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-85 - MaineMOM Services and Reimbursement › Subsection 144-101-II-85.12 - 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.
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-89 - MaineMOM Services and Reimbursement › Subsection 144-101-II-89.01 - INTRODUCTION

Current through 2024-29, July 17, 2024
MaineMOM is a model of care that incents the integration
						and coordination of Perinatal Care and Opioid Use Disorder (OUD) treatment to
						meet MaineCare members' health care needs through Per Member Per Month (PMPM)
						payments tied to quality outcomes. MaineMOM Services are provided through three
						(3) distinct models of care:
1.
					 MaineMOM Integrated Model Services,
2. MaineMOM Partnership Model Services,
					 and
3. MaineMOM Perinatal
					 Navigation Model 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-89 - MaineMOM Services and Reimbursement › Subsection 144-101-II-89.03 - MEMBER ELIGIBILITY

Current through 2024-29, July 17, 2024
To receive MaineMOM services, members must meet the
						eligibility requirements set forth in this section.
89.03-1
General Eligibility
Members must meet the eligibility criteria described in
						Chapter I, Section
						1 of the MBM and in the
MaineCare Eligibility Manual
, 10-144 Chapter 332.
89.03-2
Specific
					 Requirements
All diagnoses and qualifying risk factors must be
						documented in the member's Care Plan.
Members must be diagnosed with an OUD, in accordance with
						the current version of the DSM; AND have a second chronic condition OR be at
						risk of having a second chronic condition.
A. Eligible Chronic Conditions as Second
					 Chronic Condition:
1. mental health
					 condition;
2. additional SUD (other
					 than OUD);
3. tobacco
					 use;
4. diabetes;
5. heart disease;
6. overweight or obesity as evidenced by a
					 body mass index over 25;
7. chronic
					 obstructive pulmonary disease (COPD);
8. hypertension;
9. hyperlipidemia;
10. developmental and intellectual
					 disorder;
11. circulatory
					 congenital abnormality;
12.
					 asthma;
13. acquired brain injury;
					 or
14. seizure disorder.
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-89 - MaineMOM Services and Reimbursement › Subsection 144-101-II-89.04 - ENROLLMENT AND DUPLICATION OF SERVICES

Current through 2024-29, July 17, 2024
89.04-1
Member Identification
The MaineMOM provider shall identify members who are
						potentially eligible for services under Section
						89.03. The MaineMOM
						provider will submit potentially eligible members to the Department or the
						Department's Authorized Entity through a certification process to approve
						services. Each member's eligibility must be based on a diagnosis rendered
						within the past year from the date of the certification request.
89.04-2
Enrollment and
					 Duplication of Services
A.
Enrollment
: The MaineMOM provider shall identify members for
					 services based on the service eligibility criteria. The provider shall give
					 potentially eligible members information about the benefits of participating in
					 MaineMOM services. The member can choose to receive services once confirmed
					 eligible. The Department, or its Authorized Entity, must approve members
					 through a certification process with the certification effective the earliest
					 date without risk of duplicative services. The member can choose not to
					 participate in MaineMOM services at any time by notifying the MaineMOM
					 provider, the Department, or its Authorized Entity, for certifications of
					 services.
B.
Duplication of
					 Services:
As set forth in Section
					 89.09
					 (Reimbursement), the Department will not reimburse for duplicative services for
					 members. If the Department, or its Authorized Entity, determines the member is
					 receiving a duplicative service through a certification process, the member
					 chooses which service they want to receive. The Department, or its Authorized
					 Entity, will notify members that they cannot receive duplicative services and
					 will keep a record of documentation as to the members' choice of service. A
					 member may only be in one health home program at a time.
C.
Requests and Referrals:
Members may request MaineMOM services or be referred for services through the
					 Department's maternal and child health referral system. MaineMOM providers must
					 provide a referral contact at their service location to facilitate the
					 connection to services.
D.
Documentation of Consent:
MaineMOM providers must retain
					 documentation of consent for all members in the member record. Consent
					 documentation must, at a minimum:
1. Indicate
					 that the individual has received information explaining the purpose of MaineMOM
					 services and the services provided; and
2. Indicate that the individual has consented
					 to receive the MaineMOM services and understands their right to choose, change,
					 or disenroll from their MaineMOM provider at any time.
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-89 - MaineMOM Services and Reimbursement › Subsection 144-101-II-89.07 - REPORTING REQUIREMENTS

Current through 2024-29, July 17, 2024
In addition to the documentation and reporting
						requirements as defined in Chapter I, Section
						1, and other reports that may be
						required by the Department, or its Authorized Entity, MaineMOM providers shall
						report as follows.
A.
Core Standards.
The MaineMOM provider
					 shall report on the Core Standards in Section
					 89.06-2.
B.
Behavioral and Physical
					 Health Integration.
The MaineMOM provider shall report on
					 Behavioral and Physical Health Integration in Section
					 89.06-2(F).
C.
MaineMOM Quality
					 Measures.
The MaineMOM provider shall submit data necessary
					 to compile and report on Quality Measures as identified by the Department, or
					 its Authorized Entity. Data sources may include but are not limited to claims,
					 clinical data, the DHHS Enterprise Information System, certification
					 submissions, and surveys.
Providers who fail to timely or adequately file reports
						or satisfy the benchmarks defined by the Department may be terminated from
						providing Section
						89 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-89 - MaineMOM Services and Reimbursement › Subsection 144-101-II-89.08 - DOCUMENTATION AND CONFIDENTIALITY

Current through 2024-29, July 17, 2024
In addition to the requirements, above and set forth in
						Chapter I, Section
						1, of the MBM, the MaineMOM
						provider must maintain a specific record and documentation of services for each
						member receiving covered services.
A.
Records:
The member's record must minimally include:
1. Name, address, birthdate, and MaineCare
					 identification number;
2. Diagnoses
					 that support eligibility for services herein, including the most recent
					 documentation of diagnoses that substantiate ongoing eligibility for
					 services;
3. The Screening and
					 Comprehensive Assessment (Section
					 89.05-1(A)(1)),
					 and any reassessments that occur, to which must include the signature and
					 credentials of the individual performing the service;
4. The Care Plan and any updates to the Care
					 Plan, which must include the signature and credentials of the individual
					 performing the service and the date of any updates;
5. Correspondence to and from other
					 providers;
6. Release of
					 information statements as necessary, signed by the member, including right
					 notification, rules and regulations, confidentiality statement and release of
					 information;
7.
					 Documentation/record entries (i.e., progress notes) that clearly reflect
					 implementation of the Care Plan and the member's response to treatment, as well
					 as subsequent amendments to the plan. Progress notes for each service provided,
					 including the date of service, the type of service, the place of the service or
					 method of delivery (i.e., phone contact), the Care Plan goal to which the
					 service relates to, the duration of the service, the progress the member has
					 made towards goal attainment, the signature and credentials of the individual
					 performing the service, whether the individual has declined services in the
					 Care Plan, and timelines for obtaining needed services; and
8. A record of discharge/transfer planning,
					 beginning at admission and any referrals made.
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-89 - MaineMOM Services and Reimbursement › Subsection 144-101-II-89.09 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
Section
						89 MaineMOM Providers are
						reimbursed a monthly Per Member Per Month (PMPM) payment for each Section
						89 member receiving services from
						the provider, based on which
Model Service the member is utilizing at the end of the
						month. Providers may only receive a PMPM payment if they satisfy the minimum
						requirements set forth in this section.
89.09-1
Minimum Requirements for
					 MaineMOM Reimbursement
To be eligible for PMPM payment, for each member for each
						billing month, the MaineMOM provider shall meet the following Minimum
						Requirements for all MaineMOM Providers:
1. Document each service provided to each
					 member, for each billing month, as required by these rules, in order to be
					 eligible to receive the PMPM reimbursement; AND
2. Deliver at least one (1) office visit with
					 the MOUD Prescriber (89.05-2) each month, unless billing for MaineMOM Perinatal
					 Navigation Model Services (89.06-5); AND
3. Deliver at least one (1) individual or
					 group SUD Counseling visit monthly (89.05-3), unless billing for MaineMOM
					 Perinatal Navigation Model Services (89.06-5); AND
4. Conduct toxicology screenings as
					 clinically appropriate, in accordance with services described in Sections
					 89.06-1 through
					 89.06-4;
					 AND
5. Deliver at least one (1)
					 Health Home Service (89.05-1) to the member within the calendar month, pursuant
					 to the member's Care Plan.
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-89 - MaineMOM Services and Reimbursement › Subsection 144-101-II-89.10 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
A. The MaineMOM
					 provider shall attest through a claims process that the MaineMOM provider has
					 performed the necessary minimum billable requirements (Section
					 89.09-1) each month
					 to receive payment for Section
					 89 members.
B. Billing for medications (Section
					 89.05-4), shall be
					 as follows:
1. When a prescription for
					 medication is written, but not dispensed at the MaineMOM provider, the
					 dispensing pharmacy shall bill for the medication in accordance with MBM,
					 Section 80, "Pharmacy
					 Services".
2. When a prescription
					 for medication is dispensed by the MaineMOM provider, the MaineMOM provider
					 shall include the billing for the medication on the applicable UB or 1500 claim
					 form.
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-90 - Physician Services › Subsection 144-101-II-90.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
90.01-1
Cosmetic Procedures and
					 Surgery
Cosmetic procedures and cosmetic surgery are any
						procedure or surgery done primarily to improve or change appearance without
						improving the way the body works.
90.01-2
Elective Surgery
Elective surgery is surgery that can be scheduled in
						advance, is not an emergency, and, if delayed, would not result in death or
						permanent impairment of health.
90.01-3
Physician services
Physician services are those services provided by a
						licensed physician or other qualified rendering provider, within the scope of
						practice of his or her profession as defined by state law in the state where
						services are provided, or under the personal supervision of an individual
						licensed under state law to practice medicine or osteopathy.
90.01-4
Rendering Provider
The rendering provider is the trained and appropriately
						licensed professional who actually renders the medical service to a
						member.
90.01-5
Supplies and Materials
Supplies and materials are items provided by the
						rendering provider, such as sterile trays, drugs, dressings, wadding, and
						plaster. Providers must use the appropriate Healthcare Common Procedure Coding
						System (HCPCS) code for supplies and materials, and the charges must not exceed
						the total acquisition costs. MaineCare does not reimburse for shipping,
						handling, and related costs. Requirements for financial record keeping are
						detailed in
MaineCare Benefits Manual
(MBM), Chapter I,
						Section 1.03-8.
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-90 - Physician Services › Subsection 144-101-II-90.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Individuals must meet financial eligibility 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-90 - Physician Services › Subsection 144-101-II-90.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each MaineCare member is eligible for those medically
						necessary covered services as set forth below. The Department 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-90 - Physician Services › Subsection 144-101-II-90.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
A covered service is a service for which the Department
						may make payment. The Department covers those reasonably necessary medical and
						remedial services that are provided in an appropriate setting and recognized as
						standard medical care required for the prevention and/or treatment of illness,
						disability, infirmity or impairment and which are necessary for health and
						well-being.
The Department will not give additional reimbursement to
						providers who are salaried by a hospital for services billed by the hospital
						and whose payment is included in the hospital cost report for services provided
						while a member is hospitalized as an inpatient or receiving outpatient
						services.
When a non-MaineCare provider covers the practice for a
						MaineCare provider and performs services, MaineCare will only reimburse the
						MaineCare billing provider. The MaineCare billing provider must maintain
						adequate records to document the actual rendering provider. The MaineCare
						billing provider is responsible for reimbursing the non-MaineCare
						provider.
Providers should direct any questions about coverage of
						particular services to the Provider Relations Unit prior to provision of the
						service.
90.04-1
Anesthesiology
					 Services
A.
Reimbursement of
					 Anesthesiology Services
The Department covers anesthesiology services when
						personally performed or medically directed by a rendering provider
						appropriately licensed or certified in the state in which he or she is
						practicing. All anesthesiology providers must practice only within the scope of
						his or her licensure or certification, and qualified to deliver treatment under
						this Section.
(1) Anesthesiology
					 services include the following activities:
(a) Pre-operative examination and
					 evaluation;
(b) Prescribing an
					 anesthetic plan;
(c) Administration
					 and monitoring of the full anesthesia service; and
(d) Post-anesthesia care.
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-90 - Physician Services › Subsection 144-101-II-90.06 - SERVICES FOR MEMBERS IN DIFFERENT SETTINGS

Current through 2024-29, July 17, 2024
90.06-1
Nursing Facilities (NF) and
					 Other Group Care
A.
Nursing
					 Facility Admissions
The admission of a member to an NF under the MaineCare
						program requires prior approval from the Department of Health and Human
						Services.
Approval for admission is given only when a member meets
						the medical eligibility requirements for NF services, as set forth in Chapter
						II, Section
						67, Nursing Facility Services, of
						the MBM
,
and when adequate alternate arrangements cannot be
						made for home or community based care. NF applicants must receive a medical
						eligibility assessment with the Department's approved assessment instrument
						(see Section
						67 ).
B.
On-Going Nursing Facility
					 Care
When the physician continues to serve as the attending
						physician to members after they enter an NF, or accepts as new patients members
						who are receiving care in an NF, he or she is expected to provide, at a
						minimum, those physician services that are required, by federal regulations and
						by the
State of Maine Regulations Covering the Licensing and
						Functioning of Nursing Facilities
, to be provided in licensed
						MaineCare approved facilities.
C.
Documentation in Member's
					 Chart
All services provided to members in group care facilities
						by the physician or rendering provider are to be documented by the provider in
						the member's chart maintained in the facility. All orders to be carried out by
						facility staff are to be signed by the physician or rendering provider. A
						rubber stamp of the signature is not considered adequate.
D.
Referrals by Attending
					 Physician
Professional services in a group care facility are only
						covered when ordered by the attending physician or the rendering provider
						working under his/her supervision.
E.
Physicians with Facility
					 Ownership
No charges may be made for services provided to members
						in a group care facility by a physician or rendering provider in a physician's
						practice who derives a direct or indirect profit from ownership of the
						facility, except for emergency services provided for acute illness.
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-90 - Physician Services › Subsection 144-101-II-90.07 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
When MaineCare does not cover specific procedures, all
						services related to that procedure are not covered, including physician,
						facility, and anesthesia services. Services that are not reimbursable by
						MaineCare include, but are not limited to:
90.07-1
Cosmetic Surgery
Surgeries that are performed solely for cosmetic reasons
						are not covered by MaineCare. MaineCare defines cosmetic surgery as any surgery
						done primarily to improve or change appearance without improving the way the
						body works.
Procedures that may potentially performed for either
						cosmetic or medical reasons require prior authorization documenting the medical
						indication for the procedure.
MaineCare does cover some potentially cosmetic procedures
						when done to correct deformities resulting from cancer, disease, trauma, or
						birth defects, as detailed in Section
						90.05. Examples of
						non-covered cosmetic surgery are:
A.
					 Circumcision, which is usually a cosmetic procedure, is not covered unless
					 medically necessary. Circumcision that is routine or cosmetic including routine
					 newborn circumcision is not covered. Circumcision for preventative, social,
					 ethnic, or religious reasons, regardless of age, is not covered. MaineCare
					 covers some circumcisions with an appropriate medical indication.
B. Piercings and removal of tattoos.
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-90 - Physician Services › Subsection 144-101-II-90.08 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
The following policies and procedures supplement the
						general information within this section:
90.08-1
Medical Record
					 Requirements
Each provider shall maintain financial and professional
						records of sufficient quality to fully and accurately document the nature,
						scope, and details of the health care provided. Providers shall provide copies
						of financial and professional records to the Department in the form and manner
						requested without charge to the Department or the member. Chapter I details the
						five (5) year requirement for maintaining records.
A. Physicians must maintain one office
					 medical record for each member even in group practices, partnerships, and other
					 shared practices. Providers must document specific services rendered in
					 chronological order. Chapter I provides additional requirements for
					 record-keeping. The medical records corresponding to office, home, nursing
					 facility, hospital, outpatient and emergency room services billed to the
					 Department must include but shall not be limited to:
1. Date of each service ordered and
					 provided;
2.
2. Member's name, name of responsible person
					 (if different from the member, e.g., parent or guardian), date of birth, and
					 MaineCare ID number;
3. Name and
					 title of provider performing the service if it is other than the billing
					 physician;
4. Medical history/
					 including member's health condition;
5. Pertinent findings on
					 examination;
6. Medications
					 administered or prescribed, when applicable;
7. Description of treatment, when
					 applicable;
8. Recommendations for
					 additional treatments or consultations;
9. Medical goals;
10. Supplies dispensed or prescribed (if
					 any);
11. Tests and results; and
12. Dated provider
					 signature.
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-90 - Physician Services › Subsection 144-101-II-90.10 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Providers must bill in accordance with the Department's
						billing requirements for the CMS 1500 specific to Physician
						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-91 - Physician Services › Subsection 144-101-II-91.03 - MEMBER ELIGIBILITY FOR COMMUNITY CARE TEAM SERVICES

Current through 2024-29, July 17, 2024
CCT services are for Members who are high-risk and/or
						high-cost and whose health care needs are more intense than can be managed
						solely by a primary care provider. CCTs will request qualifying Members be
						added to their panels.
To be eligible for CCT services, the Member must:
1. Be diagnosed with two (2) or more chronic
					 conditions (91.03-1) and meet one of the general eligibility requirements
					 (91.03-3); or
2. Be diagnosed with
					 one (1) chronic condition (91.03-1), be at risk for another chronic condition
					 (91.03-2), and meet one of the general eligibility requirements (91.03-3).
All diagnoses related to eligibility must be documented
						in the Member's EHR.
91.03-1
Chronic Conditions
1. a mental
					 health condition (excluding Serious and Persistent Mental Illness and Serious
					 Emotional disturbance, as defined in MBM, Section
					 92, Behavioral Health
					 Homes;
2. a substance use
					 disorder;
3. tobacco use;
4. diabetes;
5. heart disease;
6. overweight or obese as evidenced by a body
					 mass index over 25 for an adult or the 85th
					 percentile for a child;
7. Chronic
					 Obstructive Pulmonary Disease (COPD);
8. hypertension;
9. hyperlipidemia;
10. developmental and intellectual
					 disorders;
11. circulatory
					 congenital abnormalities;
12.
					 asthma;
13. acquired brain
					 injury;
14. seizure disorders;
					 and
15. HIV/AIDS.
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-91 - Physician Services › Subsection 144-101-II-91.04 - MEMBER ELIGIBILITY FOR HOME SERVICES

Current through 2024-29, July 17, 2024
There are three (3) HOME service tiers: Intensive,
						Stabilization, and Maintenance. Members shall first meet the Intensive Tier
						criteria to receive HOME covered services. Once Intensive Tier eligibility is
						established, the HOME Provider shall assess Members for meeting Stabilization
						and Maintenance Tier criteria to ensure appropriate reimbursement. The Member's
						service tier may cycle back and forth between each tier, as indicated by the
						eligibility criteria.
Documentation of the Member's criteria for movement
						between tiers shall be retained in the Member's record. The expected intensity
						level of the covered services differs in each tier, but the covered services
						remain the same.
To be eligible for any HOME Provider service Tier,
						Members must meet the below eligibility criteria for one of the tiers and have
						at least two (2) chronic conditions or one (1) chronic condition and be at risk
						for a second chronic condition, in accordance with 91.03-1 and 93.03-2.
91.04-1
Intensive Tier: Member
					 Eligibility
For HOME Provider Intensive Tier services, Members
						must:
1. Currently be homeless and
					 have Long-term Homelessness; or
2.
					 Currently be homeless and have previously been in the Intensive Tier.
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-91 - Physician Services › Subsection 144-101-II-91.06 - COMMUNITY CARE TEAM COVERED SERVICES

Current through 2024-29, July 17, 2024
91.06-1
Comprehensive Care Management
The CCT willcoordinate and provide access to culturally
						and linguistically appropriate comprehensive care management, care
						coordination, and transitional care across settings for eligible Members.
						Levels of care management may change according to Member needs over
						time.
The CCT shall develop a Plan of Care with each Member
						served. The Plan of Care shall be recorded in the Member's record and in the
						CCT's EHR and include the Member's health goals and the services and supports
						necessary to achieve those goals (including prevention, wellness, specialty
						care, behavioral health, transitional care and coordination, and social and
						community services as needed). The CCT shall be responsible for the management,
						oversight, and implementation of the Plan of Care, including ensuring active
						Member participation and that measurable progress is made on the plan's goals.
						Services shall also include:
1. A
					 comprehensive biopsychosocial assessment, conducted face-to-face or via
					 telehealth in accordance with Chapter I, Section 4, which includes the
					 following components:
a. Physical health,
					 including oral health;
b. Mental
					 health, including any history of depression or anxiety;
c. Substance use (including at a minimum,
					 Screening Brief Intervention and Referral to Treatment (SBIRT)
					 services);
d.
					 Medications;
e.
					 Allergies;
f. Family
					 history;
g. Social
					 supports;
h. Housing
					 status;
i. Financial
					 status;
j. Nutritional
					 status;
k. Education;
l. Military service, if applicable;
m. Legal issues;
n. Vocational background;
o. Spirituality and religious preferences;
					 and
p. Leisure and recreational
					 activities.
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-91 - Physician Services › Subsection 144-101-II-91.07 - HOME COVERED SERVICES

Current through 2024-29, July 17, 2024
The HOME Provider shall conduct outreach to underserved
						Members with high emergency services utilization, chronic conditions, complex
						care coordination needs, and Long-term Homelessness in need of intensive HOME
						services. The HOME services tier in which the Member is enrolled will determine
						the intensity level required for each service.
91.07-1
Comprehensive Care
					 Management
Comprehensive Care Management includes the
						following:
1. Within the first thirty
					 (30) days following a Member's enrollment for HOME services, the HOME Provider
					 shall conduct a face-to-face comprehensive assessment which shall include:
a. An individual housing
					 assessment;
b. A SPDAT or Y-SPDAT
					 assessment;
c. A psychosocial
					 assessment, which shall include, at minimum, a history of trauma and abuse;
					 housing instability; substance use; general health and capabilities; behavioral
					 health and capabilities; and medication needs. The psychosocial assessment
					 shall also identify Member strengths and how they can be optimized to promote:
i. Medical and behavioral health
					 goals;
ii. Housing goals;
iii. Available support systems;
iv. Community integration;
v. Employment and/or educational status; and
vi. Self-management and
					 self-advocacy.
The SPDAT or Y-SPDAT assessment shall be repeated every
						90 days or more often when indicated by a significant change in the Member's
						circumstances or needs. Comprehensive reassessment must reoccur as changes in
						the Member's needs warrants or, at a minimum, 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-91 - Physician Services › Subsection 144-101-II-91.08 - REPORTING REQUIREMENTS

Current through 2024-29, July 17, 2024
In addition to the documentation and reporting
						requirements of the
MaineCare Benefits Manual
, Chapter I,
						Section I, and other reports that may be required by the Department, the CCTs
						and HOME Providers shall report in the format designated and frequency
						determined by the Department, including:
1. The Core Standards: The CCTs and HOME
					 Providers shall report on the Core Standards in Section
					 91.02.
2. Performance Measures: The CCTs and HOME
					 Providers shall submit data necessary to compile and report on performance
					 measures as identified by the Department. Data sources may include, but are not
					 limited to, claims, clinical data, surveys, risk scores, and administrative
					 encounter data.
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-91 - Physician Services › Subsection 144-101-II-91.09 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
1. Reimbursement is specified in Chapter III,
					 Section 91.
2. CCTs and HOME
					 Providers are eligible for reimbursement for each Member for each Billing Month
					 if they provide at least one Section
					 91.06 or
					 91.07 Covered Service
					 in accordance with the Member's Plan of Care.
3. For Members receiving HOME services and
					 residential or facility services concurrently, as allowable in 91.05, the HOME
					 Provider shall attest to the Member at the next less intensive tier of services
					 or remain attested at Maintenance Tier for the duration of the residential or
					 facility services. When residential or facility services end, the HOME Provider
					 shall attest to the Member at the most appropriate tier based on the Member's
					 current criteria.
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-92 - Behavioral Health Home Services › Subsection 144-101-II-92.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
92.01-1
Behavioral Health Home
					 Organization (BHHO)
- A BHHO is a community-based mental health
					 organization, that is licensed in the state of Maine, has been approved by
					 MaineCare to provide Section
					 92 services for members (both
					 adults and children) eligible for such services, and that satisfies the
					 additional provider requirements and standards set forth herein. The BHHO is
					 the lead Behavioral Health Home entity.
92.01-2
Electronic Health Record
					 (EHR)
- An EHR is a systematic collection of electronic health
					 information about individual MaineCare members. It is a record in digital
					 format that is capable of being shared across different health care settings by
					 a Department-designated health information exchange(s) (HIE), a
					 Department-designated network connected enterprise-wide information system(s),
					 and other information networks or exchanges. An EHR supports Clinical EHR
					 functions, such as intake, clinical care, task management, and case management
					 where appropriate, and has HL7 interoperability capabilities to support the
					 electronic sharing of portions of the patient's record.
92.01-3
Health Home Practice
					 (HHP)
- A HHP is an enhanced primary care practice that has been
					 approved by MaineCare to provide Section
					 92 services for members (both
					 adults and children) eligible for such services, and satisfies the additional
					 provider requirements and standards set forth herein.
92.01-4
National Committee for Quality
					 Assurance (NCQA)
- a private, 501(c)(3) not-for-profit organization
					 dedicated to improving health care quality.
92.01-5
Plan of Care
- The Plan
					 of Care is a person-centered plan that describes, coordinates and integrates
					 all of a member's clinical and non-clinical health care-related needs and
					 services. The Plan of Care shall include the member's physical health and
					 behavioral health goals (including recovery-oriented goals), and the services
					 and supports necessary to achieve those goals.
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-92 - Behavioral Health Home Services › Subsection 144-101-II-92.03 - MEMBER ELIGIBILITY

Current through 2024-29, July 17, 2024
Members must meet the eligibility requirements set forth
						in this section.
92.03-1
General
					 Eligibility
. Members must meet the eligibility criteria as set forth in
					 the
MaineCare Eligibility Manual
, Chapter 1, Section 1.
92.03-2
Specific
					 Requirements
A.
Serious and
					 Persistent Mental Illness (SPMI)
.Adult members must meet the following
					 criteria. Eligibility must be supported by written diagnosis(es), rendered by a
					 physician, a physician assistant, or an independently licensed clinician,
					 within the scope of the professional's license, and the diagnosis(es) shall be
					 documented in the member's record.
(1)
					 Members must have a primary mental health diagnosis under the most current
					 edition of the
Diagnostic and Statistical Manual of Mental
					 Disorders
,
except that
the following diagnoses may not be
					 primary diagnoses for purposes of this eligibility requirement:
(a) Delirium, dementia, amnestic, and other
					 cognitive disorders;
(b) Mental
					 disorders due to a general medical condition, including neurological conditions
					 and brain injuries;
(c) Substance
					 use or dependence;
(d) Intellectual
					 disability;
(e) Adjustment
					 disorders;
(f) Z-codes;
					 or
(g) Antisocial personality
					 disorder.
AND
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-92 - Behavioral Health Home Services › Subsection 144-101-II-92.06 - NON-COVERED SERVICES AND LIMITATIONS

Current through 2024-29, July 17, 2024
A. A member may
					 receive Section
					 92 services from only one BHHO and
					 one HHP. BHH services do not preclude a member from receiving other medically
					 necessary services.
B. Only the
					 Covered Services set forth herein shall be reimbursable through Section 92.
C. Only one Behavioral Health Home
					 Team shall be allowed for each member receiving Section
					 92 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-92 - Behavioral Health Home Services › Subsection 144-101-II-92.07 - REPORTING REQUIREMENTS

Current through 2024-29, July 17, 2024
In addition to the documentation and reporting
						requirements of the
MaineCare Benefits Manual
, Chapter I,
						Section I, and other reports that may be required by the Department, the BHHO
						and the HHP shall report in the format designated by the Department, on
						activities and improvement upon the following. Providers that fail to timely or
						adequately file reports or satisfy the benchmarks defined by the Department may
						be terminated from providing Section
						92 services.
A.
The Core Standards:
BHHOs and
					 HHPs shall report on the Core Standards in 92.02-1(L) (BHHOs) and 92.02-2(I)
					 (HHPs).
B.
Health Home
					 Quality Measures:
The BHHO and HHP shall submit data necessary to
					 compile and report on Behavioral Health Home Performance Measures as identified
					 by the Department and posted to the Behavioral Health Home webpage. Data
					 sources may include but are not limited to claims, clinical data, the DHHS
					 Enterprise Information System, certification submissions, and
					 surveys.
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-92 - Behavioral Health Home Services › Subsection 144-101-II-92.08 - DOCUMENTATION AND CONFIDENTIALITY

Current through 2024-29, July 17, 2024
In addition to the requirements, above, and set forth in
						Chapter I, Section I, the BHHO and the HHP must maintain a specific record and
						documentation of services for each member receiving covered services.
A.
Records.
The member's record
					 must minimally include:
(1) Name, address,
					 birthdate, and MaineCare identification number;
(2) Diagnosis(es) that support eligibility
					 for services herein, including the most recent documentation of diagnoses that
					 substantiate ongoing eligibility for services;
(3) The comprehensive assessment that must
					 occur within the first thirty (30) days of initiating of services, and any
					 reassessments that occur;
(4) The
					 Plan of Care;
(5) Correspondence to
					 and from other providers;
(6)
					 Release of information statements as necessary, signed by the member or
					 guardian;
(7) Documentation/record
					 entries (i.e. progress notes) for each service provided, including the date of
					 service, the type of service, the place of the service or method of delivery
					 (i.e., phone contact), the goal to which the service relates, the duration of
					 the service, the progress the member has made towards goal attainment, the
					 signature and credentials of the individual performing the service, whether the
					 individual has declined services in the Plan of Care, and timelines for
					 obtaining needed 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-92 - Behavioral Health Home Services › Subsection 144-101-II-92.09 - MINIMUM REQUIREMENTS FOR REIMBURSEMENT

Current through 2024-29, July 17, 2024
Reimbursement for Section
						92 services shall be as
						follows:
A.
Minimum Requirements
					 for BHHO Reimbursement. The Department shall seek and anticipates receiving CMS
					 approval for this Section. Pending approval,
in order for the BHHO to be
					 eligible for the per member per month (PMPM) payment, for each member for each
					 calendar month, the BHHO shall:
(1) In
					 collaboration with the member and other appropriate providers, including but
					 not limited to the primary care practice, and in accordance with 92.05-1(A)( 2)
					 develop and/or update the Plan of Care with pertinent information from monthly
					 activities or developments;
(2)
					 Submit cost and utilization reports upon request by the Department, in a format
					 determined by the Department;
(3)
					 Scan the utilization data, as identified by MaineCare, for its assigned
					 population;
(4) Deliver at least
					 one (1) Section
					 92.05 Covered Service
					 to an enrolled member within the reporting month, pursuant to the member's Plan
					 of Care. At least one (1) of the services must include a member encounter
					 (including encounters with a member's family, guardian(s), or caregiver, if
					 appropriate and pursuant to the Plan of Care) except that the BHH may attest to
					 a member for a single month if a Section
					 92 service was delivered and a
					 member encounter was attempted, but not achieved. This exception is allowable
					 only for one month during a twelve-month period.
(5) Make payment to affiliated HHPs for their
					 members enrolled as a BHH member in those affiliated practices.
The BHHO must document each service provided to each
						member, for each calendar month, in order to be eligible to receive the PMPM
						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-93 - Opioid Health Home Services › Subsection 144-101-II-93.03 - MEMBER ELIGIBILITY

Current through 2024-29, July 17, 2024
Members must meet the eligibility requirements set forth
						in this section.
93.03-1
General
					 Eligibility
Members must meet the eligibility criteria described in
						Chapter I, Section 1 of the
MBM
and in the
MaineCare
						Eligibility Manual
, 10-144 Chapter 332.
93.03-2
Specific Requirements
All diagnoses and qualifying risk factors must be
						documented in the member's Plan of Care/ITP.
Members must be diagnosed with Substance Use Disorder,
						Opioid (as set forth in the
Diagnostic and Statistical Manual of Mental
						Disorders
(5th ed.
DSM-5
)); AND have a second chronic
						condition OR be at risk of having a second chronic condition.
A.
Eligible Chronic Conditions as
					 Second Chronic Condition
1. a mental
					 health condition;
2. an additional
					 substance use disorder (other than OUD);
3. tobacco use;
4. diabetes;
5. heart disease;
6. overweight or obese as evidenced by a body
					 mass index over 25;
7. Chronic
					 Obstructive Pulmonary Disease (COPD);
8. hypertension;
9. hyperlipidemia;
10. developmental and intellectual
					 disorders;
11. circulatory
					 congenital abnormalities;
12.
					 asthma;
13. acquired brain injury;
					 and
14. seizure
					 disorders.