# COMAR Title 10 — Maryland Department of Health

## Subtitle 11 — Maternal and Child Health

### Chapter 03 — Children's Medical Services Program

**Authority:** Health-General Article, §15-125, Annotated Code of Maryland

**Administrative History:** Effective date: September 21, 1986 (13:19 Md. R. 2121)

**Administrative History:** Regulations .03, .05, and .12 amended as an emergency provision effective January 1, 1987 (14:2 Md. R. 125); adopted permanently effective March 31, 1987 (14:6 Md. R. 715)

**Administrative History:** Regulation .12 amended effective August 24, 1987 (14:17 Md. R. 1871)

**Administrative History:** Regulations .01—.12 repealed effective November 28, 1988 (15:24 Md. R. 2769)

**Administrative History:** Regulations .01—.18 adopted effective November 28, 1988 (15:24 Md. R. 2769)

**Administrative History:** Chapter revised and recodified from COMAR 10.22.08 to COMAR 10.11.03 effective March 1, 1993 (20:4 Md. R. 371)

**Administrative History:** Regulation .01-1 adopted as an emergency provision effective November 5, 2007 (34:24 Md. R. 2154); adopted permanently effective January 14, 2008 (35:1 Md. R. 19)

**Administrative History:** Regulation .02A, B amended as an emergency provision effective November 5, 2007 (34:24 Md. R. 2154); amended permanently effective January 14, 2008 (35:1 Md. R. 19)

**Administrative History:** Regulations .03 and .08 amended as an emergency provision effective January 27, 1999 (26:4 Md. R. 269); amended permanently effective May 31, 1999 (26:11 Md. R. 855)

**Administrative History:** Regulation .03B amended as an emergency provision effective January 19, 2007 (34:4 Md. R. 396); amended permanently effective May 7, 2007 (34:9 Md. R. 825)

**Administrative History:** Regulation .03B amended as an emergency provision effective November 5, 2007 (34:24 Md. R. 2154); amended permanently effective January 14, 2008 (35:1 Md. R. 19)

**Administrative History:** Regulation .08C amended as an emergency provision effective January 19, 2007 (34:4 Md. R. 396); amended permanently effective May 7, 2007 (34:9 Md. R. 825)

**Administrative History:** Regulation .08E amended as an emergency provision effective November 5, 2007 (34:24 Md. R. 2154); amended permanently effective January 14, 2008 (35:1 Md. R. 19)

**Administrative History:** Regulation .10 amended as an emergency provision effective November 5, 2007 (34:24 Md. R. 2154); amended permanently effective January 14, 2008 (35:1 Md. R. 19)

**Administrative History:** Regulation .10D-1 adopted effective March 28, 1994 (21:6 Md. R. 467)

**Administrative History:** Regulation .10E—I repealed as an emergency provision effective January 19, 2007 (34:4 Md. R. 396); amended permanently effective May 7, 2007 (34:9 Md. R. 825)

**Administrative History:** Regulation .20C amended effective April 24, 1995 (22:8 Md. R. 596)

**Administrative History:** Regulation .20F repealed as an emergency provision effective January 19, 2007 (34:4 Md. R. 396); amended permanently effective May 7, 2007 (34:9 Md. R. 825)

**Administrative History:** Regulation .21C amended as an emergency provision effective January 19, 2007 (34:4 Md. R. 396); amended permanently effective May 7, 2007 (34:9 Md. R. 825)

**Administrative History:** Regulation .23 amended as an emergency provision effective January 19, 2007 (34:4 Md. R. 396); amended permanently effective May 7, 2007 (34:9 Md. R. 825)

**Administrative History:** Regulation .25D amended as an emergency provision effective January 19, 2007 (34:4 Md. R. 396); amended permanently effective May 7, 2007 (34:9 Md. R. 825)

**Administrative History:** Regulation .26 amended as an emergency provision effective January 19, 2007 (34:4 Md. R. 396); amended permanently effective May 7, 2007 (34:9 Md. R. 825)

**Administrative History:** Regulation .27 amended as an emergency provision effective January 19, 2007 (34:4 Md. R. 396); amended permanently effective May 7, 2007 (34:9 Md. R. 825)

**Administrative History:** Regulation .28A amended effective March 28, 1994 (21:6 Md. R. 467)

**Administrative History:** Regulation .30 repealed, new Regulations .30 and .31 adopted, and Regulation .31 recodified to Regulation .32 as an emergency provision effective January 27, 1999 (26:4 Md. R. 269); amended permanently effective May 31, 1999 (26:11 Md. R. 855)

**Administrative History:** Regulation .30 amended as an emergency provision effective January 19, 2007 (34:4 Md. R. 396); amended permanently effective May 7, 2007 (34:9 Md. R. 825)

**Administrative History:** Regulation .30 repealed and new Regulation .30 adopted as an emergency provision effective November 5, 2007 (34:24 Md. R. 2154); adopted permanently effective January 14, 2008 (35:1 Md. R. 19)

**Administrative History:** Regulation .30A amended effective March 28, 1994 (21:6 Md. R. 467); April 24, 1995 (22:8 Md. R. 596)

**Administrative History:** Regulation .31 adopted effective March 28, 1994 (21:6 Md. R. 467)

**Administrative History:** Regulation .31 amended as an emergency provision effective January 19, 2007 (34:4 Md. R. 396); amended permanently effective May 7, 2007 (34:9 Md. R. 825)

**Administrative History:** Regulation .31 repealed and new Regulation .31 adopted as an emergency provision effective November 5, 2007 (34:24 Md. R. 2154); adopted permanently effective January 14, 2008 (35:1 Md. R. 19)

**Administrative History:** Chapter revised effective April 13, 2015 (42:7 Md. R. 568)

**Administrative History:** Regulation .14B amended effective February 27, 2017 (44:4 Md. R. 252)

#### Regulation .01 Incorporation by Reference.

*COMAR 10.11.03.01*

In this chapter, the federal poverty guidelines, as amended, which are updated periodically in the Federal Register by the U.S. Department of Health and Human Services, are incorporated by reference.

#### Regulation .02 Definitions.

*COMAR 10.11.03.02*

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

B. Terms Defined.

  (1) “Agency” means a legally incorporated body or governmental unit which provides services to disabled children or their families, or both.

  (2) “Allowable cost” means the maximum amount which the Program will reimburse for the drug or product portion of the prescription.

  (3) “Appeal” means the process by which a child with special health care needs, as defined in §B(9) of this regulation, or the family on the child’s behalf, obtains a review of a decision, action, or lack of action on the part of the CMS Program or one of its designees.

  (4) “Applicant” means a child with special health care needs, as defined in §B(9) of this regulation, or the parent or guardian of a child, for whom a written application has been submitted to the CMS Program for services, but for whom eligibility has not yet been determined.

  (5) “Authorized services” means that care which is approved by the CMS Program for an eligible child.

  (6) “Care coordination services” means services to promote the effective and efficient utilization of resources to assure access to necessary comprehensive services.

  (7) “Care management plan (CMP)” means a written document that lists recommendations for care as specified by a licensed and boarded provider.

  (8) “Children’s Medical Services Program (CMS Program)” means that program which is administered by the Department pursuant to Health-General Article, §15-125, Annotated Code of Maryland, to:

    (a) Provide for specialized medical, surgical, pharmacologic, and related rehabilitative evaluation and treatment services for children with special health care needs younger than 22 years old who:

      (i) Meet the residential, identification, financial, and medical eligibility requirements; and

      (ii) Are uninsured or do not have coverage in their existing health insurance plans that cover certain types of medical care;

    (b) Provide and promote family-centered, community-based, coordinated care for children with special health care needs, and promote development of community-based, culturally competent systems of services for those children and their families throughout the State; and

    (c) Distribute funds to cover specialty diagnostic and treatment services for eligible children with special health care needs in Maryland.

  (9) “Children with special health care needs” means individuals, birth to 22 years old, who have or who are at increased risk for a chronic physical, development, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.

  (10) “Department” means the Maryland Department of Health, the single State agency designated to administer the CMS Program.

  (11) “Disabling condition” means a health-related condition or impairment that may hinder achievement of normal growth and development.

  (12) “Disposable medical supplies” means consumable or disposable items with minimal or no potential for reuse which are used to serve a medical purpose.

  (13) “Durable medical equipment” means equipment which satisfies all of the following requirements:

    (a) It can withstand repeated use;

    (b) It is used to serve a medical purpose; and

    (c) It is appropriate for use in the home.

  (14) “Federal poverty level” means the poverty guidelines, as amended, which are updated periodically in the Federal Register by the U.S. Department of Health and Human Services.

  (15) “Financial eligibility guidelines” means the schedule based upon the federal poverty level which is used to determine financial eligibility for the CMS Program.

  (16) “General hospital” means an institution which falls within the jurisdiction of Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, and is licensed as a general hospital by the Maryland Department of Health, Division of Licensing and Certification, in accordance with COMAR 10.07.01.

  (17) “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.

  (18) “Hospital” means an institution which falls within the jurisdiction of Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, and is licensed pursuant to COMAR 10.07.01, or other applicable standards established by the state in which the services are provided.

  (19) “Income” means any property or service received by a person in cash or in kind which can be applied directly to meet basic needs for food, shelter, and medical expenses.

  (20) “Long-term hospitalization” means an inpatient stay of more than 2 weeks.

  (21) “Medical assistance” has the meaning stated in COMAR 10.09.24.02.

  (22) “Medical care” means medical services and specialized care provided by physicians and allied health professionals in hospitals, convalescent facilities, clinics, private physicians’ offices, in home and other community-based settings. Medical care may include the services rendered by dentists, nurses, medical social workers, childlife specialists, nutritionists, dietitians, psychologists, physical therapists, occupational therapists, speech-language pathologists, audiologists, optometrists, ophthalmologists, technicians, and other pertinent personnel whose services may be needed by those children who are served by the CMS Program.

  (23) “Medically necessary dental care” means reasonable and appropriate diagnosis, treatment, and follow-up care as determined and prescribed by qualified, appropriate health care providers in treating a condition, disease, injury, birth defect, or development malformation to restore facial configuration or function necessary for speech, swallowing, or chewing.

  (24) “Physician specialist” means a:

    (a) Licensed medical doctor who is qualified to practice medicine in a specialty area and who is either board certified or board eligible and who has experience in the care of children; or

    (b) Resident physician under the supervision of a licensed board-certified physician.

  (25) “Preauthorization” means an approval required from the Department or its designee before the provision of services.

  (26) “Provider” means an individual or entity duly licensed or certified to render a health care service or product pursuant to these regulations through an appropriate agreement with the Department, and identified as a CMS Program provider by the issuance of an individual vendor number.

  (27) “Residency” means living in the State voluntarily with the intention of making the State the individual’s permanent home for an indefinite period and not for a temporary purpose.

#### Regulation .03 Covered Services.

*COMAR 10.11.03.03*

A. The CMS Program shall authorize covered services when a CMP has been approved.

B. The CMP shall:

  (1) Include:

    (a) All diagnoses or suspected diagnoses;

    (b) Service requested or provided;

    (c) Specific reason for the service request;

    (d) Evaluation or treatment findings;

    (e) Follow-up plans related to the service provided by the CMS Program;

    (f) Source of primary health care; and

  (2) Be reviewed and approved by the CMS Program.

C. The CMS Program may request further information from the provider in order to:

  (1) Support the information required in §B(1) of this regulation;

  (2) Assure that all services are coordinated with other services the child is receiving through the CMS Program or other programs; and

  (3) Assure that the needs of the family are addressed in relation to meeting the medical and developmental needs of the child.

D. CMS Program eligible services shall include:

  (1) Specialty clinics;

  (2) Private office care including, but not limited to, the following:

    (a) Allergy/Immunology;

    (b) Audiology and hearing;

    (c) Cardiology;

    (d) Craniofacial;

    (e) Cystic fibrosis;

    (f) Developmental pediatrics;

    (g) Endocrine;

    (h) Gastroenterology;

    (i) Genetics;

    (j) Hematology;

    (k) Infectious disease;

    (l) Nephrology;

    (m) Neurology;

    (n) Neurosurgery;

    (o) Oncology;

    (p) Ophthalmology, optometry, and vision;

    (q) Orthopedics;

    (r) Otolaryngology;

    (s) Physical medicine;

    (t) Plastic surgery;

    (u) Pulmonology;

    (v) Rheumatology;

    (w) Speech-language pathology;

    (x) Surgery; and

    (y) Urology.

  (3) Primary physician care arranged at the discretion of the CMS Program to assure access for needed specialty diagnostic evaluation, treatment, and care coordination services;

  (4) Inpatient hospital care services, which are provided by Medical Assistance affiliated hospitals; and

  (5) Professional evaluation and treatment services, which may include, but are not limited to, the following:

    (a) Audiology;

    (b) Family training and counseling regarding medical and rehabilitation needs;

    (c) Genetic counseling;

    (d) Nursing;

    (e) Nutrition;

    (f) Occupational therapy;

    (g) Physical therapy; or

    (h) Speech-language pathology.

E. Specialized activities to facilitate a special treatment program may include, but are not limited to, the following:

  (1) Equipment to provide:

    (a) Life support;

    (b) Mobility;

    (c) Stimulation; and

    (d) Aid in activities of daily living;

  (2) Orthoses to correct or prevent orthopedic disabilities, including prescription shoes and their modifications;

  (3) Prostheses to replace a missing part or to enhance the applicant's functional performance;

  (4) Formula and medication to correct metabolic and physiologic errors;

  (5) Supplies of durable and disposable items to facilitate management of specific disorders;

  (6) Approved therapies involving specific treatment as authorized by appropriate CMS Program professional staff to cure functional deficiencies;

  (7) Life sustaining medications;

  (8) Dental services provided for children with disabling conditions; and

  (9) Hearing aids and augmentative devices to improve communication.

#### Regulation .04 Rights and Responsibilities.

*COMAR 10.11.03.04*

A. Applicant.

  (1) The applicant shall furnish factual information regarding the applicant’s eligibility, and shall keep the CMS Program informed of any change in demographic, financial, medical, or insurance coverage status.

  (2) An eligible applicant shall use only Medical Assistance approved providers.

  (3) An applicant shall complete a Medical Assistance application when the applicant is considered potentially eligible.

B. CMS Program.

  (1) An applicant who meets eligibility criteria as set forth in this chapter shall have access to approved services within the budgetary limitations of the CMS Program.

  (2) The CMS Program may purchase health insurance benefits for an eligible child when all of the following conditions are met:

    (a) The cost of this expense is less than the cost of directly purchasing the child’s medical care;

    (b) The policyholder is unable to pay for the health insurance policy due to:

      (i) An increase in insurance cost;

      (ii) A change in employment;

      (iii) Loss of income;

      (iv) An increase in health-related expenses; or

      (v) The policyholder’s eligibility to purchase health insurance benefits in accordance with the Consolidated Omnibus Budget Reconciliations Act of 1985, P.L. 99-272;

    (c) The health insurance policy is issued directly from:

      (i) An authorized insurer;

      (ii) A nonprofit health services plan;

      (iii) A health maintenance organization;

      (iv) A self-insured health benefit plan; or

      (v) The employer of the family member whose health insurance provides coverage for the eligible child; and

    (d) Payment is for premiums that can be costed out as related to the applicant only.

  (3) The CMS Program may pay copays, deductibles, and coinsurance costs when the CMS Program is purchasing the health insurance benefits.

  (4) The CMS Program shall comply with the requirements of:

    (a) Title VI of the Civil Rights Act of 1964 as amended;

    (b) The Age Discrimination Act of 1975 as amended;

    (c) Section 504 of the Rehabilitation Act of 1973 as amended; and

    (d) The Americans with Disabilities Act of 1989.

  (5) The CMS Program shall determine financial assistance based on the income and allowable deductions.

  (6) The CMS Program shall provide full financial assistance for authorized services when the income is equal to or less than that which is allowable in accordance with the financial eligibility levels described in Regulation .05A(4) of this chapter.

  (7) The CMS Program shall provide full CMS Program eligible service to the extent that medical assistance for this service is not covered under Title XIX.

#### Regulation .05 General Eligibility Criteria.

*COMAR 10.11.03.05*

A. To be eligible for the CMS Program’s services, an applicant shall:

  (1) Submit a completed, signed, and dated CMS Program application;

  (2) Provide documentation of:

    (a) State residency, as this program is not meant to cover those whose sole purpose in coming to Maryland is to obtain medical care or coverage; and

    (b) Being younger than 22 years old;

  (3) Provide a form of identification for the applicant and the applicant’s parents or guardians if the applicant is less than 18 years old;

  (4) Have income that does not exceed:

    (a) 200 percent of the federal poverty level; or

    (b) 250 percent of the federal poverty level, if the applicant is eligible for a medical deduction under Regulation .07D of this chapter; and

  (5) Have an eligible medical condition as set forth in Regulation .06 of this chapter.

B. The age eligibility referred to in §A(2)(b) of this regulation may be extended 3 years beyond the 22nd birthday if the CMP:

  (1) Confirms that current treatment of the condition should be continued in order to prevent a significant disruption in the provision of necessary services; and

  (2) Documents that the applicant is without third-party insurance or entitlement coverage.

#### Regulation .06 Medical Eligibility.

*COMAR 10.11.03.06*

A. Children with special health care needs may be eligible for services covered by the CMS Program.

B. Chronic medical conditions which may render an applicant medically eligible include, but are not limited to, the following:

  (1) Chronic asthma;

  (2) Chronic renal disease;

  (3) Cystic fibrosis;

  (4) Diabetes and other endocrine disorders;

  (5) Hemophilia;

  (6) Immune deficiencies;

  (7) Juvenile rheumatoid arthritis;

  (8) Leukemia and other childhood cancers;

  (9) Phenylketonuria and other inborn errors of metabolism; and

  (10) Sickle cell anemia and other chronic anemia.

C. Other medical and surgical conditions which may render an applicant medically eligible include, but are not limited to, the following:

  (1) Biliary atresia;

  (2) Bronchopulmonary dysplasia;

  (3) Tracheal esophogeal fistula; and

  (4) Ulcerative colitis.

D. Neurodevelopmental conditions which may render an applicant medically eligible include, but are not limited to, the following:

  (1) Brain tumors;

  (2) Cerebral palsy and other central nervous system disorders;

  (3) Certain high risk neonates;

  (4) Closed head injury with residual defects;

  (5) Down's syndrome and other genetic and chromosomal anomalies;

  (6) Hydrocephalus;

  (7) Medical aspects of learning disabilities and attention deficit disorders;

  (8) Medical aspects of intellectual disability and developmental delay;

  (9) Muscular atrophies and dystrophies;

  (10) Spina bifida, myelomeningocele, and the spinal cord dysfunctions;

  (11) Other neurologic damage;

  (12) Peripheral neuromuscular disease; and

  (13) Seizure disorder.

E. Orthopedic conditions which may render an applicant medically eligible include, but are not limited to, the following:

  (1) Chronic conditions resulting from trauma;

  (2) Chronic infections of bones and joints;

  (3) Club foot and other foot deformities;

  (4) Congenital developmental hip conditions such as congenital hip dislocation;

  (5) Limb deficiencies and length discrepancies;

  (6) Skeletal dysplasias and other forms of dwarfism; and

  (7) Spinal column defects and deformities.

F. Cardiac conditions which may render an applicant medically eligible include, but are not limited to, the following:

  (1) Arrhythmias;

  (2) Congenital heart defects;

  (3) Hypertension; and

  (4) Rheumatic heart disease.

G. Craniofacial and dental conditions which may render an applicant medically eligible include, but are not limited to, the following:

  (1) Cleft lip and palate, orofacial defects;

  (2) Handicapping malocclusions; and

  (3) Medically necessary dental care related to eligible medical conditions.

H. Vision, hearing and speech-language conditions, which may render an applicant medically eligible include, but are not limited to, the following:

  (1) Amblyopia;

  (2) Cataract;

  (3) Cholesteatoma;

  (4) Chronic otitis media;

  (5) Conductive and sensory-neural hearing loss;

  (6) Otosclerosis;

  (7) Speech-language disorders;

  (8) Strabismus; and

  (9) Velopharyngeal incompetence.

I. The following are excluded from CMS Program medically eligible services:

  (1) Well child care;

  (2) Mental health;

  (3) Emergency care; and

  (4) Urgent care.

J. Care excluded from CMS Program medically eligible conditions unless the services are medically necessary due to the underlying chronic condition includes:

  (1) Dermatology;

  (2) Gynecology; and

  (3) Dental services.

#### Regulation .07 Financial Eligibility.

*COMAR 10.11.03.07*

A. An applicant's financial eligibility is based upon the composition and income of the family unit.

B. Family Unit. A family unit consists of one or more of the following members residing in the same household:

  (1) The applicant;

  (2) The natural or adoptive parents, stepparents, or legal guardian if the applicant is unmarried;

  (3) The unmarried natural or adoptive siblings of the applicant who are younger than 22 years old;

  (4) The lawful spouse of the applicant; or

  (5) Other individuals who are not included in this regulation and who are dependents for federal income tax purposes.

C. Income.

  (1) For the purpose of determining financial eligibility, the CMS Program shall treat the income of members of the family unit listed in §B of this regulation as the sole source for determining an applicant’s eligibility.

  (2) The CMS Program shall determine the family’s income from the following sources:

    (a) Wages, including sick or severance pay;

    (b) Commissions and fees;

    (c) Salaries and tips;

    (d) Profit from self-employment, including income from the operation of a farm;

    (e) The earned income tax credit (EITC);

    (f) Social Security benefits;

    (g) Veterans' Administration benefits;

    (h) Workers' Compensation benefits;

    (i) Black Lung or Agent Orange benefits;

    (j) Railroad Retirement;

    (k) Government, private, or company pensions and annuities;

    (l) Unemployment insurance benefits;

    (m) Payments from oil or mineral rights (leases);

    (n) Government payments on land;

    (o) Insurance benefits paid directly to an applicant;

    (p) Trust funds;

    (q) Individual retirement accounts (IRAs);

    (r) Keough plans;

    (s) Military allotments;

    (t) Alimony or court-ordered and voluntary child support payments received from an absent spouse, or an absent natural or adoptive parent;

    (u) Loan repayments made to the applicant or family member including, but not limited to, mortgage payments;

    (v) Lump-sum benefits or other amounts of income received on a one-time-only basis;

    (w) Profit from rental income;

    (x) Cash assistance received from non-governmental social service agencies greater than the amount allowed by Medical Assistance;

    (y) Sick pay which does not count as earnings for deduction purposes under Title II of the Social Security Act; and

    (z) Any subsidy covering basic needs for food or shelter.

  (3) If an individual in the family unit has recently resumed employment, the Program shall determine income for a 12-month period by averaging actual income for 6 months preceding resumption of employment and projected income for 6 months following resumption of employment.

  (4) If additional CMS Program services are requested 6 months after resuming employment, the CMS Program may re-determine financial eligibility based on current income.

D. Medical Deductions. The applicant may deduct the following from the applicant’s income:

  (1) Loan payments related to medical or medically related emergency debt;

  (2) Payment to a hospital or other health care provider for a member of the family unit not covered by other third-party insurance entitlements, or the Program; and

  (3) Payments for health insurance for a member of the family unit.

E. Effective Dates for Financial Eligibility.

  (1) The CMS Program shall establish financial eligibility for a 12-month period from the date a completed application is received by the CMS Program.

  (2) Exceptions to the 12-month financial eligibility period are:

    (a) If financial eligibility was determined by averaging the previous 6 months, financial eligibility shall be reconsidered after 6 months;

    (b) When an eligible applicant enrolled in the CMS Program informs the CMS Program of changes in family size, income, or expense, the CMS Program may reconsider eligibility as soon as possible if financial assistance is being given, or when the next request for services is made.

  (3) Those receiving CMS Program financial assistance shall notify the CMS Program within 10 business days of any changes in circumstance which could affect continuing financial eligibility.

#### Regulation .08 Application Process.

*COMAR 10.11.03.08*

A. The CMS Program shall make applications available to, but which are not limited to, the following agencies:

  (1) Local health department;

  (2) Admitting, social services, or business office of a participating hospital;

  (3) Cooperating agencies; and

  (4) An applicant, upon request.

B. Completion of Application.

  (1) An applicant, the applicant's parent, guardian, or representative shall submit a complete, signed application approved by the Program.

  (2) A parent of any age, or an authorized representative of the applicant who is 18 years old or older, shall complete and sign the application for an unmarried applicant younger than 18 years old.

  (3) A representative of a public or private agency, which may include a foster parent, shall complete and sign the application for a child in custody of the agency.

  (4) An applicant shall provide financial information for each employed member of the family unit as specified in Regulation .07A of this chapter.

  (5) An applicant shall provide documents verifying residency, identification, income, and medical conditions or suspected medical conditions.

  (6) The CMS Program shall make reasonable accommodations to assure that appropriate assistance is provided to those who are disabled or who are unable to speak or write English.

#### Regulation .09 Disposition of Application.

*COMAR 10.11.03.09*

A. General.

  (1) The CMS Program professional staff shall:

    (a) Review individual applications;

    (b) Determine CMS Program eligibility and services to be approved for payment by the CMS Program within 30 calendar days of receipt of the complete application;

    (c) Verify the information provided by an applicant which may include an interview:

      (i) With the applicant if the applicant is 18 years old or older, or with the applicant’s parent or guardian; and

      (ii) Which is held at a mutually convenient place and time for all parties.

  (2) If additional information is needed to determine eligibility or service needed, the Program shall:

    (a) Return the application within 15 business days of receipt; and

    (b) Advise an applicant in writing of needed documentation.

  (3) Within 30 calendar days of receipt of the completed application by the CMS Program the CMS Program shall send a written decision regarding Program eligibility to the applicant.

  (4) For renewal applications, the CMS Program shall notify an applicant in writing at least 30 calendar days before the date on which the applicant shall reapply.

B. Eligible Applicant.

  (1) An eligible applicant shall receive a letter from the CMS Program which includes, at a minimum, the following information:

    (a) The effective dates of CMS Program eligibility;

    (b) The name of the provider; and

    (c) The service to be covered by the CMS Program.

C. Ineligible Applicant.

  (1) An applicant is ineligible when the applicant does not:

    (a) Provide requested information sufficient to determine eligibility;

    (b) Complete, sign, and date the application; or

    (c) Complete an application for Medical Assistance when the applicant is potentially eligible for services covered by Medical Assistance.

  (2) An applicant determined ineligible shall receive a letter from the CMS Program informing the applicant of the reasons for the determination.

  (3) An applicant determined to be ineligible shall be advised of the right to appeal the determination in accordance with the procedures set forth in §D of this regulation.

D. Appeal Rights.

  (1) Providers filing appeals of administrative decisions made in connection with these regulations shall do so in accordance with Health-General Article, §2-207, and State Government Article, Title 10, Subtitle 2, Annotated Code of Maryland.

  (2) An applicant or eligible individual, or other authorized representative has a right to a meeting or informal conference with CMS staff responsible for a decision reflected in any notice of determination issued in this chapter.

#### Regulation .10 Record Retention and Confidentiality.

*COMAR 10.11.03.10*

A. Records.

  (1) A provider shall:

    (a) Retain and reproduce, upon request for a minimum of 6 years, records and reports required by the Department for the administration of services; and

    (b) Be responsible for maintaining patient records for services that it provides in accordance with the approved Department retention schedule.

  (2) Records referred to in §A(1) of this regulation include:

    (a) Documentation of personal interviews;

    (b) Diagnosis and treatment recommendations;

    (c) Records of professional visits and consultations;

    (d) Consultant notes which shall be appropriately initialed or signed;

    (e) Medical and laboratory data, including X-rays; and

    (f) Other data as may be required by applicable federal and State regulations.

B. Confidentiality. A provider shall assure that the release of information from an eligible applicant's record is handled in accordance with Health-General Article, §§4-301—4-309, Annotated Code of Maryland, COMAR 10.03.02, and other State and federal laws and regulations governing the confidentiality of records.

#### Regulation .11 General Conditions of Provider Participation.

*COMAR 10.11.03.11*

A. A provider of services which are covered by the CMS Program shall comply with the following general requirements:

  (1) For fee for service reimbursement, be approved by Medical Assistance in writing as a Medical Assistance provider;

  (2) For copay and deductible reimbursement, be a participating provider with the insurance plan purchased by the CMS Program for the family;

  (3) Request preauthorization on the forms designated by the CMS Program;

  (4) Adhere to administrative procedures that are established by the CMS Program for the specific treatment services; and

  (5) Maintain adequate records, including prescriptions, for a minimum of 6 years, and make them available upon request to the Department or the Department's designee.

B. The approval referenced in §A(1) of this regulation shall specify, at a minimum, the following:

  (1) Approved services which may be provided; and

  (2) Duration of approval status.

#### Regulation .12 Conditions of Hospital Participation.

*COMAR 10.11.03.12*

A hospital shall:

A. Comply with all relevant State and federal requirements related to the provision of health services and the receipt of funds;

B. Be licensed by the Department pursuant to the Hospital and Related Institutions subtitle, Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, as a hospital, and be licensed, as may be required, by other applicable State and local laws;

C. Be accredited by the Joint Commission for Accreditation of Hospitals; and

D. Provide the following services:

  (1) A physician specialist who is qualified in the area of need for which a recipient is hospitalized, and who shall supervise and be involved in:

    (a) The ongoing care of a child; and

    (b) Directing the development of the CMP and other appropriate care plans;

  (2) Pediatric physician supervision on a full-time or part-time basis to assist with:

    (a) Diagnostic evaluations;

    (b) Care planning and treatment; and

    (c) Coordination with others involved in the development of the CMP;

  (3) Nursing services provided by a qualified nurse who has academic preparation and work experience in the care of children, including the specialty area of the condition to be treated;

  (4) Surgical services, which shall have, as a minimum:

    (a) Anesthesiologists trained and experienced in the management of pediatric patients; and

    (b) An appropriate recovery area which is staffed by personnel qualified in pediatrics and equipped with appropriate types and sizes of supplies and equipment;

  (5) Available consultation in other specialty areas for the cases being treated;

  (6) Other specialized support services, which shall include, but not be limited to, the following as appropriate:

    (a) Audiology;

    (b) Nutrition;

    (c) Occupational therapy;

    (d) Physical therapy;

    (e) Psychiatry;

    (f) Psychology;

    (g) Social work services; and

    (h) Speech-language pathology;

  (7) An ongoing inpatient educational program for school-age children, which is approved by the State Department of Education, when long-term hospitalization is required;

  (8) Discharge planning procedures designed to maximize a child's recovery and rehabilitation, which shall include the following:

    (a) Predischarge planning activities to include all appropriate staff and representatives of other agencies involved or indicated;

    (b) Parental counseling regarding a child's medical and social needs after the child's release; and

    (c) Medical care planning resulting from input of the professionals concerned with a child's treatment;

  (9) A discharge summary, which shall include as a minimum, the following:

    (a) Medications, primary and secondary diagnoses, hospital course, procedures performed, and complications;

    (b) Special equipment and other home care needs; and

    (c) Follow-up plans including special transportation needs, if applicable;

  (10) A separate area for a child, with provisions made for a parent or guardian to stay 24 hours, and nonrestrictive visiting hours for a parent or guardian;

  (11) Suitable recreational facilities for children;

  (12) Facilities to isolate children with communicable diseases or other conditions requiring isolation or separation;

  (13) Access to appropriate clinical laboratory facilities providing specialized diagnostic and treatment equipment, including radiological and nuclear medicine equipment; and

  (14) Outpatient facilities to provide follow-up care.

#### Regulation .13 General Billing Procedures.

*COMAR 10.11.03.13*

A. A provider shall accept payment at the Medical Assistance rate as payment in full.

B. A provider shall submit:

  (1) Requests for payment on the form designated by the CMS Program; and

  (2) Completed reports and attachments as requested by the CMS Program.

C. A provider may not bill the CMS Program for:

  (1) Completion of forms and reports;

  (2) Broken or missed appointments;

  (3) Professional services rendered by mail or telephone; and

  (4) Services which are provided at no charge to the general public.

D. The CMS Program shall:

  (1) Make no direct payment to the family;

  (2) Pay any claim for services provided on different dates and submitted on a single form, and only if it is received by the CMS Program within 12 months of the earliest date of service; and

  (3) Pay a claim which is rejected for payment due to improper completion or incomplete information, only if it is properly completed, resubmitted, and received by the CMS Program within the original 12-month period or within 60 calendar days of rejection, whichever is later.

E. The CMS Program reserves the right to return to the provider, before payment, all:

  (1) Invoices not properly signed, completed, and accompanied by properly completed forms as required by the Department, to include any necessary preauthorization forms; and

  (2) Claims not properly completed.

F. If payment is denied by the CMS Program due to late billing, the provider may not seek payment from the child’s family.

#### Regulation .14 Billing Procedures for Physician Office Services.

*COMAR 10.11.03.14*

A. A physician shall:

  (1) Comply with all procedures listed in Regulation .13 of this chapter;

  (2) Charge the CMS Program the usual and customary charge to the general public for similar services; and

  (3) Bill the CMS Program as specified by the CMS Program.

B. The CMS Program shall:

  (1) Use the fee schedule contained in the Maryland Medical Assistance Program’s Professional Services Provider Manual and Fee Schedule, which is incorporated by reference in COMAR 10.09.02.07D;

  (2) Pay for covered services that are the lower of the:

    (a) Physician’s customary charge; or

    (b) Department's fee schedule;

  (3) Reimburse the provider for:

    (a) Dispensed drugs at rates established by COMAR 10.09.03; and

    (b) Injectable drugs at rates promulgated by the Professional Services Provider Manual and Fee Schedule referenced in §B(1) of this regulation.

C. The CMS Program reserves the right to negotiate and establish a different fee for the physician or the group of physicians under contract to a hospital to provide services when a portion of the cost of the contract is paid as the hospital’s cost.

#### Regulation .15 Billing Procedures for Medically Necessary Dental Services.

*COMAR 10.11.03.15*

A. A dentist shall comply with all procedures listed in Regulation .13 of this chapter.

B. The CMS Program shall:

  (1) Cover approved diagnostic, restorative, and preventive treatment as described in the CMP; and

  (2) Preauthorize estimates of costs.

#### Regulation .16 Billing Procedures for Orthodontic Services.

*COMAR 10.11.03.16*

A. An orthodontist shall comply with all procedures listed in Regulation .13 of this chapter.

B. The CMS Program shall:

  (1) Reimburse for correction of the full permanent dentition; and

  (2) Give special consideration to services for children with malocclusions in the mixed dentition associated with cleft palates or other craniofacial deformities

C. The CMS Program may not reimburse for preliminary visits to the orthodontist.

D. The provider may not charge the patient, parent, or guardian for orthodontic treatment, including retention visits.

#### Regulation .17 Billing Procedures for Durable Goods and Equipment.

*COMAR 10.11.03.17*

A. The durable goods and equipment providers shall comply with all procedures listed in Regulation .13 of this chapter.

B. A provider shall charge the CMS Program the usual and customary charge to the general public for similar durable goods and equipment.

C. The CMS Program shall:

  (1) Pay for covered services which are the least expensive, except for those described in §B of this regulation;

  (2) Determine, based upon expected duration of medical needs, whether durable medical equipment will be purchased or rented; and

  (3) Pay for repairs to purchased durable medical equipment and disposable medical supplies according to the Medical Assistance reimbursement rate for charges.

D. The ownership of equipment shall remain with the CMS Program and shall be recovered at the option of the CMS Program.

#### Regulation .18 Billing Procedures for Pharmacy Services.

*COMAR 10.11.03.18*

A. A pharmacy provider shall comply with all procedures listed in Regulation .13 of this chapter.

B. A pharmacy provider shall:

  (1) Upon request, produce records to verify any charge to the CMS Program; and

  (2) Charge the CMS Program the usual and customary charge to the general public for similar prescriptions.

C. Determination of allowable cost for multiple source drugs designated by the Centers for Medicare and Medicaid Services of the Department of Health and Human Services or for each drug listed in the formulary allowable cost shall be the lowest of the maximum allowable cost.

D. Payment for covered services to a pharmacy shall be made as follows:

  (1) Payment for formulary drug preparation shall be the:

    (a) Least expensive available; or

    (b) Allowable cost according to the State Title XIX Agency;

  (2) Payment for over-the-counter drugs is not covered except in extenuating circumstances at the discretion of the CMS Program.

#### Regulation .19 Billing Procedures for Hospitals.

*COMAR 10.11.03.19*

A. All hospitals shall comply with the following procedures:

  (1) Hospitals located in Maryland that participate in the CMS Program shall charge and be reimbursed at the Medical Assistance rates approved by the Health Services Cost Review Commission;

  (2) The CMS 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;

  (3) The CMS Program may not reimburse for the services of a hospital’s salaried or contractual physicians as a separate line item;

  (4) The contractual physicians' salaries shall be included in the room and board rate or the appropriate ancillary service;

  (5) When a patient is discharged from one general hospital and is admitted to another general hospital and 24 hours have not elapsed between the discharge and admission, the CMS Program shall pay only for those medically necessary days, with the payment for the patient’s hospitalization being apportioned between the two hospitals;

  (6) The CMS Program shall be contacted regarding exceptions or extenuating circumstances relating to admissions and discharges if the patient returns the same day before the hospital patient count;

  (7) All nonemergency inpatient hospital admissions require preadmission approval by the CMS Program;

  (8) Authorization is required by the CMS Program or its designee for more than one preoperative inpatient day; and

  (9) The CMS Program may not reimburse for hospital admissions where a child has been discharged due to cancellation of planned surgery or treatment. The hospital may not bill the family for these charges.

B. In addition, all out-of-state providers shall:

  (1) Participate in Title XVIII of the Social Security Act;

  (2) Have in effect a utilization review plan applicable to all patients who receive Medical Assistance under Title XIX of the Social Security Act and which meets the requirements of the Social Security Act, §186(k), unless a waiver has been granted by the Secretary of Health and Human Services; and

  (3) Meet additional conditions for participation and comply with the requirements specified in Regulation .11 of this chapter.

C. All hospital services shall be reimbursed at the Medical Assistance rate.

#### Regulation .20 Cause for Suspension or Removal and Imposition of Sanctions.

*COMAR 10.11.03.20*

A. If the Department determines that a provider, vendor, agent or employee of the provider, vendor, or a person with an ownership interest in the provider or vendor has failed to comply with these regulations, or applicable federal or State laws or regulations, the Department may initiate one or more of the following actions against the responsible party:

  (1) Suspension from the CMS Program;

  (2) Withholding of payment from the CMS Program;

  (3) Removal from the CMS Program; and

  (4) Disqualification from future participation in the CMS Program, either as a provider or vendor providing services for which CMS Program payment may be claimed.

B. If the Secretary of the United States Department of Health and Human Services suspends or removes a provider from participation in Medicare or Medical Assistance, the Department shall take similar action.

#### Regulation .21 Funding Availability.

*COMAR 10.11.03.21*

Payment under this chapter is contingent on the availability of funds in accordance with State Finance and Procurement Article, §§7-234 and 7-235, Annotated Code of Maryland.