# COMAR Title 32 — Maryland Department of Aging

## Subtitle 02 — Provider Regulations

### Chapter 02 — Certificate of Registration for Continuing Care at Home Providers

**Authority:** Human Services Article, §10-454, Annotated Code of Maryland

**Administrative History:** Effective date: May 15, 2000 (27:9 Md. R. 859)

**Administrative History:** Chapter recodified from COMAR 14.11.09 to COMAR 32.02.02, October 2000

**Administrative History:** Regulation .02H amended effective March 17, 2025 (52:5 Md. R. 239)

**Administrative History:** Regulation .10A amended effective March 17, 2025 (52:5 Md. R. 239)

**Administrative History:** Regulation .10F adopted effective March 17, 2025 (52:5 Md. R. 239)

**Administrative History:** Regulation .11C amended effective March 1, 2004 (31:4 Md. R. 319)

**Administrative History:** Regulation .14J amended effective March 17, 2025 (52:5 Md. R. 239)

**Administrative History:** Regulation .16C amended effective March 17, 2025 (52:5 Md. R. 239)

**Administrative History:** Regulation .17D amended effective March 17, 2025 (52:5 Md. R. 239)

**Administrative History:** Regulation .31 amended effective March 17, 2025 (52:5 Md. R. 239)

#### Regulation .01 Definitions.

*COMAR 32.02.02.01*

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

B. Terms Defined.

  (1) “Act” means the portion of Human Services Article, Title 10, Subtitle 4,, Annotated Code of Maryland, as specified in §10-402(a).

  (2) “Actuarial balance sheet” means a balance sheet that uses actuarial principles and practices to determine the value of certain items in the balance sheet based on actuarial techniques involving reasonable assumptions about contingencies, inflation, and the time value of money as applied to current subscribers, which items include the present value of:

    (a) Future periodic fees;

    (b) The costs of providing promised future services; and

    (c) The obligation for refundable entrance fees.

  (3) “Agreement” means an agreement between a provider and subscriber that is a contract to provide continuing care at home.

  (4) “Assisted living unit” means a unit in which the services rendered will require the provider to be licensed as an assisted living program under Health-General Article, §19-1805, Annotated Code of Maryland.

  (5) Authority Recognized by the Department.

    (a) "Authority recognized by the Department" means a person whom the Department determines has the knowledge and experience of the continuing care industry necessary to produce the particular materials required by a given regulation in this chapter.

    (b) "Authority recognized by the Department" includes an independent consultant or an employee of a provider or related entity.

  (6) “Authorized officer” means an individual holding one of the following positions with a provider:

    (a) An officer;

    (b) A general partner;

    (c) Any individual who serves on the governing body; and

    (d) A trustee of the provider.

  (7) “Break-even point” means the projected point at which a provider's total revenue from continuing care at home agreements will begin to equal or exceed the provider's total expenses.

  (8) “Certified financial statement” means a financial statement, prepared in accordance with generally accepted accounting principles by an independent certified public accountant, that includes an audit opinion, balance sheet, income statement, statement of cash flows, and the related notes to the financial statement.

  (9) “Certified financial statement for the most recent fiscal year for which a certified financial statement is available” means:

    (a) For providers who annually receive a certified financial statement within 120 days of the end of their fiscal year, the most recently dated financial statement; and

    (b) For any other providers, assuming that a certified financial statement is obtainable under generally accepted auditing standards, a certified financial statement that is not greater than 120 days old.

  (10) “Chief executive officer” means the individual whose primary responsibility is to oversee all aspects of the operation of the provider.

  (11) “Committee” means Financial Review Committee.

  (12) “Continuing care at home” means furnishing services, either directly or by contractual arrangement, to the public where:

    (a) The services include health services and assistance with the maintenance of a subscriber's dwelling;

    (b) The health services include:

      (i) Medical services,

      (ii) Nursing services,

      (iii) Assisted living or comprehensive care services in an assisted living or comprehensive care facility, or

      (iv) Assistance with the activities of daily living, other than the provision of meals, in a subscriber's dwelling;

    (c) The services are offered to individuals who are:

      (i) 60 years old or older, and

      (ii) Not related to the provider by blood or marriage;

    (d) The services are offered for:

      (i) The life of the subscriber, or

      (ii) A period in excess of 1 year; and

    (e) The services are offered under a written agreement that requires:

      (i) A transfer of assets from the subscriber to the provider,

      (ii) An entrance fee, or

      (iii) Both a transfer of assets and an entrance fee.

  (13) Control.

    (a) “Control” means the power to direct, or cause the direction of, the management and policies of a provider through the ownership of voting securities, by contract, or otherwise.

    (b) “Control” includes a parent or sole corporate member of a corporation directly participating in the initiation or approval of policies directly affecting the operations, including approval of budgets or approval of the chief executive officer of the provider.

  (14) “Department” means the Maryland Department of Aging.

  (15) “Deposit” means a portion of the entrance fee.

  (16) Deposit Agreement.

    (a) “Deposit agreement” means a preliminary agreement between the subscriber and the provider by which the provider reserves for the subscriber the right to contract for continuing care at home in return for payment by the subscriber of a deposit.

    (b) “Deposit agreement” includes any agreement of similar form and use, regardless of title, including priority agreement and reservation agreement.

  (17) Entrance Fee.

    (a) “Entrance fee” means a sum of money or other consideration, other than a surcharge, paid initially or in deferred payments, that:

      (i) Assures a subscriber continuing care at home for a term of more than 1 year or for life; and

      (ii) Is at least equal to the greater of either 12 times the monthly cost of the basic periodic fees charged under an agreement or $5,000.

    (b) “Entrance fee” includes a fee of similar form and application, regardless of title.

  (18) “Escrow agreement” means an agreement between the provider and a financial institution by which deposits and entrance fees are held in Maryland by the financial institution until release is permitted by law or regulation.

  (19) “Facility” means a physical plant and related grounds, other than a subscriber's dwelling, used to provide assisted living or comprehensive care services to continuing care at home subscribers, in accordance with this chapter.

  (20) “Financial difficulty” means the current or impending financial condition of a provider which currently impairs or may impair the ability of the provider to meet existing or future obligations to subscribers or other creditors.

  (21) “Fiscal year” means the fiscal year of the provider.

  (22) “Generally accepted accounting principles” means those accounting principles and practices adopted by the Financial Accounting Standards Board and the American Institute of Certified Public Accountants, which include the principles expressed in the American Institute of Certified Public Accountants' “Audit and Accounting Guide for Health Care Organizations”.

  (23) “Governing body” means an individual or group of individuals with authority to direct, control, and manage the policies and business affairs of the provider, including groups such as boards of directors, boards of trustees, management committees, and executive committees.

  (24) “MDH” means the Maryland Department of Health.

  (25) “MHCC” means the Maryland Health Care Commission.

  (26) “Person” means an individual, firm, association, corporation, company, trust, partnership, limited liability company, public body, or other business or nonprofit entity.

  (27) “Processing fee” means a one-time fee charged by the provider to determine the financial, mental, and physical eligibility of an individual who seeks to enter a continuing care at home agreement.

  (28) “Provider” means a person who is an applicant for, or the holder of, a certificate of registration to provide continuing care at home.

  (29) “Qualified actuary” means a member in good standing of the American Academy of Actuaries.

  (30) “Records” means the information, books, and data maintained for the operation of a provider in accordance with this chapter.

  (31) “Renewal” means the renewal of a certificate of registration required annually to permit the provider to continue to offer continuing care at home to the public.

  (32) “Secretary” means the Secretary of Aging.

  (33) “Subscriber” means an individual for whom continuing care at home is purchased under an agreement.

  (34) Subscriber's Dwelling.

    (a) “Subscriber's dwelling” means a house, apartment, condominium, cooperative, or other place where a subscriber lives and has agreed to live while receiving continuing care at home services.

    (b) “Subscriber's dwelling” does not include facilities licensed by the Maryland Department of Health as an assisted living program or a comprehensive care facility or by the Department as a continuing care facility under COMAR 32.02.01.

  (35) “Surcharge” means a separate and additional charge, other than a second-person entrance fee, imposed simultaneously with the entrance fee, that may be required of some, but not all, subscribers because of a condition or circumstance that applies only to those subscribers.

  (36) Unit.

    (a) “Unit” means a suite, room, cottage, apartment, or any other type of quarters that is located at a facility in which a subscriber is to reside while receiving assisted living or comprehensive care benefits under a continuing care at home agreement.

    (b) “Unit” includes individual beds licensed for assisted living and comprehensive care so that each assisted living bed and comprehensive care bed constitutes a unit.

    (c) “Unit” does not include a subscriber's dwelling.

#### Regulation .02 General Requirements to Offer Continuing Care at Home.

*COMAR 32.02.02.02*

A. A provider may not offer continuing care at home or collect deposits for continuing care at home without having secured the necessary feasibility study approval.

B. A provider may not provide continuing care at home without having secured an initial certificate of registration from the Department.

C. Submissions.

  (1) The submissions described in this section shall be filed with and approved by the Department.

  (2) Statement of Intent. An entity which intends to offer continuing care at home agreements shall file a statement of intent with the Department at least 30 days before submission of the feasibility study.

  (3) Application for Approval of Feasibility Study. A provider shall obtain approval by the Department of a feasibility study before a provider may collect deposits for continuing care at home. Deposits collected for continuing care at home shall be maintained in an escrow account held in Maryland in a federally insured depository under an escrow agreement approved by the Department.

  (4) Application for Preliminary Certificate. A preliminary certificate of registration is required before a provider may offer or enter into continuing care at home agreements.

  (5) Application for Initial Certificate. An initial certificate of registration is required before a provider may provide services under a continuing care at home agreement.

  (6) Application for Renewal of Certificate of Registration. A current certificate of registration or provisional renewal certificate of registration is required to continue to operate as a continuing care at home provider.

D. A provider may not offer or enter into a deposit agreement or an agreement, unless the terms of the agreements have been approved by the Department.

E. Basic Services. A provider shall, at a minimum, provide the following services to all the provider's subscribers as needed:

  (1) Care coordination services that assist subscribers to:

    (a) Determine what services they need and when they need them,

    (b) Access all the services provided or coordinated by the provider,

    (c) Identify other entities that can assist subscribers with their needs, and

    (d) Apply for and access services in addition to the basic services described in this section;

  (2) The number of home inspections required by §F of this regulation, which shall be conducted by an occupational therapist to:

    (a) Assess a subscriber's functioning and safety in the subscriber's dwelling, and

    (b) Recommend any modifications to the dwelling that would help the subscriber overcome or minimize any safety issues or functional limitations;

  (3) Assistance with activities of daily living in the subscriber's dwelling;

  (4) Skilled nursing services in the subscriber's dwelling;

  (5) The routine services of a licensed assisted living facility;

  (6) The routine services of a licensed comprehensive care facility; and

  (7) The amount of assistance with the maintenance of a subscriber's dwelling required by §H of this regulation.

F. Home Inspections by Occupational Therapist. The minimum number of home inspections by an occupational therapist that a provider shall pay for is at least:

  (1) An initial inspection upon entering the agreement and an additional inspection every other year after that; or

  (2) Five inspections during the term of the agreement, which shall be provided when requested by the subscriber.

G. Required Amounts of Assistance with Activities of Daily Living and Nursing Services.

  (1) A provider may include in its agreement a lifetime maximum dollar amount it will pay for the services required by §E(3)—(6) of this regulation. If a maximum dollar amount is used, it shall be at least $150,000. Provision of either assistance with activities of daily living or nursing services, whether delivered in the subscriber's dwelling, an assisted living facility, or a comprehensive care facility, may be counted toward the maximum.

  (2) Assistance with activities of daily living services shall be provided whenever a subscriber needs assistance with two or more activities of daily living. The threshold for when assistance with activities of daily living services will be provided may be set lower as long as the threshold standard is applied uniformly to all subscribers using consistent assessment practices.

  (3) A provider may include in an agreement a daily, weekly, or monthly benefit amount it will pay for particular services required by §E(3)—(6) of this regulation. If it does include amounts in an agreement, the amount for assistance with activities of daily living services shall be at least 50 percent of the amount specified for services of a licensed comprehensive care facility.

  (4) A provider may exclude services covered by Medicare from the services for which it otherwise would be required to pay. If a provider includes an exclusion in its agreement, services covered by Medicare may not be counted towards the lifetime maximum dollar amount permitted by §G(1) of this regulation.

H. Assistance with Dwelling Maintenance.

  (1) In order to provide assistance with the maintenance of a subscriber's dwelling, a provider shall, at a minimum, provide a referral service that refers subscribers to vendors and suppliers who will contract with a subscriber to perform repair and maintenance services.

  (2) The provider shall:

    (a) Check the liability insurance coverage and any applicable licenses; and

    (b) Review the referral list for any changes in insurance coverage, licenses, or quality of service every 2 years.

  (3) A provider may also directly provide repair and maintenance services to subscribers through its employees or contractual arrangements with third parties.

I. Payment for Basic Services.

  (1) The minimum basic services required by §E of this regulation shall be paid for by the following methods:

    (a) An entrance fee paid in advance of the receipt of the basic services;

    (b) Regular periodic charges that guarantee basic services when needed;

    (c) For some or all of the basic services required by §E(2)—(7) of this regulation, a copayment from the subscriber of 30 percent or less of the actual cost; or

    (d) A combination of the arrangements described in §I(1)(a)—(c).

  (2) A subscriber may not be charged for the minimum amount of basic services required by §§E—H of this regulation on a fee-for-service basis.

  (3) Services in excess of the minimum amount of basic services required by §§E—H of this regulation may be charged for on a fee-for-service basis.

  (4) A provider may charge on a fee-for-service basis for services other than those required by §E of this regulation.

J. A provider may not disseminate advertising or circulars which are deceptive, misleading, or likely to mislead.

K. Special Conditions.

  (1) A provider applying for a certificate of registration whose personal, professional, or financial history causes the Secretary to question the provider's financial or administrative ability to provide continuing care at home in compliance with this chapter, shall submit to the Department evidence demonstrating financial or administrative soundness, or both, as the Secretary considers appropriate. This information may only be sought in special circumstances and may not be required as a matter of course.

  (2) The Secretary shall:

    (a) Approve the application unconditionally;

    (b) Require the provider to use the services of a management firm; or

    (c) Deny the application.

  (3) A management firm required by §K(2)(b) of this regulation shall be selected by the provider subject to the approval of the Department. Approval of a management firm that currently does business in Maryland, has projects in good standing under the Act, and which has not had a fiduciary or consultant relationship with the Department may not be denied without cause. The management firm shall assume full operational and financial responsibilities. The Secretary may not require utilization of a management firm for a period that exceeds 24 months.

L. A party aggrieved by a decision of the Secretary under this regulation has the right to appeal under Regulation .31 of this chapter.

M. A provider who is denied approval of submissions required by §C(3) or (4) of this regulation may reapply 1 year after the date of denial.

#### Regulation .03 Preliminary Certificate of Registration.

*COMAR 32.02.02.03*

A. Process to Obtain a Preliminary Certificate of Registration. A person shall file a:

  (1) Statement of intent under Regulation .04 of this chapter;

  (2) A feasibility study under Regulation .05 of this chapter; and

  (3) An application under Regulation .06 of this chapter.

B. Forms and Fees for Feasibility Study and Application.

  (1) A feasibility study and an application for a preliminary certificate of registration shall be submitted with forms provided by the Department.

  (2) A fee of $20,000 shall accompany a feasibility study.

  (3) The Department may charge an additional fee, not to exceed the original fee, if resubmission of a feasibility study to the Department is required due to:

    (a) Significant changes in the assumptions upon which the feasibility study was based;

    (b) Correction of significant errors in the feasibility study; or

    (c) A significant omission in the original feasibility study submission.

#### Regulation .04 Statement of Intent to Apply for a Preliminary Certificate.

*COMAR 32.02.02.04*

A. Statement of Intent. An entity that intends to offer continuing care at home agreements shall file a statement of intent with the Department at least 30 days before submission of a feasibility study. If a feasibility study is not filed by the provider within 60 days after the statement of intent is filed, a new statement of intent shall be filed with the Department at least 30 days before submission of a feasibility study.

B. Contents. A statement of intent shall contain, at a minimum, the following information:

  (1) The name of the provider;

  (2) Whether entrance fees will be refundable or nonrefundable;

  (3) The types of agreements proposed to generate the required contract reserves;

  (4) Whether the provider is proposed to be for-profit or nonprofit;

  (5) The name of the management company, if any, that will manage the day-to-day operations;

  (6) If applicable, the name of the:

    (a) Person proposing to create or finance the provider,

    (b) Marketing consultant,

    (c) Provider's attorney, and

    (d) Preparer of the feasibility study, along with the preparer's qualifications;

  (7) A statement indicating whether any proposed comprehensive care beds will need a new certificate of need from MHCC;

  (8) Whether the provider plans to build a facility; and

  (9) Any further information the Department requires.

#### Regulation .05 Feasibility Study.

*COMAR 32.02.02.05*

A. The feasibility study shall be prepared in a form satisfactory to the Department, by an authority recognized by the Department, and shall include at least the following information:

  (1) A statement of the purpose for the proposed continuing care at home project;

  (2) A summary of the proposed continuing care at home project, which shall include the following information:

    (a) A description of the proposed geographic area in which the continuing care at home project will operate;

    (b) A statement regarding any affiliation of the provider with a religious, charitable, or other nonprofit organization, and the extent to which the organization will be responsible for the financial and contractual obligations of the provider;

    (c) The number of subscribers projected to be enrolled in 10 years;

    (d) The number of proposed assisted living units or comprehensive care units the provider plans to use; and

    (e) A description of any community spaces to be provided, such as doctor's offices, craft centers, meeting rooms, or exercise centers;

  (3) A summary of the organizational structure of the proposed provider and development team, which shall include the following information:

    (a) The ownership of the provider, including whether it is for-profit;

    (b) A description of the qualifications of the proposed manager or management company if the project is, or will be, managed on a day-to-day basis by a person other than an individual directly employed by the provider, including the business experience the manager or management company has operating or managing similar projects; and

    (c) A description of the qualifications of any other person who is significantly involved in the development of the continuing care at home project;

  (4) A summary of plans to provide for assisted living and comprehensive care units, which shall include the following:

    (a) A schedule showing the number of assisted living and comprehensive care units the provider anticipates needing as the subscriber population grows and ages;

    (b) A statement describing whether the provider plans to:

      (i) Operate its own assisted living or comprehensive care facilities,

      (ii) Contract with other facilities to provide assisted living or comprehensive care services to subscribers, or

      (iii) Create some other arrangement to provide facility-based assisted living and comprehensive care services to its subscribers;

    (c) If the provider plans to be licensed for and operate its own assisted living and nursing home facilities, a general description of the anticipated square footage of each type of unit; and

    (d) If the provider plans to be licensed for and operate its own assisted living and nursing home facilities, the number of anticipated assisted living and comprehensive care units categorized as:

      (i) Private,

      (ii) Semiprivate, and

      (iii) Suites;

  (5) A summary of the services that will be included in the periodic service fee;

  (6) A summary of the ancillary services that will not be included in the periodic service fee;

  (7) A statement describing any plans the provider has to require a subscriber to have long-term care insurance or supplemental health insurance coverage;

  (8) A statement describing any plans the provider has to become Medicare or Medicaid certified;

  (9) A statement describing any plans the provider has to offer priority access to assisted living or comprehensive care facilities;

  (10) A study that demonstrates a market exists for the proposed project, which study shall include:

    (a) A description of the market area as defined by the provider;

    (b) A table of population information including age, sex, number, income distribution, and trends of the total population and individuals 60 years old and older within the market area;

    (c) A calculation of the potential impact on the proposed project of existing continuing care at home providers, continuing care at home projects for which letters of intent have been filed with the Department, and other ventures that offer similar services in the market area, which calculation shall include the following information for each provider, project, or venture in the market:

      (i) The number of continuing care subscribers,

      (ii) The number of assisted living units and comprehensive care units,

      (iii) If services are not yet being provided, the proposed start date,

      (iv) The area marketed to,

      (v) The amount and type of entrance fees and monthly service fees, and

      (vi) The services offered;

    (d) A calculation of the potential impact on the proposed project of existing continuing care retirement communities, continuing care retirement communities for which letters of intent have been filed with the Department, and other ventures that offer similar services in the market area, which calculation shall include the following information for each community, provider, project, or venture in the market:

      (i) The number of independent living units, assisted living units, and comprehensive care units,

      (ii) The number of continuing care subscribers,

      (iii) If services are not yet being provided, the proposed start date, and

      (iv) The area marketed to;

    (e) A calculation of the market penetration rate for the proposed market;

    (f) A table of home values in the market area;

    (g) A description of the minimum age, income, and net worth eligibility requirements for the anticipated subscribers of the proposed project;

    (h) A description of new entrant assumptions by age, sex, and couple ratio;

    (i) A description of the results of testing the potential demand and acceptance of the proposed project's services and concept characteristics;

    (j) If the area in which the project is to be marketed has limited continuing care at home experience and a demographically similar area exists that has had experience with continuing care at home, a comparison that shows the:

      (i) Similarities and dissimilarities of the two markets, and

      (ii) Experiences of one or more continuing care at home providers in the comparable market, including their initial utilization experience and their penetration rates into the eligible population; and

    (k) A statement describing the estimated presales period, including when the provider projects it will have executed agreements and collected at least 10 percent of the entrance fee for at least the greater of 10 percent of the number of subscribers needed for the provider to reach its break-even point or 30 subscribers;

  (11) A plan demonstrating the financial feasibility of the proposed project including the following:

    (a) The anticipated costs of the project, including financing expenses, marketing costs, legal and administrative costs, fees and permits, and other costs;

    (b) The anticipated sources and uses of funds to finance the project, including documentation of the financial resources of the provider;

    (c) A description of the proposed financing, including anticipated terms and costs of financing the project;

    (d) Projected financial statements that are based on the information required in §(A)(12)(b) of this regulation and prepared in accordance with:

      (i) §B of this regulation,

      (ii) Generally accepted accounting principles, and

      (iii) Regulation .14 of this chapter;

    (e) A schedule of anticipated fees for a 10-year period, including any proposed escalator or other automatic adjustment provisions;

    (f) A schedule of the anticipated number of new agreements to be signed each month up to the month in which the break-even point is reached;

    (g) The proposed start date for providing services under the agreements;

    (h) A statement indicating compliance with the requirements of Regulation .14 of this chapter; and

    (i) A calculation that demonstrates the minimum number of subscribers that need to be enrolled in order for the provider to reach its break-even point;

  (12) An actuarial study, prepared or reviewed by a qualified actuary, which includes:

    (a) An actuarial balance sheet that demonstrates that, for a typical cohort of new subscribers, the sum of the entrance fees paid plus the actuarial present value of the periodic fees expected at the beginning of the agreement exceeds the actuarial present value of the costs of performing all obligations assumed by the provider, with appropriate provision for surplus;

    (b) Supporting detailed documentation for the actuarial balance sheet required in §A(12)(a) of this regulation, including a:

      (i) Projection of future population flows and service needs covered by the provider's agreements for the first 20 years, using appropriate mortality, morbidity, withdrawal, and other demographic assumptions, and

      (ii) Description of the actuarial data, assumptions, inflation factors, and methods used to create the projection;

    (c) Cash flow projection for a 20-year period, which project positive cash balances; and

    (d) The opinion of the actuary that the data and assumptions used are appropriate, the methods employed are consistent with sound actuarial principles and practices, and provision has been made for all actuarial liabilities and related statement items;

  (13) A copy of the proposed deposit agreement between the provider and prospective subscribers governing the disposition of the escrowed funds and the interest earned on them;

  (14) A copy of the proposed escrow agreement between the provider and the depository;

  (15) Proposed payment arrangements under the agreement for:

    (a) The assistance with the maintenance of the subscriber's dwelling; and

    (b) The health-related benefits;

  (16) A copy of a certificate of need issued by MHCC for any proposed comprehensive care beds the provider plans to operate for its subscribers;

  (17) The form and substance of any advertising campaign or proposed advertisement for the proposed project that is available at the time of filing; and

  (18) Any further information that the Department requires.

B. In §A(11)(d) of this regulation, the provider shall submit projected financial statements for a minimum of the first 10 years of operation that include:

  (1) Balance sheets;

  (2) Income statements, including separate supplemental income statements for each group of subscribers in each of the following environments:

    (a) Subscriber's dwelling,

    (b) Assisted living, and

    (c) Comprehensive care;

  (3) Statements of cash flow; and

  (4) The key assumptions used in preparing the projected financial statements, including, when applicable, assumptions related to utilization, turnover, inflation, debt service, personnel staffing and related salaries, interest rates, depreciation and amortization, amortization of entrance fees, raw food, insurance, real estate taxes, and reserve assumptions.

#### Regulation .06 Application for a Preliminary Certificate of Registration.

*COMAR 32.02.02.06*

A. Application. An application for a preliminary certificate of registration shall include the information described in this regulation.

B. The names and addresses of the following shall be included:

  (1) The provider;

  (2) Any affiliate, parent, or subsidiary person or business entity; and

  (3) The chief executive officer of the provider, and each affiliate, parent, or subsidiary person or business entity.

C. The application shall describe the organizational structure and management of the provider, including:

  (1) If the provider is a corporation or limited liability company, the:

    (a) Name of the corporation or limited liability company, and

    (b) State in which the corporation is incorporated or the limited liability company is formed;

  (2) If the provider is a partnership, the:

    (a) Names of the general partners,

    (b) State governing the formation of the partnership, and

    (c) Name of the primary individual responsible for managing the partnership;

  (3) If the provider is an unincorporated association, the:

    (a) Names of the members,

    (b) State governing the association's activities, and

    (c) Name of the primary individual responsible for managing the association;

  (4) If the provider is a partnership having a corporation or limited liability company as one or more of its general partners, the:

    (a) Names of each corporation or limited liability company,

    (b) State in which each corporation is incorporated or the limited liability company is formed, and

    (c) Name of the chief executive officer of each;

  (5) If the provider is a trust, the:

    (a) Name of each trustee,

    (b) Names of the owners of beneficial interests in the trust,

    (c) State whose laws govern the trust, and

    (d) Name of the primary individual responsible for overseeing the trust's activities;

  (6) The names and occupations of:

    (a) The provider's officers, directors, trustees, managing or general partners, and non-stock corporation members, and

    (b) An individual having a 10 percent or greater equity or beneficial interest in the provider;

  (7) A description of each financial interest in, or occupation with, the provider of each individual identified under §C(6) of this regulation.

D. Contracts with Related Entities.

  (1) If it is anticipated that a business entity will provide to the provider goods, premises, or services with a value of $10,000 or more within any fiscal year, and if a person identified in §C(6) of this regulation has a financial interest of 10 percent or more in the business entity, the application shall include:

    (a) The name and address of the business entities;

    (b) A description of the goods, premises, or services; and

    (c) The anticipated yearly costs the provider will incur for the goods, premises, or services.

  (2) Section D(1) of this regulation does not require the disclosure of salary, age, or benefit information of employees of the provider.

E. The application shall include a copy of all current documentation concerning the legal organization of the provider, including the corporate charter, bylaws, partnership agreement, articles of association, membership agreement, trust agreement, or similar instruments or agreements.

F. The application shall include certified financial statements of the provider for the 3 most recent fiscal years for which certified financial statements are obtainable under generally accepted accounting principles. If the provider's fiscal year ended more than 90 days before the date of the filing, then the application shall also include an income statement, which does not need to be certified, that covers a period that begins on the date the fiscal year ended and ends on a date that is within 90 days of the date of the filing.

G. The application shall include a statement of any current or prior affiliation with a religious, charitable, or other nonprofit organization, and the extent, if any, to which the affiliate organization will be responsible for the financial and contractual obligations of the provider.

H. The application shall include a copy of any proposed:

  (1) Agreements to be entered into between the provider and subscribers for continuing care at home; and

  (2) Contractual arrangement between the provider and any assisted living or comprehensive care providers.

I. A table of the most current fee structure, including escalator or other automatic adjustment provisions, shall accompany the application.

J. A statement describing the current or proposed use of any insurance program or publicly funded benefit program in the financing of care shall accompany the application.

K. A description of the arrangements that have been or will be made to obtain the personnel or outside services necessary to provide continuing care at home shall accompany the application.

L. The form and substance of any advertising campaign, advertisement, or other promotional material that has not been previously approved by the Department shall be submitted with the application.

M. Any other reasonable and pertinent information that the Department requests in writing shall be submitted with the application.

#### Regulation .07 Department Action on Feasibility Study and Application for a Preliminary Certificate of Registration.

*COMAR 32.02.02.07*

A. The Department shall approve a feasibility study when it determines that:

  (1) A certificate of need has been issued by MHCC for any new comprehensive care beds proposed by the provider for the continuing care at home project;

  (2) The construction of any new assisted living units proposed by the provider for the continuing care at home project is not inconsistent with the State Health Plan;

  (3) A reasonable financial plan has been submitted for developing and operating the proposed project, which:

    (a) Includes in the projected financial statements for all obligations and liabilities to be undertaken by the provider pursuant to the terms of the proposed continuing care at home agreement; and

    (b) Demonstrates that the project is financially feasible;

  (4) A market for the continuing care at home project appears to exist, based on reliable data, which:

    (a) Is specific to the area in which the provider intends to operate;

    (b) Takes into account competing health-related providers;

    (c) Relates the existence of a market to the age, health, sex, marital status, number, population trends, net worth, home values, and income of the potential subscribers; and

    (d) Demonstrates that the rate of penetration in the proposed market area is acceptable;

  (5) The actuarial study as required in Regulation .05 of this chapter has been submitted and includes:

    (a) An actuarial balance sheet that demonstrates that, for a typical cohort of new subscribers, the sum of the entrance fees paid plus the actuarial present value, at the beginning of the agreement, of periodic fees exceeds the actuarial present value of the costs of performing all obligations assumed by the provider, with appropriate provision for surplus;

    (b) Cash flow statements for a 20-year period, which project positive cash balances;

    (c) Supporting detailed documentation for the actuarial balance sheet which includes:

      (i) A projection of future population flows for a 20-year period, which uses appropriate morbidity, mortality, withdrawal, and other demographic assumptions,

      (ii) A projection of future service needs covered by the provider's agreements, for a 20-year period, which uses appropriate morbidity, mortality, withdrawal, and other demographic assumptions, and

      (iii) Descriptions of the actuarial data, assumptions, and methods; and

    (d) An opinion of a qualified actuary, which states that:

      (i) The data and assumptions used are appropriate,

      (ii) The methods employed are consistent with sound actuarial principles and practices, and

      (iii) Provision has been made for all actuarial liabilities and related statement items;

  (6) The projection of future population flows and health care bed needs, for the first 20 years, uses appropriate mortality, morbidity, withdrawal, and other demographic assumptions as required in Regulation .05 of this chapter;

  (7) The feasibility study was prepared by an authority recognized by the Department;

  (8) The approved escrow agreement and deposit agreement state that all deposits and entrance fees shall be held in escrow in Maryland in a financial institution until:

    (a) The issuance of an initial certificate of registration; and

    (b) The issuance of appropriate licenses or certificates by MDH and MHCC; and

  (9) A copy of the escrow agreement, executed by the provider and the financial institution, is on file with the Department.

B. The Department shall issue a preliminary certificate of registration when it determines that the following conditions have been met:

  (1) The feasibility study has been approved by the Department;

  (2) The agreement between the provider and the subscriber meets the requirements of Human Services Article, §§10-444 and 10-445, Annotated Code of Maryland, and Regulations .21—.23 of this chapter;

  (3) The required financial and organizational materials have been submitted to the Department; and

  (4) The Department has determined that the form and substance of all advertising and other promotional materials filed are not deceptive, misleading, or likely to mislead.

C. Until an initial certificate of registration has been issued, the provider shall inform the Department of any changes or additions to the information provided in the feasibility study and in the application for a preliminary certificate of registration.

#### Regulation .08 Advertising Before an Initial Certificate of Registration Has Been Issued.

*COMAR 32.02.02.08*

If a provider that has submitted a feasibility study desires to advertise a continuing care at home project before an initial certificate of registration has been issued, the provider shall submit that advertising so it is received by the Department at least 3 working days before the advertising is to be aired, distributed, or otherwise used. The envelope or package in which the submission is delivered shall indicate in prominent type that the contents are proposed advertising materials for a project that does not have an initial certificate of registration.

#### Regulation .09 Application for an Initial Certificate of Registration.

*COMAR 32.02.02.09*

A. A provider shall file an application for an initial certificate of registration on a form provided by the Department.

B. The application shall include verification that:

  (1) All licenses and certificates required as of the date of the application from MDH and MHCC have been issued;

  (2) Agreements have been executed for at least the greater of either:

    (a) 10 percent of the number of subscribers needed for the provider to reach its break-even point, or

    (b) 30 subscribers;

  (3) At least 10 percent of the total entrance fee has been collected for each agreement counted towards the requirement of §B(2) of this regulation;

  (4) The provider has received a written commitment for any planned long-term financing; and

  (5) Arrangements have been made to obtain the personnel and services necessary to provide continuing care at home.

#### Regulation .10 Action of Department on Application for an Initial Certificate of Registration.

*COMAR 32.02.02.10*

A. The Department shall issue an initial certificate of registration when it determines that all of the following conditions have been met:

  (1) The provider has been issued a preliminary certificate of registration;

  (2) The provider has received all licenses and certifications required as of that date from MDH and MHCC;

  (3) The provider has submitted documentation which demonstrates to the satisfaction of the Department that:

    (a) Agreements have been executed for at least the greater of either:

      (i) 10 percent of the number of subscribers needed for the provider to reach its break-even point, or

      (ii) 30 subscribers; and

    (b) At least 10 percent of the total entrance fee has been paid as a deposit for each of the executed agreements;

  (4) The provider has submitted documentation that demonstrates to the satisfaction of the Department that there is a commitment for any planned long-term financing;

  (5) The provider has submitted documentation that demonstrates to the satisfaction of the Department that arrangements have been made for care coordination services consistent with Regulation .02E(1) of this chapter;

  (6) The provider has submitted proposed agreements that will be entered into with respect to future health care services consistent with Regulation .02E(3—(6) of this chapter; and

  (7) The form and substance of all advertising and other promotional materials filed are not deceptive, misleading, or likely to mislead.

B. Upon receipt of an initial certificate of registration, the provider may withdraw escrowed deposits and use them to fulfill its obligations to the subscribers, as long as all required reserves are in place.

C. If the conditions in §A of this regulation are not met, the Department shall issue a denial of an initial certificate of registration, in writing, which includes the reasons for the denial. The provider may resubmit an amended application within the time limits set forth in §D of this regulation.

D. If an initial certificate of registration is not issued within 24 months of the issuance of the preliminary certificate of registration, or a longer time allowed by the Department for good cause shown, as defined in §E of this regulation, the Department shall require the provider to refund all deposits and to cease in its attempts to offer continuing care at home under that application. A further intent to provide continuing care at home shall require a new application, including a feasibility study.

E. The Department may not deny a request for an extension of time if the provider demonstrates reasonable progress toward acquiring an initial certificate of registration.

F. If the Department issues an initial certificate of registration to a provider, the provider need not re-apply to the Department to certify additional geographic territories within the State of Maryland and shall instead notify the Department in writing in advance that the provider seeks to service additional geographic territories in the State of Maryland.

#### Regulation .11 Application for Renewal Certificate of Registration.

*COMAR 32.02.02.11*

A. The provider shall file an application for a renewal certificate of registration within 120 days of the end of the provider's fiscal year on a form provided by the Department.

B. A renewal certificate of registration shall be issued for 1 year, which is in effect from 6 months after the end of the provider's most recent fiscal year to 6 months after the close of the provider's current fiscal year.

C. The application for a renewal certificate of registration shall include the following information and attachments:

  (1) Any changes or additions to the information submitted on the most recent application;

  (2) An original certified financial statement for the preceding fiscal year prepared in accordance with generally accepted accounting principles, which include the principles expressed in the American Institute of Certified Public Accounts' “Audit and Accounting Guide for Health Care Organizations”;

  (3) All exhibits or attachments to the certified financial statements, including:

    (a) A balance sheet,

    (b) An income statement,

    (c) A statement of cash flows,

    (d) The related notes to the financial statements, and

    (e) The opinion of an independent certified public accountant;

  (4) An operating budget for the current fiscal year prepared in accordance with generally accepted accounting principles;

  (5) A projection of the life expectancy and the number of subscribers who will require care in an assisted living or nursing home facility;

  (6) A projected operating budget for the next succeeding fiscal year prepared in accordance with generally accepted accounting principles;

  (7) An actuarial opinion that meets the requirements of Regulation .14F and G of this chapter;

  (8) A copy of any new continuing care at home agreement proposed for implementation in the succeeding year, and a demonstration of how the proposed agreement differs from current agreements in use;

  (9) A description of the arrangements that have been made to obtain the personnel and services necessary to continue providing continuing care at home;

  (10) A copy of each current license and certificate, if any, required to be issued by MDH;

  (11) A copy of the provider's most recent certificate of need, if any, required to be issued by MHCC;

  (12) The form and substance of any advertising campaign or proposed advertisement and other promotional materials not previously filed with the Department;

  (13) A renewal fee equal to the greater of $5,000 or $18 per subscriber enrolled at the end of the provider's previous fiscal year;

  (14) A cash flow projection for the current fiscal year and the next 2 fiscal years prepared in accordance with generally accepted accounting principles;

  (15) A statement that provides the dates of the meetings held the previous year to comply with Regulation .13 of this chapter;

  (16) A copy of the disclosure statement prepared in accordance with Regulation .15 of this chapter; and

  (17) A statement that indicates compliance with the operating reserve requirement in Regulation .14 of this chapter.

D. Actuarial Study.

  (1) Every 3 years after beginning continuing care at home operations, a provider shall submit an actuarial study, including an actuarial balance sheet, prepared or reviewed by a qualified actuary, which:

    (a) Demonstrates that the resources available for current and replacement subscribers, including the actuarial present value of periodic fees expected to be paid in the future by present subscribers, are equal to the actuarial present value of the expected costs of performing all remaining obligations to the subscribers under the subscribers' agreements, with appropriate provision for surplus;

    (b) Includes cash flow statements for 20 years which demonstrate that cash balances are projected to remain positive;

    (c) Includes a statement of the opinion of a qualified actuary as to whether:

      (i) The data and assumptions used are appropriate,

      (ii) The methods employed are consistent with sound actuarial principles and practices, and

      (iii) Provision has been made for all actuarial liabilities and related statement items; and

    (d) Includes supporting detailed documentation for the actuarial balance sheet including a projection of future population flows and service needs covered by the provider's agreements for 20 years, which projection shall use appropriate inflation factors, mortality, morbidity, withdrawal, and other demographic assumptions.

  (2) The Department may request the information required in §D(1) of this regulation more frequently to assist in the determination of possible financial difficulty as provided in Regulation .20 of this chapter.

E. If the materials required in §C of this regulation are not received in the Department within 120 days after the end of the provider's fiscal year, the Department shall charge a late fee equal to the greater of $1,000 or $10 per subscriber. The late fee shall be in addition to the renewal fee per subscriber, unless a written request for an extension is submitted to and approved by the Department within the 120-day period.

F. The Department may issue a provisional renewal certificate of registration for a period not to exceed 6 months, if a provider is found to be in possible financial difficulty as defined in Regulation .01 of this chapter, or subject to Regulation .20 of this chapter. The provisional certificate of registration may be renewed for additional periods, each period not to exceed 6 months, at the discretion of the Department.

G. Failure to file the annual renewal application or obtain an extension within 120 days after the end of a fiscal year is a violation of the Act and this chapter.

#### Regulation .12 Action of the Department on Application for Renewal Certificate of Registration.

*COMAR 32.02.02.12*

A. The Department shall approve an application for a renewal certificate of registration when it determines that:

  (1) The required documents have been filed;

  (2) The proposed and existing agreements meet the requirements of the Act and this chapter;

  (3) The provider has not been found to be in financial difficulty;

  (4) The provider has the necessary resources for providing continuing care at home;

  (5) The provider has received all required licenses and certificates from MDH and MHCC;

  (6) The form and substance of all advertising and other promotional materials filed are not deceptive, misleading, or likely to mislead;

  (7) If required under Regulation .11D of this chapter, an actuarial study, prepared or reviewed by a qualified actuary, has been submitted which:

    (a) Includes an actuarial balance sheet;

    (b) Demonstrates that the resources available for current and replacement subscribers, including the actuarial present value of periodic fees expected to be paid in the future by present subscribers, are equal to the actuarial present value of the expected costs of performing all remaining obligations to the subscribers under the subscribers' agreements, with appropriate provision for surplus;

    (c) Projects positive cash balances for a 20-year period;

    (d) Includes a statement of the opinion of a qualified actuary as to whether:

      (i) The data and assumptions used are appropriate and reasonable,

      (ii) The methods employed are consistent with sound actuarial principles and practices, and

      (iii) Provision has been made for all actuarial liabilities and related statement items;

    (e) Includes supporting detailed documentation for the actuarial balance sheet including a projection of future population flows and service needs covered by the provider's agreements, which projection shall use appropriate inflation factors, mortality, morbidity, withdrawal, and other demographic assumptions; and

    (f) Includes a cash flow projection for the next 20 years;

  (8) The disclosure statement submitted complies with Regulation .15 of this chapter;

  (9) The operating reserves comply with the requirements of Regulation .14 of this chapter; and

  (10) All renewal fees and any late fees have been paid.

B. Upon review of a provider's application for a renewal certificate of registration, the Department may make a finding of possible financial difficulty. The Department shall refer the application of a provider found to be in possible financial difficulty to the Financial Review Committee. Applications that are referred to the Committee are subject to Regulations .19 and .20 of this chapter.

C. If the conditions in §A of this regulation and, if applicable, Regulation .20 of this chapter are not met, the Department shall issue in writing a denial of an application for a renewal certificate of registration. The Department shall include the reasons for denying the application in the written denial.

#### Regulation .13 Required Information Regarding Governance.

*COMAR 32.02.02.13*

A. In General.

  (1) At least annually, each provider shall conduct a meeting, open to all of the provider's subscribers, at which an authorized officer of the provider shall present a summary of:

    (a) The provider's operations;

    (b) Significant changes from the previous year's operations; and

    (c) The provider's goals and objectives for the next year.

  (2) The governing body of the provider shall make provisions to receive and answer questions from subscribers at the meeting.

B. Committee to Meet with Subscribers.

  (1) Each governing body of a provider that does not have at least one subscriber as a member or as a regular attendee at its meetings with a right to address the governing body shall appoint a select committee of its members to meet at least twice annually with the subscriber association to address concerns of the subscribers and to ensure that the opinions of subscribers are relayed to the governing body. If the provider's subscribers do not have an association, the committee shall meet with a reasonable number of representatives, not required to exceed 15 elected by the subscribers.

  (2) In the absence of a subscriber association, the provider shall:

    (a) Mail a notice to its subscribers stating that subscribers who want to serve as a representative for all the subscribers in meetings with the governing body should submit their names to the provider so they can stand for election; and

    (b) Arrange for an election conducted by mail to elect up to 15 of those subscribers who submit their names.

#### Regulation .14 Reserve Requirements.

*COMAR 32.02.02.14*

A. Definitions.

  (1) In this regulation, the following terms have the meanings indicated.

  (2) Terms Defined.

    (a) “Binding agreement” means an unconditional, irrevocable letter of credit or line of credit agreement entered into by a provider and a financial institution.

    (b) “Debt service fund” means one or more special loan funds, established under requirements imposed by a financial institution or under applicable financing documents, into which the provider is required to deposit moneys during the provider's fiscal year to pay the current portion of the principal due and the interest accruing in that year on the provider's debt.

    (c) “Debt service reserve fund” means moneys required by a financial institution or under applicable financing documents to be deposited in a special loan fund, which are to be used to pay principal and interest payments due on the provider's debt if the provider is unable to pay when due the principal and interest from operating income or other sources.

    (d) “Market value” means readily determinable fair value.

    (e) Net Operating Expenses.

      (i) “Net operating expenses” means a provider's total operating expenses related to furnishing continuing care at home, less depreciation, amortization, unusual and infrequent expenses, and changes in the obligation to provide future services.

      (ii) “Net operating expenses” does not include interest expense if the provider has funded a debt service fund or other interest reserve under requirements imposed by a financial institution or under applicable financing documents, to the extent and in the amount the fund or reserve includes amounts to cover interest for the year in question.

    (f) “Other interest reserve” means one or more special loan funds other than debt service funds or debt service reserve funds:

      (i) Established under requirements imposed by a financial institution or under applicable financing documents; and

      (ii) Into which the provider is required to deposit moneys during the provider's fiscal year to pay interest accruing in that year on the provider's debt.

B. Operating Reserve Requirement.

  (1) Except as otherwise provided in this regulation, a provider shall set aside operating reserves equal to 15 percent of the provider's net continuing care at home operating expenses for the most recent fiscal year for which a certified financial statement is available.

  (2) A provider shall compute the operating reserves as of the end of its most recent fiscal year and shall indicate compliance by setting forth the amount actually set aside in a letter to the Department from the provider's certified public accountant or by disclosing the amount in the provider's most recent certified financial statement. The letter or certified financial statements shall be submitted with the provider's application for a renewal certificate.

  (3) A provider may apply toward the reserve required by this regulation any reserves, other than debt service reserve funds, maintained under applicable financing document requirements if the reserves are available to the provider to meet operating expenses.

  (4) For the purpose of calculating the provider's operating reserves, investments held to the credit of the reserves shall be calculated at their market value as of the end of the provider's most recent fiscal year for which a certified financial statement is available.

C. Capital Reserves. In addition to the operating reserve required under this chapter, a provider shall have a capital reserve of unencumbered, surplus assets of at least $500,000 before beginning operations and shall maintain an equal amount in reserve in order to maintain itself in good standing.

D. Contract Reserves.

  (1) Calculation. Annually a provider shall calculate a contract reserve amount to cover all its continuing care at home agreements. This calculation:

    (a) Shall place a sound value on the provider's liabilities under its continuing care at home agreements;

    (b) In the aggregate, may not be less than the pro rata gross unearned periodic and entrance fees paid pursuant to the subscribers' agreements;

    (c) May not use an interest rate greater than the maximum allowable interest rate established annually by the National Association of Insurance Commissioners for calculating reserves for whole life insurance policies, with maturities 20 or more years after issue;

    (d) May not assume an inflation rate of benefits:

      (i) Greater than the interest rate used, or

      (ii) Less than the interest rate used minus two percentage points;

    (e) Shall use the 1994 Annuitant Table published by the American Society of Actuaries and adjust it accordingly for expected mortality improvements; and

    (f) Shall:

      (i) Subtract the future administrative and claim expenses from the future periodic fees for each year for each subscriber,

      (ii) Discount the result back to the current year, and

      (iii) Sum the results for each subscriber.

  (2) Funding. A provider shall fund and maintain a reserve account that equals or exceeds:

    (a) 50 percent of the calculated contract reserve amount by the end of its first year of operation;

    (b) 60 percent of the calculated contract reserve amount by the end of its second year of operation;

    (c) 70 percent of the calculated contract reserve amount by the end of its third year of operation;

    (d) 80 percent of the calculated contract reserve amount by the end of its fourth year of operation;

    (e) 90 percent of the calculated contract reserve amount by the end of its fifth year of operation;

    (f) 100 percent of the calculated contract reserve amount by the end of its sixth year of operation; and

    (g) 100 percent of the calculated contract reserve amount for every year after the provider's sixth year of operation.

  (3) Funds in the capital reserve may be counted towards satisfying the contract reserve requirements. Funds in the operating reserve may not be counted towards the contract reserve requirements.

E. Aggregate Reserves. The aggregate reserves for all continuing care at home may not be less than the aggregate reserves that a qualified actuary determines to be necessary under §G of this regulation.

F. Actuarial Opinions. Each provider shall submit annually the opinion of a qualified actuary as to whether the reserves and related actuarial items held in support of the providers' agreements are:

  (1) Computed appropriately;

  (2) Based on reasonable assumptions that satisfy contractual provisions;

  (3) Consistent with prior reported amounts; and

  (4) In compliance with applicable laws of the State.

G. Adequacy of Aggregate Reserves.

  (1) Each provider shall include with the opinion required by §F of this regulation an additional opinion of the same qualified actuary, stating whether the reserves and related actuarial items that are held in support of the agreements by the provider appear on their face to be adequate to meet its obligations under its agreements. The obligations of a provider under its agreements include benefits to be provided and associated expenses that may reasonably be expected.

  (2) A memorandum acceptable to the Secretary shall be prepared to support each opinion required under this section, and submitted to the Secretary annually.

  (3) The memorandum shall also include a statement from the actuary:

    (a) That all assumptions contained in the reserve calculations are reasonable and are calculated net of all, if any, reinsurance agreements that limit the provider's exposure to risk;

    (b) That the assumptions contained in the reserve calculation are supported by an actuarial balance sheet and a pricing analysis prepared within the past 3 years; and

    (c) Setting forth the underlying morbidity assumptions.

  (4) The Secretary may engage a qualified actuary at the expense of the provider to review each opinion and prepare a supporting memorandum if:

    (a) The provider fails to provide a supporting memorandum within the period specified by regulation; or

    (b) The Secretary determines that the supporting memorandum that the provider provides fails to meet necessary standards or is unacceptable.

  (5) Each opinion and memorandum required by this section shall be submitted with the annual renewal application required by this chapter and reflect the valuation of the reserve liabilities of the provider and be based on standards adopted by the Actuarial Standards Board.

H. Use of Reserves.

  (1) A provider shall notify the Department in writing simultaneously with withdrawing any amount from the funds available to satisfy the reserves required by this regulation.

  (2) Within 30 days of any draw, the provider shall submit to the Department a written plan for restoring promptly and prudently the funds in the reserve to the level required by this regulation.

I. Phase-In Period of Operating Reserve Requirement.

  (1) Except as provided under §I(2) of this regulation, a provider shall meet the requirements of §B of this regulation by the end of the second full fiscal year after the fiscal year in which the provider obtains its initial certificate of registration.

  (2) For the time specified in §I(3) of this regulation, a provider may meet the operating reserve requirements in §B of this regulation if the provider has a binding agreement with a financial institution that unconditionally obligates the financial institution to furnish the provider credit in the amount of the reserve required by §B of this regulation.

  (3) A provider may use the exception allowed by §I(2) of this regulation only until the earlier of the:

    (a) End of the tenth full fiscal year after the fiscal year in which the provider obtains its initial certificate of registration; or

    (b) Date on which the binding agreement with a financial institution expires.

J. Semi-Annual Reporting. For the first 5 years following the issuance of an initial certificate, a provider shall submit to the Department on a semi-annual basis a financial statement that specifies and describes the status of each reserve required by the regulation. The submission for a renewal certificate under Regulation .11 of this chapter shall count toward such reporting requirement so that the provider need only submit one additional report per year.

K. Investment Reserves. Reserves shall be maintained in reasonably liquid form in the judgment of the provider and in accordance with the provider's investment policies. For assets held to satisfy the reserves required by this regulation, the provider shall list the assets by type, number, and value. The list shall be disclosed in the provider's most recent certified financial statement or in a letter to the Department from the provider's certified public accountant. The certified financial statement or letter shall be submitted with the provider's application for a renewal certificate of registration.

#### Regulation .15 Disclosure Statement.

*COMAR 32.02.02.15*

A. General. A provider holding either a preliminary, initial, or renewal certificate of registration shall furnish, without cost, a disclosure statement to all prospective subscribers and, upon request, annually to all subscribers. A disclosure statement shall be provided to a prospective subscriber before payment of any part of the entrance fee or, if earlier, the execution of a continuing care at home agreement. The provider shall submit its initial disclosure statement to the Department for review at least 45 days before distributing the statement to any prospective or existing subscribers.

B. Disclosure Statement Revisions. A provider shall revise its disclosure statement annually. A provider shall file a revised disclosure statement with the Department within 120 days after the end of the provider's fiscal year and notify current subscribers that the revised disclosure statement is available for review. The Department shall review the disclosure statement solely to ensure compliance with this regulation.

C. Disclosure Statement Contents. The disclosure statement shall include:

  (1) The name and address of the provider;

  (2) The name and address of any parent or subsidiary person;

  (3) The organizational structure and management of the provider, including:

    (a) If the provider is a corporation or limited liability company, the:

      (i) Name of the corporation or limited liability company,

      (ii) State in which the corporation is incorporated or the limited liability company is formed, and

      (iii) Name of the chief executive officer;

    (b) If the provider is a partnership, the:

      (i) Names of the general partners,

      (ii) State governing the formation of the partnership, and

      (iii) Name of the primary individual responsible for managing the partnership;

    (c) If the provider is an unincorporated association, the:

      (i) Names of the members,

      (ii) State governing the association's activities, and

      (iii) Name of the primary individual responsible for managing the association;

    (d) If the provider is a partnership having a corporation or limited liability company as one or more of its general partners, the:

      (i) Name of each corporation or limited liability company,

      (ii) State in which the corporation is incorporated or the limited liability company is formed, and

      (iii) Name of the chief executive officer;

    (e) If the provider is a trust, the:

      (i) Name of each trustee,

      (ii) Names of the owners of beneficial interests in the trust,

      (iii) State whose law governs the trust, and

      (iv) Name of the primary individual responsible for overseeing the trust's activities; and

    (f) A statement regarding whether the provider is qualified, or intends to qualify, as a tax-exempt organization under the Internal Revenue Code;

  (4) A statement regarding any affiliation of the provider with a religious, charitable, or other nonprofit organization, and the extent to which that organization is responsible for the financial and contractual obligations of the provider;

  (5) A description of all fees collected by the provider that are not optional, including:

    (a) Entrance fees;

    (b) Additional periodic fees; and

    (c) Any additional fees for health care services that are not covered by the entrance fee and periodic fee;

  (6) The date and the amount of any changes in the fees that are not optional imposed in any of the past 5 years during which the provider was providing continuing care at home;

  (7) A statement describing provisions that have been, or will be, made to comply with the reserve requirements in Regulation .14 of this chapter;

  (8) A general statement regarding the provider's investment policy related to the required reserves, including how often the reserve funds' investments are reviewed and by whom;

  (9) A copy of the most recent certified financial statement available under generally accepted accounting principles;

  (10) A description of any long-term financing for the provider;

  (11) If operations have not begun, a summary of the most recent feasibility study approved by the Department, which shall include:

    (a) A description of the anticipated sources and uses of funds to finance the project, including related costs such as:

      (i) Financing expenses,

      (ii) Marketing costs, and

      (iii) Legal and administrative costs;

    (b) The projected balance sheets, income statements, and cash flow statements of the provider contained in the most recent feasibility study approved by the Department or, if there have been revisions to these financial projections since approval was received, then:

      (i) Include the most current projections, and

      (ii) Specify that the financial projections have been revised since the feasibility study was approved by the Department;

    (c) A projected presales schedule;

    (d) A statement indicating when the provider expects to have executed agreements for 30 percent of the number of subscribers needed for the provider to reach its break-even point;

    (e) A statement indicating when the provider plans to begin operations;

    (f) A statement indicating when the provider expects to enroll the number of subscribers needed for the provider to reach its break-even point; and

    (g) Any further information the Department requires;

  (12) If operations have begun and the provider has not enrolled the number of subscribers needed for the provider to reach its break-even point, a summary of the most recent feasibility study approved by the Department, which shall include:

    (a) A description of the sources and uses of funds to finance the project, including related costs such as:

      (i) Financing expenses,

      (ii) Marketing costs, and

      (iii) Legal and administrative costs;

    (b) The projected balance sheets, income statements, and cash flow statements of the provider shown in the most recent feasibility study approved by the Department or, if there have been revisions to these financial projections since approval was received, then:

      (i) Include the most current projections, and

      (ii) Specify that the financial projections have been revised since the feasibility study was approved by the Department;

    (c) A projected presales schedule;

    (d) A semiannual schedule which shows actual presales since operations began;

    (e) A statement indicating when the provider expects to enroll the number of subscribers needed for the provider to reach its break-even point; and

    (f) Any further information the Department requires;

  (13) A cash flow forecast statement for the current and the next 2 fiscal years;

  (14) The names and occupations of:

    (a) The provider's officers, directors, trustees, and managing or general partners; and

    (b) Any person with a 10 percent or greater equity or beneficial interest in the provider;

  (15) A description of the financial interest in or occupation with the provider of each person identified under §C(14) of this regulation;

  (16) If it is anticipated that a business entity will provide to the provider goods, premises, or services with a value of $10,000 or more within any fiscal year, and if a person identified in §C(14) of this regulation has a financial interest of 10 percent or more in the business entity, then include:

    (a) The name and address of the business entities;

    (b) A description of the goods, premises, or services; and

    (c) The anticipated yearly costs the provider will incur for the goods, premises, or services;

  (17) If the continuing care at home operations are, or will be, managed on a day-to-day basis by a person other than an individual directly employed by the provider, then include a description of the proposed manager or management company, including the business experience the manager or company has operating or managing similar operations;

  (18) A description of any matter in which an individual identified under §C(14) of this regulation has:

    (a) Been convicted of, or pleaded nolo contendere to, a felony charge involving fraud, embezzlement, fraudulent conversion, or misappropriation of property;

    (b) Been held liable, or enjoined by a final judgment, in a civil action involving fraud, embezzlement, fraudulent conversion, or misappropriation as a fiduciary;

    (c) Been subject to an effective injunctive or restrictive order of a court of record arising out of or relating to business activity or health care, including actions affecting a license to operate any facility or service for aging, impaired, or dependent persons; or

    (d) Had any state or federal license or permit suspended or revoked within the past 10 years, as a result of an action brought by a governmental agency arising out of or relating to business activity or health care, including actions affecting a license to operate any facility or service for aging, impaired, or dependent persons;

  (19) A description of the form of governance of the provider, including the composition of the governing body;

  (20) A statement that the provider shall hold the periodic meetings with subscribers as required under Regulation .13 of this chapter;

  (21) If applicable, a description of the conditions under which the provider may:

    (a) Be issued an initial certificate of registration; and

    (b) Use escrowed deposits;

  (22) If applicable, a statement of the amount of a subscriber's deposit that may be used upon issuance of an initial certificate of registration;

  (23) A summary of the basic services provided or proposed to be provided under the provider's agreements;

  (24) For each basic service a provider is required to provide by Regulation .02E of this chapter, a statement that explains:

    (a) Any limits on the amount of the basic service that will be provided to a subscriber in exchange for the entrance fee and periodic fee; and

    (b) If there is a limit, the methodology used to measure the amount of services, such as hours of service, calendar months, or the dollar value of services rendered;

  (25) A summary of any services in addition to the basic services that are provided or proposed to be provided under the provider's agreements;

  (26) For each additional service described under §C(25) of this regulation, a statement that describes which of those additional services are to be covered by the entrance fee and any periodic fees and which additional services will be made available at an extra charge;

  (27) The names of facilities with which the provider has a formal arrangement to provide services to subscribers;

  (28) A statement describing which, if any, services are portable and may be used outside the geographic service area;

  (29) A statement describing any procedures a subscriber must follow to use a benefit outside the geographic service area;

  (30) If it is the provider's policy that a subscriber maintain certain insurance, a statement describing each type of insurance required and, if applicable, the amounts of coverage required;

  (31) A statement that the provider will promptly amend its disclosure statement if, in the opinion of the provider or the Department, an amendment is necessary to prevent the disclosure statement from containing any material misstatement of fact required by this regulation to be stated in the disclosure statement or omission of a material fact required by this regulation to be stated in the disclosure statement;

  (32) If it is the provider's policy to impose a surcharge on some, but not all, subscribers because of some condition or circumstance, a statement that describes the types of conditions or circumstances that would warrant a surcharge and that a surcharge is not considered part of the entrance fee when calculating a refund under Regulation .25 of this chapter; and

  (33) Any other material information concerning the provider that the Department requires or that the provider wishes to include.

D. The disclosure statement shall contain a cover page that states in a prominent location and type face, the following:

  (1) The date of the disclosure statement;

  (2) That the issuance of a certificate of registration does not constitute approval, recommendation, or endorsement of the provider by the Department; and

  (3) That the issuance of a certificate of registration is neither evidence of, nor does it attest to, the accuracy or completeness of the information set out in the disclosure statement.

E. Any amended disclosure statement shall be:

  (1) Filed with the Department at the same time that it is delivered to a subscriber or prospective subscriber; and

  (2) Subject to all the requirements of this chapter.

#### Regulation .16 Sale, Transfer, or Reorganization of Ownership or Control.

*COMAR 32.02.02.16*

A. Sale or Transfer of Ownership or Control.

  (1) Except as provided in §B of this regulation, a provider that holds an initial or renewal certificate of registration, or a person with an ownership interest in or right to control that provider through governing body appointments or contractual or similar arrangements, may not sell or otherwise transfer, directly or indirectly, more than 50 percent of the ownership of, or right to control, the provider or a person that owns or controls a provider, unless the provider or person obtains the approval of the Department to the sale or other transfer in accordance with §§C—F of this regulation.

  (2) Any series of sales or other transfers within a 12-month period shall be aggregated for purposes of this regulation.

B. Exception for Business Reorganizations.

  (1) This regulation does not apply if:

    (a) A transfer of ownership of a provider, or a transfer of ownership or control of a person owning or controlling a provider, is part of a business reorganization; and

    (b) The same party or parties holding a majority of ownership of, or right to control, the provider before the business reorganization will retain, directly or indirectly, a majority of the ownership of, or right to control, the provider after the business reorganization.

  (2) If a sale or transfer of ownership satisfies the exception of §B(1) of this regulation, the provider shall give written notice to the Department and to the provider's subscribers 30 days before the business reorganization.

  (3) The written notice to the Department required by §B(2) of this regulation shall include:

    (a) A statement describing the reorganization in ownership including the new organizational structure;

    (b) A copy of each corporate charter, articles of incorporation, bylaws, partnership agreements, articles of association, membership agreement, or trust agreement that will govern the legal organization of the provider after the sale or other transfer;

    (c) A copy of the notice given to, or to be given to, the provider's subscribers; and

    (d) Any further information the Department requires regarding the structure of the legal entities involved in the reorganization.

C. Request for Approval of a Sale or Transfer of Ownership or Control.

  (1) A provider subject to §A of this regulation shall:

    (a) At least 90 days before the proposed effective date of the sale or other transfer, file with the Department a statement of intent to transfer ownership or control; and

    (b) At least 65 days before the proposed effective date of the sale or other transfer, give written notice of the proposed sale or other transfer to the continuing care at home subscribers of the provider and to the Department.

  (2) Along with the written notice to the Department required by §C(1)(b) of this regulation, the provider shall submit a payment to the Department of $8,000.

  (3) The written notice required by §C(1)(b) of this regulation shall specify the following information, which also shall be provided to any continuing care at home subscriber of the provider upon request:

    (a) The place and time for the meeting specified in §C(4) of this regulation;

    (b) The address of the provider and the Department to which any comments may be sent;

    (c) The name and address of affected facilities and the name and address of the new provider;

    (d) The organizational structure and management of the provider and affected facilities after the proposed sale or other transfer is completed, including:

      (i) If the provider is to be a corporation or limited liability company, then the name of the corporation or limited liability company, the state in which the corporation is incorporated or the limited liability company is formed, and the name of the chief executive officer of the provider,

      (ii) If the provider is to be a partnership, then the names of the general partners, the state governing the formation of the partnership, and the name of the primary individual responsible for managing the partnership,

      (iii) If the provider is to be an unincorporated association, then the names of the members, the state governing the unincorporated association's activities, and the name of the primary individual responsible for managing the association,

      (iv) If the provider is to be a trust, then the name of each trustee, the names of the owners of the beneficial interests in the trust, the state whose law governs the trust, and the name of the primary individual responsible for overseeing the trust's activities,

      (v) If the provider is to be a partnership having a corporation or limited liability company as one or more of its general partners, then the name of each corporation or limited liability company, the state in which the corporation is incorporated or the limited liability company is formed, and the name of the provider's chief executive officer, and

      (vi) The names and occupations of each person who will be an officer, director, trustee, general partner, principal, or person with a 10 percent or greater equity or beneficial interest in the provider after the sale or other transfer;

    (e) A copy of each corporate charter, articles of incorporation, bylaws, partnership agreement, articles of association, membership agreement, or trust agreement as it will pertain to the legal organization of the provider after the sale or other transfer;

    (f) A statement as to:

      (i) Any affiliation with a religious, charitable, or other nonprofit organization that will exist after the proposed sale or other transfer, and

      (ii) The extent, if any, to which the affiliate organization will be responsible for the financial and contractual obligations of the provider;

    (g) The name and address of each person that is likely to provide goods, premises, or services to the provider after the sale or other transfer, which goods, premises, or services will have a value of $10,000 or more within any fiscal year;

    (h) If a person identified in §C(2)(d)(vi) of this regulation has a 10 percent or greater financial interest in a person identified in §C(2)(g) of this regulation, then describe the goods, premises, or services to be provided to the provider;

    (i) A description of any proposed manager or management company that will manage the day-to-day operations of the provider after the sale or other transfer, including the business experience the manager or company has in operating or managing similar operations;

    (j) A description of each matter in which a person identified in §C(2)(d)(vi) of this regulation has:

      (i) Been convicted of, or pleaded nolo contendere to, a felony charge involving fraud, embezzlement, fraudulent conversion, or misappropriation of property,

      (ii) Been held liable, or enjoined by a final judgment, in a civil action involving fraud, embezzlement, fraudulent conversion, or misappropriation as a fiduciary,

      (iii) Been subject to an effective injunctive or restrictive order of a court of record arising out of or relating to business activity or health care, including actions affecting a license to operate a facility or service for aging, impaired, or dependent persons, or

      (iv) Had any state or federal license or permit suspended or revoked within the past 10 years, as a result of an action brought by a governmental agency arising out of or relating to business activity or health care, including actions affecting a license to operate a facility or service for aging, impaired, or dependent persons;

    (k) A financial plan, prepared by an authority recognized by the Department, in a form reasonably acceptable to the Department that:

      (i) Demonstrates the projected effects of the sale or other transfer on the financial operations of the provider,

      (ii) Includes any obligations of the provider to make payments in connection with the sale or other transfer from the financial resources of the provider,

      (iii) Includes projected 10-year balance sheets, income statements, and cash flow statements each prepared in accordance with generally accepted accounting principles, and

      (iv) Includes the key assumptions underlying the projected 10-year balance sheets, income statements, and cash flow statements;

    (l) A statement from an authority recognized by the Department that is based on the financial plan and that concludes that the proposed change in ownership is not likely to have an unreasonably adverse effect on the provider's ability to perform its obligations under its agreements; and

    (m) Any further information the Department requires.

  (4) For the first 15 days after the provider gives the notice specified in §C(1)(b) of this regulation, subscribers may submit to the provider and to the Department written questions and comments on the proposed sale or other transfer.

  (5) At least 18 days, but not later than the 25th day, after the notice specified in §C(1)(b) of this regulation is given, representatives of the provider shall hold a meeting with representatives of the subscribers to discuss the proposed sale or other transfer. Representatives of the Department may attend the meeting. Representatives of the subscribers may not exceed 15 in number. If there is a subscriber association, up to 15 representatives shall be chosen by the association. The names and addresses of the subscriber representatives shall be given by those elected representatives to the provider and to the Department. If a subscriber association does not exist, the provider shall include in the notice to subscribers required by §C(1)(b) of this regulation a statement that up to 15 subscribers can be elected to represent the subscribers in a meeting with the provider to discuss the proposed sale or transfer and that subscribers desiring to be elected should submit their names to the provider by a particular date and time. Immediately after the date and time established in the notice, the provider shall conduct an election by mail to select the subscribers receiving the most votes as representatives of the subscribers. The provider shall provide the names and addresses of the elected representatives to the Department.

  (6) For 10 days after the meeting specified in §C(4) of this regulation, subscribers may submit to the provider and to the Department additional written comments on the proposed sale or other transfer.

D. Approval of Sale or Transfer of Ownership or Control. By the 50th day after the date of the notice required by §C(1)(b) of this regulation, the Department shall issue an approval of the sale or other transfer, unless it determines that the sale or transfer is likely to have an unreasonably adverse impact on the financial stability of the provider or is likely to have an unreasonably adverse effect on a provider's capacity to perform its obligations under the continuing care at home agreements to which it is a party. The Department may extend the date for approval past the 50th day after the date of the notice required by §C(1)(b) of this regulation for good cause. The Department shall notify the provider and subscriber representatives in writing of its determination and rationale.

E. Appeal of Department Decision. The decision by the Department with respect to the proposed sale or other transfer is subject to appeal only by the provider in accordance with Regulation .31 of this chapter, and no other person shall be deemed to be a party in interest to the proceedings. If an appeal is taken by the provider, the Department shall give prompt notice of the appeal to the subscriber representatives. The Department shall give the subscriber representatives prompt notice of any decision rendered in the appeal.

F. Effective Date of Sale or Transfer of Ownership or Control. A sale or other transfer of ownership or control may not be completed until after the 15th day following the later of:

  (1) The date the Department issues an approval specified in §D of this regulation; or

  (2) If an appeal is taken under §E of this regulation, the day a hearing officer or administrative law judge renders a final decision permitting the sale or other transfer.

#### Regulation .17 Sale, Transfer, or Other Disposition of Assets.

*COMAR 32.02.02.17*

A. Definitions.

  (1) In this regulation, the following terms have the meanings indicated.

  (2) Terms Defined.

    (a) “Days cash on hand ratio” means the ratio created by the following calculation: [Unrestricted current cash and investments + Unrestricted noncurrent cash and investments] / [(Total operating expenses - depreciation and amortization) / 365].

    (b) “Debt service coverage ratio” means the ratio created by the following calculation: [Total excess of revenues over expenses + Interest, lease, depreciation, and amortization expenses / Amortization of deferred revenue + Net proceeds from the collection of entrance fees] / [Maximum annual debt service or annual lease payments].

    (c) “Future service obligation” means a financial obligation of a provider that equals any positive number resulting from the calculation to determine the amount by which the present value of the net costs of future services to be provided to the current subscribers exceeds the balance of deferred revenue from entrance fees, which calculation is required to be performed annually by generally accepted accounting principles.

    (d) “Liquid resources” means an asset that is easily converted to cash.

    (e) “Maximum annual debt service” means the greatest amount required to pay the debt service requirements of any long-term indebtedness for any fiscal year, excluding any year in which the amount due is defined in the applicable financing documents as a balloon payment.

    (f) “Operating ratio” means the ratio created by the following calculation: [Total operating expenses - Depreciation and amortization expenses] / [Total revenues - amortization of deferred revenue].

    (g) “Ordinary course of business” means transactions that occur on a routine basis without the involvement of the board of directors, or other governing body, such as paying employees and vendors, collecting fees, and selling and purchasing investments.

    (h) “Transfer” means a sale, disposition, donation, lease, or other transaction that diminishes the ownership rights that the provider has in any assets.

B. Transactions Not Included. The following transactions are not considered sales, transfers, or other dispositions of assets for purposes of §§C and D of this regulation:

  (1) Those undertaken under contractual obligations in effect on April 1, 2000;

  (2) Those made in the ordinary course of business;

  (3) Refunds of amounts under contracts entered into in the ordinary course of business;

  (4) Transfers of cash, securities, or other investment properties in connection with ordinary investment transactions;

  (5) Grants of mortgages, deeds of trust, or security interests to unrelated third parties;

  (6) Those involving easements, rights-of-way, road widening, and similar conveyances for the benefit of public bodies or utilities; and

  (7) Those made for an expansion or renovation.

C. Transfers of 10 Percent or Less of Assets.

  (1) Except as provided by §C(3) of this regulation, a provider that holds an initial or renewal certificate of registration may not transfer assets that are equal to or less than 10 percent of the provider's total assets, based on the certified financial statements for the most recent fiscal year for which a certified financial statement is available at the time of the transfer, if the transfer is likely to have an unreasonably adverse:

    (a) Impact on the financial stability of the provider; or

    (b) Effect on the provider's capacity to perform its obligations under continuing care at home agreements to which it is a party.

  (2) Unlike a transfer of assets greater than 10 percent of total assets, a transfer of assets equal to or less than 10 percent of total assets does not have to be approved in advance by the Department unless one or more of the following circumstances exists:

    (a) The transfer would result in insufficient liquid resources to cover the provider's future service obligation after the proposed transfer; or

    (b) The provider believes that the transfer may have an unreasonably adverse:

      (i) Impact on its financial stability, or

      (ii) Effect on its capacity to perform its obligations under its agreements.

  (3) In order to have a transfer subject to §C of this regulation approved in advance by the Department, the provider shall submit to the Department the following:

    (a) Identification of all assets to be sold, transferred, or otherwise disposed of;

    (b) Documentation as to why the proposed transfer is needed to maintain the financial viability of the provider;

    (c) A 10-year financial plan, prepared in accordance with generally accepted accounting principles by an independent consultant, that demonstrates the effects of the proposed transfer and includes projected balance sheets, income statements, statements of cash flows, and the key assumptions of the plan; and

    (d) Any further information the Department requires.

  (4) Within 60 days of receipt of the information required by §D(3) of this regulation, the Department shall issue a written determination that either:

    (a) Approves the transfer;

    (b) Denies the transfer; or

    (c) Seeks more information to evaluate the transfer.

  (5) If the determination of the Department is not to approve the proposed sale, transfer, or other disposition, the Department shall set forth the reasoning supporting its determination in a written communication to the provider.

D. Transfer of More than 10 Percent of Assets.

  (1) A provider that holds an initial or renewal certificate of registration may not transfer, in any 12-month period, assets in excess of 10 percent of its total assets, based on its certified financial statements for the most recent fiscal year for which a certified financial statement is available at the time of the transfer, unless the provider obtains the approval of the Department for the transfer in accordance with this regulation.

  (2) A provider subject to §D(1) of this regulation shall, at least 60 days before the proposed transfer, file with the Department a statement of intent to transfer assets and, at least 30 days before the proposed transfer, give written notice to the Department.

  (3) A statement of intent required to be filed with the Department under §D(2) of this regulation shall include the following information:

    (a) Identification of all the assets to be sold, transferred, or otherwise disposed of;

    (b) If the provider is subject to §E(1) of this regulation by reason of a series of transfers that have cumulatively exceeded the 10 percent amount, the provider shall identify all of the assets that resulted in exceeding the 10 percent amount; and

    (c) The reason for the transfer.

  (4) Along with the written notice to the Department required by §D(2) of this regulation, the provider shall submit a payment to the Department of $5,000.

  (5) A notice required to be filed with the Department by §D(2) of this regulation shall include the following information:

    (a) A statement that demonstrates that the proposed transfer is not likely to have an unreasonably adverse:

      (i) Impact on the financial stability of the provider, or

      (ii) Effect on the provider's capacity to perform its obligations under the agreements to which it is a party;

    (b) Computations, prepared by an authority recognized by the Department, of the following financial ratios for the 3 fiscal years before and after the proposed transfer:

      (i) Operating ratio,

      (ii) Day's cash on hand ratio, and

      (iii) Debt service coverage ratio;

    (c) If the provider is required by generally accepted accounting principles to perform a future service obligation calculation, a statement from an independent consultant that explains why:

      (i) The provider will have sufficient liquid resources to cover the provider's future service obligation, if one exists, after the proposed transfer, or

      (ii) The proposed transfer will have a positive impact on the provider's ability to perform its obligations in accordance with the terms of its continuing care at home agreements; and

    (d) Any other information the Department requires.

  (6) If the provider cannot meet the financial standards set forth in §E(2) of this regulation, the notice required by §D(2) of this regulation shall include the following additional information:

    (a) A 10-year financial plan, prepared in accordance with generally accepted accounting principles by an independent consultant, that demonstrates the effects of the proposed transfer and includes:

      (i) Projected balance sheets,

      (ii) Income statements,

      (iii) Statements of cash flows, and

      (iv) The key assumptions of the plan;

    (b) A statement from the independent consultant that after taking into account the provider's historic performance and future assumptions, which future assumptions the independent consultant concludes are not unreasonable, the provider will have the financial ability after the transfer to perform its obligations under the provider's agreements; and

    (c) Any further information that the Department requires.

E. Approval of Transfer of More than 10 Percent of Assets.

  (1) The Department shall approve the sale, transfer, or other disposition of assets in excess of 10 percent unless it determines that the sale, transfer, or other disposition is likely to have an unreasonably adverse:

    (a) Impact on the financial stability of the provider; or

    (b) Effect on the provider's capacity to perform its obligations under the continuing care at home agreements to which it is a party.

  (2) The Department shall approve a proposed transfer of assets in excess of 10 percent if the information required by §D(4) of this regulation adequately demonstrates that the provider:

    (a) Will be able to achieve at least one of the following financial ratios by the end of the third fiscal year after the transfer:

      (i) An operating ratio less than or equal to 0.95,

      (ii) A day's cash on hand ratio of greater than 90 days, or

      (iii) A debt service coverage ratio greater than or equal to 1.25; and

    (b) Meets one of the following standards if the provider is required by generally accepted accounting principles to perform a future service obligation calculation:

      (i) Will have sufficient liquid resources to cover the provider's future service obligation after the proposed transfer, or

      (ii) The proposed transfer will have a positive impact on the provider's ability to perform its obligations in accordance with the terms of its agreements.

  (3) The Department shall communicate its determination in writing to the provider by the 25th day after the date the Department receives the written notice required by §D(2) of this regulation, unless extended by the Department for good cause. If the determination of the Department is not to approve the proposed sale, transfer, or other disposition, the Department shall set forth the reasons supporting its determination in the written communication to the provider.

F. Appeal of a Department Decision. The determination by the Department with respect to a proposed transfer of assets is subject to appeal only by the provider in accordance with Regulation .31 of this chapter. No other person may be deemed to be a party in interest to the proceedings.

G. Effective Date of a Transfer of Assets. A transfer of assets subject to review by the Department under this regulation may not be completed until after the fifth day following the later of:

  (1) The day on which the Department issues a determination approving the transfer; or

  (2) If an appeal is taken under §F of this regulation, the day a hearing officer or administrative law judge renders a final decision permitting the transfer of assets.

#### Regulation .18 Financial Review Committee.

*COMAR 32.02.02.18*

The Financial Review Committee authorized by Human Services Article, §§10-464—10-469, Annotated Code of Maryland, shall review providers' financial matters referred to it by the Department in accordance with the provisions of COMAR 32.02.01.24.

#### Regulation .19 Referrals to the Financial Review Committee.

*COMAR 32.02.02.19*

A. The Department may refer to the Committee for its consideration:

  (1) A provider's application for a renewal certificate after review by the Department; or

  (2) A finding of possible financial difficulty, at any time.

B. Upon receipt of a referral from the Department, the Committee shall:

  (1) Request from the Department any additional material which the Committee may require;

  (2) Review the material to determine whether or not it finds the provider in financial difficulty;

  (3) Notify the Department in writing of its findings and reasons for its findings, within 45 days of receipt of the referral; and

  (4) Provide consultation to the Department regarding corrective financial plans for providers in financial difficulty when requested by the Department.

C. The Committee may request one 30-day extension if the 45-day time limit cannot be met. The Secretary may grant the extension.

D. Upon notification of a finding by the Committee, the Department shall consider the finding of the Committee and, within 25 days of receipt of the Committee's finding, make a final determination whether the provider is in financial difficulty.

#### Regulation .20 Findings of Financial Difficulty.

*COMAR 32.02.02.20*

A. Upon final determination by the Department that a provider is in financial difficulty, the Department shall notify the provider of the determination by certified mail, return receipt requested.

B. The Department may:

  (1) Consult with the Financial Review Committee to review the findings and possible corrective financial plans; and

  (2) Assist the provider to develop an adequate corrective financial plan.

C. A provider notified of a determination of financial difficulty shall:

  (1) Cooperate with the Department to develop a corrective financial plan;

  (2) Prepare a 5-year financial plan to correct the causes of the financial difficulty;

  (3) Submit the corrective plan to the Department for approval within 60 days of receipt of notification from the Department;

  (4) Amend the financial plan as the Department may advise to enable a finding of no financial difficulty;

  (5) Implement the corrective financial plan;

  (6) Submit to the Department within 60 days of the close of each fiscal year an annual progress report on the implementation of its approved financial plan; and

  (7) At the direction of the Department, revise and update its corrective financial plan if the Department finds that revisions are necessary based on review of the annual progress report or other investigation.

D. The provider may request from the Secretary a 30-day extension of the 60-day time period specified in §C(3) of this regulation. The Secretary may grant the extension.

E. After a provider has been found to be in financial difficulty, the Department may withhold a renewal certificate of registration or withdraw a current certificate of registration if the Department determines that the provider:

  (1) Did not prepare a corrective financial plan within 60 days of notification (or 90 days, if the Secretary granted an extension);

  (2) Is unwilling or unable to prepare a corrective financial plan;

  (3) Prepared a financial plan which is found by the Department to be inadequate to correct the current or impending financial difficulty; or

  (4) Failed to implement the approved corrective plan, which is demonstrated by the annual progress report or an interim investigation by the Department.

#### Regulation .21 Deposit Agreement and Processing Fee.

*COMAR 32.02.02.21*

A. A deposit agreement used before the provider has received an initial certificate of registration shall:

  (1) State that all deposits and entrance fees shall be held in escrow until the:

    (a) Issuance of an initial certificate of registration, and

    (b) Provider has been issued appropriate licenses or certificates by MDH and MHCC;

  (2) Describe the disposition of any interest earned on deposits and entrance fees;

  (3) State the amount of any processing fee and whether it will be refunded if the deposit agreement is canceled; and

  (4) Describe the disposition of the deposit if the deposit agreement is canceled before the continuing care at home agreement is executed.

B. A deposit agreement that is used after the provider has received an initial certificate of registration shall:

  (1) State that the provider may use all deposits and entrance fees at any time; or

  (2) Describe any applicable limitations on the use of deposits and entrance fees.

C. A processing fee may only be assessed against a subscriber one time and may not exceed $300.

D. If a deposit agreement does not precede a continuing care at home agreement, the provider shall ensure that the continuing care at home agreement referred to in Regulation .22 of this chapter meets the requirements of §A of this regulation.

#### Regulation .22 Continuing Care At Home Agreement.

*COMAR 32.02.02.22*

A. Each continuing care at home agreement shall:

  (1) List the total consideration paid, or to be paid, by the subscriber for continuing care at home, including a schedule or inventory that sets forth in one place the value of all entrance fees, subscription fees, property transferred, surcharges, periodic fees, donations, and other fees;

  (2) Describe in detail:

    (a) All items of service required to be provided to a subscriber by Regulation .02E of this chapter; and

    (b) Any additional services to be provided;

  (3) For each item described in §A(2) of this regulation, state whether:

    (a) There are any limits on the amount of the services to be provided; and

    (b) If there are limits, the methodology by which they will be measured or capped;

  (4) If adult day care or respite care are not provided, specifically state that they are not;

  (5) State:

    (a) Whether the provider has a formal arrangement with a facility owned or operated by another person to provide services to a subscriber;

    (b) What provisions for care will be made if an assisted living or nursing home bed is not available at a facility with which the provider has a formal arrangement, as described in §A(5)(a) of this regulation, at the time a bed is needed by a subscriber;

    (c) What the payment provisions will be for care at a facility with which the provider has a formal arrangement as described in §A(5)(a) of this regulation; and

    (d) That the provider shall promptly notify the subscriber and the Department of any change in a formal arrangement described in §A(5)(a);

  (6) Designate the categories of subscribers according to the types of entrance fee plans offered;

  (7) State that a subscriber may not be relocated except to protect the health or safety of the subscriber or for the general and economic welfare of other subscribers;

  (8) While recognizing the constraints of §A(7) of this regulation, describe the procedures the parties to the agreement are to follow in order to temporarily transfer a subscriber;

  (9) Describe the procedures the parties to the agreement are to follow in order to return a subscriber to the location where the subscriber resided before a temporary change;

  (10) While recognizing the constraints of §A(7) of this regulation, describe the procedures the parties to the agreement are to follow in order to permanently transfer a subscriber;

  (11) Describe how the procedures for changes, transfers, and returns, whether temporary or permanent, will operate if the subscriber lives with another subscriber;

  (12) State whether there will be a partial refund of an entrance fee, an additional fee, or any increase or decrease in a periodic fee in the event of an increase or decrease in the number of subscribers living together;

  (13) Describe the policies of the provider regarding subscribers unable to meet the periodic charges;

  (14) State in clear and understandable language, and in boldface type of the largest font used in the body of the agreement, the terms governing the refund of any portion of the entrance fee in the event of:

    (a) Discharge by the provider; or

    (b) Termination by the subscriber;

  (15) State the terms under which an agreement is canceled by the death of a subscriber;

  (16) State in clear and understandable language, and in boldface type of the largest font used in the body of the agreement, whether or not periodic fees, if charged, will be subject to periodic increases;

  (17) If periodic fees are subject to increase, state in clear and understandable language, and in boldface type of the largest font used in the body of the agreement, the number of days of notice that will be given by the provider before an increase becomes effective;

  (18) State that the charges for prepaid care may not be increased, if the agreement provides that care is paid for in advance, in one lump sum;

  (19) State whether funeral and burial services are furnished by the provider;

  (20) State the address of subscriber's dwelling;

  (21) Describe any procedures a subscriber must follow to amend the agreement to change the address of the subscriber's dwelling;

  (22) State whether the subscriber may assign the dwelling or agreement to another and, if so, under what conditions;

  (23) Describe what, if any, assistance with the maintenance of the subscriber's dwelling will be performed if the subscriber is not residing in the dwelling;

  (24) Describe any religious or charitable affiliations of the provider;

  (25) Describe the extent to which an affiliate organization will be responsible for the financial and contractual obligations of the provider;

  (26) State the subscriber's and provider's respective rights and obligations as to any real and personal property of the subscriber transferred to or placed in the custody of the provider;

  (27) State the rights and obligations a subscriber has regarding the use of the provider's facilities, if any, including common areas;

  (28) State the rights and obligations a provider has regarding its use of its facilities, if any, and what, if any, rights the provider has to enter a subscriber's dwelling;

  (29) State that subscribers have the right to organize and operate a subscriber's association;

  (30) State what fee adjustments, if any, will be made by the provider in the event of a subscriber's voluntary absence from the provider's geographic service area or the subscriber's dwelling for an extended period of time;

  (31) Specify the circumstances, if any, under which a subscriber will be required to apply for Medicaid, Medicare, public assistance, or any public benefit program;

  (32) State whether the provider is, or plans to be, a participant in Medicare or Medicaid;

  (33) In a separate paragraph, signed by each subscriber, state: “I have received a copy of the provider's latest certified financial statement at least 2 weeks before signing this agreement, and I have reviewed the certified financial statement provided.”;

  (34) State that the provider will make available to each subscriber, upon request, any certified financial statement or disclosure statement submitted to the Department;

  (35) If an agreement is executed before the provider has received an initial certificate, state:

    (a) The conditions that the provider must meet to be issued an initial certificate of registration by the Department; and

    (b) That all deposits and entrance fees shall be held in an escrow account in Maryland in a financial institution until:

      (i) An initial certificate of registration is issued, and

      (ii) The provider has been issued appropriate licenses or certificates by MDH and MHCC;

  (36) State that fees collected by a provider under the terms of a continuing care at home agreement may not be used for purposes other than those set forth in the agreement;

  (37) State in boldface type of the largest font used in the body of the agreement: “A preliminary certificate of registration or certificate of registration is not an endorsement or guarantee of this provider by the State of Maryland. The Maryland Department of Aging urges you to consult with an attorney and a suitable financial advisor before signing any documents.”;

  (38) State in boldface type of the largest font used in the body of the agreement: “The provider has estimated it needs x subscribers before it will be fully financially viable. A provider may begin operating before it is fully financially viable. The provider's financial viability depends on enrolling x subscribers.”;

  (39) State in boldface type of the largest font used in the body of the agreement: “Continuing care at home is a new concept in delivering services to the elderly. While it promises certain future health services, it is not an insurance product and is not as regulated or secure as an insurance policy. However, it does offer services that typically are not available through an insurance policy.”;

  (40) State which, if any, benefits are portable if the subscriber moves out of the geographic service area and which are not portable;

  (41) Describe the procedures the parties to the agreement are to follow in order for a subscriber to use portable benefits outside the geographic service area;

  (42) State the legal remedies available to a subscriber in the event of injury caused by a provider's violation of the Act;

  (43) In a separate paragraph, signed by each subscriber, state: “I have received a copy of the provider's latest disclosure statement, and I have reviewed the disclosure statement provided.”; and

  (44) State that if there are differences between the requirements for continuing care at home certification and the licensure requirements for assisted living and comprehensive care facilities, the applicable requirements most favorable to the subscriber will prevail while the subscriber is residing in an assisted living or comprehensive care facility.

B. Each continuing care at home agreement may contain any other provisions which are:

  (1) Agreed upon by the provider and the subscriber to effectuate the purpose of the contract; and

  (2) Not in conflict with the Act or this chapter, as determined by the Department.

C. A preliminary certificate of registration may not be issued by the Department if the agreement submitted with the application does not contain all of the provisions of §A of this regulation. The Department shall return to the provider for amendment any agreement which it finds in violation of this chapter. The provider shall submit the agreement to an attorney for legal sufficiency as to content and form before resubmission to the Department.

D. The provider shall request approval from the Department for any modification, addition, or deletion to the terms of a continuing care at home agreement, before the agreement is offered to or used with subscribers. If a proposed change would significantly alter an agreement, the Department may require the submission of an actuarial pricing analysis, performed by a qualified actuary, to support the financial viability of the proposed agreement.

E. Agreements are governed by the version of this regulation that was in effect at the time the agreement was executed by the parties.

#### Regulation .23 Withdrawal of Application or Rescission of Agreement.

*COMAR 32.02.02.23*

A. Withdrawal of Application. A person seeking admission to a continuing care at home program may withdraw an application at any time before execution of the continuing care at home agreement. A provider shall refund all money paid, less any nonrefundable processing fee that was specified in the deposit agreement, to a prospective subscriber who withdraws an application before signing a continuing care at home agreement.

B. Rescission of Agreement before Services Commence.

  (1) If a subscriber rescinds an agreement by giving written notice of the rescission to the provider before the provider begins to provide continuing care at home services to the subscriber, and the rescission either occurs within 90 days after entering into the agreement or because of a substantial change in the subscriber's physical, mental, or financial condition, the provider shall, within 30 days of rescission, refund all moneys paid by the subscriber except any processing fee previously specified as nonrefundable.

  (2) If a subscriber rescinds an agreement by giving written notice of the rescission to the provider before the provider begins to provide continuing care at home services to the subscriber, but more than 90 days after entering into the agreement, for any reason other than a substantial change in the subscriber's physical, mental, or financial condition, the provider shall refund the same amount specified in §B(1) of this regulation, except that the provider may require that the subscriber forfeit part of the refund. The forfeiture amount may not exceed 25 percent of any deposit paid by the subscriber.

  (3) If a subscriber rescinds an agreement by giving written notice of the rescission to the provider before the provider begins to provide continuing care at home services to the subscriber, because of a substantial change in the subscriber's physical, mental, or financial condition, the provider shall refund the same amount specified in §B(1) of this regulation.

  (4) If a subscriber dies before the date the provider begins to provide continuing care at home services to the subscriber, the agreement is automatically canceled, and the provider shall refund to the subscriber's legal representative the same amount specified in §B(1) of this regulation, except that the cancellation is not automatic and is at the option of the surviving subscriber if the agreement is in the name of two subscribers.

#### Regulation .24 Rescissions for Violation of the Act.

*COMAR 32.02.02.24*

If the terms of an agreement are in violation of the terms of the Act and a subscriber is injured by the violation, the subscriber may rescind the agreement at any time. The subscriber is entitled to treble damages for extensive injuries arising from a violation of the Act.

#### Regulation .25 Termination of the Agreement after Services Commence.

*COMAR 32.02.02.25*

A. Termination by a Subscriber. If a subscriber elects to terminate the agreement after the provider begins to provide continuing care at home services, any refund of the entrance fee is governed by the terms of the agreement.

B. Termination, Dismissal, or Discharge by the Provider.

  (1) An agreement may not permit termination of the agreement or dismissal or discharge of a subscriber from the continuing care at home program, including by involuntary transfer to a health care or mental health facility, before expiration of the agreement for any reason, unless the:

    (a) Dismissal or discharge is for just cause; and

    (b) Subscriber is given advance notice of at least 60 days.

  (2) Just cause can exist only when there is:

    (a) Nonpayment;

    (b) Material breach of:

      (i) The agreement, or

      (ii) Written reasonable rules of the provider that contractually bind the subscriber; or

    (c) Health status or behavior that constitutes a substantial threat to the health or safety of the subscriber, other subscribers, or employees or contractors of the provider.

  (3) A notice of termination, dismissal, or discharge shall include at least the following:

    (a) A statement of the intent to terminate, dismiss, or discharge;

    (b) A statement of each reason for terminating, dismissing, or discharging, which shall include at least one of the reasons stated in §B(2) of this regulation;

    (c) The facts that serve as the basis for the provider's decision to terminate, dismiss, or discharge; and

    (d) The effective date of termination, dismissal, or discharge, which shall be at least 60 days from the date the subscriber receives the notice.

  (4) An agreement may recognize that a subscriber may have to be moved without the subscriber's consent in the event of an emergency. A move or transfer of a subscriber because of an emergency may not, in and of itself, establish just cause for a termination, dismissal, or discharge.

C. Permissible Termination, Dismissal, or Discharge. In the event of a termination, discharge, or dismissal of a subscriber who lived with or signed an agreement with another subscriber, who was not terminated, then the subscriber not terminated has the option to:

  (1) Remain as a subscriber under his or her agreement; or

  (2) Terminate his or her agreement.

#### Regulation .26 Individuals Employed or Contracted by Provider.

*COMAR 32.02.02.26*

A. If a provider employs an individual or contracts with an individual to provide services to the provider's subscribers and the individual will enter a subscriber's dwelling or any combination of subscribers' dwellings more than four times in a year to deliver those services, then the provider shall:

  (1) Make sure the individual meets the requirements of §B of this regulation;

  (2) Check at least two character references for the individual to confirm the individual meets the requirements of §B(1)—(5) of this regulation; and

  (3) Have the individual submit the necessary forms and fingerprints needed to conduct a criminal history records check through the Criminal Justice Information System operated by the Department of Public Safety and Correctional Services.

B. An individual who is employed by or contracted by a provider to provide services to a subscriber in the subscriber's dwelling and who will enter a subscriber's dwelling or any combination of subscribers' dwellings more than four times in a year to deliver those services shall:

  (1) Be 18 years old or older;

  (2) Have adequate training, education, or experience to perform the duties assigned;

  (3) Have sufficient physical, emotional, and mental capacity to perform the duties assigned;

  (4) Have no convictions for crimes that have a bearing on the individual's ability to provide services consistent with the well-being of the subscribers;

  (5) Have sufficient moral character to be entrusted with providing services to elderly people who may be physically or mentally infirm;

  (6) Provide the names, addresses, and telephone numbers of at least three references attesting to the individual's meeting the requirements of §B(1)—(5) of this regulation; and

  (7) Be free from communicable diseases, as evidenced by a physician's statement.

#### Regulation .27 Public Information.

*COMAR 32.02.02.27*

A. The Department shall:

  (1) Make the information required to be provided under this chapter available to all interested persons; and

  (2) Publicize the availability of this information.

B. Information will be made available for review to all interested persons under COMAR 32.01.02.

#### Regulation .28 Inspection by the Department.

*COMAR 32.02.02.28*

A. The Department may:

  (1) Inspect any facility used to provide services under a continuing care at home agreement;

  (2) Examine the records of a provider or person that controls a provider; and

  (3) Audit or observe any service rendered under a continuing care at home agreement.

B. A provider shall cooperate with the Department in all reasonable requests to inspect, examine, audit, or observe the provider, a facility, the services, and the records of the provider.

C. If a facility is subject to licensure by MDH, the Department shall coordinate any inspection of a facility with MDH to avoid duplication.

D. Failure of the provider to permit reasonable requests for inspection, examination, or audit is a violation of this chapter.

#### Regulation .29 Removal of Records and Accounts.

*COMAR 32.02.02.29*

A. A provider may not remove from the State records or assets of the provider related to the operation of a facility or the provision of services under continuing care at home agreements without the written consent of the Department.

B. A provider may request from the Department approval to remove records or assets from the State by submitting the verification that the Department requires to establish that removal of records or assets will:

  (1) Facilitate the operations of the provider and make the operations more economical; and

  (2) Not diminish the service or protection given to the provider's subscribers.

C. The Department may not consent to the removal until the Secretary determines that the removal of records and assets meets the conditions of §B of this regulation.

#### Regulation .30 Administrative Sanctions.

*COMAR 32.02.02.30*

A. The Secretary may deny, suspend, or revoke a preliminary, initial, or renewal certificate of registration for cause. Cause for denial, suspension, or revocation includes, but is not limited to the following:

  (1) Violations of the provisions of the Act;

  (2) Violations of regulations in this chapter;

  (3) Misrepresentations of fact to the Department or to subscribers;

  (4) Submission of false financial information to the Department;

  (5) Failure to prepare or implement an adequate corrective financial plan when found to be in financial difficulty; or

  (6) Agreement terms or provisions that:

    (a) Violate the Act,

    (b) Violate regulations in this chapter, or

    (c) Are not approved by the Department.

B. The denial, suspension, or revocation of a certificate of registration is an action of the Secretary that may be appealed in accordance with Regulation .31 of this chapter.

#### Regulation .31 Appeals.

*COMAR 32.02.02.31*

An applicant for, or a holder of, a feasibility study approval, preliminary certificate, initial certificate, or renewal certificate that is aggrieved by a denial of a certificate of registration, by a revocation of a certificate of registration, or by any other action of the Department or Secretary under this chapter, may file a written appeal. An appeal of any action taken by the Department or Secretary under this chapter shall be conducted in accordance with the Maryland Administrative Procedure Act, State Government Article, Title 10, Subtitles 2 and 3, Annotated Code of Maryland, and COMAR 32.01.01.