C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-17, subsec. 144-101-II-17.05

Current through 2024-51, December 18, 2024

Subsection 144-101-II-17.05 - LIMITATIONS

17.05-1Reimbursement. MaineCare will reimburse only for covered services provided by agencies and individuals pursuant to Section 17.07-2.

17.05-2Multiple Provider. Only a single Community Support Provider may be reimbursed at the same time for services to any one member under this Section for Community Integration Services, Community Rehabilitation Services, or Assertive Community Treatment. Other Community Support Services are reimbursable under this Section to more than one Community Support Provider at a time. Requests for a waiver of the limitation on multiple providers may be approved by DHHS or an Authorized Entity, upon request and in accordance with Section 17.09-2(C).

Every Service under this Section must have an ISP as defined in 17.01-12. Coordination between all Section 17 providers is required and must be documented in the ISP. The Community Support Provider who delivers 17.04-1 (Community Integration), 17.04-2 (Community Rehabilitation Services), or 17.04-3 (Assertive Community Treatment-ACT) services must develop an Individual Support Plan (ISP) pursuant to 17.04-1(E). If a member receives one of these four (4) services as well as 17.04-4 (Daily Living Support), 17.04-5 (Skills Development), 17.04-6 (Day Support), or 17.04-7 (Specialized Group) services, provided by the same agency, each service must also be added to the member's ISP developed pursuant to 17.04-1(E). If 17.04-4 (Daily Living Support), 17.04-5 (Skills Development), 17.04-6 (Day Support), or 17.04-7 (Specialized Group) services are provided by a different Community Support Provider, the provider of the additional service is responsible for ensuring that the service is authorized, integrated and added in writing into the ISP developed by the Community Support Provider delivering 17.04-1, 17.04-2, 17.04-3 services.

17.05-3Concurrent Provision of Services. The following chart reflects covered services that may, and may not, be concurrently provided to a member:

A. Type of Service	B. Additional Services that May be Provided Concurrently with the Service Listed in Column A	C. Services that may not be Provided Concurrently with the Service Listed in Column A
Community Integration Services	1. Daily Living Support Services or Skills Development Services or Day Supports Services; and 2. Interpreter Services	1. Assertive Community Treatment 2. Community Rehabilitation Services 3. Section 92, Behavioral Health Home 4. Section 13, Targeted Case Management
Community Rehabilitation Services	1. Day Supports Services; and 2. Interpreter Services	1. Community Integration Services 2. Assertive Community Treatment 3. Daily Living Support Services 4. Skills Development Services
Assertive Community Treatment	1. Daily Living Support Services or Skills Development Services or Day Supports Services; and 2. Interpreter Services	1. Community Integration Services 2. Community Rehabilitation Services
Daily Living Support Services	1. Community Integration Services 2. Day Support Services 3. Assertive Community Treatment 4. Interpreter Services	1. Skills Development Services
Skills Development Services	1. Community Integration Services 2. Day Supports Services 3. Assertive Community Treatment 4. Interpreter Services	1. Daily Living Supports

Requests to provide concurrent services, such as any two services listed in Column B, Number 1 within each subcategory of the chart, to assist in a member's transition from one service to another, may be requested from DHHS or an Authorized Entity in accordance with 17.09-2(C). Services provided through Section 17, Community Support Services may not be provided concurrently with Clubhouse or Specialized Group services provided via Section 65, Behavioral Health Services.

17.05-4Location. Except as may be expressly provided in Section 17.04 or by federal or state statute or regulation, covered services may be provided in any community location.

17.05-5Private Non-Medical Institutions. Community Support Services specified in Sections 17.04-2 and 17.04-3 cannot be provided in a Private Non-Medical Institution, as defined in the MaineCare Benefits Manual Chapters II & III Section 97, without written authorization from DHHS or an-Authorized Entity in accordance with Section 17-09-2(C). In order to avoid duplication of services, providers furnishing services under Section 17.04-3 as part of treatment in a Private Non-Medical Institution must coordinate and not duplicate services with providers of services outside the residential setting, including but not limited to services provided in MaineCare Benefits Manual, Chapter II, Section 13 and 97.

17.05-6Utilization Review. DHHS or an - Authorized Entity - reserves the right to Review continuation of any covered services as described in this Section, applying the standards established by this Section for eligibility and for continuation of a service.

17.05-7Exclusivity of Billing. If a service may be billed under either this Section or Section 65, a Community Support Provider may bill the service under only one of those sections for a single member.

17.05-8Day Support Services. Services previously billed under this section known as or equivalent to "clubhouse" services, are defined and covered in Section 65 of the MaineCare Benefits Manual as "Mental Health Psychosocial Clubhouse Services. "Services provided under this policy consistent with the model of Psychosocial Clubhouse Services are considered duplicative with services offered via Section 65, and are not covered under this policy.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-17, subsec. 144-101-II-17.05