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-46 - Psychiatric Hospital Services › Subsection 144-101-II-46.09 - ADMISSION ELIGIBILITY AND CONTINUING ELIGIBILITY CRITERIA

Current through 2024-29, July 17, 2024
Members must be determined eligible for admission and
						continued stay. Providers must maintain a member record for each member
						documenting the medical necessity for these services. Documentation must be
						available to the Department and its Authorized Agent. There must be daily
						documentation that the admission criteria continue to be met for the member to
						remain eligible for services unless otherwise noted.
46.09-1
Psychiatric Criteria
Members must meet all of the following four (4) criteria
						in order to be eligible for psychiatric services:
1. The member has a substantiated diagnosis
					 found in the most current version of the American Psychiatric Association's
					 Diagnostic and Statistical Manual (DSM).
2. Treatment is medically necessary. Medical
					 necessity must include one (1) or more of the following:
a. The member exhibits an immediate or direct
					 threat of serious harm to self or there is a clear and reasonable inference of
					 serious harm to self, where suicidal precautions or observations on a
					 24-hour/day basis are required. This behavior must require intensive
					 psychiatric, medical and nursing treatment interventions on a 24-hour day
					 basis.
b. The member is exhibiting
					 an immediate or direct threat of serious harm to others or there is evidence
					 for clear and reasonable inference of serious harm to others. This behavior
					 must require intensive psychiatric, medical and nursing treatment interventions
					 on a 24-hour/day basis.
c. The
					 member is exhibiting an extreme disabling condition such that one cannot take
					 care of self in a developmentally appropriate level or requires assistance
					 beyond the home or residential setting. The member's symptoms must be of such
					 severity that they require 24-hour/day intensive medical, psychiatric, and
					 nursing services. Outpatient treatment would be clearly unsafe or is
					 unavailable. A lower level of care is not available or would not be adequate to
					 successfully treat those symptoms.
3. Age specific criteria:
a. For members under the age of twenty one
					 (21) or adults with a legal guardian:
i. The
					 member's family / guardian(s), where applicable and clinically indicated, are
					 willing to actively participate throughout the duration of treatment.
ii. The services can reasonably be expected
					 to improve the member's condition or prevent further regression so that
					 inpatient services will no longer be needed.
b. For members age sixty five (65) or older,
					 services are the only alternative available to maintain or restore the member
					 to the greatest possible degree of health and independent
					 functioning.
4. A clear
					 indication that the inpatient psychiatric services offered provide the member
					 with active treatment.