Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 2
Subtitle 09 - MEDICAL CARE PROGRAMS
Chapter 10.09.95 - Special Psychiatric Hospitals
Section 10.09.95.05 - Limitations
Universal Citation: MD Code Reg 10.09.95.05
Current through Register Vol. 51, No. 19, September 20, 2024
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.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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