Ch. 26, § 17. Hospital Services

(a) Hospital Services (including ancillary services provided in a hospital) shall be covered services if provided: (i) Pursuant to the written orders of a licensed physician; and (ii) By or under the supervision of a licensed physician. (b) Inpatient Hospital Psychiatric Services. Psychiatric services are limited to stabilization of acute conditions. Such services shall only be covered services when: (i) The client is evaluated by a multidisciplinary team within forty-eight (48) hours after admission; (ii) The multidisciplinary team prepares an individualized treatment plan; and (iii) The medical record documents a plan of active treatment and individual, group, or family therapy directed to achieve the goals specified in the individualized treatment plan. (c) Limitations on Hospital Services. (i) Medicaid reimbursement for outpatient hospital services shall be limited to a total of twelve (12) visits per calendar year to a hospital clinic, a hospital emergency room (for non-emergency services), and a physician's office, unless additional visits are pre-approved. (ii) Exceptions. The limitations of subsection (c)(i) shall not apply to: (A) An individual seeking emergency services who is diagnosed with an emergent condition; (B) An individual seeking family planning clinic services; (C) A client who is under age twenty-one (21); (D) A pregnant woman; (E) Items and services furnished directly by the Indian Health Services, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through a referral under a purchase order contract health service (as described in 42 C.F.R., Ch. I, Subch. M, Pt. 136, Subpart C) to an American Indian or Alaskan Native who is enrolled as a member of a Federally-Recognized Tribe or otherwise meets the definition of "Indian" at Section 4 of the Indian Healthcare Improvement Act (25 U.S.C. § 1608); (F) A resident of a nursing facility; or (G) A client who is also eligible for Medicare and where Medicare has reimbursed the provider for the claim.