Current through 2024-38, September 18, 2024
Covered services are available for individuals meeting
the eligibility requirements set forth in Section
96.02. Covered
services must be required in order to maintain the Member's current health
status, or prevent or delay deterioration of a Member and/or delay long-term
institutional care. These services require prior approval by the Department, or
its Assessing Services Agency, and are subject to the limits in Section
96.03.
Services provided must be reasonable and necessary for
meeting the medical needs of the individual, based upon the medical record, and
upon the outcome scores on the MED form, and as authorized in the plan of care.
Payment will be denied if the services provided are not consistent with the
Member's authorized plan of care. The Department may also recoup payment for
inappropriate service provision, as determined through post payment
review.
For Members age 21 and over, and those under age 21
receiving care under the family provider service option, and excluding those
classified for medication services or venipuncture services (Level VI) under
this Section, the Assessing Services Agency has the authority to determine the
plan of care, which shall specify all services to be provided, including the
number of hours for each covered service.
For Members under age 21 at any level of service, as
well as Level VI and Level VII Members, but excluding those receiving care
under the family provider service option, the PDN provider shall establish a
plan of care. The plan of care shall be based upon the Member's assessment
outcome scores recorded in the Department's Medical Eligibility Determination
form and the timeframes therein.
Section
40, "Home Health Services", shall
not replace or be delivered and reimbursed in lieu of authorized Section
96 covered services. (Section
40, "Home Health Services", must
be delivered and reimbursed pursuant to those rules.)
Covered services under this Section include the
following:
96.04-1
Private Duty
Nursing Services (PDN)
A. PDN services
must be provided according to a written plan of care, reviewed and signed by a
licensed physician, and available to the Department or the Service Coordination
Agency upon request. At least monthly nursing services must be delivered to all
Level II and III Members, as well as those Level I Members who are eligible for
services based upon the need for monthly nursing services.
B. For individuals age 21 and over, and those
under age 21 receiving care under the family provider service option, and
excluding those classified for medication services or venipuncture services
(Level VI) under this Section, PDN services shall be authorized by the
Assessing Services Agency, and ordered and monitored by the Service
Coordination Agency, in accordance with the authorized plan of care for covered
services under this Section.
C. For
individuals under age 21, as well as all individuals classified for
venipuncture services or medication services for the severely mentally disabled
(Level VI), and excluding those receiving care under the family provider
service option, the Department shall classify the Member based on the plan of
care developed by the provider, subject to the process described under Section
96.06.
D. Nursing services may be provided by:
1. an independently practicing registered
professional nurse;
2. a registered
professional nurse or licensed practical nurse employed by, or under contract
with, a licensed home health agency.
E. Except as allowed in Section 96.04-1(F)
below, nursing services shall not be covered when provided by the Member's
husband or wife, natural or adoptive parent, child, or sibling, stepparent,
stepchild, stepbrother or stepsister, father-in-law, mother-in-law, son-in-law,
daughter-in-law, brother-in-law, sister-in-law, grandparent or grandchild,
spouse of grandparent or grandchild or any person sharing a common abode as
part of a single family unit.
F.
"Special circumstances nursing" allows a relative, including a spouse or the
parent of a minor child, to be paid to provide nursing services to the Member
under this Section. To qualify for this coverage the Member's relative must
meet the requirements in (1) and (2) below.
1. The relative must: (all of the following
are required)
a. meet all licensing,
training, reporting and other requirements otherwise specified in this Section;
and
b. be employed by a licensed
home health agency; and
c. abide by
the requirement that an independent nurse or physician must conduct any
required assessments and/or develop the plan of care; and
d. implement the Member's authorized plan of
care; and
e. if applicable, expect
to continue non-reimbursed family caregiver responsibilities; and
f. pass a criminal background check. The
family nursing provider must not have any criminal convictions, except for
Class D and Class E convictions over 10 years old that did not involve as a
victim of the act a patient, client, or resident of a health care entity; or
any specific documented findings by the State Survey Agency of abuse, neglect,
or misappropriation of property of a resident, client, or
patient.
2. The relative
must: (one of the following is required)
a.
have resigned from full-time or part-time employment specifically to provide
PDN services to the Member; or
b.
have changed from full-time employment to part-time employment resulting in
less compensation in order to provide PDN services to the Member; or
c. have taken a leave of absence without pay
from employment in order to provide PDN services to the Member;
d. have incurred substantial expenses by
providing PDN services to the Member; or
e. be needed to provide an adequate number of
qualified nurses to meet the Member's plan of care because of labor conditions
or intermittent hours of care.
To apply for coverage under this Section, contact the
Director, Office of Aging and Disability Services, 11 State House Station,
Augusta, ME 04333-0011.
G. Multiple patient nursing services are for
nursing services (RN, LPN, and Independent RN) throughout this Section. The
multiple patient procedure codes and modifiers must be used whenever it is
determined (by the home health agency, the Department, or the Department's
authorized entity, whichever has authority to authorize the Member's plan of
care) to be safe and appropriate for one nurse to provide nursing services to
more than one patient in the same home or building, during the same visit and
it is specified in each Member's plan of care. Providers must bill with the
Chapter III procedure codes and modifiers designated for multiple
patients.
96.04-2
Personal Care Services
A. For
Members under the age of 21, excluding those receiving care under the family
provider service option, personal care services must be ordered by a physician
and delivered under a plan of care prepared by the PDN provider and signed by
the physician.
B. For Members age
21 and over, and for those under age 21 receiving care under the family
provider service option, personal care services must be approved by the
Department, or its Assessing Services Agency, and specified in the authorized
plan of care.
As a general rule, there shall be no more than one
personal care staff Member delivering services at a time. If the Department, or
its ASA, (or the physician for individuals under age 21) determines that an
individual, based upon his/her health status, requires more than one personal
care staff Member to perform a specific ADL task (e.g. to transfer a large
person), then this can be authorized and specified in the plan of care.
If a single provider of personal care services is
providing this service to multiple Section
96 members in a single visit, then
the two (2) or three (3) person modifier shall be used, as outlined in Chapter
III, Section
96, Private Duty Nursing and
Personal Care Services.
Personal care services include services related to a
Member's physical requirements for assistance with the activities of daily
living, including assistance with related health maintenance activities.
C. Additionally, when authorized
and specified in the Department, or ASA authorized plan of care, personal care
services may include IADL and related health maintenance tasks, which are
directly related to the Member's plan of care. These tasks must be performed in
conjunction with direct care to the Member. Health maintenance and IADL tasks
are those that would otherwise be normally performed by the Member if he or she
were physically or cognitively able to do so. It must also be established that
there is no family Member or other person available to assist with these tasks.
A child or infant shall not qualify for coverage of IADL tasks because an
infant or child does not normally perform these tasks. Coverage of IADL tasks
is provided to assist individuals with disabilities to live independently in
the community. IADL services may be authorized and covered only if the Member
also requires ADL or medication administration services. IADL services are not
covered as stand-alone personal care services; these may be covered only in
combination with ADL or medication administration services.
1. The maximum hours per week allowed for
IADL tasks for Levels I, II, III and IX is as follows: Level I is two hours;
Level II is three hours; and Level III and IX is four hours. ADL and IADL
tasks, and the allotted hours, must be specified and authorized in the plan of
care.
D. Certified
nursing assistants, home health aides, or personal support specialists may
transport a Member only to carry out necessary covered services in the Member's
plan of care. Escort services may be provided only when a Member is unable to
be transported alone, there are no other resources (family or friends)
available for assistance, and the transportation agency can document that the
agency is unable to meet the request for service.
Such documentation must be included in the Member's
record. Coverage is not available to reimburse for mileage or vehicle usage
under this Section. Only the provider's services are covered.
E. Personal care services shall be provided,
as appropriate, by a:
1. Home health aide;
or
2. Certified nursing assistant;
or
3. Personal support specialist;
or
4. Certified Residential
Medication Aide employed by a licensed assisted living agency, as defined in
§ 96.01-28, that holds a valid contract with OADS and provides medication
administration as allowable under certification.
F. Personal care services shall not be
covered when delivered by a spouse of the Member, the parents or stepparents of
a minor child, or a legally responsible relative.
G. The task time allowances set forth in
Appendix 1 must be used to authorize the time covered to complete covered and
authorized ADL tasks for the plan of care. For Members age 21 and over, and
those receiving care under the family provider services option the ASA shall
abide by Appendix 1. For Members under age 21, the PDN provider shall abide by
Appendix 1. These allowances reflect the time normally allowed to accomplish
the listed tasks. The ASA and the PDN provider will use these allowances when
authorizing a Member's care plan. If these times are not sufficient when
considered in light of a Member's unique circumstances as identified and
documented by the ASA or the PDN Provider, the ASA or the PDN Provider may make
an appropriate adjustment as long as the authorized hours do not exceed the
established limits for the Member's assessed level of care.
H. The PSS super visit is a one-hour visit to
deliver personal care services and health maintenance activities to a Member,
no more than once per day. This service may be authorized up to seven days per
week. If the Member requires more than one hour of personal care services on a
given day, then the regular PSS services must be billed with the appropriate
unit procedure codes, and the one-hour visit procedure code shall not be used.
This is not a covered service under the family provider
services option defined in Section 96.01-23.
I. Medication services delivered by Certified
Residential Medication Assistants, and unrelated to the medication services
described under Level VI, are covered services for those Members meeting the
eligibility criteria under Level IX.
96.04-3
Venipuncture Only services
(Level VII)
A. These services shall be
covered when it is the only identified nursing need and is required on a
regular basis, as ordered by the physician. An RN or LPN must deliver
venipuncture services. Personal care services are not covered services under
venipuncture services. If the Member requires additional services, then he/she
must meet (at least) the eligibility requirements for Level II or III. If the
Member qualifies for Level II or III then all services including venipuncture
services shall be authorized and delivered under Level II or III.
96.04-4
Medication and
venipuncture services (Level VI)
A.
Level VI services are directly related to the administration and/or monitoring
of medications intended for the treatment and management of mental illness in
the context of community support services for people with severe and persistent
mental illness (Level VI under this Section).
B. Monitoring services may include
venipuncture services for Members under this Section.
C. A psychiatric nurse or a registered
professional nurse must deliver these services.
D. Personal care services are not covered
services under this Section
96.04(F).If
the Member requires additional services, then he or she must meet (at least)
the eligibility requirements for Level II care. If the Member qualifies for
Level II or III then all services including medication services shall be
authorized and delivered under the Level II or III.
The following services are covered upon Centers for
Medicare and Medicaid Services (CMS) approval.
96.04-5
Care
Coordination activities are guided by the Member's authorized plan of
care. Care coordination services include the following functions:
Care Coordination is provided through in-person contact
in the Member's residence, or through telephone and other methods with the
Member, his/her family and other responsible parties, providers of service, and
others as appropriate.
For Members who choose to self-direct their services,
Care Coordination includes assisting the Member in arranging for, directing and
managing his/her self-directed services as allowed, and coordinating access to
Skills Training as defined in this Section.
A.
Responsibilities
1. Making initial contact with the Member or
the responsible party, by telephone or other appropriate method, within two (2)
business days of notification of authorization of care coordination services to
discuss choice of provider(s), service delivery options, clarify issues, and
answer questions;
2. Assisting with
the implementation of the authorized plan of care and coordinating service
providers who are responsible for delivering services, by making referrals and
providing service authorizations to qualified service provider(s) the Member
chooses; or if the Member chooses to self-direct, providing access to Skills
Training;
3. Visiting the Member at
his/her residence within 30-45 days of receipt of notification of authorization
of care coordination services to review needs and goals, and address unmet
needs;
4. Visiting the Member
annually to monitor the Member's overall health status by following up on
identified needs and issues;
5.
Making contacts with family Members, designated representatives, guardians,
providers of services or supports, the assessing services agency, and the
Department to ensure continuity of care and coordination of services;
6. Monitoring the Member's receipt of
services and reviewing the plan of care by contacting the Member at least once
per month. Monitoring calls may be reduced to a lesser frequency but not less
than quarterly if the Member requests less frequent calls and there is
documentation in the record to support this choice. Monitoring may be done by
telephone unless an in-person visit is needed to be effective;
7. Responding timely to assist the Member
with resolving problems and other concerns;
8. Advocating on behalf of the Member for
appropriate community resources and services by providing information, making
referrals and otherwise facilitating access to these supports;
9. Modifying the authorized plan of care,
within the following parameters:
a. In the
event a Member experiences a change in the need for services, the care
coordinator has the authority to adjust the frequency of services under the
authorized plan of care, in order to address the needs. However, the total
number of hours authorized for the eligibility period shall not be
exceeded.
b. In the event a Member
experiences an emergency or acute episode as defined in this Section, the care
coordinator may adjust the authorized plan of care up to fifteen (15) percent
of the monthly authorized amount, not to exceed the monthly program cap.
Services added or changed due to the emergency or acute episode may not
continue beyond fourteen (14) days.
10. Making referrals for reassessments prior
to the end of the eligibility period, and based upon a significant change in
the Member's health status or change in service needs;
11. Issuing notices of intent to suspend,
reduce or terminate, as appropriate, when the Member is ineligible for such
services or the level of services are reduced. The care coordinator may not
issue a notice to reduce or terminate services based on medical
eligibility;
B. Other
activities include, but are not limited to:
1.
Comply with the Department's internal authorization protocols,
2. Maintaining Member records,
3. Providing information as required by the
Department,
4. Following
requirements regarding mandated reporting.
96.04-6
Skills Training includes
the following functions:
A. Instructing the
Member in the management of personal support specialists. Instruction in
management of PSS includes instruction in recruiting, interviewing, selecting,
training, scheduling, and directing a competent PSS in the activities in the
authorized plan of care and obligations under this Section. Providers of skills
training must instruct each new eligible Member prior to the start of
services.
B. The provider must
document that initial skills training has occurred within thirty (30) calendar
days of the Member electing the FPSO option.
C. The Skills Training provider may
substitute a competency-based assessment in lieu of repeat instruction for
Members having previously completed such training under an earlier eligibility
period or from another provider of like services.
