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-97 - Private Non-Medical Institution Services
Subsection 144-101-II-97.05 - LIMITATIONS
Current through 2024-38, September 18, 2024
97.05-1 Collateral Contacts
Reimbursement shall be made for direct services, collateral contacts, and certain supportive services when there is not a direct encounter with the member, only as described in Chapter III, Principles of Reimbursement for PNMIs, Section 2400, and when provided by qualified staff members.
97.05-2 Non-Duplication of Services
It is the responsibility of the PNMI provider to coordinate PNMI services with other "in-home" services to address the full range of member needs. Other MaineCare covered services shall not duplicate PNMI services included in the facility's PNMI rate. Covered services, listed in the applicable Appendix, and/or in contracts with the Department, that are part of the PNMI rate are the responsibility of the PNMI to provide or arrange under contract as necessary with providers practicing within the scope of their licensure.
Services that are part of the PNMI rate may not be billed to MaineCare separately by other providers. Personal care services are included as part of the PNMI rate and shall be delivered by the PNMI provider and not by a MaineCare provider under any other Section of this Manual including PSS under Section 96, Private Duty Nursing and Personal Care Services provider or other Section of MaineCare policy.
PNMI providers must coordinate their services with all other MaineCare services, including but not limited to case managers providing services outside the residential setting, in accordance with the provisions of Chapter II, Section 13, of the MaineCare Benefits Manual, Targeted Case Management Services.
97.05-3 Out-of-State Placement
Reimbursement shall not be made for Private Non-Medical Institution services provided out of state unless the services are medically necessary, and are not available within the State and prior authorization (as described in this Section and Chapter I, of the MaineCare Benefits Manual) has been granted.
97.05-4 Bed-Hold Days
Bed-hold days are not reimbursable.
For members receiving State S.S.I. and cost-reimbursement benefits, in order for benefits to continue for a member who is temporarily admitted to a State institution, a hospital, or a nursing facility when the residential care facility provider has agreed to hold the bed, the provider must do the following:
