31.11.12.03

.03 Covered Services.

A. The Limited Benefit Plan includes the following:

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

(2) Inpatient hospital services as follows:

(a) Inpatient hospital physician and other nonfacility services; and

(b) Inpatient hospital facility services;

(3) Outpatient services as follows:

(a) Outpatient hospital physician and other health care practitioner services;

(b) Outpatient facility surgical services; and

(c) Outpatient facility nonsurgical services;

(4) Inpatient mental health and substance abuse services provided through a carrier's managed care system, including residential crisis services, in a hospital, related institution, or entity licensed by the Maryland Department of Health to provide residential crisis services, including:

(a) Physician and other nonfacility services;

(b) Facility services;

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

(a) Physician and other health care practitioner services; and

(b) Facility services;

(6) Emergency services;

(7) Detoxification in a hospital or related institution, including:

(a) Physician and other nonfacility services; and

(b) Facility services;

(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 40 years old through 75 years old, and colorectal screening for men and women 50 years old or older:

(a) 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

(b) Any other preventive service required to be offered by a federally qualified health maintenance organization;

(10) Prostate cancer screening 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, at 40 years old or older; and

(b) Prostate-Specific Antigen (PSA) screening for:

(i) African-American men 40 years old or older;

(ii) All men 40 years old or older with a family history of prostate cancer; and

(iii) All other men 50 years old or older;

(11) Colorectal screening 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;

(12) Mammography services for women:

(a) 40 years old through 49 years old once every other calendar year; and

(b) 50 years old or older once per calendar year;

(13) Home health care services provided:

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

(b) For covered persons:

(i) Who receive less than 48 hours of inpatient hospitalization following a mastectomy or removal of a testicle; or

(ii) Who undergo a mastectomy or removal of a testicle on an outpatient basis, one home visit scheduled to occur within 24 hours after discharge from the hospital or outpatient health care facility, and an additional home visit if prescribed by the covered person's attending physician;

(14) Hospice care services, including:

(a) Physician and other health care practitioner services; and

(b) Facility services;

(15) Durable medical equipment, including:

(a) Nebulizers;

(b) Peak flow meters;

(c) Prosthetic devices such as:

(i) Leg, arm, back, or neck braces; and

(ii) Artificial legs, arms, or eyes; and

(d) The training necessary to use these prostheses;

(16) Outpatient laboratory and diagnostic services;

(17) Outpatient rehabilitative services provided through a carrier's managed care system including physical therapy, occupational therapy, and speech therapy services;

(18) Chiropractic services;

(19) Skilled nursing facility services as an alternative to medically necessary inpatient hospital services, including:

(a) Physician and other nonfacility services;

(b) Facility services;

(20) Nutritional services up to a maximum of six visits per contract year per condition, for the treatment of:

(a) Cardiovascular disease;

(b) Diabetes;

(c) Malnutrition;

(d) Cancer;

(e) Cerebral vascular disease; or

(f) Kidney disease;

(21) Autologous and nonautologous bone marrow, cornea, kidney, liver, heart, lung, heart/lung, pancreas, and pancreas/kidney transplants, including:

(a) Physician and other nonfacility services; and

(b) Facility services;

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

(23) Family planning services, including:

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

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

(c) Voluntary sterilization;

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

(25) 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;

(26) Pregnancy and maternity services, including abortion, including:

(a) Physician and other nonfacility services; and

(b) Facility services;

(27) Prescription drugs;

(28) Controlled clinical trials, including:

(a) Physician and other nonfacility services; and

(b) Facility services;

(29) Diabetes treatment, equipment, and supplies;

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

(a) Physician and other nonfacility services; and

(b) Facility services;

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

(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; and

(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) 20 years old or older who have multiple risk factors; and

(b) Men who have multiple risk factors;

(34) The cost to beneficiaries of hearing aids for persons ages 18 years old or younger, every 36 months; and

(35) Osteoporosis screening as specified in Insurance Article, §15-823, Annotated Code of Maryland.

B. The services described in §A(24) 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 19 years old or younger 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) Prescription drugs are covered only as provided in the specific services in Regulation .05 of this chapter.

(2) Birth control pills, Norplant, Depo Provera, and insulin, or their generic equivalents, are also covered only as provided in the specific services in Regulation .05 of this chapter.

(3) Except as provided in §E(4) of this regulation, coverage under §A(27) of this regulation 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:

(a) The first prescription of a maintenance drug; or

(b) 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, 2 partial hospitalization days may be substituted for 1 inpatient day in a hospital or related institution.

H. Diabetes Equipment and Supplies.

(1) Under §A(29) of this regulation, diabetes equipment includes glucose monitoring equipment under the durable medical equipment coverage for insulin-using beneficiaries.

(2) Insulin pumps are not included.

(3) Under the prescription coverage for insulin-using beneficiaries, diabetes supplies include coverage for:

(a) Insulin syringes and needles; and

(b) Testing strips for glucose monitoring equipment

I. Under §A(30) of this regulation, breast prosthesis and breast reconstruction on the nondiseased breast to achieve symmetry are covered regardless of:

(1) The patient's insurance status at the time of the mastectomy; or

(2) 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.