative History:** Regulation .02B amended effective October 29, 1990 (17:21 Md. R. 2528)

**Administrative History:** Regulation .03A amended effective December 15, 1986 (13:25 Md. R. 2658); December 28, 1987 (14:26 Md. R. 2746); September 4, 1989 (16:17 Md. R. 1885); October 29, 1990 (17:21 Md. R. 2528)

**Administrative History:** Regulation .03B amended effective September 4, 1989 (16:17 Md. R. 1885); October 29, 1990 (17:21 Md. R. 2528)

**Administrative History:** Chapter repealed as an emergency provision effective December 1, 2000 (27:25 Md. R. 2277); repealed permanently effective March 19, 2001 (28:05 Md. R. 551)

### Chapter 09 — Schedules of Charges for Health Facilities Operated by or Funded in Whole or in Part by the Mental Retardation Developmental Disabilities Administration

*Repealed*

**Administrative History:** Effective date: October 7, 1985 (12:20 Md. R. 1927)

**Administrative History:** Regulation .03A amended effective December 15, 1986 (13:25 Md. R. 2659)

**Administrative History:** Chapter repealed as an emergency provision effective December 1, 2000 (27:25 Md. R. 2277); repealed permanently effective March 19, 2001 (28:05 Md. R. 551)

### Chapter 10 — Schedules of Charges for Providers of the Office of Chronic and Rehabilitative Facilities

*Repealed*

**Administrative History:** Effective date: October 7, 1985 (12:20 Md. R. 1928)

**Administrative History:** Regulation .03 amended effective September 4, 1989 (16:17 Md. R. 1885)

**Administrative History:** Chapter repealed as an emergency provision effective December 1, 2000 (27:25 Md. R. 2277); repealed permanently effective March 2001 (28:5 Md. R. 551)

### Chapter 11 — Schedule of Charges for Providers of the Medical Care Policy Administration

*Repealed*

**Administrative History:** Effective date: October 7, 1985 (12:20 Md. R. 1928)

**Administrative History:** Regulation .01 amended effective October 29, 1990 (17:21 Md. R. 2528)

**Administrative History:** Regulation .02B amended effective October 29, 1990 (17:21 Md. R. 2528)

**Administrative History:** Regulation .03 amended effective April 3, 1989 (16:6 Md. R. 728)

**Administrative History:** Regulation .03A amended effective December 15, 1986 (13:25 Md. R. 2659); December 28, 1987 (14:26 Md. R. 2746); October 29, 1990 (17:21 Md. R. 2528); October 28, 1991 (18:21 Md. R. 2307)

**Administrative History:** Regulation .03B amended effective October 29, 1990 (17:21 Md. R. 2528)

**Administrative History:** Chapter repealed as an emergency provision effective December 1, 2000 (27:25 Md. R. 2277); repealed permanently effective March 19, 2001 (28:05 Md. R. 551)