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-21 - Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-21.16 - APPENDIX III- On Behalf of Covered Activities

Current through 2024-29, July 17, 2024
The purpose of this Appendix is to detail guidelines for
						the Office of Aging and Disability Services in approving a Medical Add-On to
						the established published rate. All current statutes, regulations, decree
						provisions, policies, and licensing standards regarding medical services are
						unaffected by these guidelines. This Appendix develops criteria that warrant an
						adjustment to DHHS' established published rate for Home Support, Community
						Support, Employment Specialist Services and Work Support
						Services-Individual.
The Clinical Review Team (CRT) is the entity within OADS
						that is responsible for review and approval, of all Medical Add-On rate
						increases for services under this section.
The rate supports Members with intermittent or longer
						duration medical conditions; changes or needs that may support Medical Add-On
						include but are not limited to: support over and beyond routine services such
						as ventilators, nebulizers, diabetes management-insulin dependent, suctioning,
						seizure management-uncontrolled, chronic eating disorders, or persons with
						co-existing conditions that significantly affect physical movement and require
						near total physical assistance on a daily basis. Conditions related to
						surgeries, procedures, injuries and other short-term conditions are also
						considered for the Medical Add-On rate increase.
The following standards and practices must be
						demonstrated in order for the CRT to approve a Medical Add-On:
A.
Physician Order
1. There must be a written physician's or
					 physician assistant order, less than three (3) months old, for the Member. This
					 order must specify:
a. The specific illness or
					 condition to be addressed;
b. The
					 specific procedure(s) that will be utilized;
c. The time span over which the treatment or
					 intervention is expected to be needed. If the treatment or intervention is
					 expected to be needed for an indefinite period of time then this expectation
					 should be specified;
d. The
					 anticipated frequency of treatment or intervention on a daily, weekly, or
					 monthly basis;
e. Where applicable
					 and possible:
I. The approximate length of
					 time required for each episode of the treatment or intervention and
II. The degree of licensure or certification
					 required for those who carry out the treatment, and those who provide training
					 and oversight relative to its application.
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-21 - Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-21.18 - APPENDIX V- Additional Requirements for Section 21 Providers of Home Support Services, Shared Living, Community Support Services and Employment Specialist Services

Current through 2024-29, July 17, 2024
Providers must first be approved by OADS and subsequently
						enroll in MaineCare in order to provide services and be reimbursed under this
						Benefit.
Prior to approval and thereafter, the provider, any
						contractor or subcontractor of the provider, or other individuals compensated
						by the provider for assisting in the care of Member (s) shall be subjected to
						site visits and interviews to ensure compliance with federal and state laws and
						regulations and the operational, health, safety and environmental requirements
						set forth herein. The provider shall permit OADS representative(s) to visit the
						Member and the Member's home and program as often as DHHS deems necessary to
						assure quality services, including unscheduled visits.
The provider must submit the following to the OADS
						District Resource Coordinator:
A.
Application Form
. Initial applications shall be submitted using
					 DHHS forms to the OADS District Resource Coordinator. The initial application
					 shall be signed and dated by the provider owner and the presiding officer of
					 the Governing Body, if applicable.
B. The initial application shall be
					 accompanied by documents described in this section of rule demonstrating
					 compliance with requirements described in the following portions of these
					 rules:
1.
Organizational
					 Structure
a.
Ownership
i.
Authority
. The provider shall
					 maintain documented evidence of its source(s) of authority to provide services.
					 Such evidence will include articles of incorporation, corporate charter, or
					 similar documents.
ii.
Records
. Corporations, partnerships, or associations shall
					 maintain records of the contact information for officers, directors, charters,
					 partnership agreements, constitutions, articles of association and/or by-laws,
					 as applicable.
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-22 - Home and Community Benefits for the Physically Disabled(Repealed)

Current through 2024-29, July 17, 2024
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-23 - Developmental and Behavioral Clinic Services › Subsection 144-101-II-23.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
23.01-1
Developmental and Behavioral
					 Evaluation Clinic
means a clinic that provides Developmental and
					 Behavioral Evaluations, Child Abuse Evaluations, or Foster Care Comprehensive
					 Health Assessments for members aged birth through twenty (20) years. A
					 Developmental and Behavioral Evaluation Clinic may operate as a sub-unit of an
					 existing agency and shall be licensed by the Department of Health and Human
					 Services (DHHS or Department) to provide outpatient therapy services.
23.01-2
Approved Staff Members
means licensed professional staff who are employed directly by a Developmental
					 and Behavioral Evaluation Clinic, as well as appropriate licensed professionals
					 providing covered services by consultant arrangement, subcontract, or
					 cooperative agreement with a Developmental and Behavioral Evaluation Clinic.
					 Foster Care Comprehensive Health Assessment Services may be provided by
					 Approved Staff Members or by other qualified professionals in accordance with
					 this Section.
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-23 - Developmental and Behavioral Clinic Services › Subsection 144-101-II-23.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Members must meet the basic eligibility criteria as set
						forth in Part 2 of the
MaineCare Eligibility Manual
, 10-144
						CMR Chapter 332.
23.02-1
Birth
					 through age twenty (20).
Members aged birth through twenty (20) are
					 eligible for Developmental and Behavioral Evaluations and Child Abuse
					 Evaluations as set forth in this section.
23.02-2
Children in the care and
					 custody of the Department.
Members aged birth through eighteen (18) who
					 enter the care and custody of the Department are eligible for Developmental and
					 Behavioral Evaluations, Child Abuse Evaluations, and a Foster Care
					 Comprehensive Health Assessment (CHA) as set forth in this Section.
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-23 - Developmental and Behavioral Clinic Services › Subsection 144-101-II-23.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each member is eligible for covered services which are
						medically necessary and are provided within the maximum number of reimbursable
						evaluations as stated in this Section. 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-23 - Developmental and Behavioral Clinic Services › Subsection 144-101-II-23.05 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
23.05-1
Academic
. Any programs, services, or components of services
					 provided to members which are academic in nature are not reimbursable by
					 MaineCare. Academic services are those traditional subjects such as science,
					 history, literature, foreign languages, and mathematics.
23.05-2
Vocational
. Any
					 programs, services or components of service provided to members of which the
					 basic nature is to provide a vocational program not reimbursable by MaineCare.
					 Vocational services are organized programs directly related to the preparation
					 of individuals for paid or unpaid employment, such as vocational skills
					 training, sheltered employment.
23.05-3
Socialization &
					 Recreational Services
. Any programs, services, or components of services
					 of which the basic nature is to provide opportunities for socialization or
					 recreation are not reimbursable under the MaineCare Program unless such
					 services are provided as part of the member's service plan for which the
					 specific goals and objectives must be specifically identified in that plan.
					 These non-covered services include, but are not limited to picnics, dances,
					 ball games, parties, field trips, and social clubs.
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-23 - Developmental and Behavioral Clinic Services › Subsection 144-101-II-23.06 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
23.06-1
Setting.
The services described in this Section must be provided
					 in settings which are appropriate to the member's needs.
23.06-2
Professional Staff.
Developmental and Behavioral Evaluations, Child Abuse Evaluations, and CHAs are
					 reimbursable services when provided by appropriately licensed providers acting
					 within the scope of their licensure.
Providers shall collect and retain copies of current
						licenses of professional staff and shall produce them for purposes of
						enrollment.
23.06-3
Member's Records.
The Developmental and Behavioral Evaluation,
					 Child Abuse Evaluation, and CHA services must be performed under the direct
					 supervision of a physician and that fact must be documented in the member's
					 record.
There shall be a specific record for each member which
						shall include but not be limited to:
A. The evaluation components provided, the
					 provider(s) of each component, the goal(s) of the evaluation, and the method(s)
					 or action(s) to achieve that goal.
B. Complete results of all Developmental and
					 Behavioral Evaluations, Child Abuse Evaluation, and CHA services, including
					 reports of each individual assessment and reports of any consultations
					 held.
C. A closing summary signed
					 and dated by the physician who supervised the Developmental and Behavioral
					 Evaluation, Child Abuse Evaluation, and CHA service. The closing summary shall
					 contain, at minimum:
(1) reason for
					 referral,
(2) medical
					 considerations,
(3) functional
					 strengths and limitations,
(4) 
					 diagnosis(es),
(5)
					 recommendations.
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-23 - Developmental and Behavioral Clinic Services › Subsection 144-101-II-23.07 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
The Department shall submit to CMS and anticipates
						approval for a State Plan Amendment related to this provision.
A. Specific reimbursement rates are listed in
					 the table below and on the MaineCare Provider Fee Schedule that is posted on
					 the Department's website in accordance with
					 22 MRS
					 §3173-J(7).
Covered
									 Service
Unit of
									 Service
7/3/24
									 Rate
Developmental and Behavioral
									 Evaluation
Per Hour
$91.34
Child Abuse Evaluation
Per Hour
$209.48
CHA Initial Assessment
Per Assessment
$1,462.48
CHA Follow-up Evaluation
Per Evaluation
$357.01
B. In accordance with
					 22 MRSA
					 §3173-J (2)(D)(3),
					 every rate that did not receive a rate adjustment within the past twelve months
					 will receive an annual cost-of-living-adjustment equal to the annual increase
					 in the Consumer Price Index for Urban Wage Earners and Clerical Workers
					 (CPI-W), for the Northeast Region, or its successor index, as published by the
					 United States Department of Labor, Bureau of Labor Statistics or its successor
					 agency, every July 1st.
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-23 - Developmental and Behavioral Clinic Services › Subsection 144-101-II-23.08 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
A. Providers must
					 bill in accordance with the Department's billing instructions for the CMS1500
					 claim form.
B. CHA Billing
					 Instructions
1. CHA Initial Assessment Bundled
					 Payment
Providers may bill for the CHA initial assessment once
						they submit the CHA final report. The bundled payment for the CHA initial
						assessment includes reimbursement for the medical exam component and the CHA
						final report.
2. CHA
					 Follow-up Evaluation Bundled Payment
Providers may bill for the CHA follow-up evaluation once
						they complete the follow-up evaluation and submit reports to the Department.
						The bundled payment for the CHA follow-up evaluation includes reimbursement for
						the medical exam component and the medical report.
3. CHA Psychosocial Evaluation Component
					 Reimbursement
Providers must deliver and bill for the services that
						make up the psychosocial component of the CHA in accordance with the applicable
						section of the MBM.
Billing instructions are available upon request or from
						the Department's website at:
https://mainecare.maine.gov/Billing%20Instructions/Forms/Publication.aspx
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-24 - Day Habilitation Services for Persons with Mental Retardation (absorbed by Ch. II Section 28)

Current through 2024-29, July 17, 2024
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-25 - Dental Services and Reimbursement Methodology › Subsection 144-101-II-25.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
25.01-1
Board
means the Maine
					 Board of Dental Practice established in
					 Title 5,
					 section12004-A, subsection
					 10.
25.01-2
Dental Extern
means a
					 student in a doctoral dentistry program participating in an
					 externship.
25.01-3
Dental
					 Hygienist
means a person who holds a valid license as a dental hygienist
					 issued by the Board.
25.01-4
Dental Resident
means any person with a resident dentist license,
					 as defined in
					 32 M.R.S.
					 §18302.
25.05-5
Dental Services
means
					 diagnostic, preventive, or corrective procedures provided by or under the
					 supervision of a dentist in the practice of their profession, including
					 treatment of the teeth and associated structures of the oral cavity and
					 disease, injury, or impairment that may affect the oral or general health of
					 the MaineCare member.
25.01-6
Dental Therapist
means a person who holds a valid license as a
					 dental hygienist issued by the Board and is authorized to practice dental
					 therapy under 32 MRS Chapter 143.
25.01-7
Dentist
means a person
					 who holds a valid dentist license issued by the Board.
25.01-8
Dentistry
means the
					 scope of practice for a dentist as described in
					 32 MRS
					 §18371(1).
25.01-9
Denture
means any
					 removable full or partial upper or lower prosthetic dental appliance to be worn
					 in the human mouth to replace any missing natural teeth.
25.01-10
Denturist
means a
					 person who holds a valid denturist license issued by the Board.
25.01-11
Independent Practice Dental
					 Hygienist
means a person who holds a valid license as a dental hygienist
					 issued by the Board and who is authorized to practice independent dental
					 hygiene.
25.01-12
Teledentistry
, as it pertains to the delivery of oral health care
					 services, means the use of interactive, real-time visual, audio or other
					 electronic media for the purposes of education, assessment, examination,
					 diagnosis, treatment planning, consultation and directing the delivery of
					 treatment by individuals licensed under 32 MRS Chapter 143 (Dental Professions)
					 and includes synchronous encounters, asynchronous encounters, remote patient
					 monitoring, and mobile oral health care in accordance with practice guidelines
					 specified in rules adopted by the Board.
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-25 - Dental Services and Reimbursement Methodology › Subsection 144-101-II-25.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Individuals must meet the eligibility and residency
						requirements 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-25 - Dental Services and Reimbursement Methodology › Subsection 144-101-II-25.03 - COVERED SERVICES

Current through 2024-29, July 17, 2024
The Maine Department of Health and Human Services
						(Department) will reimburse for the below covered services when medically
						necessary and appropriately delivered by a rendering provider working within
						their scope of practice. Some covered services require prior authorization
						(PA), have age limits, and/or have additional requirements. Providers shall
						retain in the member's record a narrative of medical necessity, appropriate
						pre-operative radiographs, and any other documentation that supports medical
						necessity for each service delivered. Unless otherwise specified, all services
						are reimbursable once the entirety of the service is delivered.
Miscellaneous Dental Services that do not have an
						assigned Common Dental Terminology (CDT) code are covered with a
						Department-approved PA.
25.03-1
Diagnostic Services
A.
Oral
					 Evaluations
1. Comprehensive oral
					 evaluations are covered once per member per three (3) years per service
					 location. Comprehensive limited oral evaluations may be provided to new
					 patients or established patients who have had a significant change in health
					 conditions or other unusual circumstances.
2. Periodic oral evaluations are covered
					 twice per member per year. Any comprehensive oral evaluations that a member
					 receives shall count towards this limit.
3. Limited oral evaluations, detailed and
					 extensive oral evaluations, and re-evaluations have a combined limit of once
					 per member per service location per date of service. This means a member may
					 receive one of these types of evaluations at each eligible service location in
					 a single day, as necessary for referrals.
4. Comprehensive periodontal evaluations are
					 covered twice per member per year.
5. Oral evaluations for a member under three
					 (3) years of age, which include counseling with the primary caregiver, are
					 covered twice per year.
6.
					 Screening of a patient is covered once per member per service location per date
					 of service. Screenings include state and federally mandated screenings that
					 determine if a member needs to be seen by a dentist for a diagnosis and
					 typically include a brief oral examination.
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-25 - Dental Services and Reimbursement Methodology › Subsection 144-101-II-25.04 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
A. The Department
					 does not cover any service that is not described in Section 25.03 or that does
					 not have an approved PA if required.
B. The Department does not cover services
					 that are delivered for cosmetic or aesthetic purposes.
C. The Department does not reimburse for
					 missed appointments but they may be reported using the appropriate CDT code for
					 tracking purposes once per member per missed appointment. A member cannot be
					 billed for a missed appointment even if the member was notified in advance
					 there would be a charge.
D.
					 Dental-related services not covered in this Section of the MBM may be covered
					 in other Sections. These include, but are not limited to, some oral and
					 maxillofacial surgery and maxillofacial prosthetic 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-25 - Dental Services and Reimbursement Methodology › Subsection 144-101-II-25.05 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
25.05-1
Prior
					 Authorization
Providers shall use the appropriate PA criteria sheet on
						the Department's HealthPAS Portal when requesting PA. If a covered service does
						not have a unique criteria sheet with specific criteria, providers shall use
						the Supplemental Dental Services PA Form and include a narrative of medical
						necessity, appropriate radiographs, and any other documentation that
						demonstrates medical necessity. The Department may use PA criteria that are
						industry recognized criteria from a national company under contract. In cases
						where criteria are not met, providers may submit additional supporting evidence
						such as medical documentation to demonstrate that the requested service is
						medically necessary. Providers may submit a PA to exceed the limit for a
						covered service, and the Department will approve the PA if it determines
						exceeding the limit is medically necessary. The Department may request
						additional documentation before approving a PA if the documentation provided is
						insufficient.
25.05-2
Provider Requirements
Providers of covered services described in Section 25.03
						shall be appropriately licensed by the Board, abide by the Board's rules, and
						meet requirements and only deliver services in accordance with their scope of
						practice as defined in 32 M.R.S. Chapter 143.
Covered services rendered by Dental Residents and Dental
						Externs shall be reimbursed to entities enrolled as MaineCare providers
						employing or sponsoring Dental Residents and Dental Externs.
25.05-3
Timeframe Limits for Covered
					 Services
"Year," in the context of covered service limits, means
						"calendar year" when the limit is defined on a "per year" basis. For covered
						service limits that are defined on a multi-year basis, each "year" means a
						rolling 365-day period or the 365 days following the date of the delivery of
						the first covered service subject to the limit. For example, a "two per three
						years" limit means a member cannot receive more than two of the specified
						services in any given 1,095-day period.
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-25 - Dental Services and Reimbursement Methodology › Subsection 144-101-II-25.06 - REIMBURSEMENT METHODOLOGY

Current through 2024-29, July 17, 2024
Specific reimbursement rates are listed on the dental fee
						schedule, which is posted on the Department's website in accordance with
						22 MRSA
						§3173-J(7).
						Reimbursement for covered services may be inclusive of, but is not limited to,
						local anesthesia, sutures, materials, supplies, and routine postoperative
						care.
Reimbursement rates are based on the following
						methodology:
A.
Benchmarks
The Department calculates reimbursement rates for covered
						CDT codes using either the Commercial Median Benchmark or the All-States
						Medicaid Average Benchmark.
1. The
Commercial Median Benchmark
for each CDT code is the median of
					 Maine commercial payer dental claim allowed amounts when the claim is paid as
					 primary with an allowed amount greater than zero (0) based on data from the
					 Maine Health Data Organization's All Payer Claims Database. The Commercial
					 Median Benchmark rate for a CDT code must have equal to or greater than
					 one-hundred (100) claims billed in the source data used to set the benchmarks
					 in order for the Department to consider it reliable. Benchmarks are assessed
					 every two (2) years utilizing claims from the most recent Maine state fiscal
					 year.
2. The
Medicaid State
					 Average Benchmark
(Medicaid Benchmark) is the average of all other
					 states' Medicaid rates for a CDT code, where rates are available and reliable.
					 The Department excludes any rates as unreliable in the determination of the
					 Medicaid Benchmark when they represent outliers in comparison to the other
					 state rates, or when there is excessive variation across all state rates
					 available. If a Medicaid agency uses different child and adult rates, the
					 Department uses the average of the rates. Benchmarks are assessed every two (2)
					 years utilizing the most current rates available as of the time of the rate
					 schedule update.
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-25 - Dental Services and Reimbursement Methodology › Subsection 144-101-II-25.07 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Providers that attest to and bill for services under
						Section 25, Dental
						Services, shall not bill claims containing Current Procedural Terminology (CPT)
						or Healthcare Common Procedure Coding System (HCPCS) codes for covered services
						described in Section 25.03.
If a provider that attests to Section
						25 provides a service that is
						within their scope of practice that is not covered under Section 25.03, but is
						covered under another Section of the MBM, the provider must comply with the
						relevant Section of the MBM which authorizes coverage of that service and may
						bill for the service using the appropriate CPT or HCPCS code(s).
Providers shall bill in accordance with the Department's
						current billing instructions. Billing instructions are available upon request
						or from the Department's website at:
https://mainecare.maine.gov/Billing%20Instructions/Forms/Publication.aspx
.
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-26 - Day Health Services › Subsection 144-101-II-26.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
26.02-1
General Requirements
A member is eligible to receive services as set forth in
						this Section if he or she meets the general MaineCare eligibility requirements
						and the specific MaineCare eligibility requirements. Members must meet the
						financial eligibility criteria 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.
26.02-2
Specific Day Health Services
					 Eligibility Requirements
The member must be assessed by the Department or the
						Department's authorized agent, using the Department's approved medical
						eligibility assessment form. A member must require assistance with a
						combination of activities of daily living and nursing at specific levels in
						order to meet eligibility for specific levels of care. A member is medically
						eligible for day health services under this section if he or she meets the
						criteria set forth in (A), (B) or (C) below:
A.
Level I
: A member meets the
					 eligibility requirements for Level I if the following are met:
1. Member requires daily (seven (7) days per
					 week) "Cuing" (defined in Section
					 26.01 ) for all
					 items: 26.02-2 (A) (2), (d), (e), (f) and (g) listed below;
or
2. At least "limited assistance" (defined in
					 26.01) and a "one-person physical assist" (defined in 26.01) are needed with at
					 least two (2) of the following activities of daily living:
a.
Bed Mobility
: How person
					 moves to and from lying position, turns side to side, and positions body while
					 in bed;
b.
Transfer
:
					 How person moves between surfaces to/from: bed, wheelchair, standing position
					 (excluding to/from bath/toilet);
c.
Locomotion
: How person moves between locations, in room and other
					 areas. If in wheelchair, self-sufficiency once in chair;
d.
Eating
: How person eats and
					 drinks (regardless of skill);
e.
Toilet Use
: How person uses the toilet room (or commode, bedpan,
					 urinal): transfers on/off toilet, cleanses, changes pad, managed ostomy or
					 catheter, adjusts clothes;
f.
Bathing
: How person takes full-body bath/shower, sponge bath and
					 transfers in/out of tub/shower (exclude washing of back and hair);
					 and
g.
Dressing
: How
					 person puts on, fastens, and takes off all items of street clothing, including
					 donning/removing prosthesis.
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-26 - Day Health Services › Subsection 144-101-II-26.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
A member is eligible for as many MaineCare covered
						services as are specified in his or her individual plan of care. Beginning and
						end dates of a member's medical eligibility determination period correspond to
						the beginning and end dates for MaineCare coverage of the plan of care
						established by the Department or the Department's authorized
						agent.
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-26 - Day Health Services › Subsection 144-101-II-26.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
Day Health.
Day health services are those
						services provided outside the member's residence at a site licensed by the
						Bureau of Elder and Adult Services, on a regularly scheduled basis. The ongoing
						service may include, based on individual needs:
- monitoring of health care
- supervision, assistance with activities of daily
						living
- nursing
- rehabilitation
- health promotion activities
- exercise groups
- counseling
Noon meals and snacks are provided as a part of day
						health 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-26 - Day Health Services › Subsection 144-101-II-26.05 - LIMITATIONS

Current through 2024-29, July 17, 2024
A. Members eligible for Level I of care may
					 receive up to sixteen (16) hours per week of covered services under this
					 Section.
B. Members eligible for
					 Level II of care may receive up to twenty-four (24) hours per week of covered
					 services under this Section.
C.
					 Members eligible for Level III of care may receive up to forty (40) hours per
					 week of covered services under this Section.
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-26 - Day Health Services › Subsection 144-101-II-26.06 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
Refer to Chapter I, "General Administrative Policies and
						Procedures" for rules governing non-covered services in general. Day health
						services delivered to a member who is a resident in a private non-medical
						institution (PNMI) cannot be reimbursed under this rule.
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-26 - Day Health Services › Subsection 144-101-II-26.07 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
26.07-1
Professional Staff
Day health services are to be provided by the following
						staff in accordance with the individual written plan of care. Staff may be day
						health service employees or consultants to the service.
The following professional staff who are fully,
						provisionally or conditionally licensed or recognized to practice by the state
						or province in which services are provided, are qualified professional
						staff.
A. Registered Nurse
B.  Practical Nurse
C. Social Worker
D. Occupational Therapist
E. Physical Therapist
F. Speech Language Pathologist
G. Other Qualified Staff may include CNAs and
					 other service aides and assistants who provide day health services appropriate
					 to their level of training under the supervision of a licensed professional who
					 falls within the categories listed in subsections A through F, above.
					 Supervision may be provided on a consulting 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-26 - Day Health Services › Subsection 144-101-II-26.08 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
Reimbursement for covered services shall be the lower
						of:
A. The provider's usual and
					 customary charge; or
B. The amount
					 listed in the "Allowances for Day Health Service", Chapter III.
In accordance with Chapter I of the MaineCare Benefits
						Manual, it is the responsibility of the provider to seek payment from any other
						resources that are available for payment prior to billing MaineCare.
Reimbursement for services provided by licensed
						professionals listed in Section 26.07-1 on a consulting basis is included in
						the day health service reimbursement rate. The consulting provider must not
						bill separately for these services except for physical therapy, occupational
						therapy services, and speech therapy that are provided on an individual basis,
						rather than in a group, according to physician orders and a plan of care. These
						services may be billed in accordance with Chapter II, Section
						68, "Occupational Therapy
						Services"; Chapter II, Section
						85, "Physical Therapy Services";
						or Chapter II, Section
						109, "Speech-Language Pathology
						Services", of the MaineCare Benefits Manual.
Pursuant to P.L. 2017, ch. 460, Part B, Sec. B-2:
						Effective July 1, 2019, payment rates attributable to wages and salaries for
						personal care and related services will be increased annually by an inflation
						adjustment cost-of-living percentage in accordance with the United States
						Department of Labor, Bureau of Labor Statistics Consumer Price Index, Medical
						care services (professional services, nursing home and adult day care services)
						from the prior December. These cost of living increases shall continue annually
						until the Department has completed a rate study for adult family care services,
						adult day services or homemaker services and the rates in the rate study have
						been implemented.
Day health services provided to members of the
						Department's Home and Community Benefits for the Elderly and for Adults with
						Disabilities must be reimbursed under the relevant rule, and not under this
						Section.
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-26 - Day Health Services › Subsection 144-101-II-26.09 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Providers must bill in accordance with the Department's
						Billing Instructions.
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-28 - Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations › Subsection 144-101-II-28.03 - DURATION AND INTENSITY OF SERVICES

Current through 2024-29, July 17, 2024
Eligible MaineCare members are entitled to receive up to
						the approved number of hours of services under this Section as are medically
						necessary, approved by DHHS or its Authorized Agent, and described in an
						approved treatment plan. DHHS or its Authorized Agent will review member
						records and the proposed treatment plan in approving
						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-28 - Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations › Subsection 144-101-II-28.05 - MEMBER RECORDS, COMPREHENSIVE ASSESSMENT, INDIVIDUAL TREATMENT PLANS, AND PROGRESS NOTES

Current through 2024-29, July 17, 2024
28.05-1
Written Record
The provider must keep a specific written record for each
						member, which must include:
A.
					 Member's name, address, birth date, and MaineCare ID number;
B. A written copy of the member's
					 comprehensive assessment;
C.
					 Individual Treatment plan (ITP), including the strengths and needs identified
					 in the planning process;
D.
					 Written, signed, credentialed with licensure or certification, if applicable,
					 and dated progress notes, kept in the member's records;
E. DHHS, or its authorized agent, must
					 approve changes regarding intensity and duration of treatment services
					 provided. The Provider must document the approval of the changes in the ITP and
					 in the member's record.
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-28 - Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations › Subsection 144-101-II-28.07 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
Non-covered services are described in Chapter I of the
MaineCare Benefits Manual
(MBM). MaineCare does not cover
						services that are primarily academic, vocational, social, recreational, or
						custodial in nature.
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-28 - Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations › Subsection 144-101-II-28.08 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
28.08-1
Provider Agency Requirements
All providers of services under this Section must be
						enrolled and approved as MaineCare providers by the MaineCare Services, and all
						Providers are subject to all requirements of the
MaineCare Benefits
						Manual
, Chapter I and this Section. In addition, non-School Providers
						must be approved by the Office of Child and Family Services (OCFS), Children's
						Behavioral Health Services (CBHS).
A.
					 Rehabilitative and Community Support Services for Children with Cognitive
					 Impairments And Functional Limitations Provider Contract All non-School
					 providers must have a current contract with DHHS. The content of this contract
					 must stipulate that the provider will Comply with Rider A specifications
					 including:
1) reporting
					 requirements;
2) service
					 specifications/performance guidelines; and
3) process objectives.
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-28 - Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations › Subsection 144-101-II-28.09 - BILLING

Current through 2024-29, July 17, 2024
The documentation must demonstrate only one staff
						person's time is billed for any specific activity provided to the member.
						Billing must be accomplished in accordance with the Department's "Billing
						Instructions for Services for Children with Cognitive Impairments and
						Functional Limitations" provided by the MaineCare Services, Division of
						Customer Service: (
http://www.maine.gov/dhhs/oms/providerfiles/billing_instructions.html
)
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-28 - Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations › Subsection 144-101-II-28.10 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
28.10-1
Rates.
Reimbursement is
					 specified in the
MaineCare Benefits Manual
, Chapter III,
					 Section 28.
28.10-2
Reimbursement Allowances.
In accordance with Chapter I of the
MaineCare Benefits Manual
, it is the responsibility of the
					 provider to seek payment from every other source that is available for payment
					 of a rendered service before billing MaineCare.
MaineCare will pay the lowest of the following:
A. The fee established by
					 MaineCare;
B. The lowest payment
					 allowed by Medicare; or
C. The
					 provider's usual and customary charge.
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-29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-29.01 - INTRODUCTION

Current through 2024-29, July 17, 2024
The Home and Community Based Benefit (HCB or Benefit)
						for members with Intellectual Disabilities (ID) or Autism Spectrum Disorder
						(ASD) gives members eligible for this Benefit the option to live in their own
						home or in another home in the community thus avoiding or delaying
						institutional services. The Benefit is offered in a community-based setting as
						an alternative for members who qualify to live in an Intermediate Care Facility
						for Individuals with Intellectual Disabilities (ICF/IID). The Benefit
						supplements, rather than replaces supportive, natural personal, family, work,
						and community relationships. It does not duplicate other MaineCare
						services.
The HCB Benefit is provided under a Federal 1915(c)
						waiver that meets Federal standards. MaineCare members may receive covered
						services as detailed in other sections of the
MaineCare Benefits
						Manual
, but can receive services under only one Home and Community
						Based waiver at any one time.
In addition, the planning process includes identifying
						and documenting the member's needs in a Personal Plan. The Personal Plan
						describes certain facilitative, therapeutic, and intervention services and
						supplies with an overall goal of community inclusion.
The Benefit is a limited one. Each year the Department
						of Health and Human Services (DHHS) must identify the total number of
						unduplicated members it will provide the benefit to during that year. If there
						is no funded opening, or if a member is not eligible for a funded opening based
						on priority, the member is placed on a waiting list as described in this
						rule.