Chapter 84. Community First Choice

“Activities of daily living (ADLs)” means tasks or activities that include, but are not limited to:

“Applicant” means an individual who is applying to receive services under this chapter.

“Assistance” means that another individual:

“Case management services” means services which assist an applicant or a participant in gaining access to waiver and other covered Medicaid services.

“Case manager” means a person performing case management services under a waiver program and acting in the role of the supports planner.

“Certified medication technician (CMT)” means an individual, regardless of title, who:

“Certified nursing assistant (CNA)” means an individual, regardless of title, who:

“Community First Choice” means the Medicaid home and community-based services program implemented under this chapter in accordance with the application and any amendments to it submitted by the Department and approved by the Secretary of Health and Human Services, which authorizes the provision of certain home and community-based services under the Maryland Medical Assistance Program.

Community Setting.

“Conflicts of interest” means real or seeming incompatibility between one’s private interests and one’s public or fiduciary duties.

“Delegated nursing functions” means nursing services provided to a participant by an enrolled personal assistance worker under the supervision of a:

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

Home.

“Institution” means an establishment that furnishes, in single or multiple facilities, food, shelter, and some treatment or services to four or more individuals unrelated to the proprietor.

“Instrumental activities of daily living” means tasks or activities that include, but are not limited to:

“Medicaid” means the Program, administered by the State of Maryland under Title XIX of the Social Security Act, which provides comprehensive medical and other health-related care for categorically eligible and medically needy participants.

“Medically necessary” means that the service or benefit is:

“Nurse” means an individual who is currently licensed to practice nursing in the State under COMAR 10.27.01.

“Nurse monitor” means a registered nurse who completes nursing assessments on participants and evaluates the delivery of care.

“Nursing facility” means a facility which is participating in the Maryland Medical Assistance Program as a nursing facility pursuant to COMAR 10.09.10.

“Participant” means an individual who:

“Personal assistance provider agency” means a public or private agency that:

Personal Assistance Services.

“Plan of service” means the written support plan that:

“Preauthorized” means approved by the Department or its designee before services can be rendered.

“Program” means the Maryland Medicaid Program.

“Provider” has the same meaning as defined in COMAR 10.09.36.

“Provider agreement” means a contract between the Department and the provider for rendering the services under this chapter.

“Quality plan” means the plan developed by the Department to address quality assurance and oversight.

“Recommended plan of care” means the recommended service plan developed by a nurse after a face-to-face evaluation of an applicant or participant.

“Representative” means:

“Supports planner” means an individual who coordinates services, including:

“Telephonic timekeeping system” means a system developed by the Department for workers to time stamp the start and finish of services provided to a participant.

“Worker” means an individual who is employed by or contracts with a personal assistance provider agency to provide personal assistance services.

Be determined by the Department to need the level of care provided in a hospital, nursing facility, an intermediate care facility for individuals with intellectual disabilities, an institution providing psychiatric services for individuals younger than 21 years old, or an institution for mental diseases for individuals 65 years old or older;

Be eligible for Medicaid under an eligibility group defined in COMAR 10.09.24, except for Regulations .03C, .03-1—.03-3, and .05-2; and

Reside at home.

Be based on:

Address the applicant’s or participant’s health and safety needs;

Specify the items and services needed to safely support the participant in the community, including:

Specify the provider agency providing personal assistance services; and

Include the signature of the:

No longer meets the required level of care;

No longer resides at home;

Is without services for 30 consecutive calendar days;

Voluntarily chooses, or the participant’s legal representative chooses on the participant’s behalf, to disenroll from the Program;

Moves to another state;

Is an inpatient for 30 consecutive days or more in an institutional setting, including but not limited to a chronic hospital or nursing facility; or

Dies.

Shall meet all of the conditions for participation as a Medicaid provider as set forth in COMAR 10.09.36, except as otherwise specified in this chapter;

Shall obtain written verification of the qualifications of all individuals who render services on the provider’s behalf and provide a copy of the current license or credentials on request;

Shall implement the reporting and follow-up of incidents and complaints in accordance with the Department’s established policy by:

Shall agree to cooperate with required inspections, reviews, and audits by authorized governmental agents;

Shall agree to provide services, and to subsequently bill the Department in accordance with the reimbursement methodology specified in this chapter, for only those services covered under this chapter which have been:

Shall agree to maintain and have available written documentation of services, including dates and hours of services provided to participants, for a period of 6 years from the date of service, in a manner approved by the Department;

Shall agree not to suspend, terminate, increase, or reduce services for an individual without authorization from the Department and only after consultation and input from the participant or, when applicable, the participant’s representative;

Shall submit a transition plan to the case manager or supports planner and participant or, when applicable, the participant’s representative when suspending or terminating services;

Shall verify Medicaid eligibility at the beginning of each month that services will be rendered;

May not be a Medicaid provider or principal of a Medicaid provider that has overpayments that remain due to the Department; and

Shall be free from conflicts of interest.

Had a license or certificate suspended or revoked as a health care provider, health care facility, or direct care services worker;

Been suspended or removed from participating as a Medicaid provider under COMAR 10.09.20;

Undergone the imposition of sanctions under COMAR 10.09.36.08;

Been subject to disciplinary action, including actions by the licensing board or any provider or principal of any provider agency;

Been cited by a State agency for deficiencies which affect participants’ health and safety; or

Experienced a termination of a Medicaid provider agreement or been barred from work or participation by a public or private agency due to:

Periodically provide information about a participant in accordance with the procedures and forms designated by the Department; and

Share and discuss the documented information at the request of the participant.

Be licensed as a Residential Service Agency under COMAR 10.07.05 to provide Level Two or Level Three home care services;

Employ a registered nurse who shall:

Employ workers who will accept instruction on the personal assistance services required in the participant’s plan of service from the following:

Allow participants to have a significant role in the delivery of their specific care including:

Notify the Department in writing at least 45 days in advance of any:

Include in the notice to the Department the method for informing participants and representatives of its intent to close, change ownership, change location, or sell its business;

Include in the notice to the Department, and inform participants and representatives, of the transition plan developed by the agency to ensure continuity of services to participants;

If applicable, apply for a new license whenever ownership is to be transferred from the person or organization named on the license to another person or organization in time to assure continuity of services;

Submit a Medicaid provider application to the Department if the new owner chooses to participate in the Program;

At least monthly, collect and maintain the participant’s signature, or that of the participant’s representative when applicable, verifying services rendered; and

Conduct a criminal history records check on all direct service workers including nurses, in accordance with the procedure for a State criminal history records check established under Health-General Article, Title 19, Subtitle 19, Annotated Code of Maryland.

If required to administer medications in accordance with the plan of service, be a certified medications technician; and

If performing other delegated nursing functions, also be a certified nursing assistant.

Identified by the Department through a solicitation process; or

The area agency on aging that is enrolled to provide case management services under COMAR 10.09.54.

Responsible for monitoring and responding to a notification of an emergency by the system; and

Adequately staffed 24 hours a day, 7 days a week by properly trained staff; and

Be approved and monitored by the Department;

Provide or arrange for any installation, maintenance, training, or monitoring required for the proper operation of the device or system, if applicable; and

Receive a referral from the participant, participant’s case manager, or supports planner, based on services preauthorized in the plan of service.

Use a cooking facility or food preparation site that 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

Be 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.

A Program provider of disposable medical supplies and durable medical equipment under COMAR 10.09.12; or

The store, vendor, organization, or company which sells or rents the equipment or system, subject to Department approval.

Have a current license with the Maryland Home Improvement Commission; and

Be approved by the Department.

Assistance with activities of daily living;

Delegated nursing functions if this assistance is:

Assistance with tasks requiring judgment to protect a participant from harm or neglect;

Assistance with or completion of instrumental activities of daily living, provided in conjunction with the services covered under §B(1)—(3) of this regulation; and

Assistance with the participant’s self-administration of medications, or administration of medications or other remedies, when ordered by a physician.

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

The cost of food or meals prepared in or delivered to the home or otherwise received in the community; or

Housekeeping services, other than those incidental to services covered under §B of this regulation.

Address the individualized needs of the participant;

Be sensitive to the educational background, culture, and general environment of the participant;

Support the participant to self-direct services and exercise as much control as desired to select, train, supervise, schedule, determine duties, and dismiss the personal assistance worker; and

Ensure freedom of choice among any willing provider for all services.

Assisting the participant in developing a plan of service in consultation with the applicant or participant and any individual requested by the participant;

Assisting the participant with referral, access, and coordination of services, both Medicaid and non-Medicaid, to address the participant’s needs including, but not limited to:

Monitoring the provision of services to determine if services are received in accordance with the plan of service;

Using information technology systems developed by the Department;

Coordinating with the fiscal intermediary to assist in managing budgeted resources;

Providing guidance and support to help individuals self-direct their services; and

Administering funds for transition services.

Targeted to the individualized needs of the participant receiving the training; and

Sensitive of the educational background, culture, and general environment of the participant receiving the training.

Planning, preparing, or setting up the training; or

Following up after the training.

Purchase and installation;

Monthly cost of a covered system or rented device or equipment, including monitoring, maintenance, and repair.

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;

A portable help button to allow for the participant’s mobility; and

A motion detector when necessary for the participant’s safety.

Be preauthorized in the participant’s plan of service as necessary to:

Specifically relate to ADLs or IADLs within the approved plan of service;

Comply with policies and procedure guidance defined by the Department;

Meet necessary standards of manufacture, design, usage, and installation, if applicable;

Be provided in accordance with applicable State and local building codes and pass required inspections, if applicable; and

Not be prescribed primarily to provide comfort or convenience.

Medicaid under the State Plan as durable medical equipment or pharmacy services under COMAR 10.09.03, 10.09.12, or 10.09.67;

Medicare; or

Any other third-party payer.

Delivered to the participant’s home;

Intended for consumption at home;

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 demonstrated by having the menus certified in writing by a physician, dietitian, or nutritionist; and

At least one-third of the RDA, DRI, or therapeutic diet requirements ordered by the participant’s physician, dietitian, or nutritionist, including any ordered nutritional supplements.

Environmental controls for the home or automobile;

Personal computers, software, or accessories;

Augmentative communication devices;

Maintenance or repair of technology devices;

Self-help aids that assist with activities of daily living or instrumental activities of daily living; and

Assessments and training in the use of assistive technology.

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

Obtain additional professional advice from an occupational therapist about the:

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

Environmental factors in the facility or home;

The participant’s ability to perform activities of daily living;

The participant’s strength, range of motion, and endurance; and

The participant’s need for assistive devices and equipment.

Being available to give instruction and to answer questions;

Complying with the Department’s reportable events policy; and

Maintaining an up-to-date client profile in an electronic database designated by the Department.

Contact with the participant for the purpose of reviewing participant status at a minimum of every 6 months with at least one in-person home or workplace visit every 12 months; and

Additional nurse monitoring services at a frequency established in conjunction with the participant or, when applicable, the participant’s representative, based on the participant’s medical condition or clinical status.

The nurse monitoring provider shall use the home or workplace visit for the following purposes:

The nurse monitor shall assess the quality of personal assistance services by:

Not otherwise available under the Program;

Approved in the plan of service; and

Rendered to assist the participant in transitioning from an institution or a provider-owned residence to a home or community-based residence.

Security deposits;

Essential furnishings and moving expenses;

Set-up fees or deposits for utility services; and

Other health and safety assurances.

Televisions;

Cable television access; or

Gaming systems.

Prevent the applicant’s or participant’s admission to an institution;

Safely transition the applicant or participant from an institution, such as a nursing facility, into the community; or

Assure the health and safety of an applicant or participant in the community;

Live alone; or

Have no regular caregiver for extended parts of the day and would otherwise require extensive routine supervision to ensure the participant’s health and safety.

Service primarily for the purpose of housekeeping unrelated to the participant’s activities of daily living, such as:

Services provided by providers not approved for participation by the Department;

Expenses incurred while escorting participants:

Expenses related to room and board for either the participant or the worker;

Transition services more than 60 days post transition;

Personal assistance services provided outside the State for more than 30 days per calendar year;

Environmental adaptations to the home which:

Experimental technology or equipment.

Administrative overhead;

Travel;

Internal quality monitoring activities;

Staff supervision, training, or consultation; or

Services rendered by an individual supports planner or nurse monitor in excess of 7 hours per day unless preauthorized by the Department in writing.

Document time; and

Submit claims.

Payments for services rendered to a participant shall be made directly to a qualified provider.

A provider shall be paid the lesser of:

The Department shall publish a fee schedule for services covered under this chapter which shall be publicly available and updated at least annually or upon any changes made by the Department.

Effective July 1, 2018, the Program’s rates for covered services under Regulations .14—.16, .18D, .19, and .20 of this chapter shall increase on July 1 of each year by 3 percent, subject to the limitations of the State budget.