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10.09.67.00.htm 10.09.67.00. Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 67 Maryland Medicaid Managed Care Program: Benefits Authority: Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland
10.09.67.01.htm 10.09.67.01. 01 Required Benefits Package ― In General.. A. Except for non-covered services set forth in Regulation .27 of this chapter and the non-capitated services described in COMAR 10.09.70, an MCO shall provide its enrollees with a benefits package that includes the covered services specified in this chapter when these services are deemed to be medically necessary including services covered under the Maryland Medicaid State Plan in the amount, duration, and scope set fort
10.09.67.02.htm 10.09.67.02. 02 Benefits ― Primary Care Services.. An MCO shall provide to its enrollees medically necessary primary care services that are provided:. A. By the enrollee's PCP;. B. At the direction of the enrollee's PCP; or. C. With respect to a primary care service that is self-referred pursuant to Regulation .28 of this chapter:1) By an appropriate practitioner, acting within the scope of the practitioner's license, certification, or other legal authorization, and in accordan
10.09.67.03.htm 10.09.67.03. 03 Benefits ― Physician and Advanced Practice Nurse Specialty Care Services.. A. An MCO shall provide to its enrollees medically necessary specialty care services that are outside of the enrollee's PCP's scope of practice, or, in the judgment of the enrollee's PCP, are not services that the PCP customarily provides, is specifically trained for, or is experienced in and are provided by:1) A physician or an advanced practice nurse, acting within the scope of th
10.09.67.04.htm 10.09.67.04. 04 Benefits ― Pharmacy Services.. A. An MCO shall provide to its enrollees all medically necessary pharmaceutical services and pharmaceutical counseling, including but not limited to:1) Legend drugs;. 2) Insulin;. 3) All FDA approved contraceptives;. 4) Hypodermic needles and syringes;. 5) Enteral nutritional and supplemental vitamins and mineral products given by nasogastric, jejunostomy, or gastrostomy tube in the home;
10.09.67.05.htm 10.09.67.05. 05 Benefits ― Home Health Services.. A. Subject to the conditions specified in §B of this regulation, an MCO shall provide to its enrollees medically necessary home health services, including:1) Skilled nursing services, including the supervisory visits required by §A(2) of this regulation;. 2) Home health aide services, including biweekly supervisory visits by a registered nurse in the recipient's home, every second visit of which includes observations of the del
10.09.67.06.htm 10.09.67.06. 06 Benefits ― Habilitation Services for Medicaid Expansion Populations. A. An MCO shall provide the following medically necessary habilitation services to enrollees eligible for Medical Assistance under §1902 (a)10)A)i)VIII) of the Social Security Act:1) Physical therapy;. 2) Occupation therapy; and. 3) Speech therapy.. B. At a minimum, an MCO shall provide the services in hospital inpatient and outpatient departments and physical therapy in an outpatient community setting.
10.09.67.07.htm 10.09.67.07. 07 Benefits ― Inpatient Hospital Services.. A. An MCO shall provide to its enrollees medically necessary inpatient hospital services as specified in this regulation.B. Admission to Long-Term Care Facility.. 1) An MCO shall provide to its enrollees medically necessary long-term care facility services for:. a) The first 90 continuous days following the enrollee's admission; and. b) Any days following the first 90 continuous days of an admission until the date the MCO has obtain
10.09.67.08.htm 10.09.67.08. 08 Benefits ― Outpatient Hospital Services.. An MCO's benefits package shall include medically necessary outpatient hospital services..
10.09.67.09.htm 10.09.67.09. 09 Benefits ― Transplants.. An MCO shall provide to its enrollees medically necessary transplants..
10.09.67.10.htm 10.09.67.10. 10 Benefits ― Substance Abuse Treatment Service ― Repealed.
10.09.67.11.htm 10.09.67.11. 11 Benefits ― Diagnostic and Laboratory Services.. An MCO shall provide to its enrollees medically necessary:. A. Diagnostic services; and. B. Laboratory services, performed by a provider who:. 1) Is Clinical Laboratory Improvement Amendments (CLIA) certified; or. 2) Has a waiver of a certificate registration along with a CLIA identification number..
10.09.67.12.htm 10.09.67.12. 12 Benefits ― Long-Term Care Facility Services.. A. An MCO shall provide to its enrollees medically necessary services in a chronic hospital, a chronic rehabilitation hospital, or a nursing facility for:1) The first 90 continuous days following the enrollee's admission; and. 2) Any days following the first 90 continuous days of an admission until the date the MCO has obtained the Department’s determination that the admission is medically necessary as specified in §C of th
10.09.67.13.htm 10.09.67.13. 13 Benefits ― Disposable Medical Supplies and Durable Medical Equipment.. A. An MCO shall provide to its enrollees medically necessary disposable medical supplies and durable medical equipment, including but not limited to:1) All supplies and equipment used in the administration or monitoring of prescriptions by the enrollees; and2) Incontinency pants and disposable underpads for medical conditions associated with prolonged urinary or bowel incontinence if necessary to prevent
10.09.67.14.htm 10.09.67.14. 14 Benefits ― Vision Care Services.. A. An MCO shall provide to its enrollees medically necessary vision care services as specified in this regulation.B. For enrollees who are 21 years old or older, the MCO is responsible for providing at least one eye examination every 2 years.C. For its enrollees who are younger than 21 years old, the MCO is responsible for providing medically necessary vision services, including but not limited to:1) At least one eye exami
10.09.67.15.htm 10.09.67.15. 15 Benefits ― Podiatry Services.. A. An MCO shall provide for its enrollees medically necessary podiatry services.. B. In addition to the services described in §A of this regulation, an MCO shall provide:. 1) Diabetes care services specified in COMAR 10.09.67.24; and. 2) Routine foot care for enrollees, 21 years old or older with vascular disease affecting the lower extremities.
10.09.67.16.htm 10.09.67.16. 16 Benefits ― Outpatient Rehabilitative Services.. An MCO shall provide to its enrollees medically necessary outpatient rehabilitative services, including but not limited to physical therapy for adult enrollees.
10.09.67.17.htm 10.09.67.17. 17 Benefits ― Oxygen and Related Respiratory Equipment.. An MCO shall provide to its enrollees medically necessary oxygen and related respiratory equipment services.
10.09.67.18.htm 10.09.67.18. 18 Benefits ― Dialysis Services.. An MCO shall provide to its enrollees medically necessary dialysis services..
10.09.67.19.htm 10.09.67.19. 19 Benefits ― Family Planning Services.. An MCO shall provide to its enrollees comprehensive family planning services, including but not limited to medically necessary office visits and laboratory tests, all FDA-approved contraceptive devices, methods, and supplies, and voluntary sterilizations.
10.09.67.20.htm 10.09.67.20. 20 Benefits ― EPSDT Services.. A. An MCO shall provide, to enrollees younger than 21 years old, medically necessary Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services, including:1) EPSDT comprehensive well-child services provided in accordance with the EPSDT periodicity schedule and performed by an EPSDT-certified provider, including:a) A comprehensive health and developmental history, including an evaluation of both physical and mental health development;
10.09.67.21.htm 10.09.67.21. 21 Benefits ― Pregnancy-Related Services.. A. An MCO shall provide to its pregnant and postpartum enrollees medically necessary pregnancy-related services, including:1) Comprehensive prenatal, perinatal, and postpartum care, including high-risk specialty care when appropriate;2) Prenatal risk assessment and development of an individualized plan of care that specifies the actions required to address each identified need and is appropriately modified during the course of care;
10.09.67.22.htm 10.09.67.22. 22 Benefits ― Case Management Services for HIV-Infected Individuals.. An MCO shall provide medically necessary case management services to its qualifying enrollees, as specified in COMAR 10.09.65.10C.
10.09.67.23.htm 10.09.67.23. 23 Benefits ― Hospice Care Services.. A. An MCO shall include in its benefits package medically necessary hospice care services to enrollees who are terminally ill.B. The Department shall allow an enrollee to disenroll from an MCO and choose a new MCO if:. 1) The enrollee was auto-assigned to the MCO; and. 2) The enrollee's hospice provider does not contract with the enrollee's assigned MCO.. C. If an enrollee who is in a hospice that does not contract with the enrol
10.09.67.24.htm 10.09.67.24. 24 Benefits ― Diabetes Care Services.. A. An MCO shall provide to its qualifying enrollees medically necessary diabetes care services as specified in this regulation.B. In addition to the services included in its usual benefits package, an MCO shall provide enrollees with a diabetes diagnosis the following medically necessary special diabetes-related services:1) Diabetes nutrition counseling, consisting of one initial one-on-one session and up to 4 subsequent sessions annually;
10.09.67.25.htm 10.09.67.25. 25 Benefits ― Blood and Blood Products.. An MCO shall provide to its enrollees medically necessary blood, blood products, derivatives, components, biologics, and serums to include autologous services, whole blood, red blood cells, platelets, plasma, immunoglobulin, and albumin.
10.09.67.26.htm 10.09.67.26. 26 Benefits ― Primary Mental Health Services.. An MCO shall provide to its enrollees medically necessary primary mental health services, including appropriate referrals for service to the Department’s behavioral health ASO as described in COMAR 10.09.59
10.09.67.26-1.htm 10.09.67.26-1. 26-1 Clinical Trial Items and Services ― Coverage for Routine Costs.. A. Subject to the conditions specified in §B―F of this regulation, an MCO shall provide coverage for cost to an enrollee in an approved clinical trial for:1) Treatment provided for life-threatening conditions; or. 2) Prevention, early detection, and treatment studies on cancer.. B. Clinical trials are deemed to be automatically approved if:. 1) The treatment is:. a) Being provided or the
10.09.67.26-2.htm 10.09.67.26-2. 26-2 Plastic and Restorative Surgery.. An MCO shall provide to an enrollee medically necessary surgery to correct a deformity from disease, trauma, congenital or developmental anomalies, or to restore body functions.
10.09.67.26-3.htm 10.09.67.26-3. 26-3 Gender Transition Services.. An MCO shall provide medically necessary gender reassignment surgery and other somatic specialty care for members with gender identity disorder.
10.09.67.27.htm 10.09.67.27. 27 Benefits ― Limitations.. A. The benefits or services not required to be provided by an MCO are as follows:. 1) Experimental or investigational services, including organ transplants determined by Medicare to be experimental, except when an enrollee is participating in an authorized clinical trial as specified in Regulation .26-1 of this chapter;2) Any service or treatment that is not medically necessary;. 3) Services performed or prescribed under the direction of a person who is
10.09.67.28.htm 10.09.67.28. 28 Benefits ― Self-Referral Services.. An MCO shall be financially responsible for reimbursing, in accordance with COMAR 10.09.65.20, an out-of-plan provider chosen by the enrollee for the following services:A. Family planning services specified in COMAR 10.09.65.20A(2) (6) and (7). B. Services performed by school-based health centers, as provided in COMAR 10.09.68;. C. Pregnancy-related services for women who are pregnant and, at the time of initial enrollment, hav
10.09.67.29.htm 10.09.67.29. 29 Optional Services.. A. An MCO may provide its enrollees with additional health care services that are not required by this chapter.B. Optional health care services that an applicant intends to include in its benefits package shall be specified, including the terms and conditions for, and limitations to the provision of these services, in the applicant's initial application to the Department, as well as for periodic Departmental review.C. An MCO's provision of
10.09.67.30.htm 10.09.67.30. 30 Departmental Order to Provide Benefit or Service.. A. If the Department determines, either through the complaint resolution process specified in COMAR 10.09.72 or otherwise, that an MCO is not providing a benefit or service required by this chapter, the Department is authorized to order the MCO to provide the benefit or service.B. An MCO may appeal an order issued under §A of this regulation pursuant to COMAR 10.09.72.06B(4). C. The Department's order to provide a disputed be
10.09.67.31.htm 10.09.67.31. 31 Benefits ― Telemedicine Services.. An MCO shall provide to its enrollees medically necessary telemedicine services as described in COMAR 10.09.49.
10.09.67.9999.htm 10.09.67.9999. Administrative History Effective date:. Regulations .01―30 adopted as an emergency provision effective November 8, 1996 (23:25 Md. R. 1730) adopted permanently effective March 10, 1997 (24:5 Md. R. 408)Regulation .01 amended as an emergency provision effective January 5, 2005 (32:6 Md. R. 634) amended permanently effective April 11, 2005 (32:7 Md. R. 679)Regulation .01 amended effective December 27, 2010 (37:26 Md. R. 1787) February 16, 2015 (42:3 Md. RRegulation .01A amended e
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