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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-13 - FINANCIAL REPORTING

Current through 2024-29, July 17, 2024
13.1
MASTER
					 FILE
The following documents concerning the provider or, where
						relevant, any entity related to the Provider, will be submitted to the
						Department at the time that the cost report is filed. Such documents will be
						updated to reflect any changes on a yearly basis with the filing of a cost
						report. Such documents shall be used to establish a Master file for each
						facility in the MaineCare Program:
13.1.1 Copies of the articles of
					 incorporation and bylaws, of partnership agreements of any provider or any
					 entity related to the provider;
13.1.2 Chart of accounts and procedures
					 manual, including procurement standards established pursuant to Principle
					 6;
13.1.3 Plant layout;
13.1.4 Terms of capital stock and bond
					 issues;
13.1.5 Copies of long-term
					 contracts, including but not limited to leases, pension plans, profit sharing
					 and bonus agreements;
13.1.6
					 Schedules for amortization of long-term debt and depreciation of plant
					 assets;
13.1.7 Summary of
					 accounting principles, cost allocation plans, and step-down statistics used by
					 the provider;
13.1.8 Related party
					 information on affiliations, and contractual arrangements;
13.1.9 Tax returns of the PRTF; and
13.1.10 Any other documentation
					 requested by the Department for purposes of establishing a rate or conducting
					 an audit.
If any of the items listed in Principle 13.1.1 - 13.1.10
						are not submitted in a timely fashion the Department may impose the deficiency
						routine and fixed costs rate described in Principle 30 of these
						Principles.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-14 - REIMBURSEMENT METHOD

Current through 2024-29, July 17, 2024
14.1
Principle
. PRTFs will be reimbursed for services provided to
					 members based on a rate which the Department establishes on a prospective basis
					 and determines is reasonable and adequate to meet the costs which must be
					 incurred by an efficiently and economically operated facility in order to
					 provide care and services in conformity with applicable State and Federal laws,
					 regulations and quality and safety standards.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-15 - COST COMPONENTS

Current through 2024-29, July 17, 2024
15.1 As regards to
					 the interim payment system of reimbursement, allowable costs are grouped into
					 cost categories. The nature of the expenses dictates which costs are allowable
					 under these Principles of Reimbursement. The costs shall be grouped into the
					 following two (2) cost categories:
15.1.1
					 Routine Costs; and
15.1.2 Fixed
					 Costs.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-16 - ROUTINE COST COMPONENT

Current through 2024-29, July 17, 2024
All allowable costs not specified for inclusion in
						another cost category pursuant to these rules shall be included in the routine
						cost component subject to the limitations set forth in these Principles. The
						costs for the routine cost component shall be the routine costs defined in
						Principle 1.4 for these costs listed in Principle 16, except for facilities
						whose MaineCare rates are based on pro forma cost reports in accordance with
						Principle 23. Subsequent years will be based on the most recently audited
						fiscal year. The routine cost component is determined by adjusting routine
						costs pursuant to Principles 23.
16.1
Principle
. All expenses which providers must incur to meet state
					 licensing and federal certification standards are allowable.
16.2
Inventory Items
. All
					 inventory items used in the provision of routine services to residents are
					 required to be expensed in the year used. Inventory items shall include, but
					 are not limited to: linen and disposable items.
16.3
Allowable Costs
. Allowable
					 costs shall also include all items of expense efficient and economical
					 providers incur for the provision of routine services. Routine services mean
					 the regular room, dietary services, and the use of equipment and
					 facilities.
16.4
Allowable
					 costs for the routine component of the rate
.
16.4.1 The rate shall include but not be
					 limited to costs reported in the following functional cost centers on the
					 facility's cost report.
(a) fiscal
					 services;
(b) administrative
					 services and professional fees, including administrative\functions;
(c) plant operation and maintenance including
					 utilities;
(d) laundry and
					 linen;
(e) housekeeping;
(f) medical records;
(g) subscriptions related to resident
					 care;
(h) dietary;
(i) clerical;
(j) office supplies/telephone;
(k) conventions and meetings within the state
					 of Maine;
(l) EDP
					 bookkeeping/payroll;
(m) fringe
					 benefits, to include:
(1) payroll
					 taxes;
(2) qualified retirement
					 plan contributions;
(3) group
					 health, dental, and life insurance;
(n) payroll taxes;
(o) one (1) association dues, the portion of
					 which is not related to lobbying; and
(p) food, vitamins and food supplements.
For a more complete description of allowable costs in
						each cost center, see the explanations in Principles 16.4.1 - 16.4.2.10.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-17 - FIXED COSTS COMPONENT

Current through 2024-29, July 17, 2024
17.1 The costs for
					 the fixed cost component shall be the costs incurred by the facility in the
					 most recently audited fiscal year. Fixed costs include:
17.1.1 depreciation on buildings, fixed and
					 movable equipment.
17.1.2
					 depreciation on land improvements and amortization of leasehold improvements,
17.1.3 real estate and personal
					 property taxes,
17.1.4 real estate
					 insurance, including liability and fire insurance,
17.1.5 interest on long term debt,
17.1.6 rental expenses,
17.1.7 amortization of finance
					 costs,
17.1.8 amortization of
					 start-up costs and organizational costs,
17.1.9 facility's liability insurance,
					 including malpractice costs and Workers compensation,
17.1.10 water & sewer fees necessary for
					 the initial connection to a sewer system/water system,
For a more complete description of allowable costs in
						each of these cost centers, see the explanations in Principle
						17.2.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-18 - MEDICAL, CLINICAL, AND DIRECT CARE COSTS

Current through 2024-29, July 17, 2024
18.1
Medical, Clinical, and Direct
					 Care
costs will be reimbursed at a per diem rate per member per day
					 which is not subject to cost settlement. The per diem member per day price
					 includes services provided by the medical, clinical, and direct care services
					 staff listed below. Allowable costs include salaries, wages, and benefits for
					 medical, clinical, and direct care staff and the services listed below:
Medical Director
Clinical Coordinator
Registered Nurses
Licensed Practical Nurses
Certified Nurses Aide-Medication
Licensed Clinical Social Workers
Behavioral Health Professional.
Licensed Clinical Professional Counselors
Licensed Marriage and Family Therapists
18.2 The per diem rate (per member per day)
					 for Medical, Clinical, and Direct Care costs is $485.72. This rate includes the
					 salary and benefit costs of the staff listed in principle 18.1.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-19 - WAIVER

Current through 2024-29, July 17, 2024
The failure of the Department to insist, in any one (1)
						or more instances, upon the performance of any of the terms or conditions of
						these Principles, or to exercise any right under these principles, or to
						disapprove of any practice, accounting procedure, or item of account in any
						audit, shall not be construed as a waiver of future performance of the right.
						The obligation of the Provider with respect to future performance shall
						continue, and the Department shall not be stopped from requiring such future
						performance.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-20 - SPECIAL SERVICE ALLOWANCE

Current through 2024-29, July 17, 2024
20.1
Principle
. A special ancillary service is to be distinguished from
					 a service generally provided in the PRTF.
20.1.1 A special ancillary service is that of
					 an individual nature required in the case of a specific resident. This type of
					 service includes, but not limited to professional services such as physical
					 therapy, occupational therapy, and speech and hearing services. Special
					 services of this nature must be billed through the appropriate Section of the
					 MaineCare Members Benefit Manual required for the care of individual
					 members.
20.1.2 Board Certified
					 Behavior Analyst (BCBA) consultation with Prior Authorization.
20.1.3 Interpreter Services to address any
					 existing or newly diagnosed physical health conditions when medically necessary
					 as outlined in Chapter 1 of the MaineCare Members Benefits Manual.
20.1.4 Medical Services to address any
					 existing or newly diagnosed physical health conditions when medically necessary
					 and cannot be provided at the PRTF.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-21 - MEDICAL LEAVE AND THERAPEUTIC LEAVE ALLOWANCES

Current through 2024-29, July 17, 2024
21.1
Principle for Medical
					 Leave.
For members requiring physician ordered hospitalization for
					 treatment of an acute condition that cannot be treated in the PRTF, up to four
					 (4) consecutive days. The PRTF must maintain a physician's order for the
					 hospitalization in the member's file. Should a member be hospitalized for
					 longer than four (4) consecutive days, the PRTF must discharge the member.
					 Documentation is subject to retrospective review.
21.2
Principle for Therapeutic
					 Leave
. A member's leave of absence from the PRTF must be for therapeutic
					 reasons as directed by the team physician and as indicated in the member's
					 treatment plan. The facility must maintain a physician's order for the
					 therapeutic leave in the member's file. Therapeutic leave days are limited to
					 seven (7) days per admission. Therapeutic leave days do not have to be
					 consecutive. Documentation is subject to retrospective review.
For billing purposes PRTFs are expected to follow the
						midnight to midnight method when reporting days of leave for members, even if
						the facility uses a different definition of a day for statistical or other
						purposes. PRTFs will be reimbursed their routine and fixed costs rate, as
						stated on their rate letter, for medical leave and therapeutic leave days.
						Medical leave days will be billed using revenue code: 0185 and therapeutic
						leave days will be billed using revenue code 0184. Medical and Therapeutic
						Leave days are cost settled.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-22 - ESTABLISHMENT OF INTERIM RATE

Current through 2024-29, July 17, 2024
22.1
Initial
					 Rate
.For a PRTF's first year of operation, the Department will establish
					 an initial prospective routine and fixed cost interim rate, based on the
					 facility's pro- forma. This rate is subject to cost settlement.
22.2
Subsequent Interim Rate
.
					 For subsequent years of operation, the interim rate will be based on the most
					 recent cost settlement. If a cost settlement has not yet been calculated, the
					 interim rate will be based on the facility's pro-forma.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-23 - INTERIM AND SUBSEQUENT RATES

Current through 2024-29, July 17, 2024
23.1
Interim
					 Rate and Subsequent Year Rates
. Fifteen (15) days prior to the beginning
					 of the State fiscal year, an interim rate will be established by using the
					 fixed and routine cost component of the latest audited cost report. The interim
					 rate in subsequent fiscal years will be determined in the same manner as
					 outlined above.
23.2
Fixed
					 costs
may be adjusted upon request of the provider when sufficient
					 documentation (determined by the DHHS) has been provided to the Department.
					 These adjustments will be effective with the next issuance of an interim
					 rate.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-24 - FINAL RATE

Current through 2024-29, July 17, 2024
Upon final audit of each PRTF's cost report, the
						Department will determine a final rate of each PRTF, which cannot be greater
						than one hundred percent (100%) of all the calculated and allowable fixed cost
						and routine cost components for that PRTF.
24.2 A cost report is settled if there is no
					 request for reconsideration of the Division of Audit's findings made within the
					 required time frame or, if such request for reconsideration was made and the
					 Division of Audit has issued a final revised audit report.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-25 - FINAL AUDIT OF INTERIMRATES

Current through 2024-29, July 17, 2024
25.1
Principle.
All facilities will be required to submit a cost report
					 in accordance with Principle 13.2 at the end of their fiscal year on cost
					 report forms approved by the Department. The Department will conduct a final
					 audit of each facility's cost report, which may consist of a full scope
					 examination by Department personnel and which will be conducted on an annual
					 basis.
25.2 Upon final audit of the
					 facility's cost report for the first and subsequent years prospective years,
					 the Department will:
25.2.1 Determine the
					 actual allowable fixed costs incurred by the facility during the cost reporting
					 period;
25.2.2 Determine the actual
					 allowable routine costs incurred by the facility during the cost reporting
					 period;
25.2.3 Determine the
					 occupancy levels of the PRTF;
25.2.4 Calculate a final rate; and
25.2.5 Determine final settlement by
					 calculating the difference between the audited final rate and the interim
					 rate(s) paid to the provider times the MaineCare utilization. PRTFs that
					 transfer a cost center from one (1) cost component to another cost component
					 resulting in increased MaineCare costs will have the affected cost components
					 adjusted at time of audit.
Upon final audit of a facility's cost report, the
						Department will calculate a final prospective rate and determine the lump sum
						settlement amount either due to or from the PRTF.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-26 - SETTLEMENT OF ROUTINE AND FIXED COSTS

Current through 2024-29, July 17, 2024
26.1 The
					 Department will reimburse facilities for the allowable and actually incurred
					 routine and fixed costs which are incurred during a fiscal year. Upon final
					 audit of a facility's cost report, if the Department's share of the allowable
					 routine and fixed costs actually incurred by the facility is greater than the
					 amount paid by the Department (the fixed cost component of the final
					 prospective rate multiplied by the number of days of care provided to MaineCare
					 beneficiaries), the difference will be paid to the facility by the Department.
					 If, the Department's appropriate share of the allowable fixed costs actually
					 incurred by a facility is less than the amount paid by the Department, the
					 difference will be paid to the Department by the facility.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-27 - CALCULATION OF OVERPAYMENTS OR UNDERPAYMENTS

Current through 2024-29, July 17, 2024
Upon determination of the final rate as outlined in
						Principle 24 above, the Department will calculate the net amount of any
						overpayments or underpayments made to the facility.
If the Department determines that it has underpaid a
						facility, the Department will calculate the exact amount due and forward the
						result to the facility within thirty (30) days. If the Department determines
						that it has overpaid a facility, the Department will so notify the facility.
						Facilities will pay the total overpayment within sixty (60) days of the notice
						of overpayment or request the Department to reduce facility payments during the
						balance of its fiscal year by the amount of the overpayment. Facilities that do
						not notify the Department of the method by which they intend to repay the
						overpayment will, beginning sixty (60) days after their receipt of the notice
						of overpayment, have their subsequent payments from the Department reduced by
						the amount of overpayment.
If a facility appeals a determination of overpayment, the
						facility must repay within sixty (60) days of the notice of overpayment all
						portions of the determined overpayment except those that are expressly disputed
						and for which specific dollar values are identified. Repayment of each such
						specifically disputed portion and identified amount shall be stayed pending
						resolution of the dispute with respect thereto. The amount of money in dispute
						must be identified in the manner outlined in Principle 27.
The net amount of any over or underpayment made to the
						facility will be based on 1) the calculation of actual fixed expenses incurred
						in the prior year and 2) the estimated difference in amount due or paid based
						on the interim versus final prospective rate.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-28 - ADJUSTMENTS

Current through 2024-29, July 17, 2024
28.1 Adjustment for Appeal Decisions. The
					 Department will adjust any interim or final prospective rate to reflect appeal
					 decisions made subsequent to the establishment of those rates.
28.2 Adjustments for Capital Costs. The
					 Department will adjust the fixed cost component of an interim or final
					 prospective rate to reflect increases or decreases in capital costs.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-29 - APPEAL PROCEDURES-START UP COSTS-DEFICIENCY RATE - RATE LIMITATION

Current through 2024-29, July 17, 2024
29.1
Appeal Procedures
29.1.1 A facility may administratively appeal
					 any of the following types of Division of Audit determinations:
(1) Audit Adjustment
(2) Calculation of final prospective
					 rate
(3) Adjustment of final
					 prospective rate or a refusal to make such an adjustment pursuant to these
					 Principles.
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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Subsection 144-101-III-107-30 - DEFICIENCY ROUTINE AND FIXED COSTS RATE

Current through 2024-29, July 17, 2024
When a facility is found not to have provided the quality
						of service or level of care required, reimbursement will be made on ninety
						percent (90%) of the provider's per diem rate, unless otherwise specified. This
						"deficiency rate" will be applied following written notification to the
						facility of the effective date of the reduced rate for any of the following
						service deficiencies:
30.1 Specific,
					 documented evidence that the care provided does not meet the Federal
					 Certification and State Licensing requirements. Such penalty to be effective no
					 sooner than thirty (30) days from written notification that such deficiencies
					 exist;
30.2 Failure to correct,
					 within the time frames of an accepted Plan of Remediation or Correction,
					 deficiencies in meeting the Federal Certification, Accreditation and State
					 Licensing requirements, which cause a threat to the health and safety of
					 residents in a facility or the surrounding community;
30.3 Failure to submit a cost report,
					 financial statements, and other schedules as requested by the Division of Audit
					 and to maintain auditable records as required by these Principles and other
					 relevant regulations may result in application of the deficiency routine and
					 fixed costs rate. The deficiency routine and fixed costs rate for these items
					 will go into effect immediately upon receipt of written notification from the
					 Department.
A reduction in rate because of deficiencies shall remain
						in effect until the deficiencies have been corrected, as verified by
						representatives of the Department, following written notification by the
						provider that the deficiencies no longer exist. No retroactive adjustments to
						the full rate shall be made for the period that the deficiency rate is in
						effect unless the provider demonstrates to the satisfaction of the Department
						that there was no just cause for the reduction in 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 III - Allowances for Services › Section 144-101-III-107 - Principles of Reimbursement for Psychiatric Residential Treatment Facility Services › Appendix 144-101-III-107-I

Current through 2024-29, July 17, 2024
REVENUE CODE
DESCRIPTION
MAXIMUM ALLOWANCE
UNIT
1001
Medical, Clinical, & Direct Care Services
								  provided in a Psychiatric Residential Treatment Facility (Per Diem)
$485.72
Per day
0169
Room and Board
Routine and Fixed Costs allowance as determined
								  by the Facility's rate letter
Per day
0184
Therapeutic Leave Day
Routine and Fixed Costs allowance as determined
								  by Facility's rate letter as under 0169
Per day
0185
Medical Leave Day
Routine and Fixed Costs allowance as determined
								  by Facility's rate letter as under 0169
Per day
Procedure Code: G9007 HK
Board Certified Behavior Analyst (BCBA)
$16.60
Per 15 minutes
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 III - Allowances for Services › Section 144-101-III-113 - Transportation Services (absorbed into Ch. II Section 113)

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 III - Allowances for Services › Section 144-101-III-150 - STD Screening Clinic 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 IV › Sec2 144-101-IV-1 - Restriction Plans › Subsection 144-101-IV-1.01 - INTRODUCTION

Current through 2024-29, July 17, 2024
The Restriction Plan is an administrative procedure
						where certain MaineCare members who have a history of over-utilizing MaineCare
						benefits must receive their primary medical care from one health care provider,
						and when indicated, one hospital, one pharmacy and specified additional
						providers, (such as a behavioral health provider, dentist, eye care provider).
						The Department of Health and Human Services anticipates that restricting
						members who over-utilize services to a single primary care provider will result
						in better health care management and the reduction of the total cost 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 IV › Sec2 144-101-IV-1 - Restriction Plans › Subsection 144-101-IV-1.02 - STATEMENT OF PURPOSE

Current through 2024-29, July 17, 2024
1.02-1 The purposes
					 of the Restriction Plan are:
A. To decrease
					 and control over-utilization and/or abuse of MaineCare covered health care
					 services and/or benefits, and to minimize medically unnecessary and addictive
					 drug usage;
B. To establish a
					 method of monitoring non-emergency health care services for MaineCare members
					 who have utilized MaineCare health care services or benefits at a frequency or
					 in an amount that is not medically necessary; and
C. To assist members through education and
					 referral towards appropriate health care service and benefit use.
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 IV › Sec2 144-101-IV-1 - Restriction Plans › Subsection 144-101-IV-1.04 - ENROLLMENT OF MEMBERS IN THE RESTRICTION PLAN

Current through 2024-29, July 17, 2024
1.04-1 Identification of Members
A. The Program Integrity Unit will identify
					 members who appear to be obtaining health care services that are not medically
					 necessary. Members who are suspected of obtaining health care services that are
					 not medically necessary may be identified by the following sources:
1. Referrals or complaints from members,
					 providers, professional associations, health care professionals and other
					 citizens;
2. Referrals from the
					 Department of Health and Human Services ("DHHS"), Office of MaineCare Services,
					 Fraud Investigation and Recovery Unit, the Department of Attorney General,
					 Health Care Crimes Unit, third party payers, State of Maine Board of Pharmacy,
					 the Health and Human Services Office of Inspector General (OIG), Center for
					 Medicare and Medicaid Services (CMS), State and local law enforcement agencies,
					 and any other State or Federal agency;
3. Computer generated reports that identify
					 members who may be over-utilizing or inappropriately using health care
					 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 IV › Sec2 144-101-IV-1 - Restriction Plans › Subsection 144-101-IV-1.05 - EMERGENCY HEALTH CARE SERVICES AND NON-PRIMARY CARE PROVIDERS

Current through 2024-29, July 17, 2024
Non-primary care providers shall be reimbursed for health
						care services only in the following circumstances:
A. When the need to stabilize an emergency
					 medical condition (as defined in Section 1.02-4.B. & C., Chapter I of the
					 MaineCare Benefits Manual, also refer to Chapter IV, Section 1.03-5) exists.
					 Reimbursement is subject to the provider's later written or verbal verification
					 of that need when requested by the Program Integrity Unit;
B. When the member has been referred by the
					 primary care provider; and
C. When
					 the member has received services without a referral from providers whose
					 category of service is not covered by the restriction plan, i.e., x-ray,
					 laboratory, and optometrists.
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 IV › Sec2 144-101-IV-1 - Restriction Plans › Subsection 144-101-IV-1.06 - PLAN MONITORING

Current through 2024-29, July 17, 2024
During the period of enrollment in the Restriction Plan,
						the Program Integrity Unit will supervise and monitor utilization patterns of
						restricted members and analyze computer-generated profiles of the member's
						health care services reimbursed under MaineCare. The member will be contacted
						by the Program Integrity Unit periodically to verify that his or her medical
						needs are being met.
The member shall receive the Program Integrity Unit's
						toll-free telephone number, to clarify questions regarding restriction, seek
						assistance if access problems arise, and report complaints.
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 IV › Sec2 144-101-IV-1 - Restriction Plans › Subsection 144-101-IV-1.07 - CHANGE IN HEALTH CARE PROVIDER

Current through 2024-29, July 17, 2024
At the time the member is notified of his/her enrollment
						in the Restriction Plan, the member shall be advised that he/she may change
						his/her health care provider for any reasonable cause at a later date, by
						notifying the Program Integrity Unit. Program Integrity Unit Staff shall
						contact the proposed health care provider and arrange his/her participation in
						this member's restriction plan.
If the member, or health care provider, believes a
						second opinion is warranted or desirable, the second opinion provider payment
						may be authorized by contacting the Program Integrity Unit staff in advance of
						the second opinion.
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 IV › Sec2 144-101-IV-1 - Restriction Plans › Subsection 144-101-IV-1.08 - CHANGE IN MEMBER STATUS IN RESTRICTION PLAN

Current through 2024-29, July 17, 2024
1.08-1 Continuation of restriction, or
					 modification of enrollment into another Lock-In type, beyond the initial period
					 will be recommended when subsequent annual reviews of the member's records,
					 claims data and national standards, in accordance with the MaineCare Benefits
					 Manual, Chapter IV, by the Member Review Team indicate one or more of the
					 following:
A. Evidence of member's failure to
					 comply with the recommended plan of management from the health care providers;
B. Evidence of member's continued
					 over-utilization of services without medical necessity, which includes services
					 where payments were denied by MaineCare because the Restriction Plan protocols
					 were not followed; or
C. Member's
					 voluntary request to continue the restriction.
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 IV › Sec2 144-101-IV-1 - Restriction Plans › Subsection 144-101-IV-1.09 - MEMBER RIGHTS

Current through 2024-29, July 17, 2024
A. A member who
					 disagrees with the determination that he/she be enrolled in the Restriction
					 Plan, or a member who is aggrieved by an action or policy relating to his/her
					 involvement or continued reenrollment in the Restriction Plan is entitled to
					 oppose the action. He/she shall be informed of his/her rights to appeal.
					 AppealsRights are in accordance with MaineCare Benefits Manual, Chapter
					 I.
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 VI › Section 144-101-VI-01 - Primary Care Case Management (replaced by Section 03 on June 21, 2022) › Subsection 144-101-VI-01.01 - INTRODUCTION

Current through 2024-29, July 17, 2024
The Restriction Plan is an administrative procedure where
						certain MaineCare members who have a history of over-utilizing MaineCare
						benefits must receive their primary medical care from one health care provider,
						and when indicated, one hospital, one pharmacy and specified additional
						providers, (such as a behavioral health provider, dentist, eye care provider).
						The Department of Health and Human Services anticipates that restricting
						members who over-utilize services to a single primary care provider will result
						in better health care management and the reduction of the total cost 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 VI › Section 144-101-VI-01 - Primary Care Case Management (replaced by Section 03 on June 21, 2022) › Subsection 144-101-VI-01.02 - STATEMENT OF PURPOSE

Current through 2024-29, July 17, 2024
The purpose of Primary Care Case Management (PCCM) is to
						provide services (a medical home) to improve access to needed care and to
						reduce unnecessary and inappropriate utilization and costs by locating,
						coordinating, and monitoring health care 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 VI › Section 144-101-VI-01 - Primary Care Case Management (replaced by Section 03 on June 21, 2022) › Subsection 144-101-VI-01.03 - DEFINITIONS

Current through 2024-29, July 17, 2024
1.03-1
Children with Adoption
					 Assistance
are children for whom there is a written Adoption Assistance
					 Agreement between the Department of Health and Human Services (DHHS) and the
					 child's adoptive parent(s).
1.03-2
Chronic and Debilitating Condition
is a disease or impairment that
					 is expected to require on-going care.
1.03-3
Complaint
is a written or
					 verbal statement by a member or provider to the Office of MaineCare Services
					 (OMS) expressing dissatisfaction with some aspect of Primary Care Case
					 Management and requesting resolution of the situation.
1.03-4
Early and Periodic Screening,
					 Diagnosis, and Treatment Services
, or EPSDT, (or its successor, Chapter
					 II, Section 94, Prevention, Health Promotion and Optional Treatment Services)
					 is the benefit where MaineCare members under age twenty-one (21) receive
					 certain services under
					 42
					 U.S.C. Sections 1396d(a) and
					 (r).
1.03-5
Emergency Medical
					 Condition
means a medical condition, manifesting itself by acute
					 symptoms of sufficient severity (including severe pain) such that a prudent lay
					 person, who possesses an average knowledge of health and medicine could
					 reasonably expect that the absence of immediate medical attention could
					 reasonably be expected to result in the following:
(i) placing the health of the individual (or,
					 with respect to a pregnant woman, the health of the woman or her unborn child)
					 in serious jeopardy; or
(ii)
					 serious impairment of bodily functions, or serious dysfunction of any bodily
					 organ or part.
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 VI › Section 144-101-VI-01 - Primary Care Case Management (replaced by Section 03 on June 21, 2022) › Subsection 144-101-VI-01.05 - EXEMPT SERVICES

Current through 2024-29, July 17, 2024
1.05-1
Services Not Managed by PCPs
Certain services contained within the service categories
						listed in Section 1.04 may be accessed directly by members, i.e., without a
						PCP's referral. The particular services for which a member may self-refer
						are:
a. Family planning services. The
					 following services may be obtained by a member without a PCP referral:
(i) health education and counseling necessary
					 to make informed choices and understand contraceptive methods;
(ii) distribution of information on family
					 planning;
(iii) consultation,
					 examination and medical treatment including, but not limited to, treatment of
					 urinary tract infection or "UTI".
(iv) diagnosis and treatment of sexually
					 transmitted diseases (STDs), including lab tests;
(v) screening, testing and counseling for
					 human immunodeficiency virus (HIV);
(vi) provision of contraceptive pills,
					 devices, and supplies; and
(vii)
					 diagnosis of infertility;
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 VI › Section 144-101-VI-01 - Primary Care Case Management (replaced by Section 03 on June 21, 2022) › Subsection 144-101-VI-01.06 - EMERGENCY SERVICES

Current through 2024-29, July 17, 2024
Members who experience an emergency medical condition may
						access emergency services without first contacting their PCP for a
						referral.
Post-stabilization services will be provided to members
						and will be payable by MaineCare if (i) the services are pre-approved by the
						PCP (or his/her covering provider) or (ii) the services are not pre-approved
						because the PCP has not responded within one (1) hour after receiving the
						provider's request, or cannot be contacted for approval. In this case, the
						treating physician decides whether or not to provide post-stabilization
						services. If post-stabilization services are not pre-approved, MaineCare's
						financial responsibility for post-stabilization services ends when the enrollee
						is discharged. (Post-stabilization services do not include those exempt
						services, as described in Section 1.05. )
The PCP must ensure that his/her covering provider(s) is
						authorized to provide necessary referrals in order to comply with
						post-stabilization provisions described above.
As detailed in MBM Chapter 1, MaineCare will not cover
						any services after stabilization of the emergency condition for non citizens.
						Examples of services that are not considered an emergency medical condition
						include, but are not limited to: dialysis, organ transplants, school based
						services, personal care services, waiver services, nursing facility services
						and hospice 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 VI › Section 144-101-VI-01 - Primary Care Case Management (replaced by Section 03 on June 21, 2022) › Subsection 144-101-VI-01.07 - MEMBER PARTICIPATION IN PRIMARY CARE CASE MANAGEMENT

Current through 2024-29, July 17, 2024
1.07-1
Members Who Are Required to
					 Participate
A MaineCare member must participate in Primary Care Case
						Management if he/she is in one of the following categories:
a. Receiving Temporary Assistance for Needy
					 Families (TANF) - Adults and Children;
b. Children under the age of twenty-one (21); parents of children
					 under age eighteen (18) who receive MaineCare; pregnant women; and those
					 members eligible for transitional MaineCare; except as referenced in
					 1.07-4.
c. Women who have been
					 screened for breast or cervical cancer under the Centers for Disease Control
					 and Prevention Title XV Program and are found to need treatment for breast or
					 cervical cancer, including pre-cancerous conditions, as defined in Section
					 2150.03 of the MaineCare Eligibility Manual.
d. Adults, ages twenty-one (2 1) through sixty-four (64), who
					 do not have children or do not have children under age eighteen (18) living
					 with them and are at or below one-hundred percent (100% ) of the federal
					 poverty level. Those receiving benefits under the Non-Categorical Waiver will
					 receive benefits limited to those listed under Chapter X, Section 2, Benefit
					 for Childless Adults in the MaineCare Benefits Manual.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VI › Section 144-101-VI-01 - Primary Care Case Management (replaced by Section 03 on June 21, 2022) › Subsection 144-101-VI-01.08 - PCP PARTICIPATION IN PRIMARY CARE CASE MANAGEMENT

Current through 2024-29, July 17, 2024
1.08-1
Requirements for
					 Participation
In order to be a Primary Care Case Management PCP,
						providers must:
a. be a MaineCare
					 provider, i.e. must sign or be a party to a MaineCare Provider/Supplier
					 Agreement if appropriate to that MaineCare practice or managed care PCP
					 practice;
b. sign or be a party to
					 a MaineCare Primary Care Case Management Rider to the MaineCare
					 Provider/Supplier Agreement; and
c.
					 be a pediatrician, general practitioner, family practitioner, internist,
					 obstetrician/ gynecologist or other physician/group specialty as approved by
					 the OMS in either a solo or group practice; a rural health clinic, federally
					 qualified health center, ambulatory care clinic or hospital based/affiliated
					 outpatient clinic that employs at least one full time equivalent Primary Care
					 Provider engaged in delivering primary care; a nurse practitioner; physician
					 assistant; or a resident in a pediatric, family practice, internal medicine or
					 obstetric/gynecological training program.
d. Nurse midwives and locum tenums
					 (physicians who temporarily take the place of another) are not eligible to
					 enroll as PCPs.
e. PCPs may
					 practice only within the scope of their license.
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 VI › Section 144-101-VI-01 - Primary Care Case Management (replaced by Section 03 on June 21, 2022) › Subsection 144-101-VI-01.09 - COMPLAINTS

Current through 2024-29, July 17, 2024
1.09-1
Members with a Complaint
Members with a complaint may make a request to MaineCare
						Member Services to have it resolved. MaineCare Member Services will:
A. Keep a record of each complaint;
B. Investigate the complaint and issue a
					 verbal/written decision to the member within fifteen (15) calendar days of the
					 request. The decision must contain a clear, concise statement of the decision,
					 reasons for the decision, right of the member to access all records pertaining
					 to resolution of the complaint and help available from MaineCare Member
					 Services to obtain these records;
C. Assist, upon request, the member in
					 obtaining all records pertaining to the resolution of the complaint. Members
					 will have access to all records pertaining to the complaint. Members will also
					 be notified of their right to grieve a decision. Instructions on how to file a
					 grievance are described in Section 1.10.