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-21 - Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder › GENERAL PROVISIONS › Appendix 144-101-III-21-I

Current through 2024-29, July 17, 2024
PROCEDURE CODE
DESCRIPTION
MAXIMUM ALLOWANCE Effective
									 1/1/2022*
HOME SUPPORT: AGENCY
T2016
AGENCY HOME SUPPORT (Habilitation, residential,
									 waiver)
See Appendix II and IIB Per diem*
T2016 SC
AGENCY HOME SUPPORT (Habilitation, residential,
									 waiver) with Medical Add On
See Appendix II and IIB Per diem*
HOME SUPPORT: QUARTER HOUR
T2017
HOME SUPPORT (Habilitation, residential,
									 waiver)
$10.45 1/4 hr.*
T2017 SC
HOME SUPPORT (Habilitation, residential,
									 waiver) with Medical Add On
$10.45 1/4 hr.*
HOME SUPPORT: REMOTE
									 SUPPORT
T2017 QC
HOME SUPPORT (Habilitation, residential,
									 waiver)-REMOTE SUPPORT-Monitor Only
$2.93 1/4 hr.*
HOME SUPPORT: FAMILY CENTERED
									 SUPPORT
T2016 U5
HOME SUPPORT (Habilitation, residential,
									 waiver)- Family-Centered Support -One member served
$143.03 Per diem*
T2016 TG U5
HOME SUPPORT (Habilitation, residential,
									 waiver)- Family-Centered Support -One member served- increased level of
									 support
$305.52 Per diem*
T2016 UN U5
HOME SUPPORT (Habilitation, residential,
									 waiver)- Family-Centered Support-Two members served
$117.80 Per diem*
*The Department is seeking and anticipates receiving
						  approval from the federal Centers for Medicare and Medicaid Services for these
						  changes.
PROCEDURE CODE
DESCRIPTION
MAXIMUM ALLOWANCE Effective
									 1/1/2022
T2016 UN TG U5
HOME SUPPORT (Habilitation, residential,
									 waiver)- Family-Centered Support-Two members served- increased level of
									 support
$277.70 Per diem*
T2016 UP U5
HOME SUPPORT (Habilitation, residential,
									 waiver)- Family-Centered Support-Three members served
$100.45 Per diem*
T2016 UP TG U5
HOME SUPPORT (Habilitation, residential,
									 waiver)- Family-Centered Support-Three members served- increased level of
									 support
$252.06 Per diem*
T2016 UQ U5
HOME SUPPORT (Habilitation, residential,
									 waiver)- Family-Centered Support-Four members served-
$85.13 Per diem*
T2016 UQ TG U5
HOME SUPPORT (Habilitation, residential,
									 waiver)- Family-Centered Support-Four members served- increased level of
									 support
$229.44 Per diem*
T2016 UR U5
HOME SUPPORT (Habilitation, residential,
									 waiver)- Family-Centered Support-Five or more members served
$75.92 Per diem*
T2016 UR TG U5
HOME SUPPORT (Habilitation, residential,
									 waiver)- Family-Centered Support-Five or more members served- increased level
									 of support
$216.35 Per diem*
SHARED LIVING
S5140
SHARED LIVING (Foster Care, adult)-Shared
									 Living Model-One member served
$163.71 Per diem*
S5140 TG
SHARED LIVING (Foster Care, adult)-Shared
									 Living Model-One member served- increased level of support
$241.75 Per diem*
S5140 UN
SHARED LIVING (Foster Care, adult)-Shared
									 Living Model-Two members served
$122.78 Per diem*
S5140 UN TG
SHARED LIVING (Foster Care, adult)-Shared
									 Living Model-Two members served- increased level of support
$184.17 Per diem*
*The Department is seeking and anticipates receiving
						  approval from the federal Centers for Medicare and Medicaid Services for these
						  changes.
PROCEDURE CODE
DESCRIPTION
MAXIMUM ALLOWANCE Effective
									 1/1/2022
H2023
WORK SUPPORT (supported
									 employment)-Individual
$12.59 1/4 hr.*
H2023 SC
WORK SUPPORT (supported employment)- with
									 Medical Add On
$12.59 1/4 hr.*
H2023 UP
WORK SUPPORT (supported employment)-Group 3
									 members served
up to $4.68per 1/4 hr.*
H2023 UQ
WORK SUPPORT (supported employment)-Group 4
									 members served
up to $3.82per 1/4 hr.*
H2023 UR
WORK SUPPORT (supported employment)-Group 5
									 members served
up to $3.33 per 1/4 hr.*
H2023 US
WORK SUPPORT (supported employment)-Group 6
									 members served
Up to $2.98per 1/4 hr.*
T2015
CAREER PLANNING (Habilitation,
									 prevocational)
$61.13 hr.*
T2019
EMPLOYMENT SPECIALIST SERVICES (Habilitation,
									 supported employment waiver)
$14.41 1/4 hr.*
T2019 SC
EMPLOYMENT SPECIALIST SERVICES (Habilitation,
									 supported employment waiver)- with Medical Add-On
$14.41 1/4 hr.*
T2021
COMMUNITY SUPPORT (Day habilitation,
									 waiver)
$6.53 1/4 hr.
T2021 SC
COMMUNITY SUPPORT (Day habilitation, waiver)
									 with Medical Add On
$8.05 1/4 hr.
97755
ASSISTIVE TECHNOLOGY-ASSESSMENT
$15.15 1/4 hr.*
T2035
ASSISTIVE TECHNOLOGY -TRANSMISSION (Utility
									 Services)
Up to $50.00 per month.
A9279
ASSISTIVE TECHNOLOGY -DEVICES (Monitoring
									 feature/device, stand alone or integrated, any type, includes all accessories,
									 components and electronics, not otherwise classified)
Per invoice up to $6296.40 per year*
T2029
SPECIALIZED MEDICAL EQUIPMENT AND
									 SUPPLIES
Per itemized invoice
*The Department is seeking and anticipates receiving
						  approval from the federal Centers for Medicare and Medicaid Services for these
						  changes.
PROCEDURE CODE
DESCRIPTION
MAXIMUM ALLOWANCE Effective
									 1/1/2022
S5165 CG
HOME ACCESSIBILITY ADAPTATIONS (Repairs)
Per itemized invoice
S5165
HOME ACCESSIBILITY ADAPTATIONS (Home
									 Modifications)
Per itemized invoice
V5274
COMMUNICATION AIDS - SPEECH AMPLIFIER, AIDS,
									 COMMUNICATORS (INCLUDING REPAIR AND MAINTENANCE), ASSISTIVE DEVICES
Per itemized invoice
T1013 GN
COMMUNICATION AIDS - ONGOING VISUAL-GESTURAL
									 AND FACILITATED COMMUNICATIONS SERVICES
$6.13 1/4 hr.*
G9007
NON-traditional communication
									 CONSULTATION
$ 9.44 1/4 hr.*
92507
NON-traditional communication assessment
$9.44 1/4 hr.*
G9007 HI
CONSULTATIVE SERVICES - BEHAVIORAL
$15.58 1/4 hr.*
G9007 GO
CONSULTATIVE SERVICES - OCCUPATIONAL
									 THERAPY
$6.13 1/4 hr.*
G9007 GP
CONSULTATIVE SERVICES - PHYSICAL THERAPY
$6.13 1/4 hr. *
H0031
CONSULTATIVE SERVICES - PSYCHOLOGICAL
$20.78 1/4 hr.*
G9007 GN
CONSULTATIVE SERVICES - SPEECH THERAPY
$6.13 1/4 hr.*
H0004 SC
COUNSELING
$13.50 1/4 hr.
T1023
CRISIS ASSESSMENT
$2361.15 Per Encounter*
92507
CRISIS INTERVENTION SERVICES
$8.16 1/4 hr.*
S8990 GO
OCCUPATIONAL THERAPY (MAINTENANCE) OT/L
$10.01 1/4 hr.*
*The Department is seeking and anticipates receiving
						  approval from the federal Centers for Medicare and Medicaid Services for these
						  changes.
**These rates are used in conjunction with Appendix IIA
						  and IIB to calculate the Home Support Agency Per Diem rate.
PROCEDURE CODE
DESCRIPTION
MAXIMUM ALLOWANCE Effective
									 1/1/2022
S8990 GO U1
OCCUPATIONAL THERAPY (MAINTENANCE)- Licensed
									 Occupational Therapy Assistant (OTA/L) under the supervision of an Occupational
									 Therapist, Licensed (OT/L)
$8.99 1/4 hr.*
S8990 GP
PHYSICAL THERAPY (MAINTENANCE)
$ 10.20 1/4 hr.*
S8990 GN
SPEECH THERAPY (MAINTENANCE)-Individual
$ 13.10 1/4 hr.*
S8990 GN HQ
SPEECH THERAPY (MAINTENANCE)-Group
$ 9.82 1/4 hr.*
*The Department is seeking and anticipates receiving
						  approval from the federal Centers for Medicare and Medicaid Services for these
						  changes.
**These rates are used in conjunction with Appendix IIA
						  and IIB to calculate the Home Support Agency Per Diem rate.
MODIFIERS DESCRIPTIONS
GO Service delivered under an outpatient occupational
						  therapy plan of care
GP Services delivered under an outpatient physical
						  therapy plan of care
HQ Group Setting
CG Policy criteria applied
GN Services delivered under an outpatient speech
						  language pathology plan of care
HI Behavioral Consultation
GT Remote Support-Interactive Support
QC Remote Support-Monitor Only
U5 Home Support-Family Centered Support
SC Medically necessary service or supply
TG Complex/high tech level of care
UN Two members served
UP Three members served
UQ Four members served
UR Five members served
US Six members served
U1 Other Qualified Staff
*Provider calculated, in accordance with base rates
						  listed at Appendices IIA & IIB. For assistances with calculations see
						  Tables 1 & 2 accessible through the DHHS website:
http://www.maine.gov/dhhs/oads/MaineCare/index.shtml
or by calling 1-866-5585 (TTY): 711.