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-45 - Hospital Services › Subsection 144-101-II-45.05 - RESTRICTED SERVICES

Current through 2024-29, July 17, 2024
45.05-1
Whole
					 Blood and Packed Red Blood Cells
Each eligible member may receive as many pints of whole
						blood and packed red blood cells as are medically necessary.
In the case of a MaineCare member who is also receiving
						Title XVIII benefits, MaineCare will pay for the first three pints of blood,
						not covered under Title XVIII.
Whole blood (provided the hospital cannot obtain a
						replacement donation) and packed red blood cells will be reimbursable only for
						each pint administered.
Reimbursement will not be made on the basis of replacing
						two pints of blood for each pint received by the member regardless of whether
						the blood (either fully or partially) is provided from a blood bank or from a
						donor.
45.05-2
Newborn
					 Infants
MaineCare reimburses for services provided to newborn
						infants of MaineCare mothers during the time the mother is hospitalized.
						MaineCare will pay for services to the newborn after the mother is discharged,
						if these services are certified by the physician as being medically necessary
						and the infant is MaineCare eligible.
45.05-3
Abortions, Sterilizations and
					 Hysterectomies
MaineCare will only reimburse hospitals for these
						services if documentation meets the requirements of Chapter II, Section
						90, "Physician
						Services".
45.05-4
Dental Services
Dental services provided in a hospital setting are only
						covered for emergency care or medically necessary to be done in a hospital
						setting.
45.05-5
Private Rooms for Patients with Infectious Diseases
MaineCare will reimburse for private rooms for patients
						with infectious diseases when medically necessary to meet the patient's medical
						needs or to prevent the spread of disease.
The designee of the committee charged with infection
						control must document the medical necessity in the patient's medical record.
						The designee must formally inform the committee of his or her decisions
						regarding assigning private rooms to patients with infectious disease. The
						committee must record the designee's actions in its minutes.
45.05-6
Restricted Physician Services
					 Associated with Hospital Services
Unless prior authorization (PA) has been granted by the
						Department, DHHS will not reimburse hospitals for any costs associated with any
						restricted physician services performed in the hospital, which require PA
						pursuant to Chapter II, Section
						90 ("Physician Services") of this
						Manual. Additionally, all other Section
						90 limitations and restrictions
						apply to Section
						90 services provided in
						hospitals.
45.05-7
Organ Transplant Procedures
Please refer to Chapter II, Section
						90, Appendix A, "Physician
						Services", of this Manual for specific information related to MaineCare
						coverage of and criteria for transplant procedures.
45.05-8
Therapeutic Leave of Absence
					 During Days Awaiting Nursing Facility Placement
Effective April 1, 2013, all hospitals must inform
						patients who are in days awaiting NF placement, in writing, of their right to
						twenty (20) overnight leaves of absence per state fiscal year (July 1st through
						June 30th).
MaineCare will reimburse a hospital to reserve a bed for
						a member on an overnight leave of absence if the following conditions are
						met:
A. The patient's plan of care
					 provides for such an absence;
B.
					 The member takes no more than a total of twenty (20) therapeutic overnight
					 leaves of absence per state fiscal year;
C. The Department is called for prior
					 authorization; and
F. The
					 Department is notified if the member does not return to the facility within the
					 prior authorized leave period.