Md. Code Regs. 10.09.23.05

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.23.05 - Limitations

A. Any Program limits on services or treatments identified in this regulation are not applicable for individuals younger than 21 years old if it is shown that the treatments or services are medically necessary to correct or ameliorate identified or suspected health problems.

B. The dental covered services specified in COMAR 10.09.05.04, which follow the periodicity schedule issued by the American Academy of Pediatric Dentists, are limited to two dental examinations per participant per 12-month period.

C. Vision services specified in COMAR 10.09.14.04A, including eye examinations and eyeglasses or contact lenses, are limited to not more than once a year.

D. Environmental lead investigations:

(1) Are limited to the child's primary dwelling;

(2) Are limited to one on-site inspection per dwelling; and

(3) Do not include testing of any substances sent to a laboratory for analysis.

E. The provider covered by this chapter may not bill the Program for:

(1) Services that are:

(a) Provided while the participant is in an institution for mental disease, a hospital, or a residential treatment center, as bundled payment for institutional stays includes EPSDT services;

(b) Custodial or assist with activities of daily living;

(c) Not medically necessary;

(d) Beyond the provider's scope of practice;

(e) Rendered but not appropriately documented;

(f) Part of another service paid for by the State; or

(g) Rendered not in person, unless the services are provided in compliance with COMAR 10.09.49 and any subregulatory guidance issued by the Department;

(2) Respite services;

(3) Completion of forms or reports;

(4) Broken or missed appointments;

(5) Supplies, equipment, or items that are not medical in nature; or

(6) Services that are primarily cosmetic in nature.

Md. Code Regs. 10.09.23.05

Regulation .05 amended effective March 20, 1989 (16:5 Md. R. 629)
Regulation .05B amended as an emergency provision effective January 1, 1983 (10:1 Md. R. 22); amended permanently effective May 1, 1983 (10:7 Md. R. 634)
Regulations .05 adopted effective March 22, 2010 (37:6 Md. R. 477); amended effective 43:13 Md. R. 712, eff. 7/4/2016; amended effective 46:17 Md. R. 726, eff. 8/26/2019; amended effective 49:7 Md. R. 465, eff. 4/4/2022; amended effective 50:15 Md. R. 681, eff. 8/7/2023