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 I - Specific Policies By Service › Sec2 144-101-I-5 - COVID-19 Public Health Emergency Services › Subsection 144-101-I-5.06 - HOME HEALTH SERVICES*

Current through 2024-29, July 17, 2024
A. The Department
					 extends the period of time for Home Health Providers to submit Plans of Care to
					 the Department under MBM, Ch. II, Section 40, Home Health Services, §
					 40.02-1,
B.
Authorization
					 Process
. The current requirement of submission within five (5) business
					 days is extended to within thirty (30) business days, including for
					 certifications and recertifications.
C. The Department authorizes Advanced
					 Practice Providers (Physicians Assistants, Nurse Practitioners, and Clinical
					 Nurse Specialists) as qualified providers to order and recertify a Plan of Care
					 as described in Chapter II, Section 40.08-2 A (1).**
*MBM, Chs. II and III, Section 40, Home Health Services,
						are major substantive rules.
**The Department may implement these changes permanently
						through separate major substantive rulemaking in MBM, Chs. II and III, Section
						40.
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 I - Specific Policies By Service › Sec2 144-101-I-5 - COVID-19 Public Health Emergency Services › Subsection 144-101-I-5.08 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT)

Current through 2024-29, July 17, 2024
The Department, under Bright Futures Health Assessment
						Visits under Chapter II, Section 94.06-1, will allow for one additional health
						assessment visit per member within a year following an initial assessment via
						Telehealth for each age shown on the MaineCare Bright Futures periodic health
						assessment schedule (MBM, Ch. II, Section 96, Appendix 1).*
*
The Department shall seek and anticipates
						receiving approval of these changes from CMS retroactive to March 18, 2020.
						Pending approval, these changes are effective upon
						adoption.
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 I - Specific Policies By Service › Sec2 144-101-I-5 - COVID-19 Public Health Emergency Services › Subsection 144-101-I-5.09 - HOSPITAL SERVICES

Current through 2024-29, July 17, 2024
The Department will allocate a special supplemental pool
						for COVID-19 among the Acute Care Non-Critical Access hospitals and Critical
						Access hospitals operating in the State of Maine. Effective April 16, 2020, the
						total pool shall equal ten million dollars ($10,000,000). It will be allocated
						proportional to the 2016 MMIS base data distribution of MaineCare payment for
						inpatient and outpatient services to Acute Care Non-Critical Access hospitals
						and Critical Access hospitals, not to exceed the total supplemental pool amount
						and not to exceed allowable aggregate upper payment limits. This emergency
						supplemental payment will not be subject to cost settlement by 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 I - Specific Policies By Service › Sec2 144-101-I-5 - COVID-19 Public Health Emergency Services › Subsection 144-101-I-5.10 - PRIVATE NON-MEDICAL INSTITUTION SERVICES

Current through 2024-29, July 17, 2024
A. Reimbursement for Section 97 Private
					 Non-Medical Institution Appendix B Substance Abuse Treatment Facilities is
					 increased uniformly by 23.9% effective 3/1/2020 to 5/31/2020. *The increased
					 reimbursement under this section may not duplicate any other reimbursement a
					 provider receives for COVID-related costs under current or future state or
					 federal funding opportunities.
B.
					 The Department may cease paying the rate increase to any provider it determines
					 has received such duplicate funding, per Sec. 5.10(B), after providing advance
					 notice of that decision to the provider. This increased funding is also subject
					 to audit by 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 I - Specific Policies By Service › Sec2 144-101-I-5 - COVID-19 Public Health Emergency Services › Subsection 144-101-I-5.11 - UNINSURED INDIVIDUALS

Current through 2024-29, July 17, 2024
Effective retroactive to March 18, 2020, individuals who
						are uninsured, as defined in Section 6004(a)(3) of the federal
Families
						First Coronavirus Response Act
(
						Public Law
						116-127 ) and Section 1902 (ss) of the
Social Security Act
, shall receive coverage for testing and
						diagnosis of COVID-19. Detailed eligibility requirements are set forth in the
						MaineCare Eligibility Manual, 10-144 C.M.R. Ch. 332.
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 I - Specific Policies By Service › Sec2 144-101-I-5 - COVID-19 Public Health Emergency Services › Subsection 144-101-I-5.12 - COMMUNITY SUPPORT SERVICES

Current through 2024-29, July 17, 2024
A.
Determination of Eligibility.
Under Chapter II, Section 17.02-4(B), Members who require
						annual verification shall retain eligibility through previously-rendered
						diagnoses and clinical judgment.
B.
Community Integration Services
					 Eligibility Verification.
Retroactive to April 15, 2020, for Community Integration
						Services only, providers will verify that a member meets specific eligibility
						requirements under 17.02-3 within sixty (60) days of the start date of
						services. If eligibility verification is not submitted by close of business on
						day sixty (60), MaineCare will cease payment for services under this section on
						day sixty-one (61).
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 I - Specific Policies By Service › Sec2 144-101-I-5 - COVID-19 Public Health Emergency Services › Subsection 144-101-I-5.13 - PRIVATE DUTY NURSING AND PERSONAL CARE SERVICES

Current through 2024-29, July 17, 2024
Under MBM, Ch. II, Section 96.07-6(G)(2), the period of
						time for an individual without the required training to enroll in a certified
						training program for Personal Support Specialist (PSS) shall be extended from
						sixty (60) days to one-hundred twenty (120) days from date of hire. The period
						of time in which an individual must complete and pass the training requirements
						shall be extended from nine (9) months to twelve (12) months from date of
						hire.
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 I - Specific Policies By Service › Sec2 144-101-I-5 - COVID-19 Public Health Emergency Services › Subsection 144-101-I-5.14 - NURSING FACILITY SERVICES

Current through 2024-29, July 17, 2024
The federal Preadmission Screening and Resident Review
						(PASRR) requirements under the MBM, Ch. II, Section 67.05-1, Nursing Facility
						Services are waived for 30 days. All new admissions can be treated like
						exempted hospital discharges. After thirty (30) days, new admissions with
						mental illness or intellectual disability should receive a Resident Review as
						soon as resources become available.
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 I - Specific Policies By Service › Sec2 144-101-I-6 - Global HCBS Waiver Person-Centered Planning and Settings Rule › Subsection 144-101-I-6.01 - INTRODUCTION

Current through 2024-29, July 17, 2024
This rule implements the federal requirements for Maine's
						Section 1915(c) home and community based waiver programs set forth in
						42 C.F.R. §
												441.301(c), and includes
						requirements for person-centered service planning and for settings in which
						home and community-based waiver services ("HCBS") are provided, including
						requirements for provider-owned or controlled residential settings.
This rule implements additional requirements or changes
						to HCBS waiver programs under the following sections of the MaineCare Benefits
						Manual:
Section 18: Home and Community-Based Services for Adults
						with Brain Injury;
Section 19: Home and Community Benefits for the Elderly
						and Adults with Disabilities;
Section 20: Home and Community-Based Services for Adults
						with Other Related Conditions;
Section 21: Home and Community Benefits for Members with
						Intellectual Disabilities or Autism Spectrum Disorder; and
Section 29: Support Services for Adults with Intellectual
						Disabilities or Autism Spectrum Disorder.
In the event of conflict between the requirements of this
						rule and any rule listed above, the terms of this rule supersede and shall
						apply.
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 I - Specific Policies By Service › Sec2 144-101-I-6 - Global HCBS Waiver Person-Centered Planning and Settings Rule › Subsection 144-101-I-6.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
A. "
Coercion
" means the use of
					 force or threats, including the threat of diminishment of any right or
					 privilege, to cause a person to do something against the person's will.
B.
"Department"
means
					 the State of Maine Department of Health and Human Services.
C. "
Informed Consent''
means
					 consent voluntarily given with sufficient knowledge and comprehension of the
					 subject matter involved so as to enable the person giving consent to make an
					 informed and enlightened decision, without any element of force, fraud, deceit,
					 duress, or other form of constraint or coercion.
D. "
Member"
means a person
					 determined to be eligible for and subsequently enrolled in MaineCare benefits
					 coverage by the Office of Family Independence (OFI) in accordance with the
					 eligibility standards published by the OFI in the
MaineCare Eligibility
					 Manual
. Some Members may have restrictions on the type and amount of
					 services they are eligible to receive.
E. "
Provider"
means any
					 individual, partnership, group, association, corporation, institution, or
					 entity, and the officers, directors, owners, managing employees, or agents of
					 any partnership, group association, corporation, institution, or entity that is
					 enrolled in the MaineCare program to provide covered services to Members.
F.
"Provider-Owned or
					 Controlled Residential Setting"
means a specific, physical place in
					 which a Member resides that is owned, co-owned, and/or operated by a provider
					 of home and community-based services. The Department shall determine whether a
					 setting is a Provider-Owned or Controlled Residential Setting when authorizing
					 services for a Member at the setting.
G.
"Restraint"
means a mechanism
					 or action - whether physical or chemical - that limits or controls a person's
					 voluntary movement or deprives a person of the use of all or part of the
					 person's body. "Restraint" does not include a prescribed therapeutic device or
					 intervention, or a safety device or practice.
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 I - Specific Policies By Service › Sec2 144-101-I-6 - Global HCBS Waiver Person-Centered Planning and Settings Rule › Subsection 144-101-I-6.03 - PERSON-CENTERED PLANNING

Current through 2024-29, July 17, 2024
A Person-Centered Service Plan is required for a Member
						to receive HCBS waiver services. The following requirements shall apply to
						person-centered planning.
A.
Person-Centered Planning Process.
The Member will lead the
					 person-centered planning process where possible. The Member's representative
					 should have a participatory role, as needed and as defined by the Member
					 (unless state law confers decision-making authority to a legal representative)
					 All references to a Member or individual in this Section are intended to
					 include the role of the Member's representative. In addition to being led by
					 the Member, the person-centered planning process must:
(1) Include people chosen by the
					 Member;
(2) Provide necessary
					 information and support to ensure that the Member directs the process to the
					 maximum extent possible, and is enabled to make informed choices and
					 decisions;
(3) Be timely and occur
					 at times and locations of convenience to the Member;
(4) Reflect cultural considerations of the
					 Member and be conducted by providing information in plain language and in a
					 manner that is accessible to individuals with disabilities and persons who have
					 limited proficiency in English, consistent with
					 42 C.F.R.
					 §
													435.905(b);
(5) Offer informed choices to the Member
					 regarding the services and supports they receive and from whom;
(6) Include a method for the Member to
					 request updates to the plan as needed;
(7) Record the alternative home and
					 community-based settings that were considered and accepted or rejected by the
					 Member; and
(8) Include a
					 discussion of strategies for resolving disputes or disagreements within the
					 planning process, including clear conflict of interest guidelines for all
					 planning participants.
Providers of HCBS services for the Member, or those who
						have an interest in or are employed by a provider of HCBS services for the
						Member, must not provide case management or develop the Person-Centered Service
						Plan (PCSP), except when the Department determines that the only willing and
						qualified entity to provide case management and/or develop PCSPs in a
						geographic area also provides HCBS 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 I - Specific Policies By Service › Sec2 144-101-I-6 - Global HCBS Waiver Person-Centered Planning and Settings Rule › Subsection 144-101-I-6.04 - HOME AND COMMUNITY-BASED SETTINGS

Current through 2024-29, July 17, 2024
A.
General
					 Requirements.
Each home and community-based setting must have all of the
					 following qualities, based on the needs of the Member as indicated in the
					 Member's Person-Centered Service Plan:
This 6.04(A) provision will become legally
						effective on September 30, 2022, EXCEPT that, for those HCBS Settings that were
						approved as new settings on or after March 17, 2014, this provision is legally
						effective on the effective date of this rule.
(1) Is integrated in and supports full access
					 of the Member receiving HCBS waiver services to the greater community,
					 including opportunities to seek employment and work in competitive, integrated
					 settings, engage in community life, control personal resources, and receive
					 services in the community, to the same degree of access as individuals not
					 receiving HCBS waiver services;
(2)
					 Is selected by the Member from among setting options including non
					 disability-specific settings and an option for a private unit in a residential
					 setting. The setting options are identified and documented in the
					 Person-Centered Service Plan and are based on the Member's needs, preferences,
					 and, for residential settings, resources available for room and
					 board;
(3) Ensures the Member's
					 rights of privacy, dignity and respect, and freedom from coercion and
					 restraint, except restraints deployed in accordance with
					 34-B
					 M.R.S. §5605(14-A) to
					 protect the Member or others from imminent injury or in conformance with an
					 approved behavior management program under
					 34-B
					 M.R.S.
					 §5605(13).
(4) Optimizes, but does not regiment,
					 individual initiative, autonomy, and independence in making life choices,
					 including but not limited to daily activities, physical environment, and
					 deciding with whom to interact;
(5) Facilitates individual choice regarding
					 HCBS waiver services and supports, and - from among qualified and willing
					 MaineCare Providers - who provide them; and
(6) Complies with any and all licensing
					 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 I - Specific Policies By Service › Sec2 144-101-I-6 - Global HCBS Waiver Person-Centered Planning and Settings Rule › Subsection 144-101-I-6.05 - SETTINGS THAT ARE NOT HOME AND COMMUNITY-BASED

Current through 2024-29, July 17, 2024
HCBS waiver services may not be offered in the following
						settings:
A. A nursing
					 facility;
B. An institution for
					 mental diseases;
C. An intermediate
					 care facility for individuals with an intellectual disability
					 ("ICF-IID");
D. A hospital; or
E. Any other locations that have
					 qualities of an institutional setting. Any setting that is located in a
					 building that is also a publicly or privately operated facility that provides
					 inpatient institutional treatment, or in a building on the grounds of, or
					 immediately adjacent to, a public institution, or any other setting that has
					 the effect of isolating Members from the broader community of individuals not
					 receiving HCBS waiver services, will be presumed to be a setting that has the
					 qualities of an institution, unless CMS has determined that the setting does
					 not have the qualities of an institution and that the setting does have the
					 qualities of HCBS settings.
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 I - Specific Policies By Service › Sec2 144-101-I-6 - Global HCBS Waiver Person-Centered Planning and Settings Rule › Subsection 144-101-I-6.06 - PROVIDER QUALIFICATIONS

Current through 2024-29, July 17, 2024
To provide home and community-based waiver services, a
						provider must be enrolled in MaineCare as a provider by the Office of MaineCare
						Services, be in compliance with the Provider's MaineCare Provider Agreement,
						and satisfy all provider qualification requirements set forth in the applicable
						HCBS waiver regulations.
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 I - Specific Policies By Service › Sec2 144-101-I-6 - Global HCBS Waiver Person-Centered Planning and Settings Rule › Subsection 144-101-I-6.07 - ENFORCEMENT

Current through 2024-29, July 17, 2024
The Office of Aging and Disability Services (OADS) and/or
						the Department shall assure compliance with this rule as provided by the
						MaineCare Benefits Manual, Ch. I, Sec. I, including the Department's right to
						full access to inspect, review, or audit medical, financial and other relevant
						documents, and including the duty of MaineCare providers and rendering
						providers to make their premises available for announced or unannounced visits
						for all purposes related to the administration of the MaineCare program.
OADS' and/or the Department's failure to take any
						particular action to enforce compliance with the MaineCare Benefits Manual may
						not be deemed to waive the Department's authority to act regarding prior or
						future violations by any Provider of HCBS waiver 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-2 - Adult Family Care Services › Subsection 144-101-II-2.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
2.02-1
General Financial Eligibility Requirements
Individuals must meet 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.
2.02-2
Specific Eligibility Requirements
Members who are financially eligible must also meet
						specific eligibility requirements to determine medical necessity of AFC
						services, as determined by the MDS-ALS assessment tool. The MDS-ALS assessment
						must show the member's need for assistance or cueing with a minimum of two
						ADLs.
2.02-3
Determination of Eligibility
A.
					 MaineCare will cover services only when an individual is determined by the
					 Department or its authorized agent to be both medically and financially
					 eligible for MaineCare. For each individual seeking MaineCare coverage of AFC
					 services, the provider shall:
1. Verify the
					 Department's determination of the individual's financial eligibility for
					 MaineCare, and check for dates of eligibility. If financial eligibility has not
					 been determined, the provider shall refer the applicant, or his/her authorized
					 representative, to the local regional DHHS office if he/she is not a MaineCare
					 member. Providers should also see MaineCare Benefits Manual , Chapter I for
					 information regarding retroactive eligibility. The provider shall inform the
					 local DHHS office when a person will be moving into the facility and will need
					 financial assistance to pay for his or her care. The provider shall do this
					 whether or not the individual already receives MaineCare and/or SSI benefits.
2. Complete an MDS-ALS within
					 thirty (30) days of admission and maintain the completed assessment tool in the
					 member's record.
3. Notify the
					 local regional DHHS office when the member has been admitted. The local DHHS
					 office must also be notified at the time of discharge.
4. Submit a valid MDS-ALS assessment for the
					 member in order for the Department to compute the member's classification group
					 resource weight necessary for 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-2 - Adult Family Care Services › Subsection 144-101-II-2.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
An eligible Title XIX or XXI member is entitled to
						receive as many days of AFC services as necessary, as long as the member meet
						the eligibility for care requirements set forth under Section 2.02. The
						Department, or its authorized agent may, at any time, review a member's need
						for AFC 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-2 - Adult Family Care Services › Subsection 144-101-II-2.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
2.04-1
A.
Personal Care Services
Services
: Services covered under adult
						family care services include the following Personal Care Services:
1. Assistance with activities of daily living
					 such as bathing, dressing, eating, toileting, ambulation, transfers, changing
					 positions in bed, personal hygiene, and grooming (shaving, oral care,
					 shampooing, and nail care), bladder and bowel requirements, routine catheter
					 care and routine colostomy care;
2.
					 The performance of instrumental activities of daily living and incidental
					 household tasks essential to the activities of daily living or to the
					 maintenance of the member's health and safety within the facility, such as meal
					 preparation, and bed making, dusting and vacuuming of the member's
					 room;
3. Supervision of, or
					 assistance with, administration of prescribed medication;
4. Personal supervision or awareness of the
					 member's general safety and whereabouts; observation or monitoring of the
					 member to ensure and promote his/her health and safety; reminding the member to
					 carry out activities of daily living or of important appointments; and
					 assisting the member in adjusting to residence in the facility;
5. Arranging transportation and making phone
					 calls for appointments as recommended by medical providers, as well as
					 reporting deviations or changes from the member's normal appearance, behavior
					 or state of health to the guardian, physician, or designated health services
					 provider; and
6. Arranging or
					 providing motivational and diversionary activities (individual or group) that
					 focus on social interaction to reduce isolation or withdrawal and to enhance
					 communication and social skills.
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-2 - Adult Family Care Services › Subsection 144-101-II-2.05 - LIMITATIONS

Current through 2024-29, July 17, 2024
2.05-1
Duplication of services
is not allowed. It is the responsibility of the AFC services provider to
					 coordinate services with other "in-home" services to address the full range of
					 a member's needs. Other MaineCare-covered services must not duplicate AFC
					 covered services. For example, if a member receives Section 96, "Private Duty
					 Nursing and Personal Care Services"; or Section 40, "Home Health Services"; or
					 Section 19, "Home and Community-Based Benefits for the Elderly and Adults with
					 Disabilities", or Section 43, "Hospice Services", all personal care services
					 shall be delivered by the AFC services provider and not by a Certified Nursing
					 Assistant (CNA), Home Health Aide (HHA), Personal Care Attendant (PCA) or
					 Personal Support Specialist (PSS) as otherwise allowed in these
					 Sections.
2.05-2
Private Duty
					 Nursing Services and Personal Care Services
are subject to financial
					 "caps" as described in Section 96, "Private Duty Nursing and Personal Care
					 Services". For members who receive Private Duty Nursing services, the cost of
					 AFC services and Private Duty Nursing services combined must not exceed the
					 member's approved Private Duty Nursing and Personal Care Services "cap." It is
					 the responsibility of the Private Duty Nursing provider to monitor the cost of
					 services and stay within the "cap." The increased reimbursement provided
					 effective August 1, 2018 attributable to wages and salaries for personal care
					 and related services, which shall be increased annually by an inflation
					 adjustment pursuant to Ch. III, Sec. 2, shall not be counted towards the caps
					 described herein.
2.05-3
MaineCare Waiver Services
- A member receiving AFC services may
					 receive services under a MaineCare Waiver program such as (Section 19, "Waiver
					 Services for the Elderly and for Adults with Disabilities"; Section 22, "Waiver
					 Services for the Physically Disabled").
However, the cost of the MaineCare-covered AFC services
						shall be included within the established waiver financial "cap." The
						Department's designated agency responsible for administering the member's
						waiver services must include the cost of MaineCare-covered AFC services within
						the member's "cap." The increased reimbursement provided effective August 1,
						2018 attributable to wages and salaries for personal care and related services,
						which shall be increased annually by an inflation adjustment pursuant to Ch.
						III, Sec. 2, shall not be counted towards the caps described herein.
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-2 - Adult Family Care Services › Subsection 144-101-II-2.06 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
A. Room and board,
					 including the cost of meals and transportation for services that are not
					 otherwise covered by MaineCare.
B.
					 Household or chore services unless furnished as an integral but subordinate
					 part of the personal services, as described in Section 2.04-1(A)(2), that is
					 furnished directly to the member.
C. Other non-covered services as described in
					 Chapter I of the MaineCare Benefits Manual (MBM), including services that are
					 primarily academic, social, vocational or custodial in nature.
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-2 - Adult Family Care Services › Subsection 144-101-II-2.09 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Billing must be in accordance with the Department's "
						Billing Instructions for Adult Family 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 II - Specific Policies By Service › Section 144-101-II-3 - AMBULATORY CARE CLINIC SERVICES › Subsection 144-101-II-3.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
3.01-1
Ambulatory Care Clinic
means a school health clinic that performs any of the services described in
					 3.04-1.
3.01-2
Covered
					 Services
are those services described in 3.04 for which payment can be
					 made under Title XIX by the Department of Human Services.
3.01-3
Primary Health Care
refers to preventive, diagnostic and therapeutic services furnished by the
					 primary health care clinic's professional staff and, where appropriate, the
					 provision of supplies commonly used to support those services, basic laboratory
					 services essential for diagnosis and treatment, and emergency medical care for
					 the treatment of life-threatening injuries and acute illness.
3.01-4
Flu Clinic Provider
refers to those providers who are enrolled under this Section to be reimbursed
					 only for administration of seasonal and 2009 Influenza A (H1N1) flu vaccines.
					 Providers must meet the provider requirements for this Section or provider
					 qualifications for Home Health Agencies (Section 40 of the MaineCare Benefits
					 Manual) and must be approved by the Maine Center for Disease Control (CDC) as a
					 flu clinic site.
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-3 - AMBULATORY CARE CLINIC SERVICES › Subsection 144-101-II-3.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Individuals must meet the eligibility criteria as set
						forth in the MaineCare Eligibility Manual, 10-144 C.M.R. Ch 332. 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, as described in MaineCare Benefits Manual, Chapter
						I, prior to providing 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-3 - AMBULATORY CARE CLINIC SERVICES › Subsection 144-101-II-3.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each Title XIX recipient may receive as many covered
						services as are medically necessary. The Department reserves the right to
						request additional information to evaluate medical necessity.
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-3 - AMBULATORY CARE CLINIC SERVICES › Subsection 144-101-II-3.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
3.04-1
Covered Services for School Health Clinics
Covered services include preventive, diagnostic and/or
						therapeutic services for acute, episodic and chronic conditions furnished by
						the clinic's professional staff; supplies commonly furnished for the provision
						of these services; and basic laboratory services essential for immediate
						diagnosis and treatment.
3.04-2
Interpreter Services
All Ambulatory Care Clinics, when providing covered
						services as described in this Section of the MaineCare Benefits Manual, shall
						be reimbursed for interpreter services provided to Medicaid recipients when
						these services are necessary to communicate effectively with the recipient
						regarding health care needs.
Providers of interpreter services must be certified by
						the Registry of Interpreters for the Deaf, Inc., or working under the
						supervision of an interpreter certified by the Registry of Interpreters for the
						Deaf, Inc.
Reimbursement will be available for an interpreter's
						hourly minimum charge and beyond this first hour, reimbursement is based on the
						quarter hour including associated travel to and from the location where the
						services are performed.
Additional reimbursement for deaf Medicaid recipients
						who have non-standard signing, is available consisting of a relay interpreting
						team including a deaf interpreter, for whom signing his/her native language,
						working with a hearing interpreter. In such cases, reimbursement for two
						interpreters will be made.
Reimbursement will be at the interpreter's usual and
						customary charge not to exceed the amounts listed in Chapter III of this
						Section.
When requesting reimbursement for Interpreter Services,
						a statement of verification regarding the interpreter's certification and cost
						of performing the services shall be documented in the recipient's
						record.
3.04-3
Flu
					 Clinics
Administration of flu vaccines (seasonal and H1N1) are
						reimbursable when providers are appropriately enrolled under this Section and
						approved by the Maine CDC to administer vaccines. Providers must use
						state-supplied vaccines(provided at no cost to providers) whenever available.
						State supplied vaccines are available for H1N1 administration to all MaineCare
						members. The state also supplies seasonal flu vaccines for children. Providers
						may bill acquisition cost only for seasonal flu administration for adults, in
						addition to the administration fee. Providers must maintain documentation of
						acquisition costs to be provided to MaineCare upon request. Providers may bill
						separately for each vaccine administered. Roster billing is allowed for flu
						clinics.
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-3 - AMBULATORY CARE CLINIC SERVICES › Subsection 144-101-II-3.05 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
3.05-1
Academic Services
Any programs, services, or components of service
						provided to clients that are academic in nature are not reimbursable by
						Medicaid. Academic services are those traditional subjects such as science,
						history, literature, foreign languages, and mathematics.
3.05-2
Vocational Services
Any programs, services, or components of service
						provided to clients which basically provide a vocational program are not
						reimbursable by Medicaid. Vocational services relate to organized programs
						directly related to the preparation of individuals for paid or unpaid
						employment, such as vocational skills training or sheltered employment.
3.05-3
Socialization or
					 Recreation Services
Any programs, services, or components of services of
						which the basic nature is to provide recreation are not reimbursable under the
						Medicaid Program. These non-covered services include, but are not limited to
						picnics, dances, ball games, parties, field trips, and social clubs.
3.05-4
Custodial
					 Services
Any programs, services, or components of services which
						basically provide custodial care are not reimbursable under the Medicaid
						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-3 - AMBULATORY CARE CLINIC SERVICES › Subsection 144-101-II-3.07 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
Reimbursement for covered services provided by school
						health clinics shall be the lowest of the following:
A. The amount listed in the "Allowances for
					 Ambulatory Care Clinic Services", Chapter III, Section 3.
B. The amount allowed by the Medicare Part B
					 carrier.
C. The provider's usual
					 and customary charge.
Reimbursement for services provided by school health
						clinics is available based on a negotiated rate between the provider and the
						Office of MaineCare Services, and shall be the lowest of the amounts listed
						above.
In accordance with Chapter I, it is the responsibility of
						all Ambulatory Care Clinics to ascertain from each recipient 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 seek payment from such resources 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-3 - AMBULATORY CARE CLINIC SERVICES › Subsection 144-101-II-3.08 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Billing must be accomplished in accordance with the
						Department's "Billing Instructions for the CMS 1500 Claim Form".
MaineCare Services will replace the billing codes in
						Table 1, Chapter III, Section 3 with the codes found in Table 2 upon
						implementation of the new billing system. Providers will receive written notice
						thirty (30) days prior to implementation.
3.08-1
School Health Clinic Special
					 Instructions
Each clinic must only bill using codes for sick child
						visits and, if applicable, all adult visits. Billing for Early and Periodic
						Screening Diagnosis and Treatment (EPSDT) and immunizations for well children
						may be billed under Chapter V of the MaineCare Benefits Manual as long as
						services are provided in conformance with all requirements of that Chapter,
						including submission of the Bright Futures form. Procedure codes for EPSDT
						services will be found in the Physicians' Current Procedural Terminology (CPT)
						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 II - Specific Policies By Service › Section 144-101-II-4 - Behavioral Health Services › Subsection 144-101-II-4.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
4.01-1 Ambulatory Surgical Center (ASC) means
					 a freestanding facility that operates exclusively for the purpose of providing
					 surgical services to persons not requiring hospitalization and in which the
					 expected duration of services would not exceed 24 hours following admission.
					 The ASC must be certified by Medicare and comply with applicable licensure
					 requirements, if any, in the State or Province in which it operates.
Ambulatory Surgical Centers reimbursed as part of an
						acute care hospital are excluded as providers under this Section of the
MaineCare Benefits Manual.
4.01-2 Facility Services means items and
					 services furnished by an ASC in connection with a covered surgical
					 procedure.
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-4 - Behavioral Health Services › Subsection 144-101-II-4.02 - MEMBER ELIGIBILITY

Current through 2024-29, July 17, 2024
Individuals must meet the financial eligibility criteria
						set forth in the
MaineCare Eligibility Manual.
Some members
						may have restrictions on the type and amount of services they are eligible to
						receive.
The provider is responsible for verifying a member's
						eligibility for MaineCare prior to providing services on each occasion that
						services are provided. See Chapter I of the
MaineCare Benefits
						Manual
for more information on verifying
						eligibility.
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-4 - Behavioral Health Services › Subsection 144-101-II-4.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each MaineCare member is eligible for as many covered
						services as are medically necessary. The Department reserves the right to
						request additional information to determine medical
						necessity.
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-4 - Behavioral Health Services › Subsection 144-101-II-4.05 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
Non-covered services are services that are not billable
						under this section of policy as ASC facility services. ASC facility services do
						not include physician or anesthetist services (Section 90; Section 14 );
						laboratory (Section 55 ), radiology or diagnostic procedures (other than those
						directly related to the performance of the surgical procedure) (Section 101 );
						ambulance services (Section 5 ); or non-implantable prosthetic devices and
						durable medical equipment (other than those that serve the function of a case
						or splint or are otherwise considered integral to the performance of a covered
						surgical procedure) (Section 60 ).
Covered procedures are limited to those not expected to
						result in extensive loss of blood, but in some cases, blood and blood products
						may be required. When there is a need for blood and blood products, they are
						considered facility services and no separate charge is permitted.
Other non-covered services include those services that
						cannot be safely performed in an outpatient setting or without support of a
						fiall array of hospital diagnostic and treatment services and equipment; and
						procedures that are not covered by MaineCare (e.g., cosmetic surgery).
Services are not separately billable unless specifically
						allowed under Medicare.
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-4 - Behavioral Health Services › Subsection 144-101-II-4.06 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
4.06-1
Professional Staff
A physician is a doctor of medicine or osteopathy who
						possesses a current license to practice medicine or osteopathy in the State or
						Province in which the services are provided.
4.06-2
Member Records
There shall be a specific record for each member that
						shall include, but not necessarily be limited to:
A. The member's name, address, and birth
					 date;
B. The member's social and
					 medical history, as appropriate;
C.
					 Operative reports or procedure/treatment descriptions, as
					 appropriate;
D. A description of
					 any tests ordered and performed and their results;
E. A description of treatment or follow-up
					 care and dates scheduled for revisits;
F. Any medications and/or supplies dispensed
					 or prescribed;
G. Any
					 recommendations for and referral to other sources of care;
H. The dates on which all services were
					 provided;
I. Written progress
					 notes, which shall identify the services provided, pathology specimens
					 obtained, and where sent, as applicable;
J. Informed consents; and
K. Assessment appropriate to the nature and
					 scope of the procedure performed and the specific medical condition of the
					 individual patient.
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-4 - Behavioral Health Services › Subsection 144-101-II-4.07 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
Reimbursement for covered services shall be made as
						described below. The reimbursement rate is an all-inclusive rate and covers the
						facility costs described in 4.04(A).
4.07-1
Reimbursement
is based on
					 a fee schedule. The fee schedule reimburses at the lower of
A. 100% of the lowest amount allowed by the
					 Maine Medicare Part B carrier based on current Medicare rates; or
B. the provider's usual and customary
					 facility charge.
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 prior to
						billing the MaineCare Program.