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-4 - Behavioral Health Services › Subsection 144-101-II-4.08 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Billing must be accomplished in accordance with the
						Department's billing instructions for the CMS 1500 that providers receive in
						their enrollment packages.
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-5 - AMBULANCE SERVICES › Subsection 144-101-II-5.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
5.01-1
Advanced Life Support
					 (ALS)
ambulance service is one that provides complex specialized
					 life-sustaining equipment. Such ambulance vehicles shall be appropriately
					 licensed and equipped, and be staffed by appropriately licensed personnel who
					 are trained and authorized to provide advanced life support. Such training
					 includes administering IVs, establishing and maintaining a member's airway,
					 defibrillation of the heart, and performing other ALS procedures or providing
					 services including, but not limited to, cardiac monitoring.
5.01-2
Air Ambulance Service
provides rapid transportation by air when the member's condition is such that
					 the time needed to transport, or the necessity of transportation by land poses
					 a threat to life or seriously endangers the health of the member. Examples are
					 as follows:
(1) hemodynamic, pulmonary,
					 and/or neurological instability with potential for rapid deterioration
					 requiring critical care life support (monitoring, personnel, medications,
					 and/or specific equipment) during transport that is not available from the
					 local ground ambulance service,
(2) the member's clinical condition requires
					 that the time spent out of the hospital environment (in transport mode) be as
					 short as possible, and/or
(3) the
					 member is located in an area which is inaccessible to regular ground
					 traffic.
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-5 - AMBULANCE SERVICES › Subsection 144-101-II-5.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Individuals 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.It is the responsibility of the provider to verify a member's
						eligibility for Ambulance Services. When a newborn, for which MaineCare
						eligibility has not yet been determined, requires Ambulance Services the
						provider shall ascertain whether the mother is currently MaineCare eligible. If
						the mother is eligible, the provider shall assume that the child is
						eligible.
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-5 - AMBULANCE SERVICES › Subsection 144-101-II-5.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each Title XIX and XXI member is eligible for as many
						covered services as are medically necessary, as long as the member meets the
						eligibility for care requirements set forth under paragraph 5.02. 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-5 - AMBULANCE SERVICES › Subsection 144-101-II-5.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
A covered service is a service for which payment to a
						provider is permitted under this Section of the
MaineCare Benefits
						Manual
(MBM). The types of ambulance services that are covered for
						eligible individuals are subject to medical necessity and those which meet the
						following criteria:
5.04-1
Transportation to the hospital or medical care facility
which:
1. Has an available bed or outpatient service
					 and;
2. Has the equipment and
					 personnel to provide the required 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-5 - AMBULANCE SERVICES › Subsection 144-101-II-5.05 - RESTRICTED SERVICES

Current through 2024-29, July 17, 2024
5.05-1
Air
					 Ambulance Services
A. Air ambulance
					 services are covered services when the provider demonstrates that each of the
					 following conditions is met:
1. For in-state
					 air ambulance providers:
a. The attending
					 physician certifies it is medically inadvisable for the member to travel any
					 other way; and
b. In the case
					 where the member is airlifted from the scene of an injury or emergency illness,
					 aero medical transport has been determined to be necessary by EMS personnel at
					 the scene. The medical condition must require immediate and rapid ambulance
					 service that could not be provided by ground transportation because:
(1) the point of pick up is inaccessible by
					 land, obstacles (i.e.: heavy traffic) or
(2) great distances are involved in getting
					 the member to the nearest hospital with appropriate facilities.
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-5 - AMBULANCE SERVICES › Subsection 144-101-II-5.06 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
The amount of payment for services rendered shall be the
						lowest of the following:
A. The amount
					 listed in Chapter III, Section 5, "Allowances for Ambulance
					 Services."
B. The amount allowed by
					 the Medicare Part B carrier. Ambulance services are exempt from the coinsurance
					 and deductible limitations otherwise set forth under Chapter I, Section 1,
					 "General Administrative Policies and Procedures" in the
MaineCare
					 Benefits Manual
.
C. The
					 provider's usual and customary charge.
In accordance with Chapter I, Section 1 of the
MaineCare Benefits Manual
it is the responsibility of the
						provider to seek payment from any other source that is available for payment of
						the rendered service prior to billing MaineCare.
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-5 - AMBULANCE SERVICES › Subsection 144-101-II-5.07 - COPAYMENT

Current through 2024-29, July 17, 2024
A. A copayment will be charged to each
					 MaineCare member receiving services.The amount of the copayment shall not
					 exceed $3.00 per day for services provided, according to the following
					 schedule:
MaineCare Payment for Service
Member Copayment
$10.00 or less
$0.50
$10.01
- 25.00 $1.00
$25.01
- 50.00 $2.00
$50.01
B. The member shall be responsible for
					 copayments up to $30.00 per month whether the copayment has been paid or not.
					 After the $30.00 cap has been reached, the member shall not be required to make
					 additional copayments and the provider shall receive full MaineCare
					 reimbursement for covered services.
See Chapter I, Section 1 of the
MaineCare
						Benefits Manual
for additional information oncopayments, including
						exemptions and dispute resolution.
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-5 - AMBULANCE SERVICES › Subsection 144-101-II-5.08 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
5.08-1
Records
Records must include, but need not be limited to:
A. Name, address and MaineCare ID number of
					 the member;
B. Completed
					 Patient/Run Reporting Form; and
C.
					 Signed "Application for Emergency Involuntary Admission to a Psychiatric
					 Facility" ("Blue Paper") form, if 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-5 - AMBULANCE SERVICES › Subsection 144-101-II-5.09 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
A.
Billing must be accomplished in accordance with the
						Department's billing requirements; "Billing Instructions for CMS 1500 Claim
						Form."
B. In order to
					 receive full MaineCare reimbursement for claims submitted for a service that is
					 defined as a copayment exemption in Chapter I, Section 1 of the
MaineCare Benefits Manual
, the provider must follow billing
					 instructions.
C. Some specialized
					 services may require additional documentation to be submitted with the claim.
					 Please refer to "Billing Instructions" for details.
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-7 - FREE-STANDING DIALYSIS SERVICES › Subsection 144-101-II-7.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Members must meet the financial eligibility criteria as
						set forth in 10-144, Chapter 332, MaineCare Eligibility Manual. Some members
						may have restrictions on the type and amount of services they are eligible to
						receive. Providers are responsible for verifying a member's eligibility for
						MaineCare, as described in the MaineCare Benefit Manual, Chapter I, prior to
						providing 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-7 - FREE-STANDING DIALYSIS SERVICES › Subsection 144-101-II-7.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each eligible member may receive covered services that
						are medically necessary within the limitations of this section. The Department
						of Health and Human Services (The Department) reserves the right to request
						additional information to evaluate medical necessity and review utilization of
						services. The Department may also require prior authorization (PA) for some
						services.
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
						authorized by the provider or the Department.
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-7 - FREE-STANDING DIALYSIS SERVICES › Subsection 144-101-II-7.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
For members who are establishing Medicare eligibility,
						MaineCare will cover renal dialysis services for the first three months of
						dialysis pending the establishment of Medicare eligibility. Medicare becomes
						the primary reimbursement source for all individuals who meet Medicare
						eligibility criteria. Dialysis providers must assist MaineCare members in
						applying for and pursuing final Medicare eligibility determinations. For those
						MaineCare members who are not Medicare eligible, MaineCare will continue to be
						the payer of last resort for dialysis services.
A.
Renal Dialysis.
Medically necessary renal dialysis services for eligible MaineCare members are
					 covered under this section. Renal dialysis includes services, supplies, and
					 routine laboratory tests as specified in Section 7.05.
B.
Prescribed Drugs.
MaineCare reimburses dialysis clinics for prescribed drugs as specified in
					 Section 7.05.
C.
Training for Home Dialysis.
MaineCare reimburses for
					 home dialysis training, including self-dialysis (hemodialysis, nocturnal
					 intermittent peritoneal disease, and continuous cycling peritoneal dialysis)
					 and continuous ambulatory peritoneal dialysis training only where the MaineCare
					 member attends such training at the clinic site.
To facilitate coordination of benefits, the Department
						will follow Medicare coverage policies and claims submission requirements, as
						appropriate.
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-7 - FREE-STANDING DIALYSIS SERVICES › Subsection 144-101-II-7.05 - LIMITATIONS

Current through 2024-29, July 17, 2024
MaineCare reimburses free-standing dialysis services as
						composite or non-composite services, patterned after the Medicare Policy
						Benefits Manual, Chapter 11:
http://www.cms.hhs.gov/manuals/Downloads/bp102c11.pdf
and any successor documents. This reference details drugs and laboratory tests
						considered composite and non-composite and the expected frequency for each
						dialysis method. MaineCare will only reimburse home-based dialysis by the
						composite methodology.
The following limitations apply for all services under
						this Section:
1. Composite
					 reimbursement covers all routine personnel, drugs, laboratory tests, supplies
					 and services associated with routine dialysis.
2. Non-composite or non-routine dialysis
					 items or services as defined by Medicare include selected drugs, laboratory
					 tests, blood and supplies that may be billed according to requirements in other
					 sections of MaineCare policy, but on the same bill as the services included in
					 the composite package.
3.
					 Frequency of services must be consistent with the Medicare Policy Benefits
					 Manual, Chapter 11 - Section 30.1.
4. Other drugs- MaineCare covers certain
					 other drugs, such as epoetin alfa, outside of the composite rate when
					 documented as medically necessary in relation to dialysis.
5. Medicare Part D- MaineCare will not cover
					 drugs covered by Medicare Part D for those members who are eligible for
					 Medicare Part D. The Department may automatically enroll such eligible
					 MaineCare members without creditable coverage into Medicare Part D, and act as
					 an authorized agent on their behalf. The Department will reimburse Medicare
					 Part D Excluded Drugs for members dually eligible for Medicare Part D when
					 those drugs are otherwise covered by MaineCare.
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-7 - FREE-STANDING DIALYSIS SERVICES › Subsection 144-101-II-7.06 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
Please refer to the MaineCare Benefits Manual, Chapter I,
						General Administrative Policies and Procedures, for a general listing of
						non-covered services and associated definitions that are applicable to all
						Sections of the MaineCare Benefits Manual. In general, non-covered services
						include those items or services that are not medically necessary for the
						diagnosis and treatment of end stage renal disease (ESRD).
7.06-1 Physician Services
Physician professional services associated with dialysis
						are not included in the composite rate. Physician services are billable
						separately under Section 90 of the MaineCare Benefit Manual.
7.06-2 Missed Appointments
MaineCare will not reimburse missed
						appointments.
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-7 - FREE-STANDING DIALYSIS SERVICES › Subsection 144-101-II-7.07 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
7.07-1 Provider
					 Eligibility
A free-standing dialysis center must be a MaineCare
						provider on the date of service in order to be eligible for
						reimbursement.
In-State Providers: To be eligible for participation as
						a MaineCare provider, a free-standing dialysis center must be:
1. located and doing business in the State of
					 Maine (out-of-state providers within fifteen (15) miles of the Maine/New
					 Hampshire border and within five (5) miles of the Maine/Canada border are
					 treated the same as Maine providers in all aspects of policy requirements,
					 including enrollment, rates of reimbursement, and payment
					 methodologies);
2. certified by
					 Medicare and providing services to the standards of a Medicare provider as
					 provided in 42 CFR Part 494;
3.
					 licensed as an out-of-hospital dialysis unit by the Maine Center for Disease
					 Control and Prevention;
4. in
					 compliance with all applicable federal, state and local laws and regulations
					 and;
5. enrolled separately for
					 facilities with multiple sites with the same owner/director.
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-7 - FREE-STANDING DIALYSIS SERVICES › Subsection 144-101-II-7.08 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
A. The amount of payment for services
					 rendered by a dialysis center shall be the facility composite rate. Medically
					 necessary items or services that are not included in the composite rate may be
					 billed and reimbursed in accordance with other sections of MaineCare policy
					 (e.g., laboratory services, pharmacy services, physician services, etc.);
					 however, non-composite items or services must be documented on the same claim
					 form as the composite services.
B.
					 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 of the rendered service prior to billing the
					 MaineCare Program.
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-7 - FREE-STANDING DIALYSIS SERVICES › Subsection 144-101-II-7.09 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
All of the following conditions must be met for provider
						reimbursement under this section.
A.
					 Providers must use the Department's approved billing form, in accordance with
					 the Department's billing instructions available at
http://www.maine.gov/dhhs/oms/providerfiles/billing_instructions.html
B. Providers must bill dialysis services on a
					 monthly basis for each member. All services provided during the same month must
					 be submitted on the same claim form for MaineCare reimbursement.
C. Providers must document appropriate and
					 current diagnostic codes. These codes must accurately describe the clinical
					 diagnosis of members receiving medically necessary treatment.
D. In order to receive full MaineCare
					 reimbursement for claims submitted for a service that is defined as an
					 exemption to Chapter I, refer to the billing instructions distributed by the
					 Department in Chapter I, General Administrative Policies and Procedures.
E. Providers must provide all
					 necessary services that are covered under the facility composite rate. Failure
					 to provide an item or service covered under the composite rate will result in
					 non-payment of the composite rate for that service.
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-9 - INDIAN HEALTH SERVICES › Subsection 144-101-II-9.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Individuals must meet the eligibility criteria as set
						forth in the MaineCare Eligibility Manual, 10-144 C.M.R. Ch. 332. Some members
						may have restrictions on the type and amount of services they are eligible to
						receive. It is the responsibility of the provider to verify a member's
						eligibility for MaineCare, as described in the MaineCare Benefits Manual,
						Chapter I, prior to providing 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-9 - INDIAN HEALTH SERVICES › Subsection 144-101-II-9.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each MaineCare member may receive as many covered
						services as are medically necessary. 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-9 - INDIAN HEALTH SERVICES › Subsection 144-101-II-9.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
The following services are covered if provided by or at
						an Indian Health Services clinic and are medically necessary.
A. Services provided by physicians, physician
					 assistants, certified nurse midwives, nurse practitioners, psychologists,
					 licensed alcohol and drug counselors, licensed clinical social workers,
					 licensed clinical professional counselors and licensed professional
					 counselors;
B. Services and
					 supplies furnished as incident to services of physicians, physician assistants,
					 certified nurse midwives, nurse practitioners, psychologists, licensed alcohol
					 and drug counselors, licensed clinical social workers, licensed clinical
					 professional counselors and licensed professional counselors;
C. Any other medically necessary services
					 provided by the Indian Health Center that is included in the State's Medicaid
					 Plan. (These services must be provided in accordance with all applicable
					 sections of the MaineCare Benefits Manual in order to be
					 reimbursable.)
D. Pharmacy and
					 ambulance services, provided that the Indian Health Center enrolls and receives
					 reimbursement as prescribed under the applicable sections of the MaineCare
					 Benefits Manual.
E. Home Health
					 Services provided under the Maine Medicaid home health benefit as described in
					 Chapter II, Section 40 of the MaineCare Benefits Manual. No other services
					 provided under Section 40 will be reimbursable under this section.
F. Asthma self-management services are
					 reimbursable if they are asthma management programs developed in accordance
					 with the National Asthma Education and Prevention Program Expert Panel Report
					 3: Guidelines for the Diagnosis and Management of Asthma.
Each program must have:
a. a physician advisor;
b. a primary instructor (a licensed health
					 professional or a health educator with a baccalaureate degree. Note: licensed
					 practical nurses may only reinforce, not initiate, teaching.);
c. a pre and post assessment for each
					 participant which shall be kept as part of the member's record in accordance
					 with this Section and Chapter I of the MaineCare Benefits Manual;
d. an advisory committee which may be part of
					 an overall patient education advisory committee; and
e. a physician referral for all
					 members.
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-9 - INDIAN HEALTH SERVICES › Subsection 144-101-II-9.05 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
09.05-1.
Consultation Process
Section 1902(a)(73) of the Social Security Act (the Act)
						requires a State in which one or more Indian Health Programs or Urban Indian
						Organizations furnish health care services to establish a process for the State
						Medicaid agency to seek advice on a regular, ongoing basis. The State Medicaid
						agency should seek advice from designees of Indian health programs, whether
						operated by the Indian Health Service (IHS), Tribes or Tribal organizations
						under the Indian Self-Determination and Education Assistance Act (ISDEAA), or
						Urban Indian Organizations under the Indian Health Care Improvement Act
						(IHCIA). The Department will provide 60 days prior notice to the Tribal
						government regarding any plan amendments, waiver requests, and proposals for
						demonstration projects that are likely to have a direct effect on Indian
						Tribes, Tribal Organizations or Urban Indian Organizations.
The Department has collaborated with the Tribes to
						establish the following two-tier consultation process between representatives
						of the Tribes and the Department. When there are general changes to policies
						that do not have a direct effect on Indian Health Services the first tier of
						consultation will be utilized. The first tier consists of the following:
Written notification via the Interested Parties
						  List
												Listserv updates
												Any other correspondence that pertains to general
						  changes
When there is a direct effect to Indian Health Services
						the second tier of consultation will be utilized. The second tier consultation
						consists of the following:
Face-to-face meetings
												Direct email communications
												Written notification via the Interested Parties
						  List
												Listserv updates
												Any other correspondence that pertains to general
						  changes
												Telephone communications
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-9 - INDIAN HEALTH SERVICES › Subsection 144-101-II-9.07 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
Reimbursement for covered services provided by Indian
						Health Services can be found on the fee schedule at
http://www.maine.gov/dhhs/audit/rate-setting/documents/S3R01012010ProvSpecRatesIHS.pdf
.
The MaineCare rates incorporated in Section 9 are those
						related to Indian Health Services in effect on January 1, 2010. Any changes in
						these rates will be subject to the consultation process in sub-section 9.06-1
						and approved in accordance with procedures in Title 5 M.R.S.A. ch. 375.
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-12 - Consumer Directed Attendant Services › Subsection 144-101-II-12.01 - PURPOSE

Current through 2024-29, July 17, 2024
The purpose of this benefit is to provide medically
						necessary consumer-directed attendant services for MaineCare members eighteen
						years or older and physically disabled.
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-12 - Consumer Directed Attendant Services › Subsection 144-101-II-12.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
12.02-1
Activities of Daily Living
					 (ADLs):
For the purpose of determining eligibility, ADLs include only
					 the following:
(i)
Bed Mobility
:
					 How a member moves to and from lying position, turns side to side, and
					 positions body while in bed;
(ii)
Transfer
: How a member moves between surfaces to/from: bed,
					 wheelchair, standing position (excluding to/from bath/toilet);
(iii)
Locomotion
: How a member
					 moves between locations, in room and other areas. If in wheelchair,
					 self-sufficiency once in chair;
(iv)
Eating
: How a member eats
					 and drinks (regardless of skill);
(v)
Toilet Use
: How a member
					 uses the toilet room (or commode, bedpan, urinal), transfers on/off toilet,
					 cleanses, changes pad, manages ostomy or catheter, adjusts clothes;
(vi)
Bathing
: How a member takes
					 full-body bath/shower, sponge bath and transfers in/out of tub/shower (exclude
					 washing of back and hair); and
(vii)
Dressing
: How a member
					 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-12 - Consumer Directed Attendant Services › Subsection 144-101-II-12.05 - COVERED SERVICES

Current through 2024-29, July 17, 2024
Covered services are available for members meeting the
						eligibility requirements set forth in Section
						12.03. All covered
						services are subject to the limits in this Section. The authorized plan of care
						shall be based upon the member's assessment outcome scores recorded on the
						Department's Medical Eligibility Determination form, its definitions, time
						frames therein, and the task time allowances described in Appendix A.
Members who qualify are eligible for the following
						services:
A.
Care Coordination
					 Services
. The provider of these services coordinates and implements the
					 services in the Member's plan of care authorized by the ASA. In addition, the
					 care coordinator performs the following functions:
1. ensures that authorized services are
					 delivered according to the service plan;
2. provides resources to members to identify
					 available service options and service providers, and answers questions related
					 to the health and care of Members;
3. documents and takes appropriate action
					 concerning any changes in the general health and welfare of the
					 Member;
4. instructs the Member in
					 his or her rights and responsibilities, including the obligations under this
					 Section;
5. assesses the
					 Member/attendant relationship, including whether attendant duties are being
					 performed satisfactorily, whether attendant training is adequate or if
					 additional training is needed;
6.
					 takes appropriate action, including reporting to the Department, any evidence
					 of public nuisance, substance abuse, harassment, neglect, exploitation, or
					 fraud on the part of the attendant, Member, Member's household or
					 visitor;
7. documents and
					 investigates all complaints from any party within two (2) business days and
					 resolving all complaints within thirty (30) days;
8. establishes and maintains Member files in
					 accordance with requirements under 12.08-4;
9. Makes face-to-face contact with the member
					 at least every 3 months. All other care coordination services provided can be
					 done either face-to-face or through phone contact. See Section
					 12.06 for limits to
					 this service.
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-12 - Consumer Directed Attendant Services › Subsection 144-101-II-12.06 - LIMITS

Current through 2024-29, July 17, 2024
A. Personal Care Services are limited to the
					 following number of hours per week:
Level I - 10 hours for ADLs, 2 hours for IADLs = Totaling
						12 hours
Level II - 15 hours for ADLs, 3 hours for IADLs =
						Totaling 18 hours
Level III - 24 hours for ADLs, 4 hours for IADLs =
						Totaling 28 hours
B. Skills
					 training shall not exceed 14.25 hours annually including the time required for
					 initial instruction.
C. Care
					 Coordination Services shall not exceed 18 hours annually.
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-12 - Consumer Directed Attendant Services › Subsection 144-101-II-12.07 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
The following services are non-covered services:
A. Room and board;
B. Travel time and mileage by the Service
					 Coordination Agency staff, and/or the attendant to and from the location of the
					 member's residence and mileage for travel by the attendant in the course of
					 delivering a covered service;
C.
					 Case management services;
D.
					 Transportation to and from medical appointments is not covered under this
					 Section and must be referred to a local MaineCare transportation agency (see
					 Section
					 113 of the
MaineCare
					 Benefits Manual
);
E.
					 Household tasks except when delivered as an integral part of the authorized
					 plan of care;
F. Services provided
					 by the member's family member, as defined in Section 12.02-10;
G. Custodial care or respite care;
H. Services received when a member enters a
					 hospital, nursing facility, private non-medical institution, or Intermediate
					 Care Facility for the Individuals with Intellectual Disabilities as an
					 inpatient, or any other Assisted Housing Program that is licensed to provide
					 personal care services or when a member is receiving personal care services
					 under "Private Duty Nursing/Personal Care Services," Section
					 96, or is receiving any "Home and
					 Community-Based Benefits," "Home Based Care services," or any other service
					 where personal care services are covered;
I. Other services described as non-covered in
					 Chapter I of the
MaineCare Benefits Manual
, including
					 vocational, recreational, custodial and educational activities.
J. Services provided by a personal attendant
					 who has any criminal convictions, except for Class D and Class E convictions
					 over ten (10) years old that did not involve as a victim of the act, a patient,
					 client, or resident of a health care entity; or (b) any specific documented
					 findings by the State survey Agency of abuse, neglect or misappropriation of
					 property of a resident, client or patient;
K. Services provided not in the presence of
					 the member, unless in the provision of covered IADLs;
L. On-call services;
M. Services that are in excess of the limits
					 described under 12.06.
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-12 - Consumer Directed Attendant Services › Subsection 144-101-II-12.09 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
A. Reimbursement for covered services shall
					 be the lower of the following:
1. The amount
					 listed in Chapter III, Section
					 12, "Allowances for
					 Consumer-Directed Attendant Services;"
2. The lowest amount listed by Medicare;
					 or
3. The Service Coordination
					 Agency's usual and customary charge.
In accordance with Chapter I, it is the responsibility of
						the provider to seek payment from any other sources that are available for
						payment of the rendered services prior to billing MaineCare.
Reimbursement under this Section is subject to the unit
						rounding requirements and other reimbursement requirements listed in Chapter I
						of the
MaineCare Benefits Manual
.
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-12 - Consumer Directed Attendant Services › Subsection 144-101-II-12.10 - COPAYMENT

Current through 2024-29, July 17, 2024
Requirements regarding copayment disputes and exemptions
						are contained in Chapter I of the
MaineCare Benefits
						Manual.
A. A copayment will
					 be charged to each MaineCare member receiving services, with the exception of
					 those exempt, as specified in the
MaineCare Eligibility
					 Manual
. The amount of the copayment shall not exceed $3.00 per day for
					 services provided, according to the following schedule:
MaineCare Payment for Services
Member Copayment
$10.00 or less
$.50
$10.01 - 25.00
$1.00
$25.01 - 50.00
$2.00
$50.01 or more
$3.00
B. The member shall be responsible for
					 copayments up to $5.00 per month whether the copayment has been paid or not.
					 After the $5.00 cap has been reached, the member shall not be required to make
					 additional copayments and the provider shall receive full MaineCare
					 reimbursement for covered 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-13 - TARGETED CASE MANAGEMENT SERVICES › Subsection 144-101-II-13.02 - COVERED SERVICES

Current through 2024-29, July 17, 2024
A Covered Service is a MaineCare service for which
						payment can be made by the Department. The following services are covered when
						provided to an eligible member by an approved Targeted Case Management Agency
						and qualified staff:
A.
Comprehensive Assessmentand Periodic Re-assessment
of an eligible
					 member to determine service needs, including those activities that focus on
					 needs identification, to determine the need for any medical, educational,
					 social or other services. The comprehensive assessment and re-assessment must
					 be conducted through face-to-face contact with the member and, where
					 appropriate, consultation with other providers and with the member's family. A
					 comprehensive assessment must be completed within the first thirty (30) days of
					 initiation of services, and reassessment must occur as change in the member's
					 needs warrants or at a minimum on an annual basis. These activities include but
					 are not limited to the following:
1. Taking
					 client history;
2. Identifying the
					 needs of the individual and completing related documentation; and
3. Gathering information from other sources
					 (family members, medical providers, social workers, and educators) if
					 necessary, to form a complete assessment.
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-13 - TARGETED CASE MANAGEMENT SERVICES › Subsection 144-101-II-13.03 - ELIGIBILITY FOR SERVICES

Current through 2024-29, July 17, 2024
An individual may be found eligible to receive MaineCare
						Targeted Case Management services if the following requirements are met:
13.03-1
General Eligibility
					 Requirements
Individuals must meet the eligibility criteria as set
						forth in the MaineCare Eligibility Manual, Chapter I, Section 1. Some members
						may have restrictions on the type and amount of services they are eligible to
						receive.
Designated case management agencies shall be responsible
						for confirming the member's eligibility for case management services. If the
						individual is not currently receiving MaineCare, he or she will be referred to
						a district office of the Department of Health and Human Services, Office of
						Integrated Access and Support, to determine eligibility for MaineCare.
13.03-2
Specific Eligibility
					 Requirements
In order to receive Targeted Case Management Services,
						members must meet criteria for one of the four following target groups:
A. Members must meet the eligibility criteria
					 for one of the following targeted population groups:
1. Case Management Services for Children with
					 one of the following:
a. Behavioral Health
					 Disorders,
b. Developmental
					 Disabilities, and/or
c. Chronic
					 Medical Conditions.
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-13 - TARGETED CASE MANAGEMENT SERVICES › Subsection 144-101-II-13.04 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each eligible member may receive covered services that
						are medically necessary within the limitations of this section. The Department
						reserves the right to request additional information to evaluate medical
						necessity and review utilization of services. The Department will require prior
						authorization (PA) for some targeted case management services reimbursed under
						this section (refer to 13.07-2). The Department may require utilization review
						for all services reimbursed under this section. Providers must work with the
						Department or its Authorized Agent to provide this information.
Members may receive case management services for as long
						as they meet the general criteria for eligibility described above and the
						specific criteria in the appropriate sections, below.
Case management services will discontinue if:
1. The member or legal guardian no longer
					 desires case management services; or
2. The member is no longer eligible to
					 receive benefits pursuant to 13.03.
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-13 - TARGETED CASE MANAGEMENT SERVICES › Subsection 144-101-II-13.05 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
1. Payment for
					 Targeted Case Management Services must not duplicate payments made to public
					 agencies or private entities under other program authorities for case
					 management or service coordination services.
2. Case Management does not include the
					 direct delivery of an underlying medical, educational, social or other service
					 to which an eligible member has been referred.
3. Payments for case management services
					 under this Section must not duplicate payments for similar services made under
					 other sections of MaineCare policy or other funding sources.
4. Only
one
Comprehensive
					 Targeted Case Manager is allowed.
5. Payments for the documentation of progress
					 notes are not allowable 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-13 - TARGETED CASE MANAGEMENT SERVICES › Subsection 144-101-II-13.06 - LIMITATIONS

Current through 2024-29, July 17, 2024
13.06-1
One Comprehensive Case
					 Manager
1. New members to this service
					 must choose only
one
approved Comprehensive Targeted
					 Case Management provider.
2.
					 Documentation of the member's choice of comprehensive case management services
					 must be retained in the member's record and will serve as an enrollment,
					 dis-enrollment, or reenrollment of the member with the provider.
3. MaineCare Services will reimburse only for
					 Targeted Case Management Services provided by the approved provider chosen by
					 the member new to the service and only for
one
Comprehensive Targeted Case Manager.
4. A member may choose a new Comprehensive
					 Targeted Case Management provider at any time.
5. In specific circumstances and through
					 prior authorization, members may be eligible to receive a 30 (thirty) day
					 transition period in which two (2) comprehensive case managers may provide
					 services concurrently. This applies only when members are transitioning from
					 one eligibility category to another (e.g. child to adult).
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-13 - TARGETED CASE MANAGEMENT SERVICES › Subsection 144-101-II-13.07 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
13.07-1
Service Requirements
A. The member
					 must be given the option of whether or not to utilize Targeted Case Management
					 Services.
B. If the member chooses
					 Targeted Case Management Services, he/she must also be given a choice of
					 providers approved by the Department.
C. Services must be provided in settings
					 accessible to the member.
D. Each
					 member must have an Individual Care Plan based on a Comprehensive Assessment or
					 Re-Assessment. The Individual Care Plan and Comprehensive Assessment and
					 Re-Assessment must contain all of the necessary components as stated in
					 13.07-3.