Md. Code Regs. 10.09.04.05

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

Section 10.09.04.05 - Limitations

The Program does not cover the following:

A. Nonskilled services rendered by licensed nurses, physical therapists, occupational therapists and speech pathologists;

B. Services and medical supplies that are not medically necessary and appropriate;

C. Durable medical equipment except as covered under COMAR 10.09.12;

D. Services primarily for the purpose of housekeeping, including but not limited to:

(1) Cleaning of floor and furniture;

(2) Laundry; and

(3) Shopping;

E. Home health aide services unless biweekly supervisory visits by a registered nurse in the participant's home are made, every second visit of which shall include observations of the delivery of services by the aide to the participant;

F. Home health aide services rendered to participants with chronic conditions when those participants require only assistance with activities of daily living as defined in Regulation .01B of this chapter unless preauthorized as specified in Regulation .06 of this chapter;

G. Meals;

H. More than one visit per type of service per day, unless preauthorized as specified in Regulation .06 of this chapter;

I. Any service or combination of services specified in Regulation .04 of this chapter and rendered during any 30-day period for which payments by the Program to the provider exceed the Medicaid average nursing facility rate unless preauthorized as specified in Regulation .06 of this chapter;

J. Four or more hours of care per day whether the 4-hour limit is reached in one visit or in several visits in one day unless preauthorized as specified in Regulation .06 of this chapter;

K. Services for investigational and experimental purposes;

L. Services specified in Regulation .04 of this chapter to persons eligible for Medicare coverage of those services;

M. A service not documented as received by the participant as indicated by the participant's signature or the signature of a witness on the home health agency's official form;

N. Supervisory visits by a registered nurse to monitor services of a home health aide;

O. Initial assessments by a therapist or a registered nurse;

P. Services provided for the convenience or preference of the participant or primary caregiver rather than as required by the participant's medical condition;

Q. Services specified in Regulation .04 of this chapter which duplicate or supplant services performed by the participant and those services rendered by the participant's family;

R. Services which are covered by other insurance or entitlement programs;

S. Newborn early discharge services provided more than one time to a participant;

T. A newborn early discharge visit provided on the same day as another skilled nursing visit billed under this chapter; and

U. Home health services ordered by an:

(1) Individual who is not enrolled as a provider in the Program with an active status on the date of service; and

(2) Entity, facility, or another provider that is not an individual.

Md. Code Regs. 10.09.04.05

Regulations .05L amended, and .05M adopted as an emergency provision effective July 17, 1990 (17:16 Md. R. 1984); adopted permanently effective November 1, 1990 (17:20 Md. R. 2427)
Regulation .05F, I amended effective November 12, 1990 (17:22 Md. R. 2656)
Regulation .05F, J amended effective April 4, 1988 (15:7 Md. R. 849)
Regulation .05 amended effective December 27, 2010 (37:26 Md. R. 1787)
Regulation .05W amended effective March 10, 2008 (35:5 Md. R. 641); amended effective 44:26 Md. R. 1214, eff. 1/1/2018; amended effective 48:12 Md. R. 470, eff. 6/14/2021