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-65 - Behavioral Health Service › Subsection 144-101-II-65.05 - COVERED SERVICES

Current through 2024-29, July 17, 2024
65.05-1
Crisis Resolution Services
Services are immediate crisis-oriented services provided
						to a member with a serious problem of disturbed thought, behavior, mood or
						social relationships, and/or crises originating from problems associated with
						an intellectual disability, autism, or other related condition. Services are
						oriented toward the amelioration and stabilization of these acute emotional
						disturbances to ensure the safety of a member or society and can be provided in
						an office or on scene. "On scene" can mean a variety of locations including
						member homes, school, street, emergency shelter, and emergency rooms.
Services include all components of screening, assessment,
						evaluation, intervention, and disposition commonly considered appropriate to
						the provision of emergency and crisis mental health care, to include
						co-occurring mental health and substance use conditions. Crisis Resolution
						Services are individualized therapeutic intervention services available on a
						twenty-four (24) hour, seven (7) day a week basis and provided to eligible
						members by providers that have a contract with DHHS to provide these
						services.
Covered services include direct telephone contacts with
						both the member and the member's Parent or Guardian or adult's member's
						guardian when at least one face-to-face contact is made with the member within
						seven (7) days prior to the first contact related to the crisis resolution
						service. The substance of the telephone contact(s) must be such that the member
						is the focus of the service, and the need for communication with the Parent or
						Guardian without the member present must be documented in the member's
						record.
Staff providing Crisis Services include Clinicians,
						Mental Health Rehabilitation Technicians (MHRT), Behavioral Health
						Professionals (BHP), or Direct Support Professionals (DSP) with certification
						at the level appropriate for the services being delivered and for the
						population being served. Supervisors of MHRT, BHP, and DSP staff must be
						Clinicians, within the scope of their licensure.
To provide Children's Crisis Resolution Services as a
						BHP, the employee must meet the education requirement and complete the required
						BHP training within the prescribed time frames, as described in 65.05-9(D) and
						65.05-9(E).
A treatment episode includes face-to-face visits and
						related follow up phone calls, as clinically indicated, up to a sixty (60) day
						period after the first face-to-face visit.
65.05-2
Crisis Residential
					 Services
Crisis Residential Services are individualized
						therapeutic interventions provided to a member during a psychiatric emergency,
						and/or crises originating from problems associated with an intellectual
						disability, autism, or other related condition to address mental health and/or
						co-occurring mental health and substance use conditions for a time-limited
						post-crisis period, in order to stabilize the member's condition. These
						services may be provided in the member's home or in a temporary out-of-home
						setting and include the development of a crisis stabilization plan. Components
						of crisis residential services include assessment; monitoring behavior and the
						member's response to therapeutic interventions; participating and assisting in
						planning for and implementing crisis and post-crisis stabilization activities;
						and supervising the member to assure personal safety. Services include all
						components of screening, assessment, evaluation, intervention, and disposition
						commonly considered appropriate to the provision of emergency and crisis mental
						health care.
Staff providing Crisis Residential Services for members
						with mental health as a primary condition include Clinicians, MHRTs, BHPs and
						DSPs with certification at the level appropriate for the services being
						delivered and the population being served. To provide Children's Crisis
						Resolution Services as a BHP, the employee must meet the education requirement
						and complete the required BHP training within the prescribed time frames, as
						described in 65.05-9(D) and 65.05-9(E).
Staff who have not completed certification requirements
						in full within six (6) months of the date of hire, or within twelve (12) months
						for staff who are employed at the time this rule goes into effect, are not
						eligible to perform reimbursable services with any provider until certification
						is complete.
Supervisors of MHRT, BHP, and DSP staff must be a
						Clinician, practicing within the scope of their licensure.
For children's Crisis Residential Services determination
						of the appropriate level of care shall be based on tools approved by DHHS and
						clinical assessment information obtained from the member and
						Family.
65.05-3
Outpatient Services
Outpatient Services are professional assessment,
						counseling and therapeutic Medically Necessary Services provided to members, to
						improve functioning, address symptoms, relieve excess stress and promote
						positive orientation and growth that facilitate increased integrated and
						independent levels of functioning. Services are delivered through planned
						interaction involving the use of physiological, psychological, and sociological
						concepts, techniques and processes of evaluation and intervention.
Services include a Comprehensive Assessment, diagnosis,
						including co-occurring mental health and substance use disorder diagnoses,
						individual, Family and group therapy, and may include Affected Others and
						similar professional therapeutic services as part of an integrated
						Individualized Treatment Plan.
Services must focus on the developmental, emotional needs
						and problems of members and their families, as identified in the Individualized
						Treatment Plan.
These services may be delivered during a regularly
						scheduled appointment or on an emergency after hours basis either in an agency,
						home, or other community-based setting, such as a school, street or emergency
						shelter.
Coordination of treatment with all included parties (as
						appropriate to the outpatient role), including PCP's, or other medical
						practitioners, and state or other community agencies, is well
						documented.
Children's Outpatient Services offer ways to improve or
						to stabilize the member's Family living environment in order to minimize the
						necessity for out-of-home placement of the member, to assist Parents or
						Guardians and Family members to understand the effects of the member's
						disabilities on the member's growth and development and on the Family's ability
						to function, and to assist Parents and Family members to positively affect
						their member's development.
For children's Outpatient Services determination of the
						appropriate level of care shall be based on clinical assessment information
						obtained from the member and Family.
These services may be provided by a Clinician or
						Substance Use Qualified Staff practicing within the scope of their
						licensure.
A. There is a limit on
					 Children's mental health, substance use and co-occurring mental health and
					 substance use Outpatient Services of seventy-two (72) quarter-hour units of
					 service per year. For a member to receive services beyond seventy-two (72)
					 quarter-hour units of service in a service year for Children's Mental Health,
					 substance use, or co-occurring mental health and substance use Outpatient
					 Services, the following conditions must be satisfied:
1. Any member receiving Children's mental
					 health, substance use, or co-occurring mental health and substance use
					 Outpatient Services must have a Serious Emotional Disturbance or a mental
					 health, substance use or co-occurring mental health and substance use diagnosis
					 in accordance with the current
Diagnostic and Statistical Manual of
					 Mental Disorders
or in the DC 0-5 National Center for Clinical Infant
					 Programs
Diagnostic Classifications of Mental Health and Developmental
					 Disabilities of Infancy and Early Childhood Manual
.
2. Evidence that continued treatment is
					 necessary to correct or ameliorate a mental health, substance use or
					 co-occurring condition and must be documented in the member's file.
					 Documentation must include prior treatment, progress, if any, and clinical
					 justification that additional treatment is medically necessary. For substance
					 use and co-occurring mental health and substance use services, members must
					 meet ASAM Level 0.5 or Level 1 placement criteria for individual, family or
					 group outpatient services.
AND
3.
					 The member must be participating in treatment and making progress toward goals
					 or, if the member is not making progress, there must be an active strategy in
					 place to improve progress toward goals. Family participation is required in
					 treatment services to the greatest degree possible, given the individual needs
					 as well as Family circumstances.