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 II - Specific Policies By Service › Section 144-101-II-45 - Hospital Services › Subsection 144-101-II-45.12 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
A. Only providers
					 that qualify as "provider based" entities under
					 42
					 CFR 413.65 may bill under this Section of the
MaineCare Benefits Manual
.
B. Copies of MaineCare billing instructions
					 may be downloaded at
http://www.maine.gov/dhhs/oms/providerfiles/billing_instructions.html
.
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-45 - Hospital Services › Subsection 144-101-II-45.13 - REPORTING REQUIREMENTS

Current through 2024-29, July 17, 2024
Acute Care Critical Access Hospitals and Private
						Psychiatric Hospitals must submit National Drug Codes (NDC) for all outpatient
						claims for all single source drugs (as defined in
						42 CFR
						447.502) and all multiple source drugs (as
						defined in
						42 CFR
						447.502) .
Drugs purchased through Section 340B of the
Public Health Service Act
(referred to as 340B hospitals) are
						exempt from this requirement.
Hospitals are responsible for updating their enrollment
						applications, and submitting an updated 340B Provider Agreement to reflect 340B
						status when it changes. Hospitals participating in 340B shall comply with
						42 USC
						§
												256b(a)(5)(A)(i),
						which prohibits duplicate discounts or rebates (manufacturers are protected
						from giving a 340B discount and a Medicaid rebate on the same drug). In
						accordance with
						42 USC
						§
												256b(a)(5)(A)(ii),
						hospitals participating in 340B shall comply with a CMS-established mechanism,
						or establish their own mechanism, to ensure that they are in compliance with
						the duplicate discount prohibition. For more information on duplicate discounts
						refer to the following website
https://www.hrsa.gov/opa/programrequirements/medicaidexclusion/index.html
.
MaineCare will not pay for drugs that do not have a CMS
						rebate agreement unless they are medically necessary and any PA that is
						required under Section
						90 of the
MaineCare
						Benefits Manual
has been approved in accordance with that
						Section.
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-46.02 - PROVIDER ELIGIBILITY

Current through 2024-29, July 17, 2024
46.02-1
Psychiatric Hospitals Serving Individuals Age Sixty-five (65) or Older
					 for Inpatient Services
In order to be enrolled as a MaineCare provider, and to
						receive reimbursement, the provider must be licensed as a psychiatric hospital
						by the Department of Health and Human Services and must be certified by
						Medicare.
46.02-2
Psychiatric Hospitals Serving Members Under Age Twenty one (21) for
					 Inpatient Services
In order to be enrolled as a MaineCare provider, and to
						receive reimbursement, the provider must be licensed by the Department of
						Health and Human Services as a psychiatric hospital and must be accredited by
						the Joint Commission on Accreditation of Health Care Organizations.
46.02-3
Psychiatric
					 Hospitals Providing Outpatient and Partial Hospitalization Services
In order to be enrolled as a MaineCare provider and to
						receive reimbursement, the provider must be licensed by DHHS as a psychiatric
						hospital and be accredited by the Joint Commission on Accreditation of Health
						Care Organizations.
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-46.04 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each MaineCare member is eligible for those medically
						necessary covered services set forth in Section 46.05. See Utilization Review
						Requirements in Section 46.08.
Katie Beckett Eligibility will be reviewed annually by
						DHHS, which reserves the right to request additional information to evaluate
						medical necessity. Responses to requests for additional information must be
						made available to the Department within sixty (60) days in order to maintain
						eligibility. The Office of Integrated Access and Support is notified when
						members no longer meet eligibility as set forth in this Section, and reassesses
						continued MaineCare eligibility in another category using guidelines set forth
						in the MaineCare Eligibility Manual.
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-46.05 - COVERED SERVICES

Current through 2024-29, July 17, 2024
All covered services are subject to Utilization Review as
						set forth in Section 46.08, and all covered services must be medically
						necessary, as defined in Chapter I, Section 1.
46.05-1
Inpatient Psychiatric Hospital
					 Services
Covered services include those services ordinarily
						provided in a psychiatric hospital for the twenty four (24) hour care and
						treatment of an inpatient under the supervision of a psychiatrist and in
						accordance with the member's plan of care.
46.05-2
Partial Hospitalization
					 Services
Partial hospitalization services must be designed to meet
						the treatment and rehabilitative needs of the member as identified in a
						treatment plan. Services include, but need not be limited to, individual, group
						and activities components designed to develop members' emotional and physical
						capability in areas of daily living, community integration and interpersonal
						functioning. Outpatient services include but need not be limited to: diagnosis
						and assessment; individual, family and group therapy; medication evaluation,
						education and monitoring; stress management; and daily living skills training
						services.
46.05-3
Outpatient Services
Outpatient Services are professional assessment,
						counseling and therapeutic services provided to members to relieve excess
						stress and promote positive orientation and growth toward more integrated and
						independent levels of functioning. Services are delivered through planned
						interaction involving the use of physiological, psychological, and sociological
						concepts, techniques and processes of evaluation and intervention.
Services include diagnosis and assessment, psychometric
						evaluation, intervention services by psychological examiners, individual,
						group, and family therapy, specialized treatment for sexual abuse victims or
						offenders, medication review and chemotherapy, and similar professional
						therapeutic services. Services must include a direct encounter with the member.
						Services must focus on the special developmental and emotional needs and
						problems of the member where appropriate.
In order to be eligible for reimbursement the need for
						services must be documented in the treatment plan and is subject to approval
						and Utilization Review by the Department and its Authorized Agent according to
						guidelines set forth in Section 46.08.
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-46.06 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
Services that are not reimbursable are:
1. outpatient meals
2. outpatient transportation
3. leave days
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-46.07 - DETERMINATION OF ELIGIBLITY

Current through 2024-29, July 17, 2024
All members requesting eligibility must be determined to
						be in need of the psychiatric hospital services provided by providers enrolled
						under this Section. The determination of medical eligibility is made
						concurrently with the determination of financial eligibility in order to
						expedite the determination of the member's overall eligibility for psychiatric
						hospital services.
46.07-1
Financial Eligibility Determination Procedure
Financial eligibility will be determined by the DHHS's
						Office of Integrated Access and Support.
46.07-2
Medical Eligibility
					 Determination Procedure
Before authorization for reimbursement may be made, a
						complete evaluation of the member must be made, a plan of care established, a
						certification of need of service completed, and Central Enrollment as defined
						in Section 46.08 completed.
A.
Medical, Psychiatric, and Social Evaluations
An attending physician or staff physician must make a
						medical evaluation of each member's need for care and appropriate professional
						personnel must make a psychiatric and social evaluation. This evaluation must
						include all requirements detailed in Hospital Licensing regulations. In
						addition, each medical evaluation must include:
1. Diagnosis
2. Summary of present medical
					 findings
3. Medical
					 history
4. Mental and physical
					 functional capacity
5.
					 Prognosis
6. Measurable short and
					 long term goals
7. Specific
					 treatment modalities to be utilized
8. The responsibilities of each team
					 member
9. Treatment received by the
					 member shall be documented to justify the diagnosis and the treatment and
					 rehabilitation activities carried out; and
10. A physician's recommendation of
					 inpatient, partial hospitalization or outpatient services for the member. In
					 the case of an individual who applies for MaineCare while receiving inpatient,
					 partial hospitalization or outpatient services, a recommendation by a physician
					 for continued care must be made as part of the medical evaluation.
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-46.08 - DEPARTMENTAL UTILIZATION REVIEW

Current through 2024-29, July 17, 2024
The Department requires utilization review (UR) for
						services reimbursed under this section. Utilization Review is performed by the
						Department or its Authorized Agent in coordination with the provider's internal
						UR process.
Central Enrollment is a process of determining baseline
						eligibility for behavioral health treatment. DHHS or its Authorized Agent shall
						facilitate referrals to appropriate service providers, expedite delivery of
						service to members, and reliably track the service status of members enrolled
						in the system and gather data that will inform DHHS of resource development
						needs. This is part of the UR process.
Utilization Review is a formal assessment of the medical
						necessity, efficiency and appropriateness of services and treatment plans on a
						prospective, concurrent or retrospective basis. The provider is required to
						notify the DHHS or its Authorized Agent upon initiation of all services in this
						Section in order for the Authorized Agent to begin utilization
						review.
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-46.10 - PLAN OF CARE REQUIREMENTS

Current through 2024-29, July 17, 2024
A written plan of care must be established for each
						member receiving psychiatric hospital services and must include at minimum
						items described under 46.10-1, General Contents. Plans of care for Inpatient
						Services and Partial Hospitalization/ Outpatient services are described in
						Sections 46.10-2 and 46.10-3, respectively. Plans of Care must be available to
						the Department and its Authorized Agent.
An interdisciplinary team of professionals must develop a
						plan of care for each such member within fourteen (14) days after the member's
						admission and must review the plan at least every thirty (30) days
						thereafter.
46.10-1
General
					 Contents of Plans of Care
Plans of care shall at a minimum include the
						following:
A. Diagnosis, symptoms,
					 complaints, and complications indicating the need for inpatient, partial
					 hospitalization or outpatient services;
B. A description of the functional level of
					 the member, including strengths and weaknesses;
C. Measurable short and long term
					 goals;
D. Any orders for:
1. Medications,
2. Treatments,
3. Restorative and rehabilitative
					 services,
4. Activities,
5. Therapies,
6. Social services,
7. Diet, or
8. Special procedures recommended for the
					 health and safety of the member.
E. Plans for continuing care, including
					 review and modification to the plan of care; and
F. Plans for discharge (see 46.12).
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-46.11 - HOSPITAL UTILIZATION REVIEW PLAN REQUIREMENTS

Current through 2024-29, July 17, 2024
Each Psychiatric Hospital must have in effect a written
						Utilization Review Plan that provides for review of each member's need for
						inpatient, partial hospitalization or outpatient services furnished by the
						hospital and must meet the following requirements:
46.11-1
Utilization Review
					 Committee
A.
Utilization Review
					 Plan
The Plan must:
1. Provide for a committee to perform the
					 Utilization Review activities described in this manual;
2. Describe the organization, composition and
					 functions of the committee; and
3.
					 Specify the frequency of meetings of the committee.
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-46.12 - DISCHARGE PLANNING

Current through 2024-29, July 17, 2024
Each hospital shall maintain a written record of
						discharge planning procedures, as required for licensure set forth in 10-144
						CMR, Chapter 112, Regulations for the Licensure of General and Specialty
						Hospitals in the State of Maine.
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-46.13 - INSPECTIONS OF CARE

Current through 2024-29, July 17, 2024
A team, whose composition is specified at 46.13-1, will
						inspect at least annually the care and services provided to each member
						receiving inpatient services in the hospital. No hospital shall be notified of
						the time of inspection more than forty-eight (48) hours before the scheduled
						arrival of the team.
46.13-1
Team Composition
The Inspection Team shall consist of one or more
						psychiatric nurse consultants, a medical social work consultant, MSW level
						social worker and a psychiatrist or physician knowledgeable about inpatient
						services in psychiatric hospitals.
46.13-2
Personal Contact With And
					 Observation Of Members And Review Of Records
The Team's inspections must include review of each
						member's record.
A. For members under
					 age twenty one (21) receiving inpatient services, the inspections must also
					 include personal contact with and observation of each member.
B. For members age sixty five (65) or older
					 receiving inpatient services, if the record does not contain complete periodic
					 assessments described at 46.10, or if the Team deems such reports inadequate,
					 the inspection will also include personal contact with and observation of the
					 member.
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-46.14 - MEMBER APPEALS

Current through 2024-29, July 17, 2024
Member appeals are described in MaineCare Benefits
						Manual, (10-144 CMR, Chapter 101) Chapter I, Section 1.
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-46.15 - PROGRAM INTEGRITY

Current through 2024-29, July 17, 2024
Requirements for Program Integrity are included in
						Chapter I of the MaineCare Benefits Manual (MBM).
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-46.16 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
Reimbursement for psychiatric hospitals is made in
						accordance with the "Principles of Reimbursement for Hospital Services" as
						defined in Chapter III, Section 45 of this Manual.
In accordance with Chapter I of the MaineCare Benefits
						Manual, it is the responsibility of the provider to seek payment from any other
						resources that are available for payment of a rendered service prior to billing
						MaineCare.
To qualify for reimbursement of laboratory services
						provided in a psychiatric hospital those laboratory services must be in
						compliance with the rules implementing the Clinical Laboratory Improvement
						Amendments (CLIA '88) and any amendments thereto. This information is available
						at www.cms.hhs.gov/clia [File Link Not Available].
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-46.17 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Billing must be accomplished in accordance with the
						Department's billing requirements set forth in the MaineCare Benefits Manual,
						Chapter III, Section 45, and "Billing Instructions: Claim Form CMS-1500" or
						"Billing Instructions for UB-04" available at
http://www.maine.gov/dhhs/oms/providerfiles/billing_instructions.html
.
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-50 - ICF-MR Services › Subsection 144-101-II-50.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
50.01-1
Intermediate Care Facility for
					 Persons with Mental Retardation (ICF-MR)
is a facility that meets State
					 licensing and Federal certification requirements for ICFs-MR. An ICF-MR
					 provides, under an agreement with the Department of Health and Human Services
					 (DHHS), health-related care and a rehabilitative services program for members
					 with mental retardation or members with related conditions who do not require
					 the degree of care and treatment that a hospital or skilled nursing facility is
					 designed to provide, but require care and services above the level of room and
					 board.
There are two types of ICF's-MR: ICF-MR Nursing Facility
						and ICF-MR Group Home Facility. Both types must meet appropriate State
						licensing and Federal certification requirements.
A.
ICF-MR Nursing Facility:
To
					 assist each member to reach his or her maximum level of functioning
					 capabilities, an ICF-MR Nursing Facility provides, under an agreement with the
					 Department of Health and Human Services, twenty-four (24) hours, seven (7) days
					 a week, of licensed nurse supervision of coordinated health treatment and
					 rehabilitative services for persons who have mental retardation or persons with
					 related conditions (See Section 50.01-11 for definition of "persons with
					 related conditions").
B.
ICF-MR Group Home Facility:
An ICF-MR Group Home Facility provides
					 a supportive and protective setting and twenty-four (24) hour, seven (7) days a
					 week, of non-nursing supervision for persons who have mental retardation or
					 persons with related conditions (See Section 50.01-11 for definition of
					 "persons with related conditions"). The facility must assure the coordination
					 of health and rehabilitative services to assist each member in reaching his or
					 her maximum level of functioning capabilities.
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-50 - ICF-MR Services › Subsection 144-101-II-50.02 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Eligible Title XIX or XXI members are entitled to receive
						as many days of ICF-MR services as are medically necessary.
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-50 - ICF-MR Services › Subsection 144-101-II-50.03 - STANDARDS OF CARE

Current through 2024-29, July 17, 2024
In order to qualify for reimbursement under Section 50,
						IC Fs-MR must meet the requirements contained in Regulations Governing the
						Licensing and Functioning of Intermediate Care Facilities for Persons with
						Mental Retardation as are currently in effect. ICFs-MR must also comply with
						the Principles of Reimbursement in Chapter III, Section 50 and all requirements
						of Title XIX of the Social Security Act and the regulations issued pursuant
						thereto.
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-50 - ICF-MR Services › Subsection 144-101-II-50.04 - LICENSE

Current through 2024-29, July 17, 2024
All ICFs-MR including those operated by the State of
						Maine must be licensed as an ICF-MR by DHHS in order to qualify for
						reimbursement. However, the license shall not be considered valid evidence that
						the facility meets all requirements for certification under MaineCare
						regulations if the Secretary of Health and Human Services has established, on
						the basis of on-site monitoring survey or other federal review, that DHHS'
						survey agency has failed to properly apply federal certification standards or
						procedures.
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-50 - ICF-MR Services › Subsection 144-101-II-50.05 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
50.05-1
General and Specific Requirements
In order to be eligible for ICF-MR services, all the
						following standards must be met:
A.
General MaineCare Eligibility Requirement.
Individuals must meet
					 the eligibility criteria as set forth in the MaineCare Eligibility Manual. The
					 eligibility determination process is administered by the Office of Integrated
					 Access and Support.
B.
Specific MaineCare Requirements.
1. The Department or the Department's
					 authorized agent must determine the individual's medical eligibility, as
					 described in Section 50.06; and
2.
					 Individuals must be diagnosed by a physician as having mental retardation or a
					 related condition, which is manifested before the person reaches age twenty-two
					 (22); and
3. Individuals must
					 require active treatment of ICF-MR services, as defined in this Section. An
					 individual's eligibility cannot be based merely on his/her diagnosis. General
					 and specific requirement determinations are processed concurrently in order to
					 expedite the decision of the applicant's overall eligibility for ICF-MR
					 services. Once an applicant is found eligible, the Department will review
					 eligibility requirements on an annual basis.
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-50 - ICF-MR Services › Subsection 144-101-II-50.06 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
50.06-1
Admissions to an ICF-MR Facility
MaineCare coverage of ICF-MR services must begin only
						after an applicant is determined eligible by the Department's Office of
						Integrated Access and Support, determined medically eligible by the Department
						or the Department's authorized agent, and classified by the Department as
						needing an ICF-MR level of care.
A.
Admission from a Hospital
The following criteria must be met if a member is to be
						admitted from a hospital:
1. If the
					 applicant is not a MaineCare member, the hospital's discharge planner or other
					 designated person must refer the individual, family member, or guardian to the
					 regional office of the Office of Integrated Access and Support for MaineCare
					 eligibility determination.
2. The
					 hospital must complete the Department's designated assessment form (currently
					 BMS-85) and fax it to the Department. The hospital must complete the assessment
					 form no less than twenty-four (24) hours prior to the denial of acute level of
					 care or discharge from a hospital.
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-50 - ICF-MR Services › Subsection 144-101-II-50.08 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
A. Maintenance
					 therapy (repetitive services not requiring the skills of a qualified physical
					 or occupational therapist or the use of complex and sophisticated physical or
					 occupational therapy procedures) is not a covered service, except as provided
					 in Section 50.07-3(D). Services related to activities for the general good and
					 welfare of members, e.g., general exercises to promote overall fitness and
					 flexibility and activities to provide diversional or general motivation, do not
					 constitute physical or occupational therapy for MaineCare purposes.
B. Payment by a relative of an additional
					 amount to enable a member to obtain non-covered services such as a private room
					 (single bed), telephone, television, and authorized bed hold days is permitted.
					 However, the additional charge for non-covered services must not exceed the
					 charge to individuals who privately pay. The supplement for a private room must
					 be no more than the difference between the private pay rate for a semi-private
					 room and a private room.
C. ICF-MR
					 services may not include services of a vocational or academic nature unless the
					 service meets the criteria in Section 50.07-8. These and other services that
					 are non-covered are referred to in Chapter I of the MaineCare Benefits
					 Manual.
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-50 - ICF-MR Services › Subsection 144-101-II-50.09 - CLASSIFICATION FOR CERTAIN CHILDREN WITH DISABILITIES AGED EIGHTEEN AND UNDER FOR HOME CARE (KATIE BECKETT)

Current through 2024-29, July 17, 2024
The classification for certain disabled children age
						eighteen (18) and under for home care has additional criteria above and beyond
						that of typical MaineCare. All of the following criteria must be met for a
						child to receive MaineCare under this eligibility option:
A.
Age and Disability:
The child
					 must be eighteen (18) years of age or younger and be determined disabled by
					 standards established through the Social Security Act. A disability
					 determination is made as part of the application process.
B.
Level of Care:
The member
					 must require a level of care that is typically provided in Intermediate Care
					 Facilities for Persons with Mental Retardation. Although the member does not
					 have to be admitted, relocated nor have a history of admissions to an
					 institution, he or she must need the level of care provided there.
C.
Appropriateness of Community-Based
					 Care:
The child must be able to receive or currently be receiving
					 appropriate care outside an institutional setting that provides that level of
					 care.
D.
Cost Limits of
					 Community-Based Care:
The total annual cost to MaineCare for home care
					 through this eligibility option must be not greater than the amount MaineCare
					 would pay for the child's care in an 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 II - Specific Policies By Service › Section 144-101-II-50 - ICF-MR Services › Subsection 144-101-II-50.10 - RIGHT OF APPEAL

Current through 2024-29, July 17, 2024
Only the member or his or her family or representative
						may appeal a decision of the Department or its authorized agent made pursuant
						to this Section.
If the member, his or her family or representative
						disagrees with the classification or reclassification to a different level of
						care of the member, a fair hearing may be requested pursuant to Chapter I of
						the MaineCare Benefits Manual.
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-50 - ICF-MR Services › Subsection 144-101-II-50.11 - PROGRAM INTEGRITY

Current through 2024-29, July 17, 2024
Refer to Chapter I of the MaineCare Benefits Manual for
						Program Integrity (formerly Surveillance and Utilization Review)
						functions.
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-50 - ICF-MR Services › Subsection 144-101-II-50.12 - CONFIDENTIALITY

Current through 2024-29, July 17, 2024
Refer to Chapter I of the MaineCare Benefits Manual for
						confidentiality requirements.
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-50 - ICF-MR Services › Subsection 144-101-II-50.13 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
A per diem rate of reimbursement for routine services and
						certain supplies and equipment is established according to Section 50, Chapter
						III, and payment is made directly to the facility as a MaineCare vendor
						payment.
If a service is covered in the per diem rate, the ICF-MR
						may not utilize personnel or organizations that bill MaineCare separately for
						MaineCare payment for services rendered to ICF-MR residents.
For therapy consultations, as described in Sections
						50.07-3(H) and 50.07-4(F), provided to ICFs-MR, reimbursement must be at
						reasonable cost according to Principles of Reimbursement for ICF-MR Section
						5010.
Please see Sections 50.06-5, Payment of Bed Holds for
						Short-Term Hospitalizations, 50.06-6, Leave of Absence, 50.07-3(G), PT and OT
						Services, and 50.07-4(E), Speech and Hearing Services for detailed information
						on reimbursement limitations for these areas of this policy.
The reimbursement rate for the developmental training
						program shall be established by the Department.
In accordance with Chapter 1 of the MaineCare Benefits
						Manual, it is the responsibility of the provider to seek reimbursement from any
						other sources that are available for payment of the rendered service prior to
						billing MaineCare.
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-50 - ICF-MR Services › Subsection 144-101-II-50.14 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Billing must be accomplished in accordance with the
						Department's "Billing Instructions for Intermediate Care Facilities for Persons
						with Mental Retardation," available online at
www.maine.gov/bms/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 II - Specific Policies By Service › Section 144-101-II-55 - Laboratory Services › Subsection 144-101-II-55.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Individuals must meet the eligibility criteria as set
						forth in the
MaineCare Eligibility Manual
. Some members may
						have restrictions on the type and amount of services they are eligible to
						receive. It is the responsibility of the provider to verify a member's
						eligibility for MaineCare, as described in
MaineCare Benefits
						Manual
, Chapter I, Section I, prior to providing services.
Additional specific eligibility criteria are set forth
						for each service.
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-55 - Laboratory Services › Subsection 144-101-II-55.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each Title XIX recipient is eligible for as many covered
						services as are medically necessary. The Department reserves the right to
						request additional information to evaluate and determine medical
						necessity.
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-55 - Laboratory Services › Subsection 144-101-II-55.05 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
55.05-1
Physician's Office Laboratory
Physicians in private practice will be reimbursed only
						for those Laboratory Services provided in his/her office by the physician or
						the office staff, using the office equipment and supplies.
When only Laboratory Services are provided, an office
						visit charge may not be made.
55.05-2
Referrals
For necessary Laboratory Services not done in the
						physician's office, the physician may make a written referral to:
A. The laboratory department of a
					 hospital;
B. An Independent
					 Laboratory.
The physician may not charge for making the
						referral.
The provider of the service is to charge the Department
						of Human Services directly and provide a written report of test results to the
						physician.
Prohibition on referrals
. Except as provided
						in federal rule, a physician who has a financial relationship with an entity,
						or who has an immediate family member who has a financial relationship with the
						entity, may not make a referral to that entity for the furnishing of clinical
						Laboratory Services for which payment otherwise may be made under
						Medicaid.
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-55 - Laboratory Services › Subsection 144-101-II-55.06 - CONFIDENTIALITY

Current through 2024-29, July 17, 2024
The disclosure of information regarding individuals
						participating in the Medicaid program is strictly limited to purposes directly
						connected with the administration of the Medicaid program. Providers shall
						maintain the confidentiality of information regarding these individuals in
						accordance with 42 CFR symbol 167 if "Kino MT" is 11431
et
						seq
. and other applicable sections of state and federal law and
						regulation.
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-55 - Laboratory Services › Subsection 144-101-II-55.07 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
The MaineCare rates are posted on the Maine Health PAS
						Portal Provider Fee Schedule. Rates other than drug prices for new or changed
						codes (any CPT or HCPCS code) are determined based on the following lowest
						benchmark:
A. The fee for service rate
					 is set at seventy percent (70%) of the 2009 CMS rate or seventy (70%) of the
					 rate in the year CMS assigns a rate for that code. Where no other options are
					 applicable, the Department researches other State Medicaid agencies that cover
					 the relevant service/code. The Department then bases its rates on the average
					 cost of the relevant services/codes from those other agencies.; or
B. The lowest amount allowed by Medicare Part
					 B for Maine area "99" fee including the appropriate Medicare fee adjustments
					 for place of service and modifiers; or
C. If CMS approves, the provider's usual and
					 customary charge.
In accordance with Chapter I, Sec. 1 of the
MaineCare Benefits Manual
, it is the responsibility of the
						provider to seek payment from any other source that is available for payment of
						a rendered service prior to billing the Office of MaineCare.
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-55 - Laboratory Services › Subsection 144-101-II-55.08 - COPAYMENT

Current through 2024-29, July 17, 2024
55.08-1
Copayment Amount
A. A copayment will be charged to each
					 Medicaid recipient receiving services. According to the following schedule, the
					 amount of the copayment shall not exceed $1.00 per day for services provided,
Copayment Amount
Medicaid Payment for
								  Services
Recipient Copayment
$10.00 or less
$ .50
$10.01 - or more
$1.00
B. The recipient shall be responsible for
					 copayments up to $10.00 per month whether the copayment has been paid or not.
					 After the $10.00 cap has been reached, the recipient shall not be required to
					 make additional copayments and the provider shall receive full Medicaid
					 reimbursement for covered services.
C. No provider may deny services to a
					 recipient for failure to pay a copayment. Providers must rely upon the
					 recipient's representation that he or she does not have the cash available to
					 pay the copayment. A recipient's inability to pay a copayment does not,
					 however, relieve him/her of liability for a copayment.
D. Providers are responsible for documenting
					 the amount of copayments charged to each recipient (regardless of whether the
					 recipient has made payment) and shall disclose that amount to other providers,
					 as necessary, to confirm previous copayments.
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-55 - Laboratory Services › Subsection 144-101-II-55.09 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
A. Billing must be
					 accomplished in accordance with the Department's "Instructions for Completion
					 CMS-1500 (02-12)."
B. All services
					 provided on the same day must be submitted on the same claim form for Medicaid
					 reimbursement.
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-60 - Medical Supplies and Durable Medical Equipment › Subsection 144-101-II-60.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
60.01-1
Activities of Daily Living
					 (ADL)
are those activities related to personal care including but not
					 limited to: showering, bowel/bladder management, eating, functional mobility,
					 personal device care (hearing aids, etc.), personal hygiene, and
					 toileting.
60.01-2
Adjusted
					 Acquisition Cost
is the lowest price paid to a supplier by an eligible
					 provider for Durable Medical Equipment or medical/surgical supplies after
					 adjustments for quantity discounts, any prompt payment discounts and excluding
					 all associated costs, including but not limited to, shipping, freight,
					 handling, and insurance costs. Wheelchair providers need not adjust the price
					 paid to a supplier based on any prompt payment discount.
60.01-3
Department
is the Maine
					 Department of Health and Human Services.
60.01-4
Durable Medical Equipment (DME)
					 is:
A. Equipment that can withstand
					 repeated use;
B. Primarily used to
					 serve a medical purpose and is medically necessary and reasonable for the
					 treatment of the member's disability, illness, or injury or to improve an
					 altered body function. Examples of items that are not primarily used for
					 medical purposes include air conditioners, pools, exercise equipment, and
					 equipment primarily used for the convenience of a caregiver;
C. Not generally useful to a person in the
					 absence of disability, illness, or injury; and
D. Medical supplies, equipment, and
					 appliances suitable for use in any setting in which normal life activities take
					 place and is in safe and reasonably good condition and suitable for its
					 intended use.
All four (4) of the above criteria must be met for
						coverage under this Section. Specific definitions and criteria are located on
						the MaineCare Health PAS Online Portal.
Home/Environmental modifications do not meet the
						definition of medical supplies or DME and are not covered under this
						Section.
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-60 - Medical Supplies and Durable Medical Equipment › Subsection 144-101-II-60.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Individuals must meet the eligibility criteria as set
						forth in the
MaineCare Eligibility Manual
. Some members may
						have restrictions on the type and amount of services they are eligible to
						receive.
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-60 - Medical Supplies and Durable Medical Equipment › Subsection 144-101-II-60.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each Title XIX and XXI member is eligible for as many
						covered services as are medically necessary and subject to limitations within
						this Section. The Department reserves the right to request additional
						information to determine medical necessity or expected therapeutic benefit of
						prescribed supplies or equipment.