C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-45, subsec. 144-101-II-45.04

Current through 2024-51, December 18, 2024

Subsection 144-101-II-45.04 - COVERED SERVICES

45.04-1Semi-Private Accommodations

Reimbursement will be made for eligible members for placement in semi-private accommodations (two (2) or more beds).

45.04-2Intensive Care or Coronary Care

Accommodations in an intensive care unit or a coronary care unit are reimbursable if ordered by the patient's physician as medically necessary.

45.04-3Drugs and Biologicals

A.Drugs and Biologicals

Drugs, vaccines, cultures, and other preparations made from living organisms and their products, used in diagnosing, immunizing, or treating members (biologicals) are covered. Drugs and biologicals furnished by a hospital for a patient's use outside of the hospital are not covered as inpatient services.

B.Hospital Pharmacies Affiliated with a Nursing Facility

A hospital that is affiliated with a nursing facility through common ownership or control is allowed to dispense covered MaineCare prescription drugs through its pharmacy to members in that nursing home. The drugs must be dispensed by a registered pharmacist according to dispensing regulations.

Billing must be accomplished in accordance with MBM Section 80, "Pharmacy Services", and Section 67, "Nursing Facility Services."

45.04-4Supplies, Appliances and Equipment

Supplies, appliances and equipment are covered if they are surgically implanted or are an integral part of a hospital procedure and it would be medically contraindicated to limit the patient's use of the item to his or her hospital stay (e.g.: cardiac valves, pacemakers, tracheotomy tubes, halovests, titanium rods, etc.).

A temporary or disposable item that is medically necessary to facilitate the patient's discharge from the hospital, and is required until the patient can obtain a continuing supply, is covered as an inpatient service for up to a ten (10) day supply.

MaineCare will separately reimburse for Long Acting Reversible Contraceptives (LARC), in addition to the hospital DRG reimbursement, if the device is placed immediately postpartum in the inpatient setting. Billing for the LARC must be submitted on a separate claim using type of bill code 0121 (inpatient billed as outpatient) with the appropriate HCPC code.

Except as noted above, supplies, appliances, including prosthetic devices, and equipment furnished to an inpatient or outpatient for use outside of the hospital must have prior authorization in accordance with and meet criteria in Chapter II, Section 60, "Supplies and Durable Medical Equipment", of this Manual, and reimbursement must be made to a supplier of durable medical equipment. MaineCare will not reimburse a hospital or supplier of durable medical equipment for the rental or purchase of a therapy bed (specialty air beds built into a hospital bed frame).

45.04-5Ancillary, Diagnostic and Therapeutic Services

Ancillary, diagnostic and therapeutic services that are medically necessary are covered services subject to limitations in Section 45.05.

45.04-6Swing-Bed and Days Awaiting Placement Services

The provision of acute care services to a member in a swing-bed must be consistent with requirements set forth in this Section of the Manual.

NF swing-bed and days awaiting placement services must meet all state and federal laws, including federal Medicaid laws and regulations and the "Nursing Facility Services" requirements set forth in Section 67 of this Manual, and members must be eligible for NF level of services as determined by an assessment conducted by the Department or its Authorized Agent. Members in swing-bed and days awaiting placement are exempt from both:

i) pre-admission screening for mental illness and mental retardation; and

ii) Minimum Data Set + (MDS+) resident assessment screening.

45.04-7Asthma Self-Management Services

Asthma self-management services are reimbursable if they are based on the Open Airways or Breathe Easier curricula or any other asthma management services that are approved by the National Heart, Lung and Blood Institute/American Lung Association or the Asthma and Allergy Foundation of America.

Each service must have:

A. a physician advisor;

B. a primary instructor (a licensed health professional or a health educator with a baccalaureate degree);

C. a pre and post assessment for each member that shall be kept as part of the member's record;

D. an advisory committee that may be part of an overall patient education advisory committee; and

E. a physician referral for all participants.

45.04-8Outpatient Diabetes Self-Management Training Services

Diabetes Self-Management and Training (DSMT) services for members with diabetes (any form) can be rendered by qualified outpatient hospitals in Maine that have current National DSMT site recognition/accreditation, and have a current DSMT

Letter of Understanding (LOU) with the DHHS, Maine CDC, Diabetes Unit. These outpatient hospitals will be reimbursed when the provider furnishes these services to a MaineCare member whose physician, primary care provider, or non-physician practitioner has prescribed these services for the management of the member's diabetes. The services consist of:

1. Any/all diabetes education and support services outlined within the most current American Diabetes Association (ADA) - National Standards for Diabetes Self-Management Education and Support and Clinical/Medical Care Standards for people with diabetes (any form).

2. The order for education and support services is initiated with a physician referral, written or electronic, that provides the order for Diabetes Self-Management Training (DSMT) services for patients with a diabetes diagnosis.

When the MaineCare member is under age twenty-one (21), MaineCare will also reimburse for this service when provided to the people who provide the member's daily care.

45.04-9Hospital Based Physician Services

Effective July 1, 2006, only provider practices that qualify as "provider-based" entities under 42 C.F.R. § 413.65 are covered services.

45.04-10Outpatient Partial Hospitalization Services

Provider Requirements: Outpatient Partial Hospitalization services can be offered only in Acute Care Non-Critical Access Hospitals or in an Acute Care Non-Critical Access hospital-based clinic or in a distinct part of the Acute Care Non-Critical Access Hospital, if listed in the Hospital's license. This service is not covered in free standing clinics.

Outpatient Partial Hospitalization Programs (OPHPs) are structured to provide intensive psychiatric care through active treatment that utilizes a combination of the clinically recognized items and services described in § 1861 (ff) of the Social Security Act (the Act). The treatment program of a OPHP closely resembles that of a highly structured, short-term hospital inpatient program. It is treatment at a level more intense than outpatient day treatment or psychosocial rehabilitation. Programs providing primarily social, recreational, or diversionary activities are not considered partial hospitalization.

Outpatient Partial Hospitalization is active treatment that incorporates an individualized treatment plan which describes the coordination of services wrapped around the particular needs of the member. Services include a multidisciplinary team approach to patient care under the direction of a physician. Partial hospitalization services include:

A. Individual or group therapy;

B. Occupational therapy;

C. Care management/care coordination;

D. Services of other staff (social workers, psychiatric nurses, and others) trained to work with psychiatric patients;

E. Drugs and biologicals that cannot be self-administered and are furnished for therapeutic purposes (subject to limitations specified in 42 C.F.R. 410.29);

F. Individualized activity therapies that are not primarily recreational or diversionary. These activities must be individualized and essential for the treatment of the Member's diagnosed condition and for progress toward treatment goals;

G. Family and/or natural support counseling services for which the primary purpose is the treatment of the Member's condition;

H. Member training and education, to the extent the training and educational activities are closely and clearly related to the Member's care and treatment of his/her/their diagnosed psychiatric condition; and

I. Medically necessary diagnostic services related to mental health treatment.

Covered services delivered by the multi-disciplinary team must be provided by practitioners acting within the scope of their licensing or certification. Practitioners include, but are not limited to:

A. Physician, Psychiatrist;

B. Physician Assistant;

C. Nurse Practitioner;

D. Registered nurse, Licensed Practical Nurse, Certified Nursing Aide;

E. Psychologist;

F. Licensed Master of Social Work and Conditionally Licensed Master of Social Work;

G. Licensed Clinical Professional Counselor and Conditionally Licensed Clinical Professional Counselors;

H. Licensed Marriage and Family Therapists and Conditionally Licensed Marriage and Family Therapists;

I. Certified Intentional Peer Support Specialist;

J. Occupational Therapists;

K. Speech Therapists;

L. Other staff qualified to treat mental health conditions.

To be eligible for partial hospitalization services, the member must need more active and inclusive treatment than is provided in an outpatient service, but not need full-time hospitalization or institutionalization. Upon admission, a physician must certify that the member admitted to Partial Hospitalization Services would require inpatient services if partial hospitalization services were not provided. The certification must identify the diagnosis and psychiatric need for partial hospitalization. Services must be delivered according to an individualized plan of care and must be reasonable and necessary to treat the presentation of serious psychiatric symptoms and to prevent relapse or hospitalization.

The individualized treatment plan must:

A. Be prescribed and signed by a physician;

B. Identify treatment goals, describes coordination of services, and designed to address the member's identified needs;

C. Directly address the presenting symptoms;

D. Be used to evaluate the member's response to treatment;

E. Describe ongoing efforts to restore the member to a higher level of functioning which will allow them to discharge to a lower level of care or remain in this level of care in order to prevent relapse or future hospitalization;

F. Identify any needed resources and supports upon discharge.

Outpatient Partial Hospitalization Services must be documented on a progress note that must include:

A. Date of service and duration of service (including time in/time out);

B. A description of the nature of the treatment service provided;

C. The member's response to the therapeutic intervention and its relation to goals indicated on the treatment plan;

D. Signature of the practitioners delivering services.

Members in OPHP may be discharged by either stepping up to an inpatient level of care, which would be required for Members needing 24-hour supervision, or stepping down to a less intensive level of outpatient care when the Member's clinical condition improves or stabilizes and they no longer require structured, intensive, multimodal treatment.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-45, subsec. 144-101-II-45.04