The following are covered services reimbursable under MaineCare. All services delivered will ensure that member voice and choice are reflected in all Plan development:
17.04-1Community Integration Services. Community Integration Services includes a biopsychological assessment of the member, an evaluation of community services and natural supports needed by the member who satisfies the eligibility requirements of Section 17.02, and rapport building through assertive engagement and linking to necessary natural supports and community services while providing ongoing assessment of the efficacy of those services. Community Integration Services involve active participation by the member or guardian. The services also involve active participation by the member's family or significant other, unless their participation is not feasible or is contrary to the wishes of the member or guardian. These services are provided as indicated on the ISP. These services may not be provided in a group.
A Community Support Provider furnishing Community Integration Services must employ a certified MHRT/C who performs the following:
A. Identifies the medical, social, residential, educational, vocational, emotional, and other related needs of the member;B. Performs a psychosocial assessment, including history of trauma and abuse, history of substance use, general health, medication needs, self-care potential, general capabilities, available support systems, living situation, employment status and skills, training needs, and other relevant capabilities and needs;C. Facilitate formal and informal opportunities for career exploration during service delivery time for working-age and transition age youth participants;D. Provides assertive, persistent engagement to build rapport and trust with individuals who may be reluctant to accept those services necessary to meet their individual goals;E. Develops an ISP that is based on the results of the assessment in Section 17.04-1(B), which includes: 1. Statements of the member's desired goals and related treatment and rehabilitation goal(s);2. A description of the service(s) and natural support(s) needed by the member to address the goal(s);3. A statement for each goal of the frequency and duration of the needed service(s) and support(s);4. The identification of providers of the needed service(s) and natural support(s);5. The identification and documentation of the member's unmet needs;6. A review of the plan at least every ninety (90) days to determine the efficacy of the services and natural supports and to formulate changes in the plan as necessary; and7. A goal addressing the member's needs and access to primary care, specialty care, and routine appointments.F. Coordinates referrals and advocates access by the member to the service(s) and natural support(s) identified in his or her Individual Support Plan;G. Participates in ensuring the delivery of crisis intervention and resolution services, providing follow-up services to ensure that a crisis is resolved and assistance in the development and implementation of crisis management plans;H. Assists in the exploration of less restrictive alternatives to hospitalization;I. Makes face-to-face contact with other professionals, caregivers, or individuals included in the treatment plan in order to achieve continuity of care, coordination of services, and the most appropriate services for the member per their ISP;J. Contacts the member's guardian, family, significant other, and providers of services or natural supports to ensure the continuity of care and coordination of services between inpatient and community settings;K. Evaluates service provision to determine whether the member's ISP needs to be revised, whether a new plan is needed, or whether services should be terminated;L. Provides information and consultation with the member receiving Community Support Services, to the member, his or her family, or his or her immediate support system, in order to assist the member to manage the symptoms or impairments of his or her illness with a focus on independence;M. Assists the member in restoring and improving - communication skills needed to request assistance or clarification from supervisors and co-workers when needed and in -enhancing skills and employing strategies to overcome or address psychiatric symptoms that interfere with seeking, obtaining, and maintaining a job; andN. Documents evidence of the member's access to primary and specialty care appointments, to minimally include an annual primary care provider visit. This can be in the form of a clinical note or after visit summary.17.04-2Community Rehabilitation Services. Community Rehabilitation Services support the development of the necessary skills for living in the community, and promote recovery, and community inclusion. Services include individualized combinations of the following, and are delivered by a team, with primary case management for eachmember assigned to one team member. Community Integration Services as defined in Section 17.04-1 of the MaineCare Benefits Manual Daily Living Support Services as defined in Section 17.04-4 of the MaineCare Benefits Manual Skills Development Services as defined in Section 17.04-5 of the MaineCare Benefits ManualServices must be available twenty-four (24) hours a day, seven (7) days a week. Staff must be at a work site twelve (12) hours per day and on call the remainder.
A minimum of one (1) face-to-face contact per day, seven (7) days per week must be provided.
The team providing services must be provided by a team made up of MHRT/1's and MHRT/C's, delivering services within the scope of their certifications. The minimum staffing ratio for the team is one (1) staff person to six (6) members. Replacement staff and supervisors are excluded from calculation of the staffing ratio.
Services must be prior authorized by the Department or an Authorized Entity and be appropriate to meet the clinical and rehabilitation needs of the member.
17.04-3Assertive Community Treatment. Assertive Community Treatment (ACT) provides individualized intensive integrated services that are delivered by a multi-disciplinary team of practitioners and are available twenty-four (24) hours a day, every day, three hundred and sixty-five (365) days a year. ACT services are delivered primarily in the community and not in an office based setting. Assertive interventions, including street outreach, are employed by the team as appropriate. ACT teams must provide at least on average, per member, three (3) face-to-face contacts with the member per week. There may be exceptions to the three (3) face-to-face contact requirements and the member's record must clearly document why the contacts did not occur, such exceptions may include; 1. All attempts to reach and meet with the member, including if the member was unavailable or the contact occurred through a closed door.2. Contacts to transition the member to another level of care.3. Variations in the number of weekly face-to-face contacts i.e. two (2) contacts in one week and four (4) the next. If the member is seen as not tolerating or benefitting from the level of intensity of ACT services, the member should be re-evaluated for a different service or level of care.
ACT teams must assume clinical responsibility for all members on the team and must offer all of the following services and support:
Individual assessment and individual support plan development; Development and implementation of a comprehensive crisis management plan and provision of follow-up services, including emergency face-to-face contact, if necessary, to assure services are delivered and the crisis is resolved; Use and promotion of informal and natural supports to assist the member with integration in the community; Contacts with the member's parent, guardian, other family members, and providers of services or natural supports, as appropriate, to ensure continuity of care and coordination of services within and between inpatient and community settings; Individual, group and family outpatient therapy, supportive counseling or problem-solving activities in order to maintain and support the member's recovery and provide the support necessary to help the member manage the symptoms of the member's illness and co-occurring substance use disorder; Linking and evaluating the efficacy of services and natural supports, and formulating changes to the individual support plan as necessary; Medication services, including medication management and administration, which minimally includes: 1) one (1) face-to-face contact per month with the psychiatrist; or a psychiatric and mental health nurse practitioner (NP);2) capacity to administer medications daily in a member's home or community by an appropriately licensed or certified ACT team professional. Employment assistance including facilitating formal and informal opportunities for career exploration and assisting the member in obtaining and maintaining competitive employment; and Housing assistance. A. The minimum overall staffing ratio for an ACT team is one (1) staff person to ten (10) members. Administrative staff are excluded from calculation of the staffing ratio. ACT team staff must include; 1. a Team Leader, who may be one of the staff listed below but must bean independently licensed professional. The team leader must spend at least twenty five percent (25%) of his or her work hours providing direct service to the members. The team leader must be at least one (1.0) FTE (full time equivalent);2. a psychiatristor a psychiatric and mental health clinical nurse specialist (CNS), or a psychiatric and mental health nurse practitioner (NP), who is at least one-half (.5) FTE for every fifty (50) members and provides clinical leadership to the team in conjunction with the Team Leader;3. a registered nurse, who is at least one (1.0) FTE for every fifty (50) members;4. a certified rehabilitation counselor or employment specialist, who spends at least ninety percent (90%) of his or her time on employment related activities and who is at least one (1.0) FTE for every fifty (50)members;5. a Certified Intentional Peer Support Specialist (CIPSS), The Department is seeking and anticipates receiving CMS approval for this section. Pending approval, the CIPSS shall beat least one (1) FTE; and6. a substance use disorder counselor who is at least one-half (.5) FTE for every fifty (50) members.B. Multidisciplinary teams may also include any of the following; 1. a licensed occupational therapist,3. a licensed psychologist, or4. a licensed clinical social worker or a licensed clinical professional counselor.17.04-4Daily Living Support Services. Daily Living Support Services are designed to assist a member to maintain the highest level of independence possible. The services provide personal supervision and therapeutic support to assist members to develop and maintain the skills of daily living. The services help members remain oriented, healthy, and safe. Without these supportive services, members likely would not be able to retain community tenure and would require crisis intervention or hospitalization. These services are provided to members in or from their homes or temporary living quarters in accordance with an individual support plan. Support methods include modeling, cueing, and coaching. The services do not include specialized crisis support services as described in the MaineCare Benefits Manual,Chapter II, Section 65, Behavioral Health Services, subsection 65.06-1, Crisis Resolution. Daily Living Support Services are provided by an MHRT-1, except that when Daily Living Support Services includes administration and supervision of medication, a CRMA must provide that portion of the services.Daily Living Support Services do not include:
A. Programs, services or components of services that are primarily opportunities for socialization and activities that are solely recreational in nature (such as picnics, dances, ball games, parties, field trips, religious activities, social clubs, camp and companionship activities).B. Programs, services or components of services the basic nature of which is to maintain or supplement housekeeping, homemaking or basic services for the convenience of a person receiving services (including housekeeping, shopping, childcare and laundry services). A Community Support Provider who furnishes services to a member under Sections 17.04-1 or 17.04-3 may also contract with DHHS to furnish Daily Living Support Services to the member concurrently. Requests for these concurrent services must be approved by DHHS or an Authorized Entity, in accordance with Section 17.09-2(B). If approved, the provider shall review the member's ISP, developed pursuant to 17.04-1(E), at least every ninety (90) days to determine whether the Daily Living Support Services should be continued. DHHS or an Authorized Entity must determine at least every ninety (90) days whether to authorize continuation of the services upon request in accordance with Section 17.09-2(B).
A Community Support Provider may furnish Daily Living Support Services to a member, even though the provider is not concurrently furnishing services to the member under Sections 17.04-1 or 17.04-3 or Section 92. In that event, another Community Support Provider who is under contract with DHHS to provide services under Sections 17.04-1 or 17.04-3 or Section 92 must review the member's ISP, developed pursuant to 17.04-1(E) or Section 92 at least every ninety (90) days and determine whether the Daily Living Support Services should be continued. DHHS or an Authorized Entity must determine at least every ninety (90) days whether to authorize continuation of the services, upon request in accordance with Section 17.09-2(B). Daily Living Support Services may not be provided concurrently to the member under Section 17.04-5, Skills Development Services.
17.04-5Skills Development Services. Skills Development Services involve face-to-face contact with the member, with or without family or non-professional caregivers, that restore and improve the member's skills and abilities essential to independent living (i.e. self-care and daily life management). Services may be provided to an individual or in a group setting and are targeted to enhance access to community resources, with natural supports, increase independence to promote successful community integration. Skill enhancement is provided through structured interventions for attaining goals identified in the ISP. Progress on goals will be reviewed at least every ninety (90) days to determine the efficacy of the services and natural supports and to formulate changes in the plan as necessary. Skills Development Services are provided by an MHRT/C and when Skills Development includes administration and supervision of medication, a CRMA must provide that portion of the services.
When Skills Development Services are related to supporting employment for a member, they must be billed with the code for "Ongoing Support to Maintain Employment." Such services are focused on managing behaviors or symptoms that interfere with an individual's ability to obtain or retain employment. Services include instruction in dress, grooming and socially acceptable behaviors in the workplace, supportive contacts on or off the job, instruction and skill development on how to request workplace accommodation, how to solve problems and resolve coworker conflict.
When Skills Development Services are provided to a member for ten (10) or fewer hours per week, continuation of the services beyond one (1) year requires, upon request, prior authorization by DHHS or an Authorized Entity -, in accordance with Section 17.09-2(B). When services are provided for more than ten (10) hours per week, DHHS or an Authorized Entity must review continuation of the services every ninety (90) days in accordance with Section 17.09-2(B). Skills Development may be provided in a group when facilitated by qualified staff and comply with 17.10-2. Skills Development Services may not be provided concurrently to the member with Section 17.04-4.
17.04-6Day Supports Services. Day Supports Services, formerly known as "day treatment," focus on training designed to assist the member in the acquisition, retention, or improvement of self-help, socialization, and adaptive skills. These services take place in an agency environment. They are offered most often in a group setting and are provided by certified MHRT/Cs under the supervision of, or are co-facilitated by, a mental health professional as defined in 17.07-1. Day Supports Services are covered for one (1) year from the start date of the services unless, upon request of the provider, DHHS or an Authorized Entity - approves continuation of the services in accordance with Section 17.09-2(B).17.04-7Interpreter Services. Interpreter Services for MaineCare members who are hearing impaired or who do not speak English may be reimbursed in accordance with Chapter I, Section 1.06-3, of the MaineCare Benefits Manual. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-17, subsec. 144-101-II-17.04