Sec. 10.09.53.05. Limitations

A. Under this chapter, the Program does not cover the following:

(1) Home health services that are covered under COMAR 10.09.04;

(2) Services rendered by a nurse, CNA, or HHA who is a member of the participant’s immediate family or who ordinarily resides with the participant;

(3) Custodial services;

(4) Services not deemed medically necessary at the initial assessment or the most recent plan of care review;

(5) Services delivered by a nurse, CNA, or HHA who is not directly supervised by a registered nurse who documents all supervisory visits and activities;

(6) Services not preauthorized by the Department or the Department's designee, with the exception of the initial assessment;

(7) Services provided to a participant in a hospital, residential treatment center, or an intermediate care facility for individuals with intellectual disabilities or a residence or facility where nursing services are included in the living arrangement by regulation or statute, or otherwise provided for payment;

(8) Services not directly related to the plan of care;

(9) Services specified in the plan of care, when the plan of care has not been signed by the recipient or the recipient's legally authorized representative, the Department or the Department's designee, and the recipient's primary medical provider, when the services are covered under COMAR 10.09.27;

(10) Services described in the plan of care whenever a major change occurs in the recipient's medical condition or skilled nursing care needs;

(11) Services not ordered by the recipient's primary medical provider as a result of a partial or complete EPSDT screen;

(12) Services specified in Regulation .04 of this chapter which duplicate or supplant services rendered by the recipient's family caregivers or primary caregivers as well as other insurance, privilege, entitlement, or program services that the recipient receives or is eligible to receive;

(13) Services specified in Regulation .04 of this chapter to recipients eligible for any third-party liability coverage of those services;

(14) Services provided for the convenience or preference of the recipient or the primary caregiver rather than as required by the recipient's medical condition;

(15) Services which are not initially ordered before the start of care and renewed every 60 days by the participant’s primary medical provider;

(16) Services provided by a nurse, CNA, or HHA who does not possess a valid, current, and nontemporary nursing license or certifications to provide services in the jurisdiction in which services are rendered;

(17) Services provided by a nurse, CNA, or HHA who does not have a current cardiopulmonary resuscitation (CPR) certification for the period during which the services are rendered;

(18) Direct payment for supervisory visits that do not meet acceptable standards of practice in accordance with COMAR 10.27.09, 10.27.10, and 10.27.11;

(19) Services rendered to a participant by a nurse, CNA, or HHA in the assigned staff’s home;

(20) Services not documented; and

(21) Respite services.

B. Services to substitute for care ordinarily rendered by the caregiver or caregivers shall be considered medically necessary:

(1) When the services meet the requirements of Regulation .04A of this chapter; and

(2) When the:

(a) Participant requires an awake and alert caregiver at all times;

(b) Caregiver or caregivers provide documentation, including work schedule, commuting times, and school attendance records as defined in Regulation .01 of this chapter, that substitute care is necessary to allow employment or school attendance; or

(c) Caregiver or caregivers provide documentation of emergency circumstances, as determined by the Department, including but not limited to the inability of the primary caregiver to provide care due to hospitalization or an acute debilitating illness for up to a 60-day period.

C. The Program shall only cover one-to-one nursing when a participant’s condition requires that level of service and shared services are not an option.

D. Nursing services may only be provided to EPSDT eligible individuals under 21 years old.

E. The Program does not cover nursing 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.