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-96 - Private Duty Nursing and Personal Care Services › Subsection 144-101-II-96.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
Covered services are available for individuals meeting
						the eligibility requirements set forth in Section
						96.02. Covered
						services must be required in order to maintain the Member's current health
						status, or prevent or delay deterioration of a Member and/or delay long-term
						institutional care. These services require prior approval by the Department, or
						its Assessing Services Agency, and are subject to the limits in Section
						96.03.
Services provided must be reasonable and necessary for
						meeting the medical needs of the individual, based upon the medical record, and
						upon the outcome scores on the MED form, and as authorized in the plan of care.
						Payment will be denied if the services provided are not consistent with the
						Member's authorized plan of care. The Department may also recoup payment for
						inappropriate service provision, as determined through post payment
						review.
For Members age 21 and over, and those under age 21
						receiving care under the family provider service option, and excluding those
						classified for medication services or venipuncture services (Level VI) under
						this Section, the Assessing Services Agency has the authority to determine the
						plan of care, which shall specify all services to be provided, including the
						number of hours for each covered service.
For Members under age 21 at any level of service, as
						well as Level VI and Level VII Members, but excluding those receiving care
						under the family provider service option, the PDN provider shall establish a
						plan of care. The plan of care shall be based upon the Member's assessment
						outcome scores recorded in the Department's Medical Eligibility Determination
						form and the timeframes therein.
Section
						40, "Home Health Services", shall
						not replace or be delivered and reimbursed in lieu of authorized Section
						96 covered services. (Section
						40, "Home Health Services", must
						be delivered and reimbursed pursuant to those rules.)
Covered services under this Section include the
						following:
96.04-1
Private Duty
					 Nursing Services (PDN)
A. PDN services
					 must be provided according to a written plan of care, reviewed and signed by a
					 licensed physician, and available to the Department or the Service Coordination
					 Agency upon request. At least monthly nursing services must be delivered to all
					 Level II and III Members, as well as those Level I Members who are eligible for
					 services based upon the need for monthly nursing services.
B. For individuals age 21 and over, and those
					 under age 21 receiving care under the family provider service option, and
					 excluding those classified for medication services or venipuncture services
					 (Level VI) under this Section, PDN services shall be authorized by the
					 Assessing Services Agency, and ordered and monitored by the Service
					 Coordination Agency, in accordance with the authorized plan of care for covered
					 services under this Section.
C. For
					 individuals under age 21, as well as all individuals classified for
					 venipuncture services or medication services for the severely mentally disabled
					 (Level VI), and excluding those receiving care under the family provider
					 service option, the Department shall classify the Member based on the plan of
					 care developed by the provider, subject to the process described under Section
					 96.06.
D. Nursing services may be provided by:
1. an independently practicing registered
					 professional nurse;
2. a registered
					 professional nurse or licensed practical nurse employed by, or under contract
					 with, a licensed home health agency.
E. Except as allowed in Section 96.04-1(F)
					 below, nursing services shall not be covered when provided by the Member's
					 husband or wife, natural or adoptive parent, child, or sibling, stepparent,
					 stepchild, stepbrother or stepsister, father-in-law, mother-in-law, son-in-law,
					 daughter-in-law, brother-in-law, sister-in-law, grandparent or grandchild,
					 spouse of grandparent or grandchild or any person sharing a common abode as
					 part of a single family unit.
F.
					 "Special circumstances nursing" allows a relative, including a spouse or the
					 parent of a minor child, to be paid to provide nursing services to the Member
					 under this Section. To qualify for this coverage the Member's relative must
					 meet the requirements in (1) and (2) below.
1. The relative must: (all of the following
					 are required)
a. meet all licensing,
					 training, reporting and other requirements otherwise specified in this Section;
					 and
b. be employed by a licensed
					 home health agency; and
c. abide by
					 the requirement that an independent nurse or physician must conduct any
					 required assessments and/or develop the plan of care; and
d. implement the Member's authorized plan of
					 care; and
e. if applicable, expect
					 to continue non-reimbursed family caregiver responsibilities; and
f. pass a criminal background check. The
					 family nursing provider must not have any criminal convictions, except for
					 Class D and Class E convictions over 10 years old that did not involve as a
					 victim of the act a patient, client, or resident of a health care entity; or
					 any specific documented findings by the State Survey Agency of abuse, neglect,
					 or misappropriation of property of a resident, client, or
					 patient.
2. The relative
					 must: (one of the following is required)
a.
					 have resigned from full-time or part-time employment specifically to provide
					 PDN services to the Member; or
b.
					 have changed from full-time employment to part-time employment resulting in
					 less compensation in order to provide PDN services to the Member; or
c. have taken a leave of absence without pay
					 from employment in order to provide PDN services to the Member;
d. have incurred substantial expenses by
					 providing PDN services to the Member; or
e. be needed to provide an adequate number of
					 qualified nurses to meet the Member's plan of care because of labor conditions
					 or intermittent hours of care.
To apply for coverage under this Section, contact the
						Director, Office of Aging and Disability Services, 11 State House Station,
						Augusta, ME 04333-0011.
G. Multiple patient nursing services are for
					 nursing services (RN, LPN, and Independent RN) throughout this Section. The
					 multiple patient procedure codes and modifiers must be used whenever it is
					 determined (by the home health agency, the Department, or the Department's
					 authorized entity, whichever has authority to authorize the Member's plan of
					 care) to be safe and appropriate for one nurse to provide nursing services to
					 more than one patient in the same home or building, during the same visit and
					 it is specified in each Member's plan of care. Providers must bill with the
					 Chapter III procedure codes and modifiers designated for multiple
					 patients.