Md. Code Regs. 10.09.69.12

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

Section 10.09.69.12 - Limitations

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.

Md. Code Regs. 10.09.69.12

Regulations .12 adopted as an emergency provision effective November 8, 1996 (23:25 Md. R. 1730)
Regulations .12 adopted effective March 10, 1997 (24:5 Md. R. 408)
Regulations .12 adopted effective February 2, 2004 (31:2 Md. R. 84)
Regulation .12B amended effective November 5, 2007 (34:22 Md. R. 1977)
Regulation .12C amended effective November 6, 2006 (33:22 Md. R. 1732); amended and recodified from .11 effective 45:13 Md. R. 665, eff. 7/2/2018; amended effective 51:12 Md. R. 619, eff. 6/24/2024.