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-107 - Psychiatric Residential Treatment Facility Services
Subsection 144-101-II-107.04 - MEMBER ELIGIBILITY
Universal Citation: 10 ME Code Rules ยง 144-101-II-107.04
Current through 2024-52, December 25, 2024
107.04-01 General Eligibility
To access PRTF services, members must meet all the following criteria:
A. Be under the
age of 21.
B. Meets Clinical
Certification of Need (CCON) requirements, as set forth in 107.04-02.
C. The parent or legal guardian, when
applicable has approved of this level of service; and
D. The member meets all other MaineCare
eligibility requirements.
107.04-02 Clinical Certification of Need (CCON) for PRTF Services
A. CCON
Team
1. An independent team consisting of the
following individuals must complete the CCON for each member seeking care in a
PRTF. No member of the team may be employed by or have a consultant
relationship with the admitting PRTF. The team must consist of the following
individuals:
a. A physician;
b. A licensed master's level clinician with
clinical experience in child psychiatry. Eligible provider types include:
i. LCSW;
ii. LCPC;
iii. Psychiatric Mental Health Nurse
Practitioner;
iv. Physician's
Assistant;
c. An
individual with specific knowledge of the member's situation. The
parent/guardian (when applicable) or designee must fill this role. This
individual may be a current provider, family or community member, case manager,
or other individual with relevant knowledge. In the event of multiple
providers, only one individual may be designated to serve this role. The
parent/guardian will have the opportunity to select this individual to serve on
their behalf; and
d. A
representative of the Office of Child and Family Services.
B. Certification Requirements
1. The CCON team must unanimously certify all
the following:
a. The member has an active
psychiatric condition and functional deficits qualifying as a Serious Emotional
Disturbance (SED) meeting the criteria below. The member must be reassessed
annually at minimum (within twelve (12) months of the last determination) by
licensed mental health professional acting within the scope of their licensure
to determine if the member continues to qualify as having an SED:
i. Have a primary diagnosis listed in
Appendix A with a severity specifier of moderate to severe (when applicable)
when applied to the current condition of the youth, as determined by a licensed
mental health professional acting within the scope of their licensure, for the
previous six (6) month period or must be reasonably predicted to last six (6)
months; and
ii. The member must
also consistently and persistently demonstrate behavioral abnormalities to a
significant degree, well outside the normative developmental expectations for
the previous six (6) month period or must be reasonably predicted to last six
(6) months. Behavioral abnormalities cannot be attributed to intellectual,
sensory, or health factors.
iii.
The member must additionally display at a minimum, four (4) of the following
conditions:
a. failure to establish or
maintain developmentally and culturally appropriate relationships with adult
caregivers or authority figures;
b.
failure to demonstrate or maintain developmentally and culturally appropriate
peer relationships;
c. failure to
demonstrate a developmentally appropriate range and expression of emotion or
mood;
d. disruptive behavior
sufficient to lead to isolation in or from school, home, therapeutic, or
recreation settings;
e. behavior
that is seriously detrimental to the youth's growth, development, safety, or
welfare, or to the safety or welfare of others; or
f. behavior resulting in substantial
documented disruption to the family including, but not limited to, adverse
impact on the ability of family members to secure or maintain gainful
employment.
b.
Ambulatory (community-based) resources available in the community, including
Private Non-Medical Institutions (PNMI), do not meet the treatment needs of the
member, as evidenced by one of the following:
i. The youth has behavior that puts the youth
at substantial documented risk of harm to self;
ii. The youth has persistent, pervasive, and
frequently occurring oppositional defiant behavior, aggression, or impulsive
behavior related to the SED diagnosis which represents a disregard for the
wellbeing or safety of self or others; or
iii. There is a need for continued treatment
beyond the reasonable duration of an acute care hospital and documented
evidence that appropriate intensity of treatment cannot be provided in a
community setting.
The member need not have accessed or exhausted all other available services; however, the team must make a determination that these other services are inadequate to meet the member's needs.
c. Treatment of the member's
psychiatric condition requires medical supervision seven days per week and 24
hours per day, on an inpatient basis and under the direction of a physician.
d. Services can reasonably be
expected to improve the member's condition or prevent further regression so
that the services will no longer be needed.
2. Additionally, the CCON team must provide
documentation of the following:
a. Member's
diagnosis or diagnoses;
b. Summary
of present medical finding;
c.
Relevant medical, psychiatric, and behavioral history;
d. Mental and physical functional capacity;
e. Prognoses, to the extent
determinable;
f. The member's
created or updated CANS assessment; and
g. Documentation describing any community
based services previously accessed by the member as well as their efficacy and
challenges faced.
3.
Prior Authorization
a. The CCON documentation
must contain relevant information as described in Sections 107.04-02.B (1-2)
above, which must be submitted for Prior Authorization (PA) to the Department
or the Department's third-party administrator. Prior Authorization is required
for all PRTF services.
4.
Copies of the CCON documentation must be submitted to the PRTF upon the
member's admission, and every 60 days thereafter in accordance with the CCON
process.
C. Duration of
Care
1. PRTF services may continue to be
provided as long as medically necessary as determined by the Treatment Plan and
described in the CCON.
2. The CCON
process must be completed every 60 days to meet federal utilization control
requirements.
3. A continued stay
Prior Authorization (PA) must be completed every 60 days.
Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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