# COMAR Title 10 — Maryland Department of Health

## Subtitle 09 — Medical Care Programs

### Chapter 81 — Increased Community Services (ICS) Program

**Authority:** Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland

**Administrative History:** Effective date: June 11, 2012 (39:11 Md. R. 687)

**Administrative History:** Regulation .40C amended effective July 4, 2016 (43:13 Md. R. 712)

**Administrative History:** Regulation .41 amended effective July 4, 2016 (43:13 Md. R. 712)

**Administrative History:** Regulation .41 repealed effective December 11, 2025 (52:23 Md. R. 1198)

**Administrative History:** Regulation .41 adopted effective December 11, 2025 (52:23 Md. R. 1198)

#### Regulation .01 Purpose.

*COMAR 10.09.81.01*

The purpose of the Increased Community Services (ICS) Program is to enable certain nursing facility residents to access home and community-based services by allowing those nursing facility residents to contribute to the cost of care through a monthly assessment and thus enabling those individuals to live at home with ICS and other Medicaid services instead of in a nursing facility.

#### Regulation .02 Definitions.

*COMAR 10.09.81.02*

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

B. Terms Defined.

  (1) “Activities of daily living” means bathing, eating, toileting, dressing, and mobility including transfer.

  (2) “Adult Evaluation and Review Services (AERS)” means an entity within the local health department which, in accordance with this chapter and COMAR 10.09.30, evaluates ICS applicants and participants.

  (3) “Agency-employed attendant” means an attendant who is employed by, or under contract with, an attendant care provider agency.

  (4) “Applicant” means an individual who has submitted to the Department an application for the ICS Program.

  (5) “Assessment fee” means the fee the participant is required to pay as a condition of eligibility for the ICS Program and Medical Assistance benefits.

  (6) “Assistance” means that another individual:

    (a) Physically performs an activity for the participant;

    (b) Physically helps the participant to perform an activity;

    (c) Is present while the participant performs an activity because the participant's safety or health may be jeopardized if the activity is not monitored or performed due to the participant's physical or mental status; or

    (d) Cues or encourages the participant to perform the activity.

  (7) “Assisted living services provider” means a provider licensed by the Department in accordance with COMAR 10.07.14 and enrolled in the Maryland Medical Assistance Program to provide the services covered under Regulation .37 of this chapter.

  (8) “Attendant” means an individual who provides a participant with attendant care services.

  (9) “Attendant care provider agency” means an agency that is enrolled in the Maryland Medical Assistance Program to provide the services covered under Regulation .30 of this chapter.

  (10) “Attendant Care Services” means assistance with activities of daily living, instrumental activities of daily living, and performance of delegated nursing functions.

  (11) “Case management agency” means an agency enrolled by the Maryland Medical Assistance Program to provide case management services to ICS applicants and participants.

  (12) “Case management services” means services that assist an applicant or a participant to gain access to ICS services, Medicaid State Plan services, and other community services.

  (13) “Delegated nursing functions” means services, other than assistance with activities of daily living and instrumental activities of daily living, provided to a participant by:

    (a) An enrolled attendant under the supervision of an enrolled licensed registered nurse in accordance with COMAR 10.27.11; or

    (b) A nurse practitioner in accordance with COMAR 10.27.07.

  (14) “Department” means the Maryland Department of Health, or its authorized agent acting on behalf of the Department.

  (15) “Determination” means a decision by the Department regarding an applicant's or participant's eligibility for the ICS Program.

  (16) “Fiscal intermediary” means an agency that is under contract with the Department to provide fiscal intermediary services.

  (17) “Fiscal intermediary services” means certain employer-related payroll functions, such as State and federal tax withholding and Social Security withholding, performed on behalf of participants who elect to use the participant-employed model of attendant care services.

  (18) Home.

    (a) “Home” means the place where the participant resides.

    (b) “Home” does not include a hospital, nursing facility, or other institution that is regulated under:

      (i) COMAR 10.22.03 for licensed community-based residential facilities for individuals with intellectual or developmental disabilities; or

      (ii) COMAR 10.21.22 for residential rehabilitation programs for individuals with serious or chronic mental illness.

  (19) "Increased Community Services (ICS) Program” means the Medicaid home and community-based services program implemented under this chapter in accordance with the HealthChoice Section 1115 Waiver approved by the Centers for Medicare and Medicaid Services.

  (20) “Instrumental activities of daily living” means tasks or activities that include:

    (a) Preparing a light meal;

    (b) Performing light chores;

    (c) Shopping for groceries;

    (d) Traveling beyond a walking distance;

    (e) Managing finances and handling money;

    (f) Using the telephone; and

    (g) Planning and making decisions.

  (21) “Maryland Medical Assistance Program” 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 low income and medically indigent persons.

  (22) “Medicaid” means the Maryland Medical Assistance Program.

  (23) “Medical day care” means medically supervised, health-related services provided in an ambulatory setting to medically disabled adults who, because of the degree of impairment, need health maintenance and restorative services that support their community living.

  (24) “Medical day care center” means a facility operated for the purpose of providing medical day care services in an ambulatory care setting to medically disabled adults who do not require 24-hour inpatient care, but because of the degree of impairment, are not capable of full-time independent living.

  (25) “Medically necessary” means 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 currently 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 consumer, family, or provider.

  (26) “Nurse” means an individual who is currently licensed to practice nursing in the State.

  (27) “Nurse monitor” means a registered nurse who provides nursing supervision of attendants in accordance with COMAR 10.27.11 and this chapter.

  (28) “Nursing facility” means an institution which is licensed by the Department under COMAR 10.07.02.

  (29) “Nursing facility services” means services provided to individuals who do not require hospital care, but who, because of a mental or physical condition, require skilled nursing care and related services, rehabilitative services, or, on a regular basis, health-related care and services above the level of room and board.

  (30) “Nursing supervision” means a nurse monitor's supervision of an attendant in accordance with COMAR 10.27.11 and this chapter.

  (31) “Participant” means an individual who meets the qualifications for participation in the ICS program as specified in Regulation .03 of this chapter and is enrolled with the Department to receive ICS services.

  (32) “Participant-employed attendant” means an attendant who does not work for an attendant care provider agency and who may be chosen, trained, supervised, and fired by the participant.

  (33) “Participant-employed model” means the delivery of attendant care services when:

    (a) An ICS participant chooses the attendant who will render services;

    (b) The attendant is an enrolled Medicaid provider; and

    (c) The participant utilizes services of a fiscal intermediary.

  (34) “Plan of care” means the recommended or revised recommended service plan developed by AERS after an evaluation of an applicant or participant.

  (35) “Plan of service” means the written plan that:

    (a) Is developed jointly by the applicant or participant and the case manager;

    (b) Is based upon:

      (i) The AERS evaluation;

      (ii) The AERS plan of care; and

      (iii) The case manager's face-to-face interview with the applicant or participant;

    (c) Addresses the applicant's or participant's needs and desires; and

    (d) Specifies the type, amount, frequency, costs, and duration of all ICS and other Medicaid services required to safely support the participant in the community.

  (36) “Provider” means an entity which is enrolled in the Maryland Medical Assistance Program to provide one or more of the services covered under Regulations .22 — .37 of this chapter.

  (37) “Quality plan” means the plan developed by the Department to address quality assurance and oversight for the ICS program.

  (38) “Registered nurse” means an individual licensed to practice as a registered nurse under Health Occupations Article, Title 8, Annotated Code of Maryland.

  (39) “Room and board” means rent or mortgage, utilities, maintenance, furnishings, and food, which are provided in, or associated with, an individual’s place of residence.

  (40) “State Plan” means the document approved by the Centers for Medicare and Medicaid Services describing the nature and scope of the Maryland Medical Assistance Program in accordance with federal requirements at §1902(a) of Title XIX of the Social Security Act.

#### Regulation .03 Participant Eligibility.

*COMAR 10.09.81.03*

A. General Requirements.

  (1) To be eligible for participation in the ICS Program, an applicant or participant shall be determined by the Department to meet the conditions of §§B — E of this regulation.

  (2) A participant's eligibility for ICS services shall be reevaluated by the Department every 12 months or more frequently if needed due to a significant change in the participant's condition, needs, or financial status.

  (3) The Department shall have 45 days from the date of a complete application to make an eligibility determination.

B. Technical Eligibility. To be eligible for the services covered under this chapter, an applicant or participant shall be determined by the Department to meet the technical eligibility criteria for ICS services if the individual:

  (1) Had been living in a nursing facility at the time of application and for at least the last 6 months before the date of application and meets all eligibility requirements before transitioning into the community;

  (2) Had been eligible for Medicaid for at least 30 consecutive days immediately before being enrolled in the ICS Program;

  (3) Is not otherwise eligible for services covered under:

    (a) The authority of §1915(c) of Title XIX of the Social Security Act; or

    (b) The Programs of All-Inclusive Care for the Elderly under COMAR 10.09.44;

  (4) Is at least 18 years old;

  (5) Has a plan of service that:

    (a) Includes Medical Assistance and ICS services necessary to safely serve the participant in the community; and

    (b) Is determined by the Department to cost less than the cost to Medicaid if the individual were to remain in the institution;

  (6) Is offered the choice between ICS and nursing facility services;

  (7) Chooses, or the individual’s authorized representative chooses on the individual’s behalf, to receive ICS services;

  (8) Is being discharged from a nursing facility into ICS services in the community and would be institutionalized in a nursing facility if not for the ICS services;

  (9) Resides in a home, as defined under Regulation .02B of this chapter; and

  (10) Uses at least one ICS service within a 12-month period.

C. Medical Eligibility.

  (1) An applicant shall be determined by the Department’s utilization control agent to need nursing facility services covered under COMAR 10.09.10.

  (2) Every 12 months, or more frequently if determined necessary by the Department due to a significant change in the participant's condition or needs, AERS shall revaluate the participant to verify the continued need for nursing facility services.

D. Financial Eligibility. An ICS participant shall:

  (1) Without regard to any assets of a spouse, meet the resource limit for Long-Term Care Medical Assistance set forth in COMAR 10.09.24.08M;

  (2) Receive income, after all available disregards and exclusions set forth in COMAR 10.09.24.07L and 10.09.24.07J, without regard to any income of a spouse, that exceeds 300 percent of the current monthly Supplemental Security Income payment rate, known as the Federal Benefit Rate (FBR);

  (3) Pay to the Department an assessment fee equal to the amount by which income, after all available disregards and exclusions set forth in COMAR 10.09.24.07L and 10.09.24.07J, exceeds 300 percent of the FBR, as follows:

    (a) The initial assessment shall be paid to the Department not later than 15 days from the date of the assessment invoice sent by the Department to the participant, unless the exception in §D(4) of this regulation applies;

    (b) Subsequent assessments shall be paid on or before the last day of the month on which the assessment invoice is sent to the participant by the Department; and

    (c) If a participant receives a past due notice, the participant has 15 days from the date of the notice to remit payment; and

  (4) Be allowed an exception to the initial monthly assessment if discharged from the nursing facility on a date other than the first of the month, in which case the participant shall be required to pay the first assessment before the first day of the first full month of ICS participation.

E. Medical Assistance Eligibility.

  (1) An individual is not eligible to receive ICS services during a penalty period under COMAR 10.09.24.08-1 or 10.09.24.08-2 due to disposal of assets or establishment of a trust.

  (2) All provisions of COMAR 10.09.24 which are applicable to aged, blind, or disabled institutionalized persons are applicable to ICS applicants and participants, with the following exceptions:

    (a) COMAR 10.09.24.06B(2)(a)(ii);

    (b) COMAR 10.09.24.08G(1);

    (c) COMAR 10.09.24.08H;

    (d) COMAR 10.09.24.10B(2) — (3);

    (e) COMAR 10.09.24.10C;

    (f) COMAR 10.09.24.10D(2)(a), (b), and (h);

    (g) COMAR 10.09.24.10D(3) — (6);

    (h) COMAR 10.09.24.10-1B(1);

    (i) COMAR 10.09.24.10-1B(4);

    (j) COMAR 10.09.24.10-1B(7);

    (k) COMAR 10.09.24.10-1C(3)(a); and

    (l) COMAR 10.09.24.15A-2(2).

F. Cost of Care.

  (1) For a participant whose home is an assisted living facility, the Department shall reduce its monthly payment for assisted living services by the amount remaining after deducting from the individual's total nonexcluded monthly income the following amounts in the following order:

    (a) A personal needs allowance, consisting of the amount established in accordance with COMAR 10.09.24.10D(2)(c) and the assisted living provider's monthly charge to the participant for room and board; and

    (b) Incurred medical expenses in accordance with COMAR 10.09.24.10D(2)(f) and (g).

  (2) The Department shall determine the amount of available income to be paid by a participant towards the cost of assisted living services.

  (3) The participant shall pay the assisted living services provider directly for the participant’s cost of care and room and board.

G. Participant Cap and Registry for ICS Participation.

  (1) The Department shall establish a cap, approved by the federal Centers for Medicare and Medicaid Services (CMS), on the number of participants who may receive the services covered under this chapter at any one time, based on available State and federal funding.

  (2) Eligible individuals shall be enrolled in the ICS Program on a first-come, first-served basis until the participant cap is reached.

  (3) Once the CMS-approved participant cap is reached, a registry of applicants shall be established by the Department on a first-come, first-served basis.

H. Termination of Participation. A participant shall be terminated from participation in the ICS Program if the participant:

  (1) No longer meets the eligibility requirements specified in §§B — E of this regulation;

  (2) Voluntarily chooses, or the participant's legal representative chooses on the participant's behalf, to disenroll from the ICS Program;

  (3) Moves to another state;

  (4) Is an inpatient for 30 consecutive days or more in a hospital or nursing facility; or

  (5) Dies.

I. Re-Entering the ICS Program.

  (1) If a participant is terminated from the ICS Program, the same individual may re-enter the ICS Program, provided:

    (a) That the individual meets all of the requirements §§B — E of this regulation; and

    (b) There is available capacity.

  (2) If an individual cannot find a community residence before his or her application expires, the individual may reapply to the ICS Program as long as the individual continues to meet all other eligibility requirements.

#### Regulation .04 Conditions for Provider Participation — General Requirements.

*COMAR 10.09.81.04*

A. To participate as a provider of a service covered under Regulations .22 — .37 of this chapter, a provider shall:

  (1) Meet all of the conditions for participation as a Maryland Medical Assistance Program provider as set forth in COMAR 10.09.36, except as otherwise specified in this chapter;

  (2) Meet the licensure and certification requirements specified in this chapter, if applicable;

  (3) Meet the applicable conditions for provider participation in this chapter;

  (4) Apply in accordance with the conditions of participation under Regulations .05 — .20 of this chapter, by completing the application forms designated by the Maryland Medical Assistance Program;

  (5) Have a signed provider agreement in effect with the Maryland Medical Assistance Program;

  (6) Verify the qualifications of all individuals who render ICS services on the provider's behalf, and provide a copy of the current license or credentials of these individuals upon request;

  (7) Provide services in accordance with:

    (a) A participant's plan of service;

    (b) The provider agreement;

    (c) The ICS Program; and

    (d) All relevant federal, State, and local laws and regulations;

  (8) Agree to inform the case manager within 24 hours, and within 7 calendar days file a written report on a form designated by the Department, in the case of any threat to the health, safety, or welfare of the participant such as:

    (a) Potential eviction;

    (b) Suspected abuse or neglect; or

    (c) Significant interruption of service;

  (9) Immediately notify the Adult Protective Services office at the local department of social services and law enforcement if the provider believes that the participant has been subjected to abuse, neglect, self-neglect, or exploitation in the community, in accordance with COMAR 07.06.14.04;

  (10) Agree to cooperate with required inspections, reviews, and audits by authorized governmental representatives;

  (11) Agree to provide services, and to subsequently bill the Department in accordance with the payment procedures specified at Regulation .40 of this chapter for only covered services which have been:

    (a) Preapproved in the participant's plan of service;

    (b) Provided in a manner consistent with the participant's plan of service; and

    (c) Authorized in the provider agreement as within the scope of the provider's Medicaid participation;

  (12) Agree to maintain and have available written documentation of ICS services, including dates and hours of services provided to participants for a period of 6 years, in a manner approved by the Department;

  (13) Agree not to suspend, terminate, increase, or reduce services for a participant without authorization from the participant’s case manager; and

  (14) Agree to comply with the requirements in the Department's quality plan for the ICS Program.

B. To participate as a provider of a service covered under this chapter, a provider or its principals may not, within the past 24 months, have:

  (1) Been subject to sanctions under COMAR 10.09.36.08;

  (2) Had a license or certificate suspended or revoked as a health care provider, health care facility, or provider of direct care services;

  (3) Been subject to a disciplinary action by a licensing board;

  (4) Been cited by a State agency for deficiencies which affect recipients' health and safety; or

  (5) Been terminated under a reimbursement agreement with or been barred from work or participation by a public or private agency due to:

    (a) Failure to meet contractual obligations; or

    (b) Fraudulent billing practices.

C. A provider who renders health-related services to participants, including attendants, participant trainers, occupational therapists, speech and language therapists, physical therapists, nutritionists, dietitians, medical day care centers, and registered nurses, shall agree to:

  (1) Periodically indicate the condition of a participant in accordance with the procedures and forms designated by the Department; and

  (2) Share and discuss the documented information at the request of the participant.

#### Regulation .05 Specific Conditions for Provider Participation — Participant Training.

*COMAR 10.09.81.05*

To participate in the ICS Program as a provider of participant training under Regulation .22 of this chapter, a provider shall:

A. Be a self-employed trainer or an agency that employs qualified trainers in accordance with §§B and C of this regulation;

B. Demonstrate experience in the skill being taught; and

C. Be willing to meet at the participant's home to provide services.

#### Regulation .06 Specific Conditions for Provider Participation — Family Training.

*COMAR 10.09.81.06*

To participate in the ICS Program as a provider of family training services under Regulation .23 of this chapter, a provider shall:

A. Be:

  (1) One of the following self-employed professionals:

    (a) Registered nurse or nurse practitioner licensed according to COMAR 10.27.01 and 10.27.07;

    (b) Occupational therapist licensed according to COMAR 10.46.01;

    (c) Speech-language pathologist licensed according to COMAR 10.41.03; or

    (d) Physical therapist licensed according to COMAR 10.38.01; or

  (2) An agency which employs or contracts with a licensed professional specified in §A(1) of this regulation who will render the service; and

B. Demonstrate experience in the skill being taught.

#### Regulation .07 Specific Conditions for Provider Participation — Case Management Services.

*COMAR 10.09.81.07*

To participate in the ICS Program as a provider of case management services under Regulation .24 of this chapter, a provider shall:

A. Be enrolled as a case management provider in accordance with COMAR 10.09.55.15-3;

B. Accept all referrals from the Department, or other designated agency; and

C. Be monitored by the Department.

#### Regulation .08 Specific Conditions for Provider Participation — Transition Services.

*COMAR 10.09.81.08*

To participate in the ICS Program as a provider of transition services under Regulation .25 of this chapter, a provider shall be the case management provider in accordance with Regulation .07 of this chapter and shall:

A. Assist individuals to transition from a nursing facility to a community-based residence; and

B. Arrange and coordinate the services necessary to facilitate the transition.

#### Regulation .09 Specific Conditions for Provider Participation — Environmental Assessments.

*COMAR 10.09.81.09*

To participate in the ICS Program as a provider of environmental assessments under Regulation .26 of this chapter, a provider shall:

A. Be a licensed occupational therapist, or an agency or professional group employing a licensed occupational therapist;

B. Receive a referral from the participant's case manager, based on services preauthorized in the plan of service; and

C. Document the provider's findings and recommendations on a form approved by the Maryland Medical Assistance Program.

#### Regulation .10 Specific Conditions for Provider Participation — Environmental Accessibility Adaptations.

*COMAR 10.09.81.10*

A. To participate in the ICS Program as a provider of environmental accessibility adaptations under Regulation .27 of this chapter, a provider shall:

  (1) Be the store, vendor, or contractor, from which the adaptation is purchased;

  (2) Provide or arrange for any required installation, servicing, or training; and

  (3) Provide services according to a written schedule indicating an estimated start date and completion date.

B. If construction is involved, the provider shall also meet the following requirements:

  (1) Be properly licensed by the State as a contractor or builder;

  (2) Be properly bonded;

  (3) Obtain all necessary State and local permits;

  (4) Ensure that the work passes the required inspections; and

  (5) Perform all work in accordance with State and local building codes.

#### Regulation .11 Specific Conditions for Provider Participation — Personal Emergency Response Systems.

*COMAR 10.09.81.11*

To participate in the ICS Program as a provider of personal emergency response systems under Regulation .28 of this chapter, a provider shall:

A. Be the store, vendor, organization, or company which sells, rents, installs, services, or runs the device or service;

B. Provide or arrange for any installation, servicing, training, or monitoring required for the device or system; and

C. Assure that any response center is:

  (1) Responsible for monitoring or responding to a notification of an emergency by the system; and

  (2) Adequately staffed 24 hours a day, 7 days a week by properly trained staff.

#### Regulation .12 Specific Conditions for Provider Participation — Assistive Technology.

*COMAR 10.09.81.12*

To participate in the ICS Program as a provider of assistive technology services under Regulation .29 of this chapter, a provider shall:

A. Be one of the following entities:

  (1) The store, vendor, organization, or company which sells or rents the equipment or system; or

  (2) A Maryland Medical Assistance Program provider of disposable medical supplies and durable medical equipment under COMAR 10.09.12;

B. Provide or arrange for any installation, servicing, training, or monitoring required for the proper operation of the equipment or system; and

C. Provide services in accordance with written estimated start and completion dates.

#### Regulation .13 Specific Conditions for Provider Participation — Attendant Care Services.

*COMAR 10.09.81.13*

A. To participate in the ICS Program as a provider of attendant care services under Regulation .30 of this chapter, unless otherwise exempted under §F of this regulation, an attendant shall:

  (1) Be a participant-employed or agency-employed attendant;

  (2) Be at least 18 years old;

  (3) Be legally eligible for employment rendering attendant care services in the State;

  (4) Be able to communicate, read, write, and follow directions in English;

  (5) Be currently certified from a nationally recognized organization in the following areas:

    (a) Cardiopulmonary resuscitation; and

    (b) Basic first aid;

  (6) Receive instruction and training on the attendant care services required in the participant's plan of service from the nurse monitor before rendering services;

  (7) Be supervised by a nurse monitor in accordance with the requirements of Regulation .31 of this chapter;

  (8) Accept instruction and training from:

    (a) The participant;

    (b) The nurse monitor;

    (c) The case manager;

    (d) A treating physician;

    (e) Other involved professionals; or

    (f) A Department representative;

  (9) Submit to a pre-employment criminal background investigation for which the individual shall:

    (a) Submit an application for a criminal history record check to the Criminal Justice Information System Office, Department of Public Safety and Correctional Services;

    (b) Direct the Department of Public Safety and Correctional Services to send the criminal history report to the Department; and

    (c) Pay for the criminal history record check and report; and

  (10) Agree to submit written documentation of services rendered to each participant to the case manager on a form designated by the Department.

B. To participate in the ICS Program as a provider of attendant care services under Regulation .30 of this chapter, unless otherwise exempted under §F of this regulation, an attendant may not:

  (1) Be a spouse;

  (2) Be a parent of a dependent child;

  (3) Be an individual who has full and unrestricted powers of guardianship;

  (4) Render services to any participant before being evaluated by a nurse monitor as able to:

    (a) Understand and carry out the attendant care services specified in the participant's plan of service; and

    (b) Perform the required duties;

  (5) Unless meeting the conditions of §C of this regulation, have been convicted of, received a probation before judgment for, or entered a plea of nolo contendere to, a felony or any crime involving moral turpitude, drugs, or theft, or have any other criminal history that indicates behavior which is potentially harmful to participants; or

  (6) Be listed on the Maryland Geriatric Nursing Assistants Registry or any other registry with a determination of abuse, misappropriation of property, or neglect.

C. If requested by the provider applicant, the Department may waive the provisions of §B(5) of this regulation if the applicant demonstrates that:

  (1) The conviction, probation before judgment, or a plea of nolo contendere to a felony or any crime involving moral turpitude, drugs, or theft was entered more than 10 years before the date of the provider application; and

  (2) The criminal history does not indicate behavior that is potentially harmful to participants.

D. If required to perform any delegated nursing functions as defined in Regulation .02B of this chapter, an attendant who meets the requirements of §§A and B of this regulation, shall also:

  (1) Be certified as:

    (a) A nursing assistant in accordance with COMAR 10.39.01; or

    (b) If required to administer medications:

      (i) Certified medicine aide in accordance with COMAR 10.39.03; or

      (ii) Medication technician in accordance with COMAR 10.39.04;

  (2) Be supervised by a nurse monitor; and

  (3) Comply with the requirements of the Maryland Board of Nursing as set forth in COMAR 10.27.11.

E. To participate in the ICS Program as an agency provider of attendant care services, a provider agency shall:

  (1) Be one of the following:

    (a) A public or private agency that has been approved by the Department of Human Services, in accordance with COMAR 07.06.14;

    (b) A Medicaid provider of:

      (i) Home health services under COMAR 10.09.04; or

      (ii) Personal care services under COMAR 10.09.20.03B; or

    (c) A residential services agency certified in accordance with COMAR 10.07.05;

  (2) Employ or contract with attendants, who meet the requirements in §§A — C of this regulation, in sufficient numbers to ensure that a qualified attendant is available to provide the attendant care services ordered in the plan of service;

  (3) Supervise each attendant who is employed by or under contract with the attendant care provider agency;

  (4) Employ or contract with licensed registered nurses to act as nurse monitors and provide nursing supervision, in accordance with Regulations .14 and .31 of this chapter;

  (5) Be available to give instructions to attendants and to answer questions during a normal working day, including having a nurse monitor available to respond to medical or health-related issues that are within the scope of the nurse's license;

  (6) Keep accurate records on each participant receiving attendant care services from the agency, which contain:

    (a) The plan of service;

    (b) Identification of each attendant providing services to the participant;

    (c) Dates and times when attendants worked;

    (d) Tasks the attendants performed;

    (e) Nurse monitors' instructions to the attendants; and

    (f) Progress notes and observations on the attendant and the participant;

  (7) Keep records and submit reports as required by the Department;

  (8) Maintain 24-hour availability by beeper for emergencies; and

  (9) Submit written documentation of services rendered to each participant as required by the Maryland Medical Assistance Program and on a form designated by the Department.

F. Exemptions.

  (1) Subject to approval by the Department, participant-employed attendants may be exempted from the qualifications described at §A(2), (4), and (5) of this regulation at the request of the participant.

  (2) Providers that have been exempted from any qualification may only serve the participant or participants who have requested the exemption.

  (3) The Department may:

    (a) Grant exemptions; and

    (b) Revoke exemptions for cause.

#### Regulation .14 Specific Conditions for Provider Participation — Nursing Supervision of Attendants.

*COMAR 10.09.81.14*

A. To participate in the ICS Program as a provider of nursing supervision of attendants under Regulation .31 of this chapter, a provider shall be:

  (1) A self-employed registered nurse or nurse practitioner licensed according to COMAR 10.27.01 and 10.27.07; or

  (2) An agency or clinic which employs registered nurses or nurse practitioners licensed according to COMAR 10.27.01 and 10.27.07.

B. The registered nurse or nurse practitioner who renders nursing supervision services shall:

  (1) Be an individual who is:

    (a) Self-employed; or

    (b) Employed by or under contract with an agency as specified in §A(2) of this regulation;

  (2) Meet the requirements of the Maryland Board of Nursing regarding nursing services and delegation of nursing functions in accordance with COMAR 10.27.11;

  (3) Be willing to delegate nursing tasks to unlicensed, certified individuals according to COMAR 10.27.11; and

  (4) Maintain detailed, written documentation of services rendered to participants including progress notes and service outcomes, as specified by the Department.

C. A provider shall ensure that a nurse monitor is available to provide the nursing supervision services specified in Regulation .31 of this chapter.

#### Regulation .15 Specific Conditions for Provider Participation — Home Delivered Meals.

*COMAR 10.09.81.15*

To participate in the ICS Program as a provider of home-delivered meals under Regulation .32 of this chapter, a provider shall:

A. Be approved and monitored by the Department; and

B. Use a cooking facility or food preparation site that:

  (1) Has a food service license issued by the local health department, in accordance with COMAR 10.15.03, or an appropriate license from the state in which the site is located; and

  (2) Is approved for each licensing renewal based on inspections performed by State sanitarians in accordance with COMAR 10.15.03, or by the licensing authority in the state in which the site is located.

#### Regulation .16 Specific Conditions for Provider Participation — Dietitian and Nutritionist Services.

*COMAR 10.09.81.16*

To participate in the ICS Program as a provider of dietitian and nutritionist services under Regulation .33 of this chapter, a provider shall be a:

A. Dietitian or nutritionist who is licensed in accordance with COMAR 10.56.01 and Health Occupations Article, Title 5, Annotated Code of Maryland; or

B. Professional group or agency which employs an individual who is licensed in accordance with §A of this regulation.

#### Regulation .17 Specific Conditions for Participation — Behavior Consultation Services.

*COMAR 10.09.81.17*

To participate in the ICS Program as a provider of behavior consultation services, as specified in Regulation .34 of this chapter, a provider shall:

A. Be:

  (1) A health services agency that:

    (a) Employs a qualified individual or individuals to render behavior consultation services; and

    (b) Assures supervision of, or consultation to, the individual rendering behavior consultation services by a licensed mental health professional or by a bachelor's level nurse with 4 years of experience in psychogeriatrics or with an appropriate graduate degree; or

  (2) An individual who is:

    (a) Qualified to render behavior consultation services; and

    (b) Licensed to practice independently;

B. Assure that the individual who renders behavior consultation services:

  (1) Is a licensed Registered nurse; Psychologist; or Clinical social worker; and

  (2) Has:

    (a) Experience in psychogeriatrics;

    (b) Direct experience working with elderly individuals with dementia or behavioral problems; and

    (c) Demonstrated ability to perform assessments; and

C. Assure response within 24 hours to a referral from a participant's case manager for behavior consultation services.

#### Regulation .18 Specific Conditions for Provider Participation — Medical Day Care.

*COMAR 10.09.81.18*

To participate in the ICS Program as a provider of medical day care services under Regulation .35 of this chapter, a provider shall:

A. Be licensed according to COMAR 10.12.04; and

B. Meet the requirements of COMAR 10.09.07.

#### Regulation .19 Specific Conditions for Participation — Senior Center Plus.

*COMAR 10.09.81.19*

To participate in the ICS Program as a provider of Senior Center Plus services, as specified in Regulation .36 of this chapter, a provider shall:

A. Be approved and monitored by the Maryland Department of Aging as a nutrition service provider;

B. Meet all local and State requirements to operate as a nutrition site, which include but are not limited to inspection and approval of the facility by the local fire marshal, periodic fire drills, and inspection and approval by the local sanitarian to assure compliance with health department requirements for food service facilities;

C. Assure that the facility is accessible to individuals with disabilities;

D. Maintain adequate records on participants, including progress notes and outcomes;

E. Provide at least one staff person per eight clients, with additional staffing if required by the Maryland Department of Aging depending on participants' functional levels;

F. Employ as the center's manager or in another staff position an individual who:

  (1) Is a licensed health professional or a licensed social worker;

  (2) Has at least 3 years’ experience in direct patient care at an adult day care center, nursing facility, or health-related facility;

  (3) Is literate and able to communicate in English; and

  (4) Participates in training specified and approved by the Maryland Department of Aging;

G. Provide Senior Center Plus services, as specified in Regulation .36 of this chapter, to participants at least 4 hours a day, 1 or more days a week on a regularly scheduled basis, in an out-of-home, outpatient setting;

H. Serve at least one nutritional meal per day that:

  (1) Is prepared in a licensed food service establishment;

  (2) Meets at least one-third of the daily recommended dietary allowance; and

  (3) Does not constitute a full nutritional regimen of three meals per day;

I. Serve snacks, as desired by the participants, when the day program exceeds 6 hours; and

J. Have menus reviewed and approved quarterly by a registered dietitian for nutritional adequacy.

#### Regulation .20 Specific Conditions for Participation — Assisted Living.

*COMAR 10.09.81.20*

A. To participate in the ICS Program as an assisted living services provider, a provider shall:

  (1) Be licensed by the Department at the time that services are rendered, in accordance with COMAR 10.07.14, to provide assisted living services:

    (a) At the Level 2 moderate level of care or Level 3 high level of care; and

    (b) For the level of care needed by each participant residing in the facility, including any needed resident-specific waiver in accordance with COMAR 10.07.14.09;

  (2) Meet the requirements of COMAR 10.07.14 for Assisted Living Programs;

  (3) Be or employ a manager who is literate, able to communicate in English, and qualified as:

    (a) A licensed physician;

    (b) A licensed registered nurse;

    (c) A licensed practical nurse; or

    (d) An individual with at least 3 years’ experience in direct patient care in a private home, certified home, or health-related facility;

  (4) Employ an alternate assisted living manager who meets the requirements as specified in §A(3) of this regulation;

  (5) Have at least one staff person per eight residents on duty at all times during daytime hours, and a staff-to-resident ratio at night sufficient to provide the required services and maintain the facility in a safe and orderly condition, and such additional staffing as required by the Department or the Maryland Department of Aging depending on residents' functional levels;

  (6) Participate in training on the ICS Program billing process and other ICS Program requirements, as specified by the Department and the Maryland Department of Aging;

  (7) Have appropriate insurance coverage for the provider and its employees and vehicles if the provider transports participants to medical, social, recreational, and other services;

  (8) Cooperate with other service providers and quality assurance monitors by:

    (a) Facilitating on-site visits of authorized quality assurance monitors to review compliance with ICS and regulatory requirements;

    (b) Facilitating a case manager's on-site visits to the facility, which shall occur at least quarterly, to review the facility, regulatory compliance, service provision, and participants' status and needs;

    (c) Communicating with a participant's case manager concerning the participant's status, needs, and service provision;

    (d) Informing the case manager within 1 working day of any significant change in the participant's status and service needs;

    (e) Facilitating, as necessary and appropriate, the delivery of authorized ICS and State Plan services in the plan of service; and

    (f) Facilitating the ICS participant's relocation to comparable housing, if necessary, including transfer of all personal belongings and financial arrangements; and

  (9) Submit claims consistent with the provisions of Regulation .40 of this chapter.

B. Bed Reservations. If bed reservations are offered to participants who are absent from an assisted living facility, the bed reservations policy shall:

  (1) Be provided to all residents and, where appropriate, the resident's representative, at admission;

  (2) Be fairly and consistently applied to all residents;

  (3) Specify that the bed reservation service is not a Medicaid covered service;

  (4) Clearly state that it is the resident's decision whether to reserve the bed; and

  (5) Specify that the participant's payments for bed reservation days may not exceed the full Medicaid per diem rate for Level II or Level III assisted living services, as applicable.

C. Designated Units. An assisted living provider may limit Medicaid participation to designated units only if approved by the Maryland Department of Aging and the facility resident agreement contains the following provision: The facility's participation in the Maryland Medical Assistance Program is limited to one or more designated units and, in order to access Medicaid benefits, the resident shall reside in a designated unit.

#### Regulation .21 Covered Services — General.

*COMAR 10.09.81.21*

The Maryland Medical Assistance Program shall reimburse for the services specified in Regulations .22 — .37 of this chapter when, pursuant to the requirements of this chapter, these services have been preapproved by the Department in the participant's plan of service and documented as:

A. Necessary to prevent institutionalization in a nursing facility; and

B. Cost-neutral to the ICS Program, in accordance with Regulation .38E of this chapter.

#### Regulation .22 Covered Services — Participant Training.

*COMAR 10.09.81.22*

A. Definition. “Unit of service” means an hour of service rendered one-on-one by a qualified provider to a participant, not including the time spent by the provider:

  (1) Planning, preparing, or setting up the training;

  (2) Following up after the training; or

  (3) Traveling to and from the training.

B. Participant training includes instruction and skill building in such areas as how to recruit, select, train, direct, supervise, and fire participant-employed attendants, money management, budgeting, independent living, meal planning, and other areas specified in the participant's plan of service.

C. The topics covered by participant training shall:

  (1) Be specified in the participant's plan of service as necessary to safely maintain the participant at home;

  (2) Be targeted to the individualized needs of the participant; and

  (3) Be sensitive of the educational background, culture, and general environment of the participant.

D. Participant training shall include updates as necessary to maintain or improve skills, if these updates are in the plan of service.

#### Regulation .23 Covered Services — Family Training.

*COMAR 10.09.81.23*

A. Definitions.

  (1) “Family member” means an individual who:

    (a) Lives with or provides assistance to the participant; and

    (b) Is not paid to provide the care.

  (2) “Unit of service” means an hour of service rendered by a qualified provider to one or more family members at the same time in the participant's home or the provider's office, regardless of the number of family members trained at one time, not including the time spent by the provider:

    (a) Planning, preparing, or setting up the training;

    (b) Following up after the training; or

    (c) Traveling to and from the training.

B. Family training includes instruction about treatment regimens and the use of equipment specified in the plan of service.

C. The topics covered by family training shall be:

  (1) Specified in the participant's plan of service as necessary to safely maintain the participant at home;

  (2) Targeted to address the individualized needs of the participant; and

  (3) Sensitive of the educational background, culture, and general environment of the family member.

D. Family training shall include updates in the plan of service as necessary to continue to safely maintain the individual at home.

#### Regulation .24 Covered Services — Case Management.

*COMAR 10.09.81.24*

A. Definition. “Unit of service” means a 15-minute increment of service rendered by a qualified provider to a participant or the participant's representative.

B. Case management services shall be targeted to address the individualized needs of the participant and be sensitive to the educational background, culture, and general environment of the participant.

C. Case management services include time spent by a qualified provider conducting any of the following activities:

  (1) Assisting with an initial or annual ICS Program eligibility process;

  (2) Assisting with an application and maintaining all public and private benefits, resources, and entitlements;

  (3) Conducting an assessment of needs, and developing a person-centered plan of services, to include all services needed to live safely in the community;

  (4) Assisting with referral, access, and coordination of services, both Medicaid and non-Medicaid, to address the individual's needs including, but not limited to:

    (a) Community integration;

    (b) Medical services;

    (c) Social services;

    (d) Educational services;

    (e) Behavioral health;

    (f) Legal services; and

    (g) Housing;

  (5) Contacting ICS Program providers and Medicaid State Plan providers not less than monthly and documenting that services were received in the amount, type, frequency, and duration described in the plan of services;

  (6) Ensuring timely receipt of all other services and documenting follow-up;

  (7) Facilitating referral to other programs if the individual is denied ICS Program services; and

  (8) Using information technology systems developed by the Department.

#### Regulation .25 Covered Services — Transition Services.

*COMAR 10.09.81.25*

A. Definition. “Unit of service” means a one-time service that is:

  (1) Not otherwise available under the ICS Program;

  (2) Approved in the plan of service; and

  (3) Rendered to a participant by a qualified provider to assist the participant in transitioning from a nursing facility or assisted living facility to independent living.

B. Transition services may include some or all of the following:

  (1) Security deposits;

  (2) Essential furnishings and moving expenses;

  (3) Deposits or fees for utility services; and

  (4) Other health and safety assurances including pest eradication.

C. Transition services may not include recreational items such as televisions, cable TV access, or DVD players.

#### Regulation .26 Covered Services — Environmental Assessments.

*COMAR 10.09.81.26*

A. Definition. “Unit of service” means the completion of:

  (1) An on-site environmental assessment of the participant’s home; and

  (2) A form approved by the Maryland Medical Assistance Program.

B. An environmental assessment may not be provided before the effective date of the participant's eligibility for ICS Program services.

C. The service may be recommended by a multidisciplinary team in the plan of service for a participant when the service is considered necessary to:

  (1) Ensure the health and safety of a participant with special environmental needs; and

  (2) Obtain additional professional advice from an occupational therapist about the:

    (a) Physical structure of a participant's home or residence; and

    (b) Functional or mental limitations or disabilities of a participant as they relate to the environment.

D. Included in the environmental assessment, as necessary and appropriate, may be:

  (1) An evaluation of the presence and likely progression of a disability or a chronic illness or condition in a participant;

  (2) Environmental factors in the facility or home;

  (3) The participant's ability to perform activities of daily living;

  (4) The participant's strength, range of motion, and endurance;

  (5) The participant's need for assistive devices and equipment; and

  (6) The participant's, family's, or service provider's knowledge of health, safety, and stress reduction factors.

E. Based on an inspection of the home and interviews with the participant, family, or service provider, the provider shall complete a form, to be reviewed by the case manager, which details the provider's findings and recommendations as to a participant's need for ICS Program services.

#### Regulation .27 Covered Services — Environmental Accessibility Adaptations.

*COMAR 10.09.81.27*

A. Definition. “Unit of service” means one or more physical adaptations to a participant's home or place of residence which is completed as one job by a qualified provider and which constitute a single accessibility adaptation.

B. If the owner of the home is the participant, environmental accessibility adaptations may be made only if approved by the participant, in the participant's plan of service.

C. If the owner is not the participant, environmental accessibility adaptations may be made only if approved by the owner of the home, who agrees that the participant will be allowed to remain in the residence for at least 1 year, and if approved by the participant, in the participant’s plan of service.

D. Environmental accessibility adaptations shall include those physical adaptations or modifications to the participant's home which are required to make it accessible to the participant because of the:

  (1) Physical structure of the residence; or

  (2) Participant's specific functional needs.

E. Environmental accessibility adaptations may include but are not limited to:

  (1) Visual fire alarms;

  (2) Telecommunication type machines (TTYs);

  (3) Ramps;

  (4) Grab bars or handrails;

  (5) Stair glides;

  (6) Widening of doorways;

  (7) Modification of bathroom or kitchen facilities to make them physically accessible;

  (8) Specialized electrical and plumbing systems to accommodate the medical equipment and supplies which are necessary for the participant's welfare;

  (9) Locks, buzzers, or other devices on doorways to prevent or stop wandering; and

  (10) Home modifications to help a participant identify the physical environment.

F. To be reimbursed, all services shall:

  (1) Be provided in accordance with applicable State and local building codes; and

  (2) Pass required inspections.

#### Regulation .28 Covered Services — Personal Emergency Response Systems.

*COMAR 10.09.81.28*

A. Definition. “Unit of service” means any of the following:

  (1) Purchase and installation;

  (2) Maintenance or repair; or

  (3) Monthly cost of a covered system or rented device or equipment.

B. A personal emergency response system is an electronic device or system which enables a participant to secure help in an emergency and may include:

  (1) A device connected to the participant's telephone or other device and programmed to signal, upon activation of a help button, a response center with properly trained staff on duty 24 hours a day, 7 days a week;

  (2) A portable help button to allow for the participant's mobility; and

  (3) A motion detector when necessary for the participant's health, safety, and welfare.

#### Regulation .29 Covered Services — Assistive Technology.

*COMAR 10.09.81.29*

A. Definition. “Unit of service” means a device or appliance that is purchased as one item, including:

  (1) Any required training in the use of the device; and

  (2) An assessment for the use of the device, if the assessment is:

    (a) Performed directly by the provider; and

    (b) Routinely included as part of the provider's cost for the item.

B. Assistive technology includes nonexperimental technology or adaptive equipment, excluding service animals, which enables a participant to live in the community and to participate in community activities.

C. Assistive technology may include:

  (1) Environmental control units for participants' homes to allow spontaneous or programmed control of household appliances and other home devices;

  (2) Personal computers, software, and computer accessories which enable participants to function more independently;

  (3) Maintenance and repair of the covered assistive technology devices and equipment;

  (4) Augmentative communication and communication-enhancement devices;

  (5) Aids for daily living and self-help aids used in activities such as eating, bathing, cooking, dressing, toileting, and home maintenance; and

  (6) Equipment needed to adapt the participant's or family's automotive vehicle for personal transportation such as:

    (a) Adaptive driving aids;

    (b) Hand controls; and

    (c) Wheelchair lifts, and other lifts used for personal transportation.

D. To be covered under this chapter, each item of assistive technology shall meet applicable standards of manufacture, design, usage, and installation.

#### Regulation .30 Covered Services — Attendant Care Services.

*COMAR 10.09.81.30*

A. Definition. “Unit of service” means an hour of service that is in the plan of service and rendered to a participant by a qualified provider in the participant's home or in a community setting.

B. Except as provided in §C of this regulation, the ICS Program covers the following attendant care services:

  (1) Assistance with activities of daily living;

  (2) Delegated nursing functions, such as assistance with the participant's administration of medications or other remedies, when ordered by a physician, if this assistance is:

    (a) Specified in the participant's plan of service; and

    (b) Rendered in accordance with the Maryland Nurse Practice Act, COMAR 10.27.11, and other requirements of the Maryland Board of Nursing;

  (3) Assistance with protecting a participant from harm or neglect;

  (4) Assistance with instrumental activities of daily living, provided as incidental to the services covered under §B(1) — (3) of this regulation; and

  (5) Accompanying the participant outside of the home during the participant's community activities.

C. Attendant care services may not include:

  (1) Services rendered to anyone other than the participant or primarily for the benefit of anyone other than the participant;

  (2) The cost of food or meals;

  (3) Housekeeping services, other than those incidental services covered under §B(4) of this regulation;

  (4) Expenses related to room and board for either the participant or the attendant;

  (5) Expenses incurred while escorting a participant to obtain medical diagnosis or treatment; or

  (6) Skilled medical services performed by individuals with a professional medical license or certification.

#### Regulation .31 Covered Services — Nursing Supervision of Attendants.

*COMAR 10.09.81.31*

A. Definition. “Unit of service” means an hour of service rendered by a nurse monitor to a participant in the participant's home or another community-based setting.

B. Nursing supervision services include the following:

  (1) Development of the participant's plan for attendant care:

    (a) After consultation with the participant, family members, participant's personal physician, case manager, and other providers; and

    (b) In conformance with the participant's:

      (i) AERS evaluation;

      (ii) AERS plan of care; and

      (iii) Plan of service;

  (2) Providing health-related information and training to the attendant concerning topics related to the care, or progress, of the participant, including:

    (a) The performance of the services in the participant's plan for attendant care; and

    (b) Information that should be brought to the attention of the attendant care provider agency, the nurse monitor, personal physician, or case manager;

  (3) Ensuring that each attendant to be supervised by the provider meets the requirements in Regulation .13A, B, and D of this chapter;

  (4) Nursing supervision of the participant's medical condition and the care rendered by an attendant, including any delegated nursing functions performed by an attendant, in accordance with COMAR 10.27.11 and the schedule specified in §B(5) of this regulation, by reviewing the:

    (a) Participant's plan of service and specific plan for attendant care;

    (b) Interactions between the participant and the attendant;

    (c) Attendant's performance and ability to render the required services; and

    (d) Participant's medical condition and need for attendant care services or for referral to other services;

  (5) Providing the necessary type and frequency of nursing supervision required in accordance with COMAR 10.27.11, with the exception of COMAR 10.27.11.04C, including visits to a participant's home or other service delivery site for observation at least every:

    (a) 45 days if the attendant administers medications to the participant;

    (b) 3 months if the attendant assists the participant with self-administration of medications;

    (c) 4 months if the attendant does not administer medications or assist the participant with medication self-administration; or

    (d) At a greater frequency established by the nurse monitor due to the participant's medical condition or clinical status;

  (6) Rendering a professional evaluation, in accordance with Regulation .13B(3) of this chapter, of a attendant's ability to carry out the participant's specific plan for attendant care; and

  (7) Documenting an action plan to address health and safety or medical concerns, including missed nursing supervision visits, and providing a copy of the plan to the case management agency within 5 business days.

C. The services covered under this regulation may not include nursing services other than those services described in this regulation.

#### Regulation .32 Covered Services — Home-Delivered Meals.

*COMAR 10.09.81.32*

A. Definition. “Unit of service” means one meal delivered to the participant's home, including the cost of the food, food preparation, and delivery.

B. The meal shall be intended for consumption at home.

C. This service may not constitute the participant's full nutritional regimen of three meals per day.

D. Each meal shall:

  (1) Be nutritionally adequate for the participant's age based on the Recommended Dietary Allowance (RDA) or Dietary Reference Intake (DRI), as established by the Food and Nutrition Board of the National Research Council; and

  (2) Meet either of the following:

    (a) At least one-third of the RDA or DRI; or

    (b) Therapeutic or restrictive diet requirements ordered by the participant's physician, dietitian, or nutritionist, including any ordered nutritional supplements.

E. The ICS Program's coverage under this regulation may not:

  (1) Result, when combined with home-delivered meals received under Title III of the Older Americans Act, in public funding for the participant's full daily nutritional regimen of three meals; or

  (2) Supplant payment for home-delivered meals under Title III.

#### Regulation .33 Covered Services — Dietitian and Nutritionist Services.

*COMAR 10.09.81.33*

A. Definition. “Unit of service” means an hour of service rendered one-on-one by a qualified provider for a participant in the participant's home or the provider's office.

B. Dietitian and nutritionist services shall include:

  (1) The provision of a nutrition care plan as part of the ICS Program multidisciplinary team process;

  (2) Nutrition care planning, nutrition assessment, and dietetic instruction; and

  (3) Services within the scope of practice of the nutritionist's or dietitian's license, as defined by:

    (a) Health Occupations Article, Title 5, Annotated Code of Maryland; and

    (b) Regulations under COMAR 10.56 for the Board of Dietetic Practice.

C. Dietitian and nutritionist services may not include services rendered on a group basis or in a classroom setting.

D. The services shall be:

  (1) Covered if the participant's medical condition requires the judgment, knowledge, and skills of a licensed nutritionist or licensed dietitian;

  (2) Targeted to the individualized needs of the participant, rather than being of general interest;

  (3) Sensitive to the educational background, culture, religion, eating habits, preferences, and general environment of the participant; and

  (4) Specified in the participant's plan of service as necessary to:

    (a) Ensure the participant's health and safety; and

    (b) Prevent the participant's institutionalization or hospitalization.

#### Regulation .34 Covered Services — Behavior Consultation Services.

*COMAR 10.09.81.34*

A. Definition. “Unit of service” means an hour of service rendered by a qualified individual during a home visit to a participant, not including:

  (1) The time spent on related activities before or after the home visit; or

  (2) The time spent on supervisory or consultative services to the provider.

B. A provider may bill for the length of a home visit to a participant, upon completion of the services specified in §D of this regulation.

C. Behavior consultation services may be preauthorized by a participant's plan of care as necessary and appropriate when:

  (1) A participant's behavior is:

    (a) Disruptive;

    (b) Potentially dangerous to the participant's or another person's health and functioning; or

    (c) Placing the participant at risk of institutionalization due to health and safety concerns; and

  (2) Advice is needed as to how to manage the disruptive behavior of a participant.

D. Behavior consultation services include a:

  (1) Home visit by an individual qualified to render services to:

    (a) Evaluate a participant's acute behavior change;

    (b) Assess the situation;

    (c) Determine the contributing factors; and

    (d) Recommend interventions and treatments;

  (2) Written report prepared for review by the case manager and the assisted living services provider or the participant's family, which assesses the situation and makes recommendations; and

  (3) Verbal review of the report with the case manager and the assisted living services provider or the participant's family to discuss:

    (a) The report's findings and recommendations; and

    (b) A course of action, including any related needed medical interventions.

#### Regulation .35 Covered Services — Medical Day Care.

*COMAR 10.09.81.35*

A. Definition. “Unit of service” means a day of service rendered by a qualified provider to a participant in accordance with COMAR 10.09.07.

B. The ICS Program reimburses for a day of care which includes the following services:

  (1) Health care services supervised by the director, medical director, or health director, which emphasize primary prevention, early diagnosis and treatment, rehabilitation and continuity of care, including the following:

    (a) Participation in the development of the individual participant's plan of care;

    (b) Participation in the determination of the participant's medical, psychosocial, and functional status;

    (c) Consultation with the participant's personal physician; and

    (d) Consultation with staff regarding a participant's condition and health care needs;

  (2) Nursing services performed by a registered nurse or by a licensed practical nurse under the supervision of a registered nurse which include:

    (a) The evaluation of the needs of the participants for nursing care;

    (b) The supervision of any nursing staff;

    (c) Preventive and maintenance services;

    (d) Observation and monitoring of participant's condition;

    (e) Rehabilitative services;

    (f) The teaching and training activities in appropriate self-care techniques;

    (g) The supervision of medication normally self-administered;

    (h) The provision of health education;

    (i) Discharge planning; and

    (j) Nursing services that may be delegated to other staff in accordance with COMAR 10.27.11;

  (3) Physical therapy services, performed by or under supervision of a licensed physical therapist, that:

    (a) Are of a diagnostic, rehabilitative, therapeutic, or maintenance nature, and are provided based on the assessment by the physician that the:

      (i) Participant will improve significantly in a reasonable and generally predictable period of time; or

      (ii) Services are necessary for the establishment of a safe and effective maintenance program required in connection with a specific disease state;

    (b) Are directly related to the physician's written plan of care which specifies:

      (i) Part or parts to be treated;

      (ii) Type of modalities or treatments to be rendered;

      (iii) Expected results of physical therapy treatments; and

      (iv) Frequency and duration of treatment;

    (c) The complexity of the services, or the condition of a participant, require the judgment, knowledge, and skills of a licensed physical therapist; and

    (d) The services are considered to be an effective treatment according to accepted standards of medical practice;

  (4) Occupational therapy services, performed by an occupational therapist, that meet the following conditions:

    (a) The treatment requires the special skills of an occupational therapist;

    (b) The services are directly related to the physician's written plan of care which specifies the:

      (i) Treatment to be rendered;

      (ii) Frequency and duration of the treatment; and

      (iii) Expected results;

    (c) The treatment is provided with the expectation that there will be a significant practical improvement in a participant's level of functioning within a reasonable period of time; and

    (d) The services fall within one or more of the following categories:

      (i) Evaluation and reevaluation of a participant's level of functioning by administering diagnostic and prognostic tests;

      (ii) Selection and teaching of task-oriented therapeutic activities designed to restore physical function;

      (iii) Teaching of compensatory techniques to improve the level of independence in the activities of daily living;

      (iv) Training in the use of supportive and adaptive equipment, and assistive devices required for independent performance according to COMAR 10.09.12; and

      (v) Improvement of mobility skills;

  (5) Personal care services which include assistance with activities of daily living;

  (6) Nutrition services which include the following:

    (a) Meals and snacks as specified under COMAR 10.12.04.19;

    (b) Therapeutic diets as specified under COMAR 10.12.04.19; and

    (c) Dietary counseling and education;

  (7) Social work services performed by a licensed, certified social worker, or licensed social work associate which include:

    (a) Screening and interviewing, or assisting designated staff with screening and interviewing prospective participants to determine the general appropriateness of the individual for the full assessment process for medical day care services;

    (b) Ongoing services to include:

      (i) Identifying the emotional and social needs of participants during the rendering of medical day care services;

      (ii) Maintaining linkages with community support resources for the participant including relatives, friends, and other care providers;

      (iii) Counseling to improve the participant's response to the plan of care, chronic condition, and prospects for recovery or stabilization, but does not include diagnosing or treating mental disorders;

      (iv) Counseling a participant and a participant's family in the availability and utilization of public and private community services, referral to, and coordination of these services;

      (v) Assisting participants in obtaining health care services that are not available through the medical day care center, such as vision care, podiatry, or medical equipment;

      (vi) Counseling participants to assist with acclimation to the medical day care center's services and to promote active involvement in their plan of care;

      (vii) Coordinating and implementing group and family counseling in conjunction with plan of care goals;

      (viii) Writing notes in the participant's records that reflect the social work activities performed; and

      (ix) Participating in the multidisciplinary team meetings; and

    (c) Discharge planning and referral services including:

      (i) Written procedures for discharge, referral, and follow-up;

      (ii) A discharge summary with post discharge goals;

      (iii) Recommendations for continuing care; and

      (iv) Referral to appropriate community service agencies and health care providers to facilitate the participant's return to more independent living;

  (8) Activity programs in accordance with COMAR 10.12.04.14C; and

  (9) Transportation services that:

    (a) Are provided or arranged for a participant by the medical day care staff;

    (b) Maximize the following types of transportation services:

      (i) Walking, for a person who lives within walking distance of the medical day care center and who is sufficiently mobile;

      (ii) Family-supplied transportation provided by friends, neighbors, or volunteers; and

      (iii) Public transportation services;

    (c) Are procured by the provider after options described in §B(9)(b) of this regulation have been exhausted;

    (d) Are the responsibility of the provider to:

      (i) Arrange contractual agreements with transportation providers to meet the transportation needs of the participants; and

      (ii) Group participants, where possible, in the same taxi, van or specially equipped vehicles, to minimize the cost of transportation;

    (e) Are provided in accordance with a primary transportation plan and a back-up plan;

    (f) Are documented, indicating the type of transportation used by each participant;

    (g) Are scheduled to ensure that a participant's one-way transit time does not exceed 1 hour as specified under COMAR 10.12.04.27; and

    (h) Are included in the day of care for:

      (i) Trips and outings which are part of the activities program; and

      (ii) A participant's medical appointment escorted by center staff.

C. The day care service shall be:

  (1) Authorized in the participant's plan of service;

  (2) Medically necessary;

  (3) Adequately described in progress notes in the participant's medical record, signed and dated by the individual providing care; and

  (4) Provided to participants documented to be present at the medical day care center a minimum of 4 hours a day.

#### Regulation .36 Covered Services — Senior Center Plus.

*COMAR 10.09.81.36*

A. Definition. “Unit of service” means a day of attendance by a participant for at least 4 hours, not including transportation to and from the center.

B. Senior Center Plus services include a program of structured group recreational activities, supervised care, assistance with activities of daily living and instrumental activities of daily living, and socialization provided in an out-of-home, outpatient setting. Social and recreational activities designed for elderly and disabled individuals, and one nutritious meal shall be provided by the center.

C. This program is designed to promote the participants' optimal functioning and to improve their orientation and cognitive ability.

D. A provider may choose to provide transportation to and from the site of the Senior Center Plus services. These transportation services:

  (1) May not be included in the provider's daily rate negotiated with the Maryland Department of Aging; and

  (2) Shall be reimbursed through some other funding source for transportation services.

E. Senior Center Plus does not cover:

  (1) Transportation;

  (2) Direct health care; or

  (3) A full regimen of three meals per day.

#### Regulation .37 Covered Services — Assisted Living Facility.

*COMAR 10.09.81.37*

A. Definition. “Unit of service” means a day of service and does not include days that the participant was not residing in the provider's assisted living facility, meaning that the participant:

  (1) Had not yet moved into the facility;

  (2) Had moved out of the facility;

  (3) Was an inpatient at a hospital, nursing facility, or other medical institution for one or more nights; or

  (4) Was absent from the provider's facility for more than 7 nights during a calendar month at the participant's choice for personal reasons, such as to visit family or take a vacation.

B. Assisted living services shall include the provision of:

  (1) A structured, supportive environment in a home-like setting;

  (2) Personal care and chore services including:

    (a) Assisting the participant, as necessary, with performing activities of daily living and instrumental activities of daily living, including cuing the participant to perform these activities;

    (b) Routine housekeeping, laundry, household care, and chore services needed to maintain the facility as a clean, sanitary, and safe environment; and

    (c) Menu planning, food shopping, and meal preparation and serving;

  (3) Basic personal hygiene supplies, including but not limited to:

    (a) Soap;

    (b) Bathroom tissue;

    (c) Paper towels;

    (d) Toothpaste;

    (e) Toothbrush; and

    (f) Shampoo;

  (4) 24-hour supervision of participants to assure health and safety;

  (5) Assistance with medication administration, in accordance with COMAR 10.27.11 and COMAR 10.07.14;

  (6) Recreational and social activities;

  (7) Reminding the participant of medical appointments;

  (8) Assistance with transportation arrangements to Program and other needed services;

  (9) Conferring with the participant's case manager about the participant's status and service needs;

  (10) Assisting the participant in accessing needed medical or mental health services in emergency situations; and

  (11) Other services specified for assisted living programs in COMAR 10.07.14.

C. Assisted living services shall reflect the participants' individualized needs and preferences.

D. Assisted living services reimbursed under this chapter may not include room and board.

#### Regulation .38 Conditions for Reimbursement.

*COMAR 10.09.81.38*

The Maryland Medical Assistance Program shall reimburse for the services specified in Regulations .22 — .37 of this chapter, if the service:

A. Is recommended in the applicant’s or participant's plan of service as necessary in order to:

  (1) Prevent admission to a nursing facility;

  (2) Safely deinstitutionalize the individual from a nursing facility into the community; or

  (3) Assure the participant’s health and safety in the community;

B. Has been preapproved by the Department in the participant's plan of service;

C. Is provided to an enrolled participant who meets the qualifications for eligibility specified in Regulation .03 of this chapter;

D. Is appropriate, relative to other community-based services;

E. Is cost-neutral for the ICS Program after receipt of the monthly assessment fee and by calculating, on an annualized basis, the cost of services covered under this chapter and other State Plan services that are not covered for nursing facility residents; and

F. Is provided by a Medicaid provider of ICS Program services who meets the appropriate conditions for participation under this chapter.

#### Regulation .39 Limitations.

*COMAR 10.09.81.39*

A. Reimbursement may be made by the Maryland Medical Assistance Program only if the requirements of this chapter are met.

B. The total reimbursement by the Maryland Medical Assistance Program for environmental accessibility adaptations and assistive technology combined is limited to the amount specified at Regulation .40C(4)(f)(ii) or (h)(ii) of this chapter during the participant’s annual plan of service period, with exceptions allowed at the Department's discretion in the following circumstances:

  (1) The amount exceeds the limit, but will allow the individual to return home from a nursing facility or avoid immediate placement in a nursing facility, and does not exceed the participant's cost neutrality under Regulation .38E of this chapter; or

  (2) Expenditures in excess of the annual limit will reduce the participant's ongoing Medicaid cost of care significantly without exceeding the participant's cost neutrality.

C. Reimbursement for services or equipment estimated to cost more than the amount specified in Regulation .40C(4)(g)(ii) of this chapter shall be preapproved by the Department based on at least two cost estimates obtained from prospective vendors.

D. Reimbursement by the Maryland Medical Assistance Program for environmental accessibility adaptations covered under Regulation .27 of this chapter is limited to modifying two residences of the participant every 3 consecutive years.

E. Excluded from coverage under Regulation .27 of this chapter are adaptations or improvements to the home which:

  (1) Are of general utility, such as carpeting, roof repair, and central air conditioning;

  (2) Are not of direct medical or remedial benefit to the participant; or

  (3) Add to the home's total square footage.

F. Reimbursement by the Maryland Medical Assistance Program for personal emergency response systems covered under Regulation .28 of this chapter may only be allowed for participants who:

  (1) Are alone for significant parts of the day;

  (2) Have no regular caregiver for extended parts of the day; and

  (3) Would otherwise require extensive routine supervision to ensure the participant's health and safety.

G. The Maryland Medical Assistance Program may not reimburse for attendant care services provided under this chapter if:

  (1) On the same date of service, a participant also received personal care services under COMAR 10.09.20; or

  (2) Rendered for more than 23 hours for a participant on the same date of service.

H. Reimbursement for the following services shall be limited to 8 hours per service per date of service:

  (1) Family training;

  (2) Participant training; or

  (3) Nursing supervision.

I. The total amount of reimbursement by the Maryland Medical Assistance Program for transition services is limited to a one-time expense of $3,000 per participant, with exceptions allowed at the Department's discretion.

#### Regulation .40 Payment Procedures — General.

*COMAR 10.09.81.40*

A. Request for Payment.

  (1) An approved provider shall:

    (a) Submit a request for payment for the services covered under this chapter according to procedures set forth in COMAR 10.09.36.04; and

    (b) Include the following information on the request:

      (i) Date or dates of service;

      (ii) Participant's name and Medical Assistance number;

      (iii) Provider's name, location, and identification number;

      (iv) Nature, procedure code or codes, and unit or units of the covered services provided; and

      (v) Amount of reimbursement requested.

  (2) The provider shall submit a request for payment in a manner approved by the Maryland Medical Assistance Program.

  (3) Participant-employed attendants shall submit a request for payment to a designated fiscal intermediary who shall:

    (a) Submit bills to the Department;

    (b) Withhold appropriate taxes; and

    (c) Remit reimbursement to the provider for services rendered.

  (4) A request for payment shall include all units of service rendered, as defined in Regulations .22 — .37 of this chapter, during a given time period for a participant.

  (5) Except as specified in §A(3) of this regulation, the provider shall bill the Department, or its authorized agent, in accordance with the payment methodology specified in Regulation .41 of this chapter for services approved by the Department.

B. Billing time limitations for the services covered under this chapter are set forth in COMAR 10.09.36.06.

C. Payments.

  (1) Payments for services rendered to a participant shall be made:

    (a) Directly to a qualified provider; or

    (b) To a designated fiscal intermediary for distribution to participant-employed attendants.

  (2) A provider shall be paid the lesser of:

    (a) The provider’s customary charge to the general public unless the service is free to individuals not covered by Medicaid; or

    (b) The rate established in Regulation .41 of this chapter.

  (3) Payment by the Department for the services covered under this chapter:

    (a) Shall be considered as payment in full; and

    (b) May not supplement or be supplemented by payment from other sources, such as the participant, family, a public program, or private agency.

D. The ICS Program’s rates as specified in Regulation .41A — C, E, I — M, O, and P of this chapter shall increase on July 1 of each year beginning July 1, 2012, subject to the limitations of the State budget, by the lesser of:

  (1) 2.5 percent; or

  (2) The change from March to March in the medical care component of the Consumer Price Index for all urban consumers (CPI-U) for the Washington-Baltimore area.

#### Regulation .41 Payment Procedures — Rates.

*COMAR 10.09.81.41*

A. To receive payment as a provider of services covered under Regulations .23, .24, and .33—.37 of this chapter, a provider shall submit claims in accordance with procedures outlined in the Department's billing manual.

B. Billing time limitations for the services covered under this chapter are set forth in COMAR 10.09.36.06.

C. Payments.

  (1) Payments shall be made directly to a qualified provider.

  (2) A provider shall be paid the lesser of:

    (a) The provider's customary charge to the general public unless the service is free to individuals not covered by Medicaid; or

    (b) The rates established in §D of this regulation.

D. Rates.

  (1) For dates of service beginning July 1, 2024, fees per unit of service shall be as follows:

    (a) Assisted Living Level II, No Medical Day Care—reimbursed at the maximum rate of $90.74 per day;

    (b) Assisted Living Level III, No Medical Day Care—reimbursed at the maximum rate of $114.51 per day;

    (c) Assisted Living Level II, Medical Day Care—reimbursed at the maximum rate of $68.09 per day;

    (d) Assisted Living Level III, Medical Day Care—reimbursed at the maximum rate of $85.86 per day;

    (e) Behavioral Consultation—reimbursed at the maximum rate of $99.25 per hour;

    (f) Case Management—Administrative—reimbursed at the maximum rate of $93.06 per hour or $23.2645 per 15-minute unit;

    (g) Case Management—Comprehensive—reimbursed at the maximum rate of $93.06 per hour or $23.2645 per 15-minute unit;

    (h) Case Management—Ongoing—reimbursed at the maximum rate of $93.06 per hour or $23.2645 per 15-minute unit;

    (i) Dietitian and Nutritionist Services—reimbursed at the maximum rate of $99.25 per hour;

    (j) Family 1/1 Training—reimbursed at the maximum rate of $99.25 per hour;

    (k) Medical Day Care Services—reimbursed at the maximum rate of $116.59 per day; and

    (l) Senior Center Plus—reimbursed at the maximum rate of $72.19 per day.

  (2) The ICS Program’s rates for covered services under Regulations .23, .24, and .33—.37 of this chapter shall be adjusted subject to the limitations of the State budget.

#### Regulation .42 Recovery and Reimbursement.

*COMAR 10.09.81.42*

Recovery and reimbursement are as set forth in COMAR 10.09.36.07.

#### Regulation .43 Cause for Suspension or Removal and Imposition of Sanctions.

*COMAR 10.09.81.43*

Cause for suspension or removal and imposition of sanctions is as set forth in COMAR 10.09.36.08.

#### Regulation .44 Appeal Procedures for Providers.

*COMAR 10.09.81.44*

Appeal procedures for providers are those set forth in COMAR 10.09.36.09.

#### Regulation .45 Appeal Procedures for Applicants and Participants.

*COMAR 10.09.81.45*

Appeal procedures for applicants and participants are those set forth in COMAR 10.09.24.13 and 10.01.04.

#### Regulation .46 Interpretive Regulation.

*COMAR 10.09.81.46*

State regulations are interpreted as set forth in COMAR 10.09.36.10.