Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.12 - Limited Benefit Plan › Section 31.11.12.03 - Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
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 Department of Health and Mental Hygiene 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.