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-65 - Behavioral Health Service
Subsection 144-101-II-65.01 - DEFINITIONS

Universal Citation: 10 ME Code Rules ยง 144-101-II-65.01

Current through 2024-38, September 18, 2024

Definitions for the purposes of Section 65 are as follows:

65.01-1 American Society of Addiction Medicine Criteria (ASAM) is level of care criteria establishing what services are medically necessary for a member.

65.01-2 Affected Other is an individual with a demonstrated Family relationship with a member whose substance use has led to clinically significant impairment or distress for the individual. In order for an Affected Other to participate in Family therapy, there must be a family relationship with a MaineCare eligible member. Affected Others seeking individual therapy must have MaineCare coverage themselves.

65.01-3 Authorized Entity is an organization authorized by the Department of Health and Human Services (DHHS) to perform specified functions pursuant to a signed contract or other approved signed agreement.

65.01-4 Best Practices are treatment techniques, procedures and protocols described in detail where the effectiveness of these practices has been established through consensus among experts in the field. Key portions of these practices have been documented in research studies to be effective in selected treatment settings.

65.01-5 Central Enrollment is a process of determining baseline eligibility for behavioral health treatment.

65.01-6 Certified Clinical Supervisor (CCS) is a Clinician who is credentialed by the Maine State Board of Alcohol and Drug Counselors, 02-384 CMR chapter 6, and must conduct supervision as defined in the regulations for Licensing/Certifying of Substance Abuse Programs, 14-11 8 CMR chapter 5, section 11, in the State of Maine.

65.01-7 Certified Employment Specialist means an individual who has completed an Association of Community Rehabilitation Educators (ACRE) approved course, or other employment specialist training approved by DHHS and who maintains certification.

65.01-8 Certified Intentional Peer Support Specialist (CIPSS) means an individual who has completed the DHHS Office of Behavioral Health (OBH) curriculum for CIPSS and receives and maintains certification.

65.01-9 Child is a person between the ages of birth through twenty (20) years of age. Children aged eighteen (18) through twenty (20) years of age and children who are emancipated minors may choose to receive children's mental health services or adult mental health services, both of which are covered under this Section, whichever best meets their individual needs.

65.01-10 Child and Adolescent Functional Assessment Scale (CAFAS) is a multi-dimensional rating scale, which assesses a member's degree of impairment in day-to-day functioning due to emotional, behavioral, psychological, psychiatric, or substance use problems.

65.01-11 Clinician is an individual appropriately licensed or certified in the state or province in which he or she practices, practicing within the scope of that licensure or certification, and qualified to deliver treatment under this Section. A Clinician includes the following: Licensed Clinical Professional Counselor (LCPC); Licensed Clinical Professional Counselor-Conditional (LCPC-C); Licensed Clinical Social Worker (LCSW); Licensed Master Social Worker- Conditional Clinical (LMSW-CC); Licensed Marriage and Family Therapist (LMFT); Licensed Marriage and Family Therapist-Conditional (LMFT-C); Licensed Alcohol and Drug Counselors (LADC), Certified Alcohol and Drug Counselors (CADC); Physician; Psychiatrist; Advanced Practice Registered Nurse Psychiatric and Mental Health Practitioner (APRN-PMH-NP); Advanced Practice Registered Nurse Psychiatric and Mental Health Clinical Nurse Specialist (APRN-PMH-CNS); Psychological Examiner; Physician Assistant (PA); Registered Nurse (RN) or Licensed Clinical Psychologist.

65.01-12 Community Inclusion means the participation of a member in typical community activities that are both age and developmentally appropriate and are identified in the Individualized Treatment Plan (ITP).

65.01-13 Comprehensive Assessment is an integrated evaluation of the member's medical and psycho-social needs, including co-occurring mental health and substance use needs to determine the need for treatment and/or referral, and to establish the appropriate intensity and level of care.

65.01-14 Continuing Education Unit (CEU) is a measure used in continuing education programs, particularly those required in a licensed profession. The Maine Department of Education recognizes CEUs as approved continuing education credits that teachers, education technicians and others can apply to licensure or certification requirements. DOE recognizes 4.5 CEUs as equal to 3 semester hours.

65.01-15 Co-occurring Capable Providers are organized to welcome, identify, engage, and serve members with co-occurring mental health and substance use disorders, and to incorporate attention to these issues in all aspects of Co-occurring Services including linkage with other providers, staff competency and training. Clinicians must practice within the scope of their individual license(s) and follow all applicable mental health and substance use regulations in regard to member records including, but not limited to Comprehensive Assessments, Individualized Treatment Plans (ITP) and progress notes.

65.01-16 Co-occurring Disorders are any combination of a mental health and substance use disorder diagnosis.

65.01-17 Co-occurring Services are integrated services provided to a member who has both a mental health and a substance use disorder diagnosis. This includes persistent disorders of either type in remission; a substance related or induced mental health disorder and a diagnosable disorder that co-occurs with interacting symptoms of the other disorder.

When mental health and substance use disorder diagnoses occur together, each is considered primary and is assessed, described and treated concurrently. Co-occurring Services consist of a range of integrated, appropriately matched interventions that may include Comprehensive Assessment, treatment and relapse prevention strategies that may be combined, when possible within the context of a single treatment relationship. Co-occurring Services also include addressing Family therapy or counseling issues involving mental health, substance use or other disorders where MaineCare services cover Family therapy or counseling.

65.01-18 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (also known as DC 0-5), is the current version published by Zero To Three: National Center for Infants, Toddlers and Families. The publication formulates categories for the classification of mental health and development disorders manifested early in life.

65.01-19 Diagnostic and Statistical Manual of Mental Health Disorders (DSM) is the current version published by the American Psychiatric Association. The manual is used to classify mental health diagnoses and provide standard categories for definition of mental health disorders.

65.01-20 Evidence Based Practices (Practices Based on Scientific Evidence) are prevention or treatment practices that are based on consistent scientific evidence demonstrating that the treatment improves member outcomes. Elements of the practice are standardized, replicable and effective within a given setting and for particular populations and diagnosis or behavior. The practice is sufficiently documented through research to permit the assessment of fidelity to the model. As a result, the degree of successful implementation of the service can be measured by the use of a standardized fidelity tool that operationally defines the essential elements of practice. There must be no clinical or empirical evidence or theoretical basis indicating that the treatment constitutes a substantial risk of harm to those receiving the treatment, compared to its likely benefits.

65.01-21 Family, unless otherwise defined in this Section, means the primary caregiver(s) in a member's daily life (which may include a biological or adoptive Parent, foster Parent, legal guardian or designee), a spouse or significant other, biological or adoptive Child, foster Child, stepchild, significant other's child, sibling, stepparent, stepbrother or stepsister, brother-in-law, sister-in-law, grandparent, spouse of grandparent or grandchild, a person who provides Kinship Care, or any person sharing a common abode as part of a single-Family unit.

65.01-22 Functional Behavior Assessment (FBA) is a process of gathering information from multiple sources to hypothesize and understand what reliably predicts and maintains a problem behavior. The FBA evaluates behavior to analyze the antecedent and consequence as a reinforcement of a problem behavior. Behaviors are defined in measurable terms. The FBA uses a validated assessment which may also include interview, direct and/or indirect observation in the member's natural environment, functional analysis, preference assessment, assessment of reinforcement effectiveness, data collection, and reporting. The FBA will be used for the purpose of developing individualized Positive Behavior Support Plans for members receiving Developmental Disability and Behavioral Health Intensive Outpatient Program (DD/BH-IOP) Services.

65.01-23 Functional Family Therapy (FFT) is a Family strengths-based clinical assessment and intervention model built on a foundation of acceptance and respect. FFT addresses risk and protective factors within and outside of the Family that impact adolescents and their adaptive development the ages of eleven (11) and eighteen (18). FFT consists of five major components: engagement, motivation, relational assessment, behavior change, and generalization. The intervention averages eight (8) to twelve (12) sessions for mild to moderate needs and up to thirty (30) sessions for members with complex needs. Services include face-to-face or telehealth sessions with adolescent and/or Family members, telephone outreach and team meetings that include adolescent and or Family members. FFT must maintain treatment integrity and meet fidelity criteria developed by FFT, LLC. FFT therapists must be certified by FFT, LLC.

65.01-24 Imminent Risk is the immediate risk of a Child's removal from the home and/or community due to the specific circumstances as described in Children's Home and Community Based Treatment.

65.01-25 Individualized Treatment Plan (ITP) is a plan of treatment based on a Comprehensive Assessment developed by a Clinician.

65.01-26 Kinship Care is the full-time care, nurturing, and protection of members by relatives, members of their tribes or clans, godparents, stepparents, or any adult who has a kinship bond with a Child.

65.01-27 Medically Necessary Services are services provided as described in Section 65.06 Covered Services and as defined in Chapter I, Section 1 of the MaineCare Benefits Manual.

65.01-28 MHRT/C means an individual who has received Mental Health Rehabilitation Technician/Community certification from DHHS.

65.01-29 Multi-Systemic Therapy (MST) is an intensive Family-based treatment that addresses the determinants of serious disruptive behavior in members and their families. It is a short-term treatment approach that usually takes three (3) to six (6) months. The treatment typically includes three (3) to six (6) hours/week of clinical treatment. MST is a manualized, researched practice with a strong evidence base: MST therapist must be highly accessible to members, and typically provide twenty-four (24) hour a day, seven (7) days a week coverage for members which may include non face-to-face and telephonic collateral contact. Outcomes are evaluated continuously. MST services must maintain treatment integrity and meet the fidelity criteria developed by MST Services, Inc. MST therapists must be certified by MST Services, Inc. (http://www.mstservices.com). MST-Problem Sexualized Behavior (MST-PSB) includes additional training and supervision in addition to standard MST protocols.

65.01-30 NTA/Psychometrician is a Neurobehavioral Testing Assistant/Psychometrician. Psychometrics is the field of study concerned with the theory and technique of psychological measurement, which includes the measurement of knowledge, abilities, attitudes, personality traits, and education.

65.01-31 Natural Supports include the relatives, friends, neighbors, and community resources that a member or Family goes to for support. They may participate in the treatment team but are not MaineCare reimbursable.

65.01-32 Opioid Treatment Program (OTP) with Methadone Services are services provided by a program or practitioner engaged in opioid use disorder treatment of individuals that include the dispensing of an opioid agonist treatment medication (i.e., methadone), along with a comprehensive range of medical and rehabilitative services, when clinically necessary, to an individual to treat the adverse medical, psychological, or physical effects related to opiate addiction. Compliance with Federal and State laws and regulations that govern treatment, including, but not limited to, DHHS, Office of Behavioral Health, the Center for Substance Abuse Treatment (Division of the Substance Abuse and Mental Health Services Administration), the US Drug Enforcement Agency, the US Food and Drug Administration, and the State Pharmacy Board is required in the provision of services.

65.01-33 Parent or Guardian may be the biological, adoptive, or foster Parent or the legal guardian. They may participate in the treatment team but are not MaineCare reimbursable.

65.01-34 Parental Participation means that the Parent or caregiver is involved in the treatment team; participates in the assessment process; and helps develop the ITP for the purpose of the design, delivery, and evaluation of treatment specific to the member's mental health needs. The Parent or caregiver participates in treatment and models and reinforces skills learned.

65.01-35 Permanency means that a member lives in a planned living arrangement either with a Parent or other caregiver and can return to the Parent or caregiver from a stay in a hospital, a residential treatment or correctional facility.

65.01-36 Positive Behavior Support Plan (PBSP) includes individualized, strengths-based strategies based on positive reinforcement techniques that are designed to increase a member's use of prosocial and positive behaviors and decrease negative or detrimental behaviors. The PBSP summarizes the findings of the Functional Behavioral Assessment and is used for the purpose of developing individualized strategies for members receiving DD/BH IOP Services.

65.01-37 Practice Methods shall mean treatment techniques, procedures, therapeutic modalities, and protocols. For example, a practice method is Dialectical Behavior Therapy or Cognitive Behavioral Therapy.

65.01-38 Preschool and Early Childhood Functional Assessment Scale (PECFAS) is a multi-dimensional rating scale that assesses the psychosocial functioning of members aged three (3) to seven (7) years.

65.01-39 Prior Authorization (PA) is the process of obtaining prior approval as to the medical necessity and eligibility for a service.

65.01-40 Promising and Acceptable Treatment is defined as treatment that has a sound theoretical basis in generally accepted psychological principles. There must be substantial clinical literature to indicate the value of the treatment with members who experience the diagnostic problems and behaviors for which this treatment is needed. The treatment is generally accepted in clinical practice as appropriate for use with members who experience these diagnostic problems and behaviors. There must be no clinical or empirical evidence or theoretical basis indicating that the treatment constitutes a substantial risk of harm to those receiving it, compared to its likely benefits. The treatment must have a book, manual, or other available writing that specifies the components of the treatment protocol and describes how to administer it. An individual, who has been certified in the provision of the Promising and Acceptable treatment, if such certification exists, must provide services. The existence of a certification standard for a treatment does not, by itself, indicate that the treatment meets the standard for a Promising and Acceptable treatment.

65.01-41 Serious Emotional Disturbance (SED) is when a member has a mental health and/or a co-occurring substance use disorder diagnosis, emotional or behavioral diagnosis, in accordance with the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), that has lasted for or can be expected to last for at least one (1) year, which has resulted in functional impairment that substantially interferes with or limits the child's role or functioning in family, school, or community activities. Youth with SED may be at risk for more restrictive placement, including but not limited to, psychiatric hospitalization, as a result of this condition for which other less intensive levels of service have not been effective (e.g. traditional outpatient services).

65.01-42 Serious and Persistent Mental Illness means a mental health condition had by a person who is age eighteen (18) or older or is an emancipated minor with:

1. A primary diagnosis of Schizophrenia or Schizoaffective disorder in accordance with the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM); or

2. Another primary mental health diagnosis in accordance with the current version of the DSM, with the exception of Neurocognitive Disorders, Neurodevelopmental Disorders, Antisocial Personality Disorder and Substance Use Disorders, who:
a) has a written opinion from a Clinician, based on documented or reported history, stating that he/she is likely to have future episodes, related to mental illness, with a non-excluded DSM diagnosis, that would result in or have significant risk factors of homelessness, criminal justice involvement or require a mental health inpatient treatment greater than seventy-two (72) hours, or residential treatment unless community support services and/or evidence based outpatient treatment is provided; based on documented or reported history(an oral or written history obtained from the member, a provider, or a caregiver); or

b) has received treatment in a state psychiatric hospital, within the past 24 months, for a non-excluded DSM diagnosis; or

c) has been discharged from a mental health residential facility, within the past 24 months, for a non-excluded DSM diagnosis; or

d) has had two or more episodes of inpatient treatment for mental illness, for greater than seventy-two (72) hours per episode, within the past twenty-four (24) months, for a non-excluded DSM diagnosis; or

e) has been committed by a civil court for psychiatric treatment as an adult; or

f) until the age of twenty-one (21), was eligible as a Child with serious emotional disturbance, and has a written opinion from a Clinician, in the last twelve (12) months, stating that he/she has risk factors for mental health inpatient treatment or residential treatment, unless ongoing case management or community support services are provided;

AND

3. Has significant impairment or limitation in adaptive behavior or functioning directly related to the primary diagnosis and defined by the Level of Care Utilization System (LOCUS, as defined in Chapter II, Section 17 of the MaineCare Benefits Manual), or other acceptable standardized assessment tool adopted by the Department through rulemaking and administered at least annually. If using the LOCUS, the member must have a LOCUS score, as determined by a LOCUS Certified Assessor, of seventeen (17) (Level III) or greater.

65.01-43 Strengths-Based Approach is defined as a way to assess, plan, and deliver treatment incorporating the identified strengths and capabilities of the member and Family.

65.01-44 Substance Use Qualified Staff in order to provide substance use outpatient therapy, staff must be a Licensed Alcohol and Drug Counselors (LADC), a Certified Alcohol and Drug Counselors (CADC); or a Physician (MD or DO), a Licensed Clinical

Psychologist, a Licensed Clinical Social Worker (LCSW), a Licensed Clinical Professional Counselor (LCPC), a Licensed Marriage and Family Therapist (LMFT), a Registered Professional Nurse certified as a Psychiatric Nurse or Advanced Practice Psychiatric and Mental Health Registered Nurse (APRN), who meet the education and experience as defined in the regulations for Licensing/Certifying of Substance Abuse Programs, 14-118 CMR Chapter 5, in the State of Maine.

All services are provided under the direction of a Physician (MD or DO) or Psychologist and supervised by a Certified Clinical Supervisor (CCS).

65.01-45 Trauma Focused Cognitive Behavioral Therapy (TF-CBT) is a modality of outpatient therapy. TF-CBT is a targeted psychotherapeutic approach that helps children and adolescents address the negative effects of traumatic stress. TF-CBT is a structured therapy model that incorporates psychoeducation, affect regulation techniques, cognitive-behavioral techniques, coping skill development, reprocessing of traumatic memories, and Family therapy. TF-CBT incorporates the opportunity for conjoint therapy with Parents/caregivers and the Child, in which Parents/caregivers can learn about the impact of trauma on children, learn how to support positive coping and affect regulation skills in their Child, develop effective communication with their Child, support the Child in processing traumatic memories, and enhance the Child's sense of safety.

65.01-46 Trauma Informed Care is the provision of behavioral health services that includes:

1. An understanding of psychological trauma, symptoms, feelings and responses associated with trauma and traumatizing relationships, and the development over time of the perception of psychological trauma as a potential cause and/or complicating factor in medical or psychiatric illnesses.

2. Familiarity with current research on the prevalence of psychological (childhood and adult) trauma in the lives of members with serious mental health and substance use disorders and possible sequelae of trauma (e.g., post-traumatic stress disorder (PTSD), depression, generalized anxiety, self-injury, substance use, flashbacks, dissociation, eating disorder, revictimization, physical illness, suicide, aggression toward others).

3. Providing physical and emotional safety; maximizing member choice and control; maintaining clarity of tasks and boundaries; ensuring collaboration in the sharing of power; maximizing empowerment and skill building.

4. Consideration of all members as potentially having a trauma history, understanding as to how such members can experience re-traumatization and ability to interact with members in ways that avoid re-traumatization.

5. An ability to maintain personal and professional boundaries in ways that are informed and sensitive to the unique needs of a member with a history of trauma.

6. An understanding of unusual or difficult behaviors as potential attempts to cope with trauma and respect for member's coping attempts and avoiding a rush to negative judgments.

65.01-47 Utilization Review is a formal assessment of the medical necessity, efficiency and appropriateness of services and Individualized Treatment Plans on a prospective, concurrent or retrospective basis. The provider is required to notify DHHS or an Authorized Entity upon initiation of all services provided under Section 65 in order for the Authorized Entity to begin Utilization Review.

65.01-48 V-9 Extended Care or Status is a written agreement for continued care allowing a member eighteen (18) through twenty (20) years of age to continue to be under the care and custody of DHHS. Normally, a member who reaches the age of eighteen (18) is automatically dismissed from custody and achieves full adult rights and responsibilities. The member may negotiate a written agreement with DHHS, Office of Child and Family Services for the following reasons:

1. To obtain a high school diploma or general equivalency diploma, or obtain post-secondary educational or specialized post-secondary education certification;

2. To participate in an employment skills support service;

3. To access mental health or other counseling support, including Co-occurring Services;

4. To meet specialized placement needs;

5. The member is pregnant and needs parenting support; or

6. The member has medical and special health conditions or needs.

7. No member in care may be accepted for continuing services after his or her eighteenth (18th) birthday unless an "Application and Agreement of Responsibility for Continued Care" (V-9) has been signed by both the member and the member's caseworker prior to the member's eighteenth (18th) birthday. Most members having this status must participate in full time secondary or post-secondary education approved by the DHHS caseworker and that caseworker's supervisor.

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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