Sec. 10.67.06.07. Benefits — Inpatient Hospital Services

A. An MCO shall provide to its enrollees medically necessary inpatient hospital services as specified in this regulation.

B. Admission to Long-Term Care Facility.

(1) An MCO shall provide to its enrollees medically necessary long-term care facility services for:

(a) The first 90 continuous days following the enrollee's admission; and

(b) Any days following the first 90 continuous days of an admission until the date the MCO has obtained the Department's determination that the admission is medically necessary as specified in §B(2) of this regulation.

(2) For any long-term care facility admission that is expected to result in a length of stay exceeding 90 days, an MCO or long-term care facility shall request a determination by the Department that the admission is medically necessary.

(3) The Department’s determination as described in §B(2) of this regulation is only applicable if the enrollee is still in the long-term care facility on the 91st day.

(4) Acute care services provided within the first 90 days following an enrollee's admission to a long-term care facility do not constitute a break in calculating the 90 continuous day requirement if the enrollee is discharged from the hospital back to the long-term care facility.

C. The Department shall render a determination with respect to the medical necessity of a stay in a long-term care facility as specified in §B of this regulation within 3 business days of receipt of a complete application from the MCO.

D. Childbirth - Length of Stay and Home Visits.

(1) Except as provided in §D(2) and (3) of this regulation, the criteria and standards used by an MCO in performing utilization review of hospital services related to maternity and newborn care, including length of stay, shall be in accordance with the medical criteria outlined in the Guidelines for Perinatal Care, which is incorporated by reference in COMAR 10.67.04.01.

(2) Unless the enrollee decides, in consultation with her attending provider, that less time is needed for recovery, an MCO shall provide or reimburse the cost of hospitalization including at least the following length of stay for an enrollee recovering from childbirth:

(a) 48 hours of inpatient hospitalization care following an uncomplicated vaginal delivery; or

(b) 96 hours of inpatient hospitalization care following an uncomplicated cesarean section.

(3) If the enrollee elects to be discharged earlier than the length of stay specified in §D(2) of this regulation, the MCO is required to provide a home visit or visits pursuant to Regulation .21B-D of this chapter.

E. In addition to the mother's length of stay required to be afforded by §D(2) of this regulation, whenever a mother is required to remain hospitalized after childbirth for medical reasons and she requests that her newborn remain in the hospital while she is hospitalized, the MCO shall afford the newborn additional hospitalization while the mother remains hospitalized, for up to 4 days.

F. If an enrollee is in the hospital at the time of disenrollment from the MCO, and remains eligible for Medical Assistance, the MCO is responsible for covering the remainder of that hospital admission following disenrollment.

G. An MCO shall provide for a private hospital room when:

(1) The enrollee's condition requires a need for isolation; or

(2) The enrollee requires admission and only private rooms are available.

H. Payment For Ancillary Services.

(1) Effective January 1, 2009, an MCO shall pay for all medically necessary ancillary services provided on inpatient hospital days including those days for which the inpatient hospitalization is otherwise appropriately denied.

(2) A denial of an inpatient ancillary service shall be based on the medical necessity of the specific ancillary service.

(3) An MCO is not required to pay for ancillary services if the entire hospitalization in §H(1) of this regulation is appropriately denied.

I. Transports between hospitals are covered by the MCO when:

(1) A medically necessary covered service is not available at the hospital where an enrollee is being treated; and

(2) The enrollee is not being discharged from the sending hospital.