Sec. 10.14.02.09. Hospital Services

A. To be considered a participating hospital in the Program, the provider shall:

(1) Be licensed as a hospital in Maryland or a jurisdiction bordering Maryland;

(2) Agree to abide by the provisions set forth in this regulation by signing and sending to the Department the designated Departmental form;

(3) Agree to accept, as payment in full, the amount paid by the Program pursuant to §E of this regulation;

(4) Agree not to bill an eligible patient for an additional charge for the reimbursed hospital services provided; and

(5) Maintain adequate records for a minimum of 5 years and, upon request, allow the Department access to the records.

B. The participating hospital shall receive reimbursement for the following services:

(1) Medically necessary inpatient hospital service for the number of days, per admission, including preoperative days certified by the utilization control agent, which is:

(a) Necessary for the provision of diagnostic, curative, palliative, or rehabilitative treatment for breast cancer or cervical cancer; and

(b) Described in the eligible patient's medical record in sufficient detail to support the invoices submitted for services; and

(2) Medically necessary outpatient hospital service which is:

(a) Necessary for the provision of diagnostic, curative, palliative, or rehabilitative treatment for breast cancer or cervical cancer; and

(b) Described in the eligible patient's medical record in sufficient detail to support the invoices submitted for services.

C. Limitations. The limitations on coverage of some hospital inpatient and outpatient services contained in COMAR 10.09.92.05 apply to this Program.

D. Preauthorization Requirements.

(1) The following surgical procedures require preauthorization when performed on a hospital inpatient basis unless the patient is already a hospital inpatient for another condition, or an unrelated procedure is being done simultaneously which itself requires surgical hospitalization. If an emergency necessitates performing any of the listed procedures on an inpatient basis, the provider shall request and obtain post-authorization before billing. The procedures are:

(a) Biopsy;

(b) Breast biopsy if a two-stage procedure is planned for a possible malignancy;

(c) Colposcopy;

(d) Cryotherapy alone;

(e) Cryotherapy with biopsy or dilation and curettage, or both;

(f) Dilation and curettage;

(g) Excision of benign lesion; and

(h) Hysteroscopy.

(2) Authorization is required by the Program for all preoperative inpatient days.

E. The participating hospital is responsible for:

(1) Submitting a bill for the reimbursed services provided on the designated Departmental form as follows:

(a) If an eligible patient is uninsured, or is insured but the insurance does not provide coverage for the reimbursed service, the participating hospital shall send the Department the bill for the service, with a denial from the patient’s insurance carrier, within 12 months of the date of discharge or outpatient service; or

(b) If an eligible patient is covered by Medicare or other insurance, the participating hospital shall bill:

(i) Medicare or the other insurance for the procedure or service; and

(ii) The Department for the outstanding deductible and patient contribution amount;

(2) Documenting the sum collected from the eligible patient's insurer as a patient collection; and

(3) Submitting properly completed attachments with the bill as requested by the Department.

F. Reimbursement Principles.

(1) The Program shall reimburse for a room and board charge for the day of admission, and may not reimburse for a room and board charge for the day of discharge from the participating hospital.

(2) The participating hospital may not collect a total payment, including the eligible patient's insurance and the Department's payment, which exceeds the provider's rate established by the Department or its designee.

(3) A participating hospital may not bill the Program a charge exceeding that charged the general public for a similar service.

(4) The Department may not reimburse the participating hospital for:

(a) Completion of a form or report;

(b) A broken or missed appointment;

(c) A professional service rendered by mail or telephone; or

(d) A service which is provided at no charge to the general public.

(5) The Department may not make direct payment to an eligible patient.

G. Reimbursement Rates.

(1) A participating hospital located in Maryland shall be reimbursed by the Department:

(a) Pursuant to COMAR 10.09.92.07A(2)-(4) and B for an eligible patient who is uninsured or who has insurance that does not provide coverage for the reimbursed service;

(b) Pursuant to COMAR 10.09.92.07A(8) and (9) for an eligible patient who is covered by Medicare; or

(c) For an eligible patient who has insurance other than Medicare that provides coverage for the reimbursed service, the outstanding deductible and patient contribution amount required by the insurer.

(2) A participating hospital located in a state bordering Maryland shall be reimbursed by the Department:

(a) Pursuant to COMAR 10.09.92.07B for an eligible patient who is uninsured or who has insurance that does not provide coverage for the reimbursed service;

(b) Pursuant to COMAR 10.09.92.07A(8) and (9) for an eligible patient who is covered by Medicare; or

(c) For an eligible patient who has insurance other than Medicare that provides coverage for the reimbursed services, the outstanding deductible and patient contribution amount required by the insurer.

(3) A participating hospital located in the District of Columbia shall be reimbursed by the Department:

(a) Pursuant to COMAR 10.09.92.08A and B for an eligible patient who is uninsured or who has insurance that does not provide coverage for the reimbursed service;

(b) Pursuant to COMAR 10.09.92.07A(8) and (9) for an eligible patient who is covered by Medicare; or

(c) For an eligible patient who has insurance other than Medicare that provides coverage for the reimbursed services, the outstanding deductible, and patient contribution required by the insurer.

H. The Program shall reimburse for claims submitted pursuant to this regulation as set forth in Regulation .21 of this chapter.