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-97.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
97.02-1
General Eligibility Criteria
The following individuals are eligible for medically
						necessary covered Private Non-Medical Institution services as set forth in this
						Manual:
Individuals must meet the basic eligibility criteria as
						set forth in Part 2 of the
MaineCare Eligibility Manual
, 10-144
						CMR Chapter 332. There are restrictions on the type and amount of services that
						members are eligible to receive and they must meet specific eligibility
						criteria detailed below.
97.02-2
Medical Necessity
Services in PNMIs must be medically necessary, as
						evidenced by meeting the medical eligibility criteria set forth in this
						section. A physician or primary care provider must also document in writing
						that this model of service is medically necessary for the member, and both the
						physician and the PNMI provider must keep this documentation in the member's
						file. For all PNMI services, this documentation must be completed as part of
						the prior authorization process conducted by the Department and/or its
						Authorized Agent.
97.02-3
Medical Eligibility for Appendix B: Substance Use Facilities
Members must require residential substance use treatment
						as assessed by the provider and documented in the individual service plan and
						member's file using the following criteria: American Society of Addiction
						Medicine, ASAM Patient Criteria for the Treatment of
Disorder, Second Edition, revised (2001), Level III,
						Residential/Inpatient Treatment Criteria. Members must continue to meet Level
						III for continued eligibility.
The Department or its Authorized Agent will conduct
						utilization review to assure medical necessity of these services.
97.02-4
Prior Authorization
					 and Medical Eligibility for Appendix C: Medical and Remedial Facilities
Appendix C facilities must contact the Department's
						Office of Aging and Disability Services, who must verify that members meet the
						medical eligibility requirements for residential care as indicated by the
						Medical Eligibility Determination (MED) tool assessment.
A member meets the medical eligibility and admission
						criteria for Appendix C PNMI only if that person meets one or more of the
						following eligibility requirements:
Requires cuing seven (7) days per week for eating,
						  toilet use, bathing, and dressing; OR
												Requires limited assistance and a one (1) person
						  physical assist with at least two (2) of the seven (7) activities of daily
						  living (ADLs) including bed mobility, transfer, locomotion, eating, toilet use,
						  bathing, or dressing; OR
												Requires preparation and administration of
						  regularly scheduled prescribed medications two (2) or more times per day that
						  is or otherwise would be performed by a person legally qualified to administer
						  prescribed medications; OR
												Requires any of the following nursing services, at
						  least once per month, that are or otherwise would be performed by or under the
						  supervision of a registered professional nurse, as described below:
												 administration of treatments, procedures, or
						  dressing changes which involve prescribed medications, for post-operative or
						  chronic conditions according to physician orders, that require nursing care and
						  monitoring. These treatments include:
												 administration of medication via a tube;
						  tracheostomy care;
												 urinary catheter change;
												urinary catheter irrigation;
												 barrier dressings for Stage 1 or 2 ulcers;
						  
												chest Physical Therapy (PT) by RN;
												oxygen therapy by RN;
												or other physician-ordered treatments;
						  OR
												Professional nursing assessment, observation, and
						  management for problems including wandering, physical or verbal abuse or
						  socially inappropriate behavior; OR
Professional nursing assessment,
						  observation and management for impaired memory, and impaired recall ability,
						  and impaired cognitive ability; OR
Exhibits moderately to significantly impaired
						  decision-making ability that will result in reasonably foreseeable unsafe
						  behavior when not appropriately supervised as measured by the cognition section
						  of the MED tool; OR
												Presents an imminent risk of harm or a probable
						  risk of significant deterioration, as determined by the Department or the
						  Department's Authorized Agent, of the individual's physical, mental or
						  cognitive condition if the individual resides or would reside outside of a
						  licensed facility.
97.02-5
Prior Authorization
					 Requirements for Appendix D Child Care Facilities
All children's services under this Section with the
						exception of crisis services require prior authorization using eligibility
						criteria set forth in these rules.
Providers must submit all documentation required for
						prior authorization according to the guidelines of this Section and Chapter I
						of this Manual to the appropriate Department Regional Office of the Office of
						Child and Family Services.
All required assessment tools must be completed within
						the last ten (10) days prior to submission of the prior authorization request.
						The DHHS Intensive Temporary Residential Treatment Team (ITRT) in each Region
						will review the information submitted to determine whether the child meets the
						criteria set forth below. The Team will determine the child's level of severity
						and recommend appropriate providers who can meet the needs of the child.
Providers must obtain prior authorization for current
						residents using these same assessments at the next continuing stay review.
						Reassessment is required to assure that medical necessity criteria are met for
						continuing stay in either Level I or Level II programs. Each prior
						authorization letter sent to the provider and the child/guardian shall indicate
						the model of service the child is eligible for.
Children must be assessed using the tools mentioned below
						and providers must submit all requested documentation to the appropriate
						Department Regional Office of Child and Family Services. Failure to submit
						requested information will result in disapproval of the prior authorization
						request. The Department will not reimburse for services that have not been
						prior approved.
Crisis service providers must contact the Department
						within 48 hours of initiation of service to begin the prior authorization
						process for continued provision of services.
Any change in a child's location or program within an
						agency or to another agency requires prior authorization.
97.02-6
Assessment Tools for Appendix D
					 Child Care Facilities
The following assessment tools are used in assessing
						eligibility for Children's PNMI services, though none of the tools are used as
						the sole determinant of eligibility.
Children's Habilitation Assessment Tool (CHAT) assesses
						functioning in three domains: behavior, social skills, and life skills using
						interviews for individuals 6 to 18 years of age diagnosed with intellectual
						disabilities or pervasive developmental disorders.
Child and Adolescent Functional Assessment Scale (CAFAS)
						assesses the functioning due to emotional, behavioral, psychological,
						psychiatric, or substance use problems in individuals 6 through 17 years of
						age. A trainedrater completes the scale.
Global Assessment Functioning (GAF) is a numeric scale (0
						through 100) used by mental health clinicians and physicians to subjectively
						rate social, occupational and psychological functioning, e.g., how well or
						adaptively one is meeting various problems-in-living. Children and adolescents
						under the age of 18 may be evaluated on the Children's Global Assessment Scale,
						or C-GAS.
97.02-7
Medical Eligibility Criteria for Appendix D Child Care Facility
					 Services
There are four models of PNMI services for Appendix D
						Child Care Facilities:
1.
Intellectual Disabilities and Pervasive Developmental Disorder (PDD)
					 Conditions: Child and Adolescent Intensive Temporary Behavioral Health
					 Treatment in a Residential Setting
There are two levels of PNMI services for children with
						intellectual disabilities and/or PDD and other symptoms requiring this
						intensity of service. A child is eligible for only one level of service at a
						time. Initial priorauthorization will not be given for more than thirty days at
						a time and continuing stay will be assessed at a minimum of every ninety days
						thereafter.
All of the following criteria set forth below must be
						met, in addition to criteria for either Level I or Level II services, as
						detailed below. The child must have:
An Axis I or II diagnosis from the most current
						  version of the DSM, and
													 A disorder that has lasted for at least six (6)
						  months or is expected to last for at least one (1) year in the future,
						  and
													A current need for therapeutic treatment or
						  availability of a therapeutic on-site staff response on a twenty-four hour
						  basis, and
													A disorder that is amenable to treatment in a
						  residential setting, and
													 even with intensive community intervention,
						  including services and supports, there is significant potential that the child
						  will be hospitalized, or there is a clear indication that the child's condition
						  would significantly deteriorate and would require a higher model of service
						  than can be provided in the home and community.
In addition to the above criteria, the child must meet
						the following criteria for either Level I or Level II services:
Level I Criteria
Significant recent aggression across multiple
						  environments or severe enough within one environment to have caused serious
						  injury or there is significant potential of serious injury to self or others;
						  or
													 Recent homicidal ideation with risk of harm to
						  others, or
													 Recent suicidal ideation with risk of harm to
						  self; or
													 Symptoms of intellectual disabilities or Pervasive
						  Developmental Disorder so severe that it results in an inability to care for
						  oneself to a developmentally appropriate level even with home and community
						  supports and services; or
													Has not responded to less restrictive level of care
						  or would have a significant risk of harm to self or others if a less
						  restrictive setting were attempted; and
													 An assessment using the Children's Habilitation
						  Assessment Tool (CHAT) with a score of 30 or higher or Global Assessment
						  Functioning (GAF) tool score of 50 or lower with description of specific
						  symptoms justifying the score.
Level II Criteria
The Child must meet all the level I service
						  criteria and in addition:
													Frequency, intensity and duration of intervention
						  required to address daily repeated aggression and potential for harm to self or
						  others, or
													 Frequency, intensity and duration of assistance
						  required to address activities of daily living and
													 potential for harm to self or others either
						  directly or as a consequence of being unable to maintain ADL's and
													Children's Habilitation Assessment Tool (CHAT)
						  score of 35 or higher, or a Global Assessment Functioning (GAF) score of 40 or
						  lower with description of specific symptoms justifying the score.
2.
Child Mental Health Conditions: Child and Adolescent Intensive Temporary
					 Behavioral Health Treatment in a Residential Setting
There are two levels of PNMI services for children and
						adolescents with Mental Health Conditions.
The child must meet all of the criteria set forth
						below:
The child must have either an Axis I or II
						  diagnosis from the most current version of the DSM, and
													 The child's disorder has lasted for at least six
						  (6) months or is expected to last for at least one year in the future,
						  and
													 The child has a current need for therapeutic
						  treatment or availability of a therapeutic on-site staff response on a
						  twenty-four hour basis, and
													The child's disorder is amenable to treatment in a
						  residential setting, and
													 Even with intensive community intervention,
						  including services and supports, there is significant potential that the child
						  will be hospitalized, or there is a clear indication that the child's condition
						  would significantly deteriorate and would require a higher model of service
						  than can be provided in the home and community.
In addition, the child must meet the criteria below for
						Level I or Level II services:
Level I Criteria
Significant recent aggression across multiple
						  environments or severe enough within one environment to have caused injury or
						  there is significant potential of injury to self or others; or
													 Recent homicidal ideation with risk of harm to
						  others, or
													 Recent suicidal ideation with risk of harm to
						  self; or
													 Symptoms of mental illness so severe that it
						  results in an inability to care for oneself in a developmentally appropriate
						  manner, even with home and community supports or services; or
													Has not responded to less restrictive model of
						  service or would have a significant risk of harm to self or others if a less
						  restrictive setting were attempted; and
													 A Child and Adolescent Functional Assessment Scale
						  (CAFAS) score of 100 or higher or Global Assessment Functioning (GAF) score of
						  50 or lower with description of specific symptoms justifying the
						  score.
Level II Criteria
Frequency, intensity and duration of intervention
						  required to address daily repeated aggression and potential for harm to self or
						  others, or
													Frequency, intensity and duration of assistance
						  required to address Activities of Daily Living and potential for harm to self
						  or others either directly or as a consequence of being unable to maintain ADL's
						  and
													A Child and Adolescent Functional Assessment Scale
						  (CAFAS) 8 scale score of 120 or higher, or Global Assessment Functioning (GAF)
						  score of 40 or lower with description of specific symptoms justifying the
						  score.
A.
Temporary High Intensity Service for Child and Adolescent Intensive
					 Temporary Behavioral Health Treatment in Residential Setting for 1)
					 Intellectual Disabilities and Pervasive Developmental Disorder Condition
					 providers, and 2) Child Mental Health Condition providers
The purpose of this temporary service is to stabilize a
						child who is currently residing in an Appendix D PNMI and experiences an
						escalation in behavioral discontrol in order to avoid the need to hospitalize
						the child. This service, provided only in an Appendix D PNMI for the express
						purpose of maintaining a child in the PNMI program, must be Prior Authorized
						and will be subject to Continuing Stay Review no later than every seven (7)
						calendar days. An Individualized Treatment Plan detailing the issue that has
						caused this request to be made must be submitted to the OCFS regional Intensive
						Treatment Review Team with the request for Prior Authorization that
						demonstrates why the child or others are not safe without this level of
						service, changes in treatment in an effort to decrease the unsafe behaviors,
						and documents a discharge plan with specific discharge criteria from this level
						of service.
The typical length of service is no more than seven (7)
						days and should not exceed thirty (30) days. In situations where this Level is
						sought for thirty (30) days or more, a Continuing Stay Review will be required
						and a new program considered that would more appropriately meet the child's
						needs.
The child must meet all eligibility criteria set forth
						below. The child must meet eligibility criteria for
a. Intellectual Disability and Pervasive
					 Developmental Disorder Conditions Level I or II; OR
b. Child Mental Health Conditions Level I or
					 II,
AND
c. The child
					 must have extreme needs that would otherwise result in immediate
					 hospitalization or placement in an out-of-state institution due to immediate
					 serious repeated physical harm to self or others or immediate risk of repeated
					 serious physical harm to self or others that could not otherwise be predicted
					 or planned for at the time of admission. This level of care is not intended as
					 a first response to aggression but as a last resort when other clinical and
					 medical interventions have been exhausted.
Brief hospitalizations for medication and behavioral
						stabilization are not grounds for seeking this level of care.
3.
Crisis
					 Stabilization Residential Services
Crisis Stabilization services are individualized
						therapeutic interventions provided to a child during a psychiatric emergency to
						address mental health and/or co-occurring mental health and substance use
						conditions for a time-limited post-crisis period, in order to stabilize the
						member's condition. Psychiatric emergency is when the child is in imminent risk
						of serious harm to self or others and even with intensive community
						intervention, including services and supports, there is significant potential
						that the member will be hospitalized.
Components of crisis stabilization include assessment,
						monitoring behavior and the member's response to therapeutic interventions;
						participating and assisting in planning for and implementing crisis and post
						stabilization activities, and supervising the child to assure personal
						safety.
While crisis services do not require prior authorization,
						providers must contact the Department within forty-eight (48) hours to get
						approval of continued reimbursement for this service using the prior approval
						process detailed in this Section.
4.
Therapeutic Foster Care: Child and
					 Adolescent
Intensive Temporary Behavioral Health Treatment in
						a Residential Setting
Therapeutic Foster Care is a family-based service
						delivery approach providing treatment to children with moderate to severe
						mental health, behavioral health and developmental needs. Treatment is
						delivered through services integrated with key interventions and supports
						provided by therapeutic foster parents who are trained supervised and supported
						by qualified therapeutic foster care program staff. The delivery of treatment
						is a shared responsibility between the independently licensed clinical staff,
						the independently licensed social work staff and the therapeutic foster
						parents. Therapeutic foster care is designed to allow children receiving
						treatment to reside in a family like setting as opposed to institutional
						settings, while receiving treatment.
To be eligible for these services, the child must be in
						DHHS or Department of Corrections custody and must require therapeutic
						intervention detailed above.
The child must meet the following criteria:
A Child and Adolescent Functional Assessment Scale
						  (CAFAS) 8 scale score of 50 higher, and
													an Axis I or II diagnosis from the most current
						  version of the DSM, and
													 The child's disorder must have lasted for at least
						  six (6) months or is expected to last for at least one year in the future,
						  and
													A current need for therapeutic treatment or
						  availability of a therapeutic on-site staff response on a twenty-four-hour
						  basis, and
													 Even with intensive community intervention,
						  including services and supports, significant potential that the child will be
						  hospitalized, or there is a clear indication that the child's condition would
						  significantly deteriorate and would require a higher model of service than can
						  be provided in the home and community.