This chapter establishes the methodology by which the Department shall reimburse licensed Community Supported Living Arrangements providers for: Services, the provision of which begins after June 30, 2000; and Existing services provided under contract which the Department shall convert to this rate system. The rates are based on the service needs of the individual and an allowance for indirect expenses incurred by licensees. Reimbursement for supplemental services are for services not covered by the rates. Services reimbursed by the Community Supported Living Arrangements payment system established by this chapter are paid for by Medicaid funds or, in whole or in part, by State general funds. This chapter does not limit the Administration's ability to contract for other services or additional services according to State procurement laws and as set forth in this chapter. The Community Supported Living Arrangements payment system is subject to the budget appropriation approved by the General Assembly. The Administration pays for the most effective service at the most efficient cost. In this chapter, the following terms have the meanings indicated. Terms Defined. “Actual costs” means all direct and indirect costs that the provider incurs for labor performed or goods delivered. “Administration” means the Developmental Disabilities Administration. “Base services” means services covered by the rate. “Community Supported Living Arrangements (CSLA)” has the meaning stated in COMAR 10.22.01.01B(12). “Department” means the Maryland Department of Health. “Direct services” means services provided directly to the individual. “Existing services” means a service provided continuously to an individual by the same provider beginning on or before June 30, 2000. “Fiscal management services (FMS)” means a person approved by the Administration and designated as an Organized Health Care Delivery System under COMAR 10.22.20 that: Assists individuals and families in managing their funds and paying for services; and Is responsible for submitting financial reports to the individual and Administration. “Hours of service” means the preauthorized hours of direct services made available to the individual being served as identified in the individual plan. “Individual plan (IP)” has the meaning stated in COMAR 10.22.01.01B(27). “Licensee” means a provider of Community Supported Living Arrangement services licensed under COMAR 10.22.02.01A. “New individuals” means those individuals starting Community Supported Living Arrangements services with a licensee after June 30, 2000. Professional Services. “Professional services” means services provided by an individual authorized to perform these services under Health Occupations Article, Annotated Code of Maryland. “Professional services” includes but is not limited to direct, on- going nursing services and behavioral services provided in accordance with COMAR 10.22.10. “Rate” means the amount the Department pays for an hour of CSLA service and covers all actual costs incidental to providing the service, including but not limited to coordination of the service; nursing review of services; administrative costs; staff hiring, training, travel, and supervision; and program direction. The hours of service are used to determine the rate. “Self-directed services” means services, as approved by the Administration: That an individual arranges; and For which the individual reimburses the provider. “Supplemental services” means preauthorized services not covered by the rate. “Support broker” means a person employed by individuals and families, who have been determined eligible by the Administration, that helps them: Decide what services and supports are best for them; and Access and manage the chosen services and supports. To provide CSLA services and seek reimbursement from the Administration, a licensee shall: Be licensed in accordance with Health-General Article, Title 7, Annotated Code of Maryland, and COMAR 10.22.02; Comply with: COMAR 10.22.08; and COMAR 10.09.26; Execute an agreement with the Administration; Comply with the Administration's reporting and record-keeping requirements, including: Submitting an annual cost report on a form approved by the Administration not later than 6 months after the end of the State fiscal year that: Documents the licensee's actual expenditures for the fiscal year being reported; Is based on the licensee's audited financial statement; Includes a work sheet reconciling the cost report to the financial statement; and Is certified by an independent certified public accountant, who is not an employee of the licensee or any affiliated organization, for the actual days each individual received services; and Retaining documentation of the costs for supplemental services for at least 6 years after the expenses are incurred; and Submitting an annual wage and benefits survey in a format approved by the Administration by the later of 60 days after: The last day of the pay period for which the data is requested; or Receipt of a request from the Administration for wage survey information. Submit to the Administration for its approval the number of hours of service an individual needs per week, as documented by the individual's IP, on a form specified by the Administration. For reports and data required under this chapter, the Administration may, with notice, suspend payment of 25 percent of the provider's per diem rate until the report or data is received. For the annual cost report and the annual wage and benefits survey, the Administration may, after notice and an opportunity to be heard, fiscally sanction providers as set forth in Health-General Article, §7-910(c), Annotated Code of Maryland. The Department shall reimburse the licensee: For new individuals served after June 30, 2000, according to the rates set forth in this regulation; and For individuals receiving existing services, by converting those contracts to the Community Supported Living Arrangements Payment System if appropriate between: July 1, 2000, and December 31, 2000, if the individuals are living in their own residences, and January 1, 2001, and June 30, 2001, if the individuals are living with their families. The Administration determines the rate based on the number of preauthorized hours of service each individual needs each week as documented by the individual's IP. If an individual does not need the same amount of services each week, the rate is determined by the number of preauthorized hours of service in a 4-week period divided by 4, and is at least 1 hour each week. The Department shall pay a daily amount per individual calculated by multiplying the number of hours of service each week approved for the individual by the hourly rate and dividing by seven. The basic rates for CSLA services are set forth in §I of this regulation. These rates do not include professional services. Under the rates, the Department may pay for up to 82 hours of service each week. If awake-overnight or one-to-one services are indicated in the individual's IP, and are not included in the 82 hours of base rate service, the Administration may: Preauthorize and approve additional hours of service beyond 82 hours after reviewing the IP and any additional documentation the Administration requests; and Reimburse the licensee as set forth in §J of this regulation for these services. Professional Services. The Administration may preauthorize and approve professional services if: The individual's IP, and any additional documentation the administration requires indicates the service is necessary; and The provider submits documentation that: The individual is not eligible for medical assistance, For individuals who are Medicaid eligible, the service sought is not a service covered by the Maryland Medical Assistance Program, or If the individual is Medicaid eligible and the service is covered by the Maryland Medical Assistance Program, the provider submits documentation that the Maryland Medical Assistance Program has denied coverage, and the agency is pursuing an appeal. If the Administration approves and preauthorizes a professional service, the Administration shall reimburse the provider for professional services according to the rate schedule in §K of this regulation except that the Administration may procure services to be reimbursed at a higher rate if: The provider submits documentation that it cannot find a professional to render services at this rate; The usual and customary rate charged by the professional for the service is above the rate of this regulation; and The rate that the Maryland Medical Assistance Program reimburses the professional for this service is higher than the rate established by §K of this regulation. Fiscal Year 2020 Tables for CSLA’s Personal Supports Hourly Rates. State Fiscal Year 2019 CSLA’s Personal Supports Rates: Table for One Individual in a Dwelling Receiving CSLA Services. State Fiscal Year 2020 CSLA’s Personal Supports Rates: Table for Two Individuals in a Dwelling Receiving CSLA Services. State Fiscal Year 2020 CSLA’s Personal Supports Rates: Table for Three Individuals in a Dwelling Receiving CSLA Services. State Fiscal Year 2020 CSLA’s Personal Supports Rates: Table for 1:1 Support or Not More than 8 Hours of Awake-Overnight Support per Residence for Individuals Receiving CSLA Services Regardless of the Number of Individuals in a Dwelling. State Fiscal Year 2020 CSLA’s Personal Supports Rates: Table for Professional Services for Individuals Receiving CSLA Services Regardless of the Number of Individuals in a Dwelling. Supplemental services do not include any services that are in the Maryland Medical Assistance Program and can be provided to an individual and reimbursed under the Medical Assistance Program, or any services covered by private insurance, including Medicare. Supplemental services include: Respite; Expenses related to the operation and maintenance of the individual's vehicle; Medical equipment; Structural modifications for accessibility; Habitation start-up; Assistive technology; Other services as preauthorized and approved by the Administration; and Housing costs, if: The individual is unable to pay the full amount of ongoing housing costs, and There are no other State or federal resources available to pay for the ongoing housing costs. In order for the Administration to reimburse a licensee for supplemental services, the Administration shall preauthorize the service and approve the cost. To be approved for reimbursement of supplemental services, except housing, the licensee shall: Submit a written request to the Administration justifying the request, including: Recommendations from the individual's team, Documentation from appropriate professionals, and Other documentation the Administration requires; and Justify the basis of the proposed costs and submit supporting documentation, such as: Bids from vendors, Advertisements for the item, and Rates of a proposed vendor. To be approved for reimbursement of supplemental housing costs, the licensee shall submit a written request to the Administration documenting: The individual's income and expenses; The housing costs; and Efforts to obtain other State or federal assistance with housing costs. In deciding whether to authorize supplemental services, the Administration shall: Consider the documentation submitted by the provider in this regulation; Consider the proposed cost for the service; If appropriate, visit the individual in the setting where the continuous supplemental services are to be provided; and Review the licensee's efforts to meet the individual's needs within existing resources. The licensee shall submit invoices or electronic claims in the form determined by the Administration. The Administration shall pay the lower of either: Reasonable customary and actual costs not to exceed the cost to the general public; or Medicaid-approved rates. Reasonable customary and actual costs are determined and authorized by the Administration before the delivery of the service. The Department shall reimburse the licensee for preauthorized supplemental services upon submission of an invoice. The Administration shall contract for services needed by an individual as documented in the IP and preauthorized but not covered by rates or supplemental services in accordance with the State's procurement requirements. If there is an existing contract for family support services or individual support services, the contract amount less the amount to be paid for fiscal management services shall be used in determining the amount of money available for purchasing support services and support brokerage services in an individual's budget. If there is no existing contract for family support services or individual support services, the CSLA rates less the amount to be paid for fiscal management services shall be used in determining the amount of money available for purchasing support services and support brokerage services in an individual's budget. Health-General Article, §§2-104(b), 7-306.1, 7-307, 7-714, 7-910(c), 15-105, 15-107, and 16-201, Annotated Code of Maryland; Ch. 102, Acts of 2001 Effective date: Regulations .01—.09 adopted as an emergency provision effective July 1, 2000 (27:15 Md. R. 1397); adopted permanently effective October 30, 2000 (27:21 Md. R. 1976) Regulation .02B amended effective March 13, 2006 (33:5 Md. R. 520) Regulation .03 amended as an emergency provision effective July 1, 2001 (28:15 Md. R. 1395); amended permanently effective October 1, 2001 (28:19 Md. R. 1684) Regulation .03 amended as an emergency provision effective July 1, 2002 (29:15 Md. R. 1139); amended permanently effective October 14, 2002 (29:20 Md. R. 1588) Regulation .03A amended as an emergency provision effective July 1, 2003 (30:14 Md. R. 934); amended permanently effective September 29, 2003 (30:19 Md. R. 1333) Regulation .04 amended as an emergency provision effective July 1, 2001 (28:15 Md. R. 1395); amended permanently effective October 1, 2001 (28:19 Md. R. 1684) Regulation .04 amended as an emergency provision effective July 1, 2002 (29:15 Md. R. 1139); amended permanently effective October 14, 2002 (29:20 Md. R. 1588) Regulation .04 amended as an emergency provision effective July 1, 2003 (30:14 Md. R. 934); amended permanently effective September 29, 2003 (30:19 Md. R. 1333) Regulation .04I, J, K amended effective December 20, 2004 (31:25 Md. R. 1790); March 13, 2006 (33:5 Md. R. 520); December 7, 2006 (33:24 Md. R. 1906); December 31, 2007 (34:26 Md. R. 2263); March 23, 2009 (36:6 Md. R. 491); October 4, 2010 (37:20 Md. R. 1394); April 15, 2013 (40:7 Md. R. 611); July 7, 2014 (41:13 Md. R. 752); October 12, 2015 (42:20 Md. R. 1265); April 9, 2018 (45:7 Md. R. 345); May 20, 2019 (46:10 Md. R. 488); October 5, 2020 (47:20 Md. R. 875) Regulation .10 adopted effective March 13, 2006 (33:5 Md. R. 520)