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Regulation Forms (MDH Employees Only)
January 5, 2018
Volume 45• Issue 1 • Pages 21—22
MARYLAND DEPARTMENT OF HEALTH
Subtitle 09 MEDICAL CARE PROGRAMS
10.09.36 General Medical Assistance Provider Participation Criteria
Authority: Health-General Article, §§2-104(b) 15-103, and 15-105, Annotated Code of Maryland
Notice of Proposed Action
The Secretary of Health proposes to amend Regulations
COMAR 10.09.36 General Medical Assistance Provider Participation Criteria
Statement of Purpose
The purpose of this action is to:
(1) Define the terms “affiliated line of business” and “affiliation”;
(2) Clarify the meaning of “withhold payment”;
(3) Explain the Program’s policy regarding backdating enrollment effective dates for new providers; and
(4) Enable the Program to terminate enrollment for lines of business affiliated with terminated providers.
Comparison to Federal Standards
There is no corresponding federal standard to this proposed action.
Estimate of Economic Impact
The proposed action has no economic impact.
Economic Impact on Small Businesses
The proposed action has minimal or no economic impact on small businesses.
Impact on Individuals with Disabilities
The proposed action has no impact on individuals with disabilities.
Opportunity for Public Comment
Comments may be sent to Michele Phinney, Director, Office of Regulation and Policy Coordination, Maryland Department of Health, 201 West Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499 (TTY 800-735-2258), or email to firstname.lastname@example.org, or fax to 410-767-6483. Comments will be accepted through February 5, 2018. A public hearing has not been scheduled.
A. (text unchanged)
B. Terms Defined
(1)—(2) (text unchanged)
(3) “Affiliated lines of business” means an individual or entity with an affiliation, as defined in §B(4) of this regulation, to another provider.
(4) “Affiliation” means:
(a) A 5 percent or greater direct or indirect ownership interest that an individual or entity has in another organization;
(b) A general or limited partnership interest that an individual or entity has in another organization;
(c) An interest in which an individual or entity exercises operational or managerial control over or directly or indirectly conducts the day-to-day operations of another organization, either under contract or through some other arrangement, regardless of whether the managing individual or entity is a W–2 employee of the organization; and
(d) An interest in which an individual is acting as an officer or director of a corporation.
“Withhold payment” means the Program’s decision to not pay or suspend payment to a provider as a sanction for failure to comply with applicable federal or State laws or regulations or because of a credible allegation of fraud.
.03 Conditions for Participation.
—F. (text unchanged)
G. Enrollment Effective Date.
(1) Unless a provider is enrolled under the provisions of §G(2) or (3) of this regulation, the effective date of a provider’s enrollment is the date
the Program completes all federally required screenings, which may include a site visit, following
the Program’s receipt of the provider’s submission of a complete
application with all required supporting documents;
(2) If the Program requires the provider to be enrolled in an approved status with Medicare prior to enrollment in the Program, the enrollment effective date is the more recent of the following dates:
(a) The Medicare approval date; or
(b) 9 months before the provider’s Medicaid application date.
(3) If an out-of-State provider of emergency transportation services or emergency services
meets provider enrollment requirements on the date of service, the enrollment effective date is the date the provider renders the emergency services.
.08 Cause for Suspension or Removal and Imposition of Sanctions.
A. (text unchanged)
B. If the Program, federal government, or another state Medicaid agency terminates a provider, the Program may terminate all of the provider’s affiliated lines of business enrolled with the Program.
.09 Filing Appeal.
A. Source of Appeals.
(1) A provider may file an appeal from a proposed Program action to:
(a)—(b) (text unchanged)
(c) Remove the provider from the Program;
(d) Disqualify the provider from future participation in the Program, either as a provider or as a person providing services for which Program payment will be claimed
(e) Recover an overpayment.
(2) (text unchanged)
B.—E. (text unchanged)
Secretary of Health
201 W. Preston Street, Baltimore, MD 21201-2399
(410) 767-6500 or 1-877-463-3464
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