In this chapter, the following terms have the meanings indicated. Terms Defined. “Attending physician” means: A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State; or A nurse practitioner who meets the qualifications set forth in COMAR 10.27.07. “Bereavement counseling” means counseling services provided to the participant's family after the participant's death. “Cap period” means the 12-month period beginning November 1 of each year and ending October 31 of the following year, which is used in the annual application of the limitation on reimbursement at the general inpatient and inpatient respite care rates. “Core services” means the hospice services that must routinely be provided directly by hospice employees, that is, nursing care, physician services, medical social services, and counseling. “Department” means the Department as defined in COMAR 10.09.36.01. “Election period” means a period for which a recipient may elect to receive hospice care in accordance with Regulation .04 of this chapter. “Health Maintenance Organization (HMO)” means an organization which has contracted with the Department to deliver specific health care services to recipients in accordance with COMAR 10.09.16. “Home” means that place of residence occupied by a participant. For purposes of hospice care, home may include a nursing facility. “Hospice” means a public agency or private organization or subdivision of either of these that: Is primarily engaged in providing care to terminally ill individuals; Meets all applicable State and local licensing and regulatory requirements; and Is participating in Medicare as a hospice care provider. “Hospice nurse practitioner” means a nurse practitioner who: Is an employee of the hospice; and Meets the qualifications set forth in COMAR 10.27.07. “Hospice physician” means a doctor of medicine or osteopathy who is: Employed by or contracted by the hospice; and Legally authorized to practice medicine and surgery by the State. “Hospital” means an institution which is participating in Medicare or in a Medical Assistance Program as a hospital. “Interdisciplinary group” means a group of provider employees who provide or supervise hospice care, and include at least a: Doctor of medicine or osteopathy; Registered nurse; Social worker; and Pastoral or other counselor. “Managed care organization (MCO)” has the meaning stated in Health-General Article, §15-101, Annotated Code of Maryland. “Medical Assistance Program” means a program of comprehensive medical and other health-related care for indigent and medically indigent persons, jointly financed by the federal and State governments and administered by states under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq. “Medicare” means Medicare as defined in COMAR 10.09.36.01. “Nursing facility” means a facility or a distinct part of a facility which is participating in a Medical Assistance Program as a nursing facility provider. “Participant” means a recipient who is eligible, has elected, and is receiving hospice care in accordance with the provisions of this chapter. “Plan of care” means a written, individualized care plan established and maintained for each recipient enrolled by a hospice provider. “Program” means the Maryland Medical Assistance Program. “Provider” means a hospice that meets the requirements of Regulation .03 of this chapter and which, through a provider agreement signed with the Department, has been identified as a Program provider by the issuance of an individual account number. “Provider agreement” means a contract between the Department and the provider. “Recipient” means recipient as defined in COMAR 10.09.36.01. “Representative” means a person who is, because of the recipient's mental or physical incapacity, authorized, in accordance with the State law to execute or revoke an election for hospice care, to advise concerning the plan of care, or to terminate medical care on behalf of the terminally ill individual. “Respite care” means short-term care furnished to a participant for the purpose of providing rest or relief for family members or other individuals routinely furnishing at-home care to the participant. “Room and board” means services provided to a participant who is a nursing facility resident. “Skilled nursing facility” means a nursing facility or a distinct part of a nursing facility which is participating in Medicare as a skilled nursing facility. “Terminally ill” means that the individual has a medical prognosis of a life expectancy of 6 months or less if the illness runs its normal course. In order to participate in the Program, a provider shall be licensed by the Department pursuant to Health-General Article, Title 19, Subtitle 9, Annotated Code of Maryland, or shall be legally authorized to provide hospice care in the jurisdiction in which the services are provided, and shall obtain other licenses as may be required by applicable State and local laws. Employees of the provider who provide hospice care services must be licensed, certified, or registered in accordance with applicable federal, State, and local laws. General requirements for participation in the Program are that providers shall: Meet all conditions for participation as set forth in COMAR 10.09.36.03, except as otherwise specified in this regulation; and Ensure that the licensure requirements as provided in Regulation .02 of this chapter are met. Specific requirements for participation in the Program as a hospice care provider are that the provider shall: Meet the requirements of §A of this regulation. Be a participating Medicare hospice. Provide information about a participant's election, continuation, and termination of hospice care in accordance with procedures established by the Program. Provide directly or make available through arrangements the covered services in Regulation .06 of this chapter. Make nursing services, physician services, and drugs and biologicals routinely available on a 24-hour basis. Make all other covered services available on a 24-hour basis to the extent necessary to meet a participant's needs for care as specified in the participant's plan of care. Have a written policy, approved by the Program, which assures that the release of information from the participant's record is handled in accordance with applicable State and federal laws and regulations governing confidentiality. Ensure that all core services are routinely provided directly by the provider's employees. Volunteers under the jurisdiction of the provider are considered provider employees. Contracted staff may be used to supplement employees only when necessary during periods of peak patient loads, under extraordinary circumstances, or to obtain physician specialty services. Provide bereavement counseling, even though it is not a reimbursable service. An individual may elect to receive hospice care during one or more of the following election periods: An initial 90-day period; A subsequent 90-day period; or An unlimited number of subsequent 60-day periods. The periods of care indicated in §A of this regulation are available in the order listed and may be elected separately at different times. An election period or an extended election period shall terminate before expiration when one of the following conditions is met: The participant dies; The election of hospice care is revoked in accordance with Regulation .05D of this chapter; The participant's eligibility for Medical Assistance is cancelled; The Program determines that the election period or extended election period shall be terminated for cause. Cause for termination may include, but shall not be limited to: A change in the participant's prognosis as being terminally ill; Relocation by the participant to a place of residence where a hospice care provider is not available; or Action or behavior of the participant that makes continuation of hospice care inappropriate, such as misconduct, fraud, or repeated instances of willfully and knowingly seeking services related to the terminal illness from other than the designated provider. When a participant revokes the election of hospice care, in accordance with Regulation .05D of this chapter, during an election period, any remaining days in that election period shall be forfeited. Thereafter, the participant may elect hospice coverage for any remaining election periods for which the participant is eligible. When a participant revokes the election of hospice care during an extended election period, further Program coverage of hospice care shall be forfeited. The waiver of rights to Program payments described in Regulation .05B(5) of this chapter shall expire as of the effective date of termination of the election period or extended election period. To be eligible for hospice care, written certification of terminal illness shall be obtained by the hospice for each of the election periods listed in Regulation .04 of this chapter. Procedures for certification of terminal illness are as follows: The hospice shall obtain the written certification before the hospice submits a claim for payment; If the hospice is unable to obtain written certification within 2 calendar days after an election period begins, an oral certification shall be obtained within 2 calendar days and a written certification shall be obtained before the hospice submits a claim for payment; Certifications shall be completed not more than 15 calendar days before the start of the election period; For the initial election period, the hospice shall obtain written certification statements and shall document oral certification statements in accordance with §A(2) of this regulation from: The medical director of the hospice or the physician member of the hospice interdisciplinary team; and The attending physician, if there is an attending physician; For subsequent election periods, certification by one of the physicians listed in §A(4) of this regulation is required; All certifications shall: Be signed and dated by the certifying physician; and Include the date of the election for which the certification applies; Certifications shall be based on the certifying physician’s clinical judgment regarding the normal course of the recipient’s illness and conform to the following requirements: Document that the participant’s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course; Clinical information documenting the prognosis of a terminal illness shall accompany the certification and shall be filed in the medical record; Clinical information for the initial election period may be provided orally and shall be documented in the medical record and included as part of the hospice’s eligibility assessment; A brief narrative written by the certifying physician: Shall be included in the certification; Shall be located immediately before the certifying physician’s signature or included as an addendum signed by the certifying physician; Shall include a statement inserted directly above the certifying physician’s signature and based on a review of the participant’s medical record or examination of the participant; Shall reflect the participant’s individual clinical circumstances; and May not contain checkboxes or standard language used for all participants; To determine continued eligibility for hospice care, a face-to-face encounter by the hospice physician or the hospice nurse practitioner shall occur: When a stay across all hospices is anticipated to reach the third election period; and Not more than 30 days before the third election period and any subsequent election period; and A narrative associated with an election period requiring a face-to-face encounter shall include: An explanation of why the clinical findings support a prognosis of a terminal illness; and A written attestation of the date of the encounter and that the clinical findings were provided to the certifying physician. A recipient 21 years old or older meeting the eligibility requirements and electing to receive hospice care shall file a signed election declaration with the provider which shall contain the following: A statement that the recipient or the representative elects hospice care for the recipient; Identification of the provider that will furnish hospice care to the recipient; The effective date of the election, which may not be earlier than the date that the election is made; A statement that the recipient or representative acknowledges being given a full description of hospice care and of its palliative rather than curative nature as it relates to the recipient's terminal illness and related conditions; A statement that the recipient or representative understands that the recipient waives all rights to Program payments for the duration of the election of hospice care for the following services: Hospice care provided by a hospice other than the provider designated by the recipient or representative, unless provided under arrangements made by the designated provider; and Any services covered by the Program that are related to treatment of the terminal condition or a related condition, or that are equivalent to hospice care, except for services provided by: The designated provider; Another hospice under arrangements made by the designated provider; The recipient's attending physician if that physician is not an employee of the designated provider or receiving compensation from the provider for those services; or A nursing facility as room and board, if the recipient is a resident of a nursing facility and would be eligible under the Program for nursing facility services if hospice care was not elected; and The signature of the recipient or representative. A recipient younger than 21 years old meeting the eligibility requirements and electing to receive hospice care shall file a signed election declaration with the provider which shall contain the following: A statement that the recipient or the representative elects hospice care for the recipient; Identification of the provider that will furnish hospice care to the recipient; The effective date of the election, which may not be earlier than the date that the election is made; A statement that the recipient or representative acknowledges being given a full description of hospice care and of its palliative nature as it relates to the recipient's terminal illness and related conditions; A statement that the recipient or representative understands that hospice services shall be made available without forgoing Program payments for curative treatment for the terminal illness; and The signature of the recipient or representative. The election of hospice care shall be considered to continue uninterrupted through the first election period and through any subsequent election periods and any extended election periods, as long as the participant: Remains in the care of a provider; and Does not have the hospice care terminated under the provisions of Regulation .04D of this chapter. The election of hospice care may be revoked by the participant or representative at any time for any reason during an election period or an extended election period. Revocation requires the following: The participant or representative shall file a statement with the provider that includes the following information: A statement that the participant or representative revokes the election of Program coverage of hospice care and understands that the participant forfeits the remaining days in the election period; The date that the revocation is to be effective, which may not be earlier than the date the revocation is made; and The signature of the participant or representative. As of the effective date of the revocation of the election of hospice care, the recipient: Is no longer covered under the Program for hospice care; Resumes Program coverage of services waived under §B(5) of this regulation; and Forfeits Program coverage of hospice care for any days remaining in the election period, but may at a future time elect hospice care for any remaining election period for which the recipient is eligible. A participant may designate a new provider of hospice care not more than once during an election period. Designation shall be as follows: The designation of a new provider is not a revocation of the election of hospice care under §D of this regulation. To designate a new provider, the participant or representative shall file with the previously designated provider and with the newly designated provider, a statement that includes the following information: The names of the previously designated provider and the new provider; The effective date of the change of providers; and The signature of the participant or representative. A change in ownership of the provider is not considered a change in the participant's designation of a provider and requires no action on the participant's part. The provider shall maintain the statements described in this regulation and provide copies or related information to the Program on request. Hospice care includes the services listed in §B of this regulation when the services are: Provided to an eligible recipient who elects hospice care, in accordance with Regulation .05 of this chapter; Reasonable and necessary for the palliation or management of the participant's terminal illness and related conditions; Consistent with the plan of care established before the services are provided; Provided by appropriately qualified personnel; Administered according to accepted standards of practice; and Routinely provided directly by provider employees, when they are the core services listed in §B(1)—(4) of this regulation, except that the provider may contract for supplemental services during peak patient loads, under extraordinary circumstances, or to obtain physician specialty services. The following are covered hospice care services: Nursing care provided by a nurse licensed as a registered nurse in the jurisdiction in which services are provided or by an individual under the supervision of a registered nurse; Medical social services provided by a social worker who is: In compliance with the social work licensing requirements of the jurisdiction in which service is provided; and Working under the direction of a physician; Physician services performed by a physician as described in 42 CFR §§410.20—410.25, except that the services of the provider's medical director or physician member of the interdisciplinary group shall be performed by a doctor of medicine or osteopathy; Counseling services provided to the participant and the family members or other persons caring for the participant at home, including: Dietary counseling; Counseling to train the participant's family or other caregivers in providing care; Spiritual counseling to help the participant and the family or other caregivers in the home to adjust to the participant's approaching death; Bereavement counseling for the family after the participant's death; and Additional counseling provided by interdisciplinary group members, as well as by other qualified professionals as necessary; Short-term inpatient care subject to the following conditions: General inpatient care may be provided to meet the participant's needs for pain control or for acute or chronic symptom management that cannot be met in other settings; Inpatient respite care may be furnished to provide rest or relief for family members or other individuals routinely furnishing at-home care to the participant; and General inpatient care and inpatient respite care shall be provided in a: Hospice that meets the conditions of participation for providing inpatient care directly as set forth in 42 CFR §418.100; or Hospital, skilled nursing facility, or nursing facility that meets the special hospice standards regarding 24-hour nursing service and patient areas as set forth in 42 CFR §418.100(a) and (e); Medical appliances and supplies, including drugs and biologicals, which are needed for the palliation and management of the terminal illness and related conditions; Home health aide and homemaker services furnished by qualified individuals, who are under the general supervision of a registered nurse; and Physical therapy, occupational therapy, and speech-language pathology services provided by qualified individuals for purposes of symptom control or to enable the participant to maintain activities of daily living and basic functional skills. When a recipient is enrolled in Medicare Part A, Program payment for hospice care shall be limited to payment of the recipient's Medicare hospice care co-insurance amounts for drugs and biologicals and for respite care and, where applicable, room and board for residents of a nursing facility under Regulation .08E of this chapter. Reimbursement Principles. The Program shall pay the provider at one of four rate categories for each day that the participant is under the provider's care, subject to the conditions, limitations, and exceptions set forth in this chapter. The payment rates for providers shall be those established by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services for hospice care under a Medical Assistance Program. The daily rates are prospective rates, and there shall be no retroactive adjustment of payment other than the limitation on payment for inpatient care set forth in §C of this regulation. Categories of Hospice Care for Reimbursement. Routine Home Care. The provider shall be paid the routine home care rate for each day the participant is under the care of the provider and another rate is not payable under §B(2)—(4) of this regulation. The routine home care rate is paid without regard to the volume or intensity of covered services provided on a given day. The routine home care rate is paid at one of the following levels, whichever is applicable: An enhanced rate for the first 60 days in which the participant is enrolled in hospice; or A lesser rate for day 61 and thereafter. Continuous Home Care. The provider shall be paid the continuous home care rate for each day the participant is at home, under the care of the provider, and all of the following requirements are met: There is a brief period of crisis during which the participant requires continuous care, which is primarily nursing care to achieve palliation or management of acute medical symptoms. Nursing care shall be provided by either a registered nurse or a licensed practical nurse, and a nurse must be providing care for more than half the period. Homemaker or home health aide services may be provided to supplement the nursing care. A minimum of 8 hours of care must be provided during a 24-hour day which begins and ends at midnight, but the hours of care need not be continuous. The continuous home care rate is divided by 24 hours to arrive at an hourly rate. For every hour or part of an hour of continuous home care furnished, the hourly rate shall be paid to the provider, up to 24 hours a day. If less skilled care is needed on a continuous basis to maintain the patient at home during a period of crisis, or if less than 8 hours of continuous home care is provided during a day, payment shall be made at the routine home care rate. Inpatient Respite Care. The provider shall be paid the inpatient respite care rate for each day the participant is in a qualified inpatient facility for the purpose of respite care, subject to the following requirements: Payment shall be made at the inpatient respite care rate for a maximum of 5 consecutive days at a time, including the day of admission but not counting the day of discharge; Payment for the sixth and any subsequent day of inpatient respite care shall be made at the routine home care rate; For the day of discharge, payment shall be made at the routine or continuous home care rate, as appropriate, unless the participant dies as an inpatient; and Payment shall be made at the inpatient respite care rate for the day of discharge if the participant is discharged deceased. Inpatient respite care may not be provided when the participant is a resident of a nursing facility. General Inpatient Care. The provider shall be paid the general inpatient care rate for each day the participant is in a qualified inpatient facility for care, subject to the following requirements: The inpatient care is required for procedures necessary for pain control or for acute or chronic symptom management which cannot be provided in other settings; Payment shall be made at the general inpatient rate for the day of admission and for all subsequent inpatient days, except for the day of discharge; For the day of discharge, payment shall be made at the routine or continuous home care rate, as appropriate, unless the participant dies as an inpatient; and Payment shall be made at the general inpatient rate for the day of discharge if the participant is discharged deceased. Limitation on Payment for Inpatient Care. Payment to a provider for inpatient care shall be limited according to the total number of days of inpatient care the provider furnished to participants during a specific cap period, excluding the days of inpatient care furnished to participants diagnosed with Acquired Immune Deficiency Syndrome (AIDS). For the cap period, the aggregate number of inpatient days reimbursed for general inpatient and inpatient respite care (excluding inpatient days reimbursed for participants with AIDS) may not exceed 20 percent of the aggregate total number of days of hospice care the provider furnished to all participants (excluding days of hospice care furnished to participants with AIDS) during the same period. The limitation on payment for inpatient care days is calculated as follows: Subtract the days of care furnished to participants with AIDS from the total days of care furnished by the provider to all participants during the cap period; Subtract the days of inpatient care furnished to participants with AIDS from the total days of inpatient care furnished by the provider to all participants during the cap period; The maximum allowable number of reimbursable inpatient days is determined by multiplying by 0.2 the adjusted total number of days of hospice care the provider furnished to participants during the cap period, as determined in §C(3)(a) of this regulation; If the adjusted total number of inpatient care days the provider furnished to participants during the cap period, as determined in §C(3)(b) of this regulation, is less than or equal to the maximum allowable number of reimbursable inpatient days, no payment adjustment is necessary; and If the adjusted total number of inpatient care days the provider furnished to participants during the cap period exceeds the maximum allowable number of reimbursable inpatient days, the payment limitation and the refund to the Program shall be determined by: Calculating a ratio of the maximum allowable number of reimbursable inpatient days to the adjusted total number of inpatient care days, and multiplying this ratio by the total reimbursement to the provider during the cap period for general inpatient and inpatient respite care days (minus the reimbursement for inpatient care days furnished to participants with AIDS); Multiplying excess inpatient care days by the routine home care rate; Adding together the amounts calculated in §C(3)(e)(i) and (ii) of this regulation; and Refunding to the Program the difference between the interim reimbursement made for non-AIDS inpatient care during the cap period and the amount determined in §C(3)(e)(iii) of this regulation. This limitation shall be applied once a year, at the end of the cap period. Service Intensity Add-On. In addition to the routine home care rate paid under §B(1) of this regulation, the provider shall be paid for visits made by a social worker or a registered nurse, when provided during routine home care in the last 7 days of the participant’s life. The service intensity add-on payment is equal to the continuous home care hourly rate divided by four. The provider shall be paid in 15-minute increments for a maximum of four hours daily. Payment for Physician Services. The per diem rates are designed to reimburse for those administrative and general supervisory activities performed by physicians who are employees of or are working under arrangements with the provider. These activities are generally performed by the physician serving as the medical director or the physician member of the provider's interdisciplinary group. The included activities consist of participation in establishment of care plans, supervision of service delivery, periodic review and updating of care plans, and establishment of governing policies. In addition to the daily rates, the Program shall make separate payment to the provider for physician services, subject to the following requirements: The services shall be direct patient care services furnished to a participant under the care of the provider; The services shall be furnished by an employee of the provider or furnished under arrangements made by the provider; The provider shall have a liability to reimburse the physician for the services rendered; The provider shall bill for the physician services in accordance with procedures established by the Program; A payment may not be made for physician services furnished on a volunteer basis; and Payment to the provider for physicians' services shall be made in accordance with the fee schedule contained in COMAR 10.09.02. A physician who is designated as the attending physician by a participant and who also volunteers services to the provider is considered an employee of the provider, whose direct patient care services furnished to the participant on a nonvolunteer basis shall be reimbursed to the provider in accordance with §D(2) of this regulation. A physician who is designated as the attending physician by a participant and who is not an employee of the provider or receiving compensation from the provider shall be paid by the Program in accordance with COMAR 10.09.02. The attending physician may bill the Program only for personal professional services. When a participant resides in a nursing facility, the Program shall pay an additional per diem amount for room and board to the provider, subject to the following requirements: The additional amount shall be paid only for those days that the provider is reimbursed at the routine or continuous home care rate for hospice care furnished to the participant; The amount shall be the per diem reimbursement established by the Program to pay for room and board in the facility; The amount shall be paid to the provider only when the provider and the facility have a written agreement under which the provider is responsible for the professional management of the participant's hospice care and the facility agrees to provide room and board to the participant; While the provider is being reimbursed for hospice care furnished to a participant residing in a nursing facility, Program payment to the facility shall be discontinued; and The Department of Human Services shall determine the application of a recipient's resource to the cost of hospice care pursuant to COMAR 10.09.24 and COMAR 10.09.25. The provider: Shall collect a recipient's resource available for hospice care as certified by the Department of Human Services, May not collect a total payment, including the recipient's resource and the Department's payment, which exceeds the amount the provider would be paid in accordance with this regulation for a day of hospice care, and Shall show sums collected from a recipient's available resource as patient collection. Requests for Payment. Requests for payment for hospice care services rendered shall be submitted as set forth in COMAR 10.09.36.04. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36. Recovery and reimbursement shall be as set forth in COMAR 10.09.36.07. Cause for suspension or removal and imposition of sanctions shall be as set forth in COMAR 10.09.36.08. Appeal procedures for providers shall be as set forth in COMAR 10.09.36.09. State regulations shall be interpreted as set forth in COMAR 10.09.36.10. Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland Effective date: October 1, 1989 (16:16 Md. R. 1751) Regulation .08G amended as an emergency provision effective January 28, 1991 (18:3 Md. R. 301); emergency status expired April 8, 1991 (18:9 Md. R. 1004) Regulation .08G amended as an emergency provision effective April 9, 1991 (18:9 Md. R. 1005); amended permanently effective October 7, 1991 (18:18 Md. R. 2004) Chapter revised effective September 16, 1991 (18:18 Md. R. 2005) Regulation .01B amended effective July 22, 2013 (40:14 Md. R. 1174) Regulation .04 amended effective July 22, 2013 (40:14 Md. R. 1174) Regulation .05 amended effective July 22, 2013 (40:14 Md. R. 1174) Regulation .07B, C amended effective July 22, 2013 (40:14 Md. R. 1174) Regulation .08 amended effective July 21, 2025 (52:14 Md. R. 712)