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

Current through Register Vol. 51, No. 14, July 12, 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.