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10.09.44.00.htm 10.09.44.00. Title 10 MARYLAND DEPARTMENT OF HEALTH Subtitle 09 MEDICAL CARE PROGRAMS Chapter 44 Programs of All-Inclusive Care for the Elderly (PACE) Authority: Health-General Article, §2-104(b) 15-103, and 15-105, Annotated Code of Maryland
10.09.44.01.htm 10.09.44.01. 01 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) "Community spouse" means an individual who:. a) Lives in the community outside a long-term care facility;. b) Is not determined to meet the criteria for participation for:. i) PACE under this chapter; or. ii) A waiver under §1915(c) of the Social Security Act; and. c) Is married to an institutionalized spouse.. 2) "Continuous period of institutionalization" mea
10.09.44.02.htm 10.09.44.02. 02 Application for Qualification as a PACE Provider.. An applicant for participation in the Program as a PACE provider shall submit to the Department and CMS a complete PACE application that describes how the entity meets all requirements in 42 CFR 460 et seq.
10.09.44.03.htm 10.09.44.03. 03 PACE Provider.. A. Only one PACE provider may operate in the State.. B. The PACE provider shall comply with:. 1) 42 CFR 460 et seq.. 2) This chapter;. 3) The provider agreement signed with the Department;. 4) COMAR 10.09.36;. 5) Standards in P.L. 101-330, Americans with Disabilities Act of 1990, 42 U.S.C. §12101 et seq.. 6) Any other applicable regulations, transmittals, and guidelines issued by the Department that are in effect; and
10.09.44.04.htm 10.09.44.04. 04 Term of the Provider Agreement.. A. The duration or term of the agreement between the Department and the PACE provider is specified in the provider agreement.B. The provider agreement shall provide for automatic amendment, renegotiation, or termination, or all of the above, of the provider agreement by either party if any part of the provider agreement's provider benefit package is changed under the State Plan.C. Termination..
10.09.44.05.htm 10.09.44.05. 05 Participant Eligibility.. A. An eligible person shall:. 1) Reside in the PACE approved service area upon enrollment;. 2) Be 55 years old or older;. 3) Be able to be maintained in a community-based setting with the assistance of PACE at the time of enrollment without jeopardizing the participant's health or others' health or safety;4) Be determined by the Department to need the level of care required under the State Plan for coverage of nursing facility services for longer than 4
10.09.44.06.htm 10.09.44.06. 06 Participant Enrollment.. A. The Department shall enroll eligible persons who have chosen to enroll in the PACE provider.. B. The PACE provider shall enter into an enrollment agreement with a qualified recipient on the form approved by the Department.C. The PACE provider shall enroll eligible recipients in the order in which they apply, and may not discriminate on the basis of health status in its enrollment, re-enrollment, or disenrollment procedures.
10.09.44.07.htm 10.09.44.07. 07 Termination of Participant's Enrollment.. A. Termination of a participant's enrollment may be initiated by the:. 1) PACE provider;. 2) Department;. 3) Participant; or. 4) Participant's legal guardian or legal representative.. B. All enrollment terminations require prior approval by the Department.. C. General Requirements for Processing Disenrollments.. 1) The Department shall establish a monthly cut-off date for the receipt of disenrollment forms as fa) Disenrollments receive
10.09.44.08.htm 10.09.44.08. 08 Participant Rights.. The PACE provider shall ensure notification and protection of the rights of enrollees according to 42 CFR §460.110 and 42 CFR §460.112.
10.09.44.09.htm 10.09.44.09. 09 Covered Services.. A. Except as limited or expanded by the PACE benefit package specified in the PACE program agreement, the PACE provider shall directly provide, arrange, purchase, or otherwise make available, as medically necessary and appropriate, the services specified in the State Plan and the PACE benefit package.B. The PACE benefit package for all participants, regardless of the source of payment, shall include the following:
10.09.44.10.htm 10.09.44.10. 10 Limitations on Coverage.. Limitations on coverage are as specified in the PACE program agreement and 42 CFR §460.96..
10.09.44.11.htm 10.09.44.11. 11 Authorization Requirements.. The PACE provider shall obtain approval by the Department before any changes in the following:. A. Service contract agreements;. B. PACE provider benefit package;. C. PACE provider's service area;. D. PACE provider's enrollment limit;. E. PACE provider agreement; or. F. PACE provider structure..
10.09.44.12.htm 10.09.44.12. 12 Marketing and Information.. A. The PACE provider agreement shall specify the methods by which the PACE provider will assure the Department that its marketing plans, procedures, and materials are accurate and do not mislead, confuse, or defraud the Department or potential participants.B. The PACE provider's marketing plan and all marketing procedures and materials require approval by the Department before implementation and utilizatC. The PACE provider may not participate in:.
10.09.44.13.htm 10.09.44.13. 13 Quality Assurance and Improvement Systems.. A. The PACE provider shall comply with 42 CFR Part 460, Subpart H (Quality Assessment and Performance Improvement)B. The PACE provider shall comply with requirements designated by the Department..
10.09.44.14.htm 10.09.44.14. 14 Record Keeping.. The PACE provider shall comply with 42 CFR §460.210..
10.09.44.15.htm 10.09.44.15. 15 Reports and Data Collection.. A. The PACE provider shall collect and submit to the Department service-specific encounter data by service type in the format and at the frequency designated by the Department and in conformance with the Department's computer coding requirements.B. The PACE provider shall prepare and submit to the Department reports related to third-party liability as required by Regulation .20 of this chapter.C. The PACE provider shall immediately notify the
10.09.44.16.htm 10.09.44.16. 16 Confidentiality.. A. Subject to the requirements of 42 CFR Part 431 Subpart F, the PACE provider and its contractors may not release or disclose any information concerning a participant to anyone other than the Department except with the written permission of the:1) Participant; or. 2) Participant's attorney, legal representative, or legal guardian.. B. For all information, records, data, and data elements collected and maintained by the PACE provider to facilitate operatio
10.09.44.17.htm 10.09.44.17. 17 Financial Solvency.. The PACE provider shall comply with 42 CFR §460.80 and 42 CFR §460.208..
10.09.44.18.htm 10.09.44.18. 18 Subcontractual Relationships.. A. Consistent with this chapter, the PACE provider, in performing its obligations under this chapter and the PACE program agreement, may either engage its own employees and agents or utilize the services of persons, firms, and other entities by means of contractual relationships.B. The PACE provider shall have a contractor agreement for all services which are not provided directly by the PACE provider through its own employees and agents.
10.09.44.19.htm 10.09.44.19. 19 Internal Grievance Procedure.. The PACE provider shall comply with the grievance procedures described at 42 CFR §460.120―124..
10.09.44.20.htm 10.09.44.20. 20 Third-Party Liability.. A. The PACE provider shall identify and collect money owing from responsible third parties liable for the cost of health care services furnished by the PACE provider to its participants.B. Upon request from the Department, the PACE provider shall convey any information regarding third-party liability to the Department and the U.S. Department of Health and Human Services.C. If both the Department and the PACE provider have a right of subrogation
10.09.44.21.htm 10.09.44.21. 21 Payment Rates and Procedures.. A. The Department shall:. 1) Pay the PACE provider for each participant based on the fixed capitation payment or payments specified in the provider agreement for the PACE provider benefit package; and2) Calculate the PACE provider's capitation payment or payments as a percentage of the cost to the program specified in the provider agreement of providing the same benefit package on a fee-for-service basis to an actuarially equivalent nonenrolled g
10.09.44.22.htm 10.09.44.22. 22 Payment for Emergency Services.. A. The PACE provider shall be responsible for prompt payment for all emergency services received by participants.B. If a claim is submitted to the PACE provider within 9 months of the date of service, the PACE provider shall reimburse a hospital emergency facility and provider, without requiring prior authorization or approval for payment from the PACE provider, for:1) Emergency services;. 2) Medical screening services rendered at an emerg
10.09.44.23.htm 10.09.44.23. 23 Cause for Suspension or Removal and Imposition of Sanctions.. Cause for suspension or removal and imposition of sanctions under this chapter are set forth in COMAR 10.09.36.08.
10.09.44.24.htm 10.09.44.24. 24 Appeal Procedures.. A. The PACE provider shall comply with 42 CFR §460.122.. B. PACE provider appeal procedures under this chapter are set forth in COMAR 10.09.36.09.. C. PACE participant appeals are set forth in COMAR 10.09.24.13..
10.09.44.25.htm 10.09.44.25. 25 Interpretive Regulation.. Interpretation of this regulation is subject to COMAR 10.09.36..
10.09.44.9999.htm 10.09.44.9999. Administrative History Effective date:. Regulations .01―25 adopted as an emergency provision effective November 1, 2002 (29:25 Md. R. 1979) adopted permanently effective April 28, 2003 (30:8 Md. R. 540)Regulation .01B amended effective October 14, 2013 (40:20 Md. R. 1652).
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