Current through 2024-38, September 18, 2024
*The Department is seeking, and anticipates receiving,
approval from CMS for this Section. Pending approval, the change will be
effective.
A covered service is a service for which payment to a
provider is permitted under this Section of the MaineCare Benefits
Manual. In order to be reimbursed under this Section, covered services
must be delivered under a timely and complete plan of care, signed and
certified by a qualified Physician and meet the authorization requirements as
outlined under Section 40.02-1. The plan of care must meet the requirements of
Section
40.08. The CMS-485
must be completed for each member under this Section. There must be
documentation of a face-to- face encounter with the certifying physician or
allowed nonphysician practitioner as listed in Section 40.01-7. If the
Department or its Authorized Entity determines that the services are no longer
medically necessary, the Department will not reimburse the HHA for continuing
services.
Any of the following services may be offered as the sole
Home Health Service and shall not be contingent upon the provision of another
service.
A.
Skilled Nursing
Services. To be covered as skilled nursing services, the services must
meet the following conditions:
1) require the
skills of a registered nurse or a licensed practical nurse under the
supervision of a registered nurse, to be safe and effective, considering the
inherent complexity of the service, the condition of the member and accepted
standards of medical and nursing practice; and
2) be medically necessary to the treatment of
the member's illness or injury. Medical necessity of services is based on the
condition of the member at the time the services were ordered and what was, at
that time, expected to be appropriate treatment throughout the certification
period; and
3) be required on an
intermittent or part-time basis (as defined in Section 40.01-14 and 40.01-20).
To meet the requirement for intermittent skilled nursing care, a member must
have a medically predictable recurring need for skilled nursing service; and be
ordered by the physician for the member and are included in the physician's
plan of care.
B.
Home Health Aide Services. Home health aide services must be
ordered by the physician and specified as to frequency and duration in the
physician's plan of care for the member. The services must be medically
necessary to provide personal care to the member, to maintain health, or to
facilitate treatment of the member's illness. Covered services include, but are
not limited to:
1) personal care
services;
2) simple dressing
changes that do not require the skills of a registered or licensed
nurse;
3) assisting the member with
self-administering medications that do not require the skills of a registered
or licensed nurse; home health aides cannot administer medications;
4) assistance with activities that directly
support skilled therapy services and are listed on the Maine State Board of
Nursing approved nursing assistant skills checklist;
5) routine care of prosthetic and orthotic
devices;
6) incidental services.
When a home health aide visits a member to provide a health-related service,
the home health aide may also perform some incidental services that do not meet
the above definition (for example, light cleaning, preparing a meal, removing
trash, or shopping). However, the purpose of the home health aide visit must
not be solely to provide these incidental services.
C.
Physical Therapy, Occupational
Therapy, and Speech-Language Pathology Services. Physical therapy,
occupational therapy and speech-language pathology services must meet the
following criteria:
1) prescribed by a
physician;
2) directly and
specifically related to an active treatment regimen;
3) of such a level, complexity and
sophistication that the judgment, knowledge, and skills of a licensed therapist
are required;
4) performed by a
licensed therapist or by a licensed therapist assistant under the supervision
of a licensed or registered therapist, each operating within the scope of his
or her license;
5) provided based
on the physician's assessment that the member has rehabilitation potential
(defined in Section 40.01-23) and will improve significantly in a predictable
period.
a. Once rehabilitation potential has
been established for members aged twenty-one (21) or older, they are
specifically eligible only for physical and occupational therapy in the
following circumstances:
i. treatment
following an acute hospital stay for a condition affecting range of motion,
muscle strength, and physical functional abilities. Services must be initiated
within sixty (60) days from the date of the physician's certification of the
member's rehabilitation potential; and/or
ii. treatment after a surgical procedure
performed for the purpose of improving physical function. Services must be
initiated within sixty (60) days from the date of the physician's certification
of the member's rehabilitation potential; and/or
iii. treatment in those situations in which a
physician has documented that the member has, in the preceding thirty (30)
days, required extensive assistance (defined in Section 40.01-6) with at least
one-person physical assist (defined in Section 40.01-19) in the performance of
one (1) or more of the following activities of daily living: eating, toileting,
locomotion, transfer or bed mobility;
iv. palliative care is limited to one (1)
visit per year to design a plan of care and train the member or caretaker of
the member to implement the plan or to reassess the plan of care;
6) considered under
accepted standards of medical practice to be a specific and effective treatment
for the member's condition; and
7)
certified by the physician in a current certification
period.
D.
Medical
Social Services. Medical social services that are provided by a
qualified medical social worker may be covered as Home Health Services when
medical social services are required:
1) 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; and
2) the plan of care indicates how the
services that are required necessitate the skills of a qualified medical social
worker.
3) services may include:
assessments of the social and emotional factors related to the member's
illness, need for care, response to treatment and adjustment to care;
assessment of the relationship of the member's medical and nursing requirements
to the member's home situation, financial resources, and availability of
community resources; appropriate action to obtain available community resources
to assist in resolving the member's services to address general problems that
do not clearly and directly impede treatment or recovery, as well as long-term
social services, such as ongoing alcohol counseling, are not covered.
4) certified by the physician or other
allowed practitioner as defined in 40.01-7, authorized according to 40.08-1 and
documented by the certifying physician according to 40.08-4.15.
E.
Non-Routine Medical
Supplies
1) In order to carry out the
physician ordered service for the Member, it may be necessary for the Home
Health Services provider to obtain and utilize particular medical supplies that
are required for performance of the ordered procedure. The Home Health Service
provider can bill for these "non-routine medical supplies", as defined in
Chapter II, Section 40.01-16, in addition to the per unit rate it is
paid.
2) The Department or its
designee will maintain a Home Health Services Supply List of non-routine
medical supplies covered under Chapter II. Only non-routine medical supplies
meeting the criteria contained in Section 40.01-16 and included on this list
may be approved for reimbursement by the Department. The Department will make
the list readily available to providers directly from the Department and
electronically at the Provider Tab, "Portal Tools" section in the Procedure
Code Lookup" at:
http://www.maine.gov/dhhs/oms.
3) All covered supplies must be billed in
accordance with the billing instructions for Home Health Services providers.
Non routine medical supplies covered under Section
40 must be billed at the lower of
either the acquisition cost or the durable medical equipment price which can be
found at
https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx?RootFolder=%2FProvider%20Fee%20Schedules%2FCustom%20Fee%20Schedules&FolderCTID=0x012000264D1FBA0C2BB247BF40A2C571600E81&View=%7B69CEE1D4-A5CC-4DAE-93B6-72A66DE366E0%7D
4) Members or providers on behalf
of members may request coverage for an item not currently on the Home Health
Services Supply List by sending a written request to the Division of Consumer
Services, explaining how the item meets the criteria of Section 40.01-16. In
order to add an item to the Home Health Services Supply List for reimbursement,
the Department or its designee must be satisfied that the item meets the
criteria for a "non-routine medical supply" as defined by Section
40.01-16.
* F.
Telemonitoring Services
1)
Telemonitoring services are intended to collect a member's health-related data,
such as pulse and blood pressure readings, that assist healthcare providers in
monitoring and assessing the member's medical conditions.
2) Telemonitoring will be reimbursed only
when provided by a certified Home Health Agency.
3) A note, dated prior to the beginning of
service delivery, and demonstrating the necessity of home telemonitoring
services, must be included in the member's file. In the event that services
begin prior to the date recorded on the provider's note, services delivered in
that month will not be covered.
4)
Telemonitoring services must be included in the member's plan of
care.
5) Home Health Agency
Requirements:
Home Health Agencies utilizing telemonitoring services
are responsible for:
a) Evaluating a
member to determine if telemonitoring services are medically necessary for that
member. The Home Health Agency must verify that a Health Care Provider's order
or note, demonstrating the necessity of telemonitoring services, is included in
the members' file. The provider ordering the service must be a provider with
prescribing privileges (physician, nurse practitioner, or physician
assistant);
b) Evaluating the
member to ensure that the member is cognitively and physically capable of
operating the telemonitoring equipment or verifying that the member has a
caregiver willing and able to assist with the equipment;
c) Evaluating the member's residence to
determine suitability for the telemonitoring services. If the residence appears
unable to support telemonitoring services, the Home Health Agency may not
implement telemonitoring services in the member's residence unless necessary
adaptations are made. Adaptations are not reimbursable by MaineCare;
d) Developing a plan of care that includes
the delivery of telemonitoring services;
e) Educating and training the member on the
use, maintenance, and safety of the telemonitoring equipment. The cost of this
education and training is included in the monthly flat rate paid by MaineCare
to the Home Health Agency:
f)
Remote monitoring and tracking of the member's health data by a registered
nurse, nurse practitioner, physician assistant or physician, and responding
with appropriate clinical interventions. The Home Health Agency and Health Care
Provider utilizing the data shall maintain a written protocol that indicates
the manner in which data shall be shared in the event of emergencies or other
medical complications;
g) Engaging
in telephonic services with the member on at least a monthly basis;
h) Ensuring that telemonitoring equipment
remains in good working order;
i)
Maintainingthe equipment. The cost of maintenance is included in the monthly
flat rate paid by MaineCare to the Home Health Agency;
j) Disconnecting and removing equipment from
the member's home when telemonitoring services are no longer necessary or
authorized.
k) Complying with all
applicable requirements listed in Chapter II, Section
40, Home Health Services.
