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-28 - Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations › Subsection 144-101-II-28.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
A covered service is a service provided to a member for
						which payment may be made under the MaineCare Program, and through contract
						with DHHS. Assessment and treatment are covered services when provided to an
						eligible member by an approved staff so long as the services are medically
						necessary as defined in this section. Treatment is provided in the home and/or
						community in either individual or group settings and requires prior
						authorization and utilization review.
28.04-1
Treatment Services for Children
					 with Cognitive Impairments and Functional Limitations
are medically
					 necessary treatment services for members under the age of twenty one (21).
					 Treatment services are designed to retain or improve functional abilities which
					 have been negatively impacted by the effects of cognitive or functional
					 impairment and are focused on behavior modification and management, social
					 development, and acquisition and retention of developmentally appropriate
					 skills. Services include problem solving activities in order to help the member
					 develop and maintain skills and abilities necessary to manage his or her
					 behavioral health treatment needs, learning the social skills and behaviors
					 necessary to live with and interact with other community members and
					 independently, and to build or maintain satisfactory relationships with peers
					 or adults, learning the skills that will improve a member's self-awareness,
					 environmental awareness, social appropriateness and support social integration,
					 and learning awareness of and appropriate use of community services and
					 resources.
28.04-2
Specialized Services for Children with Cognitive Impairments and
					 Functional Limitations
are medically necessary, evidence based treatment
					 services for members under the age of twenty one (21), that utilize behavioral
					 interventions designed to improve socially significant behaviors and
					 developmentally appropriate skills to a measurable degree. Services include
					 problem solving activities in order to help the member develop and maintain
					 skills and abilities necessary to manage his or her behavioral health treatment
					 needs, learning the social skills and behaviors necessary to live with and
					 interact with other community members and independently, and to build or
					 maintain satisfactory relationships with peers or adults, learning the skills
					 that will improve a member's self-awareness, environmental awareness, social
					 appropriateness and support social integration, and learning awareness of and
					 appropriate use of community services and resources.
*The Department is seeking, and anticipates
						receiving, approval from CMS for this Section. Pending approval, these changes
						will be effective.
28.04-3 *
BCBA Services
are
					 services performed by a BCBA in connection with Specialized Services for
					 Children with Cognitive Impairments and Functional Limitations (Specialized
					 Services). The BCBA is responsible for the supervision and delivery of the
					 Specialized Services. BCBA services are defined as the following:
1. Conduct Functional Behavioral Assessments
					 (FBA). FBAs are a process of gathering information from multiple sources to
					 hypothesize and understand what reliably predicts and maintains a problem
					 behavior. The FBA evaluates behavior to analyze the antecedent and consequence
					 as a reinforcement of a problem behavior. Behaviors are defined in measurable
					 terms. The FBA uses a validated assessment which may also include interview,
					 direct and/or indirect observation in the member's natural environment,
					 functional analysis, preference assessment, assessment of reinforcement
					 effectiveness, data collection, and reporting. An initial FBA is limited to
					 fifteen (15) hours. One update is allowed per year, limited to ten (10)
					 hours;
2. Conduct Individual
					 Treatment Plan development, positive behavior support planning, and periodic
					 reviews/revision of the ITP and positive behavior support plan. Planning
					 services are limited to six(6) hours for developing the initial treatment plan,
					 and up to one (1) hour per month to review, and update as necessary, the
					 treatment plan;
3. Conduct summary
					 and analysis of data on Member progress, and review data trends with staff to
					 refine Member treatment. Summary and data analysis services are limited to one
					 (1) hour per Member per month;
4.
					 Conduct evidence-based practices congruent with Specialized Services with
					 Members in accordance with the Member's Individualized Treatment Plan.
					 Specialized Services are limited to two (2) hours per Member per month.
5. Conduct coordination of Member
					 care with other providers. Coordination Services are limited to two (2) hours
					 per Member per month;
6. Conduct
					 parent training on behavioral principles and interventions specific to the
					 Member. Parent training services are limited to six (6) hours per Member per
					 quarter;
7. Conduct monthly Member
					 treatment team meetings. There is a limit of one (1) hour per Member per month
					 for monthly Member treatment team meetings;
Providers may request additional hours/units beyond the
						stated limitations above when deemed medically necessary through supported
						documentation and Prior Authorization through the Department or its Authorized
						entity.