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 › Subsection 144-101-III-97-1600 - 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 PNMI, or a duly authorized representative must:
1600.1 Comply with the provisions of Chapter
					 I; and Chapters II, III, and the applicable Appendix of Section 97 of the
MaineCare Benefits Manual
.
1600.2 Submit master file documents and cost
					 reports in accordance with the provisions of Sections 3100 and 3300 of these
					 Principles. Children's Residential Care providers under Appendix D must also
					 submit these documents and cost reports, which the Department utilizes in
					 setting appropriate reimbursement rates.
1600.3 Maintain adequate financial and
					 statistical records and make them available for inspection by an authorized
					 representative of the Department, State, or the Federal government upon
					 request.
1600.4 Assure that annual
					 records are prepared in conformance with Generally Accepted Accounting
					 Principles (GAAP), except where otherwise required.
1600.5 Assure that the construction of
					 buildings and the maintenance and operation of premises and residential
					 services comply with all applicable health and safety standards.
1600.6 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 per diem rate described in Section 7000
					 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-97 - Private Non-Medical Institution Services › Subsection 144-101-III-97-1700 - COVERED SERVICES

Current through 2024-29, July 17, 2024
See applicable section of Chapter II, Section 97, Private
						Non-Medical Institution 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 › Subsection 144-101-III-97-1900 - TERMINATION UNDER TITLE XIX

Current through 2024-29, July 17, 2024
Termination of participation in Title XIX will result in
						the provider being terminated simultaneously from financial participation under
						PNMI cost reimbursement.
Alternatively, termination of participation in cost
						reimbursement will result in the provider being terminated simultaneously from
						participation in Title XIX. Conditions that may result in termination of
						participation in MaineCare are listed in Chapter I of the
MaineCare
						Benefits Manual
. These conditions may result in termination of the
						provider contract to provide PNMI services:
1900.1 The Federal Government fails to
					 provide agreed upon funds; or
1900.2 The State share of funds is
					 unavailable; or
1900.3 The life,
					 health, or safety of persons served is endangered, in the opinion of the
					 Department; or
1900.4 The provider
					 fails to submit fiscal or program reports on the prescribed dates; or
1900.5 Either the Department or
					 the provider receives a written notice from the other for any reason stating
					 that termination will occur in no later than 30 days; or
1900.6 The provider fails to meet the
					 applicable licensing regulations after a reasonable time for correction, or if
					 the provider fails to deliver services in accordance with the plan of care;
					 or
1900.7 The license to operate is
					 revoked by Department or court action, or if the facility's owner or its
					 administrator is convicted of any crime related to operation of the facility;
					 or
1900.8 The same services can be
					 provided at a lower rate on a fee-for-service basis or if the per diem rate is
					 greater than the rates that third party payers are paying for comparable
					 services under comparable circumstances.
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 › Subsection 144-101-III-97-2000 - ACCOUNTING REQUIREMENTS

Current through 2024-29, July 17, 2024
2000.1 All financial
					 and statistical reports must be prepared in accordance with Generally Accepted
					 Accounting Principles (GAAP), consistently applied, unless specific variations
					 are required by these principles.
2000.2 The provider must establish and
					 maintain a financial management system that assures adequate internal control
					 and accuracy of financial data, the safeguarding of assets and operational
					 efficiency.
2000.3 The provider
					 must report on an accrual basis, unless it is a State or municipal institution
					 that operates on a cash basis, unless the Department and the Department
					 providing the State share of MaineCare reimbursement approves exceptional
					 circumstances. The provider whose records are not maintained on an accrual
					 basis must develop accrual data for reports on the basis of an analysis of the
					 available documentation. The provider must retain all such documentation for
					 audit purposes.
2000.4 It is the
					 duty of the provider to notify the Division of Audit within 5 days of any
					 change in its customary charges to the general public. The provider may submit
					 a rate schedule to the Department to satisfy this requirement if the schedule
					 allows the Department the ability to determine with certainty the charge
					 structure of the Private Non-Medical Institution.
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 › Subsection 144-101-III-97-2300 - COST RELATED TO RESIDENT CARE

Current through 2024-29, July 17, 2024
2300.1 In order
					 to be allowable, compensation must be reasonable and for services that are
					 necessary and related to PNMI services. The services must actually be performed
					 and incurred by the PNMI or its contractors. Providers must report all
					 compensation to all appropriate state and federal tax authorities to the extent
					 required by law for income tax, social security, and unemployment insurance
					 purposes.
Providers may not claim reimbursement for personal
						expenses unrelated to member care. Bonuses that are part of a written policy of
						the provider and which require some measurable and attainable employee job
						performance expectations are allowable. Bonuses based solely on the
						availability of any anticipated savings are not allowable.
2300.2 Costs incurred for PNMI 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.
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 › Subsection 144-101-III-97-2400 - ALLOWABILITY OF COST

Current through 2024-29, July 17, 2024
2400.1 Allowable
					 costs shall include salaries and wages for direct service staff.
See applicable Appendix for each type of PNMI for the
						list of approved direct service staff:
Appendix B Substance Use Treatment Facilities
Appendix C Medical and Remedial Service
						Facilities
Appendix D Children's Residential Care Facilities
Appendix E Community Residences for Persons with Mental
						Illness
Appendix F Non-Case Mixed Medical and Remedial
						Facilities
2400.2 Allowable
					 costs shall also include the following taxes and benefits applicable to direct
					 service staff as defined in the applicable Appendix:
Payroll taxes/unemployment payroll taxes
Health insurance
Dental insurance
Employer term life/disability insurance
Qualified retirement contributions
Worker's Compensation insurance
2400.3 The Department will approve the direct
					 care staffing.
2400.3.1 The Department will
					 determine the reasonableness of costs based on the budget submitted prior to
					 the beginning of the provider's fiscal year, subject to final approval by the
					 Office of MaineCare Services and the Department. The total amount approved in
					 the budget will serve as a cap for reimbursement.
2400.3.2 A Rate Letter will inform the
					 provider of the approved total cost cap and per diem rate based on a review of
					 the submitted budget per Section 2400, Chapter III, General Provisions. For
					 case mix facilities covered under Appendix C, the rate letter informs the
					 agency of the Industry Price and Average Case Mix Index.
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 › Subsection 144-101-III-97-2500 - NON-ALLOWABLE COSTS

Current through 2024-29, July 17, 2024
An unallowable 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 › Subsection 144-101-III-97-2600 - SUBSTANCE OVER FORM

Current through 2024-29, July 17, 2024
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.
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 › Subsection 144-101-III-97-2700 - RECORD KEEPING AND RETENTION OF RECORDS

Current through 2024-29, July 17, 2024
2700.1 Providers must make all financial and
					 member records available to representatives of the State of Maine, Department
					 of Health and Human Services or the U.S. Department of Health and Human
					 Services, or the Maine Attorney General's Office, as required by Section
					 2700.3.
The Department will give providers a three-day notice
						when requesting fiscal records.
2700.2 Each provider must maintain complete
					 documentation, including accurate financial and statistical records, to
					 substantiate the data reported on the cost report.
2700.3 Complete documentation means clear
					 evidence of all of the financial transactions of the provider and affiliated
					 entities, including but not limited to census data, ledgers, books, invoices,
					 bank statements, canceled checks, payroll records, copies of governmental
					 filings, time records, time cards, purchase requisitions, purchase orders,
					 inventory records, basis of apportioning costs, matters of provider ownership
					 and organization, resident service charge schedule and amounts of income
					 received by service, Federal and State income tax information, asset
					 acquisition, lease, sale, or any other action, franchise or management
					 arrangement, or any other record which is necessary to provide the Commissioner
					 with the highest degree of confidence in the reliability of the claim for
					 reimbursement. For purposes of this definition, affiliated entities will extend
					 to realty, management, and other entities for which any reimbursement is
					 directly or indirectly claimed, whether or not they fall within the definition
					 of related parties.
2700.4 The
					 provider must maintain all such records for at least 5 years from the date of
					 settlement of the final audit. The Division of Audit must keep all cost
					 reports, supporting documentation submitted by the provider, correspondence,
					 work papers and other analysis supporting audits for a period of three years.
					 In the event of litigation or appeal involving rates established under these
					 regulations, the provider and Division of Audit must retain all records that
					 are in any way related to such legal proceeding until the proceeding has
					 terminated and any applicable appeal period has lapsed.
2700.5 When the Department determines that a
					 provider is not maintaining records as outlined above for the determination of
					 reasonable cost in the PNMI, the Department, upon determination of just cause,
					 may impose the deficiency rate as described in Section 7000 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-97 - Private Non-Medical Institution Services › Subsection 144-101-III-97-2900 - BILLING PROCEDURES

Current through 2024-29, July 17, 2024
2900.1 Substance use
					 treatment facilities, children's residential care facilities, and community
					 residences for persons with mental illness will bill the Department of Health
					 and Human Services and be reimbursed at the agreed rate in accordance with
					 MaineCare billing instructions for the UB-92 Claim Form.
2900.2 Medical and remedial service
					 facilities will bill the Department of Health and Human Services and be
					 reimbursed at the agreed rate in accordance with MaineCare billing instructions
					 for the UB-92 Claim Form.
2900.3
					 Claims cannot include dates of service that overlap the provider's fiscal
					 years.
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 › Subsection 144-101-III-97-3000 - REIMBURSEMENT METHOD

Current through 2024-29, July 17, 2024
3000.1 The
					 Department will reimburse facilities for services provided to members based on
					 a rate that the Department establishes on a prospective basis and determines is
					 reasonable and adequate to meet the costs incurred by an efficiently and
					 economically operated facility. The provider must provide care and services in
					 conformity with applicable State and Federal laws, regulations, and quality and
					 safety standards.
3000.1.1 Except for
					 Appendices B and D facilities, the Department will limit reimbursement to the
					 approved amount in Section
					 2400. Appendices B
					 and D facilities receive a standard rate not subject to Section 2400
					 adjustments for allowability of cost.
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 › Subsection 144-101-III-97-3100 - FINANCIAL REPORTING

Current through 2024-29, July 17, 2024
3100.1 Master File
When requested by the Department the provider must
						submit the following documents to the Office of MaineCare Services or its
						designee. Providers must update documents to reflect any changes. The
						Department will use the following documents to establish a master file for each
						facility in MaineCare:
3100.1.1 Copies
					 of the articles of incorporation and bylaws, of partnership agreements of any
					 provider or any entity related to the provider;
3100.1.2 Chart of accounts and procedures
					 manual, including procurement standards;
3100.1.3 Plant layout;
3100.1.4 Terms of capital stock and bond
					 issues;
3100.1.5 Copies of
					 long-term contracts, including but not limited to leases, pension plans, profit
					 sharing, and bonus agreements;
3100.1.6 Schedules for amortization of
					 long-term debt and depreciation of plant assets;
3100.1.7 Summary of accounting principles,
					 cost allocation plans, and step-down statistics used by the provider;
3100.1.8 Related party information on
					 affiliations, and contractual arrangements;
3100.1.9 Tax returns of the Private
					 Non-Medical Institution; and
3100.2.0 Any other documentation requested by
					 the Department for purposes of establishing a rate.
If any of the items listed in Subsections 3100.1.1
						through 3100.2.0 are not submitted in a timely fashion, the Department may
						impose the deficiency per diem rate described in Section 7000 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-97 - Private Non-Medical Institution Services › Subsection 144-101-III-97-3400 - SETTLEMENT OF COST REPORTS

Current through 2024-29, July 17, 2024
3400.1 Uniform Desk
					 Review
See applicable PNMI Appendix for uniform desk review
						procedures.
3400.2
					 Calculation of the Final Settlement Eff. 7/
See A See Applicable Appendix for calculation of the
						final settlement. Calculation of the final settlement is subject to
						reimbursement methods, limits, and reductions set forth in this Section.
						Appendix D facilities are not subject to cost 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 › Subsection 144-101-III-97-3500 - ADJUSTMENTS TO AUDIT SETTLEMENTS (Except for Appendices B and D)

Current through 2024-29, July 17, 2024
3500.1 Finalized cost report determinations
					 and decisions may be reopened and corrected when the Division of Audit finds
					 new and material evidence submitted by the provider or discovered by the
					 Department or evidence of a clear and obvious material error.
3500.2 Reopening means an affirmative action
					 taken by the Division of Audit to re-examine the correctness of a determination
					 or decision that is otherwise final. Such action may only be taken:
3500.2.1 At the request of either the
					 Department or a provider, within the applicable time period set out in
					 paragraph 3500.4; and,
3500.2.2
					 When the reopening may have a material effect (more than one percent) on the
					 provider's MaineCare rate payments.
A correction is a revision (adjustment) in the Division
						of Audit's determination, otherwise final, that is made after a proper
						re-opening. The Division may make a correction, or require the provider to file
						an amended cost report.
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 › Subsection 144-101-III-97-3600 - SETTLEMENTS OF OVERPAYMENTS OR UNDERPAYMENTS (Except for Appendices B and D)

Current through 2024-29, July 17, 2024
3600.1
					 Underpayments: If, at the time the audit is completed, the Department
					 determines that it has underpaid a facility; the Department will pay the amount
					 due and forward the result to the facility within thirty working
					 days.
3600.2 Overpayments:
3600.2.1 If the Department has overpaid a
					 provider, it will recover overpayments by offset, recoupment, or other methods
					 allowed by law.
3600.2.2 The
					 department may withhold payment on pending or future claims in an amount equal
					 to the overpayment, pursuant to State and federal law. The amount may be
					 withheld all at once or over a period of time established by the Department.
					 Amounts are to be repaid within 90 days of the date the audit is finalized
					 unless otherwise negotiated by the Department.
3600.2.3 If there are insufficient claims
					 sent to the Department against which the Department can offset the amount of an
					 overpayment, the Department will direct the provider to remit the payment in
					 full. If repayment is not made, the Department may exercise any or all
					 appropriate action against the provider and exercise all other civil remedies
					 in order to recover the overpayments.
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 › Subsection 144-101-III-97-4000 - PUBLIC HEARING

Current through 2024-29, July 17, 2024
The State of Maine will provide for public hearings as
						described MBM, Chapter I.
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 › Subsection 144-101-III-97-5000 - WAIVER

Current through 2024-29, July 17, 2024
The failure of the Department to insist, in any one or
						more instances, upon the performance of any of the terms or conditions of these
						Principles, or to exercise any right under these principles, or to disapprove
						of any practice, accounting procedure, or item of account in any audit, will
						not be construed as a waiver of future performance of the right.
The obligation of the provider with respect to future
						performance shall continue, and the Department shall not be stopped from
						requiring such future performance.
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 › Subsection 144-101-III-97-6000 - POST AUDIT APPEAL PROCEDURES (Except for Appendices B and D)

Current through 2024-29, July 17, 2024
6000.1 These provisions apply only to appeals
					 after audit adjustment. See MBM, Chapter I for all other appeals procedures. A
					 provider may administratively appeal an audit adjustment made by the Division
					 of Audit.
6000.2 An administrative
					 appeal will proceed in the following manner:
6000.2.1 Within sixty (60) days of receipt of
					 an audit or other appealable determination, the facility must request, in
					 writing, an informal review before the Director of the Division of Audit or
					 his/her designee. The facility must forward, with the request, any and all
					 specific information it has relative to the issues in dispute, note the
					 monetary amount each issue represents and identify the appropriate principle
					 supporting the request. Only issues presented in this manner and timeframe will
					 be considered at an informal review or at a subsequent administrative hearing.
6000.2.2 The Director or his/her
					 designee will notify the facility in writing of the decision made as a result
					 of the informal review. If the facility disagrees with the results of the
					 informal review, the facility may request an administrative hearing before the
					 Commissioner or a presiding officer designated by the Commissioner. Only issues
					 presented in the informal review will be considered at the administrative
					 hearing. A request for an administrative hearing must be made, in writing,
					 within sixty (60) days of receipt of the decision made as a result of the
					 informal review.
6000.2.3 To the
					 extent the Department rules in favor of the provider, the audit report will be
					 revised.
6000.2.4 To the extent the
					 Department upholds the original determination of the Division of Audit, review
					 of the results of the administrative hearing is available in conformity with
					 the
Administrative Procedure Act
,
					 5 M.R.S.A.
					 §11001
et
					 seq
.
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 › Subsection 144-101-III-97-7000 - DEFICIENCY PER DIEM RATE (Except for Appendices B and D)

Current through 2024-29, July 17, 2024
In addition to the deficiency rate, civil and/or monetary
						sanctions may be applied by the State agency responsible for licensing the
						facility when a facility is found not to have provided the quality of service
						or level of care required. The Department will reimburse at 90% of the
						provider's per diem rate, unless otherwise specified. This "deficiency rate"
						will be applied following written notification to the facility of the effective
						date of the reduced rate for any of the following service deficiencies:
7000.1 Staffing over a period of two weeks or
					 more does not meet the Federal Certification and State Licensing
					 requirements;
7000.2 Food service
					 does not meet the Federal Certification and State Licensing
					 requirements;
7000.3 Specific,
					 documented evidence that the care provided does not meet the Federal
					 Certification and State Licensing requirements. Such penalty to be effective no
					 sooner than 30 days from written notification that such deficiencies
					 exist;
7000.4 Failure to correct,
					 within the time frames of an accepted Plan of Correction, deficiencies in
					 meeting the Federal Certification and State Licensing requirements, which cause
					 a threat to the health and safety of residents in a facility or the surrounding
					 community;
7000.5 Failure to submit
					 a cost report, financial statements, and other schedules as requested by the
					 Division of Audit, and to maintain auditable records as required by these
					 Principles and other relevant regulations may result in application of the
					 deficiency per diem rate, suspension, withholding of, or recoupment of
					 MaineCare reimbursement. The deficiency per diem rate for these items will go
					 into effect immediately upon receipt of written notification from the
					 Department.
7000.6 Failure to
					 complete acceptable assessments, as defined in Appendix C.
A reduction in rate because of deficiencies will remain
						in effect until the deficiencies have been corrected, as defined in the
						applicable Appendix, or as verified by representatives of the Department,
						following written notification by the provider that the deficiencies no longer
						exist. No retroactive adjustments to the full rate will be made for the period
						that the deficiency rate is in effect unless the provider demonstrates to the
						satisfaction of the Department that there was no just cause for the reduction
						in 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-97 - Private Non-Medical Institution Services › Subsection 144-101-III-97-8000 - START UP COSTS APPLICABILITY

Current through 2024-29, July 17, 2024
Prior to admitting residents, certain costs are incurred,
						which are referred to as start-up costs. No start-up costs can be allowed for
						the PNMI component.
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-A

Current through 2024-29, July 17, 2024
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-B - SUBSTANCE USE TREATMENT FACILITIES › Section 144-101-III-97-B-1000 - PURPOSE

Current through 2024-29, July 17, 2024
The purpose of Appendix B is to identify reimbursement
						  regulations that are specific to substance use treatment facilities under
						  Chapter III, Private Non-Medical Institutions (PNMI) services of the
MaineCare Benefits Manual
. The general provisions of Chapter
						  III for 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.
						  These regulations identify which costs are reimbursable within Section 97,
						  Chapters II and III and Appendix B, Private Non-Medical Institution Services of
						  the
MaineCare Benefits Manual
. As of November 15, 2010,
						  Substance Use Treatment Facilities under this Appendix are reimbursed using a
						  standard rate for each defined type of substance use treatment service, and are
						  not subject to establishment of interim rates and cost settlement procedures,
						  as detailed in Section 97, Chapter III. Rates may be found at
http://www.maine.gov/dhhs/audit/rate-setting/index.shtml
.
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-B - SUBSTANCE USE TREATMENT FACILITIES › Section 144-101-III-97-B-1200 - AUTHORITY

Current through 2024-29, July 17, 2024
The authority of the Department of Health and Human
						  Services to accept and administer funds which may be available from State
						  and/or Federal sources for the provision of the services as set forth in
						  Appendix B is contained in
						  22
						  MRSA Section3173-D and Title XIX of the
						  Social Security Act as Amended;
						  42 U.S.C.A. §
													1396
et
						  seq
.
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-B - SUBSTANCE USE TREATMENT FACILITIES › Section 144-101-III-97-B-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 substance use
						  treatment by qualified staff of a Private Non-Medical Institution as defined in
						  Section 97.01-1(A) of the
MaineCare Benefits Manual
.
The term "facility" as used throughout these
						  Principles of Reimbursement refers to private non-medical institutions licensed
						  and funded by the State of Maine, Department of Health and Human Services
						  (DHHS) Office of Behavioral Health under Sections 4.06, 4.08, 4.09, 4.10, 4.11
						  and/or 4.13 of the "Regulations for Licensing/Certifying of Substance Abuse
						  Treatment Facilities in the State of Maine," but excludes any
						  Department-licensed facilities staffed by a solo 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-B - SUBSTANCE USE TREATMENT FACILITIES › Section 144-101-III-97-B-2400 - SERVICE COMPONENTS OF THE STANDARD RATE

Current through 2024-29, July 17, 2024
Providers must follow all State of Maine licensing
						  regulations and guidelines for staffing levels and must maintain professional
						  staffing sufficient to serve the individual needs of each recipient as
						  reflected in his individual service plan (as defined in Chapter II, §97. )
						  Professional services may be provided only within the scope of the
						  professional's license.
2400.1 The
						standard per diem rates provided for Detoxification (non-hospital based),
						Halfway House Services, Extended Care, Residential Rehabilitation Services
						(Type I), Residential Rehabilitation Services (Type II), Adolescent Residential
						Rehabilitation and Personal Care Substance Use (Substance Use Shelter Services)
						are intended to include the service costs listed below. Providers may not bill
						separately under this section or any other section of the
MaineCare
						Benefits Manual
for providing these services. Salaries and wages for
						direct service staff and services listed below:
Physicians
Psychiatrists
Psychologists
Licensed clinical social workers
Licensed clinical professional counselors
Licensed professional counselors
Licensed marriage and family therapists
Registered nurses
Practical nurses
Licensed alcohol and drug counselors
Psychiatric nurses
Personal care services staff
Clinical Consultants
Other qualified alcohol and drug treatment staff as
						  defined in 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.
2400.2 The Department shall
						determine the reasonableness of the treatment costs on an annual basis.
						Providers must submit any requested data to the Department including, but not
						limited to, utilization data.
2410
						The rates in this Section include a State-mandated service tax. The
						State-mandated service tax is a tax on the value of PNMI services pursuant to
						 36 M.R.S.
						§2552. Since providers will no longer
						receive Rate letters detailing this information, they will need to calculate
						the service tax of reimbursed services.
2460 The total costs shall be allocated to
						rehabilitation and to personal care.
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-B - SUBSTANCE USE TREATMENT FACILITIES › Section 144-101-III-97-B-2500 - NON-ALLOWABLE COSTS

Current through 2024-29, July 17, 2024
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-B - SUBSTANCE USE TREATMENT FACILITIES › Section 144-101-III-97-B-3400 - 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
						therein, and allowable costs.
3400.1.3 Based on the results of the uniform
						desk review, the Division of Audit may:
a.
						Request more information,
b. Issue
						a final report of findings, or
c.
						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-B - SUBSTANCE USE TREATMENT FACILITIES › Section 144-101-III-97-B-5120 - PERSONAL CARE SERVICES

Current through 2024-29, July 17, 2024
PNMI services approved and funded by OBH in licensed
						  facilities may also provide personal care services necessary for the promotion
						  of ongoing treatment and recovery. PNMI facilities must be receiving funds from
						  OBH, 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-B - SUBSTANCE USE TREATMENT FACILITIES › Section 144-101-III-97-B-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,
						the following reimbursement rates will be effective retroactive to July 1,
						2016* and August 1, 2018*** as indicated below:
The following capitated rates apply to Appendix B
						  services.
SERVICE
									 DESCRIPTION
AMOUNT Effective
									 7/1/19
AMOUNT Effective
									 11/1/21*
UNIT
Medically Supervised Withdrawal Services (Non
									 Hospital based)
$217.48
$385.55
per diem
Medically Supervised Withdrawal Services (Non
									 Hospital based - exception rate for low RN
$238.12
per diem
Halfway House services
$106.09
$165.67
per diem
Extended Care
$116.89
$137.21
per diem
Residential Rehabilitation Type I
$224.44
$287.91
per diem
Residential Rehabilitation Type II
$119.65
$165.67
per diem
Adolescent Residential Rehabilitation
$187.67
$254.78
per diem
Personal Care Substance Use (Substance Use
									 Shelter Services)
$56.87
$56.87
per diem
The Department shall seek approval from CMS for
						  this Section (for the rates * above).
Members are assessed as described in Chapter II,
						  Section 97, and assigned to one of the types of substance use treatment
						  services described above. Providers bill the Department on a per diem basis for
						  each member receiving service. The capitated rate includes all PNMI services
						  required by the member for his or her type of service including all staffing
						  required pursuant to State of Maine licensing guidelines and as identified in
						  the members individual service plan. There is no cost settlement for Appendix B
						  PNMI services.
6000.2 The
						provider must submit, upon request, such data, statistics, schedules, or other
						information required by the OMS and OBH.
6000.3 The standardized rate for each
						Substance use treatment service type will begin November 15, 2010.
6000.4 Providers must ensure that the
						increase in reimbursement rates effective August 1, 2018 is applied in full to
						wages and benefits for employees who provide direct services. Providers must
						document compliance with this requirement in their financial records and
						provide such documentation upon request. The increase must be granted or paid
						out retroactively from the date the Department begins reimbursing the increased
						rates.
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-2000 - DEFINITIONS

Current through 2024-29, July 17, 2024
2010
Member
as used throughout
						this Appendix refers to an individual who is MaineCare eligible.
2020
Room and Board
costs means
						those costs that are not medical and remedial services costs and are not
						covered services under Appendix C.
2030
Resident Assessment Instrument (RAI)
is the
						assessment tool approved by the Department for use by the provider to obtain an
						accurate, standardized, reproducible assessment of each resident's functional
						capacity. It consists of the Minimum Data Set- Residential Care Assessment
						instrument (hereinafter MDS-RCA), the training manual for the MDS-RCA Tool, and
						any updates provided by the Department.
2040
Remote Island Facility
for
						the purposes of this section, means a facility located on an island not
						connected to the mainland by a bridge.
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-4000 - FACILITIES EXEMPT FROM THE CASE MIX PRICING METHOD

Current through 2024-29, July 17, 2024
The following types of medical and remedial PNMIs are
						  exempt from case mix pricing method and will be reimbursed in accordance with
						  Appendix F:
* Facilities whose total population consists of
						  residents diagnosed with HIV/AIDS;
* Facilities whose total population consists of
						  residents who are blind;
* Facilities whose total population consists of
						  individuals with severe and prolonged mental illness;
* Facilities serving individuals with intellectual
						  disabilities and other development disabilities; and
* CARF Accredited Brain Injured Facilities.
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-5000 - CASE MIX ADJUSTED DCP

Current through 2024-29, July 17, 2024
The basis for case mix adjustment is a resident
						  classification system that groups residents into classes according to their
						  assessed conditions and the resources required to care for them. The DCP is
						  multiplied by the average case mix weight for all MaineCare residents in the
						  facility as of the payment roster date. The PA is added to the case mix
						  adjusted DCP and becomes the facility's MaineCare rate. The Direct Care Price
						  will be inflated annually. Every six months the Department will adjust data for
						  facility-specific acuity.
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-6000 - PEER GROUPS

Current through 2024-29, July 17, 2024
The Department will classify facilities into one of
						  four peer groups. The peer groups are divided as follows: freestanding
						  facilities with 15 or fewer beds, facilities that are not freestanding with 15
						  or fewer beds or facilities with 16 to 24 beds, facilities with 25 or more
						  beds, and Specialty Alzheimer's Units. Each peer group has its own DCP and PA
						  calculated in accordance with Sections
						  3000 and
						  9000. The Department will
						  notify facilities the amounts of the DCP and PA.
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-8000 - CASE MIX PAYMENT SYSTEM

Current through 2024-29, July 17, 2024
8010
Industry-Specific DCP
The Department multiplies the industry-specific DCP
						  for each peer group by the facility's average MaineCare case mix so that this
						  payment system can take into consideration that some residents are more costly
						  to care for than others. Thus, the system requires:
a) The assessment of residents on the
						Department's approved MDS-RCA form;
b) The classification of residents into
						groups that are similar in resource utilization by use of the case mix resident
						classification groups defined in Section 9020 of this Appendix; and
c) A weighting system that quantifies the
						relative cost of caring for different classes of residents by direct service
						staff to determine a resident's case mix index.