Sec. 10.20.01.07. Provider Reimbursement

A. To qualify as a provider, a pharmacy shall:

(1) Maintain a permit from the Department pursuant to Health Occupations Article, Title 12, Annotated Code of Maryland, or from the appropriate agency in the state in which the pharmacy is located;

(2) To the extent required by law, be licensed and legally authorized to practice or deliver services in the state in which the service is provided; and

(3) Be a provider in the Maryland Medical Assistance Program.

B. The Program shall reimburse for treatment directly related to a recipient's ESRD or a condition that is a direct result of the recipient's ESRD.

C. The Program shall reimburse the incurred costs of prescription drugs and other pharmaceutical products determined to be medically necessary by the recipient's physician for treatment directly related to the recipient's ESRD or a condition that is a direct result of the recipient's ESRD.

D. Before invoicing the Program, providers of Program-approved services shall first seek reimbursement from all other payment sources of the recipient including, but not limited to, insurance coverage, Medicare, Medical Assistance, and PAC. If the other sources reject a claim or pay less than the amount allowed by the Program, the provider may then submit the claim to the Program for review.

E. A pharmacy provider may invoice the Program for reimbursement of legend drugs covered through the major medical component of a recipient's third-party insurance. The Program shall then seek reimbursement from the recipient's major medical coverage.

F. When a recipient who is a Medicare beneficiary is provided a service that is covered by Medicare and the Program, Program payment shall be limited to payment of the recipient's Medicare deductible and co-insurance amounts.

G. The Program may not reimburse for Medical Assistance covered services if the recipient is a Medical Assistance recipient.

H. When a service is covered by a recipient's health insurance plan under which the provider agrees to accept payment by the health insurance plan as payment in full for the service, payment may not be made by the Program.

I. The Program may not make a direct payment to a recipient.

J. Program reimbursement for outpatient dialysis treatment shall be consistent with the limits established and rates paid by Medicare.

K. Program reimbursement for other than outpatient dialysis treatment shall be consistent with the limits established and rates or fees paid by the Maryland Medical Assistance Program for the service except as otherwise indicated in this regulation. For services reimbursed on a fee basis, only the Medical Assistance net reimbursement amount will be paid.

L. Reimbursement for preauthorized out-of-State renal transplantation services may not exceed rates paid for the same or similar services in Maryland.

M. Program reimbursement for pharmacy services is as follows:

(1) The Program shall only pay for legend drugs and diabetic supplies itemized on the Kidney Disease Program of Maryland Reimbursable Drug List;

(2) A pharmacy provider shall charge the Program the provider’s usual and customary charge to the general public for legend drugs;

(3) Drugs shall be reimbursed by the Program as follows:

(a) Program payment for a legend drug shall be the lower of the provider's charge or the Medical Assistance allowable cost for the drug;

(b) In addition to payment for the legend drug ingredient cost, the Program shall establish and pay a dispensing fee for legend drugs;

(c) Duration of coverage for immunosuppressant drugs shall be consistent with Medicare policy;

(d) The Program shall only pay for a generic equivalent unless a brand is specified as medically necessary by the prescribing physician;

(e) The Program may not pay for more than a 34-day supply of an approved drug during a 26-day period;

(f) The Program may not pay for replacement of lost medications;

(g) The Program may pay for replacement of stolen medications when the claim is accompanied by a police report;

(h) A pharmacy provider shall maintain on file a hard copy of each prescription filled for a recipient; and

(i) The Program may not pay for legend drugs which are not FDA approved for the prescribed usage or which the FDA has declared to be “less-than-effective”.

N. Reimbursement for Epogen (Epoetin alfa), dispensed as part of the dialysis procedure, shall be consistent with Medicare rates. Reimbursement shall be limited to dialysis facilities.

O. Reimbursement for Procrit (Epoetin alfa) shall be consistent with Medicare rates. Coverage is limited to active renal transplant recipients.

P. The Program shall provide reimbursement for access surgery required by a recipient for dialysis treatment even though the access surgery may predate the recipient's date of certification for Program benefits as established in accordance with Regulation .03 of this chapter.

Q. To receive reimbursement from the Program a provider shall:

(1) Accept payment by the Program as payment in full and make no additional charge to any person for services covered by the Program;

(2) Provide services without regard to race, color, age, sex, national origin, marital status, or physical or mental handicap;

(3) Verify the recipient's Program eligibility each time a service is provided by viewing the recipient's Kidney Disease Program identification card with a valid through date;

(4) Notify the Program immediately of any recipient or provider activity or circumstance that affects eligibility, benefits, or reimbursement;

(5) Maintain the confidentiality of all recipient information;

(6) Submit the request for payment for services rendered according to procedures established by the Program and in the form designated by the Program; and

(7) Maintain and make available administrative and medical records in accordance with the following requirements:

(a) Administrative and medical records shall contain documentation that is sufficient in quantity, scope, and detail to confirm that services are provided in accordance with this chapter;

(b) Records shall be maintained for a minimum of 6 years; and

(c) Records shall be made available on request to the Department or the Department's designee.