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-50 - ICF-MR Services › Subsection 144-101-II-50.07 - COVERED SERVICES

Current through 2024-29, July 17, 2024
50.07-1
Routine Services, Supplies, and Equipment Included in Regular Rate for
					 Reimbursement
Routine services, supplies, and equipment must be
						supplied by the facility as part of the regular rate of reimbursement. Routine
						services include regular room, dietary services, rehabilitation treatment
						services and nursing services, minor medical and surgical supplies, and the use
						of equipment and facilities.
ICFs-MR are expected to furnish the equipment and
						services (see attached Appendix) normally used in the care of the their
						resident population (e.g. children's wheelchairs) as part of their reasonable
						cost.
50.07-2
Supplies and Equipment for Which the Department may be Billed by a Supplier or
					 Pharmacy
Equipment and supplies which, when ordered by a physician
						or other medical practitioner legally qualified to order such equipment and
						supplies, may be payable to a supplier or pharmacy in accordance with the
						policies established in Section 60, Medical Supplies and Durable Medical
						Equipment and Section 80, Pharmacy Services of the MaineCare Benefits
						Manual.
For purposes of reimbursement, acute care general
						hospitals that are affiliated with the facility through the same corporate
						structure, or have an ICF-MR as a distinct part of a larger institution, may be
						a provider of medical supplies and durable medical equipment for members who
						are residents of the hospital-based ICF-MR.
50.07-3
Physical Therapy (PT) and
					 Occupational Therapy (OT) Services
Physical and occupational therapy services must be
						directly and specifically related to an active written treatment regimen
						designed by the physician after any necessary consultation with the qualified
						physical or occupational therapist, and the services must be included in the
						written plan of care. To constitute physical or occupational therapy, a service
						furnished to a member must be reasonable and necessary for the treatment of his
						or her illness or condition. The necessary services must be of such a level of
						complexity and sophistication, or the condition of the member must be such,
						that the judgment, specialized knowledge, and skills of a qualified physical or
						occupational therapist are required. Please refer to Section 85, Physical
						Therapy Services and Section 68, Occupational Therapy Services for criteria of
						the practitioner and covered services.
Adult members (age twenty-one (21) and over) are
						specifically eligible only for:
A.
					 Treatment following an acute hospital stay for a condition affecting range of
					 motion, muscle strength, and physical functional abilities; and/or
B. Treatment after a surgical procedure
					 performed for the purpose of improving physical function; and/or
C. Treatment in those situations in which a
					 physician or primary care provider has documented that the patient has at some
					 time during the preceding thirty (30) days required extensive assistance (see
					 Section 50.01-5) in the performance of one or more of the following activities
					 of daily living: eating, toileting, locomotion, transfer or bed mobility;
					 and/or
D. Medically necessary
					 treatment for other conditions including maintenance of function and palliative
					 care, however, services for palliative care and maintenance of function are
					 limited to one (1) visit per year to design a plan of care, train the member or
					 caretaker of the member to implement the plan or to reassess the plan of
					 care.
E. Services for adults who
					 meet the specific eligibility requirements in Section 50.05-1(B)(1-3) above
					 must be initiated within sixty (60) days from the date of physician or primary
					 care provider certification.
F.
					 Services for adults who do not meet the criteria in Section 50.05-1(B)(1-3)
					 must be medically necessary as documented by a certification by a physician or
					 primary care provider, however, such treatment is limited to no more than one
					 (1) visit per condition by qualified staff.
G. Limitations:
a. MaineCare will not reimburse for more than
					 two (2) hours of PT per day and/or no more than two (2) hours of OT per day. If
					 the member is under twenty-one (21) years old and these limits need to be
					 exceeded due to medical necessity, then prior authorization is required as
					 detailed in Chapter II, Section 94 of the MaineCare Benefits Manual.
b. PT or OT services can be provided by a
					 home health agency certified as a Medicare provider, or an outpatient
					 department of an acute hospital, or a licensed independent therapist as defined
					 in Chapter II, Sections 68 and 85 of the MaineCare Benefits Manual.
c. ICFs-MR may bill for services of PT and/or
					 OT on their staff or under a contract with them. Reimbursement for services
					 provided by a licensed independent physical or occupational therapist will be
					 limited to the maximum allowance as defined in Chapter III, Sections 68 and 85
					 of the MaineCare Benefits Manual.
d. For purposes of reimbursement, acute care
					 general hospitals that are affiliated with the facility through the same
					 corporate structure, or have an ICF-MR as a distinct part of a larger
					 institution, must bill the Department as a provider of physical or occupational
					 therapy services on the ICF-MR billing form for patients who are residents of
					 the hospital-based ICF-MR.
H. PT and OT Consultations
Types of consultation that will be approved:
a. In-service education programs for staff
					 members who have not been trained to carry out procedures that may be delegated
					 by a physical or occupational therapist.
b. Professional consultation provided to
					 administrators with respect to purchasing equipment or modification of a
					 physical plant to meet the needs of members.