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-46 - Psychiatric Hospital Services
Subsection 144-101-II-46.07 - DETERMINATION OF ELIGIBLITY
Current through 2024-38, September 18, 2024
All members requesting eligibility must be determined to be in need of the psychiatric hospital services provided by providers enrolled under this Section. The determination of medical eligibility is made concurrently with the determination of financial eligibility in order to expedite the determination of the member's overall eligibility for psychiatric hospital services.
46.07-1 Financial Eligibility Determination Procedure
Financial eligibility will be determined by the DHHS's Office of Integrated Access and Support.
46.07-2 Medical Eligibility Determination Procedure
Before authorization for reimbursement may be made, a complete evaluation of the member must be made, a plan of care established, a certification of need of service completed, and Central Enrollment as defined in Section 46.08 completed.
An attending physician or staff physician must make a medical evaluation of each member's need for care and appropriate professional personnel must make a psychiatric and social evaluation. This evaluation must include all requirements detailed in Hospital Licensing regulations. In addition, each medical evaluation must include:
The attending staff physician must establish and sign a written plan of care for each member, which must at minimum include the items described at Section 46.10.
46.07-3 Coordination With Medicare
Medicare provides a lifetime limit of one hundred and ninety (190) inpatient days of care in a psychiatric hospital. In general, MaineCare benefits are limited to payment of the Medicare coinsurance and deductible for MaineCare-eligible Medicare beneficiaries as stated in Chapter I of the MaineCare Benefits Manual.
The following describes the additional requirements for authorization of MaineCare coverage in the event that a member applies for inpatient psychiatric hospital coverage after the one hundred and ninety (190) day lifetime limit or ninety (90) day spell-of-illness limit is exhausted or after the member's Medicare benefits are terminated for any other reason.
A copy of the Medicare Exhaustion of Benefits notice must be included in the member's record.
