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-19 - Home and Community Benefits for the Elderly and Adults with Disabilities
Subsection 144-101-II-19.04 - COVERED SERVICES

Universal Citation: 10 ME Code Rules ยง 144-101-II-19.04

Current through 2024-38, September 18, 2024

All covered services must be provided in accordance with all state and federal laws, including but not limited to requirements in 42 C.F.R. § 441.301(c). Covered services are available for members meeting the eligibility requirements set forth in Section 19.02. 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 avoid long-term institutional care. Services under this Section require prior approval by the Department, or its Assessing Services Agency (ASA), and are included in the calculation of the member's program cap. Services shall not be reimbursed until both medical and financial MaineCare eligibility have been approved. Members who meet the eligibility requirements for services under this Section are eligible for the following services, as included by the ASA in the Authorized Plan of Care:

19.04-1 Assistive Technology Device and Services means devices and services that are used to increase, maintain, or improve a member's functional capabilities to perform Activities of Daily Living or Instrumental Activities of Daily Living. An Assistive Technology Device may include an item, piece of equipment or product, whether acquired commercially, modified, or customized. An Assistive Technology Service means a service that directly assists a member in the selection, acquisition, or use of an Assistive Technology Device.

Assistive Technology Services include:

A. services consisting of purchasing, leasing, or otherwise providing for the acquisition of Assistive Technology devices for members; and

B. services consisting of selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing Assistive Technology device.

This service will only be authorized when the requested equipment and supplies are medically necessary, improve or maintain the member's level of independence, ability to access needed supports and services in the community or if required to ensure a member's health and welfare. All other reimbursement of Assistive Technology must be explored and utilized, including all Medicaid State Plan services, prior to reimbursement of Assistive Technology services under this Section. Documentation must describe how the member's expected use, purpose and intended place of use have been matched to features of the products requested in order to achieve the desired outcome in an efficient and cost-effective manner.

Examples of items that may be covered are voice-activated, motion-activated and electronic devices, communication devices and mobility devices.

Vehicle modifications are excluded under this Section. Examples of other items that are excluded are recreation or quality of life items, such as televisions, microwave ovens and other general household appliances.

This need maybe identified by the ASA at the time of assessment or upon a service need referral by the Service Coordination Agency (SCA), subject to the service limits of this Section. The SCA will make a referral to the Waiver Services Provider (WSP), who will be responsible for the coordination, implementation and oversight of the service. A thorough evaluation of all Assistive Technology will be completed prior to service delivery by the WSP and Assistive Technology consultants, if appropriate.

19.04-2 Assistive Technology-Remote Monitoring means real time remote support monitoring of the member with electronic devices to assist them to remain safely in their homes. Remote monitoring services may include a range of technological options including in-home computers, sensors, and video camera linked to a provider that enables 24/7 monitoring and/or contact as necessary.

Final approval for remote monitoring must be made by the Department, Office of Aging and Disability Services upon a recommendation by the ASA or SCA. In making such a recommendation the ASA or the SCA must consider and document the following information:

A. number of hospitalizations in the past year;

B. use of emergency room in the past year;

C. history of falls in the last six months resulting in injury;

D. member lives alone or is home alone for significant periods of time;

E. service access challenges and reasons for those challenges;

F. history of behavior indicating that a member's cognitive abilities put them at a significant risk of wandering; and

G. other relevant information for the request.

A thorough evaluation of all Assistive Technology will be completed prior to service delivery by the WSP and appropriate Assistive Technology consultants. The member's record must document the member's consent and commitment to the Assistive Technology plan elements including all assistive communication, environmental control and safety components. The provider will comply with all federal, state and local regulations that apply to its business including but not limited to "Electronic Communications Privacy Act of 1986." Any services that use networked services must comply with Health Insurance Portability and Accountability Act requirements.

Use of remote monitoring requires sufficient Back Up Plans and the SCA will be responsible for ensuring that the member has at least two adequate back-up plans prior to making a referral to the WSP for this service.

19.04-3 Assistive Technology-Transmission means transmission of data for use of an Assistive Technology Device, Assistive Technology Service, and/or Remote Monitoring via internet or cable utility.

19.04-4 Care Coordination Services are services provided by the SCA (through the care coordinator) to help the member access services in the Authorized Plan of Care. Care Coordination Services require the SCA to engage in Person-Centered Planning. Care Coordination Services assist members in receiving appropriate, effective, and efficient services, which allows the member to retain or achieve the maximum amount of independence possible and desired. Care Coordination Services are designed to assist the member with identifying immediate and long-term needs so that the member is offered choices in service delivery based on his or her needs, preferences, and goals.

A. Responsibilities of the Service Coordination Agency
1. Making initial contact with the member or the responsible party, by telephone or other appropriate method, within two (2) business days of notification of authorization by the ASA of Care Coordination Services to discuss the Authorized Plan of Care, service delivery options, choice of provider(s), preferred frequency of service delivery based on the member's needs consistent with the timeframe of the service authorization (i. e. weekly/monthly), clarify issues, and answer questions;

2. Ensuring implementation of the Authorized Plan of Care and coordinating service providers who are responsible for delivering services, by making referrals and providing Service Orders to qualified service provider(s) the member chooses; or if the member chooses the Participant-Directed Option, providing access to Skills Training;

3. Visiting the member at his/her residence no later than thirty (30) days of receipt of notification of authorization by the ASA of Care Coordination Services to engage with the member in the Person-Centered Planning process as defined in 19.01-26. Person-Centered Planning encourages the member to maintain their independence, retain connections to their community (as part of the community inclusion/competitive integrated employment process) including making connections with family and friends, and to receive support in a manner that respects their goals, interests, values and preferences. The process includes identifying and documenting, with the member, the full complement of supports and services in place (including but not limited to mental health and medical services), as well any additional service needs of the member. This process results in a Person-Centered Plan and must comply with 42 C. F. R. § 441. 301(c). The Person-Centered Plan must be reviewed and updated if requested by a member, as a member's needs may require, and in any event, no less than every 12 months.

4. Develop, document, and provide copies to the member of the member's Back-Up Plan; complete a Risk Assessment and complete the Health and Welfare Tool approved by the Office of Aging and Disability Services;

5. Providing training and/or information concerning protections from abuse, neglect and exploitation, to members and legal guardians, including how to notify the appropriate authorities, at the time of initial plan development and at least annually thereafter.

6. For members receiving Personal Care Services through an agency, conducting face-to-face monitoring with the member at least annually to monitor the member's overall health status by completing the Health and Welfare Tool and following up on identified needs and issues;

7. For members authorized to receive Attendant Services through the Participant-Directed Option, conducting face-to-face monitoring with the member at least every six (6) months to monitor the member's overall health status by completing the Health and Welfare Tool and following up on identified needs and issues;

8. Assessing the member/provider relationship, including whether PSS or Attendant duties are being performed satisfactorily;

9. Monitoring the overall health status of the member;

10. Documenting receipt, investigation and resolution of all complaints from any party related to services under this Section;

11. Making contacts with members, family, designated representatives, guardians, providers of services or supports, the Assessing Services Agency, and the Department to ensure continuity of care and coordination of services;

12. Monitoring the member's receipt of services and reviewing the Authorized Plan of Care by contacting the member at least once per month, or more frequently upon request by the member. Monitoring calls may be reduced to a lesser frequency but not less than quarterly if the member requests less frequent calls and there is documentation in the record to support this choice. Monitoring may be done by telephone unless an in-person visit is needed to be effective as determined by the SCA or the Department;

13. Responding timely to assist the member with resolving problems and other concerns;

14. Advocating on behalf of the member for appropriate community resources and services by providing information, making referrals and otherwise facilitating access to these supports, including employment and support;

15. Modifying the Authorized Plan of Care in the event a member experiences an emergency or acute episode as defined in this section. The care coordinator may adjust the Authorized Plan of Care up to fifteen (15) percent of the monthly authorized amount, not to exceed the monthly program cap. Services added or changed due to the emergency or acute episode may not continue beyond fourteen (14) days.

16. Making referrals for reassessments prior to the end of the eligibility period, and based upon a Significant Service Change in the member's condition;

17. Issuing notices of intent to suspend, reduce or terminate, as appropriate, when the member is ineligible for such services or the level of services are reduced. The care coordinator may not issue a notice to reduce or terminate services based on medical eligibility;

18. Other activities include, but are not limited to:
a) Complying with the Department's protocols for submitting provider service authorizations through MeCare to the Department's MaineCare claims system,

b) Maintaining member records,

c) Providing information as required by the Department, and

d) Following requirements regarding mandated reporting.

19.04-5 Environmental Modifications are in-home physical modifications to the member's residence, as documented in the member's Authorized Plan of Care, which are necessary to ensure the health and welfare of the member or which enable the member to function with greater independence in the home, and are not covered or available under any other funding source.

Environmental Modifications include the following medically necessary modifications to the member's residence:

A. Ramps;

B. Lifts, such as porch or stair lifts and hydraulic, manual or other electronic lifts;

C. Modifications to bathroom facilities such as: roll-in showers, sink, bathtub, toilet and plumbing modifications, water faucet controls, floor urinal and bidet adaptations and turn-around space adaptations;

D. Modifications to kitchen facilities such as: sink modifications, sink cut-outs, and water faucet controls, turn-around space adaptations, surface adjustments/additions and cabinetry adjustments/additions; and

E. Specialized accessibility/safety adaptations such as: door-widening, electrical wiring, grab bars and handrails, automatic door openers/doorbells, voice activated, light activated, motion activated and electronic devices, fire safety adaptations, medically necessary air filtering devices, low-pile carpeting, and smooth or non-skid flooring needed to assure safe ambulation or wheelchair mobility.

Adaptations under this Section must require a physical modification to the home and shall not be duplicative of services covered by this or other sections of the MaineCare Benefits Manual.

All requests for, and repairs to, Environmental Modifications must be authorized in advance by the Department, or the ASA. The Department, or the ASA, shall make the determination of medical necessity for Environmental Modifications. Reimbursement shall not be provided for general house repairs or re-modeling. Modification of motor vehicles is not covered under this Section.

All Environmental Modifications must be provided in accordance with applicable Federal, State or local building codes and, if applicable, performed by or supervised by State licensed/certified professionals. The WSP shall maintain documentation in support of services billed to the Department.

Reimbursement for Environmental Modifications under this Section shall be provided only when payment for these services may not be made under any other Section of this Manual.

19.04-6 Financial Management Services (FMS) are those services provided by a Fiscal Intermediary to members who elect the Participant-Directed Option:

A. Assisting members in verifying Attendant citizenship status;

B. Collecting and processing timesheets of Attendants and disbursing Attendant payments;

C. Assisting members who have Budget Authority to determine Attendant wages;

D. Processing payroll, withholdings, filings and payment of applicable Federal, state and local employment-related taxes and insurances;

E. Establishing and maintaining member files in accordance with this section;

F. Conducting required background checks, including checks of the Certified Nursing Assistant (CNA) Registry, Office of Inspector General (OIG) Exclusions list, and criminal background checks; and

G. Assisting members with resolving questions and complaints.

Through the FMS, the Fiscal Intermediary acts as an agent of the employer (i. e. , the member or the member's Representative) in accordance with Federal Internal Revenue Service Codes and Procedures.

19.04-7 Home Delivered Meals are meals that are either hot, cold, shelf stable, or frozen meals, and that are delivered to the member's home, up to one meal per member per day, and up to seven days per week.

19.04-8 Home Health Services are nursing services, physical therapy, occupational therapy, speech therapy, home health aide (HHA) services, and medical social services, delivered at the member's place of residence, under physician orders and authorized by the ASA.

Home Health Services are provided in fifteen (15) minute increments or on a "visit" basis. However, only home health agencies that are Medicare certified and licensed in the State of Maine may bill on a "visit" basis. The type and frequency of each covered home health service must be authorized by the ASA in the Authorized Plan of Care. The home health provider shall develop a nursing plan of care, which shall include the personal support and nursing services authorized by the ASA or the Department, and the medical treatment plan which shall be reviewed and signed by the member's physician. The Department authorizes Advanced Practice Providers (Physicians Assistants, Nurse Practitioners, and Clinical Nurse Specialists) as qualified providers to order and recertify a Plan of Care. This plan shall be provided to the SCA at no additional cost.

Home Health Services under this Section include the following, which may be provided by an independent contractor with the exception of LPN, MSW and home health aide/ CNA services.

A. Registered Nurse services include:
1. Initiating a plan of nursing treatment and revising it as necessary. Copies of the nursing treatment plan, regardless of the reimbursement source shall be made available to the SCA;

2. Skilled nursing services not reimbursable by Medicare or another third party;

3. Informing the physician, the care coordinator and other parties, as appropriate, of changes in the member's condition and needs;

4. Teaching the member and family about meeting nursing and related needs;

5. Performing all other duties and responsibilities within the scope of the nursing license.

Registered nurse supervisory visits made for the sole purpose of supervising other home health staff are not billable as a visit and are, therefore, not reimbursable as an HCB service. If nursing services are delivered as part of the visit, those nursing services may be covered.

B. Licensed Practical Nurse services include all duties and responsibilities within the scope of the nursing license.

C. Physical Therapy services are those restorative services provided in accordance with physician orders, by a physical therapist, or by a physical therapist assistant working under the direct supervision of a licensed physical therapist, licensed in Maine in which services are provided, and acting within the scope of that license.

In order for pool therapy to be covered under this Section, physician orders are required and pool therapy must be specified in the Authorized Plan of Care. Physical therapy services delivered in a pool setting must be provided by a licensed physical therapist. No additional reimbursement will be provided for pool fees.

D. Occupational Therapy services are those restorative services provided in accordance with physician orders, by an Occupational Therapist, Registered (OTR), or by a Certified Occupational Therapist Assistant (COTA) under the direct supervision of an OTR, licensed in Maine, and acting within the scope of that license. These services include:
1. Task-oriented activities such as treatment to prevent or correct physical or emotional deficits or to minimize the disabling effect of these deficits in the life of the member;

2. Evaluation of sensory motor abilities, assessment of the development of self-care activities and capacity for independence, assessment of the physical capacity for prevocational and work tasks, assessment of play and leisure performance and assessment of living areas for the disability; and

3. Specific occupational therapy techniques such as assistance with Activities of Daily Living skills, the fabrication and application of splinting devices, sensory motor activities, the use of specifically designed manual and creative activities, guidance in the selection and use of adaptive equipment, specific exercises to enhance functional performance, and treatment techniques to improve physical capabilities for activities. The occupational therapist assists the physician in evaluating level of function, helps develop and revise a plan of treatment, and prepares clinical and progress notes.

E. Speech-Language Therapy services are those services which are provided by an individual licensed in Maine, and acting within the scope of that license as a Speech-Language Pathologist, which include speech, voice and language evaluation, diagnosis and plan of care, speech, voice and language therapy and/or aural rehabilitation, speech pathology, collateral services, speech and language periodic re-evaluation, speech pathology diagnostic services, hearing screening, and speech, voice and/or language screening. The speech language pathologist assists the physician in evaluating level of function, helps develop the plan of treatment and prepares clinical and progress notes.

F. Home Health Aide/Certified Nursing Assistant Services are delegated and overseen by a registered nurse. Written instructions for member's care are prepared by a registered nurse or therapist as appropriate. Duties include:
1. the performance of simple procedures as an extension of therapy services;

2. assistance with ADLs and IADLs as detailed in the Authorized Plan of Care;

3. assistance with medications that are allowed under the scope of practice;

4. reporting changes in the member's condition and needs to the nurse; and

5. completing appropriate records.

G. Medical Social Services are provided by an individual with a Masters of Social Work (MSW) who is licensed in Maine, and acts within the scope of that license. The social worker:
1. assists the physician and other team members in understanding the significant social and emotional factors related to the health problems;

2. participates in the development of the medical treatment plan;

3. educates the family regarding the member's health status and Authorized Plan of Care;

4. Performs all other duties and responsibilities within the scope of social work licensure.

19.04-9 Personal Care Services (also known as Personal Support Services), include Personal Care Services delivered by an agency related to a member's physical requirements for assistance with ADLs as defined in 19.01-1, including assistance with Health Maintenance Activities as defined in 19.01-17. Personal Care Services will not be authorized for the sole purposes of aiding with IADLs. Personal Care Services may include IADLs as defined in 19.01-18 when detailed in the Authorized Plan of Care and given the following conditions:

The ASA will use the allowances in Appendix I to determine the time necessary to complete authorized ADL and IADL tasks. If these times are not sufficient when considered in light of a member's unique circumstances as identified and documented by the ASA, the ASA may make an appropriate adjustment subject to the limits in this Section.

ADL tasks include assistance with:

1. Bed mobility, transfer, and locomotion activities to get in and out of bed, wheelchair or motor vehicle;

2. Using the toilet and maintaining continence;

3. Health Maintenance Activities as defined in Section 19.01-16;

4. Bathing, including transfer;

5. Personal hygiene which may include combing hair, brushing teeth, shaving, washing and drying face, hands, and perineum;

6. Dressing; and

7. Eating, and clean up.

IADL services must be authorized and specified in the Authorized Plan of Care. IADL tasks include assistance with:

1. grocery and prepared food shopping, assistance with obtaining medication, to meet the member's health and nutritional needs;

2. routine housework, including sweeping, washing and/or vacuuming of floors, cleaning of plumbing fixtures (toilet, tub, sink), appliance care, changing of linens, refuse removal;

3. laundry done within the residence or outside of the home at a laundry facility;

4. meal preparation and clean up; and

5. assistance with household budgeting activities as directed by the member for the member.

In the event that a spouse is serving as the member's PSS, pursuant to Section 19.08-8(B)(5), below, the PSS may not provide IADL services.

19.04-10 Attendant Services include Health Maintenance Activities as defined in 19.07-17 and ADL and IADL tasks as outlined above in 19.04-9, in accordance with the Authorized Plan of Care. Attendant Services will not be authorized for the sole purpose of aiding with IADLs.

19.04-11 Living Well for Better Health is an evidenced-based Chronic Disease Self-Management Program (CDSMP) developed by Stanford University and designed to help people gain self-confidence in their ability to control their symptoms and to learn how their health problems affect their lives. Living Well for Better Health services are delivered to members outside of the home through providers that meet the qualifications outlined in Section 19.08-2. Services are in the form of small-group, highly interactive workshops, and facilitated by a pair of leaders, one or both of whom are non-health professionals with chronic disease themselves. Workshops are six weeks long with meetings occurring once per week for 2 1/2 hours. Workshop topics include:

1. How to deal with frustration, fatigue, pain, and isolation;

2. Ways to maintain and improve strength, flexibility, and endurance;

3. Managing medications;

4. How to communicate effectively with family, friends, and health professionals and;

5. Healthy eating.

19.04-12 Matter of Balance (Falls Prevention) is an evidenced-based program designed to provide individuals with practical strategies to reduce the fear of falling and increase activity levels. Matter of Balance services are delivered to members outside of the home through providers that meet the qualifications outlined in Section 19.08-3. Services are delivered via group intervention, with class sessions lasting two hours each over the course of eight weeks. Classes are led by a trained facilitator meeting the qualifications outlined in Section 19.04-12. During the class, members learn to:

1. View falls as controllable;

2. Set goals for increasing activity;

3. Exercise to increase strength and balance; and

4. Make changes to reduce fall risk at home.

19.04-13 Personal Emergency Response Systems (PERS) is an electronic device that enables certain high-risk members to secure help in the event of an emergency. The member may also wear a portable "help" button to allow for mobility. The system is connected to a member's phone and programmed to signal a response center once a "help" button is activated. The response center is staffed by trained professionals.

PERS are covered only for those members who live alone, or who are alone for significant parts of the day, have no regular caretaker for extended periods of time, and who would otherwise require extensive routine supervision. PERS can serve as a backup plan to assure access to emergency assistance. Reimbursement is limited to the installation fee and the monthly phone charge for the emergency response system and the home unit communicator.

19.04-14 Transportation Services are offered in order to enable members to gain access to Section 19 services, as specified by the Authorized Plan of Care. Transportation services for Section 19 services are provided under the MaineCare Benefits Manual, Section 113 (Non-Emergency Transportation services).

19.04-15 Respite Services are provided to a member who is unable to care for him or herself, and who requires care on a short-term basis due to the temporary absence of, or to provide relief for, the caregiver who normally provides the care.

Respite Services shall be provided in the member's home, or it shall be provided in a licensed nursing facility. Federal financial participation shall not be claimed for room and board except when provided as part of Respite Services in a licensed nursing facility. A facility must bill the WSP for reimbursement of respite services provided in an institution. For respite services delivered in the member's home, the appropriate staff for meeting the member's needs (i. e., RN, HHA/CNA or PSS) can be utilized and reimbursement shall be at that worker's regular rate. All respite services must be billed using the appropriate respite procedure code and rate (home: number of hours per RN or HHA/CNA or PSS; or nursing facility service component only).

19.04-16 Skills Training is a service that provides members and Representatives with the information and skills necessary to carry out their responsibilities when choosing to participate in the Participant-Directed Option. This is a required service for members utilizing the Participant-Directed Option.

Skills Training services instruct the member in the management of Attendant Services under the Participant-Directed Option. Instruction in management of Attendant Services includes instruction in recruiting, interviewing, selecting, training, scheduling, discharging, and directing a competent Attendant in the activities in the Authorized Plan of Care and requirements under this Section. Skills Training must include information on how to report suspected abuse, neglect and exploitation to Adult Protective Services.

Skills Training must occur prior to the start of services. Initial Skills Training must occur within thirty (30) calendar days of referral for Skills Training. The SCA may extend the thirty (30) day timeframe for good cause (e. g. hospitalization of the member or Representative). A competency-based assessment may be performed in lieu of Skills Training for members who have previously completed such training.

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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