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 II - Specific Policies By Service › Section 144-101-II-29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-29.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
29.02-1 Abuse is defined in
					 22 MRSA
					 §3472 and means the infliction of
					 injury, unreasonable confinement, intimidation or cruel punishment that causes
					 or is likely to cause physical harm or pain or mental anguish; sexual abuse or
					 sexual exploitation; financial exploitation; or the intentional, knowing or
					 reckless deprivation of essential needs. "Abuse" includes acts and
					 omissions.
29.02-2
Activities
					 of Daily Living (ADL) are:
A.
Bed
					 Mobility
: How person moves to and from lying position, turns side to
					 side, and positions body while in bed;
B.
Transfer
: How person moves
					 between surfaces to/from: bed, wheelchair, standing position (excluding to/from
					 bath/toilet);
C.
Locomotion
: How person moves between locations, in room and other
					 areas. If in wheelchair, self-sufficiency once in chair;
D.
Eating
: How person eats and
					 drinks (regardless of skill);
E.
Toilet Use
: How person uses the toilet room (or commode, bedpan,
					 urinal), transfers on/off toilet, cleanses, changes pad, manages ostomy or
					 catheter, adjusts clothes;
F.
Bathing
: How person takes full-body bath/shower, sponge bath and
					 transfers in/out of tub/shower (exclude washing of back and hair);
					 and
G.
Dressing
: How
					 person puts on, fastens, and takes off all items of street clothing, including
					 donning/removing prosthesis.
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-29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-29.05 - COVERED SERVICES

Current through 2024-29, July 17, 2024
29.05-1
Assistive Technology
- Assistive technology device means an item,
					 piece of equipment, or product system, whether acquired commercially, modified,
					 or customized, that is used to increase, maintain, or improve functional
					 capabilities of members. Assistive technology service means a service that
					 directly assists a member in the selection, acquisition, or use of an assistive
					 technology device.
If authorized, the Department expects that Home
						Support-Remote Support Hours will be implemented within 90 days of
						assessment.
Assistive Technology includes;
(A) Assistive Technology-Assessment:
1. The evaluation of the assistive technology
					 needs of a member, including a functional evaluation of the impact of the
					 provision of appropriate assistive technology and appropriate services to the
					 member in the customary environment of the member;
2. The coordination and use of necessary
					 therapies, interventions, or services with assistive technology devices, such
					 as therapies, interventions, or services associated with other services in the
					 service plan;
3. The training or
					 technical assistance for the member, or, where appropriate, the family members,
					 guardians, advocates, or authorized representatives of the member;
					 and
4. The training or technical
					 assistance for professionals or other individuals who provide services to,
					 employ, or are otherwise substantially involved in the major life functions of
					 members.
Assistive Technology-Assessment is subject to a combined
						limit per year. See Section
						29.07 below.
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-29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-29.06 - NON COVERED SERVICES

Current through 2024-29, July 17, 2024
Services for which reimbursement is not allowed under
						this Section include, but are not limited to, the following:
29.06-1 Services not identified by the
					 Personal Plan;
29.06-2 Services to
					 any MaineCare member who receives services under any other federally approved
					 MaineCare Home and Community based waiver program;
29.06-3 Services to any member who is a
					 nursing facility resident, or ICF/IID resident, psychiatric hospital resident,
					 or hospital resident;
29.06-4
					 Services that are reimbursable under any other sections of the
MaineCare Benefits Manual
;
29.06-5 Any service otherwise reimbursable
					 under the
Rehabilitation Act of 1973
or the Individuals with
Disabilities Education Act
, including but not limited to job
					 development and vocational assessment or evaluations;
29.06-6 Room and board; The term "room" means
					 shelter type expenses, including all property related costs such as rental or
					 purchase of real estate and furnishings, maintenance, utilities, and related
					 administrative services. The term "board" means three meals a day; or any other
					 full nutritional regimen. Board does not include the provision of a meal at an
					 adult day health or similar facility outside the member's home. Board also does
					 not include the delivery of a single meal to a member at his/her own home
					 through a meals-on-wheels service;
29.06-7 Work Support-Individual or Work
					 Support-Group or Employment Specialist Services when the member is not engaged
					 in employment;
29.06-8 Home
					 Accessibility Adaptations unless the service has been determined
					 non-reimbursable under Medical Supplies and Durable Equipment, Section
					 60 or other sections of the
MaineCare Benefits Manual
;
29.06-9 A member may not have wages from
					 employment paid for with MaineCare reimbursement: and
29.06-10 Services provided directly or
					 indirectly by the legal guardian will not be reimbursed unless the legal
					 guardian is the member's parent, sibling or other biological family member.
					 This rule will not be avoided by adult 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 II - Specific Policies By Service › Section 144-101-II-29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-29.08 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each member receiving services under this Section is
						eligible for as many covered services as are authorized by DHHS in the member's
						personal plan. Services are authorized to meet the needs identified in the
						member's most recent assessment, subject to limits on covered service
						components specified elsewhere in this Section.
29.08-1
Voluntary Termination
-
					 A member who currently receives the benefit, but no longer wants to receive the
					 benefit, will be terminated, after DHHS receives written notice from the member
					 that he or she no longer wants the benefit.
29.08-2
Involuntary Termination
- DHHS will give written notice of termination to a member at least ten (10)
					 days prior to the effective date of the termination, providing the reason for
					 the termination, and the member's right to appeal such decision. A member may
					 be terminated from this benefit for any of the reasons listed below:
A. The member is determined to be financially
					 or medically ineligible for this benefit or MaineCare;
B. The member is determined to be a nursing
					 facility resident, psychiatric hospital, hospital, or ICF/IID resident for six
					 months;
C. The member is determined
					 to be receiving MaineCare services from another Home and Community Based Waiver
					 benefit;
D. The member is no longer
					 a resident of the State of Maine;
E. The health and welfare of the member can
					 no longer be assured because:
1. The member
					 or immediate family, guardian or caregiver refuses to abide by the Personal
					 Plan or other benefit policies;
2.
					 The home or home environment of the member becomes unsafe to the extent that
					 benefit services cannot be provided without risk of harm or injury to the
					 member or to individuals providing covered services to the member; or
3. There is no approved Personal
					 Plan.
F. The member has
					 not received at least one waiver service in a thirty (30) day period;
					 or
G. The annual cost of the
					 member's services under this waiver exceeds fifty percent (50%) of the
					 state-wide average annual cost of care for an individual in an ICF/IID, as
					 determined by the DHHS.
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-29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-29.09 - MEMBER RECORDS

Current through 2024-29, July 17, 2024
Each provider serving the member must maintain a specific
						record for each member it serves in accordance with the requirements of Chapter
						I of the
MaineCare Benefits Manual
. The member's record is
						subject to DHHS's review.
In addition, the member's records must contain:
A. The member's name, address, birth date,
					 MaineCare identification number, guardian contacts and emergency
					 contacts;
B. The member's social
					 and medical history, including allergies and diagnoses;
C. The member's Personal Plan; and
D. Written progress notes that identify any
					 actions related to progress towards the achievement of the goals, services and
					 needs established by the member's Personal Plan signed by the staff performing
					 the service.
DHHS will conduct a review of provider records that may
						include, but is not limited to, staff schedules, payroll records and member
						records to substantiate service delivery and units of
						authorization.
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-29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-29.11 - APPEALS

Current through 2024-29, July 17, 2024
In accordance with Chapter I of the
MaineCare
						Benefits Manual
, members have the right to appeal in writing or
						verbally any decision made by DHHS to reduce, deny or terminate services
						provided under this benefit. The right to appeal does not extend to changes in
						law or policy adversely affecting some or all recipients. The appeal must be
						(a) requested in writing and mailed to the address below, or (b) requested by
						telephone by calling Local: 207-287-6598, Toll Free: 1-800-606-0215 or
						TTY:711.
Office of Aging and Disability Services
Department of Health and Human Services
11 State House Station
Augusta, ME 04333-0011
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-29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-29.12 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
Reimbursement methodology for covered services shall be
						the amount listed in Chapter III, Section
						29, Allowances for Support
						Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder
						or the provider's usual and customary charge, whichever is lower.
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 of the rendered
						service prior to billing MaineCare. Therefore, a service provider under this
						benefit is expected to seek payment from sources other than MaineCare that may
						be available to the member.
DHHS will conduct a review of provider records that may
						include, but is not limited to, staff schedules, payroll records and member
						records to substantiate service delivery and units of
						authorization.
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-29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-29.13 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Providers must bill in accordance with DHHS billing
						instructions.
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-29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-29.14 - APPENDIX I-Guidelines for Approval of Medical Add-On in Maine Rate Setting

Current through 2024-29, July 17, 2024
The purpose of this Appendix is to detail guidelines for
						Office of Aging and Disability Services in approving a Medical Add-On to the
						established published rate. All current statutes, regulations, decree
						provisions, policies, and licensing standards regarding medical services are
						unaffected by these guidelines. This Appendix develops criteria that warrant an
						adjustment to the DHHS's established published rate for Community Support,
						Employment Specialist Services and Work Support Services.
The Clinical Review Team (CRT) is the entity within OADS
						that is responsible for review and approval, of all Medical Add-On rate
						increases for services under this section.
The rate is designed to support Members with intermittent
						or longer duration medical conditions. Changes or needs that may be considered
						for Medical Add-On include but are not limited to: 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.
						Conditions related to surgeries, procedures, injuries and other short term
						conditions are also considered for the Medical Add-On rate increase.
The following standards and practices must be
						demonstrated in order for the CRT to approve a Medical Add-On:
A.
Physician Order
1. There must be a written physician or
					 physician's assistant's order, less than three (3) months old for the member.
					 This order must specify:
a. The specific
					 illness or condition to be addressed;
b. The specific procedure(s) that will be
					 utilized;
c. The time span over
					 which the treatment or intervention is expected to be needed. If the treatment
					 or intervention is expected to be needed for an indefinite period of time then
					 this expectation should be specified;
d. The anticipated frequency of treatment or
					 intervention on a daily, weekly, or monthly basis;
e. Where applicable and possible:
i. The approximate length of time required
					 for each episode of the treatment or intervention and
ii. The degree of licensure or certification
					 required for those who carry out the treatment, and those who provide training
					 and oversight relative to its application.
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-29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-29.15 - APPENDIX II - "On Behalf Of" Covered Services

Current through 2024-29, July 17, 2024
"On Behalf Of" Covered Services:
Support and supervision that is offered whenever the
						staff and the member are in the same physical environment is considered
direct support time.
This would include, for
						example, staff waiting for a member during a medical appointment or a home
						visit. Examples of acceptable services include:
Services and time that are directly related to a member:
						such as scheduling medical appointments, dental appointments and therapy
						appointments. This includes any time staff may need to spend discussing with a
						physician, dentist, or therapist any intervention regarding the member.
Services and time that are directly related to a member
						that are associated with that member's personal plan, medical plan or
						behavioral plan including in-service training specific to a member's personal
						plan, consultations with supervisors, therapist, clinicians, member's employer
						and or medical staff; services relating to a member's parent, guardian or Maine
						Developmental Services Oversight and Advisory Board (MDSOAB)representative;
						documentation, reports and presentations to review committees.
Services and time that are directly related to a member
						that are associated with home visits, family events and or family reunification
						including transporting a member to their parents, guardian, or friends home for
						visits, returning a member to their home, and any time spent during such a
						visit such as attending a family function with the member.
Services and time that are directly related to a member's
						safety such as "shadowing" a member as he or she learns to take a bus.
"On Behalf Of" Non-Covered Services:
Services and time that are related to group services, or
						time that cannot be directly linked to member's Personal Plan. For example,
						grocery shopping for a home.
Services and time that are related to home cleaning, home
						maintenance, facility cleaning or facility maintenance.
Services and time that are related to staff training,
						unless the training is specific and exclusive to the member.
Services and time that are related to landscaping, snow
						removal, spring clean-up or similar activities.
Services and time that are related to securing or
						maintaining a license or certificate such as a group home license, or CARF
						accreditation.
Services and time that are related to staff recruitment,
						even if the staff is being recruited for the member.
Services and time provided by a salaried staff member
						unless there is evidence that the salaried staff was working as a Direct
						Support Professional for the time being claimed.
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-29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-29.16 - APPENDIX III Performance Measures

Current through 2024-29, July 17, 2024
The primary goal of Performance Measurement is to use
						data to determine the level of success a service is achieving in improving the
						health and well-being of members. Performance Goals and Performance Measures
						assist to monitor quality, inform and guide reimbursement decisions and
						conditions of provider participation across MaineCare services. This focus on
						Performance Measurement is anticipated to enhance the overall quality of
						services provided and raise the level of public accountability for both the
						DHHS and MaineCare providers.
29.16-1
Performance Goals
Members receiving this service will experience improved
						or preserved functional abilities while being able to live in a safe and stable
						setting within the community.
29.16-2
Performance Measures
a. 65% of members receiving Work
					 Support-Individual services will have worked a total number of hours of paid
					 employment during the quarter that is greater than the total number of Work
					 Support-Individual support hours they received during the quarter.
b. 100% of members receiving Work Support
					 Services-Group making less than minimum wage, will have a Personal Plan in
					 place that identifies how Work Supports is being utilized to increase the
					 member's productivity and ensure good job match in order to move toward an
					 hourly wage that meets or exceeds the State of Maine minimum wage
					 standard.
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-29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-29.17 - APPENDIX IV- Additional Requirements for Section 29 Providers of Community Support Services, Employment Specialist Services, and Shared Living

Current through 2024-29, July 17, 2024
Providers must first be approved by OADS and subsequently
						enroll in MaineCare in order to provide services and be reimbursed under this
						Benefit.
Prior to approval and thereafter, the provider, any
						contractor or subcontractor of the provider, or other individuals compensated
						by the provider for assisting in the care of member(s) shall be subject to site
						visits and interviews to ensure compliance with federal and state laws and
						regulations and the operational, health, safety and environmental requirements
						set forth herein. The provider shall permit OADS representative(s) to visit the
						member and the member's home and program as often as DHHS deems necessary to
						assure quality services, including unscheduled visits.
The provider must submit the following to the OADS
						District Resource Coordinator:
A.
					 Application Form. Initial applications shall be submitted using DHHS forms to
					 the OADS District Resource Coordinator. The initial application shall be signed
					 and dated by the provider owner and the presiding officer of the Governing
					 Body, if applicable.
B. The initial
					 application shall be accompanied by documents described in this section of rule
					 demonstrating compliance with requirements described in the following portions
					 of these rules:
1.
Organizational
					 Structure
a.
Ownership
i.
Authority
. The provider shall
					 maintain documented evidence of its source(s) of authority to provide services.
					 Such evidence will include articles of incorporation, corporate charter, or
					 similar documents.
ii. Records.
					 Corporations, partnerships, or associations shall maintain records of the
					 contact information for officers, directors, charters, partnership agreements,
					 constitutions, articles of association and/or by-laws, as applicable.
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-30 - Family Planning Agency Services › Subsection 144-101-II-30.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
30.01-1
Family Planning
refers
					 to the informed and voluntary determination by the member of desired family
					 size and timing of child bearing and to reproductive health care both directly
					 and indirectly related to child bearing.
30.01-2
A Family Planning Agency
is a non-profit organization, public or private, engaged in providing the
					 services described under 30.01-3. Those services which are administered by the
					 Department of Health and Human Services are developed in consultation,
					 coordination, or on a contractual basis with family planning agencies in the
					 State.
30.01-3
Family
					 Planning Services
include, but are not limited to, the following:
A. Consultation with trained personnel
					 regarding family planning, contraceptive procedures, immunizations, and
					 sexually transmitted diseases.
B.
					 Distribution of literature relating to family planning, contraceptive
					 procedures, and sexually transmitted diseases.
C. Provision of contraceptive procedures and
					 contraceptive supplies by those qualified to do so under the laws of the State
					 in which services are provided.
D.
					 Referral of members to physicians or health agencies for consultation,
					 examination, tests, medical treatment and prescription for the purposes of
					 family-planning, contraceptive procedures, and treatment of sexually
					 transmitted diseases, as indicated.
E. Immunization services where medically
					 indicated and linked to sexually transmitted diseases including but not limited
					 to Hepatitis B immunizations.
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-30 - Family Planning Agency Services › Subsection 144-101-II-30.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Individuals must meet the eligibility criteria as set
						forth in the
MaineCare Eligibility Manual
.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-30 - Family Planning Agency Services › Subsection 144-101-II-30.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each MaineCare member as defined in Title XIX of the
Social Security Act
and XXI State Children's Health Insurance
						Program member, respectively, is eligible for as many covered services as are
						medically necessary and subject to limitations within this Section. The
						Department reserves the right to request additional information to determine
						medical necessity or expected therapeutic benefit of prescribed supplies or
						equipment.
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-30 - Family Planning Agency Services › Subsection 144-101-II-30.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
A covered service is a service for which payment to a
						provider is permitted under this section of the
MaineCare Benefits
						Manual
.The types of Family Planning Agency services are as described
						in sub-sections 30.04-1 through 30.04-8.
30.04-1
Initial Patient Visit
An initial patient visit refers to an annual visit
						furnished no more frequently than once every 11 months, approximately 1 hour in
						length, which visit must include:
A.
					 Pre-examination counseling and instruction concerning family planning methods,
					 sexually transmitted diseases, immunizations, and reproductive health, all of
					 which will normally take 15 minutes of the visit.
B. Obtaining a medical and social
					 history.
C. Pre-exam preparation,
					 including: blood pressure, height, weight, hemoglobin/hematocrit as
					 indicated.
D. Physical examination
					 of the reproductive organs which may include a Pap smear and breast exam for
					 women, and, when indicated, a screening for gonorrhea, chlamydia, condlyloma,
					 HSV, hepatitis B, HIV, and vaginal infections. If a Pap smear has been
					 furnished within the preceding 12 months by another provider and the results of
					 a negative smear are documented in the member's chart, the repetition of this
					 exam will not be reimbursed. If a Pap smear furnished within the preceding 12
					 months has shown a positive finding and if those results have been documented
					 in the member's chart, then MaineCare reimbursement for an initial patient
					 visit shall be made.
This visit may also include:
E. Prescription and dispensation
					 of the contraceptive method chosen by the member.
F. Provision of related contraceptive
					 supplies.
G. Consultation and
					 referral, when appropriate.
Record entries relative to the patient visit, both
						initial and annual, must be made by qualified family planning agency staff (MD,
						P.A., Nurse Practitioner, Certified Nurse Midwife, or family planning
						specialists).A family planning specialist may make record entries relative to
						counseling, instruction, and other support services provided under the
						supervision of one of practitioners listed above.
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-30 - Family Planning Agency Services › Subsection 144-101-II-30.05 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
MaineCare reimbursement shall be made only for those
						family planning counseling, instruction and medical services which are provided
						directly to the member.
A. Infertility
					 Treatment is not a covered service.
B. Reimbursement for abortion services may be
					 made only when special criteria are met. See Section 90, "Physician
					 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-30 - Family Planning Agency Services › Subsection 144-101-II-30.06 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
30.06-1
Professional and Other Qualified Staff
A. Physicians employed by a family planning
					 agency may provide family planning medical and counseling services by virtue of
					 possession of a current license to practice medicine in the State or Province
					 in which the services are performed.
Each agency shall employ a physician to provide medical
						direction for the agency's health care activities and counseling and for
						medical supervision of the health care staff.
B. A physician assistant may provide family
					 planning, medical and counseling services when he or she has obtained Full or
					 Temporary Licensure from the Board of Licensure in Medicine or Osteopathy,
					 which must be renewed bi-annually in accordance with Board rules. Such services
					 may be performed only when delegated by a physician in accordance with the
					 rules and regulations governing physician assistants.
C. A family planning nurse practitioner or
					 certified nurse-midwife may provide family planning, medical and counseling
					 services which are supported by written protocols when he or she is a graduate
					 of a certified nurse practitioner program with specialization in Family
					 Planning, Obstetrics-Gynecology, Women's Health Care or its equivalent and when
					 he or she holds a current nurse practitioner or nurse-midwife license to
					 practice in the State or Province in which services are provided.
D. A licensed dietitian may provide dietary
					 counseling, dietary instruction and other nutritional services when employed by
					 a family planning agency and when he or she is licensed by the Board of
					 Licensing of Dietetic Practice in the State or Province in which services are
					 provided.
E. A family planning
					 specialist may provide counseling, instruction, and other support services
					 under the coordination and oversight of a family planning nurse practitioner,
					 certified nurse-midwife, physician or physician assistant when he or she has
					 had at least 1 year of experience in a related setting, or at least 1 year of
					 education in a relevant field.
In addition, there must be documentation of successful
						completion of a family planning agency's formal training and orientation
						program in each family planning specialist's record. Those family planning
						specialists employed by a family planning agency prior to June 1, 1987, shall
						be deemed qualified to provide services if, for such persons, documentation of
						related training and prior experience is present.
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-30 - Family Planning Agency Services › Subsection 144-101-II-30.07 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
A. The maximum amount of payment for service
					 rendered shall be the lowest of the following:
1. The provider's usual and customary
					 charge.
2. The amount listed in
					 Chapter III, Section 30, and the Department's rate setting website:
www.maine.gov/dhhs/audit/rate-setting/index.shtml
.
3. The lowest amount allowed by Medicare Part
					 B when such service is covered.
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-30 - Family Planning Agency Services › Subsection 144-101-II-30.08 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Family Planning Service providers shall bill for services
						under this Section in accordance with the billing requirements of the
						Department of Health and Human Services, including use of the CMS 1500 claim
						form. For instructions and to download a CMS 1500 sample claim form see the OMS
						"Billing Instructions web page, available at:
http://www.maine.gov/dhhs/oms/providerfiles/billing_instructions.html
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-31 - Federally Qualified Health Center Services › Subsection 144-101-II-31.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
31.01-1
Ambulatory services
are
					 services provided by a federally qualified health center other than those core
					 services described in Section 31.04-1 that are also included in the State's
					 Medicaid Plan and that are provided in accordance with all applicable sections
					 of the
MaineCare Benefits Manual
. This includes dental
					 services provided by dentists, independent practice dental hygienists
					 (effective October 1, 2013, subject to approval by CMS),dental hygienists, and
					 licensed dental entities.
31.01-2
Covered services
are those services described in Section 31.04 for
					 which payment can be made under Title XIX and XXI by the Department of Health
					 and Human Services.
31.01-3
Federally Qualified Health Center (FQHC)
refers to a facility or
					 program that is federally qualified and may also be known as a community health
					 center, migrant health center, or health-care program for the homeless. A
					 center is "federally qualified" if it:
A. is
					 receiving a grant under Section 330 of the
Federal Public Health
					 Service (PHS) Act
;
B. is
					 receiving funding from such a grant under a contract with the recipient of a
					 grant and meets the requirements to receive a grant under Section 330 of the
					 PHS Act;
C. is determined by the
					 Secretary of the Department of Health and Human Services, to meet the
					 requirements for receiving such a grant (look-alike), based on the
					 recommendation of the Health Resources and Services Administration (HRSA)
					 within the Public Health Service;
D. was treated by the Secretary (of Health
					 and Human Services), for purposes of Medicare Part B, as a comprehensive
					 federally funded health center as of January 1, 1990; or
E. is an outpatient health program or
					 facility operated by a tribe or tribal organization under the
Indian
					 Self-Determination Act
or by an urban Indian organization receiving
					 funds under Title V of the
Indian Health Care Improvement
					 Act
.
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-31 - Federally Qualified Health Center Services › Subsection 144-101-II-31.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Individuals must meet the 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.
It is the responsibility of the provider to verify a
						member's eligibility for MaineCare as described in 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 II - Specific Policies By Service › Section 144-101-II-31 - Federally Qualified Health Center Services › Subsection 144-101-II-31.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each Title XIX and Title XXImember 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-31 - Federally Qualified Health Center Services › Subsection 144-101-II-31.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
All services must be provided within the HRSA-approved
						scope of service area, or to HRSA-Designated Medically Underserved Populations
						(MUP) at federally approved center locations such as school-based health
						centers, and be otherwise provided in conformance with Federal
						requirements.
Covered services include core services, and other
						ambulatory services contained in the State's Medicaid plan, and in the FQHC's
						scope of project for base year 1999 as approved by HRSA, and any approved
						change in scope of service as amended, or as specifically approved by the Maine
						Department of Health and Human Services (DHHS). FQHCs must submit their
						HRSA-approved scope of project for base year 1999, or if established after
						1999, for their first year of operation, and all subsequent HRSA-approved
						amendments to scope of project.
31.04-1
Core services
include:
A. services provided by physicians, physician
					 assistants, advanced practice registered nurses, clinical psychologists,
					 licensed clinical social workers, and licensed clinical professional
					 counselors;
B. services and
					 supplies furnished as incident to services of approved and appropriate licensed
					 practitioners. In order for incidental services to be covered, FQHC employees
					 must perform the incidental service, unless it is an FQHC service routinely
					 performed by contracted personnel or providers. Services provided by auxiliary
					 personnel not in the employ of the FQHC, even if provided on the physician's
					 order or included in the FQHC's bill, are not covered as incident to a
					 physician's service. Thus, non-physician diagnostic and therapeutic services
					 that an FQHC obtains, for example, from an independent laboratory, an
					 independent licensed or otherwise qualified provider, or a hospital outpatient
					 department are not covered FQHC services;
C. visiting nurse services (as described in
					 Section 31.04-4 ).
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-31 - Federally Qualified Health Center Services › Subsection 144-101-II-31.05 - NONCOVERED SERVICES

Current through 2024-29, July 17, 2024
Unless the Department specifically approves an additional
						service, covered services are limited to those services HRSA approved in the
						FQHC's scope of project. See Chapter I of the
MaineCare Benefits
						Manual
for additional details on non-covered
						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-31 - Federally Qualified Health Center Services › Subsection 144-101-II-31.08 - COPAYMENT

Current through 2024-29, July 17, 2024
A. Providers will charge a copayment to each
					 MaineCare member receiving services, unless the member is exempt under the
					 provisions of Chapter I of the
MaineCare Benefits Manual
.
					 Effective 8/1/14, no copayment shall be charged for smoking cessation treatment
					 services. The amount of the copayment shall not exceed $3.00 per day for
					 services provided, according to the following schedule:
MaineCare Payment for
								  Service
Member Copayment
$10.00 or less
$ .50
$10.01 - 25.00
$1.00
$25.01 - 50.00
$2.00
$50.01 or more
$3.00
B. The member shall be responsible for
					 copayments up to $30.00 per month whether the copayment has been paid or not.
					 After the $30.00 cap has been reached, the member shall not be required to make
					 additional copayments and the provider shall receive full MaineCare
					 reimbursement for covered services. Providers are subject to the Department's
					 copayment requirements. Refer to Chapter I, "General Administrative Policies
					 and Procedures", for rules governing copayment requirements, exemptions and
					 dispute resolution.
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-31 - Federally Qualified Health Center Services › Subsection 144-101-II-31.09 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Providers billing for FQHC services must bill using
						standard CPT and HCPC procedure codes as detailed in Chapter III, Section 31,
						Table 1. For Core and Ambulatory Services, as described under Covered
						Services-Section 31. 04, providers must bill T1015 and include the appropriate
						revenue codes. When billing, providers must use a UB 04 claim form. Effective
						October 1, 2010, in addition to billing the code T1015 for Core and Ambulatory
						Services, providers must also report all services provided including all
						procedures with the standard CPT and HCPC5 codes on the UB 04 claims form for
						reporting purposes.
In accordance with Chapter I of the
MaineCare
						Benefits Manual
, it is the responsibility of the provider to seek
						payment from other third party payers prior to billing MaineCare for a rendered
						service. If a member has capitated third party coverage other than MaineCare,
						and if that third party carrier requires a member co-pay but makes no
						fee-for-service payment to cover FQHC services, MaineCare reimbursement will be
						limited to the amount of the co-pay alone.
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-32 - Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders (Repealed) › Subsection 144-101-II-32.01 - INTRODUCTION (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 II - Specific Policies By Service › Section 144-101-II-32 - Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders (Repealed) › Subsection 144-101-II-32.02 - DEFINITIONS (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 II - Specific Policies By Service › Section 144-101-II-32 - Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders (Repealed) › Subsection 144-101-II-32.03 - DETERMINATION OF ELIGIBILITY (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 II - Specific Policies By Service › Section 144-101-II-32 - Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders (Repealed) › Subsection 144-101-II-32.04 - COVERED 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 II - Specific Policies By Service › Section 144-101-II-32 - Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders (Repealed) › Subsection 144-101-II-32.05 - POLICIES AND PROCEDURES (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 II - Specific Policies By Service › Section 144-101-II-32 - Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders (Repealed) › Subsection 144-101-II-32.06 - LIMITATIONS (Repealed)

Current through 2024-29, July 17, 2024