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-96 - Private Duty Nursing and Personal Care Services › Subsection 144-101-II-96.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
96.01-1
Private Duty Nursing (PDN) and
					 Personal Care Services (PCS)
are those covered services provided to an
					 eligible Member, as defined in this Section, when determined to be medically
					 necessary, when prior approved, and in the best interest of the Member
					 according to the orders and written plan of care reviewed and signed by a
					 licensed physician. With the exception of those medically necessary services
					 that are prior authorized for children under the age of 21, all services
					 provided are not to exceed the cost limits set forth in Section
					 96.03.
96.01-2
Covered Services
are
					 those services for which payment can be made under Title XIX or XXI by the
					 Department of Health and Human Services.
96.01-3
Private Duty Nursing
					 Services
are those services that are provided by a registered nurse
					 and/or a licensed practical nurse, in accordance with the Board of Nursing
					 Regulations, under the direction of the Member's physician, to a Member in his
					 or her place of residence or outside the Member's residence, when normal life
					 activities take the Member outside his or her residence (school, preschool,
					 daycare, medical appointments, etc.). Reimbursement for services provided
					 outside a Member's residence can include only authorized nursing services and
					 authorized personal care services and may not exceed that which would have been
					 allowed strictly in a home setting. For purposes of this Section, "place of
					 residence" does not include such institutional settings as nursing facilities,
					 intermediate care facilities for individuals with intellectual disabilities
					 (ICFs-IID), or hospitals. If nursing services are covered under a private
					 non-medical institution's per diem rate, then Level I, II, III, VI, VII private
					 duty nursing services are not allowed under this Section.
96.01-4
Personal Care Services
are those Activities of Daily Living (ADL), Instrumental Activities of Daily
					 Living (IADL), and medication administration services provided to a Member by a
					 home health aide, certified nursing assistant, personal support specialist
					 (PSS), or certified residential medication aide (CRMA), as appropriate, while
					 completing tasks in accordance with an authorized plan of care. Under this
					 Section, personal care services are not covered in the following settings:
					 nursing facilities, intermediate care facilities for individuals with
					 intellectual disabilities, hospitals, or adult family care homes, or assisted
					 living facilities that do not meet the definition in § 96.01-28. If
					 personal care services are covered under a private non-medical institution's
					 per diem rate, then Level I, II, III, VI, VII personal care services are not
					 allowed under this Section.
96.01-5
A Unit of Service
is a reimbursable unit of direct service as
					 specified in Chapter III of this Section. A unit of service requires personal
					 contact in or outside the Member's place of residence made for the purpose of
					 providing a covered service. When two or more persons provide separate and
					 distinct types of services simultaneously, each must be recorded
					 separately.
96.01-6
Average
					 Monthly Cost
is one twelfth of the average annual cost of nursing
					 facility services as defined by the Department of Health and Human Services.
					 The costs of MaineCare physical therapy, occupational therapy, speech and
					 hearing services and medical social worker services shall not be included in
					 the calculation of this average monthly cost.
96.01-7
Cuing
means any spoken
					 instruction or physical guidance which serves as a signal to do something.
					 Cuing is typically used when caring for individuals who are cognitively
					 impaired.
96.01-8
Limited
					 Assistance
is a term used to describe an individual's self-care
					 performance in activities of daily living, as defined by the Minimum Data Set
					 (MDS) assessment process. It means that although the individual was highly
					 involved in the activity over the last 7 days, or 24 to 48 hours if in a
					 hospital setting, help of the following type(s) was provided:
- Guided maneuvering of limbs or other non-weight-bearing
						assistance three or more times, or
- Guided maneuvering of limbs or other non-weight-bearing
						assistance three or more times plus weight-bearing support provided only one or
						two times.
96.01-9
One-person Physical Assist
requires one person to provide either
					 weight-bearing or non-weight-bearing assistance for an individual who cannot
					 perform the activity independently over the last 7 days, or 24 to 48 hours if
					 in a hospital setting. This does not include cuing.
96.01-10
Extensive Assistance
means although the individual performed part of the activity over the last 7
					 days, or 24 to 48 hours if in a hospital setting, help of the following type(s)
					 was provided:
- Weight-bearing support three or more times, or
- Full staff performance during part (but not all) of the
						last 7 days.
96.01-11
Total Dependence
means full staff performance of the activity
					 during the entire previous 7 day period across all shifts, or during each 8
					 hour period in 24 hours.
96.01-12
Significant Change
means a major change in the Member's status
					 that is not self-limiting, impacts on more than one area of functional or
					 health status, and requires multi-disciplinary review or revision of the plan
					 of care. A significant change assessment is appropriate if there is a
					 consistent pattern of change with either two or more areas of improvement, or
					 two or more areas of decline.
96.01-13
Assessing Services Agency
					 (ASA)
is authorized to conduct face-to-face assessments, using the
					 Department's Medical Eligibility Determination (MED) form, and the timeframes
					 and definitions contained therein, to determine medical eligibility for covered
					 services. Based upon a Member's assessment outcome scores recorded in the MED
					 form, the ASA is responsible for authorizing a plan of care, which must specify
					 all services to be provided under this Section, including the number of hours
					 for services, and the provider types. The ASA is the Department's Authorized
					 Entity for medical eligibility determinations, care plan development, and
					 authorization of covered services under this Section. The ASA conducts
					 assessments for all Members age 21 and over and those under age 21 receiving
					 care under the family provider services option, and excluding those Members
					 classified for medication or venipuncture services under this
					 Section.
96.01-14
Authorized
					 Entity
means an organization authorized by the Department to perform
					 functions under a valid contract or other approved, signed agreement. The
					 Assessing Services Agency is the Authorized Entity under this
					 Section.
96.01-15
Service
					 Coordination Agency
is an organization that has the capacity to provide
					 Care Coordination and Skills Training to eligible Members under Private Duty
					 Nursing and Personal Care Services, and has met the MaineCare provider
					 enrollment requirements of the Department. In addition to Care Coordination and
					 Skills Training, the Service Coordination Agency is responsible for
					 administrative functions, including but not limited to, maintaining Member
					 records, submitting claims, conducting internal utilization and quality
					 assurance activities, and meeting the reporting requirements of the Department.
					 The Service Coordination Agency must coordinate with the Department's
					 contracted Fiscal Intermediary for those Members who have chosen to direct
					 their personal care services through the FPSO. The Service Coordination Agency
					 providing care coordination services to a Member may not be a provider of
					 direct care services.
96.01-16
Contraindicated
means the Member's condition renders some
					 particular line of treatment improper or undesirable.
96.01-17
Medical Eligibility
					 Determination Form
means the form approved by the Department for medical
					 eligibility determinations and service authorization for the plan of care based
					 upon the assessment outcome scores. The definitions, scoring mechanisms and
					 time-frames relating to this form are outlined in Section 96.02-4 and provide
					 the basis for services and the care plan authorized by the ASA. The care plan
					 summary contained in the MED form documents the authorized service plan. The
					 care plan summary also identifies other services the Member is receiving, in
					 addition to the authorized services provided under this Section. For all
					 Members age 21 and over, and those under age 21 receiving care under the family
					 provider services option, and excluding those classified for medication
					 services or venipuncture services under this Section, the Assessing Services
					 Agency has the authority to conduct the medical eligibility determination. For
					 all Members under age 21, excluding those receiving care under the family
					 provider service option, and for all those classified for medication services
					 or venipuncture services under this Section, the PDN provider conducts the
					 medical eligibility determination.
96.01-18
Authorized Plan of Care
means a plan of care that is authorized by the Assessing Services Agency, or
					 the Department, which shall specify all services to be delivered to a Member
					 under this Section, including the number of hours for all covered services. The
					 plan of care must be based upon the Member's assessment outcome scores recorded
					 in the Department's medical eligibility determination form.
96.01-19
Activities of Daily Living
					 (ADL)
that will be considered for the purpose of determining eligibility
					 are:
A.
Bed Mobility
: How person
					 moves to and from lying position, turns side to side, and positions body while
					 in bed;
B.
Transfer
:
					 How person moves between surfaces to/from: bed, wheelchair, standing position
					 (excluding to/from bath/toilet);
C.
Locomotion
: How person moves between locations, in room and other
					 areas. If in wheelchair, self-sufficiency once in chair;
D.
Eating
: How person eats and
					 drinks (regardless of skill);
E.
Toilet Use
: How person uses the toilet room (or commode, bedpan,
					 urinal), transfers on/off toilet, cleanses, changes pad, manages ostomy or
					 catheter, adjusts clothes;
F.
Bathing
: How person takes full-body bath/shower, sponge bath and
					 transfers in/out of tub/shower (exclude washing of back and hair);
					 and
G.
Dressing
: How
					 person puts on, fastens, and takes off all items of street clothing, including
					 donning/removing prosthesis.