Md. Code Regs. 10.09.92.04

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

Section 10.09.92.04 - Covered Services

A. The Program covers the services listed in §B of this regulation according to the conditions and requirements indicated.

B. The Program covers the following hospital services:

(1) Medically necessary emergency services as defined in COMAR 10.09.36.01, including triage, related ancillary services, and when necessary, observation stays of a participant who presents to a hospital emergency department;

(2) Medically necessary services performed in an outpatient department of a hospital;

(3) Medically necessary services performed at a freestanding medical facility;

(4) Medically necessary inpatient hospital services meeting the following criteria:

(a) Inpatient days, including preoperative days, determined to be medically necessary by the Department or its designee;

(b) Admissions from an emergency department resulting in a medically necessary inpatient stay; and

(c) Elective admissions that the Department or its designee determines to be medically necessary;

(5) Inpatient stays determined to be medically necessary due to an emergent condition by the Department or its designee for a nonqualified alien;

(6) Administrative days, which may include select ancillary services, determined to be necessary by the Department or its designee; and

(7) Medically necessary services performed in an acute rehabilitation hospital when the participant meets the following criteria at the time of admission:

(a) Requires active and ongoing therapeutic intervention of multiple therapy disciplines, one of which shall be physical or occupational therapy;

(b) Requires and can reasonably be expected to actively participate in, and benefit from, the therapy, which generally consists of

(i) At least 3 hours of therapy a day, at least 5 days a week; or

(ii) In well-documented cases, at least 15 hours of intensive rehabilitation therapy within a 7 day consecutive period;

(c) Is sufficiently stable to be able to actively participate in the therapy program; and

(d) Requires supervision by a licensed physician, who has specialized training and experience in inpatient rehabilitation, which includes:

(i) Conducting face-to-face visits with the patient at least 3 days a week to assess the patient both medically and functionally; and

(ii) Modifying the course of treatment as needed to maximize the participant's capacity to benefit from the rehabilitation process.

C. The coverage of ancillary services during administrative days as described under §B(6) of this regulation applies to special pediatric hospitals under COMAR 10.09.94.

Md. Code Regs. 10.09.92.04

Regulation .04 adopted effective 44:7 Md. R. 354, eff. 4/10/2017; amended effective 51:12 Md. R. 619, eff. 6/24/2024.