Md. Code Regs. 10.09.29.07

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.09.29.07 - Payment Procedures

A. Reimbursement Principles.

(1) The Department will make no direct reimbursement to any State-operated residential treatment center for recipients. The Department will claim federal fund recoveries from the Department of Health and Human Services for services to federally eligible Title XIX patients in these residential treatment centers.

(2) The Department will pay the residential treatment center the lesser of the provider's customary charge or the provider's per diem costs for covered services according to the principles established under Title XVIII of the Social Security Act, as required in 42 CFR 413, or on the basis of charges not to exceed $750 per day effective July 1, 2021 through December 31, 2022, or $850 per day effective January 1, 2023. The average increase in the Department's reimbursement to the provider per inpatient day for each fiscal year over the cost-settled rate for the previous fiscal year, State Fiscal Year 2019 final cost per diem effective July 1, 2021, may not exceed the rate of increase of the Hospital Wage and Price Index plus 1 percentage point, described in 42 CFR § 413.40. The target rate percentage increase for each calendar year will equal the prospectively estimated increase in the Hospital Wage and Price Index (market basket index) for each year, plus 1 percentage point. If the service is free to individuals not covered by Medicaid:

(a) The provider:

(i) May charge the Program; and

(ii) Shall be reimbursed in accordance with the provisions of this regulation; and

(b) The provider's reimbursement is not limited to the provider's customary charge.

(3) An in-State children's residential treatment center shall be reimbursed the lesser of:

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

(b) The provider's per diem cost for covered services established in accordance with Medicare principles of reasonable cost reimbursement as described in 42 CFR 413 ;

(c) Effective July 1, 2021, $750 per day; or

(d) Effective January 1, 2023, $850 per day.

(4) The Department rebases prices in §A(2) and (3) of this regulation between every 2 and 4 years. Prices may be rebased more frequently if the State determines that there is an error in the data or in the calculation that results in a substantial difference in payment, or if a significant change in provider behavior or costs has resulted in payment that is inequitable across providers. In years in which rates are not rebased, rates are subject to annual indexing.

(5) For purposes of §A(3)(b) of this regulation, the percentage increase in the Department's cost reimbursement to the provider, per inpatient day for each cost reporting year over the cost-settled payment rate for the previous cost reporting year, State Fiscal Year 2019 final cost per diem effective July 1, 2021, may not exceed the Centers for Medicare and Medicaid Services' published federal fiscal year market basket index relating to hospitals excluded from the prospective payment system, plus 1 percent.

(6) The rate stated in §A(2) and (3)(c) of this regulation shall be updated annually for each provider's cost reporting period by the Centers for Medicare and Medicaid Services' published federal fiscal year market basket index relating to hospitals excluded from the prospective payment system.

(7) Effective July 1, 2021, the rate stated in §A(2) and (3)(c) of this regulation shall be updated annually for each provider's cost reporting period by the Centers for Medicare and Medicaid Services' published federal fiscal year market basket index relating to hospitals excluded from the prospective payment system, plus 1 percent.

(8) Out-of-State Providers. To be reimbursed for services provided to Maryland Medical Assistance recipients, an out-of-State provider shall be licensed or formally approved as a psychiatric facility or as an inpatient program in a psychiatric facility, either of which is accredited by the Joint Commission on Accreditation of Healthcare Organizations.

B. Recipient's Contribution.

(1) The local department of social services or the State-operated facility's fiscal agent shall determine the amount the recipient has available to pay toward the cost of medical or remedial care for inpatient services, and so inform the provider.

(2) The provider shall collect from the recipient that amount as shown available on the designated form.

(3) The provider may not collect a total amount, including the amount the recipient has available and the Department's payment, which exceeds the provider's rate established by the Department or its designee.

(4) The provider shall show to the Department sums collected from the recipient.

C. The provider shall submit request for payment on the form designated by the Department.

D. The provider shall submit, with invoices, properly completed attachments as requested by the Department.

E. A provider may not bill the Program a charge exceeding that charged the general public for similar services.

F. The provider may not bill the Department for:

(1) Completion of forms and reports;

(2) Broken or missed appointments; or

(3) Professional services rendered by mail or telephone.

G. The Department will make no direct payment to the recipient.

H. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.

I. The Department reserves the right to return to the provider, before payment, all invoices not properly completed.

Md. Code Regs. 10.09.29.07

Regulations .07 adopted as an emergency provision effective July 1, 1986 (13:13 Md. R. 1474); adopted permanently effective December 1, 1986 (13:24 Md. R. 2559)
Regulations .07 amended as an emergency provision effective July 1, 1992 (19:15 Md. R. 1383); amended permanently effective November 1, 1992 (19:21 Md. R. 1891)
Regulation .07A amended effective February 6, 1989 (16:2 Md. R. 159)
Regulation .07A amended as an emergency provision effective November 17, 1995 (22:25 Md. R. 1958); adopted permanently effective April 8, 1996 (23:7 Md. R. 552)
Regulation .07A amended effective February 12, 2007 (34:3 Md. R. 298); April 5, 2010 (37:7 Md. R. 571)
Regulation .07H amended as an emergency provision effective January 28, 1991 (18:3 Md. R. 301); emergency status expired April 8, 1991 (18:9 Md. R. 1004)
Regulation .07H amended as an emergency provision effective April 9, 1991 (18:9 Md. R. 1005); amended permanently effective October 7, 1991 (18:18 Md. R. 2004); amended effective 43:13 Md. R. 713, eff. 7/4/2016; amended effective 49:7 Md. R. 462, eff. 4/4/2022; amended effective 50:15 Md. R. 682, eff. 8/7/2023