Md. Code Regs. 10.67.06.12 - Benefits - Long-Term Care Facility Services
A. An MCO shall provide to its enrollees
medically necessary services in a chronic hospital, a chronic rehabilitation
hospital, or a nursing facility for:
(1) The
first 90 continuous days following the enrollee's admission; and
(2) 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 §C of this regulation.
B. 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. 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.
D. The Department's determination as
described in §C of this regulation is only applicable if the enrollee is
still in the long-term care facility on the 91st day.
E. The Department shall render a
determination with respect to the medical necessity of a stay in a nursing
facility as specified in §C of this regulation within 3 business days of
receipt of a complete application from the MCO.
F. A determination by the Department that the
admission is medically necessary does not relieve the MCO of the obligation to
pay for the admission through the day on which the determination is
made.
G. An MCO shall use the
Department's criteria for determining medical necessity for the days described
in §A(1) of this regulation.
Notes
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