1.06-1
Covered Services
All covered services reimbursable by MaineCare must be
medically necessary and described in the MBM. MaineCare members are eligible
for as many covered services as are medically necessary and within the
limitations outlined in applicable sections of this Manual. The Department
reserves the right to require additional medical opinions or evaluations by
appropriate professionals of its choice concerning medical necessity or
expected therapeutic benefit of any requested service.
Covered services include those services described in
other Chapters of this Manual and other medically necessary health care,
diagnostic services, treatment, and other measures, as required by the
Omnibus Reconciliation Act of 1989.
These services are intended to correct or ameliorate
defects and physical and mental illnesses and conditions discovered by the
screening services described in the Manual sections applicable to EPSDT for
members under age twenty-one (21), whether or not such services are (otherwise)
covered under the Medicaid State Plan as long as they would otherwise be
federally allowable under the State Plan.
1.06-2
Interpreter Services
A. Providers must ensure that MaineCare
members are able to communicate effectively with them regarding their medical
needs. MaineCare will reimburse providers for interpreters required for limited
and non-English speaking members and/or deaf/hard of hearing members, when
these services are necessary and reasonable to communicate effectively with
members regarding health needs. Interpreter services can only be covered in
conjunction with another covered MaineCare service or medically necessary
follow-up visit(s) to the initial covered service.
MaineCare will pay for two (2) interpreters for deaf
MaineCare members who use a sign language other than American Sign Language or
who use a unique non-spoken method of communication and require a relay
interpreting team including a deaf interpreter working with a hearing
interpreter.
B. Family
members or personal friends may be used as interpreters, but cannot be paid.
"Family" means any of the following: 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.
Family members or friends, with the exception of those
individuals under the age of 18, may be used as non-paid interpreters
if:
1. requested by the member; and
2. the use of this friend or
family member does not compromise the effectiveness of services or violate the
member'sconfidentiality; and
3. the
member is advised that an interpreter is available at no charge to the
member.
C. If a paid
interpreter is hired, providers can select the interpreter. However, should the
interpreter provide transportation to the member, MaineCare will not reimburse
the interpreter for transporting the member while concurrently billing for
interpreter services. All interpreter services must be provided in accordance
with the Americans with Disabilities Act.
D. A provider may not bill MaineCare for an
interpreter service supplied by an entity in which the provider, any owner of
the provider, or an immediate family member of the provider or any of its
owners has any direct or indirect ownership or financial interest, unless:
1. The provider also reimburses other
entities for the provision of interpreter services; and 2. The entity providing
the interpreting service makes those services commercially available to
MaineCare providers or other businesses that do not share a direct or indirect
familial ownership interest with the interpreting entity.
E. When providers request reimbursement for
any interpreter services, the services must be included in the member record.
Documentation must include a statement verifying the interpreter
qualifications, date, time and duration of service, language used, the name of
the interpreter, and the cost of performing the service.
F. Providers are responsible for ensuring
that interpreters protect patient confidentiality and adhere to an interpreter
code of ethics. Providers shall document that interpreters have provided
evidence of having read and signed a code of ethics for interpreters equivalent
to the model included as Appendix #1. This shall be deemed as compliance with
this requirement.
G. Providers of
interpreter services must be licensed by the Maine Department of Professional
and Financial Regulation as Certified Interpreters/Transliterators, Certified
Deaf Interpreters, Limited Interpreters/Transliterators, or as Limited Deaf
Interpreters.
H. Providers must use
the following code when billing for interpreter services for deaf/hard of
hearing members and non-English speaking members:
T1013 Sign language or oral interpreter
services per fifteen minutes.
The actual billable amount should be the lesser of the
interpreter's usual and customary charge and the rate authorized by the
Department.
Any other codes for interpreter services listed in the
specific service sections of the MBM are no longer valid.
I. Providers may use language interpreter
services conducted via telephone or other audio/video means. These services may
come from local resources, national language interpreter services such as
LanguageLine Solutions or comparable services. Wherever feasible, providers
should use local and more cost-effective interpreter services.
When billing for language interpreter services conducted
via telephone or other audio/video means, providers should use the T1013
procedure code with a GT modifier and include copies of the invoice with the
claim. Reimbursement is by invoice.
J.
Exceptions and Limitations
1. Hospitals, ICF/IID Intermediate Care
Facility for Individuals with Intellectual Disabilities, and nursing facilities
may not bill separately for either language or deaf/hard of hearing interpreter
services. For hospitals, ICF/IIDs, and nursing facilities, these costs will be
allowable and are included in the calculation of reimbursement.
2. The Department will not pay for
interpreter services when there is a primary third party payer if the primary
third party payer is required to cover the interpreter services.
3. The Department will not reimburse for
interpreter travel time or wait time.
1.06-3
Presumptive Eligibility for
Services for Pregnant Women
A.
Presumptive eligibility can only be determined by qualified providers. The term
"qualified provider" is defined in
42 U.S.C. §
1396r-1. Examples of qualified providers to
determine eligibility are: Federally Qualified Health Centers; Indian Health
Centers; Rural Health Clinics; Family Planning Agencies; WIC Agencies.
B. Pregnancy-related services are
those services that are necessary for the health of the pregnant woman or
fetus, or that have become necessary as a result of the woman having been
pregnant.
1.06-4
Non-Covered Services
A. MaineCare
will not reimburse for non-covered services. Providers may bill members for
non-covered services only if, prior to the provision of the service, the
provider has clearly explained to the member that MaineCare does not cover the
service and that the member will be responsible for the payment. Providers must
document in the member's record that the member was told, prior to provision,
that the service was not a MaineCare covered service and that the member is
responsible for the payment.
B. The
following services are considered non-covered services. Costs for these
non-covered services are not reimbursable by MaineCare, or by the member unless
the notification requirements described in Section 1.06-4(A) have been met.
MaineCare does not reimburse for:
1. Services not described in the MBM, or
related Principles of Reimbursement;
2 Experimental procedures or drugs not
approved by the Food and Drug Administration (FDA);
3. Services that are primarily custodial
care, respite care, socialization, academic, religious, vocational, or
educational, unless specifically permitted elsewhere in this Manual including:
a.
Custodial Services
Custodial Services are any services, or components of
services, of which the basic nature is to provide custodial
care.
b.
Socialization
or Recreational Services
Socialization or recreational services are any services,
or components of services, of which the basic nature is to provide
opportunities for socialization, or those activities that are solely
recreational in nature. These non-covered services include, but are not limited
to picnics, dances, ball games, parties, field trips, and social clubs.
c.
Academic/Educational
Services
Any services or components of service provided to
members that are academic or educational in nature. Academic services include,
but are not limited to, those traditional subjects such as science, history,
literature, foreign languages, and mathematics.
d.
Vocational
Services
Vocational services include organized programs such as
vocational skills training, or sheltered employment, that prepare individuals
for paid or unpaid employment.
4. Services that have prerequisites that have
not been met as defined in the appropriate section of the MBM, including prior
authorization and medical eligibility requirements;
5. Any items or services that have been
purchased elsewhere that are required to be purchased through a volume purchase
agreement between the state and a provider;
6. Services provided without a pre-admission
screening and/or concurrent review as required by the Department;
7. Services provided by a psychiatric
facility, institution for mental diseases, or institutional service provided
for members age twenty-one (21) to sixty-five (65). No federal financial
participation is available for these services or this population;
8. Administrative tasks, including
verification of MaineCare eligibility, updating member contact information,
scheduling of appointments, tasks performed for the provider's own
administrative purposes, and similar activities. Certain administrative tasks
may be covered when described in the appropriate Section of the MBM; and 9. Any
other services not provided in conformance with the requirements of this
Manual.
C.
Coverage Limitations Associated with Managed Care
MaineCare will not cover the cost of services denied by
a managed care plan when the service was denied because the member did not
comply with the plan's requirements. When a member receives services not in
compliance with the managed care plan, the member is responsible for paying for
those services. Examples of member non-compliance include but are not limited
to, failure to obtain the necessary referral from the managed care plan or
receiving services from a provider that does not participate in the managed
care plan. This applies both to MaineCare managed care benefits and private
managed care plans. There is an exception for members with emergency medical
conditions that are screened, stabilized, and transferred as required by
federal law.
Providers of MaineCare Managed Care services, as noted in
Chapter VI Primary Care Case Management, must have a referral from the member's
primary care provider site prior to the member visit. Certain services are
exempt from needing a referral from the primary care provider and are outlined
under Chapter VI, Section 1, Primary Care Case Management, Section
1.05.
D.
Request for Rule Change
or New Rules for MaineCare Coverage of Non-Covered Services
1. When a member or provider requests
authorization for MaineCare coverage of a service not currently covered by
MaineCare, that request will be denied (see exception in Section E, for members
with EPSDT). The individual or group making the request may contact MaineCare
Services, Director, Division of Policy, to request a formal review of a
proposed new service. Appropriate staff will then review the request.
2. MaineCare Services will
consider, but is not obligated to cover, health interventions within the
specified service sections if they meet all of the following outcome criteria:
a. The intervention is for a medical
condition;
b. There is sufficient
evidence to draw conclusions about the effects of the intervention on health
outcomes;
c. The evidence
demonstrates that the intervention can be expected to produce its intended
effects on health outcomes;
d. The
intervention's expected beneficial effects on health outcomes outweigh its
expected harmful effects; and
e.
The intervention is the most cost-effective method available to address the
medical condition.
3. Key
definitions to support the above statements are:
a. Medical Condition: A disease, an illness,
or an injury. A biological or psychological condition that lies within the
range of normal human variation is not considered a disease, illness, or
injury.
b. Health Outcomes:
Outcomes of medical conditions that directly affect the length or quality of a
person's life.
c. Sufficient
Evidence: Evidence is considered to be sufficient to draw conclusions if it is
peer reviewed, is well controlled, directly or indirectly relates the
intervention to health outcomes, and is reproducible both within and outside of
research settings.
d. Health
Intervention An activity undertaken for the primary purpose of preventing,
improving, or stabilizing a medical condition. Activities that are not
considered health interventions include those that are primarily custodial, or
part of normal existence, or undertaken primarily for the convenience of the
patient, family, or practitioner.
e. Cost: An intervention is considered cost
effective if there is no other available intervention that offers a clinically
appropriate benefit at a lower cost.
E. As described in Section
1.14, the Department
shall take all reasonable and necessary steps to ensure that all requests for
prior authorization of services for MaineCare members receiving EPSDT that are
determined to be non-covered under this Manual, be considered for coverage
under EPSDT, prior to being denied as non-covered.
1.06-5
Broken Appointments
Providers may not bill members for broken appointments,
even if providers advised members prior to the service. However, providers may
refuse to continue to see members who have repeatedly broken appointments
without prior notice. In such situations, providers must provide prior notice
of office policies concerning no-shows to members before refusing to continue
to see those members.
1.06-6
Rental Equipment
Members for whom the Department is renting medical
equipment (for example, certain wheelchairs or C-PAPs) are required to return
the equipment following the end of the authorization period.