Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-28 - Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations › Subsection 144-101-II-28.06 - LIMITATIONS

Current through 2024-29, July 17, 2024
The following limitations apply to reimbursement of
						services:
28.06-1
Services for
					 Children With Cognitive Impairments and Functional Limitations
MaineCare will limit reimbursement for services under
						this Section to those covered services documented and approved in the treatment
						plan that are medically necessary and developmentally appropriate.
						Reimbursement is also contingent upon the provider's adherence to any
						applicable licensing standards and contractual agreements set forth by DHHS or
						its Authorized Agent. MaineCare will not reimburse for services provided during
						the child's regular sleeping hours. All Section
						28 Services must meet requirements
						of central enrollment and will be subject to prior authorization and ongoing
						utilization review by the Department of Health and Human Services or Authorized
						Agent.
28.06-2
Non-Duplication of Services
Services as defined under this Section are not covered if
						the member is receiving comparable or duplicative services under this or
						another Section of the
MaineCare Benefits Manual
. A member may
						not receive services if they are in a residential treatment facility or if they
						are receiving services in an institution, including, but not limited to Section
						45, "Hospital Services", Section
						46, "Psychiatric Facility
						Services", Section
						50, "ICF-MR", Section
						67, "Nursing Facilities" and
						Section
						97, Appendix D, "Private
						Non-Medical Institutions" except that this service may be provided while a
						member is receiving Treatment Foster Care provided by a Private Non-Medical
						Institution.
28.06-3
Group Treatment
Reimbursement for group treatment must be prior
						authorized. Group Treatment is limited to no more than eight (8) members in a
						group. When group treatment is provided to a group of more than four (4)
						members it must be provided by at least two (2) qualified staff at a
						time.
When group treatment is provided by more than one
						qualified staff at the same time, they can bill as follows:
a. One qualified staff seeks reimbursement
					 for the provision of services to the total number of members in the group; or
b. Each qualified staff bills for
					 services provided to a portion of the total number of members in the group.
					 Each qualified staff may bill only for the members for whom the other staff has
					 not billed. The total amount submitted by both staff for MaineCare
					 reimbursement must not exceed the total number of members in the group. For
					 example, if there are eight (8) members in the group each staff may bill for
					 the session, accounting for four (4) members each.
The staff billing for the member is responsible for
						maintaining all clinical records.