Md. Code Regs. 10.09.56.22

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.56.22 - Payment Procedures

A. Request for Payment.

(1) An approved provider shall submit requests for payment for the services covered under this chapter according to the procedures set forth in COMAR 10.09.36.04B or otherwise established by the Program.

(2) The provider shall:

(a) Bill the Program in accordance with the payment methodology specified in §§D and E of this regulation;

(b) Accept payment from the Program as payment in full for the services covered under this chapter and make no additional charge to the participant or any other party for these services; and

(c) Submit a request for payment in a manner approved by the Program, which includes the:

(i) Date or dates of service;

(ii) Participant's name and Medicaid number;

(iii) Provider's name, location, and Program identification number;

(iv) Type, procedure code or codes, and unit or units of covered services provided; and

(v) Amount of reimbursement requested.

B. Documentation Required.

(1) Payments by the Program or its designee may be withheld if the provider fails to submit requested evidence of services provided, staff qualifications, corrective action plans, or other types of documentation related to ensuring the health and safety of a participant.

(2) Payments shall be released upon receipt and approval by the Program or its designee of the requested documentation.

(3) An appeal by the provider under COMAR 10.01.03 does not stay the withholding of payments.

C. Billing time limitations for the services covered under this chapter are the same as those set forth in COMAR 10.09.36.06B.

D. Payments.

(1) Payments shall be made only to a qualified provider for services covered under this chapter which are rendered to a participant.

(2) Providers shall be paid the lesser of:

(a) The provider's customary charge to the general public unless the service is free to individuals not covered by Medicaid; or

(b) The rate established according to the fee schedule published by the Department.

(3) The program shall only pay for services at the lesser of:

(a) The fee for service schedule; or

(b) The actual cost.

(4) The Program's rates as specified in §D(2)(a)-(g) of this regulation shall be effective January 1, 2015 and shall increase on July 1 of each year, subject to the limitations of the State budget, by the lesser of:

(a) 2.5 percent; or

(b) The change from March to March in the medical care component of the Consumer Price Index for all urban consumers (CPI-U) for the Washington-Baltimore area.

E. Rates.

(1) The Department shall publish a fee schedule for services covered under this chapter that shall be publicly available and updated at least annually or upon any changes made by the Department.

(2) Subject to the limitations of the State budget, the Program's rates as specified in this regulation shall increase by 4 percent each year through Fiscal Year 2026.

(3) Effective July 1, 2022, the Program shall pay according to the following fee-for-service schedule:

(a) Residential habilitation services and retainer payments reimbursed at one of the following all-inclusive, maximum rates for a participant:

(i) $283.69 per unit for the regular level of service; or

(ii) $567.45 per unit for the intensive level of service.

(b) Therapeutic integration services reimbursed at the maximum rate of $17.19 per unit.

(c) Intensive therapeutic integration services reimbursed at the maximum rate of $21.49 per unit.

(d) Intensive individual support services reimbursed at the maximum rate of $21.49 per unit.

(e) Respite care reimbursed at the maximum rate of $16.80 per unit.

(f) Family consultation reimbursed at the maximum rates of $70.55 per unit.

(g) Adult life planning services reimbursed at the maximum rate of $70.55 per unit.

(h) Environmental accessibility adaptations reimbursed at the maximum rate of $2,104 per 36-month period amount billed by the provider, which shall be the lesser of the:

(i) Amount authorized by the State Department of Education; or

(ii) Actual cost of the job.

(4)Effective July 1, 2023, the Program shall pay according to the following fee-for-service schedule:

(a)Residential habilitation services and retainer payments reimbursed at one of the following all-inclusive, maximum rates for a participant:

(i)$283.69 per unit for the regular level of service; or

(ii)$567.45 per unit for the intensive level of service.

(b)Therapeutic integration services reimbursed at the maximum rate of $8.5950 per unit.

(c)Intensive therapeutic integration services reimbursed at the maximum rate of $10.7450 per unit.

(d)Intensive individual support services reimbursed at the maximum rate of $10.7450 per unit.

(e)Respite care reimbursed at the maximum rate of $8.4000 per unit.

(f)Family consultation reimbursed at the maximum rate of $35.2750 per unit.

(g)Adult life planning services reimbursed at the maximum rate of $35.2750 per unit.

(h)Environmental accessibility adaptions reimbursed at the maximum rate of $2,104 per 36-month period amount billed by the provider, which shall be the lesser of the:

(i)Amount authorized by the State Department of Education; or

(ii)Actual cost of the job.

Md. Code Regs. 10.09.56.22

Regulations .22C as an emergency provision effective July 1, 2002 (29:17 Md. R. 1376); emergency status extended at 30:3 Md. R. 176 and 30:10 Md. R. 667; amended permanently effective April 14, 2003 (30:7 Md. R. 487)
Regulation .22D amended effective February 8, 2010 (37:3 Md. R. 176)
Regulation .22D amended effective October 31, 2011 (38:22 Md. R. 1346); amended effective 43:7 Md. R. 449, eff.4/11/2016; amended effective 46:10 Md. R. 485, eff. 5/20/2019; amended effective 50:23 Md. R. 1004, eff. 11/27/2023; amended effective 51:18 Md. R. 809, eff. 9/16/2024.