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10.09.69.00.htm 10.09.69.00. Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE 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. Definitions of terms for this chapter are specified in COMAR 10.09.62.. B. Additional Terms Defined. "Cause" means a significant change in medical condition such that it is no longer medically efficacious for the individual to remain in the MCO as determined by the Department.
10.09.69.03.htm 10.09.69.03. 03 Eligibility.. A. An individual is eligible to participate in the REM program if the individual:. 1) Is eligible for Maryland Medicaid Managed Care;. 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;. 2) Any requested documentation verifying an indivi
10.09.69.04.htm 10.09.69.04. 04 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 and reviewed;.
10.09.69.05.htm 10.09.69.05. 05 Benefits.. A REM participant is eligible for the following:. A. Fee-for-service Medicaid benefits available to a Program recipient 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 including the participant's medi
10.09.69.06.htm 10.09.69.06. 06 Requirements for Provider Licensing or Certification.. A. A case manager providing case management service under this chapter shall be a:. 1) Licensed registered nurse who is qualified to practice in the State; or. 2) Licensed social worker who is qualified to practice in the State.. B. The following professionals providing fee-for-service or optional services under this chapter to REM participants shall be licensed or certified to practice in the jurisdic
10.09.69.07.htm 10.09.69.07. 07 Conditions for Participation ― General Requirements.. An individual, agency, or provider rendering services or medical care pursuant to this chapter shall:A. Meet the applicable conditions for participation set forth in COMAR 10.09.36;. B. Meet the licensure and certification 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 ac
10.09.69.08.htm 10.09.69.08. 08 Specific Conditions for Provider Participation.. A. Chiropractic Service Providers. To participate in the Program, the chiropractic service provider shall:1) Meet the conditions set forth in Regulation .07 of this chapter;. 2) Develop a goal-directed treatment plan that is based on an evaluation conducted during the initial assessment, unless the Department determines a more frequent review period is appropriate, which includes but is not limited to:
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. Physician prescribed;. C. Preauthorized, when required, by the Department;. D. Rendered in accordance with accepted health professional standards;. E. Rendered in accordance with the treatment plan or physician's order, or both; and.
10.09.69.10.htm 10.09.69.10. 10 Covered Optional 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 licensed physician or licensed chiropractor;. 3) The qualifying REM diagnosis or related illness shows a deterioration or unrelieved worsening symptoms and other traditional treatments have been i4) The treatment enhances or restores the participant's level of functioning; or.
10.09.69.11.htm 10.09.69.11. 11 Covered Optional Services ― Private Duty Nursing, Certified Nursing Assistant, and Home Health Aide.A. The Program shall cover shift nursing services provided by a licensed registered nurse or a licensed practical nurse when:1) The complexity of the service or the condition of a participant requires the judgment, knowledge, and skills of a licensed nurse for a shift of 4 or more continuous hours;2) The services are delivered to the participant in the participant's home,
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 service has been recommended by the participant's case manager, ordered by the participant's physician, and preauthorized, when necessary, by the Department.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
10.09.69.13.htm 10.09.69.13. 13 Preauthorization Requirements.. A. The Department or its designee shall preauthorize all services covered in Regulations .10 and .11 of this chapter with the exception of initial assessments unless otherwise specified.B. The Department 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.
10.09.69.9999.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
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