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-50 - ICF-MR Services
Subsection 144-101-II-50.07 - COVERED SERVICES

Universal Citation: 10 ME Code Rules ยง 144-101-II-50.07

Current through 2024-38, September 18, 2024

50.07-1 Routine Services, Supplies, and Equipment Included in Regular Rate for Reimbursement

Routine services, supplies, and equipment must be supplied by the facility as part of the regular rate of reimbursement. Routine services include regular room, dietary services, rehabilitation treatment services and nursing services, minor medical and surgical supplies, and the use of equipment and facilities.

ICFs-MR are expected to furnish the equipment and services (see attached Appendix) normally used in the care of the their resident population (e.g. children's wheelchairs) as part of their reasonable cost.

50.07-2 Supplies and Equipment for Which the Department may be Billed by a Supplier or Pharmacy

Equipment and supplies which, when ordered by a physician or other medical practitioner legally qualified to order such equipment and supplies, may be payable to a supplier or pharmacy in accordance with the policies established in Section 60, Medical Supplies and Durable Medical Equipment and Section 80, Pharmacy Services of the MaineCare Benefits Manual.

For purposes of reimbursement, acute care general hospitals that are affiliated with the facility through the same corporate structure, or have an ICF-MR as a distinct part of a larger institution, may be a provider of medical supplies and durable medical equipment for members who are residents of the hospital-based ICF-MR.

50.07-3 Physical Therapy (PT) and Occupational Therapy (OT) Services

Physical and occupational therapy services must be directly and specifically related to an active written treatment regimen designed by the physician after any necessary consultation with the qualified physical or occupational therapist, and the services must be included in the written plan of care. To constitute physical or occupational therapy, a service furnished to a member must be reasonable and necessary for the treatment of his or her illness or condition. The necessary services must be of such a level of complexity and sophistication, or the condition of the member must be such, that the judgment, specialized knowledge, and skills of a qualified physical or occupational therapist are required. Please refer to Section 85, Physical Therapy Services and Section 68, Occupational Therapy Services for criteria of the practitioner and covered services.

Adult members (age twenty-one (21) and over) are specifically eligible only for:

A. Treatment following an acute hospital stay for a condition affecting range of motion, muscle strength, and physical functional abilities; and/or

B. Treatment after a surgical procedure performed for the purpose of improving physical function; and/or

C. Treatment in those situations in which a physician or primary care provider has documented that the patient has at some time during the preceding thirty (30) days required extensive assistance (see Section 50.01-5) in the performance of one or more of the following activities of daily living: eating, toileting, locomotion, transfer or bed mobility; and/or

D. Medically necessary treatment for other conditions including maintenance of function and palliative care, however, services for palliative care and maintenance of function are limited to one (1) visit per year to design a plan of care, train the member or caretaker of the member to implement the plan or to reassess the plan of care.

E. Services for adults who meet the specific eligibility requirements in Section 50.05-1(B)(1-3) above must be initiated within sixty (60) days from the date of physician or primary care provider certification.

F. Services for adults who do not meet the criteria in Section 50.05-1(B)(1-3) must be medically necessary as documented by a certification by a physician or primary care provider, however, such treatment is limited to no more than one (1) visit per condition by qualified staff.

G. Limitations:
a. MaineCare will not reimburse for more than two (2) hours of PT per day and/or no more than two (2) hours of OT per day. If the member is under twenty-one (21) years old and these limits need to be exceeded due to medical necessity, then prior authorization is required as detailed in Chapter II, Section 94 of the MaineCare Benefits Manual.

b. PT or OT services can be provided by a home health agency certified as a Medicare provider, or an outpatient department of an acute hospital, or a licensed independent therapist as defined in Chapter II, Sections 68 and 85 of the MaineCare Benefits Manual.

c. ICFs-MR may bill for services of PT and/or OT on their staff or under a contract with them. Reimbursement for services provided by a licensed independent physical or occupational therapist will be limited to the maximum allowance as defined in Chapter III, Sections 68 and 85 of the MaineCare Benefits Manual.

d. For purposes of reimbursement, acute care general hospitals that are affiliated with the facility through the same corporate structure, or have an ICF-MR as a distinct part of a larger institution, must bill the Department as a provider of physical or occupational therapy services on the ICF-MR billing form for patients who are residents of the hospital-based ICF-MR.

H. PT and OT Consultations

Types of consultation that will be approved:

a. In-service education programs for staff members who have not been trained to carry out procedures that may be delegated by a physical or occupational therapist.

b. Professional consultation provided to administrators with respect to purchasing equipment or modification of a physical plant to meet the needs of members.

50.07-4 Speech and Hearing Services

A. All covered services provided under Section 109 of the MaineCare Benefits Manual must be ordered or requested in writing by a physician, physician assistant, or advanced practice registered nurse as allowed by the respective licensing authority and his or her scope of practice.

B. Covered speech-language pathology services for members aged twenty-one (21) or older is also limited to those members who have been assessed to have rehabilitation potential as defined in Section 50.01-12. A member's rehabilitation potential must originate from a physician or primary care provider.

Adult members (age twenty-one (21) and over), must have an initial evaluation by a physician or primary care provider that documents that the member has experienced a significant decline in his/her ability to communicate orally, safely swallow or masticate, and that the member's condition is expected to improve significantly in a reasonable, predictable period of time as a result of the prescribed treatment plan. This requirement will not apply to members with Medicare coverage or other third party health insurance until the coverage for speech-language pathology services by the other payor has been exhausted.

C. The member must also receive an initial evaluation by a speech-language pathologist that supports the physician or primary care provider's determination that rehabilitation potential exists.

D. If speech-language pathology services are to be continued beyond a period of six (6) months, a re- evaluation by a speech-language pathologist must be completed every sixth month from the initial determination of rehabilitation potential, in order to determine that rehabilitation potential continues to exist. A report of the results of the speech-language pathologist's six-month re-evaluation must be sent to the member's physician or primary care provider, who will use that information to decide if rehabilitation potential continues to exist. If the physician or primary care provider agrees in writing that rehabilitation potential continues to exist, the member may continue to receive speech-language pathology services for an additional six (6) month period.

E. Limitations:
a. Speech and hearing services when provided in an ICF-MR setting, are reimbursable to the following types of providers only: a home health agency certified as a Medicare provider, or a speech and hearing clinic certified as a Medicare provider, or a licensed speech-language pathologist, or audiologist, or a speech and hearing agency as defined in Section 109 of the MaineCare Benefits Manual.

b. ICFs-MR may bill for services of a speech-language pathologist or audiologist on their staff or under a contract with them. Reimbursement for services provided by a speech-language pathologist or audiologist will be limited to the maximum allowance as defined in Chapter III, Section 109 of the MaineCare Benefits Manual.

c. For purposes of reimbursement, acute care general hospitals that are affiliated with the facility through the same corporate structure, or have an ICF-MR, as a distinct part of a larger institution, must bill the Department as a provider of speech and hearing services on the ICF-MR billing form for members who are residents of the hospital-based ICF-MR.

F. Consultation Services:

The following types of consultation will be approved: In-service education programs for staff members who have not been trained to carry out procedures and principles developed by the licensed speech pathologist and/or audiologist.

50.07-5 Dental Services

For every resident of an ICF-MR, the facility must provide or make arrangements for comprehensive diagnostic and treatment services, including those of licensed dentists and dental hygienists. These services are covered in Chapters II & III, Section 25, Dental Services in the MaineCare Benefits Manual.

50.07-6 Pharmacy Services

All ICFs-MR must comply with both Federal regulations and State of Maine Regulations Governing the Licensing and Functioning of Intermediate Care Facilities for Persons with Mental Retardation that define obtaining, dispensing and administering drugs and biologicals. Facilities must follow the requirements in the MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services for returns of reusable drugs and destruction of unusable drugs.

50.07-7 Other Services

The attending physician's order or the order of another licensed medical practitioner legally qualified to order services for members, is required for all other types of services provided in an ICF-MR, unless the MaineCare Benefits Manual specifically does not require an order. The provider must bill in accordance with the policies in the MaineCare Benefits Manual that apply to his or her specialty.

50.07-8 ICF-MR Developmental Training Program

Developmental training programs are defined as those programs approved by the Department that are obtained outside of the ICF-MR and provide training and services. This includes vocational services, unless these services are required or funded under a State or Federal vocational training program. Vocational services must be identified in the IPP as part of an active treatment program, and the services being provided are directly related to preparing the member for skills training that teaches the member such concepts as compliance, attending, task completion, problem solving, and safety. Training that is solely for the purpose of teaching the member the skills to perform tasks in an employment situation is not covered under this policy. The training must relate to the overall level of functioning of the member. The IPP shall include the goals and objectives of the service and the expected length of time of the service. If vocational services are not required for active treatment, there shall be no reimbursement for these services.

The developmental training program shall develop a written individual plan with established goals based on the IDT plan and the ICFs-MR total plan of care. No less than monthly progress notes shall be written in the participating member's record at the developmental training program describing the participant's progress in the program in relation to the established goals. Copies of such progress notes shall be sent to the ICF-MR. The IDT shall be reviewed jointly initially and at least quarterly by appropriate staff of the ICF-MR, the developmental training program, and if appropriate, the Qualified Mental Retardation Professional (QMRP). There shall be coordination of services to residents between the developmental training program and the ICF-MR. Utilization Review and independent professional review of the developmental training program shall be conducted as part of the ICF-MR review.

Examples of Developmental Training Programs include:

1. Activities of daily living skill training;

2. Communication skills including oral, manual, gestural and/or communication board or other augmentative communication device/system training;

3. Physical development training including sensory, gross motor to fine motor skills;

4. Behavior modification including behavior management, self-awareness, integration, and responsibilities to self and others;

5. Work adjustment training approved by the Department and not covered by other vocational rehabilitation services; and

6. Supported employment that is approved by the Department and is not covered by other vocational rehabilitation services.

Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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