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10.09.10.00.htm 10.09.10.00. Title 10 MARYLAND DEPARTMENT OF HEALTH Subtitle 09 MEDICAL CARE PROGRAMS Chapter 10 Nursing Facility Services Authority: Health-General Article, §2-104(b) 15-103, 15-105, 19-14B-01, and 19-310.1, Annotated Code of Maryland
10.09.10.01.htm 10.09.10.01. 01 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) "Accrual basis" means recording revenue in the period when earned, regardless of when collected, and recording expenses in the period when incurred, regardless of when paid.2) "Administrative day" means a day of care rendered to a recipient who no longer requires the level of care being provided.3) "Allowable cost" means costs that are includable in the per diem rate an
10.09.10.02.htm 10.09.10.02. 02 License Requirements.. In order to participate in the Program, a provider shall be licensed by the Department, pursuant to Health-General Article, §19-301 et seq. Annotated Code of Maryland, and COMAR 10.07.02, and shall obtain other licenses, as may be required by applicable State and local laws.
10.09.10.03.htm 10.09.10.03. 03 Conditions for Participation.. To participate in the Program, the provider shall:. A. Be certified by the Department at its total licensed nursing facility bed capacity as meeting the requirements of Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq. for participation as a nursing facility;B. Be in compliance with preadmission screening and resident review requirements as described by 42 CFR Part 483, Subpart C (1996)
10.09.10.04.htm 10.09.10.04. 04 Covered Services.. The Program covers routine care and the following supplies, equipment, and services when appropriate to meet the needs of the recipient:A. Those described in the Maryland Department of Health regulations entitled "Requirements for Long Term Care Facilities" 42 CFR Part 483, Subpart B (1996) subject to limitations in Regulation .05 of this chapter.B. Over-the-counter drugs.. C. Bed reservations for recipients who are on a leave of absence to visit w
10.09.10.05.htm 10.09.10.05. 05 Limitations.. The following are not covered:. A. Services by an out-of-State nursing facility unless the Department and the nursing facility execute a provider agreement;B. Audiology services;. C. Services reimbursed under Title XVIII of the Social Security Act; and. D. Services for which payment is made directly to a provider other than the nursing facility..
10.09.10.06.htm 10.09.10.06. 06 Preauthorization Requirements.. A. The Department of Human Services shall certify the recipient for financial eligibility, and the Department or its designee shall certify the recipient as requiring nursing facility services, except as provided in Regulation .26D of this chapter.B. The Department or its designee will certify as requiring nursing facility services only those financially eligible recipients requiring nursing facility services as defined in Regulation .01B of th
10.09.10.07.htm 10.09.10.07. 07 Prospective Rates.. A. A provider shall be paid the prospective rate for nursing facility services as defined in Regulation .01B of this chapter plus the Nursing Facility Quality Assessment add-on identified in Regulation .11E of this chapter.B. When necessary, each facility’s per diem rate shall be reduced by the same percentage to maintain compliance with the Medicare upper payment limit requirement.C. Power wheelchairs and bariatric beds are not included in the prospective
10.09.10.08.htm 10.09.10.08. 08 Interim Working Capital Fund.. A. A provider may request an allotment from the Interim Working Capital Fund if the facility for which an allotment is requested has not had any of the following deficiencies cited in any survey conducted by the Office of Health Care Quality during the calendar year preceding the calculation of the allotment, using the scope and severity matrix found in the Centers for Medicare and Medicaid Services State Operations Manual for Survey and Certific
10.09.10.09.htm 10.09.10.09. 09 Rate Calculation ― Administrative and Routine Costs.. A. The Administrative and Routine cost center includes:. 1) Administrative expenses;. 2) Medical records expenses;. 3) Training expenses;. 4) Dietary;. 5) Laundry;. 6) Housekeeping;. 7) Operation and maintenance; and. 8) Capitalized organization and start-up costs.. B. The Department shall initially establish cost center prices for the rate period January 1, 2015 through June 30, 2015, and thereafter rebase the co
10.09.10.10.htm 10.09.10.10. 10 Rate Calculation ― Other Patient Care Costs.. A. The Other Patient Care cost center includes:. 1) Medical director administrative expenses;. 2) Pharmacy;. 3) Recreational activities;. 4) Patient care consultant services;. 5) Food cost (unprepared). 6) Social services; and. 7) Religious services.. B. The Department shall initially establish Other Patient Care prices for the rate period January 1, 2015, through June 30, 2015, and thereafter rebase the Other Patient Care
10.09.10.11.htm 10.09.10.11. 11 Rate Calculation ― Capital Costs.. A. The Capital cost center includes:. 1) Real estate taxes; and. 2) Fair rental value.. B. Final Capital Cost.. 1) The determination of a provider's allowable final Capital per diem rate for the cost items under §A of this regulation is calculated as follows:a) Appraise each facility at least every 4 years;. b) 2 months before the period for which final Capital rates are being calculated, determine the most recent appraisal for each facility;
10.09.10.12.htm 10.09.10.12. 12 Rate Calculation ― Nursing Service Costs.. A. The Nursing Service cost center includes all nursing expenses related to the direct provision of patient care.B. The Department shall initially establish Nursing Service prices for the rate period January 1, 2015, through June 30, 2015, and thereafter rebase the Nursing Service prices between every 2 and 4 rate years. Prices may be rebased more frequently if the Department determines that there is an error in the data or in the cal
10.09.10.13.htm 10.09.10.13. 13 Ventilator Care Nursing Facilities.. Nursing facilities with licensed nursing facility beds, which have been determined by the Department to meet the standards for ventilator care under COMAR 10.07.02, shall be reimbursed as follows:A. Services for residents receiving ventilator care shall be reimbursed as follows:. 1) The Nursing Service rate identified in Regulation .12 of this chapter shall be calculated with a facility average Medicaid case mix index that incl
10.09.10.14.htm 10.09.10.14. 14 Pay-for-Performance ― Eligibility.. In order to be eligible to receive funds through the pay-for-performance program under the provisions of Regulations .15―19 of this chapter:A. The provider shall be subject to quality assessment under COMAR 10.01.20; and. B. During the 1 year period ending March 31 of the prior State fiscal year, the provider may not have been:1) Identified by the federal Centers for Medicare and Medicaid Services as a special focus facility;.
10.09.10.15.htm 10.09.10.15. 15 Pay-for-Performance ― Quality Measures.. A. Providers shall receive a composite score based on the following:. 1) Staffing levels and staff stability, as described in §B and C of this regulation, shall comprise 40 percent of each facility’s score;2) Maryland Health Care Commission Nursing Facility Family Survey, as described in §D of this regulation, shall comprise 40 percent of each facility’s score;3) Minimum Data Set Clinical Quality Indicators, as described in §E of this
10.09.10.16.htm 10.09.10.16. 16 Pay-for-Performance ― Scoring Methodology.. A. Facilities that are eligible for pay-for-performance under Regulation .14 of this chapter shall receive a score for each quality measure described in Regulation .15 of this chapter.B. For the quality measures described in Regulation .15B―E of this chapter, a facility is ranked and awarded points as follows:1) The highest ranked facility receives 100 percent of the points available;.
10.09.10.17.htm 10.09.10.17. 17 Pay-for-Performance ― Payment for Improvement.. A. In order to be eligible for improvement payment, a facility:. 1) Shall meet the eligibility criteria specified in Regulation .14 of this chapter;. 2) Shall be eligible and receive a composite score during the current fiscal year and the prior fiscal year; and3) May not be receiving a payment based upon its score as described in Regulation .19C of this chapter.B. Facilities shall be ranked according to the gre
10.09.10.18.htm 10.09.10.18. 18 Pay-for-Performance ― Scoring Data Review.. A. The Department shall report scores for pay-for-performance quality measures in Regulation .15 of this chapter, on or about July 1 of each year, based on data compiled during the prior fiscal year.B. A facility shall have 30 days from the date of the report to review and comment on performance data.C. If the Department determines that there are any errors in transcription of the data provided to the Department, or calcula
10.09.10.19.htm 10.09.10.19. 19 Pay-for-Performance ― Payment Distribution.. A. During State fiscal year 2011, 0.2445 percent of the budget allocation for nursing facility services shall be distributed based on pay-for-performance scores.B. Beginning State fiscal year 2012, and each year thereafter, 0.5 percent of the budget allocation for nursing facility services shall be distributed based on pay-for-performance scores.C. Eighty-five percent of the amount identified in §A or B of this regulati
10.09.10.20.htm 10.09.10.20. 20 Payment Procedures ― Out-of-State Facilities.. A. Out-of-State nursing facilities that are not special rehabilitation nursing facilities and do not meet the exception to cost reporting requirements set forth in Regulation .21M of this chapter shall be reimbursed at a rate that is the lesser of:1) The average Statewide quarterly rate identified by Regulation .07 of this chapter for in-State nursing facilities minus the quality assessment; and2) The out-of-State facil
10.09.10.21.htm 10.09.10.21. 21 Cost Reporting.. A. The provider shall include, for purposes of cost finding, direct and indirect costs applicable to recipient care.B. The provider shall specifically identify, in the cost report, costs associated with related organizations.C. The provider shall maintain adequate financial records and statistical data according to generally accepted accounting principles and procedures. This system of accounts will provide as a minimum:1) Maintenance of a chron
10.09.10.22.htm 10.09.10.22. 22 Desk Reviews and Field Verification.. A. Desk Reviews.. 1) The Department or its designee may conduct a desk review of the costs before establishing the Administrative and Routine and Other Patient Care prices and Nursing Service rates.2) The Department or its designee shall notify each provider participating in the Program if any adjustments resulted from the desk review.3) Desk review adjustments shall be used in the computation of any future rate for the facility or t
10.09.10.23.htm 10.09.10.23. 23 Third Party Liability Reviews and Audits of Nursing Facilities.. A. Quarterly Reports of Credit Balances. A provider shall report the credit balances of the nursing facility to the Department on a quarterly basis.B. Third Party Liability Review. The Department shall conduct a third party liability review of the reports of the credit balances provider under §A of this regulation.C. Third Party Liability Audit of Random Sample. The Department or its designee may conduct a third
10.09.10.24.htm 10.09.10.24. 24 MDS Validation and Ventilator Care Validation.. A. MDS Validation.. 1) In order to validate that the Nursing Service rate is supported by medical record documentation, accurately coded and submitted, the Department shall conduct periodic MDS validation reviews, which shall:a) Compare the MDS assessment coding with the corresponding medical record documentation to determine unsupported MDS assessments;b) Determine the completeness, timeliness, and accuracy of resident MDS ass
10.09.10.25.htm 10.09.10.25. 25 New Nursing Facilities, Replacement Facilities, and Change of Ownership.. A. The Department shall establish rates for new nursing facilities, replacement facilities, and nursing facilities with a change of ownership as outlined in §B―D of this regulation.B. New Nursing Facilities.. 1) Until such time as an appraisal for the new facility is available as set forth in Regulation .11B(1)b) of this chapter, the fair rental value per diem rate shall be based on the lower of the facili
10.09.10.26.htm 10.09.10.26. 26 Selected Costs ― Allowable.. A. Recreational Services. The allowable costs of recreational services of a facility shall be based on an hourly or salary rate, not on a fee-for-service basis.B. Over-the-Counter Drugs. The cost of over-the-counter drugs is not to exceed the average wholesale price plus 50 percent, or the usual selling price, whichever is lower.C. Leave of Absence. The Department shall pay the sum of the rates identified in Regulations .09―11
10.09.10.27.htm 10.09.10.27. 27 Selected Costs ― Not Allowable.. The following costs are not allowable in establishing prospective rates:. A. Costs not adequately documented;. B. Costs for chaplaincy training and other religious training programs;. C. Bad debts incurred by private pay or Medicare patients or third-party payers and bad debts resulting from denied costs of the Program;D. Recipient resources certified as available for medical and remedial care by the Department of Human Services which are unc
10.09.10.28.htm 10.09.10.28. 28 Recipient's Resource.. A. The Department of Human Services will determine the application of a recipient's resource to the cost of medical or remedial care pursuant to COMAR 10.09.24.B. The provider shall collect a recipient's resource available for medical or remedial care, as certified by the Department of Human Services.C. The total of a recipient's available resource for medical or remedial care and the Department's payment may not exceed the provider's per diem rate.
10.09.10.29.htm 10.09.10.29. 29 Recipient's Personal Needs Fund.. A. If a provider administers a recipient's personal needs fund, it shall administer the fund according to guidelines established by the Department.B. Upon request during normal business hours, a provider shall make available for verification by the Department or its designee the records of all transactions involving recipient's personal needs funds.C. A provider may not use a recipient's personal needs fund for care or ser
10.09.10.30.htm 10.09.10.30. 30 Reimbursement Classes.. A. The reimbursement classes for the Administrative and Routine cost center are as follows:. 1) Facilities in the Baltimore metropolitan region consisting of the following counties:. a) Anne Arundel,. b) Baltimore,. c) Carroll,. d) Harford, and. e) Howard;. 1-1) Facilities in Baltimore City;. 2) Facilities in the Washington region consisting of the following counties:. a) Charles,. b) Montgomery, and. c) Prince George's;.
10.09.10.31.htm 10.09.10.31. 31 Nursing Service Personnel and Procedures.. A. Personnel Types and Category Groupings.. Selected Personnel Types. Personnel Categories. Director of nursing (RN or LPN). Directors of nursing (DON). Assistant director of nursing (RN or LPN). RN charge nurse. Registered nurses (RN). RN staff nurse. RN relief nurse. Registry RN charge nurse. Registry RN staff nurse. LPN charge nurse. Licensed practical nurses (LPN). LPN staff nurse. LPN relief nurse. Registry LPN charge nurse.
10.09.10.32.htm 10.09.10.32. 32 Recovery and Reimbursement.. A. If the recipient has insurance or other coverage, or if any other person is obligated, either legally or contractually, to pay for or to reimburse the recipient for any service covered by this chapter, the provider shall seek payment from that source first. If an insurance carrier rejects the claim or pays less than the amount allowed by the Medical Assistance Program, the provider may submit a claim to the Program. The provider shall submit a
10.09.10.33.htm 10.09.10.33. 33 Cause for Suspension or Removal and Imposition of Sanctions.. A. If the Department determines that a provider, any agent or employee of the provider, or any person with an ownership interest in the provider has failed to comply with applicable federal or State laws or regulations, the Department may initiate one or more of the following actions against the responsible party:1) Suspension from the Program;. 2) Withholding of payment by the Program;. 3) Removal from the Program;.
10.09.10.34.htm 10.09.10.34. 34 Appeal Procedures.. A. Except as provided for in §B of this regulation, providers filing appeals from administrative decisions made in connection with these regulations shall do so according to COMAR 10.09.36.09.B. Nursing Home Appeal Board.. 1) Appeals regarding rate calculations or cost report adjustments which cannot be resolved administratively go to the Nursing Home Appeal Board.2) The Appeal Board shall be composed of the following members:.
10.09.10.35.htm 10.09.10.35. 35 Interpretive Regulation.. Except when the language of a specific regulation indicates an intent by the Department to provide reimbursement for covered services to Program recipients without regard to the availability of federal financial participation, State regulations shall be interpreted in conformity with applicable federal statutes and regulations.
10.09.10.9999.htm 10.09.10.9999. Administrative History Effective date: July 9, 1975 (2:15 Md. R. 1070). Regulation .03E amended effective January 30, 1976 (3:4 Md. R. 216). Regulation .03H amended effective December 31, 1975 (3:4 Md. R. 216). Regulation .03Q adopted as an emergency provision effective July 1, 1977 (4:15 Md. R. 1143) adopted permanently effective October 21, 1977 (4:22 Md. R. 1671)Regulation .03X amended effective September 29, 1976 (3:20 Md. R. 1143).
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