Current through 2024-38, September 18, 2024
All services must be provided within the HRSA-approved
scope of service area, or to HRSA-Designated Medically Underserved Populations
(MUP) at federally approved center locations such as school-based health
centers, and be otherwise provided in conformance with Federal
requirements.
Covered services include core services, and other
ambulatory services contained in the State's Medicaid plan, and in the FQHC's
scope of project for base year 1999 as approved by HRSA, and any approved
change in scope of service as amended, or as specifically approved by the Maine
Department of Health and Human Services (DHHS). FQHCs must submit their
HRSA-approved scope of project for base year 1999, or if established after
1999, for their first year of operation, and all subsequent HRSA-approved
amendments to scope of project.
31.04-1
Core services include:
A. services provided by physicians, physician
assistants, advanced practice registered nurses, clinical psychologists,
licensed clinical social workers, and licensed clinical professional
counselors;
B. services and
supplies furnished as incident to services of approved and appropriate licensed
practitioners. In order for incidental services to be covered, FQHC employees
must perform the incidental service, unless it is an FQHC service routinely
performed by contracted personnel or providers. Services provided by auxiliary
personnel not in the employ of the FQHC, even if provided on the physician's
order or included in the FQHC's bill, are not covered as incident to a
physician's service. Thus, non-physician diagnostic and therapeutic services
that an FQHC obtains, for example, from an independent laboratory, an
independent licensed or otherwise qualified provider, or a hospital outpatient
department are not covered FQHC services;
C. visiting nurse services (as described in
Section 31.04-4).
31.04-2
Ambulatory services
include the following:
A. Any other
ambulatory service, including any incidental supplies associated with the
performance of a service that is provided by the FQHC, and that is also
included in the State's Medicaid Plan, are reimbursable. This includes
contraception (injectable, implantable capsules, intrauterine devices) and the
administration of influenza and pneumococcal vaccines. (These services must be
provided in accordance with all applicable sections of the MaineCare
Benefits Manual in order to be reimbursable.)
B. Asthma programs are reimbursable if they
are based on the Open Airways or Breathe Easier curricula. Any other asthma
management service that is approved by the National Heart, Lung and Blood
Institute/American Lung Association or the Asthma and Allergy Foundation of
America, are also reimbursable.
Each program must have:
1. a physician advisor;
2. a primary instructor (a licensed health
professional or a health educator with baccalaureate degree);
3. a pre and post assessment for each
participant which shall be kept as part of the member's record;
4. an advisory committee which may be part of
an overall patient education advisory committee; and
5. a physician referral for all
participants.
C.
Reimbursement for Ambulatory Diabetes Education and Follow-Up (ADEF) Services,
or for similar services approved by a Centers for Medicare and Medicaid
Services (CMS) approved national accreditation organization, will be reimbursed
when a provider enrolled with the Maine Diabetes Prevention and Control
Programs furnishes this service to a MaineCare member whose physician has
prescribed this program for the management of the member's diabetes. The
service is:
1. a pre-assessment interview to
determine the member's knowledge, skills and attitudes about diabetes
management and to develop an individualized education plan and behavior change
goals;
2. a group class instruction
covering the comprehensive curriculum outlined by the Maine Diabetes Control
Project and based on the individualized education plan;
3. a meal planning interview to determine the
member's knowledge, skills and attitudes about meal planning and to develop an
individualized meal plan and behavior change goals;
4. a post-service interview to assess and
document what the member has learned during the service, and to develop a plan
for follow-up sessions to address the component areas not learned in the class
series, and finalize behavioral goals; and
5. follow-up contacts to reassess and
reinforce self-care skills, evaluate learning retention and progress toward
achieving the member's behavior change goals. At a minimum, three-month,
six-month, and one-year follow-up visits from the date of the last class are
required to complete the member's participation in the service.
When the MaineCare member is under age 21, this service
will also be reimbursed when provided to the person/people who provide the
member's daily care.
D. Effective August 1, 2014, tobacco
cessation treatment serviceswill be reimbursed, for eligible Members, provided
by physicians or other providers who can provide tobacco cessation treatment
services under their licenses or permits. There are no annual or lifetime
limits on tobacco cessationtreatment services. Counselingservices may be
provided in the form of individual or group counseling. Both forms of
counseling may be provided by licensed practitioners within the scope of
licensure as defined under State law and who are eligible to provide other
coverable services in Section 31.
Tobacco cessation treatment services includes the
provision of all pharmacotherapy approved by the Food and Drug Administration
(FDA) for tobacco dependence treatment. MaineCare members are not required to
participate in tobacco cessation counseling to receive tobacco cessation
products. Tobacco cessation products are "covered services" reimbursable
pursuant to Ch. II, Section 80.05 of the MaineCare Benefits
Manual. The services for tobacco cessation treatment are copay exempt.
Smoking cessation treatment servicesmay be billed alone, or in combination with
other FQHC services. Documentation of the tobacco cessationtreatment services
must be contained in the medical record.
31.04-3
Off-site delivery of
services furnished by health center staff are reimbursable when they are
provided away from the center and when it is documented in the member's chart
that it is the most clinically appropriate setting for the provision of
services. Examples of off-site service locations include: a nursing facility,
an emergency room, an inpatient hospital, or a member's home.
31.04-4
Visiting nurse services
will be reimbursed when:
A. a registered
nurse or licensed practical nurse provides the services to a member who is
homebound;
B. the services are
provided in accordance with a written plan of treatment;
C. the member's record documents that the
member would not otherwise receive these services;
D. the services are provided in an area for
which the Secretary of the US Department of Health and Human Services has
determined there is a shortage of home health agencies; and
E. the health center that provides in-home
services by a registered or licensed practical nurse is licensed by the State
of Maine as a home health service provider.
31.04-5
Interpreter Services -
Refer to Chapter I of the MaineCare Benefits Manual for
information about the reimbursement for interpreter
services.
