Sec. 10.09.93.09. Payment Procedures

A. Reimbursement of Maryland Chronic Hospitals.

(1) In-State chronic hospitals shall be reimbursed according to:

(a) Rates approved by the HSCRC pursuant to COMAR 10.37.03; or

(b) The administrative day rate as follows:

(i) For a participant who is not ventilator-dependent, payment for approved administrative days shall be the estimated Statewide average Medicaid nursing facility payment rate as determined by the Department; and

(ii) For a participant who is ventilator-dependent, payment for approved administrative days shall be the estimated average Medicaid nursing facility payment rate for ventilator-dependent residents as determined by the Department.

(2) State-operated chronic hospitals shall be reimbursed according to Regulation .10 of this chapter. The Department shall make no direct reimbursement to any State-operated chronic hospital.

B. Reimbursement of Out-of-State Hospitals.

(1) The Department shall reimburse an out-of-State hospital that provides a level of service equivalent to that provided at a chronic hospital only if:

(a) The proposed admission is first reviewed by the Department or its designee and the out-of-State placement is determined medically necessary according to Regulation .07A of this chapter;

(b) The hospital possesses the same certifications and accreditations as the Program requires for a comparable level of services and specific program in a Maryland chronic hospital; and

(c) The hospital meets one of the following conditions:

(i) The hospital proposes to provide a service or specific treatment that the participant cannot obtain in a Maryland chronic hospital; or

(ii) The hospital is located geographically closer to the established residence of the participant than a Maryland chronic hospital.

(2) The Department shall reimburse an out-of-State hospital at the lesser of:

(a) The average rate established by the HSCRC for an equivalent cost center for a Maryland chronic hospital; or

(b) The rate charged by the out-of-State hospital pursuant to 42 CFR Part 412, Subpart O.