Md. Code Regs. 10.67.06.27

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.06.27 - Benefits - Limitations

A. The benefits or services not required to be provided by an MCO are as follows:

(1) Experimental or investigational services, including organ transplants determined by Medicare to be experimental, except when an enrollee is participating in an authorized clinical trial as specified in Regulation .26-1 of this chapter;

(2) Any service or treatment that is not medically necessary;

(3) Services performed or prescribed under the direction of a person who is not a health care practitioner;

(4) Services that are beyond the scope of practice of the health care practitioner performing the service;

(5) Transportation services provided through grants to local governments pursuant to COMAR 10.67.19, other than assisting enrollees to access nonemergency transportation services through their local transportation grantee agency;

(6) Health-related services and targeted case management services provided to children when the services are:

(a) Specified in the enrollee's individualized family service plan (IFSP), or an individualized education program (IEP); and

(b) Delivered in the schools or through Children's Medical Services community-based providers;

(7) Autopsies;

(8) Immunizations required for travel outside the continental United States;

(9) Services received while the enrollee is outside the United States;

(10) Abortions;

(11) Diet and exercise programs for the loss of weight;

(12) Prescriptions or injections for central nervous system stimulants and anorectic agents when used for controlling weight;

(13) In vitro fertilization, ovum transplants and gamete intrafallopian tube transfer, zygote intrafallopian transfer, or other techniques used in these or similar procedures;

(14) Services to reverse a voluntary sterilization procedure;

(15) Lifestyle improvements, including smoking cessation, nutrition counseling, or physical fitness programs, unless specifically included as a covered service;

(16) Nonmedical ancillary services such as vocational rehabilitation, employment counseling, or educational therapy;

(17) Private duty nursing for adults 21 years old and older;

(18) Services incurred before the effective date of coverage for an enrollee;

(19) Dental or orthodontic care;

(20) Piped-in oxygen or oxygen prescribed for standby purposes or on an as-needed basis; and

(21) Cosmetic surgery when performed solely to maintain normal physical appearance or enhance beyond average level toward an aesthetic ideal.

B. An MCO is not required to provide any of the benefits or services which are reimbursed directly by the Department as described in COMAR 10.67.70.

Md. Code Regs. 10.67.06.27

Regulations .27 recodified from 10.09.67.27 effective 46:22 Md. R. 976, eff. 11/1/2019; amended effective 51:12 Md. R. 620, eff. 6/24/2024.