The following terms have the meanings indicated. Terms Defined. “Certified nurse midwife (CNM)” means a registered nurse who is certified by the American College of Nurse-Midwives, and is licensed in the state in which the service is provided. “Commission for the Accreditation of Birth Centers (CABC)” means the independent authority that accredits developing and existing birth centers in the United States of America, according to established national standards. “Department” means the Maryland Department of Health. “Free-standing Birth Center” means a free-standing facility not associated with a hospital that provides physician or certified nurse midwifery services. "Medical Assistance Program” means the program, financed by federal, state, and local funds, for the comprehensive medical care for persons of all ages within certain income limits. “Medically necessary” means the service or benefit is: Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition; Consistent with current accepted standards of good medical practice; The most cost efficient service that can be provided without sacrificing effectiveness or access to care; and Not primarily for the convenience of the consumer, family, or provider. “Newborn” means an infant who is not more than 48 hours old. “Participant” means an individual who is eligible for Program benefits. “Physician” means an individual legally licensed to practice medicine by the Board or in the state in which the physician's practice is located. “Program” means the Maryland Medical Assistance Program. “Provider” means a free-standing birth center. A free-standing birth center shall be certified by the Commission for the Accreditation of Birth Centers, and: Be licensed to operate in Maryland pursuant to Health General Article 19, Subtitle 3b, Annotated Code of Maryland and in accordance with the requirements as set forth in COMAR 10.05.02; or If located out-of-State, comply with the regulations of the jurisdiction in which the free-standing birth center is located. The free-standing birth center shall ensure that Clinical Laboratory Improvement Amendments (CLIA) certification exists for all clinical laboratory services performed, and: If located in Maryland, comply with requirements of Health-General Article, Title 17, Subtitles 2 and 3, Annotated Code of Maryland, and COMAR 10.10.06; or If located out-of-State, comply with other applicable standards established by the state or locality in which the service is provided. A CNM providing services in a free-standing birth center shall meet the license requirements in accordance with COMAR 10.09.21.02B. A physician providing services in a free-standing birth center shall meet the requirements in accordance with COMAR 10.09.02.02B. General requirements for participation in the Program are that a provider shall meet all conditions for participation as set forth in COMAR 10.09.36.03. Specific requirements for participation in the Program as a free-standing birth center require that the provider: Verify the licenses and credentials of all clinical professionals employed by or under contract with the free-standing birth center as set forth in COMAR 10.05.02.04. Maintain adequate documentation of each participant’s delivery service and newborn care as set forth in COMAR 10.05.02.11. Comply with safety requirements as set forth in COMAR 10.05.02.09 and COMAR 10.05.02.10. The Program covers the facility-related services provided by the free-standing birth center for the care of the delivering mother and newborn, and covers the cost of; Support staff; The use of the free-standing birth center; and Supplies, linens, and equipment. The Program does not cover laboratory or x-ray services performed by another facility. The facility performing these services shall bill the Program directly. Professional services are to be billed separately from the free-standing birth center facility fee. The Program will reimburse free-standing birth centers for: A facility fee of $2,000 for the care of the delivering mother and delivery of the newborn, if the delivery takes place at the facility; and A facility fee of $500 for the care of the newborn. If the mother is transferred to a hospital prior to delivering the newborn, the Department will reimburse as follows: If the mother was at the birth center for less than 2 hours, before the delivery of the newborn, the reimbursement will be at 25 percent of the Medicaid rate; If the mother was at the birth center for 2 to 5 hours, before the delivery of the newborn, the reimbursement will be at 50 percent of the Medicaid rate; If the mother was at the birth center for 5 to 8 hours, before to the delivery of the newborn, the reimbursement will be at 70 percent of the Medicaid rate; and If the mother was at the birth center for more than 8 hours, before the delivery of the newborn, the reimbursement will be at the full Medicaid rate. The Program shall pay for covered services at the lower of the: Provider's customary charge to the general public; or The Program’s fee. The provider shall submit a request for payment as set forth in COMAR 10.09.36.04A. The Program reserves the right to return to the provider, before payment, all invoices that are not properly completed. The Program may not make a direct payment to a recipient. Billing time limitations for claims submitted under this chapter are set forth in COMAR 10.09.36.06. If the recipient has insurance or if any other person is obligated either legally or contractually to pay for or to reimburse for any service covered by this chapter, the provider shall seek payment from that source first. If an insurance carrier rejects the claim or pays less than the amount allowed by the Medical Assistance Program, the provider may submit a claim to the Department. The provider shall submit a copy of the insurance carrier’s notice or remittance advice with the claim. If payment is made by both the Program and by the insurance or other source for the same service, the provider shall refund to the Department, within 60 days of receipt, the amount paid by the Program, or by the insurance or other source, whichever is less. The provider shall reimburse the Department for any overpayment. Causes for suspension or removal and imposition of sanctions shall be as set forth in COMAR 10.09.36.08 Appeal procedures are as set forth in COMAR 10.09.36.09. General policies governing the interpretive regulations that are applicable to all providers are set forth in COMAR 10.09.36.10. Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland Effective date: May 1, 2014 (41:8 Md. R. 471)