Chapter 07. Maryland AIDS Drug Assistance Program: Health Insurance (MADAP-PLUS)
Regulation .01 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Acquired Immunodeficiency Syndrome (AIDS)” means the medical condition caused by the Human Immunodeficiency Virus.
(2)
“Applicant” means an individual who has submitted an application to the Maryland AIDS Drug Assistance Program—Plus and whose eligibility status for the Maryland AIDS Drug Assistance Program—Plus has not yet determined.
(3)
“Core medical services” means a set of direct health care services as specified by the Ryan White Care Act Part B Program administered by the U.S. Health Resource and Services Administration.
(4)
“Department” means the Maryland Department of Health.
(5)
“Enrolled in MADAP” means that an applicant has been approved to receive Maryland AIDS Drug Assistance Program benefits.
(6)
“Health care provider” means an individual licensed to provide core medical services in the state where services are rendered.
(7)
“Human immunodeficiency virus (HIV)” means the virus that causes AIDS.
(8)
“Maryland AIDS Drug Assistance Program (MADAP)” means the program administered by the Department that provides services specified in COMAR 10.18.06.04 for enrolled recipients.
(9)
“Maryland AIDS Drug Assistance Program—Plus (MADAP-Plus)” means the program administered by the Department to pay insurance premiums, copays, coinsurance, and deductibles for drugs and core medical services.
(10)
“Medical Assistance” has the meaning stated in COMAR 10.09.24.02.
(11)
“Open formulary” means all U.S. Food and Drug Administration-approved prescription medications and related devices that are not on the list of excluded drugs and other products maintained by the Department according to COMAR 10.18.06.04-1.
(12)
“Recipient” means an individual who is enrolled in MADAP-Plus.
(13)
“Verification of eligibility” means the information a recipient provides to the Department to confirm that the recipient is still eligible to receive MADAP benefits according to COMAR 10.18.05.03B(1)(a).
Regulation .02 Eligibility.LinkCopy Citation
A.
To be eligible for MADAP-Plus coverage, an individual shall be:
(1)
Enrolled in MADAP; and
(2)
Receiving or eligible to receive health insurance and prescription drug coverage.
B.
An individual who is eligible for employer-sponsored health insurance with a prescription drug formulary that includes antiretroviral medications may not receive premium assistance unless the individual is:
(1)
Enrolled in the employer-sponsored health plan; and
(2)
Paying 50 percent or more of the total monthly health insurance premiums.
Regulation .03 Application and Enrollment.LinkCopy Citation
A.
An applicant shall apply in the manner set forth in COMAR 10.18.05.03A.
B.
A recipient and the Department shall meet the enrollment responsibilities set forth in COMAR 10.18.05.03B.
C.
The duration of the recipient’s enrollment in MADAP-Plus may not extend beyond the duration of the recipient’s enrollment in MADAP.
Regulation .04 Covered Services.LinkCopy Citation
A.
The Department shall pay for health and prescription plan premiums with a prescription drug formulary that includes antiretroviral medications.
B.
Within the limits established by the Department and in accordance with policy guidance issued by the Health Resources and Services Administration, the Department:
(1)
Shall pay for copays, coinsurance, and deductibles for drugs; and
(2)
May pay for copays, coinsurance, and deductibles associated with core medical services.
Regulation .05 Changes in Eligibility and Disenrollment.LinkCopy Citation
A.
A recipient shall inform the Department of a change in eligibility as set forth in COMAR 10.18.05.04A.
B.
If a change reported in §A of this regulation results in a recipient no longer qualifying for MADAP-Plus, the Department shall:
(1)
Determine the recipient ineligible for MADAP-Plus; and
(2)
Disenroll the recipient.
C.
If a MADAP-Plus recipient is disenrolled from MADAP, the recipient is automatically disenrolled from MADAP-Plus.
Regulation .06 Reconsideration and Appeal.LinkCopy Citation
A.
An applicant or recipient who has been notified by the Department of disenrollment or ineligibility for MADAP-Plus benefits may request reconsideration of the decision by submitting additional supporting documentation or information to the Department within 30 business days of notification.
B.
If an applicant or recipient submits a timely request for reconsideration, the Department shall:
(1)
Review all additional supporting documentation, within five business days of the Department’s receipt of the request for reconsideration; and
(2)
Issue a final decision in writing to the applicant or recipient.
C.
If an applicant or recipient is dissatisfied with the final decision of the Department, the applicant or recipient may appeal the reconsideration by requesting in writing for a hearing with the Department.
D.
The Office of Administrative Hearings shall:
(1)
Conduct a hearing according to the procedures set forth in COMAR 28.02.01;
(2)
Hold a hearing to review the decision within 45 days of the postmarked date on the letter requesting a hearing; and
(3)
Issue a decision in writing to the applicant or recipient.
E.
The Department shall pay any health insurance plan or prescription drug plan costs due pending a decision by the Office of Administrative Hearings.
F.
If the final decision finds in favor of the Department, the Department shall, upon the date of the decision, cease paying the health insurance costs allowed under this chapter and seek recovery in accordance with Regulation .08 of this chapter.
Regulation .07 Payment Procedures.LinkCopy Citation
A.
A recipient, recipient’s representative, health care provider, insurer, employer, or health plan administrator, as applicable:
(1)
May request payment costs allowed under this chapter on behalf of the recipient according to procedures established by the Department;
(2)
Shall submit a payment request that is:
(a)
An invoice for the recipient’s health or prescription drug plan insurance premium, copays, coinsurance, and deductibles for core medical services issued by an insurer, an employer, a health plan administrator, prescription drug plan administrator, or a health care provider; and
(b)
Submitted timely to allow for payment in accordance with §§A(3) and B(4) of this regulation; and
(3)
Shall make the initial request for the payment of costs within the time frames established by the health or prescription drug insurance policy.
B.
The Department:
(1)
Shall process a payment request as required by this chapter;
(2)
Shall inform a recipient or the recipient’s representative if an invoice is not paid;
(3)
Shall make payments in accordance with any applicable policies and procedures for the administration of federal funds issued pursuant to the Ryan White CARE Act Amendments of 1996, P. L. 104—146, and any subsequent modifications to the Act; and
(4)
Shall make subsequent payments:
(a)
As permitted under a health or prescription drug plan; or
(b)
Upon agreement between the Department and the:
(i)
Insurer;
(ii)
Employer;
(iii)
Health plan administrator;
(iv)
Prescription drug plan administrator; or
(v)
Health care provider.
Regulation .08 Recovery of Payments.LinkCopy Citation
If MADAP-Plus payments have been incorrectly paid or another payer has been identified, the Department shall seek recovery of the amount of those payments.
Regulation .09 Fraud.LinkCopy Citation
The Department shall pursue cases of suspected misrepresentation or fraud pursuant to Criminal Law Article, §8-503, Annotated Code of Maryland, or any other applicable statutory provision.
Regulation .10 Confidentiality.LinkCopy Citation
Unless otherwise authorized by law, the Department:
A.
Shall keep all applicant and recipient personal information confidential;
B.
May not disclose personal information kept on an applicant or recipient without the written consent of the:
(1)
Applicant;
(2)
Recipient;
(3)
Applicant’s parent or legal guardian; or
(4)
Recipient’s parent or legal guardian;
C.
Shall comply with the laws and regulations concerning the privacy and security of protected health information under:
(1)
Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and
(2)
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C; §§1320d et seq., as amended, the HITECH Act, 42 U.S.C. §§17932, et seq., as amended, and 45 CFR Parts 160 and 164, as amended, and their implementing regulations; and
D.
Shall ensure that all interactive video technology-assisted communication comply with HIPAA patient privacy and security regulations.
Regulation .11 Availability of Funding and Program Termination.LinkCopy Citation
A.
If sufficient monies are not available to fund MADAP-Plus, the Department shall take the action necessary to eliminate a deficit which may include MADAP-Plus termination.
B.
If MADAP-Plus is terminated, the Department shall provide coverage for each current recipient until the earlier of:
(1)
The date on which the next verification of eligibility is due to be submitted to the Department; or
(2)
Six months from the date MADAP-Plus is terminated.
Chapter annotations
Authority: Health-General Article, §§2-104(b) and(i) and 2-105(a) and (b), Annotated Code of Maryland
History: Effective date: February 3, 2003 (30:2 Md. R. 76)
History: Regulation .01B amended effective December 27, 2010 (37:26 Md. R. 1788); March 16, 2015 (42:5 Md. R. 486)
History: Regulation .03 amended effective December 27, 2010 (37:26 Md. R. 1788); March 16, 2015 (42:5 Md. R. 486)
History: Regulation .04 amended as an emergency provision effective January 1, 2014 (41:4 Md. R. 298); amended permanently effective May 26, 2014 (41:10 Md. R. 561)
History: Regulation .04D amended as an emergency provision effective August 11, 2004 (31:18 Md. R. 1348); amended permanently effective October 11, 2004 (31:20 Md. R. 1485)
History: Regulation .04D, E amended effective March 16, 2015 (42:5 Md. R. 486)
History: Regulation .06D amended effective March 16, 2015 (42:5 Md. R. 486)
History: Regulation .10A amended effective March 16, 2015 (42:5 Md. R. 486)
History: Regulation .16A amended effective March 16, 2015 (42:5 Md. R. 486)
History: Chapter revised effective March 28, 2016 (43:6 Md. R. 408)
History: Regulation .01B amended effective May 20, 2019 (46:10 Md. R. 488)
History: Regulation .02 amended effective May 20, 2019 (46:10 Md. R. 488)
History: Regulation .03C amended effective May 20, 2019 (46:10 Md. R. 488)
History: Regulation .04 amended effective May 20, 2019 (46:10 Md. R. 488)
History: Regulation .06F amended effective May 20, 2019 (46:10 Md. R. 488)
History: Regulation .07B amended effective May 20, 2019 (46:10 Md. R. 488)
History: Regulation .11B amended effective May 20, 2019 (46:10 Md. R. 488)