Code of Maine Rules › 14 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 193 - OFFICE OF ADULT MENTAL HEALTH › Chapter 40 - REVIEW OF REQUESTS FOR SPECIALIZED OUT-OF-STATE MENTAL HEALTH TREATMENT FOR ADULTS › Section 193-40-2 - Criteria for Specialized Out-of-state Treatment Funding

Current through 2024-29, July 17, 2024
1. Requests for funding specialized
				out-of-state mental health treatment will be considered only for adult clients
				of DMHMRSAS, as currently defined.
2. Requests for grant funding specialized
				out-of-state mental health treatment will only be considered when all other
				sources of funding have been exhausted (such as reciprocal Medicaid agreements,
				third party insurance, personal resources, etc.). Every effort must have been
				made to fund the treatment jointly with other responsible agencies
				involved.
3. The client must have a
				current psychiatric evaluation that reports findings of instability secondary
				to an Axis I major mental illness, as defined by the current edition of the
				Diagnostic and Statistical Manual. The current clinical picture must clearly
				demonstrate medical necessity for treatment, as defined by evidence of severe
				dysfunction in aspects of daily living or danger to self or others, which has
				existed for at least 6 months or longer.
4. Requests for specialized out-of-state
				mental health treatment will only be considered when it has been demonstrated
				that in-state treatment AND treatment at a lower level of care have reasonably
				been attempted and failed, OR that there is no appropriate, safe and effective
				treatment available in the state.
5. The specific treatment plan or program
				being requested must have proven efficacy in the treatment of the client's Axis
				I diagnosis, be consistent with best clinical practice and qualitatively
				different from a program available in the state of Maine. Specialized
				out-of-state treatment will be authorized only when the program and/or facility
				meets applicable licensing regulations and there is reason to expect the
				program requested will significantly improve the condition of the client,
				returning him/her to a former level of stability. At the Department's
				discretion, a Departmental staff person may be designated to conduct an on-site
				review of the program being considered.
6. Requests for specialized out-of-state
				treatment will be approved only when it can be demonstrated that without the
				requested treatment, the client will continue to be unstable or will
				deteriorate further.
7. The client
				must voluntarily accept the specialized out-of-state treatment and evidence
				some capacity to benefit from the treatment. The guardian, if applicable, must
				also approve the specialized out-of-state treatment plan.
8. The specialized out-of-state treatment
				plan must be cost effective, demonstrated by the reasonable expectation for
				reduced future behavioral or somatic medical care costs AND by favorable cost
				comparison to other similar treatments.
9. Every preauthorization of specialized
				out-of-state treatment shall be for a specific length of time. The client's
				clinical progress will be monitored during treatment, consistent with good
				utilization review practices. When it is clinically appropriate, or if the
				client's condition does not improve in a reasonable period of time, the
				authorization for continued treatment may be withdrawn and the client
				transferred to a less intensive level of care or an instate program. Such a
				withdrawal and transfer will be done with sufficient notice to the client,
				family and providers involved.
10.
				Before preauthorization will be granted, there must be a preliminary discharge
				or transition plan developed, for the client to return to an instate treatment
				program.