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10.09.78.00.htm 10.09.78.00. Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 78 Establishment, Operation, and Authority for Making Capitated Payments for Dual Eligibles Enrolled in Medicare Advantage Plans Authority: Health-General Article, §2-104(b) and 15-103(a) Annotated Code of Maryland
10.09.78.01.htm 10.09.78.01. 01 Scope.. This chapter governs payment of Medicare Part A and B cost sharing for qualified Medicare beneficiaries (QMBs) and full dual eligibles enrolled in Medicare Advantage Plans.
10.09.78.02.htm 10.09.78.02. 02 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) "Applicant" means a Medicare Advantage Plan that seeks approval from the Department to receive payment of Medicare Parts A and B cost sharing for QMBs and full dual eligibles.2) "Capitation payment" means the sum of money paid on a monthly per capita basis to a Medicare Advantage Plan by the Department on an enrollee's behalf for Medicare Parts A and B cost sharing for QMB
10.09.78.03.htm 10.09.78.03. 03 Application for Qualification as a Medicare Advantage Plan for Payment of Cost Sharing for QMBs and Full Dual Eligibles.A. To apply for participation in the Program as a Medicare Advantage Plan, an applicant shall submit an application to the Secretary using the form required by the Department.B. The Department shall review the materials submitted by the applicant and make a determination to grant or deny the application within 60 days.C. The duration or term o
10.09.78.04.htm 10.09.78.04. 04 Provider Qualifications.. A. To participate in the Program as a CMS approved Medicare Advantage Plan, an entity shall be a Medicare Advantage Plan as defined in Title XVIII, Part C of the Social Security Act.B. The Medicare Advantage Plan shall agree to indemnify and hold the Department harmless, up to the amount of any deductibles or coinsurance payments unpaid by the Medicare Advantage Plan, if CMS or any court of competent jurisdiction later determines that the Department did
10.09.78.05.htm 10.09.78.05. 05 Covered Services.. A. In exchange for receiving the monthly capitation payment from the Department, the Medicare Advantage Plan shall be responsible for paying subcontractors and non-contracted providers directly for any and all Medicare copayments, coinsurance, and deductibles, in accordance with §1902(a)10)E)i) and 1905(p)3) of the Social Security Act and the Medicare Advantage Plan's benefit package. Cost sharing does not include Medicare premiums that the Depar
10.09.78.06.htm 10.09.78.06. 06 Subcontractual Relationships.. A. The Medicare Advantage Plan shall notify its subcontractors, by a provider manual, provider bulletin, or other contractual document, that they may not seek additional payments for cost sharing from the Department, QMBs, or full dual eligibles enrolled in the Medicare Advantage Plan.B. The Medicare Advantage Plan shall provide the Department with a copy of such written notice..
10.09.78.07.htm 10.09.78.07. 07 Payment Procedures.. A. The Department shall:. 1) Issue a monthly fixed capitation payment to the Medicare Advantage Plan on behalf of each of its enrollees of $110 for calendar year 2009;2) Provide monthly listings of capitation payments made for each enrollee; and. 3) Provide monthly information on retroactive enrollments and adjustments.. B. Capitation payments shall be issued by the Department upon receipt of information from CMS confirming enrollment of QMBs a
10.09.78.08.htm 10.09.78.08. 08 Recovery and Reimbursement.. Recovery and reimbursement under this chapter are as set forth in COMAR 10.09.36.07..
10.09.78.09.htm 10.09.78.09. 09 Cause for Suspension or Removal and Imposition of Sanctions.. A. Cause for suspension or removal and imposition of sanctions under this chapter are as set forth in COMAR 10.09.36.08.B. If the Department determines after a sufficient investigation that the Medicare Advantage Plan, any agent or employee of the Medicare Advantage Plan, any person with an ownership interest of 5 percent or more in the Medicare Advantage Plan, or a related party of the Medicare Advantage Plan has fa
10.09.78.10.htm 10.09.78.10. 10 Appeal Procedures.. Appeal procedures under this chapter are as set forth in COMAR 10.01.03..
10.09.78.11.htm 10.09.78.11. 11 Interpretive Regulation.. Interpretation of this chapter is subject to COMAR 10.09.36.10..
10.09.78.9999.htm 10.09.78.9999. Administrative History Effective date: April 1, 2009 (36:6 Md. R. 490).
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