Skip to Main Content
<< Back | Return to Main COMAR Search Page

20 records match your request.

FileAbstract
10.09.69.00.htm 10.09.69.00. Title 10 MARYLAND DEPARTMENT OF HEALTH Subtitle 09 MEDICAL CARE PROGRAMS Chapter 69 Maryland Medicaid Managed Care Program: Rare and Expensive Case Management Authority: Health-General Article, §15-102.1(b)1) and 15-103(b)4)i) Annotated Code of Maryland
10.09.69.01.htm 10.09.69.01. 01 Purpose.. A. The purpose of the Rare and Expensive Case Management (REM) program is to provide case management services and subspecialty care for Maryland Medicaid Managed Care Program eligible individuals with rare and expensive conditions.B. The program is designed to provide Maryland Medicaid Managed Care Program eligible individuals diagnosed with qualifying rare and expensive conditions the following benefits when the individual elects to participate in the program:
10.09.69.02.htm 10.09.69.02. 02 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) "Activities of daily living" means tasks or activities that include but are not limited to bathing, feeding, toileting, dressing, and ambulation.2) "Business day" means any day except Saturday, Sunday, or a holiday on which State offices are closed.3) "Caregiver" means a willing and able individual who is trained in providing care to the participant.4) "Case management" mean
10.09.69.03.htm 10.09.69.03. 03 REM Eligibility.. A. An individual is eligible to participate in the REM program if the individual:. 1) Is eligible for Maryland Medicaid Managed Care as specified in COMAR 10.09.63.01;. 2) Has one or more of the diagnoses specified in Regulation .17 of this chapter; and. 3) Elects to participate in the REM program.. B. The Department shall render a determination of an individual's eligibility within 5 business days on receipt of:1) A completed REM application;.
10.09.69.04.htm 10.09.69.04. 04 Participant Enrollment and Disenrollment.. A. Anyone may refer an individual into the REM program including, but not limited to a:. 1) Family member;. 2) Physician;. 3) Discharge planner;. 4) Hospital;. 5) Clinic;. 6) Social worker; and. 7) Managed care organization (MCO). B. The Department shall enroll an individual determined eligible in the REM program when:. 1) All pertinent documentation regarding needed medical services is received, reviewed, and approved;
10.09.69.05.htm 10.09.69.05. 05 Benefits.. A REM participant is eligible for the following:. A. Fee-for-service Medical Assistance benefits available to a Medical Assistance participant not enrolled in an MCO;B. Services described in Regulations .10 and .11 of this chapter when determined medically necessary by the Department;C. A case management assessment performed by a REM case manager who shall:. 1) Gather all relevant information needed to determine the participant’s condition and needs includi
10.09.69.06.htm 10.09.69.06. 06 Requirements for Provider Qualification.. A. A case manager providing case management under this chapter shall be:. 1) An RN; or. 2) A social worker.. B. The following professionals providing services under this chapter to REM participants shall be licensed, certified, or otherwise legally authorized to practice in the jurisdiction in which the services are rendered:1) Physicians;. 2) Physician Assistants;. 3) Nurse Practitioners;. 4) RNs and LPNs;. 5) Chiropractors;.
10.09.69.07.htm 10.09.69.07. 07 Conditions for Participation ― General Requirements.. A provider rendering services pursuant to this chapter shall:. A. Meet the applicable conditions for participation set forth in COMAR 10.09.36;. B. Meet the provider qualification requirements specified in Regulation .06 of this chapter for its provider type;C. Meet the specific conditions for provider participation set forth in this chapter;. D. Provide services in accordance with the applicable requirements of this
10.09.69.08.htm 10.09.69.08. 08 Specific Conditions for Provider Participation.. A. Case Management Providers. To participate in the Program, a case management provider shall meet the conditions set forth in Regulations .06 and .07 of this chapter.B. Chiropractic Service Providers. To participate in the Program, the chiropractic service provider shall:1) Meet the:. a) Conditions set forth in Regulation .07 of this chapter; and. b) Requirements for chiropractic providers specified in COMAR 10.43.04;.
10.09.69.09.htm 10.09.69.09. 09 Covered Services ― General Requirements.. For participants in the REM program, the Program covers and shall reimburse for services specified in Regulations .10 and .11 of this chapter when these services are:A. Medically necessary;. B. Prescribed by a:. 1) Physician;. 2) Physician assistant; or. 3) Nurse practitioner;. C. Preauthorized, when required, by the Department;. D. Rendered in accordance with accepted health professional standards;. E. Rendered in accordance
10.09.69.10.htm 10.09.69.10. 10 Covered Services.. A. Chiropractic services are covered for REM participants when:. 1) Services are provided to a REM participant who is 21 years old or older;. 2) Services are provided by a physician or chiropractor;. 3) The qualifying REM diagnosis or related illness shows deterioration or worsening symptoms and other traditional treatments have been ineffective;4) The treatment enhances or restores the participant's level of functioning; or. 5) Symptoms resulting fro
10.09.69.11.htm 10.09.69.11. 11 Covered Optional Services ― Private Duty Nursing, Certified Nursing Assistant, Certified Nursing Assistant Certified as a Certified Medication Technician, Home Health Aide and Home Health Aide Certified as a Certified Medication Technician.A. The Program shall cover shift nursing services provided by an RN or LPN when:. 1) The services are more individualized and continuous than what is available under the home health program;2) The services are delivered to the participant i
10.09.69.12.htm 10.09.69.12. 12 Limitations.. A. The Department shall pay for services specified in this chapter delivered to a REM participant only if the services have been ordered by the participant's physician or nurse practitioner, and preauthorized, when necessary, by the Department or its designee.B. For REM participants, the Department may not pay for the following comparable case management services:1) HIV targeted case management as described in COMAR 10.09.32, except for HIV Diagnostic Evaluation
10.09.69.13.htm 10.09.69.13. 13 Preauthorization Requirements.. A. Except for initial assessments unless otherwise specified, preauthorization by the Department or its designee is required for all services under Regulations .10 and .11 of this chapter.B. The Department or its designee shall issue preauthorization when the Department:. 1) Determines that services are medically necessary; and. 2) Authorizes the services before the initiation or continuance of the requested service..
10.09.69.14.htm 10.09.69.14. 14 Payment Procedures ― Request for Payment.. A. A provider shall submit a request for payment for the services covered under this chapter according to the procedures set forth in COMAR 10.09.36.B. Billing time limitations for the services covered under this chapter are the same as those set forth in COMAR 10.09.36.C. The Department shall pay for covered services at the lower of:. 1) The lowest price, including negotiated contract prices, that is offered to any other purchaser fo
10.09.69.15.htm 10.09.69.15. 15 Recovery and Reimbursement.. Recovery and reimbursement under this chapter are set forth in COMAR 10.09.36..
10.09.69.16.htm 10.09.69.16. 16 Cause for Suspension or Removal and Imposition of Sanctions.. Cause for suspension or removal and imposition of sanctions is set forth in COMAR 10.09.36..
10.09.69.17.htm 10.09.69.17. 17 Table of Rare and Expensive Disease Diagnosis.. ICD10. ICD 10 Description. Age Limit. B20. Human immunodeficiency virus (HIV) disease. 0―20. C96.0. Multifocal and multisystemic Langerhans-cell histiocytosis. 0―64. C96.5. Multifocal and unisystemic Langerhans-cell histiocytosis. C96.6. Unifocal Langerhans-cell histiocytosis. D61.01. Constitutional (pure) red blood cell aplasia. D61.09. Other constitutional aplastic anemia. D66. Hereditary factor VIII deficiency. D67.
10.09.69.18.htm 10.09.69.18. 18 Appeals Procedures.. Appeal procedures are as set forth in COMAR 10.01.04 and 10.09.36..
10.09.69.9999.htm 10.09.69.9999. Administrative History Effective date:. Regulations .01―17 adopted as an emergency provision effective November 8, 1996 (23:25 Md. R. 1730). Regulations .01―17 adopted effective March 10, 1997 (24:5 Md. R. 408). Regulations .01, .02, .05, .06, .08―11, and .13 amended as an emergency provision effective July 1, 1997 (24:16 Md. R. 1151) emergency status expired December 31, 1997Regulation .01 amended effective February 9, 1998 (25:3 Md. R. 144). Regulations .01, .02, and
<< Back | Return to Main COMAR Search Page