In this chapter, the following terms have the meanings indicated. Terms Defined. “Acute hospital” means an institution that provides active, short-term medical diagnosis, treatment, and care. “Administrative day” means a day of medical services delivered to a participant who no longer requires the level of care that the provider is licensed to deliver. “Admission” means the formal acceptance by a hospital of a participant who is to be provided with room, board, and medically necessary services in an area of the hospital where patients stay at least overnight. “Ancillary services” means diagnostic and therapeutic services including but not limited to radiology, laboratory tests, pharmacy, and physical therapy services, provided exclusive of room and board. “Appropriate facility” means: A facility located within a 25-mile radius of the participant’s residence; or If acceptable to the participant, a more distant facility, which is licensed and certified to render the participant’s required level of care, except when the only facility or facilities that provide the level of care and specialized services required by the participant exceed that distance. “Concurrent review” means a periodic reauthorization of continued medical eligibility for the level of services provided by a special pediatric hospital, which allows for close monitoring of the participant’s progress, treatment goals, and objectives, performed during an inpatient hospitalization. “Date of service” means: For inpatient hospitalizations, the date of admission into a special pediatric hospital up to, but not including, the date of discharge; or For outpatient services, the date services are rendered in the outpatient department of the hospital. “Department” means the Maryland Department of Health, which is the single State agency designated to administer the Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq. “Designee” means any entity designated to act on behalf of the Department. “Diagnosis-related group” means a participant classification system adopted by the U.S. Department of Health and Human Services, in which each hospital discharge case is assigned a category based on the primary diagnosis, secondary diagnoses, if any, procedures performed, and age, sex, and discharge status of the participant. “Electronic signature” means a secure electronic identification of an individual who authorizes an electronic record or transaction. “Health Services Cost Review Commission (HSCRC)” means the independent organization within the Maryland Department of Health which is responsible for reviewing and approving rates for hospitals pursuant to Health-General Article, Title 19, Subtitle 2, Annotated Code of Maryland. “Level of care” means an assessment that an individual needs the level of services provided in a special psychiatric hospital. “Maryland Medical Assistance Program” means the program of comprehensive medical and other health-related care for indigent and medically indigent persons. “Medically necessary” means that the service or benefit is: Directly related to diagnostic, preventative, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition; Consistent with 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 participant, family, or provider. “Medicare” means the medical insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq. “Out-of-State hospital” means any hospital outside of Maryland, except for hospitals located in the District of Columbia. “Outpatient services” means services provided to the participant on the hospital campus that do not require hospital admission. “Participant” means an individual who is enrolled with the Department to receive Medical Assistance services. “Plan of treatment” means a written plan developed by a participant’s consulting physician and other appropriate clinicians, which is provided to the Department on request and includes: Diagnosis; Treatment goals; Specific procedures planned for the participant, including surgeries; Duration of treatment of each type of service ordered; Expected length of stay; and Any other appropriate information, including caregiver education and discharge plan. “Program” means the Maryland Medical Assistance Program. “Prospective payment system” means a predetermined amount of reimbursement per day for inpatient hospital services. “Provider” means a special pediatric hospital which, through agreement with the Department, has been identified as a Program provider by the issuance of a provider number. Special Pediatric Hospital. “Special pediatric hospital” means a facility licensed by the Office of Health Care Quality as a special hospital that provides nonacute medical, rehabilitation, therapy, and palliative services to children and adolescents younger than 22 years old. “Special pediatric hospital” includes an out-of-State or District of Columbia hospital identified by the Program as: A facility that provides nonacute medical, rehabilitation, therapy, and palliative services to children and adolescents younger than 22 years old; and A facility that provides nonacute medical, rehabilitation, and therapy services to individuals ages 2 through 22 with co-occurring medical and behavioral conditions. In order to participate in the Program, a provider shall: Be licensed by the Department pursuant to Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, as a hospital; and Obtain other licenses, as set forth in COMAR 10.07.01. The provider 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 10.10.01; or If located out-of-State, comply with other applicable standards established by the state or locality in which the service is provided and with the requirements of COMAR 10.09.09.02. A provider shall meet all conditions for participation as set forth in COMAR 10.09.36. To participate in the Program as a special pediatric hospital services provider, the provider shall: Meet the requirements of Title XIX of the Social Security Act for participation as a hospital, as issued by the U.S. Department of Health and Human Services; Directly provide, or make available through contractual arrangements or transfer agreements, medically necessary covered services; Accept payment by the Program as payment in full for the covered services; Make available to the Department or its designee the participant’s medical record for review and certification of medical necessity for admission and continuation of stay; and Maintain documentation of each contact with the participant as part of the complete medical record, which, at a minimum, includes: Date of service; The participant’s chief medical complaint or reason for admission or outpatient visit; A description of the services provided, including: Progress notes; Imaging studies; Laboratory results; Medication administration records; and Discharge summary; and A signature, electronic or handwritten, along with the printed or typed name of the individual providing care, with the appropriate title. If an out-of-State or District of Columbia hospital, the hospital shall: Have in effect a utilization review plan applicable to all participants who receive Medical Assistance under Title XIX of the Social Security Act which meets the requirements of §1861(k) of the Social Security Act unless a waiver has been granted by the Secretary of Health and Human Services; and Allow HealthChoice managed care organizations to pay no more and no less than the reimbursement rates established in Regulation .07 of this chapter unless the parties mutually agree to an alternative arrangement in a contract either on or after July 1, 2011. The Program covers the following inpatient services at special pediatric hospitals: A hospital admission determined to be medically necessary for a participant who is stable enough for transfer to a post-acute setting and requires medical or rehabilitative services that: Cannot be provided at a lower level of care; and Meets the medical eligibility criteria under Regulation .06 of this chapter; Administrative days for the length of time certified by the Department or its designee; Inpatient admissions for intensive occupational therapy, physical therapy, or speech therapy on a regimen which is less than 3 hours per day, 5 days per week, when these services are provided in a unit that is accredited by the Commission on Accreditation of Rehabilitation Facilities to provide rehabilitation services; and Ancillary services. The Program covers the following outpatient hospital services: Medically necessary services for the provision of diagnostic, curative, palliative, or rehabilitative treatment; and For a participant younger than 21 years old, physical therapy, occupational therapy, speech therapy, and audiology services if: The therapy provider develops a written plan of treatment in collaboration with the participant’s primary care physician and the participant or the parent or guardian of the participant; The service is provided according to the plan of treatment; and The services provider sends an update of the plan of treatment to the participant’s primary care physician every 90 days. The Program does not cover: Investigational or experimental hospital services, procedures, or drugs; Inpatient admissions or outpatient visits solely for the administration of injections, unless medical necessity and the participant’s inability to take appropriate oral medications is documented in the participant’s medical record; Outpatient visits intended to accomplish one or more of the following: Prescription drug or food supplement pick-up; Collection of specimens for laboratory procedures; Recording of an electrocardiogram; or Ascertaining the participant’s weight; Interpretation of laboratory tests or panels; Autopsies; Immunizations required for travel outside the continental United States; Leaves of absence beyond the period of the census check of the same day; Day care; Psychological evaluations and treatments except when: Ordered by a physician, and the medical necessity is documented in the participant’s medical record; or Performed as mental health service, as part of the plan of treatment; Duplicated care or services; Elective admissions to hospitals outside of Maryland and the District of Columbia unless the Department or its designee determines that comparable services are not available in Maryland, except under certain conditions where child participants are in foster care, or are for other reasons placed outside the State and are covered under certain criteria, as determined by the Department or its designee; Inpatient and outpatient diagnostic services not specifically ordered by the attending physician or other responsible practitioner; Inpatient days or services provided in excess of the days approved by the Department or its designee; Hospital laboratory tests which are coverable under COMAR 10.09.09.04, if the specimen is not obtained in the hospital; Hospital services provided outside of the United States; The completion of forms and reports; Broken or missed appointments; Professional services rendered by mail or telephone; or Telephones, televisions, or personal comfort items or services. The Department or its designee shall conduct utilization review to determine that special pediatric hospital admissions and outpatient services are authorized only when medically necessary. Review Procedure. For all admissions, the special pediatric hospital shall provide: The elements of a participant’s medical record specified by the Department or its designee for preadmission review, and request to certify the participant’s admission; and Sufficient clinical information or documentation to the Department or its designee that supports the need for admission to a special pediatric hospital including, but not limited to: Current medical health status; Treatment received to date; Proposed treatment plan for requested admission; and Expected length of stay. Admission for inpatient services may be authorized only when these services cannot be provided: On an outpatient basis; or In a facility that is licensed to provide a more appropriate level of care to the participant. Concurrent review shall be conducted as long as the participant remains hospitalized, based on the participant’s diagnosis and condition, to ensure the medical necessity of the participant’s inpatient stay, at the following intervals: After an initially authorized 14-day stay, or at the end of the expected length of stay identified at admission, whichever comes first; and Every 14 days following the initial concurrent review, in a form and including clinical documentation as specified by the Department or its designee. The Department or its designee may conduct on-site reviews after an initially authorized period of 30 days, and every 30 days thereafter until discharge. An elective inpatient hospital admission requires preadmission authorization by the Department or its designee. Administrative Days. To be paid for administrative days, the provider shall document, in a form designated by the Department, information which satisfies the conditions listed below: The participant has been determined to no longer require special pediatric hospital services, and the provider has: Received a determination from the Department or its designee that the participant requires the level of service provided in a lower-acuity facility, but an appropriate facility is not available; Established a plan for discharge during the period of administrative days, is actively pursuing placement at an appropriate level of care for the participant, and has documented this activity in the participant’s record; and Submitted documentation to the Department or its designee that placement activity was conducted no fewer than 3 days per week during the period for which payment is requested for administrative days; or The participant is no longer medically eligible to receive special pediatric hospital services but cannot be moved, and the following conditions are met: The medical reason the participant cannot be moved is documented by the attending physician in the participant’s medical record; The attending physician reevaluates the medical cause of the participant’s inability to be moved at least once every 7 days; and The provider documents the active treatments used to resolve the medical cause of the participant’s inability to be moved; To receive reimbursement for administrative days, the provider shall document that it has met the conditions of §C(1) of this regulation, at least every 14 days. Documentation shall be submitted to the Department or its designee no later than 3 business days following the end of the 14-day period. HSCRC Reimbursement Principles. Except for hospitals reimbursed under the provisions of §B of this regulation and except for administrative days, hospitals located in Maryland that participate in the Program shall charge and be reimbursed according to rates approved by the HSCRC pursuant to COMAR 10.37.03. If the Program discontinues using rates which have been approved by HSCRC, the Program shall reimburse a provider: According to Medicare standards and principles for retrospective cost reimbursement described in 42 CFR §413; or On the basis of charges if less than reasonable cost. The Department may not reimburse for the services of a hospital’s salaried or contractual physicians as a separate line item. Annual Market Basket Reimbursement Principles. Except as specified in §B(2)—(5) of this regulation, a special pediatric hospital not approved by the Program for reimbursement according to HSCRC rates shall be reimbursed according to Medicare standards and principles for retrospective cost reimbursement described in 42 CFR §413, or on the basis of charges if less than reasonable cost. In calculating retrospective cost reimbursement rates, the Department or its designee will deduct from the designated costs or group of costs those restricted contributions which are designated by the donor for paying certain provider operating costs, or groups of costs, or costs of specific groups of participants. When the cost, or group or groups of costs designated, cover services rendered to all participants, including Medical Assistance participants, operating costs applicable to all participants shall be reduced by the amount of the restricted grants, gifts, or income from endowments, thus resulting in a reduction of allowable costs. For days of service on or after July 1, 2006, in special pediatric hospitals with pediatric rehabilitation beds in Maryland not approved by the Program for reimbursement according to HSCRC rates, the Department shall reimburse these hospitals using a prospective payment system consisting of per diem rates based on service categories audited and adjusted in the provider’s fiscal year 2004 cost report. The base per diem rates shall be: Annually adjusted by the factor indicated in the Centers for Medicare and Medicaid Services Annual Market Basket Update Factor for the Long Term Care Hospital Prospective Payment System; and Determined by allocating Medicaid inpatient costs into service categories as follows: Rehabilitation categories — $1,486.58; Feeding categories — $2,213.98; Severe behavior categories — $2,544.66; and Other categories — $1,126.69. For new services established after July 1, 2006, in special pediatric hospitals with pediatric rehabilitation beds in Maryland not approved by the Program for reimbursement according to HSCRC rates, the Program shall pay at an initial rate that is set as an interim rate at the Medicaid weighted average rate of all existing inpatient per diem rates. After the first full year, actual cost data shall be used to prospectively set the new service rate. For days of service on or after July 1, 2006, in special pediatric hospitals with pediatric rehabilitation beds in Maryland not approved by the Program for reimbursement according to HSCRC rates, the Department shall reimburse hospital based outpatient services on a prospective basis that shall be adjusted annually by the difference between the: Medicaid weighted average charge increase; and Centers for Medicare and Medicaid Services Outpatient Prospective Payment System Market Basket Update Factor. For outpatient services in §B(4) of this regulation, the revenue shall be maintained at the fiscal year 2011 level beginning July 1, 2011. Out-of-State Hospitals Reimbursement Principles. An out-of-State hospital, except a hospital located in the District of Columbia, shall be reimbursed the lesser of its charges or the amount reimbursable by the host state’s Title XIX agency. The hospital shall be reimbursed for administrative days in accordance with Regulation .09E of this chapter. For outpatient services, an out-of-State hospital, except a hospital located in the District of Columbia, shall be reimbursed the lesser of its charges or the amount reimbursable by the host state’s Title XIX agency. Inpatient Services Base Rate Calculation. A hospital in the District of Columbia shall: Bill its usual and customary charges; and Be reimbursed for covered services the lesser of its percentage of charges as calculated in §A(2) of this regulation or its charges. The percentage of charges in §A(1) of this regulation is the product of the following: The cost-to-charges percentage using only those costs of the hospital reported in the hospital’s most recent cost report as determined by the Program or its designee; The lesser of 100 percent or the cost-to-charge projection percentage which is: The hospital’s cost-to-charge ratio in its most recent cost report trended by its cost-to-charge ratio in the 2 prior years’ cost reports or, if 3 years of data are not available, the hospital’s cost-to-charge ratio in its most recent cost report divided by its cost-to-charge ratio in the prior year’s cost report; and Applied from the midpoint of the report period used to develop the cost-to-charges percentage in §A(2)(a) of this regulation, to the midpoint of the prospective payment period; The percentage of the hospital’s costs which are efficiently and economically incurred as determined in accordance with §A(6) of this regulation; and The uncompensated care factor, which is equal to one plus the quotient of the hospital’s uncompensated care divided by gross revenue. Effective for dates of service starting July 1, 2012, and forward, the rate calculated for FY 2012 in accordance with §A(2) of this regulation shall be increased by 9 percent. A hospital in the District of Columbia shall be reimbursed for administrative days in accordance with Regulation .08C of this chapter. Efficiently and economically incurred District of Columbia hospitals’ costs are costs which are: Less than or equal to the adjusted costs for the same all participant refined-diagnosis related groups in Maryland hospitals; For hospitals with average lengths of stay of 18 days or more: Less than or equal to the adjusted cost for the same diagnosis-related groups in Maryland hospitals; and Categorized into the following two age groups: younger than 18 years old, and 18 years old or older; Exclusive of: Maryland case charges greater than $500,000; and District of Columbia hospital case charges greater than $500,000 times the ratio of the average charge of the District of Columbia hospital case divided by the average charge of the Maryland hospital case; and Derived from hospital costs as specified in this subsection. Maryland hospital costs are the hospitals’ charges reduced by the hospital specific ratio of operating costs to gross charges as determined by the Program or designee. There may not be a year-end cost settlement. For hospitals located in the District of Columbia that are not acute children’s hospitals, the reimbursement amount described in §A(1) of this regulation will be reduced by 2 percent. Outpatient Services. A hospital located in the District of Columbia shall: Bill its usual and customary charges; and Be reimbursed for covered services the lesser of its percentage of charges as calculated in §B(2) of this regulation or its charges. The percentage of charges in §B(1) of this regulation is the product of: The cost-to-charges percentage using only those costs of the hospital reported in the hospital’s most recent cost report as determined by the Program or its designee; and The lesser of 100 percent or the cost-to-charge projection percentage which is: The hospital’s cost-to-charge ratio in its most recent cost report trended by its cost-to-charge ratio in the 2 prior years’ cost reports or, if 3 years of data are not available, the hospital’s cost-to-charge ratio in its most recent cost report divided by its cost-to-charge ratio in the prior year’s cost report; and Applied from the midpoint of the report period used to develop the cost-to-charges percentage in §B(2)(a) of this regulation, to the midpoint of the prospective payment period. Effective for dates of service starting July 1, 2012, and forward, the rates calculated for FY 2012 in accordance with §B(2) of this regulation shall be increased by 9 percent. The analysis shall be performed by the Program or its designee. There may not be a year-end cost settlement. Outpatient reimbursement rates are implemented in conjunction with, and are applicable to, the same dates of service as inpatient rates. Cost Reporting. A special pediatric hospital provider reimbursed according to this regulation shall submit to the Department or its designee, in the form prescribed, financial and statistical data within 5 months after the end of the provider’s fiscal year unless the Department grants the provider an extension or the provider discontinues participation in the Program. When reports are not received within 5 months and an extension has not been granted: For hospitals reimbursed in accordance with Regulation .08 of this chapter, the Program shall reduce the inpatient percentage of payment for that hospital by 5 percentage points, starting the calendar month after the calendar month in which the report is due, which will remain in effect until the report has been submitted, and there will be no refund; or For a hospital reimbursed according to Medicare standards and principles for retrospective cost reimbursement as described in 42 CFR §413, the Department shall: Withhold from the provider a maximum of 5 percent of the current monthly interim payment starting the calendar month after the calendar month in which the report is due and any subsequent calendar months until the report has been submitted; and Refund withholdings at cost settlement. If a provider discontinues participation in the Program, financial and statistical data shall be submitted to the Department within 45 days after the effective date of termination. The Program may grant an extension for submission of cost reports: Upon written request by the provider, setting forth the specific reasons for the request, if the Department determines, taking into consideration the totality of the circumstances, that the request is reasonable; or Concurrent with any extension granted to the hospital by Medicare, but not to exceed 60 days from the due date of cost reports. When a report is not submitted by the last day of the 6th month after the end of the provider’s fiscal year, and the provider has not received an extension, the Department may impose, in addition to a reduction in payment percentage or withholding a percentage of interim payment pursuant to §C(2) of this regulation, one or more sanctions as provided for in Regulation .11 of this chapter. When a report is not submitted by the last day of the sixth month after the end of the provider’s fiscal year or a report is submitted but the provider cannot furnish proper documentation to verify costs, the Department shall, if applicable, make final cost settlement for that fiscal year at a certain percentage of the last final per diem rates for which the Department has verified costs for that facility, provided that the rates established will not exceed the maximum per diem rates in effect when the facility’s costs were last settled. For purposes of §C(1) — (6) of this regulation, reports are considered received when the submitted reports are completed according to instructions issued by the Department or its designee. When a report is received after imposing a reduction as specified in §C(2)(a) of this regulation, the rate of reimbursement calculated using this cost report information shall be implemented starting the 1st day of the 4th full calendar month after the month in which the report was received by the Program. The Program shall pay room and board charges for the day of admission, and may not pay room and board charges for the day of discharge from the hospital. The provider shall submit a request for payment according to procedures designated by the Department. Payments of Medicare Claims. Payment of Medicare claims is authorized if: The provider accepts Medicare assignment; Medicare makes direct payment to the provider; Medicare determined that services were medically necessary; The services are covered by the Program; and Initial billing is made directly to Medicare according to Medicare guidelines. Payment of a deductible and co-insurance related to Medicare claims shall be paid subject to the HSCRC discounts, except in the case of a participant receiving hospital services in an out-of-State facility, in which case deductible and co-insurance shall be paid in full. Out-of-State Hospital Reimbursement. The Program shall reimburse hospitals outside of Maryland, excluding the District of Columbia, at a rate that is 100 percent of the amount reimbursable by the host state’s Title XIX agency or the amount of the hospital’s actual charges in total, whichever is less. Out-of-State providers are responsible for reimbursing the Department for overpayments, in accordance with Regulation .10 of this chapter. Payment for Administrative Days. The provider shall document, on forms designated by the Department, information that satisfies the conditions stated in Regulation .06C of this chapter. The provider shall: Receive determination from the Department or its designee that the participant no longer requires the level of care that the special pediatric hospital is licensed to provide; Receive determination from the Department or its designee that the participant requires services at a lower level of acuity, and a bed in an appropriate facility is not available; and Notify the Department or its designee of discharge planning before the termination of the need for inpatient hospitalization at the level the facility is licensed to provide, and obtained a level of care determination from the agent. During the period of administrative days, the Department or its designee shall review the documentation in increments of not more than 14 days. For participants who are not ventilator-dependent, payment for approved administrative days shall be the lesser of: An estimated Statewide average Medicaid nursing home payment rate as determined by the Department; or If the hospital has a unit which is a skilled nursing facility, the allowable costs in effect under Medicare or extended services provided to participants of the unit. The Department will make no direct payment to the participant. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.06. The Department reserves the right to return to the provider, before payment, all invoices not properly completed. Noncompliance with the Program’s requirements as determined by the Department or its designee shall result in nonpayment of the claim. Payment on claims to a hospital located in the District of Columbia shall be reduced by a quarterly claims processing fee of 6 percent. General policies governing recovery and reimbursement procedures applicable to all providers are set forth in COMAR 10.09.36.07. If refund of a payment as specified in §A of this regulation is not made, the Department shall reduce its current payment to the provider by the amount of the duplicate payment, overpayment, or third-party payment. Causes for suspension or removal and imposition of sanctions shall be as set forth in COMAR 10.09.36.08. A provider filing an appeal from an administrative decision made in connection with these regulations shall do so according to COMAR 10.09.36.09. General policies governing the interpretive regulations that are applicable to providers are set forth in COMAR 10.09.36.10. Health-General Article, §§2-104(b), 15-102.8, 15-103, and 15-105, Annotated Code of Maryland Effective date: April 10, 2017 (44:7 Md. R. 354)