Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 2
Subtitle 09 - MEDICAL CARE PROGRAMS
Chapter 10.09.69 - Maryland Medicaid Managed Care Program: Rare and Expensive Case Management
Section 10.09.69.12 - Limitations
Universal Citation: MD Code Reg 10.09.69.12
Current through Register Vol. 51, No. 19, September 20, 2024
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
Services as described in COMAR
10.09.32.03CC and
.04A; and
(2) Model Waiver case
management as described in COMAR 10.09.27.
C. The REM program does not cover the following:
(1) Shift private duty nursing,
CNA or CNA-CMT, or HHA or HHA-CMT services rendered by a nurse, CNA, HHA,
CNA-CMT, or HHA-CMT who is a member of the participant's immediate family or
who ordinarily resides with the participant;
(2) Services which are not medically
necessary;
(3) Services not
supervised by an RN when delivered by the following:
(a) An RN or an LPN;
(b) A CNA;
(c) An HHA;
(d) A CNA-CMT; or
(e) An HHA-CMT.
(4) REM optional services not preauthorized
as required by the Department or its designee;
(5) REM optional services not prescribed by
the participant's physician, physician assistant, or nurse
practitioner;
(6) Services
specified in this chapter which duplicate or supplant services rendered by the
participant's family caregivers or primary caregivers as well as other
insurance, privilege, entitlement, or Program services that the participant
receives or is eligible to receive;
(7) Services provided for the convenience or
preference of the participant or the primary caregiver rather than required by
the participant's medical condition;
(8) Speech, language, or occupational therapy
services rendered in a classroom setting;
(9) Shift private duty nursing, CNA, CNA-CMT,
HHA, or HHA-CMT services ordered by a physician assistant;
(10) Custodial services;
(11) Services provided to a participant in a:
(a) Hospital;
(b) Residential treatment center;
(c) Intermediate care facility for
individuals with intellectual disabilities; or
(d) Residence or facility where nursing
services are included in the living arrangement by regulation or statute, or
otherwise provided for payment;
(12) Services not directly related to the
participant's plan of care;
(13)
Services described in the plan of care whenever a major change occurs in the
participant's medical condition or skilled nursing care needs that indicates
such services are no longer necessary;
(14) Services which are not initially ordered
before the start of care and renewed every 60 days by the participant's primary
medical provider;
(15) Services
provided by a nurse, CNA, or HHA who does not possess a valid, current, and
nontemporary nursing license or certifications to provide services in the
jurisdiction in which nursing services are rendered;
(16) Services provided by a nurse, CNA, or
HHA who does not have a current cardiopulmonary resuscitation (CPR)
certification for the period during which the services are rendered;
(17) Direct payment for supervisory visits
that do not meet acceptable standards of practice in accordance with COMAR
10.27.09, 10.27.10, and 10.27.11;
(18) Services rendered to a participant by a
nurse, CNA, or HHA in the assigned staff's home;
(19) Services not documented; and
(20) Respite services.
D. The Program shall only cover one-to-one nursing when a participant's condition requires that level of service and shared services are not an option.
E. The Program shall only cover nursing services ordered by an individual who is enrolled as a provider in the Program with an active status on the date of service.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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