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-94 - Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) › Subsection 144-101-II-94.03 - PREVENTION SERVICES

Current through 2024-29, July 17, 2024
94.03-1
Bright Futures Health Assessment Visits
A.
Bright Futures Guidelines
In Appendix 1, MaineCare has adopted the most recent
						version of the Bright Futures Guidelines for Health Supervision of Infants,
						Children and Adolescents of the American Academy of Pediatrics (
http://brightfutures.aap.org
)
						(hereinafter "Bright Futures") as the standard of care expected at health
						assessment visits for MaineCare members under the age of 21. There are nineteen
						(19) separate age appropriate MaineCare Bright Futures health assessment forms
						that delineate the age-specific guidelines for each required visit.
See Appendix 1 for the MaineCare Bright Futures periodic
						health assessment schedule that begins with a neonatal examination and
						continues up to the age of 21.
B.
Provider Requirements
In order to do health assessments under the Bright
						Futures guidelines, a provider must:
1. be a physician, a physician's assistant,
					 an advanced practice registered nurse in private practice, or those staff
					 employed in a Rural Health Clinic, an ambulatory care clinic, a hospital based
					 practice, or a Federally Qualified Health Center;
2. be a MaineCare provider, i.e. have signed
					 a MaineCare Provider/Supplier Agreement;
3. sign a Supplemental Provider
					 Agreement;
4. follow the MaineCare
					 Bright Futures periodic health assessment schedule (Appendix 1);
5. document health assessment visits on the
					 appropriate MaineCare Bright Futures health assessment form. If the health
					 assessment exam using the Bright Futures guidelines differs from the reminders
					 on the MaineCare health assessment form, please note it in the comment section
					 of the form.
If one or more components of a health assessment visit
						are performed elsewhere (e.g. by another provider because of a referral, by a
						Head Start agency or by a school), the results of the procedure(s) done by
						others must be recorded on the MaineCare Bright Futures health assessment form
						before a provider may request payment for the health assessment visit. In all
						cases, each component of the health assessment must be addressed.
6. establish and maintain a
					 consolidated health record for each member that includes, but is not limited
					 to, the following:
a. identifying information
					 (e.g. member's name, address, birth date, MaineCare ID number, and the name of
					 the caretaker, if applicable);
b.
					 comprehensive health history including information from health assessment
					 visits and/or from other providers;
c. documentation of comprehensive, unclothed
					 and age-appropriate physical examinations;
d. documentation of the diagnosis and
					 treatment of problems discovered or suspected as a result of a health
					 assessment visit; and
e. treatment
					 plan as necessary for problems discovered. A provider of treatment may modify
					 his or her treatment plan at any time. Also, a parent or other qualified
					 provider may request modification of the treatment plan.
Providers may meet these documentation requirements by
						retaining completed copies of the MaineCare Bright Futures health assessment
						forms in each child's consolidated health record; and
7. comply with Chapter I,
					 Administrative Policies and Procedures, of the MaineCare Benefits Manual and
					 any other Sections of the MaineCare Benefits Manual that apply to the services
					 they provide.
C.
Lead
1.
Blood Lead
					 Testing
MaineCare children are at significantly higher risk for
						lead exposure than other children and have higher lead levels according to
						MaineCare data.
As part of the Bright Futures health assessment visit
						done at one and two years of age, providers must test the blood for lead
						levels. MaineCare will pay MaineCare physicians, physician's assistants, and
						advanced practice registered nurses who are in private practice an enhanced
						reimbursement for venous and capillary blood draws when they are done for blood
						lead testing.
2.
Environmental Investigations
MaineCare will reimburse the Maine Department of Health
						and Human Services, Centers for Disease Control and Prevention for
						environmental investigations of a child's home or primary residence when the
						child has been diagnosed as having an elevated blood lead level. MaineCare will
						not pay for testing of substances such as soil, dust, paint or water which are
						sent to a laboratory for analysis.
D.
Immunizations
As part of the Bright Futures health assessment visit,
						providers must evaluate the member's immunization history and bring him or her
						up to date on all required immunizations. If immunizations are needed but
						cannot be administered at the time of a health assessment visit, the provider
						should recall the member to give the immunizations at a more appropriate
						time.
MaineCare recommends that providers use the Maine
						Department of Health and Human Services, Centers for Disease Control and
						Prevention, guidelines for provision of age appropriate immunizations. The
						Centers for Disease Control and Prevention uses the Federal Centers for Disease
						Control and Prevention guidelines. These guidelines may be obtained by
						contacting the Centers for Disease Control and Prevention Immunization
						Program.
E.
Health
					 Assessments Done Outside of the Normal Schedule
When children need health assessments outside of the
						normal schedule, providers must use the age appropriate MaineCare Bright
						Futures health assessment form for the age closest to the child's chronological
						age to document the visit.
When children have behavioral health issues, any
						treatment provider or individuals outside of the health care system can request
						an examination off the periodic health assessment schedule with the consent of
						the child and/or the child's parent(s) or guardian(s). Individuals outside of
						the health care system include, but are not limited to, teachers, school
						nurses, and day care providers.
F.
Follow-up Treatment
The provider must initiate medically necessary follow-up
						treatment identified as needed during a health assessment visit, including but
						not limited to treatment for defects in vision, hearing and dental care, at the
						earliest practical date commensurate with the needs of the child. Generally,
						this should happen within six months from the date of the health assessment
						visit.
Billing for follow-up treatment for health care needs
						identified during the health assessment visit must be done using the
						appropriate Evaluation and Management Current Procedural Terminology (CPT)
						codes. Do not use the MaineCare Bright Futures health assessment form when
						billing for follow-up treatment services.
Members enrolled in MaineCare managed care may need a
						referral from their primary care provider if the needed follow-up treatment is
						a "managed service."
G.
Omission of Health Assessment Components
One or more components of a health assessment visit may
						be omitted if any of the following circumstances exist. If any of the following
						circumstances exist and a component of the health assessment visit is not
						performed, the provider must record the appropriate reason on the MaineCare
						Bright Futures health assessment form.
1.
Procedure Impossible to
					 Perform
In some circumstances the member's behavior may be such
						that a procedure is impossible to perform. In the interest of providing
						comprehensive health assessments for all children, the provider should arrange
						another appointment with the member and attempt the procedure(s) again before
						submitting a claim for the health assessment visit.
2.
Religious Exemption
Some procedures, especially immunizations, are contrary
						to the religious beliefs of some members/caretakers and may be refused on that
						basis.
3.
Member/Caretaker Does Not Want Procedure Done
Members/caretakers occasionally may ask that specific
						procedures not be done. These personal requests may be granted, but should be
						distinguished from religious exemptions when possible.
4.
Procedure Not Medically Necessary or
					 Medically Contraindicated
The provider may omit a procedure if, in his/her
						professional judgment, the procedure is not medically necessary or is medically
						contraindicated.