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-40 - Home Health Services › Subsection 144-101-II-40.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
40.01-1
Authorized Entity
shall
					 mean the organization authorized by the Department to perform functions
					 pursuant to a contract or which are specified in a written agreement. The
					 Authorized Entity will perform authorizations of plans of care as
					 required.
40.01-2
Certification Period
shall mean the months, days, years, which
					 identify the period covered by the physician's plan of care. The "From" date
					 for the initial certification must match the start of care date. The "To" date
					 can be up to, but never exceed, two (2) calendar months and mathematically
					 never exceed sixty (60) days. Recertifications shall follow the same length of
					 time requirements.
40.01-3
Contraindicated
shall mean the Member's condition renders some
					 particular line of treatment improper or undesirable.
40.01-4
Duration
shall mean the
					 length of time the services are to be rendered and may be expressed in days,
					 weeks, or months. This must be specified on the physician certified plan of
					 care.
40.01-5
Eligibility
					 Period
shall mean the period of time, designated by a start and end date
					 established by the Department or its Authorized Entity, approved for coverage
					 of Home Health Services, in accordance with Section
					 40.08.
40.01-6
Extensive Assistance
means although the individual performed part of the activity over the
					 last seven (7) days, or twenty-four (24) to forty-eight (48) hours if in a
					 hospital setting, help of the following type(s) was provided:
- Weight-bearing support three (3) or more times,
						or
- Full staff performance during part (but not all) of the
						last seven (7) days.
40.01-7
Face to Face Encounter
means an encounter between the member and the certifying physician, or a
					 nurse practitioner or clinical nurse specialist who is working in collaboration
					 with the physician, or a certified nurse midwife as authorized by State law or
					 physician assistant under the supervision of the physician. The encounter may
					 be through telehealth, consistent with Section 1834(m) of the Social Security
					 Act and
					 42
					 CFR 424.22. The face-to-face encounter must
					 be related to the primary reason the patient requires Home Health Services. The
					 face-to-face encounter shall be documented by the physician responsible for
					 performing the certification for the Home Health Service as indicated in
					 40.08-4.15 and 40.08-1.D.4. The face-to-face encounter must occur within the
					 time frame set out in section 40.08-4.15,
40.01-8
Frequency
shall mean the
					 number of visits per discipline to be rendered, stated in days, weeks, or
					 months. This must be specified on the physician certified plan of
					 care.
40.01-9
Functionally
					 Significant Improvement
is the demonstrable, measurable increase in the
					 individual's ability to perform specific tasks or motions that contribute to
					 independence outside the therapeutic environment.
40.01-10
Health Care Provider
is
					 an individual or entity licensed or certified under the laws of the State of
					 Maine to provide medical or behavioral health services and must be enrolled as
					 MaineCare providers in order to be reimbursed for services.
40.01-11
Home Health Agency
					 (HHA
) means a voluntary, public or private organization, or a part of
					 such organization, that is certified under Title XVIII of the Social Security
					 Act for reimbursement for the delivery of Home Health Services.
40.01-12
Home Health Aide
					 Services
are those in-home services that are provided by a certified
					 home health aide and which are delegated and supervised by a registered nurse.
					 A certified home health aide must have satisfactorily completed a training
					 program for certified nurse assistants, consistent with the rules and
					 regulations of the Maine State Board of Nursing. Home health aides employed by
					 a Home Health Agency must also have completed an agency orientation as defined
					 by the regulations Governing the Licensing and Functioning of Home Health Care
					 Services.
40.01-13
Home
					 Health Services
are those skilled nursing and home health aide services,
					 physical and occupational therapy services, speech-language pathology services,
					 medical social services, telemonitoring services, and the provision of certain
					 medical supplies, needed on a "part-time" or "intermittent" basis. Services are
					 delivered by a Medicare certified Home Health Agency to a member in a setting
					 where normal life activities take place or in other particular settings with
					 limitations as described in Section
					 40.06. Services are
					 delivered according to the orders of a licensed physician and an authorized
					 plan of care that certify the need for the Home Health Services. Certification
					 for Home Health Services shall occur as a result of a documented face- to-face
					 encounter as defined in 40.01-7 that meets the requirements of 40.08-4.15 and
					 40.08-1.D.4.
In a nursing facility (NF) setting, only physical
						therapy, occupational therapy and/or speech-language pathology services may be
						delivered by a Home Health Agency if the NF's MaineCare reimbursement rate does
						not include these services.
40.01-14
Intermittent
, in
					 general, shall mean skilled nursing care needed on fewer than seven (7) days
					 each week or less than eight (8) hours each day for periods of up to twenty-one
					 (21) days (or longer in exceptional circumstances when the need for care is
					 finite and predictable); but as defined in CMS Publication 11 "Medicare Home
					 Health Agency Manual," and the regulations issued pursuant thereto as are most
					 currently ineffect. This manual is available on line at
http://www.cms.hhs.gov/manuals/11_hha/HH00.asp
.
40.01-15
Medical Social Services
are assessment, counseling, and assistance services that are needed by a
					 member to resolve social or emotional problems that are or are expected to be
					 an impediment to the effective treatment of the member's medical condition or
					 to affect his or her rate of recovery. Services are provided by a social worker
					 who is functioning within the scope of the license granted by the state or
					 province in which the services are performed and who has had at least one (1)
					 year of social work experience in a health care setting.
A licensed social worker shall receive consultation in
						accordance with State of Board of Social Work Registration and the Rules and
						Regulations of the Board of Social Work. The licensed social worker with more
						than two (2) years' experience shall receive consultation from a licensed
						master social worker, a licensed clinical social worker, or a certified social
						worker on a quarterly basis.
40.01-16
Non-Routine Medical Supplies
are supplies that are necessary for a particular procedure ordered by a
					 physician to be provided by Home Health Services. Non-Routine medical supplies
					 meet the following criteria;
A. The
					 non-routine medical supply must be medically necessary and reasonable for the
					 Home Health Agency provider to use in performance of the specific service for
					 the individual member as ordered by the physician in the order for
					 service.
B. The non-routine medical
					 supply must be an item that is consumable, in that its use is of limited
					 duration and it will be discarded after use. The use of the supply is confined
					 to the one Member for the particular procedure ordered by the
					 physician.
C. The non-routine
					 medical supply is appropriate for use in a setting where normal life activities
					 take place as defined in 40.02-3.
D. The covered non routine medical supply
					 must be outside the scope of usual supplies generally utilized as part of the
					 services the Home Health Agency provides. Examples of routine supplies include
					 cotton swabs, alcohol wipes and latex gloves. Routine supplies are not
					 separately reimbursed and are considered part of the rate for the Home Health
					 Service.