Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 2
Subtitle 09 - MEDICAL CARE PROGRAMS
Chapter 10.09.95 - Special Psychiatric Hospitals
Section 10.09.95.07 - Payment Procedures
Universal Citation: MD Code Reg 10.09.95.07
Current through Register Vol. 51, No. 19, September 20, 2024
A. Reimbursement Principles.
(1) The Department
will make no direct reimbursement to any State-operated hospital. The
Department will claim federal fund recoveries from the U.S. Department of
Health and Human Services for services to participants in State-operated
hospitals.
(2) The Department shall
compare the current rates with the projected upper payment limit for inpatient
days of service on or after July 1, 2012, in freestanding private psychiatric
hospitals in Maryland whose rates for commercial providers are set by the
HSCRC.
(3) If the rates do not
exceed the projected upper payment limit calculated by the Department, the
Department shall reimburse these hospitals using a rate of 94 percent of the
current rates for services set by the HSCRC for each hospital's commercial
providers in the fiscal year the prospective payments are made.
(4) If the rates do exceed the projected
upper payment limit calculated by the Department, the per diem payments to each
such hospital shall be decreased by the same proportion that the projected
upper payment limit is exceeded.
(5) If the Program discontinues using rates
which have been approved by HSCRC, the Program shall reimburse providers:
(a) According to Medicare standards and
principles for retrospective cost reimbursement described in 42 CFR § 413
; or
(b) On the basis of charges if
less than reasonable cost.
(6) The Department may not reimburse for the
services of a hospital's salaried or contractual physicians as a separate line
item. When HSCRC has included these salaries in the hospital's costs, charges
for these services shall be included in the room and board rate or the
appropriate ancillary service only.
(7) Payment advances other than those made in
accordance with HSCRC regulations may not be made routinely.
(8) Inpatient and outpatient services in
District of Columbia special psychiatric and outpatient services in in-State
special psychiatric hospitals are cost-settled on an annual basis according to
§B of this regulation.
(9)
Effective October 1, 2018, an out-of-State special psychiatric hospital shall
be reimbursed the lesser of its charges or the amount reimbursable by the host
state's Title XIX agency.
(10) An
out-of-State provider shall submit proof of host state rates on an annual
basis.
B. Retrospective Cost Reimbursement.
(1) Except as specified
in §A of this regulation, a special psychiatric hospital not approved by
the Program for reimbursement according to HSCRC rates shall be reimbursed:
(a) According to Medicare standards and
principles for retrospective cost reimbursement described in 42 CFR § 413
; or
(b) On the basis of charges,
if less than reasonable cost.
(2) In calculating retrospective cost
reimbursement rates, the Department or its designee will deduct from the
designated costs or group of costs those restricted contributions which are
designated by the donor for paying certain provider operating costs, groups of
costs, or costs of specific groups of participants. When the cost, or group or
groups of costs designated, cover services rendered to all participants,
including Medical Assistance participants, operating costs applicable to all
participants shall be reduced by the amount of the restricted grants, gifts, or
income from endowments thus resulting in a reduction of allowable
costs.
(3) Final settlement for
services in the provider's fiscal year shall be determined based on Medicare
retrospective cost principles found at 42 CFR § 413, adjusted for Medicaid
allowable costs. Allowable costs specific to the Program shall be limited to a
base-year cost per discharge increased by the applicable federal rate of
increase times the number of Program discharges for that fiscal year.
(4) Base Year. For purposes of determining
limits on the increase of cost, in accordance with Medicare regulations, the
base year shall be:
(a) For an existing
provider, the first year of entering into the Program or the first year
separate rates for the unit or units of service or services are approved;
and
(b) For a new provider, or all
of these, the 12-month period immediately before the provider was initially
subjected to target rate increases.
(5) Initial Interim Rates. In order to
establish an initial interim rate, the provider shall submit to the Department
or its designee, before the beginning of the first billing period, at least 90
days before the beginning of billing for services, the following:
(a) A detailed cost build-up, consistent with
Medicare principles and cost finding, that supports the requested
rate;
(b) A current, projected, and
prior year's charge rate schedule;
(c) Finalized prior year's Medicare cost
reports and the most current submission;
(d) A detailed revenue schedule;
and
(e) Audited financial
statements.
(6) The
provider shall supply the Department or its designee the assurances necessary
to establish that its customary charges to participants liable for payment on a
charge basis exceed the allowable cost for these services.
(7) Initial Interim Rates for Newly
Established Services or Providers.
(a) The
provider shall submit to the Department or its designee, a detailed cost
build-up, consistent with Medicare principles and cost finding, that supports
the requested rate that follows Medicare principles and cost finding.
(b) The Department will compare the rate with
a compatible facility and determine a reasonable rate that does not exceed the
projected charges.
(8)
Revision of Interim Rates.
(a) The provider
may request an interim rate revision should the actual and projected cost
exceed the interim rate by 10 percent.
(b) The provider shall furnish the Department
or its designee with appropriate schedules showing the reason for the increase
and other any other information that supports the rate increase.
(c) The Department will lower the provider's
interim rate to approximate the final allowable reasonable cost based on the
results of the prior year's review.
(d) The provider may request not more than
two interim rate revisions during the accounting year.
(9) Cost Settlement.
(a) The provider shall submit to the
Department or its designee:
(i) A Medicaid
cost report based on actual data using the cost reporting forms used by
Medicare for retrospective cost reimbursement;
(ii) A copy of the provider's Program log;
and
(iii) A finalized Medicare
cost report for the cost reporting year.
(b) The final Program cost report shall be
sufficiently detailed to support a separate cost finding for Maryland Medical
Assistance unique cost centers. The provider shall also submit a copy of its
Maryland Medical Assistance log. The submitted cost report shall be in
sufficient detail to support a separate cost finding for designated Maryland
Medical Assistance unique cost centers.
(c) Tentative cost settlements may not be
performed on a routine basis. However, the Program may, when it determines
appropriate, calculate tentative settlements. The provider shall furnish the
Department or its designee with a finalized Medicare cost report for the cost
reporting year.
(d) The Department
will base final settlement on the results of the finalized Medicare cost
reports.
C. The Program shall reimburse room and board charges for the day of admission, but may not reimburse room and board charges for the day of discharge from the hospital.
D. The provider shall submit request for payment according to procedures established by the Department.
E. Payments on Medicare claims are authorized if:
(1) The provider
accepts Medicare assignment;
(2)
Medicare makes direct payment to the provider;
(3) Medicare determined the services were
medically necessary;
(4) The
services are covered by the Program; and
(5) Initial billing is made directly to
Medicare according to Medicare guidelines.
F. Payment on Medicare claims is subject to the following provisions:
(1) Deductible and
co-insurance, according to the limits of §E of this regulation, shall be
paid subject to the HSCRC discounts, except in the case of a participant
receiving hospital services in an out-of-State facility, in which case
deductible and co-insurance shall be paid in full; or
(2) Services not covered by Medicare, but by
the Program, if medically justified according to §E of this
regulation.
G. Administrative Days.
(1) To be paid for
administrative days, the special psychiatric hospital shall document, on forms
designated by the Department, information demonstrating that the participant
who was initially eligible has been determined to no longer require special
psychiatric hospital services and the provider has:
(a) Received a determination from the
Department or its designee that the participant requires the level of service
provided in a lower-acuity facility, but an appropriate facility is not
available;
(b) Established a plan
for discharge during the period of administrative days, is actively pursuing
placement at an appropriate level of care for the participant, and has
documented this activity in the participant's record;
(c) Maintained documentation in the
participant's medical record that placement activity was conducted no fewer
than 3 days per week during the period for which payment is requested for
administrative days; and
(d)
Notified the local agency responsible for development of the discharge
treatment and education plan of the potential placement, if the participant is
at risk of a residential treatment center placement on admission;
(2) If the participant requires
the level of care provided by a residential treatment center and a bed in a
residential treatment center is not available, in order to be paid for
administrative days, the special psychiatric hospital shall document that it
timely notified local coordinating councils and any other local agency, as
appropriate, of the necessity to continue inpatient psychiatric service at a
residential treatment center before the termination of the need for inpatient
psychiatric hospitalization;
(3) If
the participant is at an inappropriate level of care but cannot be moved, in
order to be paid for administrative days, the special psychiatric hospital
shall:
(a) Provide the attending physician's
declaration that, because of physical or emotional problems, the participant is
unable to be moved;
(b) Document in
the participant's medical record the attending physician's reasons why the
participant cannot be moved; and
(c) Document the attending physician's
reevaluation of the participant's inability to be moved in the participant's
record at least every 14 days in special psychiatric hospital.
H. Payment for approved administrative days for a special psychiatric hospital seeking placement of a participant to a residential treatment center shall be the average residential treatment center rate issued pursuant to COMAR 10.09.29.13B.
I. The Department may not reimburse a special psychiatric hospital for administrative days if:
(1) The special psychiatric hospital bills
the Program for days of care for which the hospital is licensed to provide;
or
(2) The Program or the Program's
designee determines the participant no longer requires the level of care for
the days requested.
J. The Department may not make direct payment to the participant.
K. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.06.
L. The Department reserves the right to return to the provider, before payment, all invoices not properly completed.
M. Noncompliance with the Program's requirements as determined by the Department or its designee shall result in nonpayment of the claim.
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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