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-93 - Opioid Health Home Services
Subsection 144-101-II-93.03 - MEMBER ELIGIBILITY
Current through 2024-38, September 18, 2024
Members must meet the eligibility requirements set forth in this section.
93.03-1 General Eligibility
Members must meet the eligibility criteria described in Chapter I, Section 1 of the MBM and in the MaineCare Eligibility Manual, 10-144 Chapter 332.
93.03-2 Specific Requirements
All diagnoses and qualifying risk factors must be documented in the member's Plan of Care/ITP.
Members must be diagnosed with Substance Use Disorder, Opioid (as set forth in the Diagnostic and Statistical Manual of Mental Disorders (5th ed. DSM-5)); AND have a second chronic condition OR be at risk of having a second chronic condition.
Members shall be assessed by the OHH providers for high risk behaviors and other risk factors that may contribute to chronic conditions such as, but not limited to: smoking; obesity; poor nutrition; childhood trauma; risky sex practices; intravenous drug use; history of or current substance use other than opioids; and family health issues.
93.03-3 Eligibility Certification
Providers must submit certification requests to the Department or its authorized entity. Each member's eligibility shall be based on a diagnosis rendered within the past year from the date of the certification request, as documented by a professional whose scope of practice includes the ability to diagnose. Reassessments shall occur at least annually in order to ensure ongoing eligibility for services provided herein. Providers shall maintain a member's eligibility verification in the member's record.
