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-93 - Opioid Health Home Services › Subsection 144-101-II-93.04 - POLICIES AND PROCEDURES FOR MEMBER IDENTIFICATION AND ENROLLMENT

Current through 2024-29, July 17, 2024
93.04-1
Member Identification
The OHH provider shall identify members who are
						potentially eligible for OHH services based on the eligibility criteria for OHH
						Services. The OHH provider will submit potentially eligible members through a
						certification process to approve services.
93.04-2
Enrollment and Duplication of
					 Services
A.
Enrollment.
The OHH Provider shall identify members for OHH based on the OHH eligibility
					 criteria. Potentially eligible members shall be given information about the
					 benefits of participating in an OHH. The member can choose to be part of OHH
					 once confirmed eligible. They must be approved through a certification process
					 with the certification effective the earliest date without risk of duplicative
					 services. The member can choose to not participate at any time by notifying
					 their OHH provider or the Department's authorized entity for certifications of
					 OHH services.
B.
Duplication
					 of Services.
The Department will not reimburse for duplicative services
					 for members as set forth in the Reimbursement provision of this rule. If,
					 through the certification process, the member is determined to be receiving a
					 duplicative service, the member must choose which service they want to receive.
The Department's authorized entity will notify members
						that they cannot receive duplicative services and will keep a record of
						documentation as to the members' choice of service.
C.
Requests and Referrals.
Members may request OHH services or be referred for OHH services by another
					 MaineCare provider. The Department or its authorized entity shall approve or
					 deny the enrollment of such members within three (3) business days of a request
					 for services.
D.
Consent
					 Forms.
OHH providers must retain a signed consent form for all OHH
					 members in the member record. Consent documentation must, at a minimum:
1. Indicate that the individual has received
					 information in writing, and verbally as appropriate, explaining the OHH purpose
					 and the services provided; and
2.
					 Indicate that the individual has consented in writing, and verbally as
					 appropriate, to receive the OHH services and understand their right to choose,
					 change, or disenroll from their OHH provider at any time.
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-93 - Opioid Health Home Services › Subsection 144-101-II-93.06 - REPORTING REQUIREMENTS

Current through 2024-29, July 17, 2024
In addition to the documentation and reporting
						requirements of the
MBM
, Chapter I, Section I, and other
						reports that may be required by the Department, the OHH shall report in the
						format designated and frequency determined by the Department, including:
A.
The Core Standards.
The OHH shall report on the Core Standards in Section 93.02-3.
B.
Opioid Health Home Quality
					 Measures.
The OHH shall submit data necessary to compile and report on
					 OHH Quality Measures as identified by the Department. Data sources may include
					 but are not limited to claims, clinical data, the DHHS Enterprise Information
					 System, certification submissions, and surveys.
Providers who fail to timely or adequately file reports
						or satisfy the benchmarks defined by the Department may be terminated from
						providing Section
						93 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-93 - Opioid Health Home Services › Subsection 144-101-II-93.07 - DOCUMENTATION AND CONFIDENTIALITY

Current through 2024-29, July 17, 2024
In addition to the requirements, above and set forth in
						Chapter I, Section 1, of the
MBM,
the OHH must maintain a
						specific record and documentation of services for each member receiving covered
						services.
A.
Records.
The member's record must minimally include:
1.
					 Name, address, birthdate, and MaineCare identification number;
2. Diagnoses that support eligibility for
					 services herein, including the most recent documentation of diagnoses that
					 substantiate ongoing eligibility for services;
3. The comprehensive assessment that must
					 occur within the first thirty (30) days of initiating of services, and with any
					 reassessments that occur;
4. The
					 Plan of Care/ITP and any updates that occur;
5. Correspondence to and from other
					 providers;
6. Release of
					 information statements as necessary, signed by the member, including right
					 notification, rules and regulations, confidentiality statement and release of
					 information;
7.
					 Documentation/record entries (i.e. progress notes) that clearly reflect
					 implementation of the treatment plan and the member's response to treatment, as
					 well as subsequent amendments to the plan. Progress notes for each service
					 provided, including the date of service, the type of service, the place of the
					 service or method of delivery (i.e., phone contact), the goal to which the
					 service relates to, the duration of the service, the progress the member has
					 made towards goal attainment, the signature and credentials of the individual
					 performing the service, whether the individual has declined services in the
					 Plan of Care/ITP, and timelines for obtaining needed services;
8. A record of discharge/transfer planning,
					 beginning at admission and any referrals made; and
9. Adequate clinical documentation to support
					 the phrase of treatment for which the provider is
					 attesting.
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-93 - Opioid Health Home Services › Subsection 144-101-II-93.08 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
OHHs are reimbursed a Per Member Per Month (PMPM) payment
						for each OHH member, based on the member's level of care at the end of the
						billing month. The PMPM payment amount for each level of care is based on the
						expected use of OHH covered services.
93.08-1
Minimum Requirements for OHH
					 Reimbursement
In order for the OHH to be eligible for the PMPM payments
						for each billing month, the OHH shall:
A. Provide the covered services described in
					 and in accordance with 93.05, Covered Services;
B. Submit cost and utilization reports upon
					 request by the Department, in a format determined by the Department;
C. Scan panel data, as identified by the
					 Department, for its assigned population;
D. Attest to meeting the following
					 requirements:
1. Members in the IOP,
					 Induction, Maintenance, and Stabilization Levels of Care must be enrolled for a
					 minimum of fifteen (15) days in a service month for the OHH to attest for each
					 member.
2. Members in the
					 Medication Plus or Methadone Levels of Care must be enrolled for a minimum of
					 one (1) day in a service month for the OHH to attest for each member.
E. Document each service provided
					 to each member, for each billing month, as required by these rules, in order to
					 be eligible to receive the PMPM reimbursement.
F. For members in the Methadone Level of
					 Care, have them sign a release of information allowing coordination of care
					 between the OTP and the OHH.
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-93 - Opioid Health Home Services › Subsection 144-101-II-93.09 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
The OHH shall attest through a claims process that the
						OHH has performed the necessary "minimum billable activity" (Section
						93.08 ) each month to
						receive payment for Section
						93 members.
Billing for medications (93.05-5), shall be as
						follows:
A. When a prescription for
					 medication is written, but not dispensed at the OHH, the dispensing pharmacy
					 shall bill for the medication in accordance with
MBM,
Section
					 80, "Pharmacy Services".
B. When a prescription for medication is
					 dispensed by the OHH, the OHH shall include the billing for the medication on
					 the applicable UB or 1500 claim form.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-94 - Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) › Subsection 144-101-II-94.01 - INTRODUCTION

Current through 2024-29, July 17, 2024
Members under the age of twenty-one (21) may get
						medically necessary MaineCare Benefits Manual, Chapter II services for which
						they qualify. In addition, Federal Medicaid regulations require that MaineCare
						provide Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT)
						to members under the age of 21 in accordance with 42 U.S.C. symbol 167 \f "Kino
						MT" \s 111396d(a).
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-94 - Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) › Subsection 144-101-II-94.02 - ELIGIBILITY FOR SERVICES

Current through 2024-29, July 17, 2024
MaineCare members under the age of 21 are eligible for
						services described in this Section.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-94 - Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) › Subsection 144-101-II-94.04 - HEALTH PROMOTION

Current through 2024-29, July 17, 2024
94.04-1
Informing and Periodicity
MaineCare will inform all members about the availability
						of Early and Periodic Screening, Diagnosis and Treatment within sixty (60)
						calendardays of their enrollment in MaineCare and in the case of families that
						have not utilized such services, annually thereafter.
MaineCare will notify members that a health assessment
						visit is due by the first of the month in which visits are due according to the
						MaineCare Bright Futures periodic health assessment schedule (Appendix
						1).
94.04-2
Special
					 Assistance for Members under Age 21
MaineCare will provide the following assistance to
						members.
A. Arrange or schedule
					 appointments for services or treatment for problems found as a result of a
					 health assessment visit.
B. Find a
					 MaineCare provider.
C. Arrange
					 transportation.
D. Make referrals
					 for follow-up by the Maine Department of Health and Human Services, Centers for
					 Disease Control and Prevention, Public Health Nursing (PHN) staff or nursing
					 staff under contract with the Centers for Disease Control and Prevention to
					 perform PHN functions for, but not limited to, the following reasons. The
					 child:
1. does not have a primary care
					 provider;
2. is significantly
					 behind in his/her immunizations;
3.
					 is missing appointments with his or her provider(s); or
4. needs a repeat blood lead test.
Providers may use the MaineCare Bright Futures health
						assessment form to request a referral to the Centers for Disease Control and
						Prevention or may call or fax the Health Care Management Unit of MaineCare
						Services.
E.
					 Help with issues identified as a result of a health assessment visit when
					 requested by the provider.
F.
					 Provide information in alternative formats such as Braille or provide
					 interpreter services for members who are deaf/hard of hearing or who are
					 non-English or limited English speaking.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-94 - Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) › Subsection 144-101-II-94.05 - Treatment Services

Current through 2024-29, July 17, 2024
94.05-1
Providers
Providers of treatment services must:
A. be appropriately credentialed or licensed
					 individuals or entities and be working within the scope of their licensure. For
					 example: All durable medical equipment (DME) must be supplied through a DME
					 provider,
B. sign a MaineCare
					 Provider/Supplier Agreement,
C.
					 comply with Chapter I, Administrative Policies and Procedures, of the MaineCare
					 Benefits Manual, and
D. comply with
					 all MaineCare policies found in those sections of the MaineCare Benefits Manual
					 applicable to the service provided, including but not limited to provider
					 qualification requirements.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-94 - Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) › Subsection 144-101-II-94.06 - BILLING AND REIMBURSEMENT

Current through 2024-29, July 17, 2024
94.06-1
Bright Futures Health Assessment Visits
MaineCare will reimburse providers for one health
						assessment visit per member for each age shown on the MaineCare Bright Futures
						periodic health assessment schedule (Appendix 1).
A.
Physicians, Physician's Assistants,
					 Advanced Practice Registered Nurses in Private Practice
Use the Evaluation and Management Preventive Medicine
						Services and Newborn Care codes set forth in the Early and Periodic Screening,
						Diagnosis and Treatment Services Appendix to the Billing Instructions. Contact
						MaineCare Services, Provider Relations Unit to get a copy of the Appendix to
						the Billing Instructions.
Bill in accordance with the Billing Instructions of the
						Department for the CMS 1500.
B.
Federally Qualified Health Centers
					 (FQHC)/Rural Health Clinics (RHC)
Use core visit code established in the MaineCare
						Benefits Manual, Chapter III, Section 31 (FQHCs) or Section 103 (RHCs).
Bill in accordance with the Billing Instructions of the
						Department for the CMS 1500.
C.
Hospital Based/Owned Physician
					 Practices
Bill in accordance with the Department's Billing
						Instructions for the CMS 1500 or the UB 04 as appropriate.
D.
Ambulatory Care Clinics
Use codes established in the MaineCare Benefits Manual,
						Chapter III, Ambulatory Care Clinics Section 3.
Bill in accordance with the Billing Instructions of the
						Department for the CMS 1500.
E.
Durable Medical Equipment
					 providers
Use codes established in the MaineCare Benefits Manual,
						Chapter III, Section 60, Medical Supplies and Durable Medical Equipment.
Bill in accordance with the Billing Instructions of the
						Department for the CMS 1500.
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-95 - Podiatric Services › Subsection 144-101-II-95.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
95.01-1
Podiatric Care
Podiatric care is a service performed by a licensed
						podiatrist that is reasonable and medically necessary for the diagnosis or
						treatment of diseases or pathology of the foot and ankle.
95.01-2
Podiatrist
A podiatrist is a person who has special training and
						expertise in the diagnosis and treatment of problems associated with the human
						foot and ankle, and the structures that govern its function. A podiatrist
						functions within the scope of the current license granted by the State or
						Province in which the services are performed.
95.01-3
Routine Podiatric Care
MaineCare considers routine podiatric care to include
						such items as nail debridement, removing corns and calluses, trimming, cutting
						and clipping of the toenails.
95.01-4
Covered Services
Covered services are those medically necessary services
						described in Section 95.04.
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-95 - Podiatric Services › Subsection 144-101-II-95.02 - 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
						MaineCare prior to furnishing services as indicated in Chapter I of the
						MaineCare Benefits Manual.
Medical Eligibility Requirements
After an initial visit, podiatric care will only be
						covered for a member who meets all of the following requirements:
1. Has any illness, diagnosis or condition
					 that if left untreated may cause loss of function or may risk loss of limb;
					 and
2. For whom self-care or foot
					 care by a nonprofessional person would be hazardous and pose a threat to the
					 member's condition.
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-95 - Podiatric Services › Subsection 144-101-II-95.03 - DURATION OF CARE AND LIMITATIONS

Current through 2024-29, July 17, 2024
Each MaineCare member is eligible for those medically
						necessary covered services described in this Section. The Department reserves
						the right to request additional information to evaluate medical
						necessity.
Some services under this section require prior
						authorization by the Department or its Authorized Agent. The Department may use
						criteria outlined in this policy in addition to using prior authorization
						criteria that is industry recognized prior authorization criteria utilized by a
						national company under contract. In cases where the criteria are not met, the
						provider/Member may submit additional supporting evidence such as medical
						documentation, to demonstrate that the requested service is medically
						necessary.
For Podiatry services that require authorization, please
						contact the prior authorization unit. Prior authorization contact information
						and prior authorization forms, can be found at:
http://www.maine.gov/dhhs/oms/provider_index.html
.
Refer to the MaineCare Benefits Manual (MBM), Chapter I,
						General Administrative Policies and Procedures, and MBM, Section 90, Physician
						Services for additional information regarding prior authorization
						requirements.
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-95 - Podiatric Services › Subsection 144-101-II-95.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
Covered services are those services provided by
						podiatrists within the scope of their license and for which the Department may
						make payment. Covered services include those podiatric services provided
						directly by a podiatrist, laboratory and x-ray services furnished by the
						podiatrist's office and services that are specifically included in the
						Department's MaineCare Benefits Manual, Section 90, Physician Services. Some
						services require prior authorization by the Department or its Authorized Agent,
						and procedures requiring prior authorization are listed at:
						http://portalxw.bisoex.state.me.us/oms/proc/pub_proc.asp?cf=mm [File Link Not
						Available] . Services shall be covered only for members who meet the medical
						eligibility requirements in Section 95.02.
Covered services are limited to the following:
95.04-1
Podiatric Care
A.
Diagnostic and Treatment
					 Services
The diagnosis and treatment of problems of the foot, in
						an initial visit in a setting furnished with equipment appropriate to the
						practice of the profession.
B.
Podiatric Care
Podiatric care will only be covered for members who meet
						the eligibility above in Section 95.02, Eligibility for Care.
Podiatrists may bill for an office visit, or for
						podiatric care, but not both for the same visit.
C.
Bunion Surgery
The Department requires some bunion surgery to be prior
						authorized in accordance with provisions defined in Section 90.05-1, Restricted
						Services, of the MaineCare Benefits Manual, Chapter II, Section 90, Physician
						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-95 - Podiatric Services › Subsection 144-101-II-95.05 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
MaineCare will only cover routine podiatric care for
						members who meet the medical eligibility requirements in Section 95.02,
						Eligibility for 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-95 - Podiatric Services › Subsection 144-101-II-95.06 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
95.06-1
Member Records
The Department requires a specific record for each
						member, that includes, but is not necessarily limited to:
A. the member's name, address, and
					 birthdate;
B. the member's history,
					 as appropriate;
C. findings from
					 the physical examination;
D. long
					 and short range goals, as appropriate;
E. any tests ordered/performed and the
					 results;
F. treatment or follow-up
					 care;
G. any medications and/or
					 supplies dispensed or prescribed;
H. recommendations for additional treatments
					 and sources of care;
I. the dates
					 on which all services were provided; and
J. written progress notes that identifies the
					 services provided.
Entries are required for each date of service billed and
						must include the podiatrist's name and signature.
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-95 - Podiatric Services › Subsection 144-101-II-95.07 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
A. The MaineCare rates of reimbursement are
					 posted and updated on the DHHS Rate Setting website at:
http://www.maine.gov/dhhs/audit/rate-setting/index.shtml
.
					 These fee for service rates are decreased by ten percent (10%), effective April
					 1, 2012, in accordance with Public Law 2011, Chapter 477, LD 1816, Part
					 M.
B. In accordance with Chapter I,
					 it is the responsibility of the provider to ascertain from each member whether
					 there are any other resources (private or group insurance benefits, worker's
					 compensation, etc.) that are available for payment of the rendered service, and
					 to bill that potential payor 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-95 - Podiatric Services › Subsection 144-101-II-95.08 - COPAYMENT

Current through 2024-29, July 17, 2024
95.08-1
Copayment Amount
A. A copayment will be charged to each
					 MaineCare member receiving services. The amount of the copayment shall not
					 exceed $2.00 per day for services provided, according to the following
					 schedule:
MaineCare Payment for
								Service
Member Copayment
$10.00 or less
$ .50
$10.01 - 25.00
$1.00
$25.01 or more
$2.00
B. The member shall be responsible for
					 copayments up to $20.00 per month whether the copayment has been paid or not.
					 After the $20.00 cap has been reached, the member will not be required to make
					 additional copayments and the provider will 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 money available to pay the
					 copayment. A member's inability to pay a copayment does not 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.
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-95 - Podiatric Services › Subsection 144-101-II-95.09 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
A. Billing must be
					 accomplished in accordance with the Department's current billing
					 instructions.
B. All services
					 provided on the same day shall be submitted on the same claim 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-96 - Private Duty Nursing and Personal Care Services › Subsection 144-101-II-96.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
96.02-1
General and Specific Requirements
An individual is eligible to receive services as set
						forth in this Section if he or she meets the general MaineCare eligibility
						requirements, the specific MaineCare eligibility requirements, and the medical
						eligibility requirements.
96.02-2
General MaineCare Eligibility
					 Requirements
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.
96.02-3
Specific Eligibility Requirements
A. Only individuals under age 21 are eligible
					 for Level IV under this Section.
B.
					 Individuals of any age are eligible for all other Levels 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-96 - Private Duty Nursing and Personal Care Services › Subsection 144-101-II-96.06 - LIMITS

Current through 2024-29, July 17, 2024
A. Skills training shall not exceed 14.25
					 hours annually including any hours needed for initial instruction.
B. Care Coordination shall not exceed
					 twenty-four hours (24) per eligibility period except as follows: if the
					 Department determines that exceptional circumstances exist such that the health
					 and welfare of a Member cannot be met under this limit, the Department may
					 authorize additional units of care coordination services for the
					 Member.
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-96 - Private Duty Nursing and Personal Care Services › Subsection 144-101-II-96.08 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
96.08-1
Reimbursement for Private Duty
					 Nursing and Personal Support Services
Reimbursement will be made on the unit rate as specified
						in Chapter III of this Section and shall be the lower of:
A. The amount listed in Chapter III, Section
					 96, "Allowances for Private Duty
					 Nursing and Personal Care Services"; or
B. The provider's usual and customary charge.
In accordance with Chapter I of the
MaineCare
						Benefits Manual
, it is the responsibility of the provider to seek
						payment from any other sources 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-96 - Private Duty Nursing and Personal Care Services › Subsection 144-101-II-96.09 - COPAYMENT

Current through 2024-29, July 17, 2024
96.09-1
Copayment Amount
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
$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.
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-96 - Private Duty Nursing and Personal Care Services › Subsection 144-101-II-96.10 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
A. Billing must be
					 accomplished in accordance with instructions for either the CMS 1500, or the
					 UB04 Form, as appropriate.
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.
D. All providers
					 involved in the delivery of services to a Member are responsible for billing
					 for those services with appropriate procedure codes outlined in Chapter III.
Billing for services delivered to children under age 21,
						excluding those receiving care under the family provider service option, and
						for all Level VI and Level VII services, shall be submitted to 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-96 - Private Duty Nursing and Personal Care Services › Appendix 144-101-II-#2 - LEVEL OF CARE CAPS

Current through 2024-29, July 17, 2024
Members are assigned to a level of care based upon the
						eligibility criteria in Section 96.02.
The Department is seeking and anticipates receiving
						CMS approval for this Section. There are three separate proposed rate changes
						pending before CMS: one that was submitted in September 2016, one submitted in
						September 2017, and one submitted in July 2018; thus there are three
						retroactive effective dates applicable for these rates. Pending CMS approval,
						the following levels of care will be effective.
Members under the age of
						21 years can exceed the caps when it is medically necessary as outlined under
						Section 96.03(A). Reimbursement of care coordination and skills training do not
						count toward the monthly cost caps.
Level of Care
Effective 7/29/16 to 6/30/17 and 7/1/18 to
								  7/31/18
Effective 7/1/17 to 6/30/18
Effective 8/1/18 to 6/30/19
Effective 7/1/19
Level I
$925/month
$1,092/month
$1,124.00/month
$1,114.00/month
Level II
$1,165/month
$1,375/month
$1,415.00/month
$1,402.00/month
Level III
$1,904/month
$2,248/month
$2,314.00/month
$2,292.00/month
Level IV (under 21 years of age, only)
$3,532/month
$4,041/month
$4,160.00/month
$4,119.00/month
Level V
$23,966/month
$27,420/month
$28,222.00/month
$27,941.00/month
Level VIII
$847/month
$938/month
$966.00/month
$957.00/month
Level IX
$1,769/month
$2,088/month
$2,149.00/month
$2,129.00/month
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-97 - Private Non-Medical Institution Services › Subsection 144-101-II-97.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each MaineCare member is eligible for covered services
						that are medically necessary as determined by eligibility and continued
						eligibility requirements set forth in this Section. The Department reserves the
						right to request additional information to evaluate eligibility and continued
						eligibility for 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-97 - Private Non-Medical Institution Services › Subsection 144-101-II-97.04 - COVERED SERVICES - DIRECT SERVICE STAFF

Current through 2024-29, July 17, 2024
A covered service is a service for which payment to a
						PNMI provider is permitted under the rules of this Section. Direct service
						staff is defined as staff who provide the services listed in this Section.
						MaineCare covers the following services when provided in an approved setting of
						a licensed Private Non-Medical Institution in accordance with Chapter III,
						Principles of Reimbursement for Private Non-Medical Institution Services,
						provided within the scope of licensure of the facility, and billed by that
						facility, and as identified in Section
						97.08. Not all of the
						following services are included in the rate for every type of facility. Refer
						to the applicable Appendix in Chapter III for services that are included in the
						rate for each type of PNMI. The Chapter III Principles of Reimbursement for
						each type of Private Non-Medical Institution define which staff services are
						allowable. The service must be listed in the Principles of Reimbursement in
						order for the service to be reimbursable. Covered services may include, but are
						not limited to:
97.04-1 Physician
					 services
97.04-2 Psychiatrist
					 services
97.04-3 Psychologist
					 services
97.04-4 Psychological
					 examiner services
97.04-5 Social
					 worker services
97.04-6 Licensed
					 clinical professional counselor services
97.04-7 Licensed professional counselor
					 services
97.04-8 Dentist
					 services
97.04-9 Registered nurse
					 services
97.04-10 Licensed
					 practical nurse services
97.04-11
					 Psychiatric nurse services
97.04-12
					 Speech pathologist services
97.04-13 Licensed alcohol and drug counselor
					 services
97.04-14 Occupational
					 therapy services
97.04-15 Other
					 qualified mental health staff services
97.04-16 Other qualified medical and remedial
					 staff services
97.04-17 Other
					 qualified alcohol and drug treatment staff services
97.04-18 Personal care services
97.04-19 Other qualified childcare facility
					 services
97.04-20 Other qualified
					 licensed treatment foster care provider services
97.04-21 Interpreter services
97.04-22 Nurse practitioner
					 services
97.04-23 Physician
					 assistant services
97.04-24
					 Clinical consultant services
97.04-25 Physical therapy 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-97 - Private Non-Medical Institution Services › Subsection 144-101-II-97.05 - LIMITATIONS

Current through 2024-29, July 17, 2024
97.05-1
Collateral Contacts
Reimbursement shall be made for direct services,
						collateral contacts, and certain supportive services when there is not a direct
						encounter with the member, only as described in Chapter III, Principles of
						Reimbursement for PNMIs, Section 2400, and when provided by qualified staff
						members.
97.05-2
Non-Duplication of Services
It is the responsibility of the PNMI provider to
						coordinate PNMI services with other "in-home" services to address the full
						range of member needs. Other MaineCare covered services shall not duplicate
						PNMI services included in the facility's PNMI rate. Covered services, listed in
						the applicable Appendix, and/or in contracts with the Department, that are part
						of the PNMI rate are the responsibility of the PNMI to provide or arrange under
						contract as necessary with providers practicing within the scope of their
						licensure.
Services that are part of the PNMI rate may not be
						billed to MaineCare separately by other providers. Personal care services are
						included as part of the PNMI rate and shall be delivered by the PNMI provider
						and not by a MaineCare provider under any other Section of this Manual
						including PSS under Section
						96, Private Duty Nursing and
						Personal Care Services provider or other Section of MaineCare policy.
PNMI providers must coordinate their services with all
						other MaineCare services, including but not limited to case managers providing
						services outside the residential setting, in accordance with the provisions of
						Chapter II, Section
						13, of the
MaineCare
						Benefits Manual
, Targeted Case Management Services.
97.05-3
Out-of-State Placement
Reimbursement shall not be made for Private Non-Medical
						Institution services provided out of state unless the services are medically
						necessary, and are not available within the State and prior authorization (as
						described in this Section and Chapter I, of the
MaineCare Benefits
						Manual
) has been granted.
97.05-4
Bed-Hold Days
Bed-hold days are not reimbursable.
For members receiving State S.S.I. and
						cost-reimbursement benefits, in order for benefits to continue for a member who
						is temporarily admitted to a State institution, a hospital, or a nursing
						facility when the residential care facility provider has agreed to hold the
						bed, the provider must do the following:
a) Notify the Social Security Administration
					 that the member has been admitted to an institution, and
b) Notify the Social Security Administration
					 that the bed is being held for the resident.
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-97 - Private Non-Medical Institution Services › Subsection 144-101-II-97.06 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
Please refer to Chapter I of the
MaineCare
						Benefits Manual
for additional non-covered services, including
						services that are for vocational, academic, socialization or recreational
						purposes.
97.06-1
Private Room
					 and Other Non-Covered Services
The PNMI may permit payment by a relative of an
						additional amount to enable a member to obtain non-covered services such as a
						private room, telephone, television, or other non-covered services. However,
						the additional charge for non-covered services shall not exceed the charge to
						private pay residents. The supplement for a private room shall be no more than
						the difference between the private pay rate for a semi-private room and a
						private room rate. There shall be a signed statement by the member and/or
						relative making the additional payment that he/she was notified and agreed to
						the payment for non-covered services before those services were provided. This
						provision shall not apply where the standard of care in the PNMI is for a
						private room.
Private rooms, as are all PNMI room and board costs, are
						non-covered services under MaineCare, but if there is a medical necessity for a
						private room, the PNMI must make one available.
97.06-2
Personal Care Services Provided
					 by a Family Member
Personal care services provided by a family member are
						not a covered service, and may not be billed by the family or by any other
						provider.
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-97 - Private Non-Medical Institution Services › Subsection 144-101-II-97.09 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
For each MaineCare provider enrolled as a participating
						Private Non-Medical Institution, the Department will determine an interim per
						diem rate, as determined under Chapter III, Section
						97, Principles of Reimbursement
						for Private Non-Medical Institution Services
,
and the
						applicable Appendix.
Providers are required to obtain separate MaineCare
						provider number(s) for each PNMI provider type as described in Section 97.01-1.
						Upon completion of the provider's fiscal year, the providers shall submit to
						the Department, a cost report for each PNMI that has been assigned a provider
						number(s) in accordance with Chapter III of the Principles of
						Reimbursement.
Agencies that obtain public funds from another source to
						use as either a portion or as the entire State share of the PNMI rate must
						complete a Rider A as part of their Provider/Supplier Agreement to certify the
						State share of MaineCare funding. If certified public funds support only a
						portion of the PNMI rate, the full rate must be paid to the provider, with an
						adjustment made at settlement to reimburse the Department the amount certified
						in Rider A. This amount will be reported to the Department using Chapter III,
						Section
						97 rules for the submission of
						cost reports.
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 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-97 - Private Non-Medical Institution Services › Subsection 144-101-II-97.10 - BILLING INFORMATION

Current through 2024-29, July 17, 2024
Providers must bill in accordance with the Department's
						billing Instructions for the UB-04 Claim Form. Billing instructions are
						available at:
http://www.maine.gov/bms/provider.htm.
.
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-101 - Medical Imaging Services › Subsection 144-101-II-101.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Individuals must meet the eligibility criteria as set
						forth in the MaineCare Eligibility Manual. Some members may have restrictions
						on the type and amount of services they are eligible to
						receive.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-101 - Medical Imaging Services › Subsection 144-101-II-101.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
101.03-1 Medical
					 Necessity
Each MaineCare member is eligible for as many covered
						medical imaging services as are medically necessary. The Department reserves
						the right to request additional information to evaluate and determine medical
						necessity.
101.03-2 Prior
					 Authorization Requirements
Providers are reminded that some services may require
						prior authorization and are identified under the "Procedure Code Look Up" link
						at:
http://www.maine.gov/dhhs/oms/providerfiles/prov_portal_tools.html
.