Md. Code Regs. 10.09.02.04

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.02.04 - Covered Services

The Program covers the following medically necessary services rendered to participants:

A. Physicians' services rendered in the physician's office, the participant's home, a hospital, a skilled or intermediate care nursing facility, a freestanding clinic, or elsewhere when these services are:

(1) Performed by the physician or one of the following:

(a) Another licensed physician either in the physician's employ or one who renders services through a reciprocal agreement as a substitute physician,

(b) A certified registered physician's assistant, licensed registered nurse, certified psychologist, or a certified social worker, provided that the individual performing the service is in the physician's employ and is under the physician's direct supervision and performs the service within the scope of the individual's license or certification for the purpose of assisting in the provision of physicians' services,

(c) A certified nurse midwife -who performs medically necessary services within the provider's scope of practice as described in COMAR 10.27.05; and

(d) A certified nurse practitioner who performs medically necessary services within the provider's scope of practice as described in COMAR 10.27.07.

(2) Clearly related to the participant's individual medical needs as diagnostic, curative, palliative, or rehabilitative services;

(3) Adequately described in the participant's medical record;

B. Consultations;

C. Diagnostic procedures to include:

(1) Procedures related to the patient's medical needs;

(2) Laboratory services performed by a physician or personnel under the physician's direct supervision, when the physician is not required to register his office as a medical laboratory pursuant to Health-General Article, Title 17, Subtitle 2, Annotated Code of Maryland;

D. Drugs dispensed by the physician within the limitations of COMAR 10.09.03;

E. Injectable drugs administered by the provider within the limitations of COMAR 10.09.03;

F. Medical equipment and supplies dispensed by the physician within the limitations of COMAR 10.09.12;

G. Abortions performed in accordance with the Health-General Article, Title 20, Subtitles 1 and 2, Annotated Code of Maryland;

H. Sterilizations when performed according to criteria contained in 42 Code of Federal Regulations §§441.250 -441.258 and when the appropriate forms, as established by guideline, are properly completed and attached to the claim;

I. Vaccine administrations when the vaccines:

(1) Meet the following conditions for coverage under the Vaccines for Children Program:

(a) Covered under the Vaccines for Children program;

(b) Administered to participants eligible for the Vaccines for Children program; and

(c) Administered by providers eligible to be reimbursed for vaccine administration under the Vaccines for Children program; or

(2) Are supplied to providers by the federal government at no charge, including but not limited to the administration of COVID-19 vaccinations.

Md. Code Regs. 10.09.02.04

Regulation .04D amended effective December 15, 1978 (5:25 Md. R. 1854)
Regulation .04K, L adopted effective January 13, 1978 (5:1 Md. R. 18)
Regulation .04K amended effective July 1, 1978 (5:12 Md. R. 967)
Regulation .04L repealed effective July 1, 1978 (5:12 Md. R. 967)
Regulation .04A amended effective August 17, 1981 (8:16 Md. R. 1365); December 12, 1988 (15:25 Md. R. 2902)
Regulation .04A amended as an emergency provision effective July 15, 1992 (19:16 Md. R. 1467); amended permanently effective November 1, 1992 (19:21 Md. R. 1890)
Regulation .04A amended as an emergency provision effective July 1, 2002 (29:14 Md. R. 1073); amended permanently effective September 16, 2002 (29:18 Md. R. 1443)
Regulations .04 amended effective July 1, 1979 (6:13 Md. R. 1126)
Regulation .04A amended effective 41:2 Md. R. 91, eff.2/3/2014
Regulation .04C amended effective December 12, 1988 (15:25 Md. R. 2902)
Regulation .04G amended as an emergency provision effective July 2, 1979 (6:14 Md. R. 1202); adopted permanently effective November 2, 1979 (6:22 Md. R. 1779) (adopted as Regulation .04K; recodified as Regulation .04G at 6:13 Md. R. 1126)
Regulation .04G amended as an emergency provision effective July 28, 1980 (7:16 Md. R. 1588); adopted permanently effective November 28, 1980 (7:24 Md. R. 2257)
Regulation .04G amended effective December 12, 1988 (15:25 Md. R. 2902)
Regulation .04J adopted effective October 1, 1985 (12:19 Md. R. 1848)
Regulation .04 amended as an emergency provision effective December 1, 1994 (21:26 Md. R. 2183)
Regulation .04 amended as an emergency provision effective February 3, 1995 (22:4 Md. R. 231); emergency status expired May 31, 1995; adopted permanently effective August 14, 1995 (22:16 Md. R. 1221)
Regulation .04 amended effective December 16, 1996 (23:25 Md. R. 1785); March 6, 2000 (27:4 Md. R. 453); amended effective 44:17 Md. R. 834, eff. 8/28/2017; amended effective 50:13 Md. R. 512, eff. 7/10/2023