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-40 - Home Health Services
Subsection 144-101-II-40.01 - DEFINITIONS

40.01-1 Authorized Entityshall mean the organization authorized by the Department to perform functions pursuant to a contract or which are specified in a written agreement. The Authorized Entity will perform authorizations of plans of care as required.

40.01-2 Certification Periodshall mean the months, days, years, which identify the period covered by the physician's plan of care. The "From" date for the initial certification must match the start of care date. The "To" date can be up to, but never exceed, two (2) calendar months and mathematically never exceed sixty (60) days. Recertifications shall follow the same length of time requirements.

40.01-3 Contraindicated shall mean the Member's condition renders some particular line of treatment improper or undesirable.

40.01-4 Duration shall mean the length of time the services are to be rendered and may be expressed in days, weeks, or months. This must be specified on the physician certified plan of care.

40.01-5 Eligibility Period shall mean the period of time, designated by a start and end date established by the Department or its Authorized Entity, approved for coverage of Home Health Services, in accordance with Section 40.08.

40.01-6 Extensive Assistance means although the individual performed part of the activity over the last seven (7) days, or twenty-four (24) to forty-eight (48) hours if in a hospital setting, help of the following type(s) was provided:

- Weight-bearing support three (3) or more times, or

- Full staff performance during part (but not all) of the last seven (7) days.

40.01-7 Face to Face Encounter means an encounter between the member and the certifying physician, or a nurse practitioner or clinical nurse specialist who is working in collaboration with the physician, or a certified nurse midwife as authorized by State law or physician assistant under the supervision of the physician. The encounter may be through telehealth, consistent with Section 1834(m) of the Social Security Act and 42 CFR 424.22. The face-to-face encounter must be related to the primary reason the patient requires Home Health Services. The face-to-face encounter shall be documented by the physician responsible for performing the certification for the Home Health Service as indicated in 40.08-4.15 and 40.08-1.D.4. The face-to-face encounter must occur within the time frame set out in section 40.08-4.15,

40.01-8 Frequency shall mean the number of visits per discipline to be rendered, stated in days, weeks, or months. This must be specified on the physician certified plan of care.

40.01-9 Functionally Significant Improvement is the demonstrable, measurable increase in the individual's ability to perform specific tasks or motions that contribute to independence outside the therapeutic environment.

40.01-10 Health Care Provider is an individual or entity licensed or certified under the laws of the State of Maine to provide medical or behavioral health services and must be enrolled as MaineCare providers in order to be reimbursed for services.

40.01-11 Home Health Agency (HHA) means a voluntary, public or private organization, or a part of such organization, that is certified under Title XVIII of the Social Security Act for reimbursement for the delivery of Home Health Services.

40.01-12 Home Health Aide Services are those in-home services that are provided by a certified home health aide and which are delegated and supervised by a registered nurse. A certified home health aide must have satisfactorily completed a training program for certified nurse assistants, consistent with the rules and regulations of the Maine State Board of Nursing. Home health aides employed by a Home Health Agency must also have completed an agency orientation as defined by the regulations Governing the Licensing and Functioning of Home Health Care Services.

40.01-13 Home Health Services are those skilled nursing and home health aide services, physical and occupational therapy services, speech-language pathology services, medical social services, telemonitoring services, and the provision of certain medical supplies, needed on a "part-time" or "intermittent" basis. Services are delivered by a Medicare certified Home Health Agency to a member in a setting where normal life activities take place or in other particular settings with limitations as described in Section 40.06. Services are delivered according to the orders of a licensed physician and an authorized plan of care that certify the need for the Home Health Services. Certification for Home Health Services shall occur as a result of a documented face- to-face encounter as defined in 40.01-7 that meets the requirements of 40.08-4.15 and 40.08-1.D.4.

In a nursing facility (NF) setting, only physical therapy, occupational therapy and/or speech-language pathology services may be delivered by a Home Health Agency if the NF's MaineCare reimbursement rate does not include these services.

40.01-14 Intermittent, in general, shall mean skilled nursing care needed on fewer than seven (7) days each week or less than eight (8) hours each day for periods of up to twenty-one (21) days (or longer in exceptional circumstances when the need for care is finite and predictable); but as defined in CMS Publication 11 "Medicare Home Health Agency Manual," and the regulations issued pursuant thereto as are most currently ineffect. This manual is available on line at http://www.cms.hhs.gov/manuals/11_hha/HH00.asp.

40.01-15 Medical Social Services are assessment, counseling, and assistance services that are needed by a member to resolve social or emotional problems that are or are expected to be an impediment to the effective treatment of the member's medical condition or to affect his or her rate of recovery. Services are provided by a social worker who is functioning within the scope of the license granted by the state or province in which the services are performed and who has had at least one (1) year of social work experience in a health care setting.

A licensed social worker shall receive consultation in accordance with State of Board of Social Work Registration and the Rules and Regulations of the Board of Social Work. The licensed social worker with more than two (2) years' experience shall receive consultation from a licensed master social worker, a licensed clinical social worker, or a certified social worker on a quarterly basis.

40.01-16 Non-Routine Medical Supplies are supplies that are necessary for a particular procedure ordered by a physician to be provided by Home Health Services. Non-Routine medical supplies meet the following criteria;

40.01-17 Nursing Services are those services that are provided by a registered nurse (RN) and/or a licensed practical nurse, which holds a current license issued by the state or province in which services are performed.

40.01-18 Occupational Therapy Services are those restorative services provided in accordance with physician orders, by an Occupational Therapist Registered (OTR) or by a Certified Occupational Therapist Assistant (COTA) under the direct supervision of an OTR, licensed by the state or province in which services are provided and acting within the scope of that license.

40.01-19 One-person Physical Assist requires one (1) person to provide either weight-bearing or non-weight-bearing assistance for an individual who cannot perform the activity independently over the last seven (7) days, or twenty-four (24) to forty-eight (48) hours if in a hospital setting. This does not include cueing.

40.01-20 Part-time, in general, shall mean less than eight (8) hours a day or twenty-eight (28) hours a week; but as defined in CMS Publication 11 "Medicare Home Health Agency Manual and the regulations issued pursuant thereto as are most currently in effect. This manual is available on line at http://www.cms.hhs.gov/manuals/11_hha/HH00.asp.

40.01-21 Physical Therapy Services are those restorative services provided in accordance with physician orders, by a physical therapist or by a physical therapist assistant working under the direct supervision of a licensed physical therapist, licensed by the state or province in which services are provided and acting within the scope of that license.

40.01-22 Psychiatric Nursing Services are services provided by a registered professional nurse that is licensed by the state or province in which services are provided and has met requirements for approval to practice as an advanced practice psychiatric nurse or is certified as a psychiatric and mental health nurse by the appropriate national accrediting body.

40.01-23 Rehabilitation Potential is the documented expectation by a physician of measurable, "functionally significant improvement" (defined in Section 40.01-9) in the member's condition in a reasonable, predictable period of time as the result of the prescribed treatment plan. The physician documentation of rehabilitation potential must include the reasons used to support the physician expectation and must follow guidelines detailed in MaineCare Benefits Manual (MBM), Chapter II, Section 90, "Physician Services".

40.01-24 Speech-Language Pathology Services are those restorative services which are furnished in accordance with physician orders by a speech-language pathologist or speech language pathology assistant licensed by the state or province in which services are provided, who is acting within the scope of that license, and services meet the conditions described in Chapter II, Section 109 of the MBM. Services may be delivered by a speech-language pathology assistant who is registered and supervised by a Board licensed speech-language pathologist, as provided by 32 M.R.S.A., Section6003(7-A).

40.01-25 Start of Care Date (SOC) shall mean the first billable visit. This date remains the same on subsequent plans of care until the member is discharged.

40.01-26 Telemonitoring Servicesare the use of information technology to remotely monitor a member's health status through the use of clinical data while the member remains in the residential setting. Telemonitoring may or may not take place in real time.

40.01-27 The Unit of Home Health Service is fifteen (15) minutes of personal contact in a setting where normal life activities take place, other than a hospital, nursing facility, or an intermediate care facility for individuals with intellectual disabilities; made for the purpose of providing a covered service by a health worker on the staff of a Home Health Agency or by others under contract or arrangement with the Home Health Agency. If the unit of service is described as a "visit", providers will be reimbursed for a set rate regardless of the length of the visit. When two (2) or more persons simultaneously provide separate and distinct types of services, each provider's service is billed separately.

40.01-28 Unstable Medical Condition exists when the member's condition is fluctuating in an irregular way and/or is deteriorating and affects the member's ability to function independently. The fluctuations occur to such a degree that medical treatment and professional nursing observation, assessment and management are required at least three (3) times per week. An unstable medical condition requires increased physician involvement and should result in communication with the physician for adjustments in treatment and medication. Evidence of fluctuating vital signs, lab values, and physical symptoms and plan of care adjustments must be documented in the medical record.