<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".07" citation="COMAR 10.09.59.07" title_num="10" subtitle_num="09" chapter_num="59" heading="Limitations.">
  <text>The Program does not cover the following:</text>
  <paragraph num="A.">
    <text>Services not delivered in compliance with the COMAR references listed in Regulations .04 and .05 of this chapter;</text>
  </paragraph>
  <paragraph num="B.">
    <text>Services not medically necessary;</text>
  </paragraph>
  <paragraph num="C.">
    <text>Investigational or experimental drugs and procedures;</text>
  </paragraph>
  <paragraph num="D.">
    <text>Specialty mental health services for participants in an institution for mental disease as defined in 42 CFR §435.1009 unless the service is delivered through the §1115 HealthChoice Demonstration Waiver;</text>
  </paragraph>
  <paragraph num="E.">
    <text>Specialty mental health visits solely for the purpose of:</text>
    <paragraph num="(1)">
      <text>Prescribing medication;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Administering medication;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Drug or supply pick-up;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Collecting laboratory specimens;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Interpreting laboratory tests or panels; or</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Administering injections, unless the following are documented in the participant’s medical record:</text>
      <paragraph num="(a)">
        <text>Medical necessity; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The participant’s inability to take appropriate oral medications;</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>Separate reimbursement to an employee of a program for services that have been provided by and reimbursed directly to a program;</text>
  </paragraph>
  <paragraph num="G.">
    <text>Vocational counseling, vocational training at a classroom or job site, and academic or remedial educational services;</text>
  </paragraph>
  <paragraph num="H.">
    <text>Services provided to or for the primary benefit of individuals other than the participant;</text>
  </paragraph>
  <paragraph num="I.">
    <text>Outpatient Mental Health Clinic services delivered to a participant with a primary diagnosis of substance use disorder, unless the claim reflects a secondary diagnosis of mental health;</text>
  </paragraph>
  <paragraph num="J.">
    <text>An on-site psychiatric rehabilitation program visit by a participant on the same day that the participant receives medical day care services under COMAR 10.09.07;</text>
  </paragraph>
  <paragraph num="K.">
    <text>Psychiatric rehabilitation program services rendered via telehealth when:</text>
    <paragraph num="(1)">
      <text>They are rendered as a group service; or</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The total services rendered via telehealth comprise more than 50 percent of a participant’s services rendered;</text>
    </paragraph>
  </paragraph>
  <paragraph num="L.">
    <text>Non-emergency services not authorized by the ASO;</text>
  </paragraph>
  <paragraph num="M.">
    <text>Mental health services delivered by a primary care provider and reimbursed through Medicaid Fee for Service or the Maryland Medicaid Managed Care Program;</text>
  </paragraph>
  <paragraph num="N.">
    <text>Services delivered by Federally Qualified Health Centers other than those billed using the T-code or H-code, which may include the following, delivered by two separate but appropriately licensed providers:</text>
    <paragraph num="(1)">
      <text>One T-code for mental health services per day; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>One H-code for substance use disorder services per day;</text>
    </paragraph>
  </paragraph>
  <paragraph num="O.">
    <text>Supported employment services provided by a community-based psychiatric rehabilitation program, except in cases of clinic coordination;</text>
  </paragraph>
  <paragraph num="P.">
    <text>Residential crisis services;</text>
  </paragraph>
  <paragraph num="Q.">
    <text>Respite care services, other than those provided through the 1915(i) Intensive Behavioral Health Services program described in COMAR 10.09.89;</text>
  </paragraph>
  <paragraph num="R.">
    <text>Services provided to participants in a hospital inpatient setting, with the exception of services delivered by:</text>
    <paragraph num="(1)">
      <text>Physicians; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Nurse Practitioners;</text>
    </paragraph>
  </paragraph>
  <paragraph num="S.">
    <text>Housing services;</text>
  </paragraph>
  <paragraph num="T.">
    <text>Services rendered but not appropriately documented;</text>
  </paragraph>
  <paragraph num="U.">
    <text>Services reimbursed by the ASO not included in this chapter;</text>
  </paragraph>
  <paragraph num="V.">
    <text>Mobile Treatment or ACT Services without a minimum of four in-person services provided per month;</text>
  </paragraph>
  <paragraph num="W.">
    <text>Services rendered by community based specialty mental health programs with an immediate family member of an employee of the program serving on the governing body, board of directors, or advisory committee, whichever applies; and</text>
  </paragraph>
  <paragraph num="X.">
    <text>Psychiatric rehabilitation services referred by:</text>
    <paragraph num="(1)">
      <text>An individual who is not enrolled as a provider in the Program with an active status on the date of service; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>An entity, facility, or another provider that is not an individual.</text>
    </paragraph>
  </paragraph>
</regulation>