1.05-1
Services Not Managed by PCPs
Certain services contained within the service categories
listed in Section 1.04 may be accessed directly by members, i.e., without a
PCP's referral. The particular services for which a member may self-refer
are:
a. Family planning services. The
following services may be obtained by a member without a PCP referral:
(i) health education and counseling necessary
to make informed choices and understand contraceptive methods;
(ii) distribution of information on family
planning;
(iii) consultation,
examination and medical treatment including, but not limited to, treatment of
urinary tract infection or "UTI".
(iv) diagnosis and treatment of sexually
transmitted diseases (STDs), including lab tests;
(v) screening, testing and counseling for
human immunodeficiency virus (HIV);
(vi) provision of contraceptive pills,
devices, and supplies; and
(vii)
diagnosis of infertility;
b. Obstetrical services. Members may
self-refer for obstetrical services for the duration of pregnancy, and up to
sixty (60) calendar days postpartum. At sixty (60) calendar days postpartum,
the member's PCP must resume treatment/management of member's care. During
pregnancy, non-obstetrical services and treatment must also be managed and
coordinated by the member's PCP;
c
Annual gynecological examinations, that may include, but are not limited to: a
pelvic examination, a PAP smear, clinical breast examination, mammogram, CBC
and routine urinalysis;
d. Mental
health and substance abuse services;
e. Annual routine eye examinations, however,
services must be provided by an optometrist or ophthalmologist; and
f. Medical care provided in school-based
centers or well child clinics.
1.05-2
Sections of MaineCare Benefits
Manual Not Managed By PCPs
The member's PCP will not manage the following services
defined in Chapter II of this Manual. These services do not require a PCP
referral in order to be payable by MaineCare, although they may require prior
authorization by providers of that service and are subject to the requirements
of the respective section of the MBM. Reimbursement for provision of these
services will be made in accordance with the policies set forth in Chapters II
and III of this Manual and will only be made to providers enrolled with
MaineCare, in accordance with Chapter I of this Manual.
a.
Ambulance Services, Section
5.
b.
Community Support
Services, Section 17.
c.
Consumer Directed Attendant Services, Section 12.
d.
Day Habilitation Services for
Persons with Mental Retardation, Section 24.
e.
Day Health Services, Section
26.
f.
Day Treatment
Services, Section 41.
g.
Dental Services, Section 25.
h.
Early Intervention Services,
Section 27.
i.
Family
Planning Agency Services, Section 30.
j.
Home and Community Benefits for the
Elderly and for Adults with Disabilities, Section 19.
k.
Home and Community Based Waiver
Services for Persons with Mental Retardation or Autistic Disorder,
Section 21.
l.
Home and
Community Benefits for the Physically Disabled, Section 22.
m.
Hospice Services, Section 43.
n.
ICF-MR Services,
Section 50.
o.
Laboratory
Services, Section 55.
p.
Licensed Clinical Social Worker, Licensed Clinical Professional Counselor
and Licensed Marriage and Family Therapist Services, Section 58.
q.
Medical Imaging
Services, Section 101.
r.
Behavioral Health Services, Section 65.
s.
Nursing Facility Services,
Section 67.
t.
Organ
Transplant Services, Sections 45 and 90.
u.
Pharmacy Services, Section
80.
v.
Private Duty Nursing
and Personal Care Services, Section 96.
w.
Private Non-Medical Institution
Services, Section 97.
x.
Psychiatric Facility Services, Section 46.
y.
Rehabilitative Services,
Section 102.
z.
Targeted
Case Management Services, Section 13.
aa.
Transportation Services,
Section 113.
bb.
V.D.
Screening Clinic Services, Section 150.
cc.
School-Based Rehabilitation
Services, Section 104.
dd.
New MaineCare Benefits Manual, Chapter II Sections. Any new
sections added to Chapter II of the MaineCare Benefits Manual will
automatically be incorporated as part of Section 1.05 on the date the MaineCare
policy becomes effective unless these rules are revised to include the
service(s) as a Managed Service in Section 1.04.
