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Chapter 08. Maryland Medicaid Managed Care Program: Non-Capitated Covered Services

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Regulation .01 Scope.Copy Citation

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This chapter describes the services that are not the responsibility of the MCOs but are covered by the Department on a fee-for-service basis.

Regulation .02 Behavioral Health Non-Capitated Covered Services.Copy Citation

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A.
An MCO is not responsible for reimbursing for the following substance use disorder services, regardless of diagnosis:
(1)
Services delivered by a community-based provider as described in COMAR 10.09.80 with the following procedure codes:
(2)
Substance use disorder services provided to children in an ICF-A with the revenue code 0100, Residential Services, child and adolescent.
B.
An MCO is not responsible for reimbursing for the following services performed by free-standing laboratories, regardless of diagnosis:
(1)
Presumptive drug tests; and
(2)
Definitive drug tests.
C.
An MCO is not responsible for reimbursing for the laboratory services described in §B of this regulation unless billed by a:
(1)
Primary care provider; or
(2)
Other somatic care provider.
D.
An MCO is not responsible for reimbursing for the following substance use disorder services if the MCO is billed with a primary diagnosis listed in §M of this regulation:
(1)
Services delivered by an inpatient hospital with the following revenue codes:
(2)
Services delivered by an outpatient hospital with the following revenue codes:
(3)
Services delivered by an emergency department with the following revenue codes:
E.
An MCO is not responsible for reimbursing for mental health services with a primary diagnosis listed in §N of this regulation when the services are provided by a hospital and the services are the result of the treatment of mental health diagnosis.
F.
An MCO shall be responsible for reimbursing for behavioral health services delivered by the participant’s primary care provider.
G.
An MCO shall be responsible for reimbursing for somatic services related to gender identity disorder, including gender reassignment surgery.
H.
An MCO is not responsible for reimbursing the behavioral poisoning diagnoses listed in §P of this regulation in an emergency department setting.
I.
An MCO is not responsible for services billed by specialty mental health providers listed in COMAR 10.09.59 when the bill includes the specialty behavioral health diagnoses listed in §M or N in the primary diagnosis field.
J.
An MCO is not responsible for reimbursement of behavioral health crisis services as described in COMAR 10.09.16.
K.
An MCO is not responsible for behavioral health medications.
L.
An MCO is not responsible for reimbursing for services billed by a physician related to prescribing buprenorphine or Vivitrol when the following conditions are met:
(1)
The physician delivering buprenorphine has a DATA 2000 waiver;
(2)
The physician is not the participant’s primary care provider;
(3)
The primary diagnosis is substance use disorder;
(4)
The primary reason for the visit is substance use disorder treatment; and
(5)
The procedure code listed on the claims is one of the following:
M.
Table of substance use disorder diagnoses, for dates of service on or after October 1, 2015:
N.
Table of mental health diagnoses, for dates of service on or after October 1, 2015:
O.
An MCO is not responsible for services billed by a psychiatrist when the claim includes one of the following primary diagnoses:
P.
Table of poisoning diagnoses, for dates of service on or after July 1, 2016:

Regulation .03 Nonbehavioral Health Fee-For-Service Benefits.Copy Citation

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An MCO may not be required to provide any of the following benefits or services that are reimbursed directly by the Department:
A.
The remaining days of a hospital admission following enrollment in the MCO if the recipient was admitted to the hospital before the date of the recipient's enrollment;
B.
Long-term care services except for those outlined in COMAR 10.67.06.07B and COMAR 10.67.06.12A;
C.
Intermediate Care Facilities for Individuals with Intellectual Disabilities or Persons with Related Conditions (ICF/IID) services;
D.
Personal care services pursuant to COMAR 10.09.20;
E.
Medical day care services, for adults and children;
F.
The following HIV/AIDS services:
(1)
Genotypic, phenotypic, or other HIV/AIDS drug resistance testing used in the treatment of HIV/AIDS, if the service is:
(a)
Rendered by a Department-approved provider; and
(b)
Medically necessary; and
(2)
Viral load testing used in treatment of HIV/AIDS.
G.
Physical therapy, speech therapy, and occupational therapy services when:
(1)
The enrollee is younger than 21 years old; and
(2)
The services are not part of home health services or an inpatient hospital stay;
H.
Augmentative communication devices;
I.
All dental services including but not limited to outpatient surgery fees for the facility and general anesthesia.
J.
Except when a woman has been determined eligible for Medical Assistance benefits under COMAR 10.09.11, an abortion pursuant to COMAR 10.09.02.04G;
K.
Emergency transportation;
L.
Transportation services provided through grants to local governments pursuant to COMAR 10.09.19;
M.
Services provided to members participating in the State's Health Home Program as described in COMAR 10.09.33;
N.
Applied behavioral analysis (ABA) services as described in COMAR 10.09.28; and
O.
Abortions performed in accordance with Health-General Article, § 15-103, Annotated Code of Maryland.
Chapter annotations
Authority: Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland
History: Effective date:
History: Regulations .01—.11 adopted as an emergency provision effective November 8, 1996 (23:25 Md. R. 1730); adopted permanently effective March 10, 1997 (24:5 Md. R. 408)
History: Regulation .01 amended effective December 23, 2002 (29:25 Md. R. 1981)
History: Regulation .02C, D amended effective December 23, 2002 (29:25 Md. R. 1981)
History: Regulation .05B amended effective December 23, 2002 (29:25 Md. R. 1981)
History: Regulation .06B amended effective October 14, 2013 (40:20 Md. R. 1652); April 28, 2014 (41:8 Md. R. 471)
History: Regulation .06C amended as an emergency provision effective July 1, 1997 (24:16 Md. R. 1158); amended permanently effective December 29, 1997 (24:26 Md. R. 1759)
History: Regulation .07 amended as an emergency provision effective June 15, 2001 (28:13 Md. R. 1214); amended permanently effective September 17, 2001 (28:18 Md. R. 1621)
History: Regulation .07C amended effective November 6, 2006 (33:22 Md. R. 1732)
History: Regulation .07H amended effective December 23, 2002 (29:25 Md. R. 1981)
History: Regulation .08A amended effective December 23, 2002 (29:25 Md. R. 1981)
History: Regulation .10 amended as an emergency provision effective July 1, 1997 (24:16 Md. R. 1158); amended permanently effective December 29, 1997 (24:26 Md. R. 1759)
History: Regulation .10A, C amended effective October 5, 2009 (36:20 Md. R. 1528); October 28, 2013 (40:21 Md. R. 1775)
History: Regulation .10C amended as an emergency provision effective July 1, 1998 (25:16 Md. R. 1261); amended permanently effective January 1, 1999 (25:26 Md. R. 1925)
History: Regulation .10C amended effective December 25, 2000 (27:25 Md. R. 2281); November 6, 2006 (33:22 Md. R. 1732)
History: Regulation .11 repealed effective October 5, 2009 (36:20 Md. R. 1528)
History: Regulations .01—.10 under, Maryland Medicaid Managed Care Program: Specialty Mental Health System, repealed and new Regulations .01—.03 under, Maryland Medicaid Managed Care Program: Non-Capitated Covered Services, adopted effective December 22, 2014 (41:25 Md. R. 1479)
History: Regulation .02 amended effective October 26, 2015 (42:21 Md. R. 1301); August 29, 2016 (43:17 Md. R. 955); February 27, 2017 (44:4 Md. R. 253); March 26, 2018 (45:6 Md. R. 319)
History: Regulation .02L amended effective May 20, 2019 (46:10 Md. R. 487)
History: Regulation .02M amended effective May 20, 2019 (46:10 Md. R. 487)
History: Regulation .02N adopted effective February 27, 2017 (44:4 Md. R. 253)
History: Regulation .03 amended effective October 22, 2018 (45:21 Md. R. 973)
History: Regulation .03K amended effective October 26, 2015 (42:21 Md. R. 1301)
History: Regulation .03N, O amended effective August 28, 2017 (44:17 Md. R. 834)
History: Regulation .03P adopted effective August 28, 2017 (44:17 Md. R. 834)
History: Regulation .06E amended effective August 28, 2017 (44:17 Md. R. 834)
History: Chapter transferred from COMAR 10.09.70 effective November 1, 2019 (46:22 Md. R. 977)
History: Regulation .02 amended effective December 27, 2021 (48:26 Md. R. 1112); November 13, 2023 (50:23 Md. R. 1005)
History: Regulation .03F amended effective May 18, 2020 (47:10 Md. R. 515)
History: Regulation .03I amended effective June 24, 2024 (51:12 Md. R. 620)
History: Regulation .03M, N amended effective March 31, 2025 (52:6 Md. R. 267)
History: Regulation .03O adopted effective March 31, 2025 (52:6 Md. R. 267)