10.09.02.04

.04 Covered Services.

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

A. Physicians' services rendered in the physician's office, the recipient'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 providerís scope of practice as described in COMAR 10.27.05; and

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

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

(3) Adequately described in the recipient'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 upon certification by the physician performing the procedure that the procedure is necessary, based upon the physician's professional judgment, and that one of the following conditions exists:

(1) If continuation of pregnancy is likely to result in the death of the woman;

(2) If the woman is a victim of rape, sexual offense, or incest which has been reported to a law enforcement agency or a public health or social agency;

(3) If it can be ascertained by the physician within a reasonable degree of medical certainty that the fetus is affected by genetic defect or serious deformity or abnormality;

(4) If it can be ascertained by the physician within a reasonable degree of medical certainty that termination of the pregnancy is medically necessary because there is substantial risk that continuation of the pregnancy could have a serious and adverse effect on the woman's present or future physical health;

(5) That there exists medical evidence that continuation of the pregnancy is creating a serious effect on the woman's present mental health and if carried to term there is substantial risk of a serious or long lasting effect on the woman's future mental health;

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 are:

(1) Covered under the Vaccines for Children program;

(2) Administered to recipients eligible for the Vaccines for Children program;

(3) Administered by providers eligible to be reimbursed for vaccine administration under the Vaccines for Children program.