C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-21, subsec. 144-101-II-21.15

Current through 2024-51, December 18, 2024

Subsection 144-101-II-21.15 - APPENDIX II- Guidelines for Approval of Medical Add-On in Maine Rate Setting

The Standard support level is an all-inclusive reimbursement for Services defined in 21.05. At times, a Member may require increased levels of staff support due to more intensive needs. Increased level of support is not to be used for respite or in substitute for the Shared Living Provider. It is to be used in addition to the Shared Living Provider to ensure the Member's safety. DHHS may authorize an increased level of support for the purposes of additional staff for those Members who have current and documented challenging behavioral issues or high medical and safety needs. The Clinical Review Team (CRT) reviews all increased level of support requests. The CRT will use the following criteria to determine when this increased level of reimbursement to support the additional staff is utilized.

To qualify for the increased level of support a Member must have an extraordinary need listed in at least one of the categories below

1)Behavioral Issues-Members with behavioral issues and/or behavioral health challenges that significantly raise health and safety concern may have increased levels of support authorized to assist with Behavioral issues. These may include high risk behavior such as a history of sexual offense, aggression to self or others, or criminal behavior. The planning team must identify a behavioral need that requires an increased level of support and is documented in the Member's record. The Person-Centered Service Plan will outline specific activities and desired outcomes of the service being provided and those activities must be separately documented in the Member's record.

2)Medical Support- Members that require support over and beyond routine services such as ventilators, nebulizers, diabetes management-insulin dependent, suctioning, seizure management-uncontrolled, chronic eating disorders, or persons with co-existing conditions that significantly affect physical movement and require near total physical assistance on a daily basis may have an increased level of support authorized to assist with medical issues. The Person-Centered Service Plan will outline specific activities and desired outcomes of the service being provided and those activities must be separately documented in the Member's record.

For Behavioral issues and Medical Support there must be a written recommendation, less than three months old, from a Physician, Physician Assistant, Psychologist or Psychiatrist which must specify:

1) The specific illness or condition to be addressed that requires increased support;

2) The manner in which increased support will be utilized;

3) The expected duration of the increased support. If the increased support is expected to be needed for an indefinite period of time then this expectation should be specified;

4) The anticipated frequency of the increased support on a daily, weekly, or monthly basis and

5) Whether the setting where the Member is served is appropriate to carry out the physician's recommended treatment or intervention.

Process of Application for the increased level of service:

The Provider must complete the Home Support Frequency tool provided by DHHS that will summarize the support needs of the Member and submit the tool along with identified materials to the Case Manager. The Home Support Frequency tool can found at this website,

https://www.maine.gov/dhhs/oads/providers/adults-with-intellectual-disability-and-autism

The Case Manager will be responsible for reviewing the information provided, verifying that the Person-Centered Service Plan and all other information is most current.

The CRT will review the information submitted with the request, the PCSP, information in the electronic records, such as reportable events, crisis notes and case management notes as well as any applicable assessments or evaluations of the Member. Increased support that is anticipated to be needed for an extended or indefinite period of time must be reviewed and approved at least annually by the CRT.

The CRT will issue a written decision within twenty (20) working days of receipt of all required documentation. If additional information is required, a written request will be issued to the Case Manager by the CRT. Upon receipt of the additional information, the CRT will approve or deny the request in writing within ten (10) working days.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-21, subsec. 144-101-II-21.15