Issue Date: September 14, 2018
Volume 45 • Issue 19 • Pages 872—876
MARYLAND DEPARTMENT OF HEALTH
Subtitle 09 MEDICAL CARE
Notice of Proposed
The Secretary of Health proposes to:
(1) Amend Regulations .02—.04, .08, .09,
and .11 under COMAR 10.09.37 Family Planning
Program Eligibility; and
(2) Amend Regulations .01—.07 under COMAR 10.09.58 Family Planning Program.
Statement of Purpose
The purpose of this action is to:
(1) Expand family planning eligibility by increasing the income
limits and eliminating gender and age requirements for those who are able to
receive benefits, in accordance with Senate Bill 774 Maryland Medical
Assistance Program—Family Planning Services, 2018, Health and Government
(2) Update definitions for consistency with other chapters;
(3) Remove redundant references to X-ray equipment requirements;
(4) Add language to specify which provider types may provide
services under the Family Planning Program; and
(5) Clarify laboratory tests and pharmaceutical supplies covered
under the limited benefit family planning program by removing certain services
that are not medically necessary for family planning.
Comparison to Federal
There is no corresponding federal standard to this proposed
of Economic Impact
I. Summary of Economic Impact. Medicaid expenditures are expected to increase
by $193,152 in fiscal 2019 in order to expand the Medicaid Family Planning Waiver
Program to include woman and men of all ages with incomes up to 250 percent
II. Types of Economic Impact.
A. On issuing agency:
B. On other State agencies:
C. On local governments:
D. On regulated industries or
E. On other industries or trade
F. Direct and indirect effects on
Assumptions. (Identified by Impact Letter
and Number from Section II.)
and D. Assumptions are as follows:
An estimated 3,201 men and women with incomes below 200 percent FPG enroll in
the program due to the lifting of age and gender restrictions.
An estimated 5,871 men and women with incomes between 200 percent FPG and 250
percent FPG enroll in the program due to the lifting of age and gender
restrictions and an increase in income eligibility.
The annual service cost per enrollee is $32 (as this is based on serving
women, the actual annual service cost may differ to serve both men and
Medicaid incurs $48,000 in contractor costs for the vendor that maintains the
separate eligibility system for the program.
As contractor costs are based on the number of enrollees, to the extent
participation is greater, costs increase by $24,000 for each additional 5,000
Expansion of the program begins January 1, 2019.
The federal matching rate is 90 percent for family planning services and 50
percent for contractor costs.
The proposed regulations will use $38,515 general funds and $154,637 federal
Economic Impact on Small
The proposed action has a meaningful economic impact on small
business. An analysis of this economic impact follows.
The proposed action may have a meaningful economic impact on small
businesses that provide family planning services because an estimated,
additional 9,072 individuals may enroll in the program in and seek services
from small businesses.
Impact on Individuals
The proposed action has no impact on individuals with
Opportunity for Public
Comments may be sent to Michele Phinney, Director, Office of
Regulation and Policy Coordination, Maryland Department of Health, 201 W.
Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499 (TTY
800-735-2258), or email to email@example.com, or fax to 410-767-6483.
Comments will be accepted through October 15, 2018. A public hearing has not
10.09.37 Family Planning Program Eligibility
Health-General Article, §§2-104(b) [and] 15-103(a), and 15-140, Annotated
Code of Maryland
A. (text unchanged)
B. Terms Defined.
(a) "Applicant" means [a woman] an individual whose
written, signed application for the Family Planning Program has been submitted
to the Department but has not received final action.
(b) “Applicant” includes a non-pregnant [woman] individual whose
application is submitted through an authorized representative.
(2)—(4) (text unchanged)
(5) “Authorized representative” means a spouse, legal guardian,
parent, individual with power of attorney, relative or other individual
designated in writing to the Department, authorized concerning the applicant’s
or [recipient’s] participant’s eligibility
under this chapter to:
(a) Act on an applicant’s or [recipient’s] participant’s behalf;
(b) (text unchanged)
(6) “Continuing eligibility” means a [recipient’s] participant’s eligibility
for a subsequent certification period after the current
certification period, based on the Department’s redetermination of
eligibility with respect to [a woman] an
individual who is enrolled in Family Planning on the application date.
(7)—(10) (text unchanged)
(11) Earned Income.
(a) “Earned Income” means payment received by an individual in
cash or in-kind as a result of employment, including
(12) (text unchanged)
(13) "Family Planning Program” means the program established in
Health–General Article, §15-103 et seq., Annotated Code of Maryland to provide
services related to contraceptive care to [women] individuals who
meet the eligibility requirements specified in Regulation .03 of this chapter.
(14) (text unchanged)
(15) “Household [size]” [means:] means
sharing a common household.
[(a) The applicant;
(b) The spouse who resides with the applicant; and
(c) Any children younger than 19 years old who resides with the
(16) “Income” means any property or service received by a person
in cash or in-kind which can be applied directly, or by sale or conversion, to
meet basic needs for food, shelter, and medical expenses.
[(16)] (17) (text
(18) "In-kind income" means support or benefits in the
form of food or shelter, or both, received by a person.
[(17)] (19)—[(19)] (21) (text
"Recipient" means a woman who is certified as eligible for the Family
(22) “Participant” means an individual who is certified as eligible
for the Family Planning Program.
[(20)] (23)—[(21)] (24) (text
[(23)] (25) “Redetermination”
means a determination regarding the [continuing] eligibility
of a [recipient] participant.
[(24)] (26) (text
[(25)] (27) "Unearned
income" means all income which does not meet the definition of earned
income [as defined in §B of this regulation].
.03 Eligibility for Family Planning Program
A. In order to be determined eligible for benefits under the
Family Planning Program, an applicant:
(a) Have a household income that does not exceed  250 percent
of the federal poverty level; and
(b) Meet the following requirements:
(i)—(ii) (text unchanged)
(iii) Residency requirements in COMAR 10.09.24.05-3[; and].
[(c) Be under 51 years of
(2) (text unchanged)
B. An applicant whose income does not exceed  250 percent
of the federal poverty level and is determined eligible for pregnancy or
postpartum coverage under COMAR 10.09.24 shall be:
(1)—(2) (text unchanged)
A. The Department shall:
(1) (text unchanged)
(2) Give oral or written information about the eligibility
requirements, coverage, scope and related services of the Family Planning
Program, and [a woman’s] an individual’s rights
and obligations under the Family Planning Program, to any individual requesting
(3) Give [a woman] an individual requesting
Family Planning Program coverage the opportunity to apply; and
(4) Make the application available to the individual
B. (text unchanged)
C. [A woman] An individual who
wishes to apply for the Family Planning Program under this chapter shall submit
a written, signed application form to the Department. An applicant shall be
responsible for completing the application but may be assisted by another
individual of the applicant’s choice.
D. (text unchanged)
E. [A woman] An individual who
applies for the Family Planning Program may voluntarily withdraw that
application; however the application form will remain the property of the
F. (text unchanged)
G. Extension of Time Limitations.
(1) The Department may approve an extension of the time limitation
specified in §E of this regulation if:
(a) The applicant or authorized representative is actively
attempting to establish the applicant’s or [recipient’s] participant’s eligibility
but has been unable to provide the required information or verification through
no fault of the applicant, [recipient] participant,
or authorized representative; or
(2) The Department shall document the reason for the extension in
the applicant’s or [recipient’s] participant’s case
(3) (text unchanged)
H.—K. (text unchanged)
L. A [recipient] participant shall
cooperate with the Department in completing a form designated by the Department
to report pertinent information and in collecting available health insurance
benefits and other third-party payments.
.08 Determining Financial Eligibility.
An applicant is financially eligible for the Family Planning
Program if the applicant's countable net family income as determined under
Regulations .05, .06, and .07 of this chapter does not exceed  250 percent
of the federal poverty level.
.09 Certification Periods.
A. For a [recipient] participant,
certification for initial eligibility begins not sooner than the first day of
the month of application.
B. A [recipient’s] participant’s eligibility
under Regulation .03 of this chapter will end as of the:
(3) Date the Department receives notice of permanent sterilization
of a [recipient] participant;
[(4) End of the month in
which the recipient becomes age 51;]
[(5)] (4) Beginning
of the month in which the [recipient] participant is
enrolled in [Medicaid] Medicare; or
[(6)] (5) Date
a [recipient] participant becomes an inmate
in a public institution.
.11 Post–Eligibility Requirements.
A. The Department shall inform the applicant of the
applicant’s legal rights and obligations and give the applicant written
notification of the following:
(1) For an eligible [woman] individual:
(a)—(c) (text unchanged)
(2) For an ineligible [woman] individual:
(a)—(d) (text unchanged)
B. [Recipient] Participant Responsibility.
(1) A [recipient] participant shall
notify the Department within 10 business days of changes affecting the [recipient’s] participant’s eligibility.
(2) A [recipient] participant shall
limit use of the Family Planning card to the [woman] individual whose
name appears on the card.
(3) When written notice of cancellation is received, a [recipient] participant shall
discontinue use of the Family Planning card on the first day of ineligibility.
(4) (text unchanged)
(5) A [recipient] participant shall
cooperate with the State’s Medical Assistance quality control review process,
including verification of information pertinent to the determination of
(6) If the [recipient] participant refuses
to cooperate, the [recipient’s] participant’s coverage
shall end subject to the regulation governing timely and adequate notice under
[(6)] (7) If
the [recipient] participant refuses to
cooperate, the [recipient’s] participant’s coverage
shall end subject to the regulation governing timely and adequate notice under
C. Unscheduled Redeterminations.
(1) The Department shall promptly make an unscheduled
(a) The [woman’s] participant’s circumstance
suggests future changes which may affect eligibility before the due date of a
(b) Relevant facts or changes in circumstances are reported by
the [recipient] participant or an
authorized representative; or
(c) (text unchanged)
(2) The Department shall notify the [recipient] participant that
a redetermination shall establish continuing eligibility.
(4) The Department shall notify the [recipient] participant of
the required information and verifications needed to determine eligibility and
the time standards in acting in the redetermination process.
(5) (text unchanged)
(6) Eligibility Decisions.
(a) [Recipients] Participants who
are determined eligible for the remainder of the certification period shall be
sent a notice in accordance with §A(1) of this regulation.
(b) [Recipients] Participants determined
ineligible for the remainder of the certification period because of a change in
circumstances or failure to establish eligibility following a change in
circumstances, shall be sent a notice in accordance with §A(2) of this
(7) [A woman] An individual may
reapply after cancellation of current eligibility, at which time a new period
under consideration shall be established.
D. Scheduled Redeterminations.
(1) The Department shall make a scheduled redetermination of [a woman’s] a
participant’s eligibility once every 12 months.
(3)—(4) (text unchanged)
(5) The new period shall be related to the date the application is
received but may not include months in which the [woman] participant was
entitled to coverage under the current certification period.
(6) A [recipient] participant shall
be treated the same as an applicant at the time of scheduled redetermination.
(7)—(9) (text unchanged)
10.09.58 Family Planning Program
Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of
.01 Purpose and
B. Eligibility shall be established [for women] according
to COMAR 10.09.37.
(1) ["Certified nurse practitioner" means a
licensed registered nurse who:
(a) By reason of certification under COMAR 10.27.07, may practice
in Maryland as a nurse practitioner under the terms of those regulations; or
(b) Qualifies as a nurse practitioner in the state in which
services are provided.] “Advanced practice nurse” means an
individual who meets the requirements in COMAR 10.09.01.
(2)—(11) (text unchanged)
(12) “Participant” means an individual who is certified as
eligible for the Family Planning Program as described in COMAR 10.09.37.
[(12)] (13) (text
(14) “Physician assistant” means an individual who meets the
requirements in COMAR 10.09.55.
[(14)] (15)—[(16)] (17) (text
"Recipient" means a woman who is certified as eligible for the
Program according to COMAR 10.09.37.]
A. [A certified nurse practitioner] An
advanced practice nurse shall[:
(1) Be licensed to practice registered nursing in Maryland and be
certified as a nurse practitioner by the Board of Nursing; or
(2) Meet the nurse practitioner regulatory requirements of the
state in which services are provided] be licensed to practice as
described in COMAR 10.09.01.
B. A doctor of medicine or osteopath shall be licensed and legally
authorized to practice medicine in the state in which the service is
delivered as described in COMAR 10.09.02.
C. A physician assistant must be licensed to practice as described
in COMAR 10.09.55.
[C.] D.—[E.] F. (text
[F. The provider shall
ensure that all X-ray and other radiological equipment is maintained and
inspected in compliance with the requirements of Environment Article, Title 8,
Subtitle 3, Annotated Code of Maryland (Maryland Radiation Act), and meets the
standards established by COMAR 26.12.01 and 26.12.02, or other applicable
standards established by the state in which the service is provided.]
.04 Conditions of
A. Providers shall be enrolled as Medical Assistance Program
providers and shall meet the requirements for participation in the Maryland
Medical Assistance Program as set forth in COMAR 10.09.36.03, as well as the
requirements for participation as set forth in the COMAR chapter defining
the provider and covered service being rendered.
B. [If required by the state in which
services are provided, certified nurse practitioners shall have a written
agreement with a licensed physician.] Services covered in
Regulation .05A—C of this chapter shall be provided by:
(1) A physician;
(2) An advance practice nurse; or
(3) A physician assistant.
[C. Services are rendered
in accordance with recognized standards established for family
planning by the American College of Obstetricians and Gynecologists.]
[D.] C. (text
.05 Covered Services.
The following services are covered under this chapter:
A. Office medical visits [and hospital outpatient
department visits] for the primary purpose of providing age
and sex appropriate family planning [purposes] services,
(1) [Complete initial and annual physical examination
including auscultation of heart and lungs;] Focused history,
physical exam, and laboratory testing necessary to evaluate and manage the
participant’s choice of chemical, mechanical, or other method to prevent
[(2) Pelvic examination,
including bimanual and speculum, and Pap smears annually, unless clinical
indication for more frequent examination exists;
(3) Breast examination;
(4) Rectal examination, if indicated;]
[(5)] (2)—[(7)] (4) (text
B.—C. (text unchanged)
D. The following laboratory tests:
(1)—(3) (text unchanged)
[(4) Serologic tests for
(5) Gonorrhea and chlamydia screening and culture;
(6) Tests for human immunodeficiency viruses;
(7) Herpes culture;]
(4) Appropriate laboratory tests to screen for sexually
[(8)] (5) (text
[(9)] (6) Rubella
titer of females without documentation of prior rubella immunization; and
[(10)] (7) (text
[(11) Blood glucose; and
(12) Glucose tolerance tests;]
E. Pharmaceutical supplies and devices:
(2) To treat sexually transmitted infections when diagnosed during
the course of an office visit, as outlined in §A of this regulation, which are
covered under COMAR 10.09.03.04 except treatment for[;]:
(a) Human immunodeficiency virus; and
F.—G.. (text unchanged)
B. Limitations for [certified nurse practitioner] advanced
practice nurse services covered under this chapter are those set forth
in COMAR 10.09.01.05.
C.—F. (text unchanged)
G. Limitations for acute hospital services
covered under this chapter are those set forth in COMAR [10.09.06] 10.09.92.05.
H. Limitations for physician assistant services covered under this
chapter are those set forth in COMAR 10.09.55.05.
I. Limitations for ambulatory surgery centers covered under this
chapter are those set forth in COMAR 10.09.42.05.
.07 Payment Procedures.
A.—B. (text unchanged)
C. Payment procedures for [certified nurse
practitioners] advanced practice nurses are
those set forth in COMAR 10.09.01.06.
D.—E. (text unchanged)
F. [For dates of service on or after January 1, 2012,
payment] Payment procedures for clinic services
delivered in local health departments, family planning clinics, and other
free-standing clinics are those set forth in COMAR 10.09.02.07.
G.—H. (text unchanged)
I. Payment procedures for acute hospital services
are those set forth in COMAR [10.09.06.09] 10.09.92.07.
J. Payment procedures for physician assistant services are those
set forth in COMAR 10.09.55.06.
K. Payment procedures for ambulatory surgery centers are those set
forth in COMAR 10.09.42.06.
ROBERT R. NEALL
Secretary of Health
201 W. Preston Street, Baltimore, MD 21201-2399
(410) 767-6500 or 1-877-463-3464