Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 505 - APPROPRIATENESS REVIEW PROCEDURES AND CRITERIA › Section 144-505-5 - GENERAL CRITERIA

Current through 2024-29, July 17, 2024
The Maine Health Systems Agency, Inc. and the Department of
				  Human Services shall use the following general criteria relating to the
				  availability, accessibility, acceptability,. continuity, cost, and quality of
				  the service in conducting appropriateness reviews. Criteria based upon the
				  following general criteria specific to the service(s) being reviewed shall be
				  developed and published along with the written request(s) for information
				  needed by the MHSA and the Department to conduct any particular review.
				  Specific standards relating to the criteria may also be developed and published
				  prior to the formal commencement of a review by the MHSA or the Department. If
				  a service compares unfavorably with one or more of the criteria, it may result
				  in the MHSA and/or the Department finding that service to be inappropriate.
				  However, if during the course of their respective reviews the MHSA or the
				  Department determines any criterion published prior to their reviews to be
				  inadequate, that criterion shall not be used in their development of findings
				  on the service(s) in question. In the case of areawide reviews which result in
				  institution-specific findings of services provided by or through HMO's, the
				  considerations shall be limited to those set forth in paragraph (H) of this
				  section.
A. The relationship of the
				health services being reviewed to the applicable health systems plan, annual
				implementation plan, and State health plan.
B. The relationship of the services reviewed
				to the long-range development plan (if any) of the person providing the
				services.
C. The need that the
				population served has for the services, and the extent to which low income
				persons, racial and ethnic minorities, women, handicapped persons, and other
				underserved groups have access to those services.
D. The availability of less costly or more
				effective alternative methods of providing the services.
E. The relationship of the services reviewed
				to the existing health care system of the area in which the services are
				provided.
F. The availability of
				resources (including health manpower, management personnel and funds for
				capital and operating needs) for the provision of the services reviewed and the
				availability of alternative uses of these resources for the provision of other
				health services.
G. The special
				needs and circumstances of those entities which provide a substantial portion
				of their services or resources or both, to individuals not residing in the
				health service areas in which the entities are located or in adjacent health
				services areas. These entities may include medical and other health professions
				schools, multidisciplinary clinics, and specialty centers.
H. The special needs and circumstances of
				HMOs. In the case of areawide reviews which result in institution specific
				findings regarding services provided by or through an HMO, the needs and
				circumstances shall be limited to:
1. The
				needs of enrolled members and reasonably anticipated new members of the HMO for
				the existing institutional health services provided by the
				organization.
2. Whether the
				services could be obtained from non-HMO, or other HMO providers in a reasonable
				and cost-effective manner which is consistent with the basic method of
				operation of the HMO.
3. Any other
				factors which the State Agency may propose and the Secretary of the Department
				of Health and Human Services may find to be consistent with the purpose of
				Title XIII of the Act.