C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-40, subsec. 144-101-II-40.05

Current through 2024-51, December 18, 2024

Subsection 144-101-II-40.05 - COVERED SERVICES

*The Department is seeking, and anticipates receiving, approval from CMS for this Section. Pending approval, the change will be effective.

A covered service is a service for which payment to a provider is permitted under this Section of the MaineCare Benefits Manual. In order to be reimbursed under this Section, covered services must be delivered under a timely and complete plan of care, signed and certified by a qualified Physician and meet the authorization requirements as outlined under Section 40.02-1. The plan of care must meet the requirements of Section 40.08. The CMS-485 must be completed for each member under this Section. There must be documentation of a face-to- face encounter with the certifying physician or allowed nonphysician practitioner as listed in Section 40.01-7. If the Department or its Authorized Entity determines that the services are no longer medically necessary, the Department will not reimburse the HHA for continuing services.

Any of the following services may be offered as the sole Home Health Service and shall not be contingent upon the provision of another service.

A.Skilled Nursing Services. To be covered as skilled nursing services, the services must meet the following conditions:

1) require the skills of a registered nurse or a licensed practical nurse under the supervision of a registered nurse, to be safe and effective, considering the inherent complexity of the service, the condition of the member and accepted standards of medical and nursing practice; and

2) be medically necessary to the treatment of the member's illness or injury. Medical necessity of services is based on the condition of the member at the time the services were ordered and what was, at that time, expected to be appropriate treatment throughout the certification period; and

3) be required on an intermittent or part-time basis (as defined in Section 40.01-14 and 40.01-20). To meet the requirement for intermittent skilled nursing care, a member must have a medically predictable recurring need for skilled nursing service; and be ordered by the physician for the member and are included in the physician's plan of care.

B.Home Health Aide Services. Home health aide services must be ordered by the physician and specified as to frequency and duration in the physician's plan of care for the member. The services must be medically necessary to provide personal care to the member, to maintain health, or to facilitate treatment of the member's illness. Covered services include, but are not limited to:

1) personal care services;

2) simple dressing changes that do not require the skills of a registered or licensed nurse;

3) assisting the member with self-administering medications that do not require the skills of a registered or licensed nurse; home health aides cannot administer medications;

4) assistance with activities that directly support skilled therapy services and are listed on the Maine State Board of Nursing approved nursing assistant skills checklist;

5) routine care of prosthetic and orthotic devices;

6) incidental services. When a home health aide visits a member to provide a health-related service, the home health aide may also perform some incidental services that do not meet the above definition (for example, light cleaning, preparing a meal, removing trash, or shopping). However, the purpose of the home health aide visit must not be solely to provide these incidental services.

C.Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services. Physical therapy, occupational therapy and speech-language pathology services must meet the following criteria:

1) prescribed by a physician;

2) directly and specifically related to an active treatment regimen;

3) of such a level, complexity and sophistication that the judgment, knowledge, and skills of a licensed therapist are required;

4) performed by a licensed therapist or by a licensed therapist assistant under the supervision of a licensed or registered therapist, each operating within the scope of his or her license;

5) provided based on the physician's assessment that the member has rehabilitation potential (defined in Section 40.01-23) and will improve significantly in a predictable period.

a. Once rehabilitation potential has been established for members aged twenty-one (21) or older, they are specifically eligible only for physical and occupational therapy in the following circumstances:

i. treatment following an acute hospital stay for a condition affecting range of motion, muscle strength, and physical functional abilities. Services must be initiated within sixty (60) days from the date of the physician's certification of the member's rehabilitation potential; and/or

ii. treatment after a surgical procedure performed for the purpose of improving physical function. Services must be initiated within sixty (60) days from the date of the physician's certification of the member's rehabilitation potential; and/or

iii. treatment in those situations in which a physician has documented that the member has, in the preceding thirty (30) days, required extensive assistance (defined in Section 40.01-6) with at least one-person physical assist (defined in Section 40.01-19) in the performance of one (1) or more of the following activities of daily living: eating, toileting, locomotion, transfer or bed mobility;

iv. palliative care is limited to one (1) visit per year to design a plan of care and train the member or caretaker of the member to implement the plan or to reassess the plan of care;

6) considered under accepted standards of medical practice to be a specific and effective treatment for the member's condition; and

7) certified by the physician in a current certification period.

D.Medical Social Services. Medical social services that are provided by a qualified medical social worker may be covered as Home Health Services when medical social services are required:

1) to resolve social or emotional problems that are or are expected to be an impediment to the effective treatment of the member's medical condition or to affect his or her rate of recovery; and

2) the plan of care indicates how the services that are required necessitate the skills of a qualified medical social worker.

3) services may include: assessments of the social and emotional factors related to the member's illness, need for care, response to treatment and adjustment to care; assessment of the relationship of the member's medical and nursing requirements to the member's home situation, financial resources, and availability of community resources; appropriate action to obtain available community resources to assist in resolving the member's services to address general problems that do not clearly and directly impede treatment or recovery, as well as long-term social services, such as ongoing alcohol counseling, are not covered.

4) certified by the physician or other allowed practitioner as defined in 40.01-7, authorized according to 40.08-1 and documented by the certifying physician according to 40.08-4.15.

E.Non-Routine Medical Supplies

1) In order to carry out the physician ordered service for the Member, it may be necessary for the Home Health Services provider to obtain and utilize particular medical supplies that are required for performance of the ordered procedure. The Home Health Service provider can bill for these "non-routine medical supplies", as defined in Chapter II, Section 40.01-16, in addition to the per unit rate it is paid.

2) The Department or its designee will maintain a Home Health Services Supply List of non-routine medical supplies covered under Chapter II. Only non-routine medical supplies meeting the criteria contained in Section 40.01-16 and included on this list may be approved for reimbursement by the Department. The Department will make the list readily available to providers directly from the Department and electronically at the Provider Tab, "Portal Tools" section in the Procedure Code Lookup" at: http://www.maine.gov/dhhs/oms.

3) All covered supplies must be billed in accordance with the billing instructions for Home Health Services providers. Non routine medical supplies covered under Section 40 must be billed at the lower of either the acquisition cost or the durable medical equipment price which can be found at https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx?RootFolder=%2FProvider%20Fee%20Schedules%2FCustom%20Fee%20Schedules&FolderCTID=0x012000264D1FBA0C2BB247BF40A2C571600E81&View=%7B69CEE1D4-A5CC-4DAE-93B6-72A66DE366E0%7D

4) Members or providers on behalf of members may request coverage for an item not currently on the Home Health Services Supply List by sending a written request to the Division of Consumer Services, explaining how the item meets the criteria of Section 40.01-16. In order to add an item to the Home Health Services Supply List for reimbursement, the Department or its designee must be satisfied that the item meets the criteria for a "non-routine medical supply" as defined by Section 40.01-16.

F.* Telemonitoring Services

1) Telemonitoring services are intended to collect a member's health-related data, such as pulse and blood pressure readings, that assist healthcare providers in monitoring and assessing the member's medical conditions.

2) Telemonitoring will be reimbursed only when provided by a certified Home Health Agency.

3) A note, dated prior to the beginning of service delivery, and demonstrating the necessity of home telemonitoring services, must be included in the member's file. In the event that services begin prior to the date recorded on the provider's note, services delivered in that month will not be covered.

4) Telemonitoring services must be included in the member's plan of care.

5) Home Health Agency Requirements:

Home Health Agencies utilizing telemonitoring services are responsible for:

a) Evaluating a member to determine if telemonitoring services are medically necessary for that member. The Home Health Agency must verify that a Health Care Provider's order or note, demonstrating the necessity of telemonitoring services, is included in the members' file. The provider ordering the service must be a provider with prescribing privileges (physician, nurse practitioner, or physician assistant);

b) Evaluating the member to ensure that the member is cognitively and physically capable of operating the telemonitoring equipment or verifying that the member has a caregiver willing and able to assist with the equipment;

c) Evaluating the member's residence to determine suitability for the telemonitoring services. If the residence appears unable to support telemonitoring services, the Home Health Agency may not implement telemonitoring services in the member's residence unless necessary adaptations are made. Adaptations are not reimbursable by MaineCare;

d) Developing a plan of care that includes the delivery of telemonitoring services;

e) Educating and training the member on the use, maintenance, and safety of the telemonitoring equipment. The cost of this education and training is included in the monthly flat rate paid by MaineCare to the Home Health Agency:

f) Remote monitoring and tracking of the member's health data by a registered nurse, nurse practitioner, physician assistant or physician, and responding with appropriate clinical interventions. The Home Health Agency and Health Care Provider utilizing the data shall maintain a written protocol that indicates the manner in which data shall be shared in the event of emergencies or other medical complications;

g) Engaging in telephonic services with the member on at least a monthly basis;

h) Ensuring that telemonitoring equipment remains in good working order;

i) Maintainingthe equipment. The cost of maintenance is included in the monthly flat rate paid by MaineCare to the Home Health Agency;

j) Disconnecting and removing equipment from the member's home when telemonitoring services are no longer necessary or authorized.

k) Complying with all applicable requirements listed in Chapter II, Section 40, Home Health Services.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-40, subsec. 144-101-II-40.05