Md. Code Regs. 10.09.95.05

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

Section 10.09.95.05 - Limitations

A. There are limitations placed on the coverage of some special psychiatric hospital inpatient and outpatient services.

B. The Program does not cover:

(1) Special psychiatric hospital services, procedures, drugs or admissions that are investigational or experimental;

(2) Services identified by the Department or its designee as not medically necessary;

(3) Elective inpatient admissions without preauthorization;

(4) Inpatient admissions or outpatient visits solely for the administration of injections, unless medical necessity and the participant's inability to take appropriate oral medications is documented in the participant's medical record;

(5) Inpatient mental health services for an individual between 21 and 64 in a special psychiatric hospital of more than 16 beds that primarily engages in providing mental health services for an individual who is not waiver-eligible, as defined in COMAR 10.67.01.01, except:

(a) When receiving mental health services in the special psychiatric hospital immediately before the participant reached 21 years old, in which case the services may be continued until the earlier of the following:

(i) The date the participant no longer requires the services; or

(ii) The date the participant reaches 22 years old;

(b) Effective July 1, 2019, services of up to 15 days per month, when:

(i) The participant has co-occurring substance use and mental health diagnoses; and

(ii) The provider is located in-State or, effective January 1, 2022, the provider is located in a contiguous state or the District of Columbia; or

(c) Effective January 1, 2022, services up to 60 days, when:

(i) The participant has a primary mental health diagnosis; and

(ii) The provider is located in-State, a contiguous state, or the District of Columbia;

(6) Outpatient visits for one or more of the following:

(a) Prescription drug or food supplement pick up;

(b) Collection of specimens for laboratory procedures;

(c) Recording of an electrocardiogram;

(d) Ascertaining the participant's weight; and

(e) Administration of vaccines;

(7) Leaves of absence beyond the period of the census check of the same day;

(8) Psychological evaluations and treatments except when:

(a) Ordered by a physician, and the medical necessity is documented in the participant's medical record; or

(b) Performed as mental health services as part of an approved treatment plan;

(9) Telephones, televisions, or personal comfort items or services;

(10) Duplicated care or service as indicated by more than one charge for the same stay or more than one room accommodation for the same time, for example, a charge for an inpatient day and observation room charge;

(11) Administrative days for participants pending discharge to home or nonmedical institutions;

(12) Inpatient and outpatient diagnostic and laboratory services not ordered by the attending physician or other practitioner;

(13) Inpatient days provided in excess of the days approved by the Department or its designee;

(14) Hospital laboratory tests which are coverable under COMAR 10.09.09, unless the specimen is obtained in the hospital;

(15) Admissions to special psychiatric hospitals, unless the participant is diagnosed with any one of the specialty mental health codes listed in COMAR 10.09.70.02 or unless the Department or its designee grants a special exception based on the complexity of the situation at admission; or

(16) Elective admissions to hospitals outside of Maryland, except the District of Columbia, unless the Department or its designee determines that comparable services are not available in Maryland.

Md. Code Regs. 10.09.95.05

Regulation .05 adopted effective 44:7 Md. R. 354, eff. 4/10/2017; amended effective 46:18 Md. R. 774, eff. 9/9/2019; amended effective 50:8 Md. R. 338, eff. 5/1/2023