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);

C. Be in compliance with the requirements of COMAR 10.09.36;

D. Be approved for participation by the Department;

E. Have a provider agreement in effect;

F. Employ an organized medical staff or a medical director who is a licensed physician;

G. Provide, according to the needs of the recipient, those services listed in Regulation .04 of this chapter;

H. Accept payment by the Department as payment in full for covered services rendered and make no additional charge to any person for covered services except as provided for in Regulation .28 of this chapter;

I. Maintain adequate records for a minimum of 6 years and make them available, upon request, to the Department or its designee;

J. Provide services without regard to race, color, age, sex, national origin, marital status, physical or mental handicap;

K. Verify the recipient's eligibility;

L. Place no restriction on a recipient's right to select providers of his choice;

M. Have in effect a predischarge plan;

N. Agree that if the Program denies payment or requests repayment on the basis that an otherwise covered service was not medically necessary or preauthorized in accordance with Regulation .06 of this chapter, the provider may not seek payment for that service from the recipient;

O. Perform utilization control functions for all recipients designated eligible for nursing facility services as described by 42 CFR §§346.370, 456.360, 456.371, 456.380, and 456.381 (1996), and as required by the Utilization Control Plan for Selected Institutional Services Reimbursed by the Maryland Medical Assistance Program;

P. Notify the Department or its designee of patient activity or circumstance that affects placement, eligibility, or reimbursement on such form and at such time as specified by the Department;

Q. Before discharging any Medical Assistance recipient certified as requiring nursing facility services, place in the recipient's permanent medical record the following information on a consent form designated by the Department, a copy of which shall be submitted to the Department and to the Office on Aging:

(1) A certification that the recipient or guardian has:

(a) Been informed of the recipient's right to remain in the discharging facility and have the cost of care paid by the Medical Assistance Program;

(b) Been informed that the Medical Assistance Program will not pay for room and board in a setting outside of a nursing facility and that the Program may pay for the cost of medical services received outside of a nursing facility subject to medical and financial eligibility determinations and covered services limitations;

(c) Been informed of the recipient's right as a patient, as stated in the Health-General Article, §19-345, Annotated Code of Maryland;

(d) Been informed of the services provided by and the location of the alternative placement;

(e) Voluntarily given informed consent to the transfer;

(2) If the recipient or guardian is unable or unwilling to sign the consent form, submit to the Department a written explanation of the reason written consent was not obtained, a copy of which shall be placed in the recipient's medical record;

R. Agree that if the Program denies payment due to late billing, the provider may not seek payment from the recipient;

S. Include in all contracts with a cost or value over a 12-month period of $10,000 or more, with any subcontractor, a clause allowing the Department or its agent access to the subcontractor's books, documents, and records which are necessary to verify the nature and extent of costs of the services furnished under the contract in accordance with the principles established under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq., and contained in the Medicare Provider Reimbursement Manual, HCFA Publication 15-1;

T. Meet the requirements in the Certificate of Need application approved by the Maryland Health Resources Planning Commission;

U. Notify the Medical Assistance Program, in writing, of the contemplated sale of the facility or a controlling interest not less than 30 days before the date of the change of ownership;

V. Assure that an individual who is eligible for Medical Assistance at the time of application for admission to a nursing home, or would become eligible within 6 months following admission, has a long-term care assessment made available before admission, at no charge to the individual, pursuant to COMAR 10.09.30. The evaluation is advisory only and may not restrict the right of an individual to select nursing home services; and

W. Not less than 30 days before the date of any change of ownership, except when the Program agrees to a shorter period, provide the Department the notification and indemnity bond, letter of credit, or certificate of assurance required by Regulation .25D(1)—(3) of this chapter.