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-28 - Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations
Subsection 144-101-II-28.06 - LIMITATIONS
Current through 2024-38, September 18, 2024
The following limitations apply to reimbursement of services:
28.06-1 Services for Children With Cognitive Impairments and Functional Limitations
MaineCare will limit reimbursement for services under this Section to those covered services documented and approved in the treatment plan that are medically necessary and developmentally appropriate. Reimbursement is also contingent upon the provider's adherence to any applicable licensing standards and contractual agreements set forth by DHHS or its Authorized Agent. MaineCare will not reimburse for services provided during the child's regular sleeping hours. All Section 28 Services must meet requirements of central enrollment and will be subject to prior authorization and ongoing utilization review by the Department of Health and Human Services or Authorized Agent.
28.06-2 Non-Duplication of Services
Services as defined under this Section are not covered if the member is receiving comparable or duplicative services under this or another Section of the MaineCare Benefits Manual. A member may not receive services if they are in a residential treatment facility or if they are receiving services in an institution, including, but not limited to Section 45, "Hospital Services", Section 46, "Psychiatric Facility Services", Section 50, "ICF-MR", Section 67, "Nursing Facilities" and Section 97, Appendix D, "Private Non-Medical Institutions" except that this service may be provided while a member is receiving Treatment Foster Care provided by a Private Non-Medical Institution.
28.06-3 Group Treatment
Reimbursement for group treatment must be prior authorized. Group Treatment is limited to no more than eight (8) members in a group. When group treatment is provided to a group of more than four (4) members it must be provided by at least two (2) qualified staff at a time.
When group treatment is provided by more than one qualified staff at the same time, they can bill as follows:
The staff billing for the member is responsible for maintaining all clinical records.
