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-97.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
97.01-1
Authorized Agent
Authorized Agent is the organization authorized by the
						Department of Health and Human Services (DHHS) to perform specified functions
						for the Department pursuant to a signed contract or other approved signed
						agreement, including but not limited to conducting prior authorization,
						clinical review, and concurrent review of services.
97.01-2
Family
Unless defined otherwise in the Principles of
						Reimbursement of Chapter III, Section
						97, family means any of the
						following: spouse of the member, the parents or stepparents of a minor child,
						or a legally responsible relative.
97.01-3
Individual Service Plan
An Individual Service Plan (ISP) means the plan of
						service based on an individual assessment of a member's need for treatment or
						rehabilitation services made in accordance with the appropriate Principles of
						Reimbursement. Unless otherwise specified in the appropriate Principles of
						Reimbursement, this plan shall specify the service components to be provided,
						the frequency and duration of each service component, and the expected short
						and long range treatment and/or rehabilitative goals or outcome of services.
						Discharge planning must be addressed in the Individual Service Plan.
97.01-4
Interim Per
					 Diem
A per diem rate is the rate determined by the Department
						of Health and Human Services (DHHS) (per Chapter III, Principles of
						Reimbursement for PNMIs, Section 2400 and the applicable Appendix) that may be
						paid to a PNMI provider for the provision of covered services. The interim per
						diem rate will be adjusted at audit.
97.01-5
Medical Eligibility
					 Determination (MED) Tool
Medical Eligibility Determination (MED) Tool means the
						form approved by the Department for medical eligibility determinations and
						service authorization for the plan of care based upon the assessment outcome
						scores. The definitions, scoring mechanisms and timeframes relating to this
						form are outlined in Chapter II, Section 96.02-4.
97.01-6
Medical Supplies and Durable
					 Medical Equipment
Unless defined otherwise in the Principles of
						Reimbursement, medical supplies and durable medical equipment means medically
						necessary supplies and equipment listed in Chapter II, Section
						60, Medical Supplies and Durable
						Medical Equipment of the
MaineCare Benefits Manual
(MBM). All
						equipment must be directly related to member medical needs as documented in the
						individual service plan.
97.01-7
Per Diem Rate
A per diem rate is the rate determined by the Department
						of Health and Human Services (DHHS) (per Chapter III, Principles of
						Reimbursement for PNMIs, Section 2400 and the applicable Appendix) paid to a
						PNMI provider for the provision of covered services.
97.01-8
Prior Authorization
Prior Authorization (PA) is the process of obtaining
						prior approval as to the medical necessity and eligibility for a service. Prior
						Authorization is also detailed in Chapter I of the
MaineCare Benefits
						Manual
(MBM). Crisis stabilization services do not require prior
						authorization, but providers must contact the Department within 48 hours to
						complete the prior authorization process for reimbursement of continued
						services. Other PNMI services require prior authorization as detailed in this
						Section.
97.01-9
Private Non-Medical Institution
A Private Non-Medical Institution (PNMI) is defined as
						an agency or facility that is not, as a matter of regular business, a health
						insuring organization, hospital, nursing home, or a community health care
						center, that provides food, shelter, personal care, and treatment services to
						four or more residents in single or multiple facilities or scattered site
						facilities. Private Non-Medical Institution services or facilities must be
						licensed by the Department of Health and Human Services, or must meet
						comparable licensure standards and/or requirements and staffing patterns as
						determined by the Department specified in Section
						97.01 (A-F). For
						agencies serving persons with intellectual disabilities/developmental
						disabilities (ID/DD) in scattered site PNMIs, comparable licensure standards
						means those required by rule for community support services as described in
						Mental Health Agency Licensing Standards and Rights of Recipients of Mental
						Health Services, Regulations for Licensing and Certification of Alcohol and
						Drug Treatment Services.
Services provided out-of-state must be medically
						necessary and unavailable in the State of Maine, and may be subject to approval
						by the Commissioner of the Department of Health and Human Services or designee,
						as well as priorauthorization, as described in this Section and Chapter I of
						the
MaineCare Benefits Manual
.The following details those
						services in Chapter III, Section
						97:
Appendix B. Substance Use Treatment Facility
A substance use treatment facility is a PNMI that is
						maintained and operated for the provision of residential substance use
						treatment and rehabilitation services and is licensed and funded by the
						Department's Office of Behavioral Health. Substance use treatment facilities
						are also subject to rules in MBM, Chapter III, Section
						97, and Appendix B.
Appendix C. Medical and Remedial Services
						Facility
Medical and remedial services facilities are those
						facilities as defined in
						22 MRSA
						§7801 that are maintained wholly or
						partly for the purpose of providing residents with medical and remedial
						treatment services and licensed by the Department of Health and Human Services
						under the "Regulations Governing the Licensing and Functioning of Assisted
						Living Facilities." These facilities must also be qualified to receive cost
						reimbursement for room and board costs not covered under this Section.
Medical and remedial facilities are also subject to rules
						in MBM, Chapter III, Section
						97, and Chapter III, Section
						97, Appendix C.
Appendix D. Child Care Facilities
A child care facility is any private or public agency or
						facility that is maintained and operated for the provision of child care
						services, as defined in
						22
						MRSA §§8101,
						8101(1),
						and
						8101(4),
						is funded and licensed by the Department of Health and Human Services under the
						"Rules for Licensure of Residential Child Care Facilities," 10-148 CMR, Chapter
						18; and/or is licensed and funded by the Department's Children's Behavioral
						Health Services pursuant to
						34-B MRSA
						§3606.
Requests for exceptions to Department funding and
						licensure requirement may be made through written correspondence to the Office
						of MaineCare Services. Providers may make requests for exceptions to the
						Department of Health and Human Services funding and/or licensure requirement
						through written correspondence to the Office of MaineCare Services from the
						Office of Child and Family Services.
For the purpose of MaineCare reimbursement only, child
						care facility Private Non-Medical Institutions also include treatment foster
						homes, their staff and parents, licensed by the Department, and child placing
						agencies under contract with the Office of Child and Family Services. Child
						placing agencies must be licensed in accordance with the rules providing for
						the licensing of child placing agencies. Child care facilities are also subject
						to rules in MBM, Chapter III, Section
						97, and Chapter III, Section
						97, and Appendix D.
Intensive Temporary Residential (ITRT) Treatment
						Services
Intensive Temporary Residential Treatment Services (ITRT)
						are defined as child care facility private non-medical institution model of
						service services for children with intellectual disabilities, autism, severe
						mental illness, and/or emotional disorders, who require twenty-four (24) hour
						supervision to be safely placed in their home and community. ITRT must be
						provided in the least restrictive environment possible, with the goal of
						placement as close to the child's home as possible. Families must remain as
						actively involved in their child's care and treatment as possible. The purposes
						of ITRT are to provide all services to both treat the mental illness/disorder
						and to return the child to his/her family, home and community as soon as
						possible.
ITRT provide twenty-four (24) hour per day, seven (7)
						days per week structure and supportive supervised living environment and active
						behavioral treatment, as developed in a treatment plan. This environment is
						integral to supporting the learning experiences necessary for the development
						of adaptive and functional behavior to allow the child to live outside of an
						inpatient setting.
ITRT are also subject to rules in MBM, Chapter III,
						Section
						97, and Appendix D.
Appendix E. Community Residences for Persons with
						Mental Illness
A community residence PNMI is a PNMI with integral mental
						health treatment and rehabilitative services, that is licensed by the
						Department, overseen as a mental health residential treatment or supportive
						housing service by the Office of Behavioral Health, and operated in compliance
						with treatment standards established through these rules and the pertinent
						Principles of Reimbursement.
Community residences for persons with mental illness also
						include residential services for the integrated treatment of persons with dual
						disorders, which provide mental health and substance use treatment services to
						individuals with coexisting disorders of mental illness and substance use.
						These residences shall be licensed by the Department. Such residences must also
						be receiving funds from the Department for the treatment of persons with dual
						disorders. Community residences for persons with mental illness are also
						subject to rules in MBM, Chapter III, Section
						97, and Chapter III, Section
						97, Appendix E.
Appendix F. Non-Case Mixed Medical and Remedial
						Facilities
Non-case mixed facilities provide PNMI medical and
						remedial treatment services to members in specialized facilities or scattered
						site facilities not included in the case mix payment system described in
						Appendix C. These facilities specialize in solely treating members with
						specific diagnoses such as acquired brain injury, HIV/AIDS, ID/DD, or
						blindness. Services must be provided in compliance with these rules, the
						pertinent Chapter III, Principles of Reimbursement, and Chapter III, Appendix
						F, and any contractual provisions of the Department.
97.01-10
Private Non-Medical
					 Institution Services
Private Non-Medical Institution services are those
						services provided to a member at one of the above properly licensed and/or
						designated institutions, in accordance with these regulations, and in
						accordance with the pertinent Principles of Reimbursement established by the
						Department of Health and Human Services.
97.01-11
Program Allowance
A program allowance, expressed as a percentage of the
						allowable costs, as defined in Chapter III, Section 97, Sections 2400.1 and
						2400.2 may be allowed in lieu of indirect and/or PNMI related cost. See
						applicable Chapter III section and appendix.
97.01-12
Provider Agreement
A provider agreement encompasses the MaineCare Provider
						Agreement on file with the Office of MaineCare Services. Providers must also
						contract with the Department and satisfactorily meet all contract and provider
						agreement provisions.
97.01-13
Rate Letter
A rate letter is an instrument used to inform the
						provider of the approved total cost cap and per diem rate based on a review of
						the submitted budget per Chapter III, Section 2400, General Provisions. For
						case mix facilities covered under Appendix C, the rate letter informs the
						agency of the industry price, program allowance, personal care services
						component, and average case mix index.
97.01-14
Utilization Review
Utilization Review (UR) is a formal assessment of the
						medical necessity, efficiency and appropriateness of services and treatment
						plans on a prospective, concurrent, or retrospective basis