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-1000 - INTRODUCTION

Current through 2024-29, July 17, 2024
1010
Purpose
. The purpose of
						these regulations is to define the payment mechanism for Title XIX funds in
						medical and remedial services facilities under Chapter II, Section 97 - Private
						Non-Medical Institution Services of the
MaineCare Benefits
						Manual
. The Department pays a case mix adjusted industry-specific
						price for direct care services provided in medical and remedial services
						facilities, plus a program allowance and a personal care services
						component.
1020
Authority
. The authority of the Maine Department of Health and
						Human Services to accept and administer funds that may be available from
						private, local, State, or Federal sources for the provision of services set
						forth in these Principles of Reimbursement is established in Title 22 of the
Maine Revised Statutes Annotated
(MRSA), §3, §10,
						§42, §3273. The regulations are issued pursuant to authority granted
						to the Department of Health and Human Services by Title
						22 MRSA
						§42(1).
1030
Principle
. In order to
						receive payment for services according to this Appendix, a provider must be
						licensed as a residential care facility and have a provider contract specifying
						the conditions of participation in Title XIX as a Private Non-Medical
						Institution as described in Section 97, Chapter II of the
MaineCare
						Benefits Manual
. Determination of members' eligibility for PNMI
						services is made according to Chapter II, Section 97 of the
MaineCare
						Benefits Manual
. Residents 18-64 years of age and living in
						Institutions for Mental Disease are not eligible for services under this
						Appendix. However, the cost of covered services to residents of Institutions
						for Mental Diseases who are 65 years of age and over can be claimed under this
						appendix provided they meet all other requirements for eligibility.
Payment will be made for any eligible member only if
						  the provider obtains the signature of a physician prescribing covered services
						  prior to the first date of service. The PNMI must maintain this information as
						  part of the member's record at the facility.
The Department will not make payment under this
						  Appendix for residents who are family members of the owner or provider staff
						  providing medical and remedial services.
1040
Scope
. Residential Care
						Facilities that provide custodial (e.g. supervision, medication administration,
						and room and board) services to six or fewer residents and do not provide
						individualized in-home programming to persons with severe physical or
						functional disability are not eligible for payment under Appendix C. The
						Department reimburses these providers on a flat rate
						basis.