96.07-1
Eligibility Determination
Applicants for services under this Section must meet the
eligibility requirements set forth in Section 96.02. An eligibility assessment,
using the Department's approved MED assessment form, shall be conducted by the
Department, the ASA, or the PDN provider, as applicable.
Eligibility for individuals under the age of 21, and for
medication services or venipuncture services, and excluding all seeking
services under the family provider services option, shall be determined by the
PDN provider, in accordance with the requirements of Section 96.02 and the MED
form.
These services require prior approval by the Department.
All other PDN/PCS services, for Members age 21 and over, and those requesting
services under the family provider service option, require eligibility
determination and prior approval by the ASA.
Applicants ages 18 and over who meet the NF medical
eligibility criteria also qualify for Home and Community Benefits. These
benefits may provide a greater array and quantity of services than otherwise
available under this Section
96; therefore, applicants must be
assessed to determine whether they qualify for NF level of care.
Members are prohibited from receiving Home and Community
Benefits and services under this Section simultaneously, except as described in
Section 96.05(L).
A. If financial
eligibility for MaineCare has not been determined, the applicant, family Member
or guardian, must be referred to the regional Office for Family Independence,
concurrent with the relevant medical eligibility determination
process.
B. The Department, or its
ASA, shall conduct a medical eligibility assessment using the Department's
approved MED assessment form. The individual conducting the assessment shall be
a registered nurse and will be trained in conducting assessments and developing
an authorized plan of care with the Department's approved tool. The RN
assessor's findings and scores recorded in the MED form shall be determinative
in establishing eligibility for services and the authorized plan of
care.
C. The PDN provider shall
develop a nursing plan of care, which shall be reviewed and signed by the
Member's physician. It shall include the personal care and nursing services
authorized by the ASA or the Department, and the nursing plan signed by the
Member's physician.
D. The
anticipated costs of services under this Section to be provided under the
authorized plan of care must conform to the limits set forth in Section 96.03
and 96.06.
E. An individual's
specific needs for medical services must be reviewed and approved by the
Member's physician at least every 62 days, and so documented in the medical
record and nursing plan of care by the RN.
1.
Applicants, age 21 and over, and Members requesting services under the family
provider service option, who meet the eligibility criteria for PDN services, as
set forth in Section 96.02, and as documented by the Department's approved MED
assessment form, shall:
a. Be assigned, by
the ASA, to the appropriate level of care, and receive an authorized plan of
care based upon the scores, timeframes, findings and covered services recorded
in the MED assessment. The covered services to be provided in accordance with
the authorized plan of care shall:
1) not
exceed the established financial caps;
2) be authorized by the Department or its
ASA; and
3) be under the direction
of the Member's physician for the nursing plan of care.
b. The assessor shall approve an eligibility
period for the Member, based upon the scores, timeframes and needs identified
in the MED assessment for the covered services, and the assessor's clinical
judgment. The eligibility period shall not exceed 12 months.
c. Except for those Members who qualify under
Level IX, the assessor shall notify the Service Coordination Agency within two
business days of the medical eligibility determination and authorization of the
plan of care. For those Members who are eligible under Level IX, the assessor
shall forward the completed assessment and plan of care to the Licensed
Assisted Living Agency, as defined in § 96.01-28.
2. Members under age 21, excluding those
requesting services under the family provider service option.
a. Services require prior approval by the
Department. The Department shall approve an eligibility period, not to exceed
one year.
b. An individual under
age 21, who does not meet the eligibility criteria for PDN services as set
forth in Section 96.02, may be reviewed under Prevention, Health Promotion, and
Optional Treatment Services. If the provider determines that services are
medically necessary pursuant to the criteria of Prevention, Health Promotion,
and Optional Treatment Services, then services shall be provided in accordance
with a plan of care and billed under this Section, adhering to all applicable
financial caps unless authorization to exceed that cap has been granted by the
Department as outlined under Section 96.03(A).
c. If a provider determines that any of the
requested services, for an individual under age 21, are medically necessary,
but are not available from that provider, the provider shall notify the family
in writing (in the Department's approved notice format) which services are not
available from that provider. A copy of the letter shall be sent to the
Department's Prevention, Health Promotion, and Optional Treatment Services
staff, and Prevention, Health Promotion, and Optional Treatment Services staff
shall offer to assist the Member in locating other providers.
d. If the provider determines that the
PDN/PCS services are not medically necessary, then the provider shall notify
(using a notice format approved by the Department) the family in writing of
which services will be provided and which services will not be provided, or
provided only on a reduced basis. The notice shall contain an understandable
explanation of the reasons and inform them of their appeal rights and of
Prevention, Health Promotion, and Optional Treatment Services. A copy of any
denial/reduction notice shall be sent to the Prevention, Health Promotion, and
Optional Treatment Services. Prevention, Health Promotion, and Optional
Treatment Services will then offer to assist the family to see what other
services may be provided to meet the child's needs.
e. The private duty nursing services provider
shall develop a nursing plan of care and an authorized plan of care.
f. The anticipated costs of services to be
provided under the plan of care must conform to the limits set forth in Section
96.03. The costs of physical therapy, occupational therapy, speech and hearing
services shall not be included in the calculation of either the average annual
cost of institutional services or the cost of PDN services required by the
individual.
g. The PDN/Personal
care services provider shall obtain the signature of the physician on the plan
of care or a physician's order for private duty nursing and personal care
services and for the medical treatment plan. This shall be made available to
the Department or its Authorized Entity upon request. Services must also be
authorized by the Department or its Authorized Entity.
h. For services to individuals under age 21,
as well as individuals classified for venipuncture services and medication
services, but excluding those receiving services under the family provider
service option, the eligibility assessment form and the plan of care shall be
maintained in the Member's medical record, available upon request for review by
the Department. The provider must submit a copy of the medical eligibility
determination form to the Department.
i. The provider shall be responsible for
assuring that the plan of care shall not exceed the financial cap established
by the Department.
96.07-2
Redetermination of
Eligibility
A. For all Members under
this Section, in order for the reimbursement of services to continue
uninterrupted beyond the approved eligibility period, a reassessment and prior
approval of services is required and must be conducted at least 5 days prior to
and no later than the reclassification date.
For Members under the age of 21, as well as Members
classified for venipuncture services and medication services, but excluding
those receiving care under the family provider service option, the MED
assessment tool shall be submitted to MaineCare Services, Quality Improvement
Division within 72 hours of completion of the MED form, for initial assessments
or reassessments. MaineCare payment ends with the reassessment date, also known
as the eligibility end date.
B. An individual's specific needs for medical
services are reviewed at least every 62 days, and so documented in the medical
record and nursing plan of care by the RN.
96.07-3
Family Provider Service
Option. All requirements of Section
96 apply to the family provider
service option unless exempted specifically in this sub-Section, or elsewhere
in this Section. This option allows, under certain conditions specified below,
a MaineCare Member (or a family Member on his or her behalf,) to solely manage
the Member's authorized personal support services, if the Member (or a family
Member,) is a family provider agency. The management of the personal support
services includes: hiring, firing, training, maintaining records and scheduling
the PSS(s). This service option is not available to those Members who receive
services based on Level IX eligibility criteria.
A. The following provisions apply:
1. The MaineCare Member, or his or her family
Member (see below), as applicable, must be age 21 years or older, and register
with the Department as a personal care agency, pursuant to the Department's
"Rules and Regulations Governing In-Home Personal Care and Support
Workers".
2. A family Member
related by blood, marriage or adoption, or a significant other in a committed
partnership, must register as the personal care agency in order to manage the
personal care services on behalf of the MaineCare Member, if the Member does
not have the ability, or does not meet the required standards for cognitive
capacity, or otherwise does not desire to manage his or her own care.
3. The MaineCare Member must meet the minimum
standards for cognitive capacity as defined in Section 96.01-26, in order to be
the family provider agency.
4. For
children and youth under age 21 years, a parent or guardian may be the family
provider agency, if the child has all required medical eligibility
determination assessments performed by the ASA and management performed by the
Service Coordination Agency, as is required of all other Members using this
family provider service option. (Note: under other Sections of this rule,
children's services do not go through the ASA and the Service Coordination
Agency.)
5. Participation is
subject to the approval (and ongoing approval) of the Service Coordination
Agency.
6. The family provider
agency may manage personal care services for up to two family
Members.
7. The family provider
agency may hire a family Member to deliver the personal care services, with the
exception of the MaineCare Member's spouse, or the parent (including
stepparent) of a minor child who is a MaineCare Member. Refer to Federal
regulation
42 CFR
440.167, and the State Medicaid Manual,
Section 4480, "Personal Care Services" (prohibits the coverage of personal care
services delivered by these legally responsible family Members.)
8. The adult who is registered as the
personal care agency will not be paid to provide care to the Member.
9. A Member's guardian will not be paid to
provide care to the Member.
B. The family provider agency must:
1. check the Maine Registry of Certified
Nursing Assistants and Direct Care Workers and conduct a criminal history
background check for any individual hired as a personal care assistant and not
employ an individual who is prohibited from employment under Title
22
MRSA
§1717(3);
2. use a fiscal intermediary payroll entity
that has been approved by the Department;
3. receive authorization from the ASA,
including an authorized plan of care;
4. implement the authorized plan of
care;
5. comply with the
Department's quality assurance oversight activities and visits; failure to
comply will result in termination of the Member's participation in the family
provider service option.
C. As part of the family provider services
option, the Service Coordination Agency must:
1. check the Maine Registry of Certified
Nursing Assistants and Direct Care Workers and conduct a criminal background
check on the individual who registers as a personal care agency; and
2. manage the Member's authorized
professional services (i.e., RN services); and
3. assist the Member with contacting a fiscal
intermediary.
D. As part
of the family provider services option, the Assessing Services Agency must
serve as the Department's authorized entity for Members under age 21 who are
receiving services under the family provider services option as defined in
Section 96.01-23.
96.07-4
Discharge Notification
A. A
provider serving children under age 21, and Members receiving venipuncture
services and medication services, must notify the Department within 48 hours of
discharging a Member from care.
B.
A provider serving Members age 21 and over must notify the Service Coordination
Agency within 48 hours of discharging a Member from care.
96.07-5
ELECTRONIC VISIT VERIFICATION
(EVV)
Effective January 1, 2020, providers of Private Duty
Nursing Services and Personal Care Services must comply with the Maine DHHS
Electronic Visit Verification ("EVV") system for standards and requirements. In
compliance with Section 12006 of the 21st Century CURES Act (
P.L.
114-255), as codified in
42 U.S.C. §
1396b(l)(1), visits
conducted as part of such services must be electronically verified with respect
to: the type of service performed; the individual receiving the service; the
date of the service; the location of the service delivery; the individual
providing the service; and the time the service begins and ends. Providers may
utilize the Maine DHHS EVV system at no cost, or may procure and utilize their
own EVV system, so long as data from the provider-owned system can be accepted
and integrated with the Maine DHHS EVV system and is otherwise compatible.
Private Duty Nursing Level IX, care coordination, and skills training services
are exempt from EVV compliance.
96.07-6
Professional and Other
Qualified Staff
All professional staff must be conditionally,
temporarily, or fully licensed as documented by written evidence from the
appropriate governing body. All professional staff must provide services only
to the extent permitted by qualified professional staff licensure. Services
provided by the following staff are reimbursable under this Section.
A.
Registered Professional Nurse
A registered professional nurse employed directly or
through a contractual relationship with a home health agency or acting as an
individual practitioner may provide private duty nursing services by virtue of
possession of a current license to practice their health care discipline in the
state in which the services are performed.
B.
Psychiatric Registered Nurse
A registered professional nurse that is licensed by the
state or province in which services are provided and has met requirements for
approval to practice as an advanced practice psychiatric nurse or is certified
as a psychiatric and mental health nurse by the appropriate national
accrediting body.
C.
Licensed Practical Nurse
A licensed practical nurse employed directly by or
through a contractual relationship with a licensed home health agency may
provide private duty nursing services by virtue of possession of a current
license to practice their health care discipline in the state in which the
services are performed provided they are supervised by a registered
professional nurse.
D.
Home Health Aide
Any home health aide employed directly by, or acting
under a contractual relationship with, a licensed home health agency must have
satisfactorily completed training for certified nurse assistants consistent
with the rules and regulations of the Maine State Board of Nursing. Home health
aides employed by a home health agency must also have satisfactorily completed
an agency orientation as defined by the Regulations governing the Licensing and
Functioning of Home Health Care Services and be listed on the Maine Registry of
Certified Nursing Assistants and Direct Care Workers. The HHA must meet all
applicable state laws and regulations as are currently in effect.
E.
Certified Nursing
Assistant
A CNA employed by, or acting under a contractual
relationship with, a licensed home health agency must have satisfactorily
completed training for certified nurse assistants consistent with, and receive
supervision consistent with, the Rules and Regulations of the Maine State Board
of Nursing and be listed on the Maine Registry of Certified Nursing Assistants
and Direct Care Workers registry. The CNA must meet all applicable state laws
and regulations as are currently in effect.
F.
Certified Nursing
Assistant/Medications
A CNA who meets the requirements in Section 96.06-4(E)
above and has satisfactorily completed a Department-approved medication course
for Certified Nursing Assistants, consistent with the Rules and Regulations of
the Maine State Board of Nursing and be listed on the Maine Registry of
Certified Nursing Assistants and Direct Care Workers.
G.
Personal Support Specialist
(PSS)
A PSS must be employed by, or acting under a contractual
relationship with a licensed home health agency, registered personal care
agency, or licensed assisted living agency, as defined in § 96.01-28,
under contract with Office of Aging and Disability Services. The following
requirements must be met:
1.
Criminal background check and CNA and Direct Care Workers registry
check. A provider agency must check the Maine Registry of Certified
Nursing Assistants and Direct Care Workers and conduct criminal background
checks for applicants for positions as PSSs, CNAs or home health aides and must
not employ an individual who is prohibited from employment under Title
22
MRSA §1717.
2.
Training. A provider agency
must verify that a PSS meets one of the training and examination requirements
below. An individual without the required training may be hired and reimbursed
for delivering personal care services as long as the individual enrolls in a
certified training program within sixty (60) days of hire and completes
training and examination requirements within nine months of employment and
meets all other requirements. If the individual fails to pass the examination
within nine months, reimbursement for his or her services must stop until such
time as the training and examination requirements are met. A PSS must: (meet
one of the following):
a. Hold a valid
certificate of training for nursing assistants or have official documentation
of equivalent training as verified by the office of the Maine Registry of
Certified Nursing Assistants and Direct Care Workers, and be currently listed
on the Maine Registry of Certified Nursing Assistants and Direct Care Workers
without any annotation that would prohibit that individual from employment;
or
b. Hold a valid certificate of
training, issued within the past three years, for nurse's aide or home health
aide training which meets the standards of the Maine State Board of Nursing-
nursing assistant training program; or
c. Pass the competency-based examination of
didactic and demonstrated skills from the Department's approved personal
support specialist curriculum if a CNA whose status on the Maine Registry of
Certified Nursing Assistants has lapsed, or an individual who holds a valid
certificate of training issued more than three years ago, for nurse's aide or
home health aide training which meets the standards of the Maine State Board of
Nursing nursing assistant training program. A certificate of training as a
personal care assistant/personal support specialist will be awarded upon the
successful passing of this examination; or
d. Hold a valid certificate of training as a
personal support specialist/personal care assistant issued as a result of
completing the Department-approved personal support specialist training
curriculum and passing the competency-base examination of didactic and
demonstrated skills. The training course must include at least 50 hours of
formal classroom instruction, demonstration, return demonstration, and
examination. Tasks covered under this Section must be covered in the training;
or
e. Be a personal support
specialist (PSS) who successfully completed a Department-approved curriculum
prior to September 1, 2003. Such individuals will be grand fathered as a
qualified personal care assistant/PSS; or
f. Obtain a waiver from the Department, the
ASA, or the Service Coordination Agency. At their discretion, the Department,
the ASA, or the Service Coordination Agency, may waive training requirements
for Personal Support Specialists under the family provider service option if
the PSS has provided services to the Member prior to July 1, 2004 under Section
12, "Consumer Directed Attendant
Services" or the state funded Consumer Directed Home Based Care program, under
Section 63, "In-home and Community Support Services" of the Office of Aging and
Disability Services
Policy Manual. Otherwise, PSSs under the
family provider service option must meet the training and competency
requirements described above.
3.
New employee orientation
a. A PSS, newly hired by an agency, who meets
the Department's PSS training requirements, must receive an agency orientation.
The training and certification documents must be on file in the PSS's personnel
file.
b. With the exception of
family provider service option PSSs, a newly hired PSS who does not yet meet
the Department's training and examination requirements must undergo an 8 hour
orientation that reviews the role, responsibilities and tasks of the PSS. To
meet the required eight hours for orientation an agency may choose to use job
shadowing for a maximum of two (2) hours of the 8 hour time requirement. The
orientation must be completed by the PSS prior to the start of delivering
services. The PSS must demonstrate competency to the employing agency in all
required tasks prior to being assigned to a Member's home, with the exception
of health maintenance activities, where by a PSS can demonstrate competency via
on the job training once being assigned to a member's home.
c. A family provider agency must provide
adequate orientation for the PSS to meet the needs of the Member(s). Adequacy
shall be determined by the Service Coordination Agency. The provision of
orientation, including the specific dates and times of training, and the
content matter of the orientation must be documented in the PSS's personnel
record.
4. Provider
agency responsibilities include, but are not limited to the following:
a. Assure that PSSs meet the training,
competency, and other requirements of this Section. Maintain documentation of
how each requirement is met in the PSS's personnel file, including: evidence of
orientation, Maine Registry of Certified Nursing Assistants and Direct Care
Workers check, and criminal background checks, and the verification of
credentials including
b.
Initial and Supervisory visits
i.
Initial visit. A provider
agency supervisor or representative must make an initial visit to a Member's
home prior to the start of personal care services to develop and review with
the Member the plan of care as authorized by the ASA on the care plan summary
and as ordered by the care coordinator.
ii.
Scheduled supervisory
visits. Excluding the family provider service option, for Level III, IV,
and V Members, A PSS employed by a provider agency must receive on-site
supervision of the implementation of the Member's authorized plan of care by
the agency employer at least quarterly to verify competency and Member
satisfaction with the PSS performance of the care plan tasks. For Level I and
II Members, on-site supervision must be at least once every 6 months along with
quarterly phone calls to the Member. More frequent or additional on-site
supervision visits of the PSS is at the discretion of the provider agency as
governed by its personnel policies and procedures.
iii.
Supervisory visits for the family
provider service option. PSSs reimbursed under the family provider
service option must have on-site home supervisory visits by the Service
Coordination Agency to evaluate the condition of the Member, implementation of
the care plan, and the Member's satisfaction with the services. Failure to
allow the Service Coordination Agency on-site visits is grounds for terminating
reimbursement to the PSS worker or agency.
c. A provider agency must develop and
implement written policies and procedures to ensure that PSSs do not smoke or
consume alcohol or controlled substances in the Member's home or vehicle during
work hours.
d. A provider agency
must develop and implement written policies and procedures that prohibit abuse,
neglect or misappropriation of a Member's property.
5. A family Member who meets the requirements
of this Section may be a PSS and receive reimbursement for delivering personal
care services, with the exception of the MaineCare Member's spouse, or the
parent (including stepparent) of a minor child who is a MaineCare Member. Refer
to Federal regulation
42 CFR
440.167, and the State Medicaid Manual,
Section 4480, "Personal Care Services" (prohibiting the coverage of personal
care services delivered by these legally responsible family Members.)
6. The Department has the authority to recoup
funds for services provided if the provider agency does not provide required
documentation to support qualifications of the agency, staff or services
billed.
7. The Office of Aging and
Disability Services has the responsibility of ensuring the quality of services
and the authority to determine whether a PCA agency has the capacity to comply
with all service requirements. Failure to meet standards must result in
non-approval or termination of the contract for PCA
services.
H.
Fiscal
Intermediary
For purposes of this subsection, the Fiscal Intermediary
acts as an entity of the employer in accordance with Federal Internal Revenue
Service Codes and procedures in matters related to the employment of support
workers and purchases of other support services or goods. The Fiscal
Intermediary Entity has an established contract with the Department, but is not
a billable service under this Section. The use of a FI is required under the
family provider service option.
I. Certified Residential Medication Aides
(CRMAs) are allowed to administer medications to persons served by DHHS
Licensed Assisted Housing Programs, as defined in
22 M.R.S.A.
§7852, and other licensed facilities
only after they have successfully taken a 40-hour class, passed a written test,
and demonstrated medication administration competence to an RN. CRMA services
are reimbursable under this Section only when employed by the Licensed Assisted
Living Agency, as defined in § 96.01-28, that holds a valid contract with
Office of Aging and Disability Services and the CRMA is working under the
consultation of an R.N.
96.07-7
Member's Records
A.
Authorized Entity, Service
Coordination Agency and Direct Care Provider Records
There shall be a specific record for each Member which
shall include the following:
1.
Member's name, address, phone number, emergency contact, birth date;
2. The Member's medical eligibility
determination form, release of information, authorized plan of care and copies
of the eligibility determination notice and service authorizations issued by
the Service Coordination Agency for Members over age 21;
3. Names and telephone numbers of the persons
to call in case of an emergency or for advice or information. This information
must be readily available to the HHAs, CNAs, PSSs, CRMAs and other in-home care
workers;
4. The plan of care which
specifies the tasks and the schedule of tasks to be completed by the PSS, CNA,
HHA or CRMA and authorized services. Whenever a RN or LPN delivers services to
more than one patient in the same setting, during the same visit (see Section
96.04(F) multiple patient nursing services) then this service must be described
and documented in each Member's plan of care;
5. Entrance and exit times, and total hours
spent in the home for each visit by each nurse, PSS, HHA, and CNA;
6. The number of medication passes performed
by the CRMA for each Member under Level IX; and
7. Progress notes reflecting changes in the
Member's condition, needs, communications with the Member, other information
about the Member, and contacts with other involved agencies. Progress notes
must be signed and dated by the person entering the note.
B.
Authorized Plan of Care
1. The authorized plan of care must indicate
the type of services to be provided to the Member, specifying who will perform
the service, the number of hours per week, specifying the begin and end dates,
and specifying the tasks and reasons for the service.
For all Members age 21 and over, excluding those
eligible for medication services or venipuncture services, and for those
Members under age 21 receiving care under the family provider service option,
the Assessing Services Agency has the authority to determine and authorize the
plan of care.
2. Members may
receive Medicare covered services, as applicable, during the same time period
they receive MaineCare covered PDN/PCS. The authorized plan of care must
identify the types and service delivery levels of all other home care services
to be provided to the Member whether or not the services are reimbursable by
MaineCare. These additional home care services might be provided by such
individuals as homemakers, personal care attendants and companions. These
additional services shall include, but not be limited to, case management,
home-delivered meals, physical therapy, speech therapy, occupational therapy,
MSW services and hospice.
C.
Nursing Treatment Plan of
Care
The licensed home health agency provider or independent
contractor shall obtain the signature of the physician at least every 62 days
on the nursing plan of care and on the physician's orders for nursing
treatments and procedures, medications, medical treatment plan, and the
frequency and level of personal care services. (The physician orders and
nursing plan of care may be combined into one document.) These shall be made
available to the Department or its Authorized Entity upon request. Covered
services must be authorized by the Department or the ASA. Content of the
nursing treatment plan must include the following information:
1. All pertinent diagnoses, including mental
status;
2. All services, supplies,
and equipment ordered;
3. The level
of care, frequency and number of hours to be provided;
4. Prognosis, rehabilitation potential,
functional limitations, activities permitted, nutritional requirements,
medications and treatments, safety measures to protect against injury, and any
additional items the PDN services provider or physician choose to include.
Orders for care must indicate a specific range in the frequency and number of
hours. Orders may not be open-ended or "as needed;" and
5. The nursing plan of care and physician's
orders for nursing treatments and procedures must be reviewed and signed by the
Member's physician as required by the Department in this Section at least every
62 days.
D. Written
Progress Notes for Services Delivered by a Direct Care Provider must contain:
1. The service provided, date, and by
whom;
2. Entrance and exit times of
nurse's, home health aides, certified nursing assistants and personal care
assistant's visits and total hours spent in the home for each visit. Exclude
travel time (unless provided as a service as described in this
Section);
3. a written service plan
that shows specific tasks to be completed and the schedule for completion of
those tasks;
4. Progress toward the
achievement of long and short-range goals. Include explanation when goals are
not achieved as expected;
5.
Signature of the service provider; and
6. Full account of any unusual condition or
unexpected event, dated and documented.
E. Written Progress Notes for the Service
Coordination Agency must contain:
1. Date and
time of every contact with the Member and by whom; and
2. Progress toward the achievement of long
and short range goals. Include explanation when the goals are not met as
expected; and
3. Signature and date
of the Service Coordination Agency staff Member entering the note;
and
4. Full account of any unusual
condition or unexpected event, dated and documented; and
5. All entries must be signed by the
individual who performed the service. Authorized and valid electronic
signatures are acceptable.
96.07-8
Program Integrity
All providers are subject to the Department's Program
Integrity activities. Refer to Chapter I, "General Administrative Policies and
Procedures", for rules governing these functions.
96.07-9
Member Appeals
A Member or applicant has the right to appeal in writing
or verbally any decision made by the Department or its Authorized Entity, to
reduce, deny or terminate services provided under this benefit. In order for a
Member's services to continue during the appeal process, a request must be
received by the Department within 10 days of the notice to reduce or terminate
services. Otherwise, an individual has 60 days in which to appeal a decision.
Members or applicants shall be informed of their right to request an
Administrative Hearing in accordance with this Section and Chapter I of this
Manual.
A. An appeal for Members or
Applicants, aged 21 and over, and those under age 21 receiving care under the
family provider services option, must be requested in writing or verbally to:
Director
Office of Aging and Disability Services
c/o Hearings
11 State House Station
Augusta, ME 04333-0011
B. For Members under the age of 21, and for
all Members classified for medication services or venipuncture services, but
excluding those receiving care under the family provider services option, an
appeal must be made by the Member or his or her representative, in writing or
verbally, for a hearing to:
Director
MaineCare Services
Department of Health and Human Services
11 State House Station
Augusta, Maine 04333-0011
For the purposes of determining when a hearing was
requested, the date of the fair hearing request shall be the date on which the
Director receives the request for a hearing. The date a verbal request for a
fair hearing is made is considered the date of the request for the hearing.
MaineCare Services may also request that a verbal request for an administrative
hearing be followed up in writing, but may not delay or deny a request on the
basis that a written follow-up has not been received.
