Current through 2024-38, September 18, 2024
The purpose of this Appendix is to detail guidelines for
Office of Aging and Disability Services in approving a Medical Add-On to the
established published rate. All current statutes, regulations, decree
provisions, policies, and licensing standards regarding medical services are
unaffected by these guidelines. This Appendix develops criteria that warrant an
adjustment to the DHHS's established published rate for Community Support,
Employment Specialist Services and Work Support Services.
The Clinical Review Team (CRT) is the entity within OADS
that is responsible for review and approval, of all Medical Add-On rate
increases for services under this section.
The rate is designed to support Members with intermittent
or longer duration medical conditions. Changes or needs that may be considered
for Medical Add-On include but are not limited to: support over and beyond
routine services such as ventilators, nebulizers, diabetes management-insulin
dependent, suctioning, seizure management-uncontrolled, chronic eating
disorders, or persons with co-existing conditions that significantly affect
physical movement and require near total physical assistance on a daily basis.
Conditions related to surgeries, procedures, injuries and other short term
conditions are also considered for the Medical Add-On rate increase.
The following standards and practices must be
demonstrated in order for the CRT to approve a Medical Add-On:
A.
Physician Order
1. There must be a written physician or
physician's assistant's order, less than three (3) months old for the member.
This order must specify:
a. The specific
illness or condition to be addressed;
b. The specific procedure(s) that will be
utilized;
c. The time span over
which the treatment or intervention is expected to be needed. If the treatment
or intervention is expected to be needed for an indefinite period of time then
this expectation should be specified;
d. The anticipated frequency of treatment or
intervention on a daily, weekly, or monthly basis;
e. Where applicable and possible:
i. The approximate length of time required
for each episode of the treatment or intervention and
ii. The degree of licensure or certification
required for those who carry out the treatment, and those who provide training
and oversight relative to its application.
B.
Planning Team
1. The team must meet or otherwise confer for
the following purposes:
a. To review and
complete the request for Medical Add-On and any additional documentation
required for submission to the CRT.
b. To determine whether the setting where the
member is served is appropriate to carry out the physician's recommended
treatment or intervention; and
c.
To determine how the member's needs shall be met and what the staffing
requirements are.
2. All
of these determinations and recommendations must be noted in the Personal
Plan.
C.
Provider
Requirements
1. The provider must be
an enrolled MaineCare provider.
2.
For any physician or physician's assistant order specifying a skilled medical
professional who shall train, monitor, or deliver treatment, the provider must
have regular access to the professional, either as an employee, or via a
contract, or via an established relationship; or alternatively, the provider
must be able to gain this access in a time frame commensurate with the
treatment requirements.
D.
Approval Process
1. The CRT will review the information
submitted with the request, the Personal Plan, information in the electronic
record such as reportable events, crisis notes, as well as any applicable
assessments or evaluations in the member's record.
2. The CRT will issue a written decision for
the Medical Add-On, within twenty (20) working days of receipt of all required
documentation. If additional information is required, a written request will be
issued. Upon receipt of the additional information the CRT will approve or deny
the request within ten (10) working days.
3. Approvals will include a specification of
the duration of the Medical Add-On, as well as authorized daily or weekly units
of service which require the Medical Add-On.
4. Treatments or interventions that are
anticipated to be needed for an extended or indefinite period of time must be
reviewed annually or more frequently as determined by the CRT. Verification of
this continued need must be provided to the CRT within a year of the original
approval, in order for the Medical Add-On to continue.
