Subsection 144-101-II-13.02 - COVERED SERVICESA Covered Service is a MaineCare service for which payment can be made by the Department. The following services are covered when provided to an eligible member by an approved Targeted Case Management Agency and qualified staff:
A.Comprehensive Assessmentand Periodic Re-assessment of an eligible member to determine service needs, including those activities that focus on needs identification, to determine the need for any medical, educational, social or other services. The comprehensive assessment and re-assessment must be conducted through face-to-face contact with the member and, where appropriate, consultation with other providers and with the member's family. A comprehensive assessment must be completed within the first thirty (30) days of initiation of services, and reassessment must occur as change in the member's needs warrants or at a minimum on an annual basis. These activities include but are not limited to the following: 1. Taking client history;2. Identifying the needs of the individual and completing related documentation; and3. Gathering information from other sources (family members, medical providers, social workers, and educators) if necessary, to form a complete assessment.B.Development and Periodic Revision of the Individual Plan of Care is based on information collected through a comprehensive assessment or re-assessment that: 1. Specifies the goals and actions to address the medical, social, educational, and other services needed by the eligible individual. Because the assessment of the member's needs must be comprehensive, the individual plan of care must also be comprehensive to address all identified needs. Re-evaluation of the individual plan of care must occur as a change in the member's needs occurs or at a minimum every ninety (90)days. A member may decline to receive services that have been identified as needs in the individual care plan. If the member declines services listed in the individual care plan, this must be documented in the individual's case record. This 90 day re-evaluation may be completed by the comprehensive case manager.
2. Develops and periodically revises the Individual Care Plan and to the extent possible: a. Ensures the active participation of the member and as appropriate, the member's parent(s) or legal guardian;b. Works with the member (and others as appropriate) to develop goals; andc. Identifies a course of action to respond to the member's assessed needs. For a child, the plan of care must be developed with a Child and Family Team.C.Referral and Related Activities that help an eligible member obtain needed services. As part of the coordination function, the comprehensive case manager must avoid the duplication of services. The case management referral activity is completed once the referral and linkage has been made. (Referral and related activities do not include providing transportation to the service to which the member is referred, escorting the individual to the service, or providing child care so that an individual may access the service.) These activities are for the purpose of linking the member with medical, social, educational providers or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan. These activities include:
1. Making referrals to providers for needed services, including documentation, and 2. Scheduling appointments for the member.D.Monitoring and Follow-Up Activities that include activities and contacts that are necessary to ensure that the individual care plan is effectively implemented and adequately addresses the needs of the eligible member. This includes contact with the member as needed to monitor the care plan objectives and, if appropriate, periodic contact with the member's family, providers, or other entities. Monitoring may involve either face-to-face or telephone contact. These activities may be conducted as frequently as necessary, but not less than annually, to help determine whether: 1. Services are being furnished in accordance with the individual care plan;2. Services in the care plan are adequate to address the needs of the member; and3. Needs or status of the member has changed which requires necessary adjustments in the care plan and service arrangements with providers or service termination. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-13, subsec. 144-101-II-13.02