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-21 - Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-21.15 - APPENDIX II- Guidelines for Approval of Medical Add-On in Maine Rate Setting

Current through 2024-29, July 17, 2024
The Standard support level is an all-inclusive
						reimbursement for Services defined in 21.05. At times, a Member may require
						increased levels of staff support due to more intensive needs. Increased level
						of support is not to be used for respite or in substitute for the Shared Living
						Provider. It is to be used in addition to the Shared Living Provider to ensure
						the Member's safety. DHHS may authorize an increased level of support for the
						purposes of additional staff for those Members who have current and documented
						challenging behavioral issues or high medical and safety needs. The Clinical
						Review Team (CRT) reviews all increased level of support requests. The CRT will
						use the following criteria to determine when this increased level of
						reimbursement to support the additional staff is utilized.
To qualify for the increased level of support a Member
						must have an extraordinary need listed in at least one of the categories
						below
1)
Behavioral
					 Issues
-Members with behavioral issues and/or behavioral health
					 challenges that significantly raise health and safety concern may have
					 increased levels of support authorized to assist with Behavioral issues. These
					 may include high risk behavior such as a history of sexual offense, aggression
					 to self or others, or criminal behavior. The planning team must identify a
					 behavioral need that requires an increased level of support and is documented
					 in the Member's record. The Person-Centered Service Plan will outline specific
					 activities and desired outcomes of the service being provided and those
					 activities must be separately documented in the Member's record.
2)
Medical Support
- Members that
					 require support over and beyond routine services such as ventilators,
					 nebulizers, diabetes management-insulin dependent, suctioning, seizure
					 management-uncontrolled, chronic eating disorders, or persons with co-existing
					 conditions that significantly affect physical movement and require near total
					 physical assistance on a daily basis may have an increased level of support
					 authorized to assist with medical issues. The Person-Centered Service Plan will
					 outline specific activities and desired outcomes of the service being provided
					 and those activities must be separately documented in the Member's record.
For Behavioral issues and Medical Support there must be
						a written recommendation, less than three months old, from a Physician,
						Physician Assistant, Psychologist or Psychiatrist which must specify:
1) The specific illness or condition to be
					 addressed that requires increased support;
2) The manner in which increased support will
					 be utilized;
3) The expected
					 duration of the increased support. If the increased support is expected to be
					 needed for an indefinite period of time then this expectation should be
					 specified;
4) The anticipated
					 frequency of the increased support on a daily, weekly, or monthly basis
					 and
5) Whether the setting where
					 the Member is served is appropriate to carry out the physician's recommended
					 treatment or intervention.
Process of Application for the increased level of
						service
:
The Provider must complete the Home Support Frequency
						tool provided by DHHS that will summarize the support needs of the Member and
						submit the tool along with identified materials to the Case Manager. The Home
						Support Frequency tool can found at this website,
https://www.maine.gov/dhhs/oads/providers/adults-with-intellectual-disability-and-autism
The Case Manager will be responsible for reviewing the
						information provided, verifying that the Person-Centered Service Plan and all
						other information is most current.
The CRT will review the information submitted with the
						request, the PCSP, information in the electronic records, such as reportable
						events, crisis notes and case management notes as well as any applicable
						assessments or evaluations of the Member. Increased support that is anticipated
						to be needed for an extended or indefinite period of time must be reviewed and
						approved at least annually by the CRT.
The CRT will issue a written decision within twenty (20)
						working days of receipt of all required documentation. If additional
						information is required, a written request will be issued to the Case Manager
						by the CRT. Upon receipt of the additional information, the CRT will approve or
						deny the request in writing within ten (10) working days.