31.11.06.03

.03 Covered Services.

A. The comprehensive standard health benefit plan includes the following:

(1) Care in medical offices for treatment of illness or injury;

(2) Inpatient hospital services;

(3) Outpatient hospital services;

(4) Inpatient mental health and substance abuse services provided through a carrier's managed care system, including residential crisis services, up to a maximum of 60 days per covered person per year in a hospital, related institution, or entity licensed by the Maryland Department of Health to provide residential crisis services;

(5) Outpatient mental health and substance abuse services provided through a carrier's managed care system;

(6) Emergency services;

(7) Detoxification in a hospital or related institution;

(8) Ambulance services to or from the nearest hospital where needed medical services can appropriately be provided;

(9) Except for prostate cancer screening for men between 40 and 75 years old, and colorectal screening for men and women 50 years old or older, preventive services recommended in the report of the United States Preventive Services Task Force, Guide to Clinical Preventive Services, which is current when the services are rendered, and any other preventive service required to be offered by a federally qualified health maintenance organization;

(9-1) Prostate cancer screening shall be covered as set forth in the current recommendations of the American Cancer Society, which recommends an annual:

(a) Digital rectal examination for both prostate and colorectal cancer, beginning at age 40;

(b) PSA screening for African-American men and all men 40 years old and older with a family history of prostate cancer; and

(c) PSA screening for all other men 50 years old and older;

(9-2) Colorectal screening shall be covered for men and women 50 years old or older as follows:

(a) A yearly fecal occult blood test, accompanied by digital rectal examination, plus flexible sigmoidoscopy every 5 years;

(b) A colonoscopy, accompanied by digital rectal examination, every 10 years; or

(c) A double contrast barium enema, accompanied by digital rectal examination, every 5 years;

(10) Mammography services for persons ages 40 to 49 once every other calendar year, and for ages 50 and above once per calendar year;

(11) Home health care services:

(a) As an alternative to otherwise covered services in a hospital or related institution; and

(b) For contracts issued or renewed on or after November 1, 1999, for covered persons who receive less than 48 hours of inpatient hospitalization following a mastectomy or removal of a testicle or who undergo a mastectomy or removal of a testicle on an outpatient basis:

(i) One home visit scheduled to occur within 24 hours after discharge from the hospital or outpatient health care facility; and

(ii) An additional home visit if prescribed by the covered person's attending physician;

(12) Hospice care services;

(13) Durable medical equipment, including nebulizers, peak flow meters, prosthetic devices such as leg, arm, back, or neck braces, artificial legs, arms, or eyes, and the training necessary to use these prostheses;

(14) Outpatient laboratory and diagnostic services;

(15) Outpatient rehabilitative services provided through a carrier's managed care system for a maximum of:

(a) 30 physical therapy visits per condition per year;

(b) 30 speech therapy visits per condition per year;

(c) 30 occupational therapy visits per condition per year; or

(d) When provided by a federally qualified health maintenance organization, the outpatient rehabilitation service coverage specified in 42 CFR §417.101(a)(2)(iii).

(16) Chiropractic services up to 20 visits per condition per year;

(17) Skilled nursing facility services as an alternative to medically necessary inpatient hospital services up to a maximum of 100 days per year;

(18) Infertility services, except for those services excluded in this chapter;

(19) Nutritional services for the treatment of cardiovascular disease, diabetes, malnutrition, cancer, cerebral vascular disease, or kidney disease up to a maximum of six visits per year per condition;

(20) Autologous and nonautologous bone marrow, cornea, kidney, liver, heart, lung, heart/lung, pancreas, and pancreas/kidney transplants;

(21) Medical food for persons with metabolic disorders when ordered by a health care practitioner qualified to provide diagnosis and treatment in the field of metabolic disorders;

(22) Family planning services, including:

(a) Prescription contraceptive drugs or devices;

(b) Coverage for the insertion or removal of contraceptive devices;

(c) Medically necessary examination associated with the use of contraceptive drugs or devices; and

(d) Voluntary sterilization;

(23) Except for habilitative services provided in early intervention and school services, habilitative services for children 0—19 years old for the treatment of congenital or genetic birth defects;

(24) All cost recovery expenses for blood, blood products, derivatives, components, biologics, and serums to include autologous services, whole blood, red blood cells, platelets, plasma, immunoglobulin, and albumin;

(25) Pregnancy and maternity services, including abortion;

(26) Prescription drugs;

(27) Controlled clinical trials;

(28) Any other service approved by a carrier's case management program;

(29) Diabetes treatment, equipment, and supplies; and

(30) Breast reconstructive surgery as specified in Insurance Article, §15-815, Annotated Code of Maryland, and breast prosthesis;

(31) Audiology screening for newborns, limited to one screen and one confirming screen; and

(32) General anesthesia and associated hospital or ambulatory facility charges in conjunction with dental care provided to the following:

(a) Individuals who are 7 years old or younger or developmentally disabled and for whom a:

(i) Successful result cannot be expected from dental care provided under local anesthesia because of a physical, intellectual, or other medically compromising condition of the enrollee or insured; and

(ii) Superior result can be expected from dental care provided under general anesthesia;

(b) Individuals 17 years old or younger who:

(i) Are extremely uncooperative, fearful, or uncommunicative;

(ii) Have dental needs of such magnitude that treatment should not be delayed or deferred; and

(iii) Are individuals for whom lack of treatment can be expected to result in oral pain, infection, loss of teeth, or other increased oral or dental morbidity;

(33) An annual chlamydia screening test for:

(a) Women who are:

(i) Younger than 20 years old who are sexually active; or

(ii) At least 20 years old who have multiple risk factors; and

(b) Men who have multiple risk factors;

(34) The cost to beneficiaries of hearing aids for persons 0 to 18 years of age, up to $1,400 per hearing aid for each hearing-impaired ear every 36 months; and

(35) The surgical treatment of morbid obesity as specified in Insurance Article, §15-839, Annotated Code of Maryland.

A-1. Morbid Obesity.

(1) When establishing utilization review criteria for the surgical treatment of morbid obesity, a carrier or a private review agent acting on behalf of a carrier shall adhere to the requirements of COMAR 31.10.33.03.

(2) Surgical treatment of morbid obesity shall occur in a facility that is:

(a) Designated by the American Society for Metabolic and Bariatric Surgery as a Bariatric Surgery Center of Excellence; and

(b) Designated by the carrier.

(3) If a carrier does not make a designation under §A-1(2) of this regulation, the carrier shall provide benefits under the health benefit plan for the surgical treatment of morbid obesity at any facility that is designated by the American Society for Metabolic and Bariatric Surgery as a Bariatric Surgery Center of Excellence.

B. The services described in §A(23) of this regulation shall be delivered through a carrier's managed care system and shall include services for cleft lip and cleft palate, orthodontics, oral surgery, otologic, audiological, and speech therapy, physical therapy, and occupational therapy for children 0—19 years old for treatment of congenital or genetic birth defects.

C. All mental health and substance abuse services described in §A(4) and (5) of this regulation shall be delivered through a carrier's managed care system.

D. Rehabilitative services and habilitative services required to be offered in the plan shall be provided through the carrier's managed care system.

E. Prescription Drugs.

(1) Carriers shall cover prescription drugs and may, for brand name drugs, use a formulary which complies with the requirements of Insurance Article, §15-831, Annotated Code of Maryland.

(2) Carriers shall cover insulin and birth control drugs.

(3) Except as provided in §E(4) of this regulation, coverage under §A(26) of this regulation of prescription drugs includes up to a 90-day supply of maintenance drugs dispensed in a single dispensing of a prescription.

(4) Coverage of up to a 90-day supply of maintenance drugs in a single dispensing is not required for the first prescription of a maintenance drug or a change in a prescription of a maintenance drug.

F. The carrier shall provide benefits for the covered services in accordance with the terms of the contract, if:

(1) The service is rendered by a health care practitioner who is licensed under the laws of the state in which the practitioner is practicing; and

(2) The health care practitioner is practicing within the scope of the license.

G. Under §A(4) of this regulation, two partial hospitalization days may be substituted for one inpatient day in a hospital or related institution.

H. Under §A(29) of this regulation, diabetes equipment includes glucose monitoring equipment under the durable medical equipment coverage for insulin-using beneficiaries. Insulin pumps are not included. Diabetes supplies include coverage for insulin syringes and needles and testing strips for glucose monitoring equipment under the prescription coverage for insulin-using beneficiaries.

I. Under §A(30) of this regulation, breast prosthesis and breast reconstruction on the nondiseased breast to achieve symmetry is covered regardless of the patient's insurance status at the time of the mastectomy or the time lag between the mastectomy and reconstruction.

J. Under §A(32) of this regulation:

(1) Carriers may require prior authorization for covered services and associated charges in the same manner that prior authorization is required for these benefits in connection with other covered medical care;

(2) Carriers may restrict coverage to dental care that is provided by a:

(a) Fully accredited specialist in pediatric dentistry;

(b) Fully accredited specialist in oral and maxillofacial surgery; and

(c) Dentist to whom hospital privileges have been granted; and

(3) Dental care for which general anesthesia is required is not covered.