Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-17 - Community Support Services › Subsection 144-101-II-17.09 - PROGRAM INTEGRITY AND QUALITY ASSURANCE

Current through 2024-29, July 17, 2024
17.09-1
Role of Department of Health
					 and Human Services
. DHHS or an Authorized Entity is responsible for
					 Program Integrity, Quality Assurance and Utilization Review. Please refer to
					 Chapter I of the
MaineCare Benefits Manual
for more
					 information. DHHS is responsible for establishing, supporting, and maintaining
					 quality assurance policies, licensing standards, and criteria and procedures
					 for authorizing continuation of services in accordance with Section
					 17.04.
17.09-2
Waiver Criteria.
In
					 certain circumstances, DHHS may authorize waivers of Section 17.09-3 Specific
					 Requirements (eligibility), Section
					 17.04 Covered
					 Services (authorization of the continuation of services or concurrent
					 services), Section
					 17.05 Limitations
					 (the limitations on certain services), and 17.07-2 Other Qualified Individuals
					 (supervision of other qualified individuals) beyond the criteria set forth in
					 this Section. All waiver requests must be submitted to the Authorized Entity.
A.
Eligibility
Any request for a waiver of specific eligibility, as
						defined in Section 17.02-3, must explain why the member does not meet
						eligibility criteria and why the member is in need of services. The clinician
						must document that without the requested treatment, the member would likely
						deteriorate clinically to a point where the criteria in Section
						17.02 will be met; or
						demonstrate that without the requested continuation of services, the member
						would be unstable or deteriorate further; and, there is a reasonable
						expectation that the defined service(s) will reduce the current symptoms of the
						member's mental illness.
B.
Continuing or Concurrent Services
Any request for a waiver for continuing services or
						concurrent services as defined in Sections 17.04-4, 17.04-5, or
						17.04 -6 must include
						documentation that the member has improved with the current service, the
						anticipated goals of the future services, the skills development methods to be
						used, and a summary of the member's progress to date. Any approval for future
						services will be of limited duration.
C.
Limitations
Any request for a waiver of limits as defined in Section
						17.05 including
						17.05-2 "Multiple Providers", 17.05-3 "Concurrent Services", and 17.05-5
						"Private Non-Medical Institutions", must include documented demonstration that
						without the requested services, the member would be unstable or deteriorate
						further. There must be clinical evidence that the defined service(s) will
						reduce the current symptoms of the member's mental illness and that the needed
						service(s) cannot be provided in a manner that does not require a
						waiver.
D.
Supervision
Any request for a waiver of the supervision requirements
						as defined in Section 17.07-2 for Other Qualified Individuals must meet DHHS's
						licensing standards and approval. Documented approval from DHHS's Division of
						Licensing and Regulatory Services must be kept in the Other Qualified
						Individual's personnel file.
All approvals for waivers described above must follow the
						prior authorization timelines and requirements in Chapter I, Section 1.17 of
						the
MaineCare Benefits Manual.