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-23 - Developmental and Behavioral Clinic Services
Subsection 144-101-II-23.04 - COVERED SERVICES

Universal Citation: 10 ME Code Rules § 144-101-II-23.04

Current through 2024-38, September 18, 2024

The following services are covered when provided by Approved Staff Members of a Developmental and Behavioral Evaluation Clinic and billed by that clinic. The Foster Care Comprehensive Health Assessment is covered when provided by Approved Staff Members or otherwise qualified professionals in accordance with this Section.

Covered services must be provided under the direction of a physician.

23.04-1 Developmental and Behavioral Evaluation is a Multidisciplinary Evaluation of social interaction, communication, stereotyped patterns of behavior and includes evaluation of other associated developmental and behavioral problems. The evaluation is conducted by a multidisciplinary team that consists of a Psychiatrist and either a Licensed Psychologist or a Psychological Examiner. If a Licensed Psychologist is not part of the team, the team must also include a Licensed Clinical Social Worker or Licensed Clinical Professional Counselor.

The Developmental and Behavioral Evaluation components may include a Psychosocial Assessment, a Psychological Evaluation and testing, clinically appropriate interviews and observations scales to assess for Autism Spectrum Disorders, and a Psychiatric Evaluation. The Developmental and Behavioral Evaluation may, at times, also include, speech/language, occupational therapy, and physical therapy assessments.

The Developmental and Behavioral Evaluation team consults to summarize the member's functional strengths and limitations to establish diagnosis(es) and to prepare recommendations for treatment or service. The Developmental and Behavioral Evaluation team communicates its findings to the parent or guardian and if clinically appropriate, the member. The findings are also summarized in a written report provided to the parent or guardian.

Developmental and Behavioral Evaluations are limited to two (2) per member per year. Each Developmental and Behavioral Evaluation is limited to fourteen (14) hours/units per evaluation.

23.04-2 Child Abuse Evaluation means an expert forensic evaluation of a member which is conducted under the direction of a board certified pediatrician who is a trained specialist in child abuse assessment. The purpose of the Child Abuse Evaluation is to evaluate the existence and extent of any child abuse or neglect and the emotional, physical, and behavioral effects of such abuse or neglect. The Child Abuse Evaluation is a multidisciplinary evaluation. The Child Abuse Evaluation must be performed by the following licensed professionals: child abuse pediatrician; nurse practitioner or an equivalent provider; and licensed clinical social worker or an equivalent provider.

The Child Abuse Evaluation must include a detailed psychosocial intake including contact with the Department, Law Enforcement, and the member's Primary Care Physician (PCP), detailed medical examination as appropriate, clinical interview with the member and parent, medical history, and psychological testing if necessary, and review of medical records. There shall be a final team meeting(s) to determine diagnosis, finalize conclusions regarding abuse and neglect and make recommendations regarding care, treatment, and safety plans. In addition to aiding in the provision of medically necessary services to the member, the purpose of the Child Abuse Evaluation is to produce a diagnosis and treatment recommendations that may be introduced into evidence in a child protective, criminal, or other court proceeding. Child Abuse Evaluations are limited to two (2) per member per year.

The Department shall submit to CMS and anticipates approval for a State Plan Amendment for this provision:

23.04-3 Foster Care Comprehensive Health Assessment (CHA) is a medically based, interdisciplinary comprehensive health evaluation of a child in the Department's care.

A. CHA Provider Requirements

CHAs may be provided within a Developmental and Behavioral Evaluation Clinic or by other qualified providers who are not practicing in a Developmental and Behavioral Evaluation Clinic.

A Board-certified pediatrician, family physician, physician assistant, or pediatric or family nurse practitioner must complete the medical exam component of the CHA.

A licensed psychologist, licensed clinical social worker, or a licensed clinical professional counselor must complete the psychosocial evaluation component of the CHA.

Providers of the CHA must:

1. Be licensed professionals acting within the scope of their licensure;

2. Have at least one (1) year of documented experience providing comprehensive, trauma-informed care for infants, children and adolescents; and

3. Must have at least one (1) year of documented experience in one (1) or more of the following areas:

a. Child abuse, child neglect, and sexual abuse of children;

b. Developmental and behavioral issues of infants, children, and adolescents;

c. Family dynamics and their effects on children; or

d. The effects of foster care placement on children and families.

B. CHA Components

CHAs include the following five (5) components:

1. Intake

Intakes must include the following:

a. Incorporating Departmental records into the member's medical records;

b. Scheduling the CHA appointment, including the medical exam and psychosocial evaluation, to occur within fourteen (14) calendar days of the referral unless there are unforeseen and uncontrollable circumstances, such as inclement weather or illness, that prevent the appointment from occurring. If the appointment occurs after fourteen (14) business days from the referral, the provider must document the justification for the delay in the member's record;

c. Providing information about the CHA to the child's caregiver; and

d. Notifying the Department about the date and time of the CHA.

2. Medical Exam Component

The medical exam component must include the following:

a. An in-person, face-to-face examination of the child;

b. Review of the child's records concerning reasons for entering the care and custody of the Department, including but not limited to the preliminary protection order, medical records, mental health records, and school records;

c. Review of all available medical records, including past medical history, current medical needs and dental problems, medications, allergies, and immunizations, as well as health history of acute or chronic health concerns;

d. Compilation and review of the member's medical information, concerns, and needs from the member's caregiver. If the provider determines it appropriate, the provider may interview the member's birth parent(s) to obtain relevant medical history; and

e. A written medical exam report that includes the following: Findings from the medical exam, including the dates of administered and recommended laboratory, oral health, hearing, and vision screenings; recommendations for medical or remedial interventions and related follow up treatment; and a summary of the child's past medical history.

3. Psychosocial Evaluation Component

The length of the psychosocial evaluation is dependent upon the age of the child and number of caregivers interviewed.

a. The psychosocial evaluation must include the following:

i. An in-person, face-to-face interview with the child regarding, as clinically appropriate, history of trauma, social and educational functioning, family and/or caregiver relationships. The provider may conduct the psychosocial evaluation virtually if it is for the benefit of the child, and providers must document the justification in the member's record. Providers cannot conduct a virtual psychosocial evaluation for their own benefit or convenience. The maximum time for the interview for the child and foster parent(s) is two (2) hours;

ii. Review of the child's records, including early intervention services, education, and mental health records, as applicable;

iii. Appropriate screenings and assessments as determined by the evaluator; and

iv. A written psychosocial evaluation report that includes the following: the child's strengths; assessments performed with dates administered and scores; past and current psychosocial information gathered through interviews listed in this section; and recommendations for treatment and/or further evaluations, if determined appropriate by the evaluator.

b. The psychosocial evaluation may include the following:

i. Interviews with birth parent(s) when appropriate. The maximum time for the interview with birth parents is two (2) hours. These interviews may be completed in conjunction with the medical provider;

ii. A trauma screening or assessment to determine the impact of abuse and neglect experienced by the child; and

iii. Cognitive, adaptive, academic skills assessments and cognitive testing.

In determining whether to include these components in the psychosocial evaluation, the evaluator shall take into account the age of the child and current concerns about the child's medical and psychosocial health.

4. CHA Final Report

Those providers who complete the medical and psychosocial components of the CHA must jointly discuss the member's needs at a child team meeting and complete a final written report. The report must be submitted to the Department no later than twenty-one (21) calendar days after the CHA is complete.

The report must include:

a. The child's medical records used in the medical exam and psychosocial evaluation;

b. The medical exam report, including summaries of all components of the evaluation identified in this section;

c. The psychosocial evaluation report, including summaries of all components of the evaluation identified in this section; and

d. Recommendations informing the child's foster parents, caregiver(s), providers, and DHHS caseworker(s) about trauma-informed care to enhance the child's adjustment and development. Strategies may include developmental and behavioral treatment and interventions.

5. Follow-up Evaluation

Providers must conduct follow-up medical and psychosocial evaluations for members who remain in the care and custody of the Department between six (6) and eight (8) months after the initial CHA. The follow-up medical examination may only be conducted virtually if the findings from the initial examination indicate that a virtual follow-up is appropriate.

After the follow-up evaluations, providers must submit reports to the Department that include the following:

a. Results from a medical exam, which includes a review of records since the initial medical examination;

b. Results from an updated psychosocial evaluation, the psychosocial portion of which is limited to a maximum reimbursement of five (5) hours;

c. The member's medical and psychosocial needs; and

d. Recommendations for treatment that will be shared with the Department and the member's caregiver.

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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