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-26 - Day Health Services
Subsection 144-101-II-26.07 - POLICIES AND PROCEDURES

Universal Citation: 10 ME Code Rules ยง 144-101-II-26.07

Current through 2024-38, September 18, 2024

26.07-1 Professional Staff

Day health services are to be provided by the following staff in accordance with the individual written plan of care. Staff may be day health service employees or consultants to the service.

The following professional staff who are fully, provisionally or conditionally licensed or recognized to practice by the state or province in which services are provided, are qualified professional staff.

A. Registered Nurse

B. Practical Nurse

C. Social Worker

D. Occupational Therapist

E. Physical Therapist

F. Speech Language Pathologist

G. Other Qualified Staff may include CNAs and other service aides and assistants who provide day health services appropriate to their level of training under the supervision of a licensed professional who falls within the categories listed in subsections A through F, above. Supervision may be provided on a consulting basis.

26.07-2 Eligibility Determination

Applicants under this section must meet the eligibility requirements set forth in Section 26.02. An eligibility assessment, using the Department's approved MED assessment form, shall be conducted by the Department or the Department's authorized agent.

A. If financial eligibility for MaineCare has not been determined, the applicant, family member or guardian must be referred to the regional office of the Bureau of Family Independence, concurrent with the relevant medical eligibility determination process.

B. The Department or the Department's authorized agent shall conduct a medical eligibility assessment using the Department's approved MED assessment form to determine the number of hours for MaineCare covered services under this Section.

C. The provider must implement a plan of care that does not exceed the total hours authorized by the Department or the Department's authorized agent each week.

D. The anticipated costs of services under this Section under the plan of care must conform to the service limitations set forth in Section 26.05.

E. The Department or the Department's authorized agent must approve a classification period for the member, based on the scores, timeframes and needs identified in the MED assessment for the covered services, and the assessor's clinical judgment. A classification period must not exceed twelve (12) months. The authorized agent will notify the Department of each member classified, the member's medical eligibility start dates and the reassessment date. Thereafter, the authorized agent will forward the completed MED forms, eligibility notices, and other assessment paperwork to the provider chosen by the member.

F. If the Department or its authorized agent determines that the member does not meet or no longer meets the medical eligibility criteria, or is eligible for a different level of care, then the Department or its authorized agent must notify (using a notice format approved by the Department) the member in writing of which services, if any, will be provided, or which services will be provided on a reduced basis. The notice must contain an understandable explanation of the reasons, inform the member of his or her appeal rights, and conform to the notice requirements in Chapter I.

26.07-3 Plan of Care

A written plan of care must be established before services are provided. To be reimbursed, services must be consistent with the plan of care. At least one (1) of the persons involved in developing the initial care plan must be a registered nurse or an LPN under the supervision of a registered nurse.

The written plan of care shall include, but is not necessarily limited to:

A. member's name, address, birth date

B. name of member's physician, if any

C. type of day health services needed

D. who shall deliver the service

E. frequency and expected duration of the services

F. long and short term goals

G. plans for coordinating with other health and social service agencies for the delivery of services (see Medical Eligibility Determination (MED) form).

At least one (1) professional staff person, such as a nurse or social worker, shall beresponsible for the development and monitoring of care plans. The care plan is to be reviewed and updated at least every six (6) months or more often as necessary by nurse or social worker.

The plan of care should be included as a subsection of a master plan of care if multidisciplinary services are provided to a member and are coordinated by a care manager.

26.07-4 Reclassification for Continued Services

Reassessment and prior authorization of services is required for all members in order for the reimbursement of services to continue uninterrupted beyond the approved classification period. The provider must request the reassessment no more than fourteen (14) days prior to the reclassification date. The Department or its authorized agent must conduct the reassessment no later than the reclassification date. MaineCare coverage ends on the classification period end date unless a new classification period has been authorized. The provider may request an unscheduled reassessment if a significant change occurs as defined in Section 26.01.

26.07-5 Member Records

There must be a specific record for each member, which must include, but not necessarily be limited to:

A. member's name, address, sex, age, next-of-kin;

B. the Department's approved medical eligibility assessment form;.

C. medical information, including:
1. statement of significant medical problems

2. written physician orders of current medications and treatments to be delivered at the day health setting

3. statement of limitations, if any, on the member's participation in service activities

4. recommendations for therapies;

D. list of medications, prescribed and otherwise;

E. written plan of care;

F. summary notes for each date of service billed which include:
1. identification of the service provided, the date and provider;

2. signature of service provider;

3. date and full description of any unusual condition or unexpected event; and

G. monthly progress notes reflecting the progress that the member has made in relation to the plan of care. The licensed professional responsible for monitoring the plan of care must sign the progress notes, in conformance with licensing requirements.

26.07-6 Member Appeals

A member has the right to appeal in writing or orally any decision made by the Department or its authorized agent, to reduce, deny or terminate services provided under this benefit. In order for services to continue during the appeal process, a request must be received by the Department within ten (10) days of the notice to reduce or terminate services. Otherwise, an individual has sixty (60) days in which to appeal a decision. Members shall be informed of their right to request an Administrative Hearing in accordance with this Section and Chapter I of this manual.

An appeal for members must be requested in writing or orally to:

Director

Bureau of Elder and Adult Services

c/o Hearings

11 State House Station

Augusta, ME04333-0011

26.07-7 Program Integrity

All providers are subject to the Department's Program Integrity (formerly Surveillance and Utilization Review) activities. Refer to Chapter I, General Administrative Policies and Procedures for rules governing these functions.

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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