Md. Code Regs. 10.09.69.12 : MARYLAND DEPARTMENT OF HEALTH —Part 2 — MEDICAL CARE PROGRAMS — Maryland Medicaid Managed Care Program: Rare and Expensive Case Management — 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; and
(9) Shift private duty nursing, CNA, CNA-CMT, HHA, or HHA-CMT services ordered by a physician assistant.

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