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-65 - Behavioral Health Service › Subsection 144-101-II-65.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
Definitions for the purposes of Section
						65 are as follows:
65.01-1
American Society of Addiction
					 Medicine Criteria (ASAM)
is level of care criteria establishing what
					 services are medically necessary for a member.
65.01-2
Affected Other
is an
					 individual with a demonstrated Family relationship with a member whose
					 substance use has led to clinically significant impairment or distress for the
					 individual. In order for an Affected Other to participate in Family therapy,
					 there must be a family relationship with a MaineCare eligible member. Affected
					 Others seeking individual therapy must have MaineCare coverage
					 themselves.
65.01-3
Authorized Entity
is an organization authorized by the Department
					 of Health and Human Services (DHHS) to perform specified functions pursuant to
					 a signed contract or other approved signed agreement.
65.01-4
Best Practices
are
					 treatment techniques, procedures and protocols described in detail where the
					 effectiveness of these practices has been established through consensus among
					 experts in the field. Key portions of these practices have been documented in
					 research studies to be effective in selected treatment settings.
65.01-5
Central Enrollment
is a
					 process of determining baseline eligibility for behavioral health
					 treatment.
65.01-6
Certified
					 Clinical Supervisor
(CCS) is a Clinician who is credentialed by the
					 Maine State Board of Alcohol and Drug Counselors, 02-384 CMR chapter 6, and
					 must conduct supervision as defined in the regulations for Licensing/Certifying
					 of Substance Abuse Programs, 14-11 8 CMR chapter 5, section 11, in the State of
					 Maine.
65.01-7
Certified
					 Employment Specialist
means an individual who has completed an
					 Association of Community Rehabilitation Educators (ACRE) approved course, or
					 other employment specialist training approved by DHHS and who maintains
					 certification.
65.01-8
Certified Intentional Peer Support Specialist (CIPSS)
means an
					 individual who has completed the DHHS Office of Behavioral Health (OBH)
					 curriculum for CIPSS and receives and maintains certification.
65.01-9
Child
is a person
					 between the ages of birth through twenty (20) years of age. Children aged
					 eighteen (18) through twenty (20) years of age and children who are emancipated
					 minors may choose to receive children's mental health services or adult mental
					 health services, both of which are covered under this Section, whichever best
					 meets their individual needs.
65.01-10
Child and Adolescent
					 Functional Assessment Scale (CAFAS)
is a multi-dimensional rating scale,
					 which assesses a member's degree of impairment in day-to-day functioning due to
					 emotional, behavioral, psychological, psychiatric, or substance use
					 problems.
65.01-11
Clinician
is an individual appropriately licensed or certified in
					 the state or province in which he or she practices, practicing within the scope
					 of that licensure or certification, and qualified to deliver treatment under
					 this Section. A Clinician includes the following: Licensed Clinical
					 Professional Counselor (LCPC); Licensed Clinical Professional
					 Counselor-Conditional (LCPC-C); Licensed Clinical Social Worker (LCSW);
					 Licensed Master Social Worker- Conditional Clinical (LMSW-CC); Licensed
					 Marriage and Family Therapist (LMFT); Licensed Marriage and Family
					 Therapist-Conditional (LMFT-C); Licensed Alcohol and Drug Counselors (LADC),
					 Certified Alcohol and Drug Counselors (CADC); Physician; Psychiatrist; Advanced
					 Practice Registered Nurse Psychiatric and Mental Health Practitioner
					 (APRN-PMH-NP); Advanced Practice Registered Nurse Psychiatric and Mental Health
					 Clinical Nurse Specialist (APRN-PMH-CNS); Psychological Examiner; Physician
					 Assistant (PA); Registered Nurse (RN) or Licensed Clinical
					 Psychologist.
65.01-12
Community Inclusion
means the participation of a member in typical
					 community activities that are both age and developmentally appropriate and are
					 identified in the Individualized Treatment Plan (ITP).
65.01-13
Comprehensive
					 Assessment
is an integrated evaluation of the member's medical and
					 psycho-social needs, including co-occurring mental health and substance use
					 needs to determine the need for treatment and/or referral, and to establish the
					 appropriate intensity and level of care.
65.01-14
Continuing Education Unit
					 (CEU)
is a measure used in continuing education programs, particularly
					 those required in a licensed profession. The Maine Department of Education
					 recognizes CEUs as approved continuing education credits that teachers,
					 education technicians and others can apply to licensure or certification
					 requirements. DOE recognizes 4.5 CEUs as equal to 3 semester hours.
65.01-15
Co-occurring Capable
					 Providers
are organized to welcome, identify, engage, and serve members
					 with co-occurring mental health and substance use disorders, and to incorporate
					 attention to these issues in all aspects of Co-occurring Services including
					 linkage with other providers, staff competency and training. Clinicians must
					 practice within the scope of their individual license(s) and follow all
					 applicable mental health and substance use regulations in regard to member
					 records including, but not limited to Comprehensive Assessments, Individualized
					 Treatment Plans (ITP) and progress notes.
65.01-16
Co-occurring Disorders
are any combination of a mental health and substance use disorder
					 diagnosis.
65.01-17
Co-occurring Services
are integrated services provided to a member
					 who has both a mental health and a substance use disorder diagnosis. This
					 includes persistent disorders of either type in remission; a substance related
					 or induced mental health disorder and a diagnosable disorder that co-occurs
					 with interacting symptoms of the other disorder.
When mental health and substance use disorder diagnoses
						occur together, each is considered primary and is assessed, described and
						treated concurrently. Co-occurring Services consist of a range of integrated,
						appropriately matched interventions that may include Comprehensive Assessment,
						treatment and relapse prevention strategies that may be combined, when possible
						within the context of a single treatment relationship. Co-occurring Services
						also include addressing Family therapy or counseling issues involving mental
						health, substance use or other disorders where MaineCare services cover Family
						therapy or counseling.
65.01-18
Diagnostic
					 Classification of Mental Health and Developmental Disorders of Infancy and
					 Early Childhood
(also known as DC 0-5), is the current version
					 published by Zero To Three: National Center for Infants, Toddlers and Families.
					 The publication formulates categories for the classification of mental health
					 and development disorders manifested early in life.
65.01-19
Diagnostic and
					 Statistical Manual of Mental Health Disorders
(DSM) is the
					 current version published by the American Psychiatric Association. The manual
					 is used to classify mental health diagnoses and provide standard categories for
					 definition of mental health disorders.
65.01-20
Evidence Based
					 Practices
(Practices Based on Scientific Evidence) are prevention or
					 treatment practices that are based on consistent scientific evidence
					 demonstrating that the treatment improves member outcomes. Elements of the
					 practice are standardized, replicable and effective within a given setting and
					 for particular populations and diagnosis or behavior. The practice is
					 sufficiently documented through research to permit the assessment of fidelity
					 to the model. As a result, the degree of successful implementation of the
					 service can be measured by the use of a standardized fidelity tool that
					 operationally defines the essential elements of practice. There must be no
					 clinical or empirical evidence or theoretical basis indicating that the
					 treatment constitutes a substantial risk of harm to those receiving the
					 treatment, compared to its likely benefits.
65.01-21
Family,
unless
					 otherwise defined in this Section, means the primary caregiver(s) in a member's
					 daily life (which may include a biological or adoptive Parent, foster Parent,
					 legal guardian or designee), a spouse or significant other, biological or
					 adoptive Child, foster Child, stepchild, significant other's child, sibling,
					 stepparent, stepbrother or stepsister, brother-in-law, sister-in-law,
					 grandparent, spouse of grandparent or grandchild, a person who provides Kinship
					 Care, or any person sharing a common abode as part of a single-Family
					 unit.
65.01-22
Functional
					 Behavior Assessment (FBA)
is a process of gathering information from
					 multiple sources to hypothesize and understand what reliably predicts and
					 maintains a problem behavior. The FBA evaluates behavior to analyze the
					 antecedent and consequence as a reinforcement of a problem behavior. Behaviors
					 are defined in measurable terms. The FBA uses a validated assessment which may
					 also include interview, direct and/or indirect observation in the member's
					 natural environment, functional analysis, preference assessment, assessment of
					 reinforcement effectiveness, data collection, and reporting. The FBA will be
					 used for the purpose of developing individualized Positive Behavior Support
					 Plans for members receiving Developmental Disability and Behavioral Health
					 Intensive Outpatient Program (DD/BH-IOP) Services.
65.01-23
Functional Family Therapy
					 (FFT)
is a Family strengths-based clinical assessment and intervention
					 model built on a foundation of acceptance and respect. FFT addresses risk and
					 protective factors within and outside of the Family that impact adolescents and
					 their adaptive development the ages of eleven (11) and eighteen (18). FFT
					 consists of five major components: engagement, motivation, relational
					 assessment, behavior change, and generalization. The intervention averages
					 eight (8) to twelve (12) sessions for mild to moderate needs and up to thirty
					 (30) sessions for members with complex needs. Services include face-to-face or
					 telehealth sessions with adolescent and/or Family members, telephone outreach
					 and team meetings that include adolescent and or Family members. FFT must
					 maintain treatment integrity and meet fidelity criteria developed by FFT, LLC.
					 FFT therapists must be certified by FFT, LLC.
65.01-24
Imminent Risk
is the
					 immediate risk of a Child's removal from the home and/or community due to the
					 specific circumstances as described in Children's Home and Community Based
					 Treatment.
65.01-25
Individualized Treatment Plan (ITP)
is a plan of treatment based
					 on a Comprehensive Assessment developed by a Clinician.
65.01-26
Kinship Care
is the
					 full-time care, nurturing, and protection of members by relatives, members of
					 their tribes or clans, godparents, stepparents, or any adult who has a kinship
					 bond with a Child.
65.01-27
Medically Necessary Services
are services provided as described in
					 Section
					 65.06 Covered
					 Services and as defined in Chapter I, Section 1 of the
MaineCare
					 Benefits Manual
.
65.01-28
MHRT/C
means an individual who has received Mental Health
					 Rehabilitation Technician/Community certification from DHHS.
65.01-29
Multi-Systemic Therapy
					 (MST)
is an intensive Family-based treatment that addresses the
					 determinants of serious disruptive behavior in members and their families. It
					 is a short-term treatment approach that usually takes three (3) to six (6)
					 months. The treatment typically includes three (3) to six (6) hours/week of
					 clinical treatment. MST is a manualized, researched practice with a strong
					 evidence base: MST therapist must be highly accessible to members, and
					 typically provide twenty-four (24) hour a day, seven (7) days a week coverage
					 for members which may include non face-to-face and telephonic collateral
					 contact. Outcomes are evaluated continuously. MST services must maintain
					 treatment integrity and meet the fidelity criteria developed by MST Services,
					 Inc. MST therapists must be certified by MST Services, Inc.
					 (http://www.mstservices.com). MST-Problem Sexualized Behavior (MST-PSB)
					 includes additional training and supervision in addition to standard MST
					 protocols.
65.01-30
NTA/Psychometrician
is a Neurobehavioral Testing
					 Assistant/Psychometrician. Psychometrics is the field of study concerned with
					 the theory and technique of psychological measurement, which includes the
					 measurement of knowledge, abilities, attitudes, personality traits, and
					 education.
65.01-31
Natural
					 Supports
include the relatives, friends, neighbors, and community
					 resources that a member or Family goes to for support. They may participate in
					 the treatment team but are not MaineCare reimbursable.
65.01-32
Opioid Treatment Program (OTP)
					 with Methadone Services
are services provided by a program or
					 practitioner engaged in opioid use disorder treatment of individuals that
					 include the dispensing of an opioid agonist treatment medication (i.e.,
					 methadone), along with a comprehensive range of medical and rehabilitative
					 services, when clinically necessary, to an individual to treat the adverse
					 medical, psychological, or physical effects related to opiate addiction.
					 Compliance with Federal and State laws and regulations that govern treatment,
					 including, but not limited to, DHHS, Office of Behavioral Health, the Center
					 for Substance Abuse Treatment (Division of the Substance Abuse and Mental
					 Health Services Administration), the US Drug Enforcement Agency, the US Food
					 and Drug Administration, and the State Pharmacy Board is required in the
					 provision of services.
65.01-33
Parent or Guardian
may be the biological, adoptive, or foster
					 Parent or the legal guardian. They may participate in the treatment team but
					 are not MaineCare reimbursable.
65.01-34
Parental Participation
means that the Parent or caregiver is involved in the treatment team;
					 participates in the assessment process; and helps develop the ITP for the
					 purpose of the design, delivery, and evaluation of treatment specific to the
					 member's mental health needs. The Parent or caregiver participates in treatment
					 and models and reinforces skills learned.
65.01-35
Permanency
means that a
					 member lives in a planned living arrangement either with a Parent or other
					 caregiver and can return to the Parent or caregiver from a stay in a hospital,
					 a residential treatment or correctional facility.
65.01-36
Positive Behavior Support Plan
					 (PBSP)
includes individualized, strengths-based strategies based on
					 positive reinforcement techniques that are designed to increase a member's use
					 of prosocial and positive behaviors and decrease negative or detrimental
					 behaviors. The PBSP summarizes the findings of the Functional Behavioral
					 Assessment and is used for the purpose of developing individualized strategies
					 for members receiving DD/BH IOP Services.
65.01-37
Practice Methods
shall
					 mean treatment techniques, procedures, therapeutic modalities, and protocols.
					 For example, a practice method is Dialectical Behavior Therapy or Cognitive
					 Behavioral Therapy.
65.01-38
Preschool and Early Childhood Functional Assessment Scale (PECFAS)
is a multi-dimensional rating scale that assesses the psychosocial functioning
					 of members aged three (3) to seven (7) years.
65.01-39
Prior Authorization
					 (PA)
is the process of obtaining prior approval as to the medical
					 necessity and eligibility for a service.
65.01-40
Promising and Acceptable
					 Treatment
is defined as treatment that has a sound theoretical basis in
					 generally accepted psychological principles. There must be substantial clinical
					 literature to indicate the value of the treatment with members who experience
					 the diagnostic problems and behaviors for which this treatment is needed. The
					 treatment is generally accepted in clinical practice as appropriate for use
					 with members who experience these diagnostic problems and behaviors. There must
					 be no clinical or empirical evidence or theoretical basis indicating that the
					 treatment constitutes a substantial risk of harm to those receiving it,
					 compared to its likely benefits. The treatment must have a book, manual, or
					 other available writing that specifies the components of the treatment protocol
					 and describes how to administer it. An individual, who has been certified in
					 the provision of the Promising and Acceptable treatment, if such certification
					 exists, must provide services. The existence of a certification standard for a
					 treatment does not, by itself, indicate that the treatment meets the standard
					 for a Promising and Acceptable treatment.
65.01-41
Serious Emotional Disturbance
					 (SED)
is when a member has a mental health and/or a co-occurring
					 substance use disorder diagnosis, emotional or behavioral diagnosis, in
					 accordance with the current version of the
Diagnostic and Statistical
					 Manual of Mental Disorders
(DSM), that has lasted for or can be
					 expected to last for at least one (1) year, which has resulted in functional
					 impairment that substantially interferes with or limits the child's role or
					 functioning in family, school, or community activities. Youth with SED may be
					 at risk for more restrictive placement, including but not limited to,
					 psychiatric hospitalization, as a result of this condition for which other less
					 intensive levels of service have not been effective (e.g. traditional
					 outpatient services).
65.01-42
Serious and Persistent Mental Illness
means a mental health
					 condition had by a person who is age eighteen (18) or older or is an
					 emancipated minor with:
1. A primary diagnosis
					 of Schizophrenia or Schizoaffective disorder in accordance with the current
					 version of the
Diagnostic and Statistical Manual of Mental
					 Disorders
(DSM); or
2.
					 Another primary mental health diagnosis in accordance with the current version
					 of the DSM, with the exception of Neurocognitive Disorders, Neurodevelopmental
					 Disorders, Antisocial Personality Disorder and Substance Use Disorders, who:
a) has a written opinion from a Clinician,
					 based on documented or reported history, stating that he/she is likely to have
					 future episodes, related to mental illness, with a non-excluded DSM diagnosis,
					 that would result in or have significant risk factors of homelessness, criminal
					 justice involvement or require a mental health inpatient treatment greater than
					 seventy-two (72) hours, or residential treatment unless community support
					 services and/or evidence based outpatient treatment is provided; based on
					 documented or reported history(an oral or written history obtained from the
					 member, a provider, or a caregiver); or
b) has received treatment in a state
					 psychiatric hospital, within the past 24 months, for a non-excluded DSM
					 diagnosis; or
c) has been
					 discharged from a mental health residential facility, within the past 24
					 months, for a non-excluded DSM diagnosis; or
d) has had two or more episodes of inpatient
					 treatment for mental illness, for greater than seventy-two (72) hours per
					 episode, within the past twenty-four (24) months, for a non-excluded DSM
					 diagnosis; or
e) has been committed
					 by a civil court for psychiatric treatment as an adult; or
f) until the age of twenty-one (21), was
					 eligible as a Child with serious emotional disturbance, and has a written
					 opinion from a Clinician, in the last twelve (12) months, stating that he/she
					 has risk factors for mental health inpatient treatment or residential
					 treatment, unless ongoing case management or community support services are
					 provided;
AND
3. Has
					 significant impairment or limitation in adaptive behavior or functioning
					 directly related to the primary diagnosis and defined by the Level of Care
					 Utilization System (LOCUS, as defined in Chapter II, Section
					 17 of the
MaineCare
					 Benefits Manual
), or other acceptable standardized assessment tool
					 adopted by the Department through rulemaking and administered at least
					 annually. If using the LOCUS, the member must have a LOCUS score, as determined
					 by a LOCUS Certified Assessor, of seventeen (17) (Level III) or
					 greater.