Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 505 - APPROPRIATENESS REVIEW PROCEDURES AND CRITERIA › Appendix 144-505-A - Information Guidelines With Respect to Appropriateness Reviews

Current through 2024-29, July 17, 2024
The following Guidelines are to be used as the framework for
				  task forces. Plan Development committee and Bureau of Health Planning and
				  Development use in the development of specific criteria, standards and a data
				  questionnaire related to the specific institutional health service under
				  review.
A. Document the need which the
				population served, including low income persons, racial and ethnic minorities,
				women, handicapped persons and other historically underserved groups, have for
				the existing institutional health service subject to review. To assist in
				making this determination the following information may be requested:
1. A description of the community or service
				area served by the existing institutional health service. The information
				required may include a description of the geographic area served and the
				population characteristics of the population residing within the area as well
				as, to the extent practicable, the characteristics of any unique group, such as
				the elderly, residing in the service area which the particular service under
				review is intended to serve. Patient origin studies may be necessary to
				adequately document the historical service area of the service under review.
				Release of specific data, such as that stored by the Maine Health Data Service
				or the Maine Health Information center, may be required.
2. Historical utilization information,
				preferably statistical in nature, for the three most recent calendar years (or
				such other periods as may be prescribed by the Maine Health Systems Agency,
				Inc. and/or the Bureau of Health Planning and Development) of operation of the
				existing institutional health service. Such historical utilization data should
				be reconciled or reconcilable to the service area/patient origin data described
				above. The Maine Health Systems Agency, Inc. (MHSA) and/or the Bureau of Health
				Planning and Development (the Bureau) may require that the historical
				utilization data be presented on a monthly, quarterly or semi-annual basis.
				Releases of specific utilization data, such as that stored by the Maine Health
				Data Service or the Maine Health Information Center, may be required.
3. Documentation that the historical
				utilization of the existing health service subject to review has been
				appropriate, necessary and of high quality. The MHSA and/or the Bureau may
				require the facility to provide evidence, including that provided by special
				studies, from the Pine Tree Organization for Professional Standards Review or
				any other competent organization, including the Medicare or Medicaid fiscal
				intermediary, that the level of historical utilization of the existing health
				service subject to review has been appropriate, necessary, and of high
				quality.
4. A three year projection
				of expected future need and demand for the existing health service. The
				projection should take into consideration the historical utilization patterns
				of the existing health service, expected changes in the population served,
				expected changes in the facility's share of the market, expected changes in
				other relevant components of the health care system, including expected changes
				in other similar existing institutional health services. All assumptions and
				sources of data should be disclosed. The facility should also fully disclose
				how the projections relating to the service subject to review relate to the
				long-range development plans of the institution.
5. A description of the accessibility of the
				community or defined service area to the existing institutional health service
				subject to review. The description should address the geographic accessibility
				of the service, the availability of adequate transportation services to assure
				the accessibility of the service and should contain an analysis of the
				contribution of the existing institutional health service, if any, in meeting
				the health related needs of the members of any medically underserved groups and
				groups which have traditionally experienced difficulties in obtaining equal
				access to health services (for example, low income persons, racial and ethnic
				minorities, women, and handicapped persons) particularly those needs identified
				in the applicable health systems plan, annual implementation plan and State
				health plan as deserving priority.
6. An analysis of the relationship between
				the existing health service being reviewed and the existing health care system
				of the area in which the service is provided. The facility should discuss how
				the existing relationship is expected to change as it implements its long-range
				development plans. The facility should also disclose which alternatives, if
				any, might, in its opinion, be more effective and/or less costly in meeting the
				need addressed by the existing institutional health service subject to review
				and indicate if such alternatives are available and, if not, what barriers
				exist which result in such alternatives not being readily available.
7. A description of how the existing
				institutional health services subject to review relate to the applicable health
				systems plan, annual implementation plan and State health plan, and
8. If applicable, a description as to how the
				existing institutional health service subject to review relates to the:
a. special needs and circumstances of
				entities which provide a substantial portion of their services or resources or
				both to individuals not residing in the health service area in which the
				entities are located or in adjacent health service areas. These entities may
				include medical and other health professions schools,, multidisciplinary
				clinics, specialty centers and facilities which must respond to significant
				seasonal population variations, particularly those associated with tourism.
				Such entities should be required to provide documentation of the effect of such
				special circumstances.
b. special
				needs and circumstances of biomedical and behavioral research projects which
				are designed to meet a national need for which local conditions offer special
				advantages, and
c. the special
				needs and circumstances of HMO's. In the case of areawide reviews which result
				in institution-specific findings regarding services provided by or through an
				HMO, the special needs and circumstances of the HMO shall be limited to:
1 The needs of enrolled members and
				reasonably anticipated new members of the HMO for the existing institutional
				health services provided by the organization.
2 Whether the services could be obtained from
				non-HMO, or other HMO providers, in a reasonable and cost-effective manner
				which is consistent with the basic method of operation of the HMO.