Subsection 144-101-II-31.04 - COVERED SERVICESAll services must be provided within the HRSA-approved scope of service area, or to HRSA-Designated Medically Underserved Populations (MUP) at federally approved center locations such as school-based health centers, and be otherwise provided in conformance with Federal requirements.
Covered services include core services, and other ambulatory services contained in the State's Medicaid plan, and in the FQHC's scope of project for base year 1999 as approved by HRSA, and any approved change in scope of service as amended, or as specifically approved by the Maine Department of Health and Human Services (DHHS). FQHCs must submit their HRSA-approved scope of project for base year 1999, or if established after 1999, for their first year of operation, and all subsequent HRSA-approved amendments to scope of project.
31.04-1Core 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 approved and appropriate licensed practitioners. In order for incidental services to be covered, FQHC employees must perform the incidental service, unless it is an FQHC service routinely performed by contracted personnel or providers. Services provided by auxiliary personnel not in the employ of the FQHC, even if provided on the physician's order or included in the FQHC's bill, are not covered as incident to a physician's service. Thus, non-physician diagnostic and therapeutic services that an FQHC obtains, for example, from an independent laboratory, an independent licensed or otherwise qualified provider, or a hospital outpatient department are not covered FQHC services;C. visiting nurse services (as described in Section 31.04-4).31.04-2Ambulatory services include the following: A. Any other ambulatory service, including any incidental supplies associated with the performance of a service that is provided by the FQHC, and that is also included in the State's Medicaid Plan, are reimbursable. This includes contraception (injectable, implantable capsules, intrauterine devices) and the administration of influenza and pneumococcal vaccines. (These services must be provided in accordance with all applicable sections of the MaineCare Benefits Manual in order to be reimbursable.)B. Asthma programs are reimbursable if they are based on the Open Airways or Breathe Easier curricula. Any other asthma management service that is approved by the National Heart, Lung and Blood Institute/American Lung Association or the Asthma and Allergy Foundation of America, are also reimbursable. Each program must have:
2. a primary instructor (a licensed health professional or a health educator with baccalaureate degree);3. a pre 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.C. Reimbursement for Ambulatory Diabetes Education and Follow-Up (ADEF) Services, or for similar services approved by a Centers for Medicare and Medicaid Services (CMS) approved national accreditation organization, will be reimbursed when a provider enrolled with the Maine Diabetes Prevention and Control Programs furnishes this service to a MaineCare member whose physician has prescribed this program for the management of the member's diabetes. The service is: 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. a group class instruction covering the comprehensive curriculum outlined by the Maine Diabetes Control Project 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-service 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.
D. Effective August 1, 2014, tobacco cessation treatment serviceswill 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 on tobacco cessationtreatment services. Counselingservices 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 31. 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. Smoking cessation treatment servicesmay be billed alone, or in combination with other FQHC services. Documentation of the tobacco cessationtreatment services must be contained in the medical record.
31.04-3Off-site delivery of services furnished by health center staff are reimbursable when they are provided away from the center and when it is documented in the member's chart that it is the most clinically appropriate setting for the provision of services. Examples of off-site service locations include: a nursing facility, an emergency room, an inpatient hospital, or a member's home.31.04-4Visiting 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 for which the Secretary of the US Department of Health and Human Services has determined there is a shortage of home health agencies; andE. the health center that provides in-home services by a registered or licensed practical nurse is licensed by the State of Maine as a home health service provider.31.04-5Interpreter Services - Refer to Chapter I of the MaineCare Benefits Manual for information about the reimbursement for interpreter services. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-31, subsec. 144-101-II-31.04