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-60 - Medical Supplies and Durable Medical Equipment › Subsection 144-101-II-60.04 - PROVIDER REQUIREMENTS

Current through 2024-29, July 17, 2024
Providers of Medical Supplies and DME are enrolled
						MaineCare providers that:
A. Have
					 executed a MaineCare Provider Agreement with the Department of Health and Human
					 Services and have obtained a provider identification number from the
					 Department;
B. Provide Medical
					 Supplies and/or DME services to MaineCare members; and
C. Have a storefront located in Maine or
					 within fifteen (15) miles of the Maine border in New Hampshire with a
					 commercial address for the sales and service of the supplies and equipment
					 sold, rented, or otherwise provided to members and regularly staffed operating
					 hours. Providers must post hours of operation in a visible location for the
					 general public and not be solely a sales representative for a manufacturer of
					 DME or Medical Supplies.
D.
Hearing Aids only
: In addition to the requirements above, hearing
					 aids, accessories, and repairs must be provided by an individual licensed by
					 the State of Maine as an audiologist or as a licensed hearing aid dealer &
					 fitter.
The following exceptions apply:
1. DME and supplies provided to a member who
					 is residing out of state, only for the purposes of meeting an emergency medical
					 need, with PA, at the discretion of the Department, taking into account cost
					 effectiveness and medical necessity and only if the item(s) cannot be supplied
					 by a MaineCare enrolled provider;
2. A provider who is the sole provider of a
					 type of cost-effective, medically necessary DME may be enrolled only for the
					 purpose of providing that item with PA. The provider must warranty the item for
					 parts and labor.
3. The Department
					 reserves the right to issue a request for proposals for provision of any supply
					 or piece of equipment, and the resulting contract may be awarded to an
					 out-of-state provider. The Department may enter into a special purchasing
					 arrangement with one or more vendors capable of providing services to MaineCare
					 members without the vendor having a physical storefront.
4. The Department may waive the requirement
					 for providers to have a storefront in Maine or within fifteen (15) miles of the
					 border if the Department, in its sole discretion, determines that waiving that
					 requirement is in the best interests of the MaineCare program.
5. The Department will waive the requirement
					 to have a storefront in Maine or within fifteen (15) miles of the border for
					 audiologists operating outpatient services that are not enrolled as a DME
					 provider and manufacturers of specialty modified low protein foods and formulas
					 for the purpose of billing the Department as the supplier of prescription
					 metabolic foods.
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-60.05 - COVERED SERVICES

Current through 2024-29, July 17, 2024
A covered service is a service or item for which payment
						can be made by the Department, and which meets the definitions listed in
						Section 60.01 and any other
						criteria or limitations described in 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-60.06 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
60.06-1
Face-to-Face Encounter
A face-to-face encounter is a mandatory encounter
						(including encounters through telehealth (as described in Chapter I, Section
						4) and other than encounters
						incidental to services involved) between the member and a Qualified Provider
						that takes place within the six (6) months prior to the date of a written order
						for DME. The written order may be, but does not have to be, prescribed by the
						provider who performed the face-to-face encounter.
60.06-2
Medical Supplies and DME
					 Requirements
Medical Supplies and DME must meet all of the following
						requirements:
A. Comply with the
					 criteria in Section 60, including the definitions in Section
					 60.01;
B. Be prescribed by a Qualified
					 Provider;
C. Be provided to a
					 member who is not in a hospital, unless necessary for transition to home, in
					 which case the provider must comply with the criteria for emergency rental in
					 this Section;
D. Have
					 scientifically valid clinical evidence of their efficacy and not be considered
					 investigational or experimental by the Department;
E. Be approved and defined by the Food and
					 Drug Administration;
F. Be
					 cost-effective;
G. Have a warranty
					 that includes parts and labor;
H.
					 Be provided by a MaineCare authorized provider of Medical Supplies and DME who
					 has a location where members can procure repairs and servicing of items with
					 warranties and guarantees or meet one of the exceptions outlined in this
					 Section; and
I. A member's need for
					 medical supplies, equipment, and appliances must be reviewed by a physician or
					 other Qualified Provider annually.
J.
Durable Medical Equipment
					 Only
. The prescribing provider must maintain documentation that includes
					 a statement verifying the date of the face-to-face encounter for that specific
					 piece of DME and the name of the Qualified Provider who performed the
					 face-to-face encounter.
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-60.09 - PROGRAM INTEGRITY

Current through 2024-29, July 17, 2024
Program Integrity requirements are outlined 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-60 - Medical Supplies and Durable Medical Equipment › Subsection 144-101-II-60.10 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
60.10-1
General Reimbursement
					 Methodology
Effective January 1, 2023, reimbursement for medical
						supplies and DME will be the lowest of the following, unless otherwise
						specified in this section:
A. The
					 maximum MaineCare allowed amount, which the Department will establish based on:
1. 100% of the current Medicare DMEPOS Fee
					 Schedule amount; or
2. If no
					 Medicare fee schedule amount is established, the average cost of the relevant
					 services/codes from other state Medicaid agencies. These allowed amounts will
					 receive an inflation adjustment on January first of each year based on the
					 Consumer Price Index for All Urban Consumers for medical equipment and supplies
					 (CUUR0000SEMG); or
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-60.11 - CO-PAYMENT

Current through 2024-29, July 17, 2024
Co-payment dispute resolution procedures are described in
						Chapter I of the
MaineCare Benefits Manual
.
60.11-1
Co-payment amount
A. A co-payment will be charged to each
					 MaineCare member who receives Medical Supplies or DME. The amount of the
					 co-payment shall not exceed $3.00 per day for equipment or supplies, according
					 to the following schedule:
MaineCare Payment for
								  Service
Member Co-payment
$10.00 or less
$ .50
$10.01 - 25.00
$1.00
$25.01 - 50.00
$2.00
$50.01 or more
$3.00
B. The member shall be responsible for
					 co-payments up to $30.00 per month whether the co-payment has been paid or not.
					 After the $30.00 cap has been reached the member shall not be required to make
					 additional co-payments and the provider shall receive full MaineCare
					 reimbursement.
C. Members shall not
					 be charged more than $3.00 per month for any rental service.
D. No provider may deny services to a member
					 for failure to pay a co-payment. Providers must rely upon the member's
					 representation that he or she does not have the cash available to pay the
					 co-payment. A member's inability to pay a copayment does not, however, relieve
					 him/her of liability for a co-payment.
E. Providers are responsible for documenting
					 the amount of co-payments charged to each member (regardless of whether the
					 member has made payment) and shall disclose that amount to other providers, as
					 necessary, to confirm previous co-payments.
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-60.12 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
A. Providers must
					 bill in accordance with the Department's "Billing Instructions for Medical
					 Supplies and Durable Medical Equipment."
B. All claims submitted must include a
					 primary diagnosis code.
C.
					 Providers may not submit separate claims for DME that is considered to be part
					 of the initially authorized equipment.
D. Providers may not bill more than a
					 thirty-four (34) day supply at a time unless otherwise specified in this
					 policy.
E. All claims must be
					 submitted on a CMS 1500 claim form.
**Please be advised that there is no Chapter III for this
						section of policy. For information regarding reimbursement or Prior
						Authorizations and coding please visit:
https://mainecare.maine.gov/Default.aspx
which will contain a link to the HealthPAS portal. Please be advised that only
						MaineCare providers with a Trading Partners username and password will be able
						to access the HealthPAS website.
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-65 - Behavioral Health Service › Subsection 144-101-II-65.03 - ELIGIBILITY

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 1, 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-65 - Behavioral Health Service › Subsection 144-101-II-65.04 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each eligible member may receive covered services that
						are medically necessary within the limitations of this section. DHHS reserves
						the right to request additional information to evaluate medical necessity and
						review utilization of services. DHHS requires Prior Authorization (PA) for some
						services reimbursed under this section. DHHS may require Utilization Review for
						all services reimbursed 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-65 - Behavioral Health Service › Subsection 144-101-II-65.08 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
65.08-1
Clinicians and Other Qualified Staff
Clinicians
: There must be written evidence
						from the appropriate governing body that all Clinicians are conditionally,
						temporarily, or fully licensed and approved to practice. All Clinicians must
						provide services only to the extent permitted by licensure. Clinicians are
						required to follow professional licensing requirements, including documentation
						of clinical credentials.
Other Qualified Staff
: consist of a
						certified Mental Health Rehabilitation Technician (MHRT), a certified
						Behavioral Health Professional (BHP), a certified FFT therapist, or a certified
						MST therapist for the purposes of providing 65.05-9 Children's Home and
						Community Based Treatment certified by DHHS at the level appropriate for the
						services being delivered.
A provider may be reimbursed for covered services only
						if they are provided by Clinicians or other qualified staff.
65.08-2
Direct Support Professional
					 (DSP)
A DSP is a person who:
A. Successfully completed the Direct Support
					 Professional curriculum as adopted by DHHS
,
or demonstrated
					 proficiency through DHHS's approved Assessment of Prior Learning, or has
					 successfully completed the curriculum from the Maine College of Direct Support
					 within six (6) months of date of hire.
Prior to providing services to a member alone, a DSP must
						have completed the following four modules from the College of Direct Support,
						including computer based and live sessions:
1. Introduction to Developmental
					 Disabilities
2.
					 Professionalism
3. Individual
					 Rights and Choice
4. Maltreatment
Documentation of completion must be retained in the
						personnel record.
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-65 - Behavioral Health Service › Subsection 144-101-II-65.09 - APPEALS

Current through 2024-29, July 17, 2024
In accordance with Chapter I, Section 1, of the
MaineCare Benefits Manual
, members have the right to appeal in
						writing or verbally any decision made by DHHS to reduce, deny or terminate
						services provided under this benefit.
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-65 - Behavioral Health Service › Subsection 144-101-II-65.10 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
A. The amount of payment for services
					 rendered by a provider shall be the lowest of the following:
1. The amount listed in Chapter
					 III;
2. The lowest amount allowed
					 by the Medicare Part B carrier; or
3. The provider's usual and customary
					 charge.
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-65 - Behavioral Health Service › Subsection 144-101-II-65.11 - CO-PAYMENT

Current through 2024-29, July 17, 2024
Co-payment exemptions and dispute resolution are
						described in Chapter I, Section 1 of the
MaineCare Benefits
						Manual
.
Services furnished to members under twenty-one (21) years
						of age are exempted from co-payments.
Co-payment does not apply to tobacco cessation treatment
						services.
A co-payment will be charged to each MaineCare member
						twenty-one (21) and older for services. The amount of the co-payment shall not
						exceed $2.00 per day, per service or $2.00 per week for Opioid Treatment
						Program Services with Methadone for services provided according to the
						following schedule.
MaineCare Payment for
									 Services
Member Co-payment
$10.00 or less
$.50
$10.01 - $25.00
$1.00
$25.01 or more
$2.00
The member shall be responsible for co-payments up to
						twenty dollars ($20) per month per service whether the co-payment has been paid
						or not. After the twenty-dollar ($20) cap has been reached, the member shall
						not be required to make additional co-payments and the provider shall receive
						full MaineCare reimbursement for covered services.
The provider shall not deny services to a MaineCare
						member on account of the member's inability to pay a co-payment. Providers must
						rely upon the member's representation that he or she does not have the money
						available to pay the co-payment. However, the individual's inability to pay
						does not eliminate his or her liability for the co-payment.
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-65 - Behavioral Health Service › Subsection 144-101-II-65.12 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
A. Providers must
					 bill in accordance with DHHS' billing requirements for the CMS 1500 claim
					 form.
B. In order to receive full
					 MaineCare reimbursement for claims submitted for a service that is defined as
					 an exemption in Chapter I, Section 1, of the
MaineCare Benefits
					 Manual
, providers must follow the appropriate MaineCare provider
					 billing instructions.
C. All
					 services provided on the same day must be submitted on the same claim form for
					 MaineCare reimbursement.
D. For
					 billing purposes, the unit is based on member time rather than staff
					 time.
E. Providers must document
					 appropriate and current ICD diagnostic codes for members receiving Medically
					 Necessary Services in order to be reimbursed.
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-65 - Behavioral Health Service › Subsection 144-101-II-65.13 - APPENDIX I

Current through 2024-29, July 17, 2024
PROFESSIONAL STAFF
CHILDREN'S BEHAVIORAL HEALTH SERVICE
Provider
Crisis Resolution Services
Crisis Residential Services
Outpatient Services
Intensive Outpatient Program
								  Services
Family Psychoeducation
Medication Services
Neurobehavioral Status Exam/Psychological
								  Testing
Adaptive Assessments
Children's ACT
Children's Home and Community Based
								  Treatment/Collateral Contacts
Children's Behavioral Health Day
								  Treatment
Tobacco Cessation Counseling
Physician
X
X
X
X
X
X
X
X
X
Psychiatrist
X
X
X
X
X
X
X
X
X
X
X
Psychologist
X
X
X
X
X
X
X
X
X
Physician Assistant
X
X
X
X
X
X
X
X
Psychological Examiner
X
LCSW/LMFT/LCPC/
LMSW-CC/LCPC-C/ LMFT-C
X
X
X
X
X
X
X
X
X
X
LADC/CADC
X
X
X
X
APRN-PMH-NP/CNS
X
X
X
X
X
X
X
X
RNBC/RNC
X
X
X
X
X
X
X
MHRT
X
X
X
X
X
BHP
X
X
X
X
X
X
BCBA (supervision only)
X
BCBA (DD/BH only)
X
BCaBA/RBT
(DD/BH only)
X
LSW, LSX
X
Occupational Therapist
X
Speech Therapist
X
Dietician
X
Rec. Specialist
X
Peer Specialist
X
Mental Health Agency
X
X
X
X
X
X
X
X
X
X
X
X
NTA/Psycho-metrician
X
PROFESSIONAL STAFF
ADULT BEHAVIORAL HEALTH SERVICE
Provider
Crisis Resolution Services
Crisis Residential Services
Outpatient Services
Intensive Outpatient Program
								  Services
Family Psychoeducation
Medication Services
Neurobehavioral Status Exam/ Psychological
								  Testing
Tobacco Cessation Counseling
Physician
X
X
X
X
X
X
X
X
Psychiatrist
X
X
X
X
X
X
X
X
Psychologist
X
X
X
X
X
X
X
Physician Assistant
X
X
X
X
X
X
Psychological Examiner
X
LCSW/LMFT/ LCPC/LMSW-CC/LCPC-C/ LMFT-C
X
X
X
X
X
X
LADC/CADC
X
X
X
APRN-PMH-NP/CNS
X
X
X
X
X
X
X
RNBC/RNC
X
X
X
X
X
X
MHRT
X
X
X
X
DSP
X
X
X
BCBA (DD/BH only)
X
BCaBA/RBT (DD/BH only)
X
LSW, LSX
X
Occupational Therapist
X
Speech Therapist
X
Dietician
X
Rec. Specialist
X
Peer Specialist
X
Mental Health Agency
X
X
X
X
X
X
X
X
NTA/Psycho-metrician
X
PROFESSIONAL STAFF
SUBSTANCE USE SERVICES
Provider
Outpatient Services
IOP Services
OTP with Methadone
Medication Services
Tobacco Cessation Counseling
Physician (MD/DO)
X
X
X
X
X
Psychiatrist
X
X
X
X
X
Physician Assistant
X
X
X
X
Psychologist
X
X
X
X
APRN-PMH-NP/CNS
X
X
X
X
X
RNBC/RNC
X
X
X
X
LADC/CADC
X
X
X
X
ADCA
X
X
LCSW/LCPC/LMFT/ LMSW-CC/LCPC-C /LMFT-C
X
X
X
X
LSW, LSX
X
Occupational Therapist
X
Speech Therapist
X
Dietician
X
Rec. Specialist
X
Peer Specialist
X
Substance Use Agency
X
X
X
X
X
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-65 - Behavioral Health Service › Subsection 144-101-II-65.14 - APPENDIX II

Current through 2024-29, July 17, 2024
Service
Services not allowed Concurrently
Crisis Resolution
Children's Assertive Community Treatment (ACT)
Crisis Residential
Children's Assertive Community Treatment (ACT)
Outpatient-Comprehensive
								  Assessment/Therapy
Children's Assertive Community Treatment
								  (ACT)
Children's Home and Community Based Treatment/
								  Collateral Contacts
OTP with Methadone
Intensive Outpatient Program (IOP)
Family Psychoeducation
Children's Assertive Community Treatment
								  (ACT)
Children's Home and Community Based Treatment/
								  Collateral Contacts
Behavioral Therapies for Disruptive Behavior
								  Disorders
Intensive Outpatient Program (IOP)
Children's Assertive Community Treatment
								  (ACT)
Children's Home and Community Based Treatment/
								  Collateral Contacts
Outpatient - Comprehensive Assessment/Therapy
								  (Duplicative)
OTP with Methadone
Behavioral Therapies for Disruptive Behavior
								  Disorders
Medication Management
Children's Assertive Community Treatment
								  (ACT)
Neurobehavioral Status Exam
N/A
Psychological Testing
N/A
Children's Assertive Community Treatment
								  (ACT)
Crisis Resolution
Crisis Residential
Outpatient Therapy
Intensive Outpatient Program (IOP)
Family Psychoeducational Treatment
Medication Management
Children's Home and Community Based Treatment/
								  Collateral Contacts
Behavioral Therapies for Disruptive Behavior
								  Disorders
Children's Home and Community Based Treatment/
								  Collateral Contacts
Outpatient Therapy
Intensive Outpatient Program (IOP)Family
								  Psychoeducational Treatment
Children's Assertive Community Treatment
								  (ACT)
Behavioral Therapies for Disruptive Behavior
								  Disorders
OTP with Methadone
Outpatient-Comprehensive Assessment/Therapy -
								  Substance Use Intensive Outpatient Program (IOP)
Children's Behavioral Health Day Treatment
N/A
Behavioral Therapies for Disruptive Behavior
								  Disorders
Home and Community Based Treatment/Collateral
								  Contacts
Children's Assertive Community Treatment
								  (ACT)
Family Psychoeducational Treatment
Intensive Outpatient Program (IOP)
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-67 - Nursing Facility Services › Subsection 144-101-II-67.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
67.01-1
Nursing Facility
(NF)
					 means, a Skilled Nursing Facility (SNF) in the Medicare program or a Nursing
					 Facility (NF) in the Maine Care program which meets State licensing and Federal
					 certification requirements for nursing facilities and has a valid agreement
					 with the Department of Health and Human Services (
the Department
).
"Nursing facility" may include a distinct part of an
						institution which meets the above requirements.
A NF may not be an institution for mental diseases, nor
						an institution for the intellectually disabled or persons with related
						conditions.
67.01-2
Nursing Facility Services
means services that are:
- primarily professional nursing care or rehabilitative
						services for injured, disabled, or sick persons;
- needed on a daily basis and as a practical matter can
						only be provided in a nursing facility;
- ordered by and provided under the direction of a
						physician; and
- less intensive than hospital inpatient services.
67.01-3
Dually-Certified
					 Facility
is a facility that is certified to participate in both the
					 Medicare and MaineCare programs. Dually-certified facilities are not limited to
					 distinct parts since all of the beds in the facility are
					 dually-certified.
67.01-4
Swing-Bed
is a skilled Medicare certified hospital bed that may be
					 used interchangeably as an acute care bed or a skilled nursing facility bed.
					 For additional information pertaining to swing-beds refer to Chapter II,
					 Section 45, of this Manual regarding Hospital Services.
67.01-5
Utilization Review
is
					 the evaluation of the necessity, appropriateness, and efficiency of the use of
					 services, procedures, and facilities by each participating nursing facility. It
					 includes a review of the appropriateness of admissions, services ordered and
					 provided, continued stays, and discharge practices.
67.01-6
Mental Illness
(MI) or a
					 mental disorder is:
(a) schizophrenic, mood,
					 paranoid, panic or other severe anxiety disorder; somato form disorder;
					 personality disorder; other psychotic disorder; or another mental disorder that
					 may lead to a chronic disability; but
(b) not a primary diagnosis of dementia,
					 including Alzheimer's disease or a related disorder, or a non-primary diagnosis
					 of dementia unless the primary diagnosis is a major mental disorder as defined
					 in Section 67.01-6(a).
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-67 - Nursing Facility Services › Subsection 144-101-II-67.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Eligible Title XIX and XXI members are entitled to
						receive as many days of NF services as are medically necessary as long as the
						member meets the eligibility for care requirements set forth under Section
						67.02, or otherwise meets the exception specified under 67.05-1 (G). MaineCare
						coverage of NF services requires prior approval from the Department or its
						Authorized Entity. Beginning and end dates of an individual's eligibility
						period corresponds to the beginning and end dates for MaineCare reimbursement.
						The Department, or its Authorized Entity may grant eligibility for NF services
						on a short or long term basis, based upon the complexity, frequency and length
						of time that services are needed.
The Department, or its Authorized Entity may, at any
						time, review an individual's need for NF services.
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-67 - Nursing Facility Services › Subsection 144-101-II-67.06 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
A. Nursing facilities are reimbursed in
					 accordance with this Section, Chapter III, Principles of Reimbursement for
					 Nursing Facilities.
1. Except for nursing
					 facilities which provide acquired brain injury services, reimbursement for
					 ancillary services, including those provided by a NF that is a distinct part of
					 a larger institution, such as medical supplies, physical therapy, occupational
					 therapy, speech and hearing services, respiratory therapy, and pharmacy
					 services is based upon reasonable cost or the maximum allowance.
2. Acquired Brain Injury (ABI) services shall
					 be reimbursed pursuant to the "Intensive Rehabilitation NF Services for Brain
					 Injured Individuals" section of the Principles of Reimbursement only when:
a) the member is classified, by the
					 Department or its Authorized Entity, NF-ABI level pursuant to Section 67.02-5
					 and all relevant requirements;
b)
					 the services were provided during an approved NF-ABI classification period; and
c) the ABI services were delivered
					 in a CARF accredited facility (unless waived by the Department for an
					 authorized out-of-state placement), and pursuant to Section 67.05-1
					 3(H).
3. Nursing
					 facilities will be reimbursed under Chapter 115, Principles of Reimbursement
					 for Residential Care Facilities, for those members qualifying for continued NF
					 stay under Section 67.02-9.
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-67 - Nursing Facility Services › Appendix 144-101-II-67-1

Current through 2024-29, July 17, 2024
Assessment Scales
Disability Rating Scale
								(DRS)
Category
Item
Instructions
Arousability, Awareness and
								Responsivity
Eye Opening
0 =
spontaneous
1 =
to
								speech
2 =
to pain
3 =
none
Communication Ability
0 =
oriented
1 =
confused
2 =
inappropriate
3 =
incomprehensible
4 =
none
Motor Response
0 =
obeying
1 =
localizing
2 =
withdrawing
3 =
flexing
4 =
extending
5 =
none
Cognitive Ability for Self Care
								Activities
Feeding
0 =
complete
1 =
partial
2 =
minimal
3 =
none
Toileting
0 =
complete
1 =
partial
2 =
minimal
3 =
none
Grooming
0 =
complete
1 =
partial
2 =
minimal
3 =
none
Dependence on Others
Level of Functioning
0 =
completely independent
1 =
independent in special environment
2 =
mildly
								dependent
3 =
moderately dependent
4 =
markedly dependent
5 =
totally dependent
Psychosocial Adaptability
Employability
0 =
not restricted
1 =
selected jobs
2 =
sheltered workshop (non-competitive)
3 =
not
employable
Total DR Score
Total DR Score
Level of Disability
0
None
1
Mild
2-3
Partial
4-6
Moderate
7-11
Moderately Severe
12-16
Severe
17-21
Extremely Severe
22-24
Vegetative State
25-29
Extreme Vegetative State
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-68 - National Diabetes Prevention Program Service › Subsection 144-101-II-68.01 - Purpose

Current through 2024-29, July 17, 2024
The purpose of this rule is to provide medically
						necessary occupational therapy services to MaineCare members who are adults
						(age twenty-one (21) and over) who are not residing in a Nursing Facility or
						Intermediate Care Facility for Individuals with Intellectual Disabilities
						(ICF-IID), and who have rehabilitation potential; and to provide medically
						necessary occupational therapy services to MaineCare members who are under age
						twenty-one (21).
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-68 - National Diabetes Prevention Program Service › Subsection 144-101-II-68.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
68.02-1
Functionally Significant
					 Improvement
: demonstrable, measurable increase in the member's ability
					 to perform specific tasks or motions that contributes to independence outside
					 the therapeutic environment.
68.02-2
Long-Term Chronic Pain:
is any pain that has lasted or is expected to last more than sixty (60)
					 days and impacts or is expected to impact a member's level of function for more
					 than sixty (60) days.
68.02-3
Maintenance Care
: occupational services provided to a member whose
					 condition is stabilized after a period of treatment or for whom no further
					 functionally significant improvement is expected.
68.02-4
Occupational Therapy
					 Practitioner
: an individual who is licensed as an Occupational
					 Therapist, Registered/Licensed (OTR/L), Occupational Therapist, Licensed
					 (OT/L), Certified Occupational Therapy Assistant, Licensed (COTA/L) or
					 Occupational Therapy Assistant, Licensed (OTA/L).
68.02-5
Occupational Therapy
					 Services
: the assessment, planning and implementation of a program of
					 purposeful activities to develop or maintain adaptive skills necessary to
					 achieve the maximal physical and mental functioning of the individual in the
					 individual's daily pursuits. The practice of "Occupational Therapy" includes,
					 assessment and treatment of individuals whose abilities to cope with the tasks
					 of living are threatened or impaired by developmental deficits, the aging
					 process, learning disabilities, poverty and cultural differences, physical
					 injury or disease, psychological and social disabilities or anticipated
					 dysfunction
68.02-6
Pain
					 Management Care Plan:
is a plan of care ordered by a rendering or
					 servicing provider, which must include the use of at least one (1) therapeutic
					 treatment option.
68.02-7
Practitioner of the Healing Arts
: Medical Doctors, Doctors of
					 Osteopathy, and all others registered or licensed in the healing arts,
					 including, but not limited to, nurse practitioners, podiatrists, optometrists,
					 chiropractors, physical therapists, occupational therapists, speech therapists,
					 dentists, psychologists and physicians' assistants.
68.02-8
Rehabilitation
					 Potential
: documented expectation of measurable functionally significant
					 improvement in the member's condition in a reasonable, predictable period of
					 time as the result of the prescribed treatment plan.
68.02-9
Terminal Illness
: is a
					 medical condition resulting in a prognosis that a member has a life expectancy
					 of six (6) months or less if the illness runs its normal course.
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-68 - National Diabetes Prevention Program Service › Subsection 144-101-II-68.03 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Members must meet the financial 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 prior to providing services, as described in Chapter
						I.
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-68 - National Diabetes Prevention Program Service › Subsection 144-101-II-68.04 - Specific Eligibility for Care

Current through 2024-29, July 17, 2024
Services for members of all ages must be medically
						necessary. The Department or its authorized agent has the right to perform
						eligibility determination and/or utilization review to determine if services
						provided are medically necessary.
Adult members (age twenty-one (21) and over) in an
						outpatient setting must have rehabilitation potential documented by a physician
						or primary care provider (PCP). Adult members are specifically eligible only
						for:
1. Treatment following an acute
					 hospital stay for a condition affecting range of motion, muscle strength and
					 physical functional abilities. If CMS approves, the treatment must start within
					 six months of the hospital discharge and be specific to the diagnosed
					 condition;
2. Treatment after a
					 surgical procedure performed for the purpose of improving physical function. If
					 CMS approves, the treatment must start within six months of discharge and be
					 specific to the diagnosed condition;
3. Treatment for which a physician or PCP has
					 documented that the patient has, at some time during the preceding thirty (30)
					 days, required extensive assistance in the performance of one or more of the
					 following activities of daily living: eating, toileting, locomotion, transfer
					 or bed mobility;
4. Medically
					 necessary treatment for other conditions including maintenance, subject to the
					 limitations in Section 68.07;
5.
					 Maintenance care to prevent deterioration in function that would result in an
					 extended length of stay or placement in an institutional or hospital setting,
					 as documented by physician or PCP;
6. If CMS approves, rehabilitative services
					 ordered by a physician or other licensed practitioner of the healing arts for
					 the maximum reduction of physical disability and restoration of a member to
					 his/her best possible functional level;
7. If CMS approves, medically necessary
					 treatment when diagnosed with a terminal illness; or
8. Treatment used for pain management in
					 conjunction with a prescribed pain management care plan subject to section
					 68.07.
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-68 - National Diabetes Prevention Program Service › Subsection 144-101-II-68.05 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Covered services must be medically necessary and must not
						exceed the limitations set in Section 68.07. The Department or its authorized
						agent reserves the right to request additional information to evaluate 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-68 - National Diabetes Prevention Program Service › Subsection 144-101-II-68.06 - COVERED SERVICES

Current through 2024-29, July 17, 2024
MaineCare will reimburse for covered medically necessary
						services in all outpatient settings. If CMS approves, covered services
						requiring a Prior Authorization are limited to one (1) evaluation and one (1)
						treatment per each condition or per each event unless specified under 68.07.
						Services must be of such a level, complexity, and sophistication that the
						judgment, knowledge, and skills of a qualified professional staff is required
						as defined in 68.09-1.
All services must be in accordance with acceptable
						standards of medical practice and be a specific and effective treatment for the
						member's condition. Services related to activities for the general good and
						welfare of members are not MaineCare covered occupational therapy
						services.
Pursuant to
						42
						CFR§440.110, MaineCare occupational
						therapy services must be prescribed by a physician or other licensed
						practitioner of the healing arts within the scope of practice under Maine law
						and must be provided by or under the direction of a qualified professional
						staff as defined in 68.09-1.
MaineCare reimburses providers for the following
						occupational therapy services:
68.06-1
					 Evaluations or re-evaluations: For adults, one evaluation or re-evaluation per
					 member per condition or event is a covered service. For children, additional
					 evaluations or reevaluations are allowed as medically necessary.
68.06-2 Modalities: Modalities are any
					 physical agents applied to produce therapeutic changes to biologic tissues;
					 including but not limited to thermal, acoustic, light, mechanical, or electric
					 energy. Except when performing supervised modalities, the therapist is required
					 to have direct (one-on-one) continuous patient contact.
68.06-3 Therapeutic Procedures: Therapeutic
					 procedures effect change through the application of clinical skills and/or
					 services that attempt to improve function.
68.06-4 Tests and measurements: The therapist
					 is required to have direct (one-on-one) continuous patient contact in
					 performing testing and measurement.
68.06-5 Splinting: Providers may bill for
					 splinting supplies necessary for the provision of occupational therapy
					 services. Covered supplies under this Section must be billed and reimbursed at
					 the lesser of acquisition cost or the maximum allowed cost set by the
					 Department. The acquisition cost must be documented by an invoice in the
					 member's file. Please visit
http://www.maine.gov/dhhs/audit/rate-setting/documents/S68OccupationalTherapyServices.pdf
to access maximum allowed cost.
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-68 - National Diabetes Prevention Program Service › Subsection 144-101-II-68.07 - LIMITED SERVICES

Current through 2024-29, July 17, 2024
68.07-1
All
					 ages:
1. MaineCare will not reimburse
					 for more than two (2) hours of occupational therapy services per day.
2. Supervised modalities (those without
					 direct one-to-one continuous contact) that are provided on the same day as
					 modalities requiring constant attendance or on the same day as any other
					 therapeutic procedure are not billable. Billing for supervised modalities as
					 stand-alone treatment is limited to one (1) unit per modality per
					 day.
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-68 - National Diabetes Prevention Program Service › Subsection 144-101-II-68.08 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
Refer to Chapter I of the MaineCare Benefits Manual for
						additional non-covered services, including academic, vocational, socialization
						or recreational services.
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-68 - National Diabetes Prevention Program Service › Subsection 144-101-II-68.10 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
The amount of payment for services rendered shall be the
						lowest of the following:
1. The amount
					 for services is listed in Chapter III, Section 68, "Allowances for Occupational
					 Therapy Services" of the MaineCare Benefits Manual.
2. The lowest amount allowed by the Medicare
					 carrier.
3. The provider's usual
					 and customary charge.
See section 68.06-5 for reimbursement for splinting
						supplies.
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.
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-68 - National Diabetes Prevention Program Service › Subsection 144-101-II-68.11 - COPAYMENT

Current through 2024-29, July 17, 2024
Note: Requirements regarding co-payment disputes and
						exemptions are contained in Chapter I of the MaineCare Benefits Manual.
1. A copayment will be charged to each
					 MaineCare member receiving services, with the exception of those exempt, as
					 specified in the MaineCare Eligibility Manual, such as children. The amount of
					 the copayment shall not exceed $2.00 per day for services provided, according
					 to the following schedule:
MaineCare Payment for Service
Member
								Copayment
$10.00 or less
$ .50
$10.01 - 25.00
$1.00
$25.01 or more
$2.00
2. The member is responsible for copayments
					 up to $20.00 per month whether the copayment has been paid or not. After the
					 $20.00 cap has been reached, the member will not be required to make additional
					 copayments and the provider will receive full MaineCare reimbursement for
					 covered services.
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-68 - National Diabetes Prevention Program Service › Subsection 144-101-II-68.12 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
1. Providers must
					 bill in accordance with the Department's billing instructions for the CMS 1500
					 claim form.
2. All services
					 provided on the same day must be submitted on the same claim form.