Chapter 69. Maryland Medicaid Managed Care Program: Rare and Expensive Case Management
Regulation .01 Purpose.LinkCopy Citation
A.
The purpose of the Rare and Expensive Case Management (REM) program is to provide case management services and subspecialty care for Maryland Medicaid Managed Care Program eligible individuals with rare and expensive conditions.
B.
The program is designed to provide Maryland Medicaid Managed Care Program eligible individuals diagnosed with qualifying rare and expensive conditions the following benefits when the individual elects to participate in the program:
(1)
Case management services; and
(2)
REM optional services.
Regulation .02 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Activities of daily living” means tasks or activities that include but are not limited to bathing, feeding, toileting, dressing, and ambulation.
(2)
“Business day” means any day except Saturday, Sunday, or a holiday on which State offices are closed.
(3)
“Caregiver” means a willing and able individual who is trained in providing care to the participant.
(4)
“Case management” means assessing, planning, coordinating, and monitoring the delivery of medically necessary health-related services.
(5)
“Case management provider” means the Department's designee, or a subcontractor of the designee, which provides case management to participants assigned to it by the Department.
(6)
“Case manager” means, an individual who is:
(a)
A social worker with active and nationally recognized certification in case management or an RN;
(b)
Employed by the Department's designee; and
(c)
Assigned by the Department's designee to manage the care of some or all of the participants.
(7)
“Cause” means a significant change in medical condition such that it is no longer medically efficacious for the individual to remain in the MCO as determined by the Department.
(8)
“Certified medication technician (CMT)” means an individual who:
(a)
Completes a 20-hour course in medication administration approved by the Maryland Board of Nursing;
(b)
Is certified by the Maryland Board of Nursing under COMAR 10.39.04; and
(c)
Performs medication administration tasks delegated by a nurse in accordance with COMAR 10.27.11.
(9)
“Certified nursing assistant (CNA)” means an individual who:
(a)
Is certified by the Maryland Board of Nursing under COMAR 10.39.05; and
(b)
Routinely performs nursing tasks delegated by a nurse in accordance with COMAR 10.27.11.
(10)
“Certified nursing assistant certified as a CMT (CNA-CMT)” means an individual who:
(a)
Is certified by the Maryland Board of Nursing under COMAR 10.39.05 and 10.39.04;
(b)
Completes a 20-hour course in medication administration approved by the Maryland Board of Nursing; and
(c)
Routinely performs nursing tasks including medication administration tasks delegated by a nurse in accordance with COMAR 10.27.11.
(11)
“Chiropractor” means an individual who is licensed by the Maryland State Board of Chiropractic Examiners to practice chiropractic in Maryland.
(12)
“Delegated nursing services” means nursing services provided to a participant by a CNA, CNA-CMT, HHA, or HHA-CMT under the supervision of an RN in accordance with COMAR 10.27.11.
(13)
“Dental service provider” means an individual who is licensed and legally authorized to practice dentistry in the state in which the service is provided.
(14)
“Department” means the Department of Health, as defined in COMAR 10.09.36.01, or its authorized agents acting on behalf of the Department.
(15)
“Dietitian-nutritionist” means an individual who is licensed as a dietitian-nutritionist by the Maryland State Board of Dietetic Practice to practice dietetics in Maryland.
(16)
“Early and periodic screening, diagnosis, and treatment (EPSDT)” means the provision, to individuals younger than 21 years old, of preventive health care pursuant to 42 CFR §441.50 et seq., as amended, and other health care services, diagnostic services, and treatment services that are necessary to correct or ameliorate defects, physical and mental illnesses, and conditions discovered by EPSDT screening services.
(17)
“EPSDT-certified provider” means a physician, physician assistant or nurse practitioner who is certified by the Department's EPSDT program to provide well-child services according to the Department's periodicity schedule and program standards to enrollees younger than 21 years old.
(18)
“EPSDT periodicity schedule” means the list approved by the Department of required or recommended preventive health care services for children and adolescents.
(19)
“EPSDT services” means:
(a)
Screening services provided by an EPSDT-certified provider that are required or recommended on the EPSDT periodicity schedule; and
(b)
Health care services performed to diagnose, treat, or refer problems or conditions discovered during the comprehensive well-child service.
(20)
“Evaluation” means a determination of the health status of a patient in a patient's home or any other appropriate setting by a licensed professional for the purpose of designing an individual plan of care, which incorporates the modalities of treatment that will promote optimal functional ability and recuperation.
(21)
“Family member” means an adult who:
(a)
Lives with or provides care to the participant; and
(b)
Is not paid to provide the care under the REM program.
(22)
“HealthChoice” means Maryland Medicaid's Statewide mandatory managed care program as defined in COMAR 10.67.04.
(23)
“Home” means the place of residence, occupied by the participant, other than a residence or facility where nursing services are included in the living arrangement by regulation or statute, or otherwise provided for payment.
(24)
“Home health agency” means an agency licensed by the Department in accordance with COMAR 10.07.10.
(25)
“Home health aide (HHA)” means an individual who meets all the conditions of participation specified in:
(a)
42 CFR §484.36; and
(b)
Health Occupations Article, Title 8, Annotated Code of Maryland.
(26)
“Home health aide certified as a CMT (HHA-CMT)” means an individual who:
(a)
Meets all the conditions of participation specified in 42 CFR §484.36 and Health Occupations Article, Title 8, Annotated Code of Maryland; and
(b)
Completes a 20-hour course in medication administration approved by the Maryland Board of Nursing.
(27)
“Hospital” means an institution licensed by and providing services in accordance with Health-General Article, §19-301, Annotated Code of Maryland.
(28)
“Individualized education program (IEP)” means a written description of special education and related services developed by an IEP team to be implemented to meet the individual needs of a child.
(29)
“Individualized family service plan (IFSP)” means a written plan for providing early intervention and other services to an eligible child and the child's family developed by an IFSP team.
(30)
“Interdisciplinary team" means the group comprised of the case manager and relevant service providers to develop the case management plan under the overall direction and coordination of the case manager, in consultation with the participant and, when applicable, the participant's family.
(31)
“Intermediate care facility for individuals with intellectual disabilities or individuals with related conditions (ICF-IID)” means an institution licensed by the Department under COMAR 10.07.20 that provides health-related services or health rehabilitative services for individuals with intellectual disabilities or related conditions.
(32)
“Licensed practical nurse (LPN)” means an individual licensed to practice licensed practical nursing as defined in Health Occupations Article, §8-301, Annotated Code of Maryland.
(33)
“Managed care organization (MCO)” has the meaning stated in Health-General Article, §15-101, Annotated Code of Maryland.
(34)
“Medical Assistance” means the program administered by the State under Title XIX of the Social Security Act which provides comprehensive medical and other health-related care for categorically eligible and medically needy individuals.
(35)
“Medically necessary” means that the service or benefit is:
(a)
Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;
(b)
Consistent with current accepted standards of good medical practice;
(c)
The most cost-efficient service that can be provided without sacrificing effectiveness or access to care; and
(d)
Not primarily for the convenience of the participant, the participant's family, or the provider.
(36)
“Medicare” means the federal program that provides benefits to the aged and disabled under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq.
(37)
“Nurse” means an individual who is licensed to practice as a registered nurse (RN) or a licensed practical nurse (LPN) in the jurisdiction in which services are provided.
(38)
“Nurse practitioner” means an individual who is licensed and certified to practice as a nurse practitioner in the jurisdiction in which services are provided.
(39)
“Nursing facility” has the meaning stated in COMAR 10.09.10.01B.
(40)
“Nutritional counseling” means the assessment of the participant's nutritional status and education about improving their nutritional status provided by a licensed dietitian-nutritionist.
(41)
“Nutritional supplements” means enteral feeding which is medically indicated as either the sole source of nutrition or a supplement that enhances the physical well-being of the participant.
(42)
“Occupational therapist” means an individual licensed by the Maryland State Board of Occupational Therapy Practice to practice occupational therapy in Maryland.
(43)
“Participant” means an eligible individual who is enrolled in the Program.
(44)
“Physician” means an individual who is licensed or otherwise legally authorized to practice in the jurisdiction in which the services are rendered.
(45)
“Physician assistant” means an individual who is licensed to practice medicine with physician supervision as stated in the Health Occupations Article, §§15-301(d) and (e) and 15-302, Annotated Code of Maryland.
(46)
“Plan of care” means the document which governs a participant's care management which includes the:
(a)
Case management assessment report;
(b)
Interdisciplinary plan of care; and
(c)
Case management plan.
(47)
“Preauthorization” means the approval required from the Department or its designee before specific services may be rendered.
(48)
“Primary care provider (PCP)” means a physician, physician assistant, or nurse practitioner who is the primary coordinator of care for the participant, and whose responsibility it is to provide accessible, continuous, comprehensive, and coordinated health care services covering the full range of benefits required by the Maryland Medicaid Managed Care Program, as specified in COMAR 10.67.06.
(49)
“Private duty nursing” means skilled nursing services for participants, who require more individual and continuous care than is available under the home health program, which are provided by a registered nurse (RN) or a licensed practical nurse (LPN), in a participant's home or another setting when normal life activities take the participant outside his or her home.
(50)
“Program”, unless the context indicates otherwise, has the meaning stated in COMAR 10.09.36.01B.
(51)
“Progress note” means a signed and dated written notation by the RN, LPN, CNA, CNA-CMT, HHA, or HHA-CMT, which:
(a)
Summarizes facts about the care given and the participant's response during a given period of time;
(b)
Specifically addresses the established goals of treatment;
(c)
Is consistent with the participant's plan of care; and
(d)
Is written during the course of care.
(52)
“Provider” means an individual, agency, or facility, which is enrolled in the Program through an agreement with the Department, and has been identified as a Program provider by the issuance of a provider number.
(53)
“Rare and expensive case management (REM)” means a Maryland Medical Assistance program that provides case management services and optional services to eligible individuals with specific rare and expensive conditions.
(54)
“Rare and expensive condition” means a medical diagnosis or condition identified in Regulation .16 of this chapter.
(55)
“Registered nurse (RN)” means an individual licensed to practice registered nursing as defined in Health Occupations Article, §8-301, Annotated Code of Maryland.
(56)
“REM optional services” means the services listed in Regulations .10 and .11 of this chapter, which meet the general requirements under Regulation .09 of this chapter.
(57)
“Residential service agency” means an agency licensed by the Department in accordance with COMAR 10.07.05.
(58)
“Residential treatment center” means any institution which falls within the jurisdiction of Health-General Article, §19-308, Annotated Code of Maryland, and is licensed as required by COMAR 10.07.04 or other applicable standards established by the state in which the service is provided.
(59)
“School” means courses or classes for the acquisition of a General Education Diploma, a high school diploma, an associate degree, or a first-time bachelor’s degree.
(60)
“Social worker” means an individual who is licensed by the Maryland State Board of Social Work Examiners to practice social work in Maryland.
(61)
“Speech-language pathologist” means an individual who is licensed by the Maryland Board of Examiners for Audiologists, Hearing Aid Dispensers, and Speech-Language Pathologists to practice speech-language pathology in Maryland.
Regulation .03 REM Eligibility.LinkCopy Citation
A.
An individual is eligible to participate in the REM program if the individual:
(1)
Is eligible for Maryland Medicaid Managed Care as specified in COMAR 10.67.02.01;
(2)
Has one or more of the diagnoses specified in Regulation .17 of this chapter; and
(3)
Elects to participate in the REM program.
B.
The Department shall render a determination of an individual's eligibility within 5 business days on receipt of:
(1)
A completed REM application;
(2)
Any requested documentation verifying an individual meets the criteria set forth in §A of this regulation; and
(3)
Verbal or written confirmation an individual elects to participate.
Regulation .04 Participant Enrollment and Disenrollment.LinkCopy Citation
A.
Anyone may refer an individual into the REM program including, but not limited to a:
(1)
Family member;
(2)
Physician;
(3)
Discharge planner;
(4)
Hospital;
(5)
Clinic;
(6)
Social worker; and
(7)
Managed care organization (MCO).
B.
The Department shall enroll an individual determined eligible in the REM program when:
(1)
All pertinent documentation regarding needed medical services is received, reviewed, and approved;
(2)
Confirmation of the individual's election to participate in the program is received; and
(3)
The individual is being discharged from an institution or transitioning from an MCO and service coordination is complete.
C.
When an MCO participant is referred to the REM program for enrollment, the MCO shall:
(1)
Provide confirmation of the qualifying diagnosis to the Department; and
(2)
Continue to provide the MCO participant's care until the Department confirms the diagnosis and enrolls the MCO participant into REM.
D.
An individual shall be enrolled in or auto-assigned into an MCO as specified in COMAR 10.67.02, not later than 60 days from the date the individual becomes ineligible for REM, as a result of changes in the diagnosis or age group criteria specified in Regulation .17 of this chapter, except when the individual was allowed to remain in REM in accordance with §I of this regulation.
E.
A REM participant may elect to disenroll from REM and enroll in an MCO by notifying the Department of that decision except when the individual was allowed to remain in REM in accordance with §I of this regulation.
F.
Election to Remain in MCO.
(1)
An individual who becomes eligible for REM while enrolled in an MCO may elect to remain in an MCO by notifying the Department of that decision.
(2)
When a REM-eligible individual elects to remain in an MCO, the Department, in consultation with the MCO and the REM-eligible individual, may determine whether the MCO can appropriately meet the individual's medical needs within the parameters of the program benefit package as described in COMAR 10.67.06.
(3)
If the MCO determines it cannot appropriately meet the individual's medical needs, the MCO shall submit to the Department written justification for its decision.
(4)
If the Department determines the MCO can meet the individual's medical needs, the Department shall notify the MCO of its decision in writing.
(5)
If the Department determines that the MCO cannot appropriately meet the individual's needs, the Department shall issue a written determination to the individual and the MCO which includes:
(a)
The reason for the determination; and
(b)
An explanation of the individual's right to appeal the determination according to the procedures set forth in COMAR 10.01.04.
(6)
If the Department determines that the MCO can appropriately meet the individual's medical needs, the individual's election becomes effective and cannot be revoked without cause for a period of 1 year from the effective date.
G.
The Department shall allow an individual who, immediately before enrollment in REM, was receiving medical services from a specialty clinic or other setting to continue to receive services in that setting on enrollment in the REM program when the provider is willing to participate as a Medical Assistance fee-for-service provider.
H.
An individual eligible for REM who has elected to enroll in an MCO or to remain enrolled in an MCO may not receive REM services under the REM program.
I.
The Department shall disenroll from the REM program a participant who no longer meets the conditions specified in Regulation .03 of this chapter unless:
(1)
The participant does not meet the condition under Regulation .03A(1) of this chapter because the participant becomes eligible for Medicare; and
(2)
At the time the participant became eligible for Medicare the participant was approved for and was receiving private duty nursing, CNA, CNA-CMT, HHA, or HHA-CMT services under the REM program.
J.
An individual disenrolled from REM by the Department who maintains HealthChoice eligibility is subject to the MCO enrollment provisions specified in COMAR 10.67.02 except when the individual was allowed to remain in REM in accordance with §I of this regulation.
K.
Department-Initiated Disenrollment. The Department shall disenroll from REM an enrollee:
(1)
Who has been continuously institutionalized for a period of more than 90 successive days in a long-term care facility, subject to the long-term care facility obtaining the Department’s determination that the enrollee’s institutionalization has been medically necessary;
(2)
Who has been, or is expected to be, continuously institutionalized for more than 30 successive days in an institution for mental disease (IMD);
(3)
Upon admission to an intermediate care facility for individuals with intellectual disabilities or persons with related conditions (ICF/IID);
(4)
Who loses Medicaid eligibility or who changes to an assistance category not eligible for MCO enrollment, subject to COMAR 10.67.02;
(5)
Who has died; or
(6)
Who is an inmate of a public institution, including a State-operated institution or facility.
L.
Effective Date of Disenrollment. An enrollee’s disenrollment shall take effect:
(1)
Immediately when the enrollee dies;
(2)
From the first day of the month following the month in which the enrollee lost Medicaid eligibility;
(3)
On the first day of the month following the month in which the Department receives the required notification, when the enrollee permanently relocates outside of the State; or
(4)
From the first day of the month following the month in which the Department verifies an enrollee is an inmate.
Regulation .05 Benefits.LinkCopy Citation
A REM participant is eligible for the following:
A.
Fee-for-service Medical Assistance benefits available to a Medical Assistance participant not enrolled in an MCO;
B.
Services described in Regulations .10 and .11 of this chapter when determined medically necessary by the Department;
C.
A case management assessment performed by a REM case manager who shall:
(1)
Gather all relevant information needed to determine the participant’s condition and needs including the participant’s medical records;
(2)
Consult with the participant's current service providers; and
(3)
Evaluate the relevant information and complete a needs analysis including medical, psychosocial, environmental, and functional assessments; and
D.
Case management services performed by a REM case manager who shall:
(1)
When necessary, assist the REM participant, offering the participant a choice, if possible, in selecting and obtaining a PCP, who may be a specialist to the participant’s condition, giving preference to any pre-established relationships between the participant and the participant’s PCP;
(2)
Develop a plan of care in consultation with the participant, the participant's family members as authorized by the participant when possible, the PCP, and other providers rendering care that:
(a)
Includes the participant's health status and needs for medical, health-related, housing, and social services including, but not limited to:
(i)
All pertinent diagnoses including the REM qualifying diagnosis;
(ii)
Type, frequency, and duration of services;
(iii)
Treatment goals for each type of service;
(iv)
Medical equipment and supplies;
(v)
Medication;
(vi)
Social support structure;
(vii)
Current service providers;
(viii)
Assigned level of care;
(ix)
Nutritional status;
(x)
Education or vocational information;
(xi)
Current living arrangement; and
(xii)
Emergency plan, if appropriate; and
(b)
Is developed in consultation with the interdisciplinary team;
(3)
Implement the plan of care and assist the participant in gaining access to medically necessary services by linking the participant to those services;
(4)
Monitor service delivery, perform record reviews, and maintain contacts with the participant, services providers, and family members to evaluate the participant's condition and progress and to determine whether revision is needed in the plan of care or in services' delivery;
(5)
As necessary, initiate and implement modifications to the plan of care and communicate these changes to the participant, parents or caregivers, and pertinent health care providers;
(6)
Monitor a participant's receipt of EPSDT services as specified in COMAR 10.67.06; and
(7)
Assist the participant with the coordination of school health-related services such as the IEP or the IFSP as described in COMAR 10.09.50.
Regulation .06 Requirements for Provider Qualification.LinkCopy Citation
A.
A case manager providing case management under this chapter shall be:
(1)
An RN; or
(2)
A social worker.
B.
The following professionals providing services under this chapter to REM participants shall be licensed, certified, or otherwise legally authorized to practice in the jurisdiction in which the services are rendered:
(1)
Physicians;
(2)
Physician Assistants;
(3)
Nurse Practitioners;
(4)
RNs and LPNs;
(5)
Chiropractors;
(6)
Dentists;
(7)
Dietitian-Nutritionists;
(8)
Occupational therapists;
(9)
Social workers;
(10)
Speech-language pathologists; and
(11)
CNAs, HHAs, CNA-CMTs, and HHA-CMTs.
C.
A provider rendering services pursuant to this chapter shall meet all applicable licensure and certification requirements of the jurisdiction in which the provider is providing services.
D.
A provider rendering services to REM participants, pursuant to this chapter, may not have current sanctions or current disciplinary actions imposed by:
(1)
The jurisdictional licensing or certification authority;
(2)
The Medicare Program;
(3)
The Program; or
(4)
Other federally funded healthcare programs.
Regulation .07 Conditions for Participation — General Requirements.LinkCopy Citation
A provider rendering services pursuant to this chapter shall:
A.
Meet the applicable conditions for participation set forth in COMAR 10.09.36;
B.
Meet the provider qualification requirements specified in Regulation .06 of this chapter for its provider type;
C.
Meet the specific conditions for provider participation set forth in this chapter;
D.
Provide services in accordance with the applicable requirements of this chapter and all other relevant State and local laws and regulations;
E.
Verify the qualifications of all subcontracted or employed professionals and individuals engaged by the provider agency to render services covered under this chapter and provide a copy of their current licensure and credentials on request to the Department;
F.
Provide services to REM program participants in a manner consistent with the REM participant’s plan of care; and
G.
When the Department determines it is necessary, participate in the interdisciplinary team meetings for the purpose of:
(1)
Developing and implementing a participant's treatment plan or plan of care with the Department; or
(2)
Accessing a specific service.
Regulation .08 Specific Conditions for Provider Participation.LinkCopy Citation
A.
Case Management Providers. To participate in the Program, a case management provider shall meet the conditions set forth in Regulations .06 and .07 of this chapter.
B.
Chiropractic Service Providers. To participate in the Program, the chiropractic service provider shall:
(1)
Meet the:
(a)
Conditions set forth in Regulation .07 of this chapter; and
(b)
Requirements for chiropractic providers specified in COMAR 10.43.04;
(2)
Develop a goal-directed treatment plan that is based on an evaluation conducted during the initial assessment, which requires:
(a)
A review or evaluation of the treatment plan 30 days after the initial assessment; and
(b)
A review and update of the treatment plan every 90 days; and
(3)
Render services in accordance with orders written by a physician, physician assistant, or nurse practitioner.
C.
Dental Service Providers. To participate in the Program, the dental service provider shall meet the:
(1)
Conditions set forth in Regulation .07 of this chapter; and
(2)
Requirements for dental providers specified in COMAR 10.09.05.
D.
Nutritional Supplement Providers. To participate as a provider of nutritional supplements, a provider shall meet the:
(1)
Conditions of participation as set forth in Regulation .07 of this chapter; and
(2)
Criteria of the conditions for participation for pharmacy providers set forth in COMAR 10.09.03.
E.
Shift Private Duty Nursing/CNA/CNA-CMT/HHA/HHA-CMT Providers. To participate as a provider agency for shift private duty nursing, CNA, CNA-CMT, HHA, or HHA-CMT services, a provider shall:
(1)
Meet the conditions set forth in Regulation .07 of this chapter;
(2)
Meet all requirements of conditions for participation set forth in COMAR 10.09.53.03;
(3)
Participate in interdisciplinary team meetings, when requested by the Department or its designee;
(4)
Develop a goal-directed written nursing care plan that is based on an evaluation conducted during the initial assessment, which requires:
(a)
A review or evaluation of the nursing care plan 30 days after the initial assessment; and
(b)
A review and update of the nursing care plan every 90 days;
(5)
Ensure timesheets are signed by the individual rendering services;
(6)
Ensure a nurse's, CNA’s, CNA-CMT’s, HHA’s, or HHA-CMT’s shift to be not more than a total of 60 hours per week or 16 consecutive hours and that the individual is off 8 or more hours before starting another shift unless otherwise authorized by the Department;
(7)
Obtain the participant's signature or the signature of the participant's witness on the provider's official forms to verify receipt of service; and
(8)
Be licensed as a:
(a)
Residential service agency in accordance with COMAR 10.07.05; or
(b)
Home health agency in accordance with COMAR 10.07.10 which meets the conditions of participation specified by the Medicare program in 42 CFR §484.36.
F.
Occupational Therapy Providers. To participate in the Program as a provider of occupational therapy services, a provider shall:
(1)
Meet the conditions set forth in Regulation .07 of this chapter;
(2)
Be a self-employed occupational therapist licensed according to COMAR 10.46.01;
(3)
Be an agency or clinic which employs occupational therapists or be a Program provider of home health services under COMAR 10.09.04; and
(4)
Develop a goal-directed written treatment plan that is based on an evaluation conducted during the initial assessment which requires:
(a)
A review or evaluation of the treatment plan 30 days after the initial assessment; and
(b)
A review and update of the treatment plan every 90 days.
G.
Speech-Language Pathology Providers. To participate in the Program, a speech-language pathology provider shall:
(1)
Meet the conditions set forth in Regulation .07 of this chapter;
(2)
Be a self-employed speech-language pathologist according to COMAR 10.41.03 or be a Program provider of home health services under COMAR 10.09.04;
(3)
Be an agency or clinic that employs speech-language pathologists; and
(4)
Develop a goal-directed written treatment plan that is based on an initial assessment, which requires:
(a)
A review or evaluation of the treatment plan 30 days after the initial assessment; and
(b)
A review and update of the treatment plan every 90 days.
Regulation .09 Covered Services — General Requirements.LinkCopy Citation
For participants in the REM program, the Program covers and shall reimburse for services specified in Regulations .10 and .11 of this chapter when these services are:
A.
Medically necessary;
B.
Prescribed by a:
(1)
Physician;
(2)
Physician assistant; or
(3)
Nurse practitioner;
C.
Preauthorized, when required, by the Department;
D.
Rendered in accordance with accepted health professional standards;
E.
Rendered in accordance with the treatment plan or physician's, physician assistant’s, or nurse practitioner’s order, or both; and
F.
Delivered by an enrolled Medical Assistance provider.
Regulation .10 Covered Services.LinkCopy Citation
A.
Chiropractic services are covered for REM participants when:
(1)
Services are provided to a REM participant who is 21 years old or older;
(2)
Services are provided by a physician or chiropractor;
(3)
The qualifying REM diagnosis or related illness shows deterioration or worsening symptoms and other traditional treatments have been ineffective;
(4)
The treatment enhances or restores the participant's level of functioning; or
(5)
Symptoms resulting from the REM diagnosis or related illness impairs a participant's activities of daily living.
B.
Dental services are covered when services are:
(1)
Provided to a REM participant who is 21 years old or older; and
(2)
Rendered as specified in COMAR 10.09.05.
C.
Nutritional counseling services are covered when services are provided:
(1)
To a REM participant who is 21 years old or older; and
(2)
By a dietitian-nutritionist.
D.
Nutritional supplements are covered when the services:
(1)
Include nutritional supplements or enteral feeding when medically necessary other than those administered by tube; and
(2)
Are as described in COMAR 10.09.03.
E.
The Department shall cover a physician's, physician assistant’s, or nurse practitioner’s participation at interdisciplinary team meetings when the case manager, in conjunction with the team or specific team members, convenes the team meeting for the purpose of developing or reviewing the REM participant's plan of care to ensure continuity of care or access to a specific service.
F.
Occupational therapy services are covered when services are provided:
(1)
To a REM participant who is 21 years old or older;
(2)
By an occupational therapist; and
(3)
In accordance with COMAR 10.46.01 and 10.46.02.
G.
Speech-language pathology services include only those services that are provided:
(1)
To a REM participant who is 21 years old or older;
(2)
By a speech-language pathologist; and
(3)
In accordance with COMAR 10.41.02 and 10.41.03.
Regulation .11 Covered Optional Services — Private Duty Nursing, Certified Nursing Assistant, Certified Nursing Assistant Certified as a Certified Medication Technician, Home Health Aide and Home Health Aide Certified as a Certified Medication Technician.LinkCopy Citation
A.
The Program shall cover shift nursing services provided by an RN or LPN when:
(1)
The services are more individualized and continuous than what is available under the home health program;
(2)
The services are delivered to the participant in the participant's home, in school, or in other normal life activity setting or settings which occur outside the participant's home;
(3)
Services are provided to a REM participant who is 21 years old or older;
(4)
Services are determined medically necessary for a participant after the provider has completed an initial nursing assessment that reflects the participant’s need for an awake and alert caregiver;
(5)
The participant has at least one caregiver willing and able to accept responsibility for the participant’s care when the nurse, CNA, or HHA is not available;
(6)
The caregiver provides documentation of each of the following when applicable:
(a)
The caregiver’s work schedule along with commuting times;
(b)
The caregiver’s school attendance as defined in Regulation .02 of this chapter along with commuting times; and
(c)
Emergency circumstances, as determined by the Department, including but not limited to the inability of the primary caregiver to provide care due to hospitalization or an acute debilitating illness for up to a 60-day period;
(7)
Services are provided only in the absence of the willing and able caregiver during the sleeping hours and during the times documented in §A(6) of this regulation;
(8)
Services are rendered in accordance with Health Occupations Article, Title 8, Annotated Code of Maryland;
(9)
Sufficient documentation concerning the services provided is maintained by the RN or LPN including:
(a)
Verification of the participant's receipt of services as documented by the participant's signature or the signature of the participant's witness on the provider's official forms; and
(b)
Signed and dated progress notes which are reviewed monthly by the RN supervisor;
(10)
The nurse's shift is limited to not more than a total of 60 hours per week or 16 consecutive hours and the nurse is off 8 or more hours before starting another shift unless otherwise authorized by the Department;
(11)
Services are rendered by an RN or an LPN who is certified in cardiopulmonary resuscitation and the certification is renewed every 2 years; and
(12)
Monthly supervisory visits of an RN or an LPN are:
(a)
Conducted and documented by an RN supervisor; and
(b)
Based on acceptable standards of practice.
B.
The Program shall cover service`s provided by a CNA or CNA-CMT when:
(1)
The CNA or CNA-CMT is certified by the Maryland Board of Nursing and meets all the requirements to render services pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland;
(2)
The CNA-CMT has completed the training and has been certified by the Maryland Board of Nursing as a CMT;
(3)
Services are of a scope that is more individual and continuous than what is available under the home health program;
(4)
The services provided include but are not limited to:
(a)
Assistance with activities of daily living when performed in conjunction with other delegated nursing services; or
(b)
Other health care services properly delegated by an RN or an LPN pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland;
(5)
Services are rendered by a CNA or CNA-CMT who is certified in cardiopulmonary resuscitation and the certification is renewed every 2 years;
(6)
The CNAs or CNA-CMTs shift is limited to not more than a total of 60 hours per week or 16 consecutive hours and the CNA or CNA-CMT has 8 hours or more off before starting another shift unless otherwise authorized by the Department;
(7)
Sufficient documentation concerning the services provided is maintained by the CNA or CNA-CMT including:
(a)
Verification of the participant's receipt of services as documented by the participant's signature or the signature of the participant's witness on the provider's official forms; and
(b)
Signed and dated progress notes which are reviewed every 2 weeks by the RN supervisor;
(8)
Supervisory visits are conducted and documented every 2 weeks by an RN;
(9)
The services are included in the REM participant's plan of care developed by the case manager; and
(10)
Services are preauthorized by the Department.
C.
The Program shall cover services provided by a HHA or HHA-CMT when:
(1)
Services are provided by an unlicensed individual who meets all the conditions of participation specified by the Medicare program in 42 CFR §484.36 and Health Occupations Article, Title 8, Annotated Code of Maryland;
(2)
The HHA-CMT has completed the training and has been certified by the Maryland Board of Nursing as a CMT;
(3)
Services are more individualized and continuous than what is available under the home health program;
(4)
The services provided include but are not limited to:
(a)
Assistance with activities of daily living when performed in conjunction with other delegated nursing services; or
(b)
Other health care services properly delegated by an RN or LPN pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland;
(5)
Services are rendered by a HHA or HHA-CMT who is certified in cardiopulmonary resuscitation and the certification is renewed every 2 years;
(6)
The HHAs or HHA-CMTs shift is limited to not more than a total of 60 hours per week or 16 consecutive hours and the HHA or HHA-CMT has 8 hours or more off before starting another shift unless otherwise authorized by the Department;
(7)
Sufficient documentation is maintained by the HHA or HHA-CMT including:
(a)
Verification of the participant's receipt of services as documented by the participant's signature or the signature of the participant's witness on the provider's official forms; and
(b)
Signed and dated progress notes which are reviewed every 2 weeks by the RN supervisor;
(8)
Supervisory visits are conducted and documented every 2 weeks by an RN;
(9)
The services are included in the REM participant's plan of care developed by the case manager; and
(10)
Services are preauthorized by the Department.
Regulation .12 Limitations.LinkCopy Citation
A.
The Department shall pay for services specified in this chapter delivered to a REM participant only if the services have been ordered by the participant's physician or nurse practitioner, and preauthorized, when necessary, by the Department or its designee.
B.
For REM participants, the Department may not pay for the following comparable case management services:
(1)
HIV targeted case management as described in COMAR 10.09.32, except for HIV Diagnostic Evaluation Services as described in COMAR 10.09.32.03C and .04A; and
(2)
Model Waiver case management as described in COMAR 10.09.27.
C.
The REM program does not cover the following:
(1)
Shift private duty nursing, CNA or CNA-CMT, or HHA or HHA-CMT services rendered by a nurse, CNA, HHA, CNA-CMT, or HHA-CMT who is a member of the participant's immediate family or who ordinarily resides with the participant;
(2)
Services which are not medically necessary;
(3)
Services not supervised by an RN when delivered by the following:
(a)
An RN or an LPN;
(b)
A CNA;
(c)
An HHA;
(d)
A CNA-CMT; or
(e)
An HHA-CMT.
(4)
REM optional services not preauthorized as required by the Department or its designee;
(5)
REM optional services not prescribed by the participant's physician, physician assistant, or nurse practitioner;
(6)
Services specified in this chapter which duplicate or supplant services rendered by the participant's family caregivers or primary caregivers as well as other insurance, privilege, entitlement, or Program services that the participant receives or is eligible to receive;
(7)
Services provided for the convenience or preference of the participant or the primary caregiver rather than required by the participant's medical condition;
(8)
Speech, language, or occupational therapy services rendered in a classroom setting;
(9)
Shift private duty nursing, CNA, CNA-CMT, HHA, or HHA-CMT services ordered by a physician assistant;
(10)
Custodial services;
(11)
Services provided to a participant in a:
(a)
Hospital;
(b)
Residential treatment center;
(c)
Intermediate care facility for individuals with intellectual disabilities; or
(d)
Residence or facility where nursing services are included in the living arrangement by regulation or statute, or otherwise provided for payment;
(12)
Services not directly related to the participant’s plan of care;
(13)
Services described in the plan of care whenever a major change occurs in the participant's medical condition or skilled nursing care needs that indicates such services are no longer necessary;
(14)
Services which are not initially ordered before the start of care and renewed every 60 days by the participant’s primary medical provider;
(15)
Services provided by a nurse, CNA, or HHA who does not possess a valid, current, and nontemporary nursing license or certifications to provide services in the jurisdiction in which nursing services are rendered;
(16)
Services provided by a nurse, CNA, or HHA who does not have a current cardiopulmonary resuscitation (CPR) certification for the period during which the services are rendered;
(17)
Direct payment for supervisory visits that do not meet acceptable standards of practice in accordance with COMAR 10.27.09, 10.27.10, and 10.27.11;
(18)
Services rendered to a participant by a nurse, CNA, or HHA in the assigned staff’s home;
(19)
Services not documented; and
(20)
Respite services.
D.
The Program shall only cover one-to-one nursing when a participant’s condition requires that level of service and shared services are not an option.
E.
The Program shall only cover nursing services ordered by an individual who is enrolled as a provider in the Program with an active status on the date of service.
Regulation .13 Preauthorization Requirements.LinkCopy Citation
A.
Except for initial assessments unless otherwise specified, preauthorization by the Department or its designee is required for all services under Regulations .10 and .11 of this chapter.
B.
The Department or its designee shall issue preauthorization when the Department:
(1)
Determines that services are medically necessary; and
(2)
Authorizes the services before the initiation or continuance of the requested service.
C.
Authorization of services shall be rescinded by the Department or its designee when:
(1)
The participant is admitted to a hospital, residential treatment center, nursing facility, or ICF/IID;
(2)
The participant is no longer REM eligible;
(3)
The Department determines the care is no longer medically necessary; or
(4)
The participant dies.
Regulation .14 Payment Procedures — Request for Payment.LinkCopy Citation
A.
A provider shall submit a request for payment for the services covered under this chapter according to the procedures set forth in COMAR 10.09.36.
B.
Billing time limitations for the services covered under this chapter are the same as those set forth in COMAR 10.09.36.
C.
The Department shall pay for covered services at the lower of:
(1)
The lowest price, including negotiated contract prices, that is offered to any other purchaser for the same or similar service during the same time period, after extending to the Program all rebates, coupons, and negotiated discounts;
(2)
The actual charge billed by the provider; or
(3)
Any fee schedule developed for reimbursement of the same service provided under Medical Assistance.
D.
For dates of service from January 1, 2021, through June 30, 2022, the Department shall pay $445.86 for a case management assessment, as described in Regulation .05C of this chapter.
E.
For dates of service from January 1, 2021, through June 30, 2022, the Department shall make payments monthly for case management services at one of the rates specified below:
(1)
Level of Care 1: $329.22;
(2)
Level of Care 2: $196.22; or
(3)
Level of Care 3: $103.56.
F.
Effective July 1, 2022, the Department shall pay $463.69 for a case management assessment, as described in Regulation .05C of this chapter.
G.
Effective July 1, 2022, the Department shall make payments monthly for case management services at one of the rates specified below:
(1)
Level of Care 1: $342.39;
(2)
Level of Care 2: $204.07; or
(3)
Level of Care 3: $107.70.
H.
The rates found in §§E and G of this regulation are the monthly rates paid by the Department for a participant receiving case management as follows:
(1)
Level of Care 1 is intensive level of case management, assessment, and coordination of services for a participant who:
(a)
Is acutely ill;
(b)
Has an unstable clinical condition;
(c)
Has an exacerbated chronic illness; or
(d)
Has a newly diagnosed condition;
(2)
Level of Care 2 is case management to a participant who has a history of exacerbations of medical issues requiring services on an ongoing basis to attain stable service or treatment plans; and
(3)
Level of Care 3 is case management that is required on an ongoing basis to monitor a participant’s stability and treatment plans.
Regulation .15 Recovery and Reimbursement.LinkCopy Citation
Recovery and reimbursement under this chapter are set forth in COMAR 10.09.36.
Regulation .16 Cause for Suspension or Removal and Imposition of Sanctions.LinkCopy Citation
Cause for suspension or removal and imposition of sanctions is set forth in COMAR 10.09.36.
Regulation .17 Table of Rare and Expensive Disease Diagnosis.LinkCopy Citation
| ICD10 | ICD 10 Description | Age Limit |
|---|---|---|
| B20 | Human immunodeficiency virus (HIV) disease | 0—20 |
| C96.0 | Multifocal and multisystemic Langerhans-cell histiocytosis | 0—64 |
| C96.5 | Multifocal and unisystemic Langerhans-cell histiocytosis | 0—64 |
| C96.6 | Unifocal Langerhans-cell histiocytosis | 0—64 |
| D61.01 | Constitutional (pure) red blood cell aplasia | 0—20 |
| D61.09 | Other constitutional aplastic anemia | 0—20 |
| D66 | Hereditary factor VIII deficiency | 0—64 |
| D67 | Hereditary factor IX deficiency | 0—64 |
| D68.00 | Von Willebrand disease, unspecified | 0—64 |
| D68.01 | Von Willebrand disease, type 1 | 0—64 |
| D68.020 | Von Willebrand disease, type 2A | 0—64 |
| D68.021 | Von Willebrand disease, type 2B | 0—64 |
| D68.022 | Von Willebrand disease, type 2M | 0—64 |
| D68.023 | Von Willebrand disease, type 2N | 0—64 |
| D68.029 | Von Willebrand disease, type 2, unspecified | 0—64 |
| D68.03 | Von Willebrand disease, type 3 | 0—64 |
| D68.04 | Acquired von Willebrand disease | 0—64 |
| D68.09 | Other von Willebrand disease | 0—64 |
| D68.1 | Hereditary factor XI deficiency | 0—64 |
| D68.2 | Hereditary deficiency of other clotting factors | 0—64 |
| E70.0 | Classical phenylketonuria | 0—20 |
| E70.1 | Other hyperphenylalaninemias | 0—20 |
| E70.20 | Disorder of tyrosine metabolism, unspecified | 0—20 |
| E70.21 | Tyrosinemia | 0—20 |
| E70.29 | Other disorders of tyrosine metabolism | 0—20 |
| E70.30 | Albinism, unspecified | 0—20 |
| E70.40 | Disorders of histidine metabolism, unspecified | 0—20 |
| E70.41 | Histidinemia | 0—20 |
| E70.49 | Other disorders of histidine metabolism | 0—20 |
| E70.5 | Disorders of tryptophan metabolism | 0—20 |
| E70.81 | Aromatic L-amino acid decarboxylase deficiency | 0—20 |
| E70.89 | Other disorders of amino-acid metabolism | 0—20 |
| E71.110 | Isovaleric acidemia | 0—20 |
| E71.111 | 3-methylglutaconic aciduria | 0—20 |
| E71.118 | Other branched-chain organic acidurias | 0—20 |
| E71.120 | Methylmalonic acidemia | 0—20 |
| E71.121 | Propionic acidemia | 0—20 |
| E71.128 | Other disorders of propionate metabolism | 0—20 |
| E71.19 | Other disorders of branched-chain amino-acid metabolism | 0—20 |
| E71.2 | Disorder of branched-chain amino-acid metabolism, unspecified | 0—20 |
| E71.310 | Long chain/very long chain acyl CoA dehydrogenase deficiency | 0—64 |
| E71.311 | Medium chain acyl CoA dehydrogenase deficiency | 0—64 |
| E71.312 | Short chain acyl CoA dehydrogenase deficiency | 0—64 |
| E71.313 | Glutaric aciduria type II | 0—64 |
| E71.314 | Muscle carnitine palmitoyltransferase deficiency | 0—64 |
| E71.318 | Other disorders of fatty-acid oxidation | 0—64 |
| E71.32 | Disorders of ketone metabolism | 0—64 |
| E71.39 | Other disorders of fatty-acid metabolism | 0—64 |
| E71.41 | Primary carnitine deficiency | 0—64 |
| E71.42 | Carnitine deficiency due to inborn errors of metabolism | 0—64 |
| E71.50 | Peroxisomal disorder, unspecified | 0—64 |
| E71.510 | Zellweger syndrome | 0—64 |
| E71.511 | Neonatal adrenoleukodystrophy | 0—64 |
| E71.518 | Other disorders of peroxisome biogenesis | 0—64 |
| E71.520 | Childhood cerebral X-linked adrenoleukodystrophy | 0—64 |
| E71.521 | Adolescent X-linked adrenoleukodystrophy | 0—64 |
| E71.522 | Adrenomyeloneuropathy | 0—64 |
| E71.528 | Other X-linked adrenoleukodystrophy | 0—64 |
| E71.529 | X-linked adrenoleukodystrophy, unspecified type | 0—64 |
| E71.53 | Other group 2 peroxisomal disorders | 0—64 |
| E71.540 | Rhizomelic chondrodysplasia punctata | 0—64 |
| E71.541 | Zellweger-like syndrome | 0—64 |
| E71.542 | Other group 3 peroxisomal disorders | 0—64 |
| E71.548 | Other peroxisomal disorders | 0—64 |
| E72.01 | Cystinuria | 0—20 |
| E72.02 | Hartnup’s disease | 0—20 |
| E72.03 | Lowe’s syndrome | 0—20 |
| E72.04 | Cystinosis | 0—20 |
| E72.09 | Other disorders of amino-acid transport | 0—20 |
| E72.11 | Homocystinuria | 0—20 |
| E72.12 | Methylenetetrahydrofolate reductase deficiency | 0—20 |
| E72.19 | Other disorders of sulfur-bearing amino-acid metabolism | 0—20 |
| E72.20 | Disorder of urea cycle metabolism, unspecified | 0—20 |
| E72.21 | Argininemia | 0—20 |
| E72.22 | Arginosuccinic aciduria | 0—20 |
| E72.23 | Citrullinemia | 0—20 |
| E72.29 | Other disorders of urea cycle metabolism | 0—20 |
| E72.3 | Disorders of lysine and hydroxylysine metabolism | 0—20 |
| E72.4 | Disorders of ornithine metabolism | 0—20 |
| E72.51 | Non-ketotic hyperglycinemia | 0—20 |
| E72.52 | Trimethylaminuria | 0—20 |
| E72.53 | Primary hyperoxaluria | 0—20 |
| E72.59 | Other disorders of glycine metabolism | 0—20 |
| E72.81 | Disorders of gamma aminobutyric acid metabolism | 0—20 |
| E72.89 | Other specified disorders of amino-acid metabolism | 0—20 |
| E74.00 | Glycogen storage disease, unspecified | 0—20 |
| E74.01 | von Gierke disease | 0—20 |
| E74.02 | Pompe disease | 0—20 |
| E74.03 | Cori disease | 0—20 |
| E74.04 | McArdle disease | 0—20 |
| E74.09 | Other glycogen storage disease | 0—20 |
| E74.12 | Hereditary fructose intolerance | 0—20 |
| E74.19 | Other disorders of fructose metabolism | 0—20 |
| E74.21 | Galactosemia | 0—20 |
| E74.29 | Other disorders of galactose metabolism | 0—20 |
| E74.4 | Disorders of pyruvate metabolism and gluconeogenesis | 0—20 |
| E75.00 | GM2 gangliosidosis, unspecified | 0—20 |
| E75.01 | Sandhoff disease | 0—20 |
| E75.02 | Tay-Sachs disease | 0—20 |
| E75.09 | Other GM2 gangliosidosis | 0—20 |
| E75.10 | Unspecified gangliosidosis | 0—20 |
| E75.11 | Mucolipidosis IV | 0—20 |
| E75.19 | Other gangliosidosis | 0—20 |
| E75.21 | Fabry (-Anderson) disease | 0—20 |
| E75.22 | Gaucher disease | 0—20 |
| E75.23 | Krabbe disease | 0—20 |
| E75.242 | Niemann-Pick disease type C | 0—20 |
| E75.243 | Niemann-Pick disease type D | 0—20 |
| E75.244 | Niemann-Pick disease type A/B | 0—20 |
| E75.25 | Metachromatic leukodystrophy | 0—20 |
| E75.26 | Sulfatase deficiency | 0—20 |
| E75.29 | Other sphingolipidosis | 0—20 |
| E75.3 | Sphingolipidosis, unspecified | 0—20 |
| E75.4 | Neuronal ceroid lipofuscinosis | 0—20 |
| E75.5 | Other lipid storage disorders | 0—20 |
| E76.01 | Hurler’s syndrome | 0—64 |
| E76.02 | Hurler-Scheie syndrome | 0—64 |
| E76.03 | Scheie’s syndrome | 0—64 |
| E76.1 | Mucopolysaccharidosis, type II | 0—64 |
| E76.210 | Morquio A mucopolysaccharidoses | 0—64 |
| E76.211 | Morquio B mucopolysaccharidoses | 0—64 |
| E76.219 | Morquio mucopolysaccharidoses, unspecified | 0—64 |
| E76.22 | Sanfilippo mucopolysaccharidoses | 0—64 |
| E76.29 | Other mucopolysaccharidoses | 0—64 |
| E76.3 | Mucopolysaccharidosis, unspecified | 0—64 |
| E76.8 | Other disorders of glucosaminoglycan metabolism | 0—64 |
| E77.0 | Defects in post-translational mod of lysosomal enzymes | 0—20 |
| E77.1 | Defects in glycoprotein degradation | 0—20 |
| E77.8 | Other disorders of glycoprotein metabolism | 0—20 |
| E79.1 | Lesch-Nyhan syndrome | 0—64 |
| E79.2 | Myoadenylate deaminase deficiency | 0—64 |
| E79.8 | Other disorders of purine and pyrimidine metabolism | 0—64 |
| E79.9 | Disorder of purine and pyrimidine metabolism, unspecified | 0—64 |
| E80.3 | Defects of catalase and peroxidase | 0—64 |
| E84.0 | Cystic fibrosis with pulmonary manifestations | 0—64 |
| E84.11 | Meconium ileus in cystic fibrosis | 0—64 |
| E84.19 | Cystic fibrosis with other intestinal manifestations | 0—64 |
| E84.8 | Cystic fibrosis with other manifestations | 0—64 |
| E84.9 | Cystic fibrosis, unspecified | 0—64 |
| E88.40 | Mitochondrial metabolism disorder, unspecified | 0—64 |
| E88.41 | MELAS syndrome | 0—64 |
| E88.42 | MERRF syndrome | 0—64 |
| E88.49 | Other mitochondrial metabolism disorders | 0—64 |
| E88.89 | Other specified metabolic disorders | 0—64 |
| F84.2 | Rett’s syndrome | 0—20 |
| G11.0 | Congenital nonprogressive ataxia | 0—20 |
| G11.10 | Early-onset cerebellar ataxia, unspecified | 0—20 |
| G11.11 | Friedreich ataxia | 0—20 |
| G11.19 | Other early-onset cerebellar ataxia | 0—20 |
| G11.2 | Late-onset cerebellar ataxia | 0—20 |
| G11.3 | Cerebellar ataxia with defective DNA repair | 0—20 |
| G11.4 | Hereditary spastic paraplegia | 0—20 |
| G11.8 | Other hereditary ataxias | 0—20 |
| G11.9 | Hereditary ataxia, unspecified | 0—20 |
| G12.0 | Infantile spinal muscular atrophy, type I (Werdnig-Hoffman) | 0—20 |
| G12.1 | Other inherited spinal muscular atrophy | 0—20 |
| G12.21 | Amyotrophic lateral sclerosis | 0—20 |
| G12.22 | Progressive bulbar palsy | 0—20 |
| G12.29 | Other motor neuron disease | 0—20 |
| G12.8 | Other spinal muscular atrophies and related syndromes | 0—20 |
| G12.9 | Spinal muscular atrophy, unspecified | 0—20 |
| G24.1 | Genetic torsion dystonia | 0—64 |
| G24.8 | Other dystonia | 0—64 |
| G25.3 | Myoclonus | 0—5 |
| G25.9 | Extrapyramidal and movement disorder, unspecified | 0—20 |
| G31.81 | Alpers disease | 0—20 |
| G31.82 | Leigh’s disease | 0—20 |
| G31.9 | Degenerative disease of nervous system, unspecified | 0—20 |
| G32.81 | Cerebellar ataxia in diseases classified elsewhere | 0—20 |
| G37.0 | Diffuse sclerosis of central nervous system | 0—64 |
| G37.5 | Concentric sclerosis (Balo) of central nervous system | 0—64 |
| G71.00 | Muscular dystrophy, unspecified | 0—64 |
| G71.01 | Duchenne or Becker muscular dystrophy | 0—64 |
| G71.02 | Facioscapulohumeral muscular dystrophy | 0—64 |
| G71.031 | Autosomal dominant limb girdle muscular dystrophy | 0—64 |
| G71.032 | Autosomal recessive limb girdle muscular dystrophy due to calpain-3 dysfunction | 0—64 |
| G71.033 | Limb girdle muscular dystrophy due to dysferlin dysfunction | 0—64 |
| G71.0340 | Limb girdle muscular dystrophy due to sarcoglycan dysfunction, unspecified | 0—64 |
| G71.0341 | Limb girdle muscular dystrophy due to alpha sarcoglycan dysfunction | 0—64 |
| G71.0342 | Limb girdle muscular dystrophy due to beta sarcoglycan dysfunction | 0—64 |
| G71.0349 | Limb girdle muscular dystrophy due to other sarcoglycan dysfunction | 0—64 |
| G71.035 | Limb girdle muscular dystrophy due to anoctamin-5 dysfunction | 0—64 |
| G71.038 | Other limb girdle muscular dystrophy | 0—64 |
| G71.039 | Limb girdle muscular dystrophy, unspecified | 0—64 |
| G71.09 | Other specified muscular dystrophies | 0—64 |
| G71.11 | Myotonic muscular dystrophy | 0—64 |
| G71.20 | Congenital myopathy, unspecified | 0—64 |
| G71.21 | Nemaline myopathy | 0—64 |
| G71.220 | Centronuclear myopathy | 0—64 |
| G71.228 | Other centronuclear myopathy | 0—64 |
| G71.29 | Other congenial myopathy | 0—64 |
| G80.0 | Spastic quadriplegic cerebral palsy | 0—64 |
| G80.1 | Spastic diplegic cerebral palsy | 0—20 |
| G80.3 | Athetoid cerebral palsy | 0—64 |
| G82.50 | Quadriplegia, unspecified | 0—64 |
| G82.51 | Quadriplegia, C1-C4 complete | 0—64 |
| G82.52 | Quadriplegia, C1-C4 incomplete | 0—64 |
| G82.53 | Quadriplegia, C5-C7 complete | 0—64 |
| G82.54 | Quadriplegia, C5-C7 incomplete | 0—64 |
| G91.0 | Communicating hydrocephalus | 0—20 |
| G91.1 | Obstructive hydrocephalus | 0—20 |
| I67.5 | Moyamoya disease | 0—64 |
| K91.2 | Postsurgical malabsorption, not elsewhere classified | 0—20 |
| N03.A | Chronic nephritic syndrome with C3 glomerulonephritis | 0—20 |
| N03.1 | Chronic nephritic syndrome with focal and segmental glomerular lesions | 0—20 |
| N03.2 | Chronic nephritic syndrome w diffuse membranous glomrlneph | 0—20 |
| N03.3 | Chronic neph syndrome w diffuse mesangial prolif glomrlneph | 0—20 |
| N03.4 | Chronic neph syndrome w diffuse endocaplry prolif glomrlneph | 0—20 |
| N03.5 | Chronic nephritic syndrome w diffuse mesangiocap glomrlneph | 0—20 |
| N03.6 | Chronic nephritic syndrome with dense deposit disease | 0—20 |
| N03.7 | Chronic nephritic syndrome w diffuse crescentic glomrlneph | 0—20 |
| N03.8 | Chronic nephritic syndrome with other morphologic changes | 0—20 |
| N03.9 | Chronic nephritic syndrome with unspecified morphologic changes | 0—20 |
| N08 | Glomerular disorders in diseases classified elsewhere | 0—20 |
| N18.1 | Chronic kidney disease, stage 1 | 0—20 |
| N18.2 | Chronic kidney disease, stage 2 (mild) | 0—20 |
| N18.30 | Chronic kidney disease, stage 3, unspecified | 0—20 |
| N18.31 | Chronic kidney disease, stage 3a | 0—20 |
| N18.32 | Chronic kidney disease, stage 3b | 0—20 |
| N18.4 | Chronic kidney disease, stage 4 (severe) | 0—20 |
| N18.5 | Chronic kidney disease, stage 5 | 0—20 |
| N18.6 | End stage renal disease | 0—20 |
| N18.9 | Chronic kidney disease, unspecified | 0—20 |
| Q01.9 | Encephalocele, unspecified | 0—20 |
| Q02 | Microcephaly | 0—20 |
| Q03.0 | Malformations of aqueduct of Sylvius | 0—20 |
| Q03.1 | Atresia of foramina of Magendie and Luschka | 0—20 |
| Q03.8 | Other congenital hydrocephalus | 0—20 |
| Q03.9 | Congenital hydrocephalus, unspecified | 0—20 |
| Q04.3 | Other reduction deformities of brain | 0—20 |
| Q04.5 | Megalencephaly | 0—20 |
| Q04.6 | Congenital cerebral cysts | 0—20 |
| Q04.8 | Other specified congenital malformations of brain | 0—20 |
| Q05.0 | Cervical spina bifida with hydrocephalus | 0—64 |
| Q05.1 | Thoracic spina bifida with hydrocephalus | 0—64 |
| Q05.2 | Lumbar spina bifida with hydrocephalus | 0—64 |
| Q05.3 | Sacral spina bifida with hydrocephalus | 0—64 |
| Q05.4 | Unspecified spina bifida with hydrocephalus | 0—64 |
| Q05.5 | Cervical spina bifida without hydrocephalus | 0—64 |
| Q05.6 | Thoracic spina bifida without hydrocephalus | 0—64 |
| Q05.7 | Lumbar spina bifida without hydrocephalus | 0—64 |
| Q05.8 | Sacral spina bifida without hydrocephalus | 0—64 |
| Q05.9 | Spina bifida, unspecified | 0—64 |
| Q06.0 | Amyelia | 0—64 |
| Q06.1 | Hypoplasia and dysplasia of spinal cord | 0—64 |
| Q06.2 | Diastematomyelia | 0—64 |
| Q06.3 | Other congenital cauda equina malformations | 0—64 |
| Q06.4 | Hydromyelia | 0—64 |
| Q06.8 | Other specified congenital malformations of spinal cord | 0—64 |
| Q07.01 | Arnold-Chiari syndrome with spina bifida | 0—64 |
| Q07.02 | Arnold-Chiari syndrome with hydrocephalus | 0—64 |
| Q07.03 | Arnold-Chiari syndrome with spina bifida and hydrocephalus | 0—64 |
| Q30.1 | Agenesis and underdevelopment of nose, cleft or absent nose only | 0—5 |
| Q30.2 | Fissured, notched and cleft nose, cleft or absent nose only | 0—5 |
| Q31.0 | Web of larynx | 0—20 |
| Q31.8 | Other congenital malformations of larynx, atresia or agenesis of larynx only | 0—20 |
| Q32.1 | Other congenital malformations of trachea, atresia or agenesis of trachea only | 0—20 |
| Q32.4 | Other congenital malformations of bronchus, atresia or agenesis of bronchus only | 0—20 |
| Q33.0 | Congenital cystic lung | 0—20 |
| Q33.2 | Sequestration of lung | 0—20 |
| Q33.3 | Agenesis of lung | 0—20 |
| Q33.6 | Congenital hypoplasia and dysplasia of lung | 0—20 |
| Q35.1 | Cleft hard palate | 0—20 |
| Q35.3 | Cleft soft palate | 0—20 |
| Q35.5 | Cleft hard palate with cleft soft palate | 0—20 |
| Q35.9 | Cleft palate, unspecified | 0—20 |
| Q37.0 | Cleft hard palate with bilateral cleft lip | 0—20 |
| Q37.1 | Cleft hard palate with unilateral cleft lip | 0—20 |
| Q37.2 | Cleft soft palate with bilateral cleft lip | 0—20 |
| Q37.3 | Cleft soft palate with unilateral cleft lip | 0—20 |
| Q37.4 | Cleft hard and soft palate with bilateral cleft lip | 0—20 |
| Q37.5 | Cleft hard and soft palate with unilateral cleft lip | 0—20 |
| Q37.8 | Unspecified cleft palate with bilateral cleft lip | 0—20 |
| Q37.9 | Unspecified cleft palate with unilateral cleft lip | 0—20 |
| Q39.0 | Atresia of esophagus without fistula | 0—3 |
| Q39.1 | Atresia of esophagus with tracheo-esophageal fistula | 0—3 |
| Q39.2 | Congenital tracheo-esophageal fistula without atresia | 0—3 |
| Q39.3 | Congenital stenosis and stricture of esophagus | 0—3 |
| Q39.4 | Esophageal web | 0—3 |
| Q42.0 | Congenital absence, atresia and stenosis of rectum with fistula | 0—5 |
| Q42.1 | Congen absence, atresia and stenosis of rectum without fistula | 0—5 |
| Q42.2 | Congenital absence, atresia and stenosis of anus with fistula | 0—5 |
| Q42.3 | Congenital absence, atresia and stenosis of anus without fistula | 0—5 |
| Q42.8 | Congenital absence, atresia and stenosis of other parts of large intestine | 0—5 |
| Q42.9 | Congenital absence, atresia and stenosis of large intestine, part unspecified | 0—5 |
| Q43.1 | Hirschsprung’s disease | 0—15 |
| Q44.2 | Atresia of bile ducts | 0—20 |
| Q44.3 | Congenital stenosis and stricture of bile ducts | 0—20 |
| Q44.6 | Cystic disease of liver | 0—20 |
| Q45.0 | Agenesis, aplasia and hypoplasia of pancreas | 0—5 |
| Q45.1 | Annular pancreas | 0—5 |
| Q45.3 | Other congenital malformations of pancreas and pancreatic duct | 0—5 |
| Q45.8 | Other specified congenital malformations of digestive system | 0—10 |
| Q60.1 | Renal agenesis, bilateral | 0—20 |
| Q60.4 | Renal hypoplasia, bilateral | 0—20 |
| Q60.6 | Potter’s syndrome, with bilateral renal agenesis only | 0—20 |
| Q61.02 | Congenital multiple renal cysts, bilateral only | 0—20 |
| Q61.19 | Other polycystic kidney, infantile type, bilateral only | 0—20 |
| Q61.2 | Polycystic kidney, adult type, bilateral only | 0—20 |
| Q61.3 | Polycystic kidney, unspecified, bilateral only | 0—20 |
| Q61.4 | Renal dysplasia, bilateral only | 0—20 |
| Q61.5 | Medullary cystic kidney, bilateral only | 0—20 |
| Q61.9 | Cystic kidney disease, unspecified, bilateral only | 0—20 |
| Q64.10 | Exstrophy of urinary bladder, unspecified | 0—20 |
| Q64.12 | Cloacal extrophy of urinary bladder | 0—20 |
| Q64.19 | Other exstrophy of urinary bladder | 0—20 |
| Q75.0 | Craniosynostosis | 0—20 |
| Q75.1 | Craniofacial dysostosis | 0—20 |
| Q75.2 | Hypertelorism | 0—20 |
| Q75.4 | Mandibulofacial dysostosis | 0—20 |
| Q75.5 | Oculomandibular dysostosis | 0—20 |
| Q75.8 | Other congenital malformations of skull and face bones | 0—20 |
| Q77.4 | Achondroplasia | 0—1 |
| Q77.6 | Chondroectodermal dysplasia | 0—1 |
| Q77.8 | Other osteochondrodysplasia with defects of growth of tubular bones and spine | 0—1 |
| Q78.0 | Osteogenesis imperfecta | 0—20 |
| Q78.1 | Polyostotic fibrous dysplasia | 0—1 |
| Q78.2 | Osteopetrosis | 0—1 |
| Q78.3 | Progressive diaphyseal dysplasia | 0—1 |
| Q78.4 | Enchondromatosis | 0—1 |
| Q78.6 | Multiple congenital exostoses | 0—1 |
| Q78.8 | Other specified osteochondrodysplasias | 0—1 |
| Q78.9 | Osteochondrodysplasia, unspecified | 0—1 |
| Q79.0 | Congenital diaphragmatic hernia | 0—1 |
| Q79.1 | Other congenital malformations of diaphragm | 0—1 |
| Q79.2 | Exomphalos | 0—1 |
| Q79.3 | Gastroschisis | 0—1 |
| Q79.4 | Prune belly syndrome | 0—1 |
| Q79.59 | Other congenital malformations of abdominal wall | 0—1 |
| Q89.7 | Multiple congenital malformations, not elsewhere classified | 0—10 |
| R75 | Inconclusive laboratory evidence of HIV | 0—12 months |
| Z21 | Asymptomatic human immunodeficiency virus infection status | 0—20 |
| Z99.11 | Dependence on respirator (ventilator) status | 1—64 |
| Z99.2 | Dependence on renal dialysis | 21—64 |
Regulation .18 Appeals Procedures.LinkCopy Citation
Appeal procedures are as set forth in COMAR 10.01.04 and 10.09.36.
Chapter annotations
Authority: Health-General Article, §§2-104(b), 15-103(b)(4)(i), and 15-105, Annotated Code of Maryland
History: Effective date:
History: Regulations .01—.17 adopted as an emergency provision effective November 8, 1996 (23:25 Md. R. 1730)
History: Regulations .01—.17 adopted effective March 10, 1997 (24:5 Md. R. 408)
History: Regulations .01, .02, .05, .06, .08—.11, and .13 amended as an emergency provision effective July 1, 1997 (24:16 Md. R. 1151); emergency status expired December 31, 1997
History: Regulation .01 amended effective February 9, 1998 (25:3 Md. R. 144)
History: Regulations .01, .02, and .14 amended as an emergency provision effective July 1, 1998 (25:16 Md. R. 1261)
History: Regulations .01, .02, .09, .10, and .14 amended effective January 1, 1999 (25:26 Md. R. 1925)
History: Regulation .01O amended effective October 16, 2000 (27:20 Md. R. 1839)
History: Regulation .02 amended effective February 9, 1998 (25:3 Md. R. 144)
History: Regulation .02 repealed as an emergency provision effective December 1, 2000 (27:26 Md. R. 2355); emergency status extended at 28:7 Md. R. 685; repealed permanently effective June 25, 2001 (28:12 Md. R. 1109)
History: Regulation .03 amended as an emergency provision effective December 1, 2000 (27:26 Md. R. 2355); emergency status extended at 28:7 Md. R. 685; amended permanently effective June 25, 2001 (28:12 Md. R. 1109)
History: Regulation .04 amended as an emergency provision effective December 1, 2000 (27:26 Md. R. 2355); emergency status extended at 28:7 Md. R. 685; amended permanently effective June 25, 2001 (28:12 Md. R. 1109)
History: Regulation .05 amended effective February 9, 1998 (25:3 Md. R. 144)
History: Regulation .05 amended as an emergency provision effective December 1, 2000 (27:26 Md. R. 2355); emergency status extended at 28:7 Md. R. 685; amended permanently effective June 25, 2001 (28:12 Md. R. 1109)
History: Regulation .06B amended effective February 9, 1998 (25:3 Md. R. 144)
History: Regulation .08 amended effective February 9, 1998 (25:3 Md. R. 144)
History: Regulation .09B amended effective February 9, 1998 (25:3 Md. R. 144)
History: Regulation .10B amended effective February 9, 1998 (25:3 Md. R. 144)
History: Regulation .11B amended effective February 9, 1998 (25:3 Md. R. 144)
History: Regulation .13B amended effective February 9, 1998 (25:3 Md. R. 144)
History: Regulations .01—.17 repealed and new Regulations .01—.17 adopted effective February 2, 2004 (31:2 Md. R. 84)
History: Regulation .02B amended effective November 6, 2006 (33:22 Md. R. 1732)
History: Regulation .04 amended effective December 24, 2012 (39:25 Md. R. 1613)
History: Regulation .05B, C amended effective November 6, 2006 (33:22 Md. R. 1732)
History: Regulation .05C, D amended effective October 5, 2009 (36:20 Md. R. 1528)
History: Regulation .07G amended effective November 6, 2006 (33:22 Md. R. 1732)
History: Regulation .09 amended effective November 6, 2006 (33:22 Md. R. 1732)
History: Regulation .12B amended effective November 5, 2007 (34:22 Md. R. 1977)
History: Regulation .12C amended effective November 6, 2006 (33:22 Md. R. 1732)
History: Regulation .13B, C amended effective November 6, 2006 (33:22 Md. R. 1732)
History: Regulation .13C amended effective October 14, 2013 (40:20 Md. R. 1652)
History: Regulation .14E, F, G adopted effective October 5, 2009 (36:20 Md. R. 1528)
History: Regulation .14E amended effective April 4, 2011 (38:7 Md. R. 431)
History: Regulation .17 amended effective November 5, 2007 (34:22 Md. R. 1977); June 30, 2008 (35:13 Md. R. 1180); October 5, 2009 (36:20 Md. R. 1528); December 27, 2010 (37:26 Md. R. 1787); December 24, 2012 (39:25 Md. R. 1613)
History: Regulation .17 repealed and new Regulation .17 adopted effective October 26, 2015 (42:21 Md. R. 1301)
History: Chapter revised effective July 2, 2018 (45:13 Md. R. 665)
History: Regulation .02B amended effective June 24, 2024 (51:12 Md. R. 619)
History: Regulation .04F amended effective May 20, 2019 (46:10 Md. R. 486)
History: Regulation .04K, L adopted effective November 23, 2023 (50:23 Md. R. 1005)
History: Regulation .11A amended effective June 24, 2024 (51:12 Md. R. 619)
History: Regulation .12 amended effective June 24, 2024 (51:12 Md. R. 619)
History: Regulation .14 amended effective November 14, 2022 (49:23 Md. R. 996); November 23, 2023 (50:23 Md. R. 1005)
History: Regulation .14D, E amended effective May 20, 2019 (46:10 Md. R. 486); November 18, 2019 (46:23 Md. R. 1065)
History: Regulation .17 amended effective May 20, 2019 (46:10 Md. R. 486); November 14, 2022 (49:23 Md. R. 996); November 23, 2023 (50:23 Md. R. 1005)