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144-101-II-32 - Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders (Repealed) › Subsection 144-101-II-32.07 - DURATION OF CARE (Repealed)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144-101-II-32 - Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders (Repealed) › Subsection 144-101-II-32.08 - NON-COVERED SERVICES (Repealed)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144-101-II-32 - Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders (Repealed) › Subsection 144-101-II-32.09 - REIMBURSEMENT (Repealed)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144-101-II-32 - Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders (Repealed) › Subsection 144-101-II-32.10 - Increased Level of Support - Family Home (Repealed)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144-101-II-32 - Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders (Repealed) › Subsection 144-101-II-32.11 - Performance Measures (Repealed)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-35 - Hearings Aids and Services (repealed and absorbed by Ch. II Section 60)

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-40 - Home Health Services › Subsection 144-101-II-40.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
*The Department is seeking, and anticipates receiving,
						approval from CMS for this Section. Pending approval, the change will be
						effective.
40.02-1
Authorization Process.
The HHA must obtain authorization from the
					 Department or its Authorized Entity for all members receiving services under
					 this section except as provided in 40.02-5 subparagraph B.
A. Plans of Care must be submitted to the
					 Department or its Authorized Entity within five (5) business days of the start
					 of services. After the plans of care are reviewed for medical appropriateness,
					 providers will receive a final authorization for the plan of care.
B. A member who qualifies under 40.02-4 and
					 requires psychotropic medication administration or psychotropic medication
					 monitoring as his/her only services, shall be exempt from the authorization
					 process outlined above. If the member requires any additional Home Health
					 Services, these shall follow the authorization process as outlined in 40.02-1
					 subparagraph A above.
The Department or its Authorized Entity must determine if
						the member continues to meet the eligibility for care requirements in Section
						40.02.
C. Members receiving services
					 under Section
					 19, Home and Community Benefits
					 for the Elderly and for Adults with Disabilities may be eligible for nursing
					 services under this Section if Section
					 19 nursing services have been
					 deemed insufficient by the Department to meet the acute nursing needs of the
					 Member. Section
					 40 providers must seek prior
					 approval through the Office of MaineCare Services to provide Section
					 40, Home Health Nursing Services
					 to Section
					 19 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-40 - Home Health Services › Subsection 144-101-II-40.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each MaineCare member is eligible to receive as many
						covered services as are medically necessary as long as the member meets the
						eligibility requirements as set forth in Section
						40.02, and services
						are provided in accordance with a valid, authorized certification period as
						required in Section 40.08-1.D., and there has been a valid Authorization
						Process and certification has been obtained. (see 40.02-1). The Department
						reserves the right to request additional information to evaluate medical
						necessity. Coverage will be denied if the services provided are not specified
						in the authorized plan of care. Home Health Services shall be reduced, denied,
						or terminated by the Authorized Entity or the Department, as appropriate, if
						any of the following situations occur:
A. The member declines Home Health
					 Services;
B. A significant change
					 occurs in the member's medical or functional status such that a plan of care
					 can no longer be developed and implemented safely;
C. The member does not meet the medical
					 eligibility criteria for Home Health Services as set forth in Section 40.02-4,
					 as determined by the Authorized Entity or the Department;
D. The member is not financially eligible to
					 receive MaineCare benefits as set forth in Section 40. 02-3 as determined by
					 the Department;
E. When the
					 member's most recent assessment, and the clinical judgment of the Authorized
					 Entity, determine that the authorized plan of care must be changed or reduced
					 to match the member's needs as identified in the assessment, the plan of care
					 shall be modified by the Authorized Entity, or the Department, to reflect the
					 change in needs;
F. The member has
					 provided fraudulent information in connection with obtaining
					 services;
G. The Department, or the
					 Authorized Entity, documents that the member, or other person living or
					 visiting the member's residence, harasses, threatens or endangers the safety of
					 individuals delivering 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-40 - Home Health Services › Subsection 144-101-II-40.04 - STANDARDS OF CARE

Current through 2024-29, July 17, 2024
General Regulatory Compliance
All Home Health Agencies must meet the following
						standards to qualify for MaineCare reimbursement:
A. In order to qualify for reimbursement
					 under this Section, a Home Health Agency must have in effect a license pursuant
					 to the Department's Regulations Governing the Licensing and Functioning of Home
					 Health Care Services, as are currently in effect. A Home Health Agency must
					 also comply with all requirements of Title XIX of the Social Security Act and
					 the regulations issued pursuant thereto, as are most currently in effect. These
					 standards are incorporated into this Section by reference as if set out fully
					 herein. The Home Health Agency must have in effect a current MaineCare provider
					 agreement with the MaineCare program.
B. In order to qualify for reimbursement
					 under this Section a Home Health Agency must have in effect a current Medicare
					 certification to participate pursuant to §1861(o) and 1891 of the Social
					 Security Act and the regulations found at 42 CFR, Part 484, and regulations
					 issued pursuant thereto as are most currently in effect. These standards are
					 incorporated into this Section by reference as if set out fully
					 herein.
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-40 - Home Health Services › Subsection 144-101-II-40.05 - COVERED SERVICES

Current through 2024-29, July 17, 2024
*The Department is seeking, and anticipates receiving,
						approval from CMS for this Section. Pending approval, the change will be
						effective.
A covered service is a service for which payment to a
						provider is permitted under this Section of the
MaineCare Benefits
						Manual
. In order to be reimbursed under this Section, covered services
						must be delivered under a timely and complete plan of care, signed and
						certified by a qualified Physician and meet the authorization requirements as
						outlined under Section 40.02-1. The plan of care must meet the requirements of
						Section
						40.08. The CMS-485
						must be completed for each member under this Section. There must be
						documentation of a face-to- face encounter with the certifying physician or
						allowed nonphysician practitioner as listed in Section 40.01-7. If the
						Department or its Authorized Entity determines that the services are no longer
						medically necessary, the Department will not reimburse the HHA for continuing
						services.
Any of the following services may be offered as the sole
						Home Health Service and shall not be contingent upon the provision of another
						service.
A.
Skilled Nursing
					 Services
. To be covered as skilled nursing services, the services must
					 meet the following conditions:
1) require the
					 skills of a registered nurse or a licensed practical nurse under the
					 supervision of a registered nurse, to be safe and effective, considering the
					 inherent complexity of the service, the condition of the member and accepted
					 standards of medical and nursing practice; and
2) be medically necessary to the treatment of
					 the member's illness or injury. Medical necessity of services is based on the
					 condition of the member at the time the services were ordered and what was, at
					 that time, expected to be appropriate treatment throughout the certification
					 period; and
3) be required on an
					 intermittent or part-time basis (as defined in Section 40.01-14 and 40.01-20 ).
					 To meet the requirement for intermittent skilled nursing care, a member must
					 have a medically predictable recurring need for skilled nursing service; and be
					 ordered by the physician for the member and are included in the physician's
					 plan of care.
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-40 - Home Health Services › Subsection 144-101-II-40.06 - LIMITATIONS

Current through 2024-29, July 17, 2024
Services delivered under this Section shall not duplicate
						any other services delivered to the member. Duplication includes, but is not
						limited to:
A. Home health aide
					 services shall not be reimbursed for members who are receiving services under
					 Section 2, Adult Family Care Services, or Section
					 12, Consumer Directed Attendant
					 Care Services, or Section
					 18, Home and Community-Based
					 Services for Adults with Brain Injury, or Section
					 19, Home and Community Benefits
					 for the Elderly and Adults with Disabilities, or Section
					 20, Home and Community-Based
					 Services for Adults with Other Related Services, or Section
					 21, Home and Community-Based
					 Waiver Services for -Members with Intellectual Disabilities or Autistic
					 Disorder -- or Section
					 29, Support Services for Adults
					 with Intellectual Disabilities or Autism Spectrum Disorder. Personal care
					 services are covered services under these Sections.
B. If the member resides in a Section
					 50, I CF-IDD, a Home Health Agency
					 may provide services only if the facility's MaineCare reimbursement rate, or
					 the facility's contract with the seeding state agency, does not include these
					 services. Home health aide services shall not be reimbursed in Section
					 97 (PNMI) and Section
					 50 (ICF-IDD) settings because
					 personal care services are a covered service under these Sections.
C. Nursing and home health aide services
					 delivered to a member who is receiving Section
					 96, Private Duty Nursing (PDN)
					 Services & Personal Care Services, shall count towards the member's
					 authorized PDN cap. Occupational therapy, physical therapy, speech-language
					 pathology and Medical Social Services may be provided and do not count toward
					 the member's PDN cap.
D. Excluding
					 members whose medical condition is "unstable" (as defined in Section 40.01-28
					 ), assessment and management services, as well as teaching and training
					 services, are limited to two (2) certification periods or a maximum of one
					 hundred twenty (120) days, per admission.
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-40 - Home Health Services › Subsection 144-101-II-40.07 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
The following services are not reimbursable by the
						MaineCare Program under this Section:
A. Parenting skills training.
B. Nursing services, physical therapy, and
					 occupational therapy exercises that may be carried out by the member, or family
					 member or friend who is trained, willing and able to safely perform the service
					 after receiving instruction from the appropriate home health care
					 professional.
C. Services provided
					 by a personal care attendant.
D.
					 Laboratory services as defined in Section
					 55 of this Manual.
E. Blood glucose monitoring, i.e. glucometer,
					 if the member is stable and does not need teaching of diabetic
					 management.
F. Routine foot care,
					 unless the member suffers severe circulatory impairment, or metabolic,
					 neurological, or systemic diseases where nonprofessional care may pose a threat
					 to the member's condition.
G.
					 Homemaking services (for example; vacuuming, laundry) and chore services,
					 except when delivered as "incidental" services, as described in Section
					 40.05(B)(6).
H. RN supervisory visits made for the purpose
					 of supervising home health aide services to the member.
I. Nursing evaluation visits, unless skilled
					 observation and assessment by a licensed nurse would result in a change of the
					 treatment of the member.
J. Visits
					 made solely to remind the member to follow instructions.
K. Services that can be appropriately
					 provided by other community resources, e.g., homemaker services, adult
					 protective services, "Meals on Wheels".
L. Respite services.
M. Venipuncture if this is the sole skilled
					 service provided during the visit.
N. Custodial care.
O. A monthly injection if this is the sole
					 skilled nursing service provided during the visit.
P. Monthly catheter change, beyond the acute
					 phase.
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-40 - Home Health Services › Subsection 144-101-II-40.08 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
40.08-1
Authorization of the Plan of Care
All services under this Section require an authorization
						(see Section 40.02-1 ), from the Department or its Authorized Entity. At the
						Department's discretion a medical eligibility assessment may be performed in
						order to approve an authorization request. Home Health Services will be
						authorized only if all requirements set forth in this Section are met. The
						authorization determines only the medical necessity for services and does not
						establish or waive any other prerequisites for payment, such as member
						eligibility or coverage by other third party payor.
A. Notice of Approval. For all approved
					 authorization requests for Home Health Services, the Authorized Entity will
					 provide written notice to the HHA.
B. Notice of Denial or Modification and Right
					 to Appeal. For all denied or reduced authorization requests, the Authorized
					 Entity will notify both the member and the HHA of the denial or modification,
					 reason, right to appeal, and appeal procedures (see Section 40.08-5
					 ).
C. The Home Health Agency must
					 notify the Department of a member's start of care date for the initial
					 certification period. The admit/discharge form must be submitted to the
					 Department within five (5) days of admission.
D. All Home Health Services shall be
					 authorized and covered for an approved certification period. The Home Health
					 Agency must submit the following information for each certification period
					 within five (5) calendar days of the certification period end date:
1. The CMS 485, including the documentation
					 of rehabilitation potential for any physical therapy, occupational therapy and
					 speech-language pathology services being received by the member, and
2. Documentation of why the member cannot
					 receive Home Health Services in an outpatient hospital setting.
3. Documentation supporting the medical
					 necessity for the Home Health Service.
4. For the certification period at start of
					 services the Home Health Agency must also submit documentation by the
					 certifying physician that the physician himself or herself or a nonphysician
					 practitioner has had a face-to-face encounter with the individual member as
					 defined in section 40.01-7 prior to the authorization of the plan of care and
					 has documented the encounter as required by section 40.08-4.15. The beginning
					 and end dates of the individual's eligibility period correspond to the
					 beginning and end dates for MaineCare coverage of the Home Health
					 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-40 - Home Health Services › Subsection 144-101-II-40.09 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
A. The amount of payment for services
					 rendered shall be the lowest of the following:
1. The amount listed in Chapter III, Section
					 40, "Allowances for Home Health
					 Services" of the
MaineCare Benefits Manual
; or
2. The lowest amount allowed by the Medicare
					 carrier; or
3. 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-40 - Home Health Services › Subsection 144-101-II-40.10 - COPAYMENT

Current through 2024-29, July 17, 2024
A. A copayment will be charged to each
					 MaineCare member for each day Home Health Services are provided. 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
MaineCare Payment for Service
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 $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.
C. No provider may deny services to a member
					 for failure to pay a copayment. Providers must rely upon the member's
					 representation that he or she does not have the cash available to pay the
					 copayment. A member's inability to pay a copayment does not, however, relieve
					 him/her of liability for a copayment.
D. Providers are responsible for documenting
					 the amount of copayments charged to each member (regardless of whether the
					 member has made payment) and shall disclose that amount to other providers, as
					 necessary, to confirm previous copayments.
Providers are subject to the Department's copayment
						requirements. Refer to Chapter I, General Administrative Policies and
						Procedures for rules governing copayment requirements, 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-40 - Home Health Services › Subsection 144-101-II-40.11 - CONFIDENTIALITY

Current through 2024-29, July 17, 2024
The disclosure of information regarding individuals
						participating in the MaineCare program is strictly limited to purposes directly
						connected with the administration of the MaineCare program. Providers shall
						maintain the confidentiality of information regarding these individuals in
						accordance with 42 CFR § 431 et seq. and other applicable sections of
						state and federal law and regulation.
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-40 - Home Health Services › Subsection 144-101-II-40.12 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
A. Billing must be
					 accomplished in accordance with the Department's billing requirements in
					 "Billing Instructions for Home Health Agencies" that are available on the
					 provider portal at
www.maine.gov/dhhs/oms
or by contacting
					 MaineCare Provider Services, , 11 State House Station, Augusta, ME 04333, or
					 calling 1-866-690-5585.
B. In order
					 to receive full MaineCare reimbursement for claims submitted for a service that
					 is defined as an exemption in Chapter I, refer to the billing instructions
					 distributed by the Department and to Chapter I, General Administrative Policies
					 and Procedures.
C. All services
					 provided on the same day shall be submitted on the same claim form for
					 MaineCare reimbursement.
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-40 - Home Health Services › Subsection 144-101-II-40.13 - BILLING APPEALS FOR DUAL MAINECARE/MEDICARE MEMBERS

Current through 2024-29, July 17, 2024
A. An agency document must be on file signed
					 by the MaineCare member or guardian noting that services are denied Medicare
					 coverage and all claims will be submitted to MaineCare.
B. The agency will obtain and keep on file a
					 signed departmental "Authorization to Represent" form on all MaineCare members.
					 This form will be provided by the Department. The agency will present this form
					 to the Department or its designee when an Initial Determination and/or
					 Reconsideration or Administrative Law Judge is requested.
C. The Department will find the Home Health
					 Agency liable for the cost of services following an adverse decision by
					 Medicare in response to a Department appeal detailing a technical denial.
					 Examples of a technical denial shall include but not be limited to:
1) Plan of Care not authorized by a
					 physician.
2) Information not
					 received.
3) No documentation for
					 services billed.
4) Time Limit
					 Reject.
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-43 - Hospice Services › Subsection 144-101-II-43.02 - MEMBER ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
A member is eligible for covered hospice services if he
						or she meets both the General MaineCare financial eligibility requirements and
						the Hospice Services Eligibility Requirements, with the exception of the
						following: those members deemed eligible for coverage under Medicare hospice
						benefits shall not be eligible for services which would be duplicative under
						this Section.
43.02-1
General
					 MaineCare Eligibility Requirements
Individuals must meet the financial eligibility criteria
						set forth in the
MaineCare Eligibility Manual
. Some members
						may have restrictions on the type and amount of services they are eligible to
						receive.
43.02-2
Hospice Services Eligibility Requirements
A. A member must be certified by a physician
					 as having a terminal illness as set forth in Section
					 43.03-1,
					 Certification of Terminal Illness; and
B. The member or his or her Representative
					 must elect hospice benefits in lieu of other MaineCare covered services as
					 specified in Section
					 43.03-2 by
					 completing an election statement as set forth in that section. Members under
					 age 21 making said election do not waive any MaineCare covered services that
					 are related to the treatment of the child's condition for which a diagnosis of
					 terminal illness has been made.
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-43 - Hospice Services › Subsection 144-101-II-43.03 - MEMBER ELIGIBILITY PROCEDURE

Current through 2024-29, July 17, 2024
43.03-1
Certification of Terminal Illness
A. No later than two (2) calendar days after
					 the initiation of hospice care the hospice must obtain verbal certification of
					 terminal illness from the Medical Director or the physician on the hospice's
					 Interdisciplinary Team and the member's Attending Physician, if the member has
					 an Attending Physician. The hospice must obtain written certification prepared
					 by both the Medical Director or the physician on the hospice's
					 Interdisciplinary Team and the member's Attending Physician (if he/she has one)
					 and submit a copy of the certification to: Office of MaineCare Services,
					 Classification Review, 11 State House Station, Augusta, ME 04333-0011, before
					 submitting any claim for payment.
B. With respect to any subsequent election of
					 hospice benefits, the hospice must obtain written certification of the member's
					 terminal illness from the Medical Director or the physician on the hospice's
					 Interdisciplinary Team before submitting the claim for payment.
C. The certification must include:
1. The statement that the member's life
					 expectancy is six (6) months or less if the terminal illness runs its normal
					 course; and
2. The signature(s) of
					 the physician(s).
The hospice must keep the certification statement(s) 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-43 - Hospice Services › Subsection 144-101-II-43.04 - DURATION OF CARE

Current through 2024-29, July 17, 2024
The hospice benefit has two (2) ninety (90)-day benefit
						periods, followed by an unlimited number of subsequent sixty (60)-day benefit
						periods. At the beginning of each benefit period the hospice must obtain a new
						Certification of Terminal Illness.
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-43 - Hospice Services › Subsection 144-101-II-43.06 - DURATION OF CARE

Current through 2024-29, July 17, 2024
43.06-1
Member Service Provision Rights
Receipt of hospice services in no way affects the rights
						afforded to residents of a nursing facility under Chapter II, Section
						67, including those relating to
						transfer and discharge, status change notification and hearings and
						appeals.
The election of hospice by a member, however, in no way
						diminishes the responsibility of the member or nursing facility to obtain
						required prior authorization, or to comply with eligibility requirements for
						nursing facility placement.
43.06-2
Member Status Change
A. The billing provider must notify the
					 Department of the following changes in consumer status:
1. Admission to or discharge from a nursing
					 facility
2. Transfer from one
					 nursing facility to another
3.
					 Entry into or exit from hospice status
4. Transfer from one hospice to
					 another
5. Member death.
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-43 - Hospice Services › Subsection 144-101-II-43.08 - BILLING

Current through 2024-29, July 17, 2024
Billing must be accomplished in accordance with the
						Department's billing requirements as set forth at
https://mainecare.maine.gov
.
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-43 - Hospice Services › Subsection 144-101-II-43.09 - ALLOWANCES FOR HOSPICE SERVICES

Current through 2024-29, July 17, 2024
REVENUE CODE
HCPC CODE
DESCRIPTION OF
								  SERVICES
UNITS OF SERVICE
0651
T2042
Routine Home Care
Per Diem
0551
G0299
Service Intensity Add-On (direct skilled nursing
								  services of a registered nurse (RN) in the home health or hospice
								  setting
Per ¼ Hour
0561
G0155
Service Intensity Add-On (services of a clinical
								  social worker in the home health or hospice setting
Per ¼ Hour
0652
T2043
Continuous Home Care
Per Hour
0655
T2044
Inpatient Respite Care
Per Diem
0656
T2045
General Inpatient Care
Per Diem
0657
Appropriate CPT Code
Physician Services non hospice
								  services
N/A
Specific reimbursement rates are listed on the MaineCare
						Provider Fee Schedule, which is posted on the Department's web site in
						accordance with
						22 M.R.S.
						Sec.3173-J(7).
Rates for Routine Home Care services, both days 1-60 and
						days over 60, are reimbursed at 123% of the CMS published Medicaid rates,
						effective October 1 annually, plus an adjustment for regional differences in
						wages using the hospice wage index.
Continuous Home Care, Inpatient Respite Care, General
						Inpatient Care and the Service Intensity Add-On services are reimbursed at 100%
						of the CMS published Medicaid rates, effective October 1 annually, plus an
						adjustment for regional differences in wages using the hospice wage
						index.
Hospice providers will be reimbursed a per diem amount to
						cover room and board services provided by the nursing facility (NF) or
						intermediate care facility for individuals with intellectual disabilities
						(ICF-IID) for MaineCare members who have elected hospice care and reside in the
						NF or ICF-IID. This reimbursement rate is equal to 95 percent (95%) of the base
						rate paid to that particular facility of residence.
Failure by a hospice provider to comply with the Medicare
						quality reporting requirements during each fiscal year will result in a two
						percent (2%) reduction to the market basket update applied prospectively to the
						following hospice rate year.
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-45 - Hospital Services › Subsection 144-101-II-45.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
45.01-1
340B Hospital
means a
					 hospital eligible to participate in the federal 340B Drug Pricing Program
					 administered by the U.S. Department of Health and Human Services Health
					 Resources and Services Administration. Currently, only hospitals that may also
					 receive disproportionate share may participate in the 340 Drug Pricing Program.
					 Information about 340 B participation is at:
http://www.hrsa.gov/opa/
.
45.01-2
Authorized Agent
means
					 an organization authorized by the Department to perform functions pursuant to
					 these rules under a valid contract or other approved, signed
					 agreement.
45.01-3
Critical
					 Access Hospital
means a hospital licensed by the Department as a
					 critical access hospital.
45.01-4
Day(s) Awaiting Nursing Facility (NF) Placement
means any day on
					 which a hospital provides services to an inpatient that would constitute
					 post-hospital nursing facility services if provided by a nursing facility,
1. if that day falls after a quality
					 assurance or utilization review process has determined that inpatient hospital
					 services for the individual are not medically necessary;
2. if post-hospital nursing facility services
					 are not otherwise available to the individual (as described in Section
					 45.07-2); and
3. that the
					 Department or its Authorized Agent has determined is medically eligible for
					 nursing facility services as described in Chapter II, Section
					 67, of this
					 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-45 - Hospital Services › Subsection 144-101-II-45.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
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.
It is the provider's responsibility to verify a member's
						MaineCare eligibility as described in MBM, 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-45 - Hospital Services › Subsection 144-101-II-45.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
All hospital admissions and continued stays must be
						certified for medical necessity and length of stay through an appropriate
						utilization review plan.
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-45 - Hospital Services › Subsection 144-101-II-45.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
45.04-1
Semi-Private Accommodations
Reimbursement will be made for eligible members for
						placement in semi-private accommodations (two (2) or more
						beds).
45.04-2
Intensive Care or Coronary Care
Accommodations in an intensive care unit or a coronary
						care unit are reimbursable if ordered by the patient's physician as medically
						necessary.
45.04-3
Drugs and Biologicals
A.
Drugs and Biologicals
Drugs, vaccines, cultures, and other preparations made
						from living organisms and their products, used in diagnosing, immunizing, or
						treating members (biologicals) are covered. Drugs and biologicals furnished by
						a hospital for a patient's use outside of the hospital are not covered as
						inpatient services.
B.
Hospital Pharmacies Affiliated with a Nursing Facility
A hospital that is affiliated with a nursing facility
						through common ownership or control is allowed to dispense covered MaineCare
						prescription drugs through its pharmacy to members in that nursing home. The
						drugs must be dispensed by a registered pharmacist according to dispensing
						regulations.
Billing must be accomplished in accordance with MBM
						Section
						80, "Pharmacy Services", and
						Section
						67, "Nursing Facility
						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-45 - Hospital Services › Subsection 144-101-II-45.06 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
45.06-1
Private Room
Accommodations in a private room will not be reimbursable
						unless they meet conditions spelled out in Section 45.05-5 above. Hospitals may
						not bill a MaineCare member for the difference between a private room rate and
						a semi-private room rate unless the member requests a private room and signs a
						written statement acknowledging that he or she is to be billed the
						difference.
45.06-2
Routine Physician Visits
Routine physician visits are not reimbursable for members
						awaiting placement in a NF or in swing beds.
45.06-3
Admission Not Certified By
					 Utilization Review
MaineCare will not reimburse for a hospital admission
						that is not certified by a utilization review.
The only exception to this policy is when a member is
						admitted prior to utilization review for an acute condition that requires
						medically necessary treatment that is only available in a hospital and it is
						medically necessary for the treatment to be delivered prior to the time it
						feasible for the case to be reviewed. Services rendered prior to the review are
						not reimbursable unless the utilization review is conducted within one (1)
						business day of the admission. (For example, if a member is admitted on a
						Friday at 6:00 P.M., is first reviewed on Monday at 11:00 A.M. and denied at
						that time: three (3) days are reimbursable.) The member or responsible party
						must be notified in writing if these criteria will not be met and all or part
						of the admission will not be a MaineCare covered service; and must sign an
						acknowledgement of financial responsibility for this non-covered
						service.
45.06-4
Unauthorized Days Awaiting Placement or NF-level Swing Bed
					 Services
MaineCare will not reimburse for any days awaiting
						placement or NF level services providing swing beds that have not been approved
						by the Department or its 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-45 - Hospital Services › Subsection 144-101-II-45.07 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
45.07-1
Discharge Planning
Medicaid patients denied continued hospitalization as a
						result of utilization review, or denied Medicare or other third party coverage
						on the basis of no longer having medical necessity for hospitalization, shall
						be denied Medicaid coverage unless approved for days awaiting NF placement, as
						described in Section 45.07-2. A copy of the denial letter indicating the last
						day of third party coverage must be submitted to: Program Integrity, SHS 11,
						Augusta, ME, 04333.
Each hospital shall maintain a written record of
						discharge planning procedures, setting forth at least the following:
A. The name of the staff member of the
					 hospital who has operational responsibility for discharge planning.
B. The manner and methods by which such staff
					 member will function, including his or her authority and relationship with the
					 facility's staff.
C. The time
					 period in which each eligible individual's need for discharge planning will be
					 determined (which period may not be later than seven days after the day of
					 admission).
D. The local agencies
					 and individuals available to the facility as discharge planning resources, and
					 a requirement that the attending physician assist a multidisciplinary team in
					 developing discharge plans. Responsibilities for implementation shall be a team
					 decision.
E. A provision for
					 periodic review and re-evaluation of the facility's discharge planning program.
Hospital Discharge Instructions
. Hospital
						Emergency Departments are required to provide discharge instructions that
						include contact information for appropriate Health Home providers (including
						Opioid Health Home, Behavioral Health Home, and Health Home Services -
						Community Care Team providers) to eligible individuals with chronic conditions,
						including opioid use disorder, serious and persistent mental illness, and
						serious emotional disturbance.
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-45 - Hospital Services › Subsection 144-101-II-45.08 - ELIGIBILITY FOR HOME CARE FOR CHILDREN ELIGIBLE THROUGH THE KATIE BECKETT BENEFIT

Current through 2024-29, July 17, 2024
The following criteria must be met for children to be
						eligible for home care through the Katie Beckett benefit:
A.
Age and Disability
The child must be eighteen (18) years of age or younger
						and be determined disabled under Supplemental Security Income rules. The
						Medical Review Team (MRT) at the Office of Family Independence makes the
						disability determination as part of the application process.
B.
Level of Care
The child must require a level of care that is typically
						provided in a hospital, although the child does not have to be admitted,
						relocated nor have a history of admissions to a hospital. If the child requires
						a level of care that can be provided in a nursing facility, eligibility for the
						Katie Beckett benefit must be assessed under Chapter II, Section
						67 of this
						Manual.
C.
Appropriateness of Community-Based Care
The child must be able to receive or currently be
						receiving appropriate care outside a hospital setting that provides that level
						of care.
D.
Limits of
					 Cost of Community-Based Care
The total annual cost to MaineCare for home care must be
						no greater than the amount MaineCare would pay for the child's care in an
						institution.
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-45 - Hospital Services › Subsection 144-101-II-45.10 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
See Chapter III, Section
						45, "Principles of Reimbursement
						for Hospital Services".
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, including billing Medicare, as
						described under Title XVIII.
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-45 - Hospital Services › Subsection 144-101-II-45.11 - CO-PAYMENT FOR INPATIENT SERVICES, OUTPATIENT HOSPITAL CLINIC SERVICES

Current through 2024-29, July 17, 2024
A. A co-payment will be charged to each
					 MaineCare member receiving either inpatient or outpatient hospital services.
					 Two separate co-payments will be charged if the member receives both inpatient
					 and outpatient services. The amount of the co-payment shall not exceed three
					 dollars ($3.00) per day for either category of hospital services provided,
					 according to the following schedule:
MaineCare Payment for Service
Maximum Member Co-payment Per
									 Day
$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 liable for co-payments
					 up to a maximum of thirty dollars ($30.00) per calendar month for each
					 category: inpatient or outpatient service, and regardless of whether there are
					 multiple hospital service providers within the same month. After the maximum
					 thirty dollar ($30.00) monthly cap(s) has been charged to the member, the
					 member shall not be liable for additional co-payments and the provider(s) shall
					 receive full MaineCare reimbursement.
C. No provider may deny services to a member
					 for failure to pay a co-payment. Providers must rely upon the member's
					 representation that he or she does not have the cash available to pay the
					 co-payment. A member's inability to pay a co-payment does not, however, relieve
					 him/her of liability for a co-payment.
D. Providers are responsible for documenting
					 the amount of co-payments charged to each member (regardless of whether the
					 member has made payment) and shall disclose that amount to other providers, as
					 necessary, to confirm previous co-payments.
Co-payment exemptions and dispute resolution procedures
						are contained in Chapter I.