Chapter 64. Collaborative Care Model
Regulation .01 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Behavioral health care manager” means a nurse, clinical social worker, or psychologist working under the oversight and direction of the physician or other primary care provider with formal education or specialized training to provide coordination and intervention in behavioral health.
(2)
“Collaborative Care Model” means the Psychiatric Collaborative Care Model, a patient-centered, evidence-based approach for integrating physical and behavioral health services in primary care settings that includes:
(a)
Care coordination and management;
(b)
Regular, systematic monitoring and treatment using a validated clinical rating scale;
(c)
Regular, systematic psychiatric or substance use disorder caseload reviews, or both; and
(d)
Regular, systematic consultation for patients who do not show clinical improvement.
(3)
“Federally qualified health center (FQHC)" means an entity as defined by Health-General Article, §24-1301, Annotated Code of Maryland, and §1905(l)(2)(B) of the Social Security Act.
(4)
“Participant” means an individual who:
(a)
Has been determined to meet the qualifications for services under the Collaborative Care Model as specified in Regulation .04 of this chapter; and
(b)
Is enrolled with the Department to receive Medicaid services.
(5)
“Primary care provider (PCP)” means a physician, or other provider type as defined in COMAR 10.67.05.05, who is the primary coordinator of care for the enrollee, and whose responsibility is to provide accessible, continuous, comprehensive, and coordinated health services covering the full range of benefits required by the Maryland Medical Assistance Program.
(6)
“Program” means the Maryland Medical Assistance Program.
(7)
“Psychiatric consultant” means a licensed psychiatrist, psychiatric nurse practitioner, addiction medicine specialist, or any other behavioral health medicine specialist as allowed under federal regulations governing the model who is trained in psychiatry and qualified to prescribe medication.
Regulation .02 Conditions for Participation.LinkCopy Citation
A.
A provider shall meet all conditions for participation as set forth in COMAR 10.09.36.03.
B.
A provider may not knowingly employ or contract with a person, partnership, or corporation which the Program has disqualified from providing or supplying services to Program participants.
Regulation .03 Covered Services.LinkCopy Citation
The Program covers the following medically necessary services rendered to participants under the Collaborative Care Model:
A.
Care coordination and management;
B.
Regular, systematic monitoring and treatment using a validated clinical rating scale;
C.
Regular, systematic psychiatric or substance use disorder caseload reviews, or both; and
D.
Regular, systematic consultation for patients who do not show clinical improvement.
Regulation .04 Eligibility for Services.LinkCopy Citation
Eligibility for services under the Collaborative Care Model is limited to participants with a behavioral health diagnosis that is clinically appropriate for the primary care setting for which there is a validated tool to monitor symptoms and quantify outcomes.
Regulation .05 Limitations.LinkCopy Citation
Under this chapter, the Program does not cover the following:
A.
Services not specified in Regulation .03 of this chapter;
B.
Services not medically necessary;
C.
Services prohibited by the Maryland Nurse Practice Act or by the State Board of Nursing;
D.
Advanced practice nursing services included as part of the cost of:
(1)
An inpatient facility;
(2)
A hospital outpatient department; or
(3)
A freestanding clinic;
E.
Visits by or to the provider solely for the purpose of the following:
(1)
Prescription, drug, or food supplement pick-up;
(2)
Recording of an electrocardiogram;
(3)
Ascertaining the patient’s weight;
(4)
Interpretation of laboratory tests or panels; or
(5)
Prescribing or administering medication;
F.
Drugs and supplies which are acquired by the provider at no cost;
G.
Services paid under the free-standing dialysis program as described in COMAR 10.09.22;
H.
Prescriptions and injections for central nervous system stimulants and anorectic agents when used for weight control;
I.
Acupuncture;
J.
Hypnosis;
K.
Travel expenses;
L.
Investigational or experimental drugs and procedures;
M.
Services denied by Medicare as not medically justified;
N.
Specimen collection, except by venipuncture and capillary or arterial puncture, as a separate service;
O.
Laboratory or X-ray services performed by another facility, which shall be billed to the Program directly by the facility; and
P.
For certified nurse midwives, a separate visit charge on date of delivery.
Regulation .06 Payment Procedures.LinkCopy Citation
A.
The provider shall submit the request for payment of services rendered according to procedures established by the Program and in the form designated by the Program.
B.
The Program reserves the right to return to the provider, before payment, all claims not properly signed, completed, and accompanied by properly completed forms required by the Program.
C.
Unless the service is free to the general public, the provider shall charge the Program the provider’s customary charge to the general public for similar services.
D.
If the service is free to individuals not covered by Medicaid:
(1)
The provider:
(a)
May charge the Program; and
(b)
Shall be reimbursed in accordance with §G of this regulation; and
(2)
The provider’s reimbursement is not limited to the provider’s customary charge.
E.
The Program will pay for covered services, the lesser of:
(1)
The provider’s customary charge to the general public unless the service is free to individuals not covered by Medicaid; or
(2)
The Program’s fee schedule.
F.
The provider may not bill the Program or the participant for:
(1)
Completion of forms and reports;
(2)
Broken or missed appointments;
(3)
Professional services rendered by mail;
(4)
Professional services rendered via telehealth when services are indicated as an exclusion; or
(5)
Providing a copy of a participant’s medical record when requested by another provider on behalf of the participant.
G.
Reimbursement.
(1)
Providers may bill one 60-minute or 70-minute code per month, and two additional 30-minute codes per month, unless otherwise excepted in §G(2)or (3) of this regulation.
(2)
FQHCs may bill once per month, using a separate FQHC code.
(3)
If the primary care team determines that the participant’s condition requires more or less frequent visits than described above, the care manager may order an alternate schedule.
(4)
The Maryland Medical Assistance Program's procedures for payment are contained in COMAR 10.09.02.07D.
Regulation .07 Recovery and Reimbursement.LinkCopy Citation
Recovery and reimbursement are as set forth in COMAR 10.09.36.07.
Regulation .08 Causes for Suspension or Removal and Imposition of Sanctions.LinkCopy Citation
Causes for suspension or removal and imposition of sanctions are as set forth in COMAR 10.09.36.08.
Regulation .09 Appeal Procedures.LinkCopy Citation
Providers filing appeals from administrative decisions made in connection with these regulations shall do so according to COMAR 10.09.36.09.
Chapter annotations
Authority: Health-General Article, §15–141.1, Annotated Code of Maryland
History: Effective date: August 5, 2024 (51:15 Md. R. 707)