reglab/statecodes huggingface dataset:
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-C - MEDICAL AND REMEDIAL SERVICE FACILITIES › Section 144-101-III-97-C-9000 - REGIONS

Current through 2024-29, July 17, 2024
The Department defines regions for calculation of
						  inflation as:
Region I - Cumberland County, Knox County, Lincoln
						  County, Sagadahoc County, and York County.
Region II - Androscoggin County, Franklin County,
						  Kennebec County, Oxford County, and Somerset County.
Region III - Penobscot County, Piscataquis County,
						  Waldo County, Hancock County, and Washington County.
Region IV - Aroostook County.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-D - CHILDREN'S RESIDENTIAL CARE FACILITIES › Section 144-101-III-97-D-1000 - PURPOSE

Current through 2024-29, July 17, 2024
The purpose of Appendix D is to identify reimbursement
						  specific to Children's Residential Care Facilities, child placing agencies,
						  therapeutic foster care providers, or Intensive Temporary Out of Home Treatment
						  Services providers under Section 97, Chapter III, Private Non-Medical
						  Institutions (PNMI) services of the
MaineCare Benefits Manual
.
						  This Appendix identifies capitated rates for Children's Residential Care
						  Facilities. As of August 1, 2009, Children's Residential Care Facilities under
						  this appendix are reimbursed a capitated fee for services, and are not subject
						  to establishment of interim rates, as detailed in Section 97, Chapter
						  III.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-D - CHILDREN'S RESIDENTIAL CARE FACILITIES › Section 144-101-III-97-D-1200 - AUTHORITY

Current through 2024-29, July 17, 2024
The authority of the Department of Health and Human
						  Services to accept and administer funds that may be available from State and
						  Federal sources for the provision of the services set forth in this Appendix of
						  Reimbursement is contained in
						  22 M.R.S.A.
						  Sec.42 and Sec.
						  3173.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-D - CHILDREN'S RESIDENTIAL CARE FACILITIES › Section 144-101-III-97-D-1210 - DEFINITIONS

Current through 2024-29, July 17, 2024
The term "member" as used throughout this Appendix
						  refers to an individual who has been determined to be eligible for MaineCare by
						  the Department of Health and Human Services and who is receiving mental health
						  treatment and/or rehabilitative services as a resident of a children's
						  residential care facility as defined in Section 97.01-1(B) of the
MaineCare Benefits Manual
.
The term "facility" as used throughout these Principles
						  of Reimbursement refers to a children's residential care facility, as defined
						  by Section 97.01-1(B) of the
MaineCare Benefits Manual
. Also,
						  as stated in Section 97.01-1(B) for MaineCare reimbursement purposes, this term
						  also includes child placing agencies and therapeutic foster care
						  providers.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-D - CHILDREN'S RESIDENTIAL CARE FACILITIES › Section 144-101-III-97-D-2400 - SERVICE COMPONENTS OF THE STANDARD RATE

Current through 2024-29, July 17, 2024
Providers must follow all State of Maine Licensing
						  guidelines for staffing levels and must maintain specific staffing listed below
						  sufficient to serve the individual needs of each child as identified in the
						  child's individual service plan (as defined in Chapter II, Section 97 ) and
						  approved by the Department. Staffing is also detailed in MBM, Chapter II,
						  Section 97. Services may only be provided within scope of licensure for the
						  respective professional.
2400.1
						Appendix D PNMI services for: Intellectual Disabilities/Developmental
						Disabilities, Mental Health, and Crisis Stabilization Residential Services
						include the following components in the standardized rate, which may not be
						billed separately under this or other Sections of MaineCare:
a. Psychiatrist services
b. Psychologist services - treatment/not
						testing
c. Licensed clinical social
						worker services
d. Licensed
						clinical professional counselor services
e. Licensed professional counselor
						services
f. Licensed practical
						nurse services
g. Psychiatric nurse
						services
h. Licensed alcohol and
						drug counselor services
i.
						Behavioral Health Professional
j.
						Pediatric Neurologist
k. Other
						Qualified Mental Health Professional
l. Behavioral Health Professional
						services
m. Board certified behavior
						analyst services*
n. Board
						certified assistant behavior analyst*
o. Registered behavior technician
						services*
*The Department shall seek CMS approval for these
						  changes.
Appendix D PNMI services for Therapeutic Foster Care
						  include the following components in the standardized rate, which may not be
						  billed separately under this or other Sections of MaineCare:
a. Therapeutic Foster Care Parents
b. Licensed Social Worker Services
c. Other Qualified Child Care
						Professional
d. Other Qualified
						Child Care Facility Professional.
Direct service staff who meet residential licensing
						  requirements are considered to be an allowable expense within an Appendix D
						  facility.
It is the responsibility of the PNMI to provide and
						  coordinate all covered services performed by direct care staff listed in this
						  Section to assure that members receive the full range of services necessary to
						  meet resident needs without duplication of services. See
MaineCare
						  Benefits Manual
(MBM), Chapter II, Section 97, Sections 97.04 and
						  97.05 regarding covered services and non-duplication of services.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-D - CHILDREN'S RESIDENTIAL CARE FACILITIES › Section 144-101-III-97-D-3400 - COST REPORTS

Current through 2024-29, July 17, 2024
Appendix D services are not audited; however providers
						  are required to submit cost reports so that the Department has accurate data
						  for rate setting purposes.
3400.1.1
						The Division of Audit shall perform a uniform desk review of each acceptable
						cost report submitted.
3400.1.2 The
						uniform desk review is an analysis of the provider's cost report to determine
						the adequacy and completeness of the report, accuracy and reasonableness of the
						data recorded thereon, and allowable costs.
3400.1.3 Based on the results of the uniform
						desk review, the Division of Audit shall:
1.
						Request more information,
2. Issue
						a final report of findings, or
3.
						Conduct a field audit and issue a final report of findings.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-D - CHILDREN'S RESIDENTIAL CARE FACILITIES › Section 144-101-III-97-D-6000 - RATE-SETTING

Current through 2024-29, July 17, 2024
6000.1 The Department is seeking and
						anticipates receiving approval from the federal Centers for Medicare and
						Medicaid Services for this Section. Pending approval, increased reimbursement
						rates will be effective retroactive to July 1, 2016:
The following capitated rates apply to Appendix D
						  services:
Intellectual Disabilities and Autism Spectrum Disorder
						  - Level I- $396.47 per diem
Intellectual Disabilities and Autism Spectrum Disorder
						  - Level II- $585.60 per diem
Child Mental Health- Level I - $330.72 per diem
Child Mental Health - Level II - $435.40 per
						  diem
Crisis Stabilization Residential Services - $539.89
						  per diem
Therapeutic Foster Care - $103.51 per diem
Therapeutic Foster Care- Multidimensional - $150.45 per
						  diem
Temporary High Intensity Service - By Report per
						  hour
6000.2 The Department
						shall seek approval from the federal Centers for Medicare and Medicaid Services
						for this Section.
The following capitated rates apply to Appendix D
						  services effective November 1, 2021:
Intellectual Disabilities/Developmental Disabilities
						  Residential Treatment Facility - $727.98 per diem
Mental Health Residential Treatment Facility - $580.09
						  per diem
Aftercare Services - Service - $53.34 per hour
Aftercare Services - Mileage - $2.13 per mile
Providers bill the Department on a per diem basis for
						  each child. The capitated rate includes all PNMI services required by child for
						  his/her category of level of care including all staffing required pursuant to
						  State of Maine licensing guidelines, and as identified in the child's
						  individual service plan. See Chapter II requirements for Temporary High
						  Intensity Services. There is no cost settlement for Appendix D PNMI
						  services.
Aftercare Services are reimbursed per hour. Aftercare
						  Services mileage may be reimbursed per mile for staff traveling from the
						  facility to the location of the Aftercare service and back, as
						  applicable.
6000.3 The
						provider must also submit, upon request, such data, statistics, schedules, or
						other information that the Department requires.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-E - COMMUNITY RESIDENCES FOR PERSONS WITH MENTAL ILLNESS › Section 144-101-III-97-E-1000 - PURPOSE

Current through 2024-29, July 17, 2024
The purpose of Appendix E is to identify reimbursement
						  regulations that are specific to residential treatment facilities for persons
						  with mental illness. The general provisions of
MaineCare Benefits
						  Manual
, Chapter III, Section 97, PNMI services contain reimbursement
						  regulations that are applicable to all categories of service under the PNMI
						  regulations. It shall be the prerogative of the Commissioner of the Department
						  of Health and Human Services to impose a ceiling on reimbursement for private
						  non-medical institutions. This Appendix identifies which costs are reimbursable
						  within Section 97, Chapter II and III, Private Non-Medical Institution Services
						  of the
MaineCare Benefits Manual
. These regulations apply to
						  reimbursement for PNMI services beginning the first day of the provider's
						  fiscal year beginning on or after July 1, 2001.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-E - COMMUNITY RESIDENCES FOR PERSONS WITH MENTAL ILLNESS › Section 144-101-III-97-E-1200 - AUTHORITY

Current through 2024-29, July 17, 2024
The authority of the Department of Health and Human
						  Services to accept and administer funds that may be available from State and
						  Federal sources for the provision of services set forth in these Principles of
						  Reimbursement is contained in
						  22 M.R.S.A.
						  §42, §
												3173.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-E - COMMUNITY RESIDENCES FOR PERSONS WITH MENTAL ILLNESS › Section 144-101-III-97-E-1210 - DEFINITIONS

Current through 2024-29, July 17, 2024
The term resident as used throughout Appendix E refers
						  to an individual who has been determined to be eligible for MaineCare by the
						  Department of Health and Human Services and who is receiving mental health
						  treatment and/or rehabilitative services and/or personal care services as a
						  resident of a residential treatment facility for persons who experience mental
						  illness, as defined in Section 97.01-1(C) of the
MaineCare Benefits
						  Manual
.
The term "facilities" as used throughout Appendix E
						  refers to residential treatment facilities for persons who experience mental
						  illness, or residences for the integrated treatment of persons with dual
						  disorders, as defined in Section 97.01-1(C) of the
MaineCare Benefits
						  Manual
. Scattered site housing is not covered under this Section of
						  policy as of August 1, 2009.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-E - COMMUNITY RESIDENCES FOR PERSONS WITH MENTAL ILLNESS › Section 144-101-III-97-E-2400 - ALLOWABILITY OF COST

Current through 2024-29, July 17, 2024
2400.1 Allowable
						costs shall include salaries and wages for direct service staff and services
						listed below:
Physicians
Psychiatrists
Psychologists
Social workers
Psychiatric nurses
Psychological examiners
Occupational therapists
Other qualified mental health staff
Personal care service staff
Clinical consultants
Licensed substance abuse staff
Licensed clinical professional counselors
Licensed professional counselors
Other qualified alcohol and drug treatment staff, as
						  defined in Chapter II, Section 97.07-2, of the
MaineCare Benefits
						  Manual
.
It is the responsibility of the PNMI to provide and
						  coordinate all covered services performed by direct care staff listed in this
						  Section to assure that members receive the full range of services necessary to
						  meet members' needs without duplication of services. See
MaineCare
						  Benefits Manual
(MBM), Chapter II, Section 97, Sections 97.04 and
						  97.05 regarding covered services and non-duplication of services.
2400.1.1 The Department shall determine the
						reasonableness of the treatment costs on an annual basis.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-E - COMMUNITY RESIDENCES FOR PERSONS WITH MENTAL ILLNESS › Section 144-101-III-97-E-2500 - NON-ALLOWABLE COSTS

Current through 2024-29, July 17, 2024
A non-allowable cost includes all costs not included in
						  Section
						  2400.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-E - COMMUNITY RESIDENCES FOR PERSONS WITH MENTAL ILLNESS › Section 144-101-III-97-E-3400 - SETTLEMENT OF COST REPORTS

Current through 2024-29, July 17, 2024
3400.1 Uniform Desk
						Review
3400.1.1 The Division of Audit shall
						perform a uniform desk review of each acceptable cost report
						submitted.
3400.1.2 The uniform desk
						review is an analysis of the provider's cost report to determine the adequacy
						and completeness of the report, accuracy and reasonableness of the data
						recorded thereon, and allowable costs.
3400.1.3 Based on the results of the uniform
						desk review, the Division of Audit shall:
1.
						Request more information
2. Issue a
						final settlement, or
3. Conduct a
						field audit and issue a final settlement.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-E - COMMUNITY RESIDENCES FOR PERSONS WITH MENTAL ILLNESS › Section 144-101-III-97-E-5120 - PERSONAL CARE SERVICES

Current through 2024-29, July 17, 2024
PNMI services approved and funded by the Department of
						  Health and Human Services-Adult Mental Health Services in licensed facilities
						  may also provide personal care services necessary for the promotion of ongoing
						  treatment and recovery. PNMIs must be receiving funds from the Department,
						  specifically for the provision of personal care services, in order to also be
						  reimbursed by MaineCare for such services.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-E - COMMUNITY RESIDENCES FOR PERSONS WITH MENTAL ILLNESS › Section 144-101-III-97-E-7000 - RATE ADJUSTMENTS FOR PROVIDERS UNDER APPENDIX E

Current through 2024-29, July 17, 2024
Providers may request rate adjustments as necessary.
						  The following section details the process for such requests. No retroactive
						  rate adjustments will be granted.
7000.1 Process for Requesting Rate
						Adjustments for Providers Covered Under Appendix E:
7000.1.2 To request a rate adjustment, the
						provider will submit an approved and revised budget on a OMS approved form to
						the OMS and to the Department. The provider will attach a narrative detailing
						the reasons for the requested adjustment, the new rate, and the total cost of
						the requested rate adjustment for the remainder of the fiscal year.
7000.1.3 The provider will designate a
						responsible individual as a primary contact for the OMS and the
						Department.
7000.1.4 The rate
						adjustment submittal date will be the date received by the Department or no
						more than seven days after the postmark date.
7000.1.5 The OMS and the Department will
						reach a decision within 30 calendar days of the rate adjustment submittal
						date.
7000.1.6 If a rate adjustment
						is approved, the effective date shall be the first day of the month following
						the rate adjustment submittal date.
7000.1.7 If the OMS denies the initial
						request, or requires additional information, the provider shall have 5 working
						days upon receipt to provide additional information. The OMS shall consider the
						additional information and make a final determination within 20 working days of
						receipt of the additional information.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-F - NON-CASE MIXED MEDICAL AND REMEDIAL SERVICES FACILITIES › Section 144-101-III-97-F-2000 - DEFINITIONS

Current through 2024-29, July 17, 2024
2010 Department as used throughout this
						Appendix refers to either the Maine Department of Health and Human
						Services.
2020 Member as used
						throughout this Appendix refers to an individual who is MaineCare
						eligible.
2030 Room and Board costs
						are those costs that are not medical and remedial services as defined in this
						Appendix, and not allowable costs to Title XIX.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-F - NON-CASE MIXED MEDICAL AND REMEDIAL SERVICES FACILITIES › Section 144-101-III-97-F-2500 - NON-ALLOWABLE COSTS

Current through 2024-29, July 17, 2024
Non-allowable costs include room and board costs, as
						  well as all costs not approved under this Appendix.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-F - NON-CASE MIXED MEDICAL AND REMEDIAL SERVICES FACILITIES › Section 144-101-III-97-F-3000 - METHOD OF PAYMENT

Current through 2024-29, July 17, 2024
3010
Per Diem
						Rates
For services provided on or after July 1, 2001, the
						  MaineCare per diem rates for existing facilities will be adjusted to add the
						  program allowance and any applicable accreditation costs. The Department will
						  base the rates on an occupancy level that is the greater of actual or 90% of
						  licensed capacity for facilities greater than 6 beds, and the greater of actual
						  or 80% for facilities with 6 or fewer beds. Once the per diem rates are
						  established, this becomes the facility's cap. This cap will be adjusted at time
						  of audit on State-mandated service tax expense, as defined in Chapter III,
						  Section 2410. See MBM, Chapter III, Section 97 regarding inflation
						  adjustments.
3020
New
						Facilities
For new facilities opening after July 1, 2002, total
						  projected allowable costs approved by the Department will be divided by the
						  estimated annual occupancy, which shall not be less than 90% of the actual
						  licensed capacity for facilities more than 6 beds or 80% in facilities of 6 or
						  fewer beds. The program allowance and costs related to accreditation, if
						  applicable, will then be added to calculate the interim MaineCare
						  rate.
3030
Request
						for Change
Requests for changes in allowable costs may be made no
						  more often than every 6 months, and only for good cause, except in emergency
						  situations. The Department will not grant retroactive rate
						  adjustments.
3040
Interim Per Diem Rates
Department personnel set interim per diem daily rates
						  as follows:
3040.1 The Office of
						Rate-Setting sets interim daily rates for medical and remedial service
						facilities not participating in the case mix payment system, and funded by the
						Department of Health and Human Services.
3040.2 The Office of Rate-Setting sets
						interim daily rates for medical and remedial service facilities not
						participating in the case mix payment system.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-F - NON-CASE MIXED MEDICAL AND REMEDIAL SERVICES FACILITIES › Section 144-101-III-97-F-4000 - JUSTIFICATION FOR EXEMPTION

Current through 2024-29, July 17, 2024
Each provider is required to evidence practices and
						  maintain documentation describing the specialized nature of its services that
						  warrants exclusion from Appendix C. In addition, each provider shall follow a
						  written quality assurance and improvement program that will incorporate
						  feedback from residents, guardians and others.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-F - NON-CASE MIXED MEDICAL AND REMEDIAL SERVICES FACILITIES › Section 144-101-III-97-F-5000 - AUDIT SETTLEMENTS

Current through 2024-29, July 17, 2024
Audit settlements will be made based on Principles of
						  Reimbursement, Chapter III and this Appendix.
5010 Reimbursement will be limited to the
						total actual allowable costs of the facility, not to exceed the maximum
						prospective rates approved by the Department, including the medical and
						remedial rate and the personal care services rate.
5020 The lesser of the cost per bed day, or
						the maximum prospective rate approved by the Department, shall be multiplied by
						the number of MaineCare eligible days to determine the total MaineCare
						cost.
5030 Final settlement consists
						of allowable costs determined through the audit, compared to the interim
						payments received by the provider.
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 III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Appendix 144-101-III-97-F - NON-CASE MIXED MEDICAL AND REMEDIAL SERVICES FACILITIES › Section 144-101-III-97-F-6000 - INFLATION ADJUSTMENT

Current through 2024-29, July 17, 2024
Except when there is specific statutory direction, the
						  Commissioner of the Department will determine if an inflation adjustment will
						  be made, the amount of that adjustment, and any performance standards related
						  to that adjustment.
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 III - Allowances for Services › Section 144-101-III-102 - Rehabilitative Services

Current through 2024-29, July 17, 2024
ALLOWED AGE
PROC CODE
Procedure Code
DESCRIPTION
MAXIMUM
ALLOWANCE
ALL AGES
96150
Clinical Assessment-Initial
$20.64/ 15 MINUTES
ALL AGES
96151
Clinical Reassessment
$20.36/15 MINUTES
ALL AGES
97532
Intensive Integrated Neurorehabilitation
$26.02/ 15 MINUTES
ALL AGES
96152
Neurobehavioral Rehabilitation- 1:1 with member
$20.98/ 15 MINUTES
ALL AGES
96153
Neurobehavioral Rehabilitation- group
$20.91/ 15 MINUTES
ALL AGES
96154
Neurobehavioral Rehabilitation- family
$20.07/15 MINUTES
ALL AGES
97535
Self Care/Home Management Reintegration
$14.39/ 15 MINUTES
ALL AGES
97535 HQ
Self Care/Home Management Reintegration- group
$ 14.39/ 15 MINUTES
ALL AGES
97537
Community/Work Reintegration
$14.05/15 MINUTES
ALL AGES
97537 HQ
Community /Work Reintegration- group
$14.05/15 MINUTES
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 III - Allowances for Services › Section 144-101-III-103 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services

Current through 2024-29, July 17, 2024
PROCEDURE CODE/
REVENUE CODE
DESCRIPTION
UNIT OF SERVICE
MAXIMUM ALLOWANCE
T1015
Clinic visit/encounter, all inclusive
per visit
by report
0521
Rural Health Clinic
T1015 HE
Clinic visit/encounter, all inclusive
per visit
by report
0521
Rural Health Clinic
T1015
Home visit/encounter, all inclusive
per visit
by report
0522
Rural Health Clinic
T1015
Visit to SNF (Part A*)
per visit
by report
0524
Rural Health Clinic
*A covered part A stay means that Medicare A will
								pay the services as the primary carrier
T1015
Visit to SNF (non-covered*)
per visit
by report
0525
Rural Health Clinic
*A non-covered stay means that Medicare A is not
								paying for the inpatient stay/services
T1015
Visit to other site
per visit
by report
0528
Rural Health Clinic
RHCs are reimbursed for all Food and Drug
								Administration (FDA) approved intrauterine devices at the rate listed on the
								MaineCare UCR: https://mainecare.maine.gov/
J1050
Injection, medroxyprogesterone acetate1 mg
1 unit
by report
0636
Pharmacy
G0108
Diabetes outpatient self-management training
								services, individual, per 30 minutes
30 minutes
by report
0521
Rural Health Clinic
G0109
Diabetes outpatient self-management training
								services, group session (2 or more) per 30 minutes
30 minutes
by report
0521
Rural Health Clinic
RHCs are reimbursed for all Food and Drug
								Administration (FDA) approved pharmacotherapy for tobacco dependence
								treatment
99406
Smoking and tobacco cessation counseling;
								individual, intermediate
3-10 minutes
$8.67
0521
Rural Health Clinic
99407
Smoking and tobacco cessation counseling;
								individual, intensive
greater than 10 minutes
$16.81
0521
Rural Health Clinic
99411
[Tobacco cessation] preventive medicine counseling
								and/or risk factor reduction intervention(s) provided to individuals in a group
								setting (separate procedure), approximately 30 minutes
per session
$11.54
0521
Rural Health Clinic
99412
[Tobacco cessation] preventive medicine counseling
								and/or risk factor reduction intervention(s) provided to individuals in a group
								setting (separate procedure); approximately 60 minutes
per session
$15.04
0521
Rural Health Clinic
G0008
Administration of influenza virus vaccine
per unit
$5.00
0521
Rural Health Clinic
G0009
Administration of pneumococcal vaccine
per unit
$5.00
0521
Rural Health Clinic
MODIFIERS
DESCRIPTION
GT
VIA INTERACTIVE AUDIO AND VIDEO TELECOMMUNICATION
								SYSTEMS
HE
BEHAVIORAL HEALTH
SL
STATE SUPPLIED VACCINE
UF
SERVICES PROVIDED IN THE MORNING (6 A.M. TO 11:59
								A.M.)
UG
SERVICES PROVIDED IN THE AFTERNOON (12 P.M. TO 5:59
								P.M.)
UH
SERVICES PROVIDED IN THE EVENING (6 P.M. TO 11:59
								P.M.)
UJ
SERVICES PROVIDED AT NIGHT (12 A.M. TO 5:59
								A.M.)
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-2 - REQUIREMENTS FOR PARTICIPATION IN MAINECARE PROGRAM

Current through 2024-29, July 17, 2024
2.1
Psychiatric Residential Treatment
					 Facilities (PRTFs)
must satisfy all of the following prerequisites in
					 order to be reimbursed for care provided to MaineCare members:
2.1.1 be licensed and certified by the Maine
					 Department of Health and Human Services-Center for Disease Control and
					 Prevention, pursuant to
					 22 M.R.S.
					 §8101(4-B) and
					 42 CFR,
					 Part 441, Subpart D, and 107.2-1.2 have a MaineCare Provider Agreement with the
					 Department of Health and Human Services.
2.1.2
MaineCare payments
shall
					 not be made to any facility that fails to meet all the requirements of
					 Principle 2.1.
2.1.3
Medical,
					 Clinical, and Direct Care Services
means services provided by a
					 qualified provider directly to a member in a PRTF as outlined in Chapter II,
					 Section 107 in accordance with covered services described in Chapter II Section
					 107.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-3 - RESPONSIBILITIES OF OWNERS OR OPERATORS

Current through 2024-29, July 17, 2024
3.1 The owners
					 or operators of a psychiatric residential treatment facility shall prudently
					 manage and operate PRTF services of adequate quality to meet its members'
					 needs. Neither the issuance of an interim rate, nor final orders made by the
					 Commissioner or a duly authorized representative shall in any way relieve the
					 owner or operator of a PRTF from full responsibility for compliance with the
					 requirements and standards of the Department of Health and Human Services or
					 Federal requirements and standards.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-4 - DUTIES OF THE OWNER OR OPERATOR

Current through 2024-29, July 17, 2024
In order to qualify for MaineCare reimbursement the owner
						or operator of a PRTF, or a duly authorized representative shall:
4.1 Comply with the provisions of Principles
					 3 and 4 setting forth the requirements for participation in the MaineCare
					 Program.
4.2 Submit master file
					 documents and cost reports in accordance with the provisions of Principles 12.1
					 and 12.2 of these Principles.
4.3
					 Maintain adequate financial and statistical records and make them available
					 when requested for inspection by an authorized representative of the Department
					 of Health and Human Services, the state, or the Federal government.
4.4 Assure that annual records are prepared
					 in conformance with Generally Accepted Accounting Principles (GAAP), except
					 where otherwise required.
4.5
					 Assure that the construction of buildings and the maintenance and operation of
					 premises and services comply with all applicable health and safety
					 standards.
4.6 Submit such data,
					 statistics, schedules or other information that the Department requires in
					 order to carry out its functions. Failure to supply the required documentation
					 may result in the Department imposing the deficiency routine and fixed costs
					 rate described in Principle 30 of these Principles.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-5 - ACCOUNTING REQUIREMENTS

Current through 2024-29, July 17, 2024
5.1
ACCOUNTING PRINCIPLES
5.1.1 All
					 financial and statistical reports shall be prepared in accordance with
					 Generally Accepted Accounting Principles (GAAP), consistently applied, unless
					 these rules require specific variations in such principles and Medicare
					 Provider Reimbursement Regulations HIM-15.
5.1.2 The provider shall establish and
					 maintain a financial management system that provides for adequate internal
					 control assuring the accuracy of financial data, safeguarding of assets and
					 operation efficiency.
5.1.3 The
					 provider shall report on an accrual basis, unless it is a state or municipal
					 institution that operates on a cash basis. The provider whose records are not
					 maintained on an accrual basis shall develop accrual data for reports on the
					 basis of an analysis of the available documentation. The provider shall retain
					 all such documentation for audit purposes.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-6 - PROCUREMENT STANDARDS

Current through 2024-29, July 17, 2024
6.1 Providers shall
					 establish and maintain a code of standards to govern the performance of its
					 employees engaged in purchasing Capital Assets. Such standards shall provide,
					 and providers shall implement to the maximum extent practical, open and free
					 competition among vendors. Providers are encouraged to participate in group
					 purchasing plans when feasible.
6.2
					 If a provider does not accept the lowest bid for a Capital Asset, the amount
					 over the lower bid that cannot be demonstrated to be a reasonable and necessary
					 expenditure is an unallowable cost. In situations not competitively bid,
					 providers must act as a prudent buyer as referenced in Principle 9.2 in these
					 Principles.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-7 - COST ALLOCATION PLANS AND CHANGES IN ACCOUNTING METHODS

Current through 2024-29, July 17, 2024
With respect to the allocation of costs to the PRTF and
						within the PRTF, the following rules shall apply:
7.1 Providers that have costs allocated from
					 related entities included in their cost reports shall include as a part of
					 their cost report submission, a summary of the allocated costs, including a
					 reconciliation of the allocated costs to the entity's financial statements
					 which must also be submitted with the MaineCare cost report. In the case of a
					 home office, related management company, or real estate management company,
					 this would include a completed Home Office Cost Statement that shows the costs
					 that are removed which are unallowable. The provider shall submit this
					 reconciliation with the MaineCare cost report.
7.2 No change in accounting methods or basis
					 of cost allocation may be made without written prior approval from the Division
					 of Audit.
7.3 Any application for a
					 change in accounting method or basis of cost allocation, which has an effect on
					 the amount of allowable costs or computation of the interim rate of payment,
					 shall be made within the first ninety (90) days of the reporting year. The
					 application shall specify:
7.3.1 the nature
					 of the change;
7.3.2 the reason for
					 the change;
7.3.3 the effect of the
					 change on the interim rate of payment; and 7.3.4 the likely effect of the
					 change on future rates of payment.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-8 - ALLOWABILITY OF COST

Current through 2024-29, July 17, 2024
8.1 If these
					 principles do not set forth a determination of whether or not a cost is
					 allowable or sufficiently define a term used, reference will be made first, to
					 the Medicare Provider Reimbursement Manual (HIM-15) guidelines, followed by the
					 Internal Revenue Service Guidelines in effect at the time of such determination
					 if the HIM-15 is silent on the issues.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-9 - GENERAL COST PRINCIPLES

Current through 2024-29, July 17, 2024
9.1
Principle
. Federal law requires that payment for PRTF services
					 provided under MaineCare shall be provided through the use of rates which are
					 reasonable and adequate to meet costs which must be incurred by efficiently and
					 economically operated facilities in order to provide care and services in
					 conformity with applicable State and Federal laws, regulations, and quality and
					 safety standards. Costs incurred by the PRTF must be reasonable, necessary, and
					 related to resident care, subject to principles relating to specific items of
					 revenue and cost.
9.2 Costs must be
					 ordinary and necessary and related to resident care. They must be of the nature
					 and magnitude that prudent and cost conscious management would pay for a
					 specific item or service.
9.3 Costs
					 must not be of the type conceived for the purpose of circumventing the
					 regulations. Such costs will be disallowed under Principle 9.
9.4 Costs that relate to inefficient,
					 unnecessary or luxurious care or unnecessary or luxurious facilities or to
					 activities not common and accepted in the PRTF field are not
					 allowable.
9.5 Wages, to be
					 allowable, must be reasonable and related to resident care and pertinent to the
					 operation of the facility. The services must actually be performed and must be
					 paid in full. The wages must be reported to all appropriate state and federal
					 tax authorities to the extent required by law for income tax, social security,
					 and unemployment insurance purposes.
9.6 Costs incurred for resident services that
					 are rendered in common to MaineCare residents as well as to non-MaineCare
					 residents, will be allowed on a pro rata basis, unless there is a specific
					 allocation defined elsewhere in these Principles.
9.7 Cost to Related Organizations Principle.
					 Costs applicable to services, facilities, and supplies furnished to the
					 provider by organizations related to the provider by common ownership or
					 control are includable in the allowable costs of the provider at the cost to
					 the related organization. However, such costs must not exceed the price of
					 comparable services, facilities, or supplies that could be purchased elsewhere.
					 Providers should reference Principle 6 of these Principles.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-10 - UPPER PAYMENT LIMITS

Current through 2024-29, July 17, 2024
10.1 Aggregate
					 payments to PRTFs pursuant to these rules may not exceed the limits established
					 for such payments in
					 42 CFR
					 447.272, using Medicare principles of
					 reimbursement.
10.2 If the Division
					 of Audit projects that MaineCare payments to PRTFs in the aggregate will exceed
					 the Medicare upper limit, the Division of Audit shall limit some or all of the
					 payments to providers to the level that would reduce the aggregate payments to
					 the Medicare upper limit as set forth in Principle 10.4.
10.3 In computing the projections that
					 MaineCare payments in the aggregate are within the Medicare Upper Limit, any
					 facility exceeding one hundred-twelve percent (112%) of the State mean
					 allowance routine service costs may be notified that additional information is
					 required to determine allowable costs under the Medicare Principles of
					 Reimbursement, including any exceptions as stated in
					 42 CFR §
												413.30(f). This information
					 may be requested within thirty (30) days of the effective date of these
					 regulations, and thereafter at the time the interim rates are set.
10.4 Facility Rate Limitations if Aggregate
					 Limit is exceeded. If the Department projects that the MaineCare payments to
					 PRTFs in the aggregate exceed the Medicare upper limit, the Department shall
					 limit payments to those facilities whose projected MaineCare payments exceed
					 what would have been paid using Medicare Principles of Reimbursement. The
Department will notify the facilities when the
						Department projects that the MaineCare payments to PRTFs in the aggregate
						exceed the Medicare upper limit and that the Department must limit payments to
						those facilities to the level that would reduce the aggregate payments to the
						Medicare upper limit.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-11 - SUBSTANCE OVER FORM

Current through 2024-29, July 17, 2024
11.1 The cost
					 effect of transactions that have the effect of circumventing these rules may be
					 adjusted by the Department on the principle that the substance of the
					 transaction shall prevail over the form.