40.08-1Authorization of the Plan of CareAll services under this Section require an authorization (see Section 40.02-1), from the Department or its Authorized Entity. At the Department's discretion a medical eligibility assessment may be performed in order to approve an authorization request. Home Health Services will be authorized only if all requirements set forth in this Section are met. The authorization determines only the medical necessity for services and does not establish or waive any other prerequisites for payment, such as member eligibility or coverage by other third party payor.
A. Notice of Approval. For all approved authorization requests for Home Health Services, the Authorized Entity will provide written notice to the HHA.B. Notice of Denial or Modification and Right to Appeal. For all denied or reduced authorization requests, the Authorized Entity will notify both the member and the HHA of the denial or modification, reason, right to appeal, and appeal procedures (see Section 40.08-5 ).C. The Home Health Agency must notify the Department of a member's start of care date for the initial certification period. The admit/discharge form must be submitted to the Department within five (5) days of admission.D. All Home Health Services shall be authorized and covered for an approved certification period. The Home Health Agency must submit the following information for each certification period within five (5) calendar days of the certification period end date: 1. The CMS 485, including the documentation of rehabilitation potential for any physical therapy, occupational therapy and speech-language pathology services being received by the member, and2. Documentation of why the member cannot receive Home Health Services in an outpatient hospital setting.3. Documentation supporting the medical necessity for the Home Health Service.4. For the certification period at start of services the Home Health Agency must also submit documentation by the certifying physician that the physician himself or herself or a nonphysician practitioner has had a face-to-face encounter with the individual member as defined in section 40.01-7 prior to the authorization of the plan of care and has documented the encounter as required by section 40.08-4.15. The beginning and end dates of the individual's eligibility period correspond to the beginning and end dates for MaineCare coverage of the Home Health Service.40.08-2Plan of Care RequirementsIn accordance with licensing requirements, all Home Health Services must be provided under a plan of care established by the HHA, individually for each member.
A.Providers Qualified to Establish a Plan of Care1. The member's physician or other specified provider as defined in 40.01-7 working in collaboration with the provider certifying the Home Health Service must establish a written plan of care. The physician must recertify and sign the plan of care for each certification period (Section 40.01-2). Recertification is required at least every 60 days.2. A HHA nurse or skilled therapist or social worker may establish an additional, discipline oriented plan of care, when appropriate. These plans of care may be incorporated into the physician's plan of care or prepared separately, but do not substitute for the physician's plan of care.B.Content of the Plan of Care. The orders on the plan of care must specify the nature, frequency and duration of each service to be provided to the member and the type of professional who must provide it. The physician must sign the plan of care before the HHA submits its claim for those services to the Department for payment. The plan of care must contain: 1. all pertinent diagnoses, including the member's mental status;2. the types of services, supplies, and equipment ordered;3. the frequency and duration of the visits for each discipline to be made. A discipline may be one (1) or more of the following: skilled nursing, physical therapy, speech-language pathology services, occupational therapy, medical social services, or home health aide;4. the prognosis, rehabilitation potential, goals, functional limitations, permitted activities, nutritional requirements, medications, and treatments;5. any safety measures to prevent injury;7. any additional items the Home Health Agency or physician chooses to include;8. the member's address and type of residence, whether private home or residential care facility, etc.; and 9. identify any other community resources and services, as well as care management, care coordination, targeted case management or social work services.C. Certification Period. Both the plan of care, required under Section 40.08-2(A)(1), and the discipline-oriented plan of care, as provided for in 40.08-2 (A)(2), must be reviewed and signed by a physician for each certification period as defined in Section 40.01-2.D. Verbal Orders 1. Services that are provided from the beginning of the certification period and before the physician signs the plan of care are considered to be provided under a plan of care established and approved by the physician if: a. the clinical record contains a documented verbal order for the care before the services are furnished; andb. the services are included in a signed plan of care.2. Any increase in the frequency of services or any addition of new services during a certification period must be authorized in advance by a physician with verbal or written orders. The Department will pay for care provided based on verbal orders only if they are followed by a written order signed by the physician before the Department is billed.40.08-3Awaiting PlacementA member who is currently receiving Home Health Services under this Section and who no longer meets the eligibility criteria under this Section, but has been determined eligible, by the Department or its Authorized Entity, for any of the following in-home long term care services, Section 96, Private Duty Nursing & Personal Care Services, any Home and Community Benefit program, Section 43, Hospice Services, or Section 12, Consumer Directed Attendant Services, may be classified as "awaiting placement". "Awaiting placement" status may be used, if necessary, until an appropriate service provider begins delivering services. Under awaiting placement status, members will be covered for services under this Section.
Coverage of services under "Awaiting placement" is for a specified period of time approved by the Department or its Authorized -Entity. For coverage to continue beyond the approved period, the HHA must submit a completed request form along with a current CMS 485, to the Authorized Entity at least five (5) calendar days prior to the end date of the member's approved period. If upon review, the Department or its Authorized Entity determines the member is no longer eligible for any of the other in-home programs, continued coverage for Home Health Services shall be denied.
40.08-4Member's RecordContent of Records
There shall be a specific record for each member, which shall include, but not necessarily be limited to:
1. The member's name, address, and birth date;2. The name of the attending physician;3. The member's social and medical history and diagnosis;4. The member's need for teaching and the member's ability to learn;5. Community resources available to meet the needs of the member;6. A personalized plan of care, which meets the requirements in Section 40.08-2 and Section 40.08-4.15;7. Plans for coordination with other health care agencies for the delivery of services. For psychiatric nursing services, plans will include coordination with other mental health and social services agencies;8. Discharge plan for the member;9. Written progress notes and/or flow sheets including (at a minimum): a. Identification of the service provided, the date, and the provider;b. Progress toward the achievement of long and short-range goals;c. Signature of the service provider; and d. Date and full description of any unusual condition or unexpected event.10. Entries are required for each date of service billed;11. The plan of care signed and reviewed as necessary by the supervising physician;12. Documentation of skilled nursing and home health aide hours. The HHA must maintain records, which show the entrance and exit times of each skilled nurse's and each aide's visits and total time spent in the home by each. Exclude travel time;13. The signed CMS-4 85 must be retained and available upon request. Complete the form in its entirety. Do not leave any blank items. However, there are items where "not applicable" (N/A) is acceptable;14. Documentation of rehabilitation potential as defined in this Section for members receiving physical therapy, occupational therapy and speech-language pathology services.15. Documentation by the physician certifying the Home Health Services that a face to face encounter meeting the requirements of 40.01-7 has taken place prior to making such certification. The documentation of the face-to-faceen counter must be a separate and distinct section of, or an addendum to, the certification and must be clearly titled, dated and signed by the certifying physician. A nonphysician practitioner performing the face-to-faceen counter must document the clinical findings of the face-to-face member encounter and communicate those findings to the certifying physician. Documentation shall indicate that the encounter has occurred no more than 90 days prior to the start of the Home Health care. If a face-to-face member encounter occurred within 90 days of the start of care but is not related to the primary reason the member requires Home Health Services, or if the member has not seen the certifying physician or allowed nonphysician practitioner within the 90 days prior to the start of the home health episode for the primary reason requiring Home Health Services, the certifying physician or nonphysician practitioner must have a face-to-face encounter with the patient within 30 days of the start of the Home Health care. The documentation shall include an explanation of why the clinical findings of the face-to-face encounter support that the patient meets the requirements of 40.02-4 C and is in need of Home Health Services.16. Prior to the provision of telemonitoring services, the HealthCare Provider shall document that it has provided the member with choice and educational information (set forth in Chapter I, Section 4, 4.06-2, Telehealth) obtained the member's written informed consent to the receipt of telemonitoring services. The Health Care Provider shall retain a copy of the signed informed consent in the member's medical record and provide a copy to the member or the member's legally authorized representative upon request. A. Documentation must indicate the MaineCare covered services that were rendered via telemonitoring Services, the location of the originating (member) site, and the location of the receiving (provider) sites.17. Health Care Providers must ensure that the telecommunication technology and equipment used at the receiving (provider) site and the originating (member) site are sufficient to allow the Health Care Provider to appropriately provide the members with services billed to MaineCare.18. Health Care Providers must comply with Section 4, Telehealth, 4.06(B), Security.40.08-5 Member AppealsSee Chapter I of the MaineCare Benefits Manual for information regarding appeals. Members under age twenty-one (21) years shall submit a request for an appeal in accordance with Chapter I. An appeal by members who are age twenty-one (21) years and over regarding services under this Section must be requested in writing and mailed to:
Director
Office of MaineCare Services
c/o Hearings
11 State House Station
242 State Street
Augusta, Maine 04333-0011
40.08-6PROGRAM INTEGRITYAll providers are subject to the Department's Program Integrity activities. Refer to Chapter I, General Administrative Policies and Procedures for rules governing these functions.
40.08-7ELECTRONIC VISIT VERIFICATIONEffective January 1, 2023, every provider of Home Health Services must comply with the Maine DHHS Electronic Visit Verification ("EVV") system for standards and requirements. In compliance with Section 12006 of the 21st Century CURES Act, as codified in 42 U.S.C. § 1396b(l)(1), visits conducted as part of such services must be electronically verified with respect to: the type of service performed; the individual receiving the service; the date of the service; the location of the service; the individual providing the service; and the time the service begins and ends. Providers may utilize the Maine DHHS EVV system at no cost, or may procure and utilize their own EVV system, so long as data from the provider-owned EVV system can be accepted and integrated with the Maine DHHS EVV system and otherwise compatible.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-40, subsec. 144-101-II-40.08