Subsection 144-101-II-103.04 - COVERED SERVICES Covered Services include core services, and other ambulatory services.
103.04-1 Core Services are billable at the PPS rate. Core Services include: A. services provided by physicians, physician assistants, advanced practice registered nurses, clinical psychologists, licensed clinical social workers, and licensed clinical professional counselors;B. services and supplies furnished as incident to services of conditionally, temporarily, fully licensed, otherwise legally recognized or approved practitioners who are designated in Section 103.06-1 of this Manual; and C. basic laboratory services essential for the immediate diagnosis and treatment of illness or injury, including, but not limited to: 1. chemical examination of urine by stick or tablet method or both (including urine ketones);2. hemoglobin test or hematocrit;4. examination of stool specimens for occult blood;6. primary culturing for transmittal to a certified laboratory. Note: To qualify for reimbursement, laboratory services must be in compliance with the rules implementing the Clinical Laboratory Improvement Amendments of 1988 (CLIA "88") and any related amendments.
D. emergency medical care treating life-threatening injuries and acute illnesses, including drugs and biologicals such as:E. visiting nurse services (as described in 103.04-4).103.04-2Other Ambulatory Services include: A. Podiatric services for the diagnosis and treatment of problems concerning the human foot. These are limited by the conditions in Chapter II, Section 95, "Podiatry Services", of the MaineCare Benefits Manual.B.Prevention, Health Promotion and Optional Treatment Services ((PHPOT) formerly EPSDT) provided to eligible children in accordance with Chapter II, Section 94, of the MaineCare Benefits Manual.C. Asthma programs are reimbursable if they are based on the Open Airways or Breathe Easier curricula. Any other asthma management service which is approved by the National Heart, Lung and Blood Institute/American Lung Association or the Asthma and Allergy Foundation of America, is also reimbursable. Each asthma program must have:
2. primary instructor (a licensed health professional or a health educator with baccalaureate degree);3. pre-assessment and post-assessment for each participant which shall be kept as part of the member's record;4. an advisory committee which may be part of an overall patient education advisory committee; and5. a physician referral for all participants. Note: Providers should bill the actual cost of the asthma program upon completion of the service, using the procedure code listed in Chapter III, Section 103.
D. Ambulatory Diabetes Education and Follow-Up (ADEF) Services, or similar services approved by the Centers for Medicare and Medicaid Services (CMS) approved national accreditation organization, will be reimbursed when a provider enrolled with the Maine Diabetes and Prevention Control Program furnishes this service to a MaineCare member whose physician has prescribed this program for the management of the member's diabetes. The service includes:1. a pre-assessment interview to determine the member's knowledge, skills and attitudes about diabetes management and to develop an individualized education plan and behavior change goals;2. group class instruction covering the comprehensive curriculum outlined by the Maine Diabetes and Prevention Control Program and based on the individualized education plan;3. a meal planning interview to determine the member's knowledge, skills and attitudes about meal planning and to develop an individualized meal plan and behavior change goals;4. A post-assessment interview to assess and document what the member has learned during the service, and to develop a plan for follow-up sessions to address the component areas not learned in the class series, and finalize behavioral goals; and5. follow-up contacts to reassess and reinforce self-care skills, evaluate learning retention and progress toward achieving the member's behavior change goals. At a minimum, three-month, six-month, and one-year follow-up visits from the date of the last class are required to complete the member's participation in the service. When the MaineCare member is under age 21, this service will also be reimbursed when provided to the person/people who provide the member's daily care.
E. Effective August 1, 2014, Tobaccocessation treatment services will be reimbursed, for eligible Members, provided by physicians or other providers who can provide tobacco cessation treatment services under their licenses or permits. There are no annual or lifetime limits ontobacco cessation treatment services. Counseling services may be provided in the form of individual or group counseling. Both forms of counseling may be provided by licensed practitioners within the scope of licensure as defined under State law and who are eligible to provide other coverable services in Section 103. Tobacco cessation treatment services includes the provision of all pharmacotherapy approved by the Food and Drug Administration (FDA) for tobacco dependence treatment. MaineCare members are not required to participate in tobacco cessation counseling to receive tobacco cessation products Tobacco cessation products are "covered services" reimbursable pursuant to Ch. II, Section 80.05 of the MaineCare Benefits Manual. The services for tobacco cessation treatment are copay exempt. Tobacco cessation treatment services may be billed alone, or in combination with other RHC services. Documentation of the tobacco cessation treatment services must be contained in the medical record.
F. Contraception (injectable, implantable capsules, intrauterine devices) and the administration of influenza and pneumococcal vaccines.103.04-3Off-site delivery of services furnished by clinic staff are reimbursed when Rural Health Clinic Services are provided away from the clinic and when it is documented in the member's chart that it is the most appropriate setting for the provision of services. Examples of off-site service locations include: a nursing facility, an emergency room, or a member's home.103.04-4Visiting nurse services will be reimbursed when: A. a registered nurse or licensed practical nurse provides the services to a member who is homebound;B. the services are provided in accordance with a written Plan of Treatment; C. the member's record documents that the member would not otherwise receive these services;D. the services are provided in an area that the Secretary of the U.S. Department of Health and Human Services has determined has a shortage of home health agencies; andE. the Rural Health Clinic that provides in-home services by a registered licensed practical nurse is licensed by the State of Maine as a home health service provider.103.04-5Interpreter Services - Refer to Chapter I of the MaineCare Benefits Manual for information about reimbursement for interpreter services. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-103, subsec. 144-101-II-103.04