Current through Register Vol. 51, No. 19, September 20, 2024
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;
(2) Confirmation of the individual's election
to participate in the program is received; and
(3) The individual is being discharged from
an institution or transitioning from an MCO and service coordination is
complete.
C. When an MCO
participant is referred to the REM program for enrollment, the MCO shall:
(1) Provide confirmation of the qualifying
diagnosis to the Department; and
(2) Continue to provide the MCO participant's
care until the Department confirms the diagnosis and enrolls the MCO
participant into REM.
D.
An individual shall be enrolled in or auto-assigned into an MCO as specified in
COMAR 10.09.63, not later than 60 days from the date the individual becomes
ineligible for REM, as a result of changes in the diagnosis or age group
criteria specified in Regulation .17 of this chapter, except when the
individual was allowed to remain in REM in accordance with §I of this
regulation.
E. A REM participant
may elect to disenroll from REM and enroll in an MCO by notifying the
Department of that decision except when the individual was allowed to remain in
REM in accordance with §I of this regulation.
F. Election to Remain in MCO.
(1) An individual who becomes eligible for
REM while enrolled in an MCO may elect to remain in an MCO by notifying the
Department of that decision.
(2)
When a REM-eligible individual elects to remain in an MCO, the Department, in
consultation with the MCO and the REM-eligible individual, may determine
whether the MCO can appropriately meet the individual's medical needs within
the parameters of the program benefit package as described in COMAR
10.09.67.
(3) If the MCO determines
it cannot appropriately meet the individual's medical needs, the MCO shall
submit to the Department written justification for its decision.
(4) If the Department determines the MCO can
meet the individual's medical needs, the Department shall notify the MCO of its
decision in writing.
(5) If the
Department determines that the MCO cannot appropriately meet the individual's
needs, the Department shall issue a written determination to the individual and
the MCO which includes:
(a) The reason for
the determination; and
(b) An
explanation of the individual's right to appeal the determination according to
the procedures set forth in COMAR 10.01.04.
(6) If the Department determines that the MCO
can appropriately meet the individual's medical needs, the individual's
election becomes effective and cannot be revoked without cause for a period of
1 year from the effective date.
G. The Department shall allow an individual
who, immediately before enrollment in REM, was receiving medical services from
a specialty clinic or other setting to continue to receive services in that
setting on enrollment in the REM program when the provider is willing to
participate as a Medical Assistance fee-for-service provider.
H. An individual eligible for REM who has
elected to enroll in an MCO or to remain enrolled in an MCO may not receive REM
services under the REM program.
I.
The Department shall disenroll from the REM program a participant who no longer
meets the conditions specified in Regulation .03 of this chapter unless:
(1) The participant does not meet the
condition under Regulation .03A(1) of this chapter because the participant
becomes eligible for Medicare; and
(2) At the time the participant became
eligible for Medicare the participant was approved for and was receiving
private duty nursing, CNA, CNA-CMT, HHA, or HHA-CMT services under the REM
program.
J. An
individual disenrolled from REM by the Department who maintains Health Choice
eligibility is subject to the MCO enrollment provisions specified in COMAR
10.09.63 except when the individual was allowed to remain in REM in accordance
with §I of this regulation.
K.
Department-Initiated Disenrollment. The Department shall disenroll from REM an
enrollee:
(1) Who has been continuously
institutionalized for a period of more than 90 successive days in a long-term
care facility, subject to the long-term care facility obtaining the
Department's determination that the enrollee's institutionalization has been
medically necessary;
(2) Who has
been, or is expected to be, continuously institutionalized for more than 30
successive days in an institution for mental disease (IMD);
(3) Upon admission to an intermediate care
facility for individuals with intellectual disabilities or persons with related
conditions (ICF/IID);
(4) Who loses
Medicaid eligibility or who changes to an assistance category not eligible for
MCO enrollment, subject to COMAR 10.67.02;
(5) Who has died; or
(6) Who is an inmate of a public institution,
including a State-operated institution or facility.
L. Effective Date of Disenrollment. An
enrollee's disenrollment shall take effect:
(1) Immediately when the enrollee
dies;
(2) From the first day of the
month following the month in which the enrollee lost Medicaid
eligibility;
(3) On the first day
of the month following the month in which the Department receives the required
notification, when the enrollee permanently relocates outside of the State;
or
(4) From the first day of the
month following the month in which the Department verifies an enrollee is an
inmate.
