C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-65, subsec. 144-101-II-65.05
Services are immediate crisis-oriented services provided to a member with a serious problem of disturbed thought, behavior, mood or social relationships, and/or crises originating from problems associated with an intellectual disability, autism, or other related condition. Services are oriented toward the amelioration and stabilization of these acute emotional disturbances to ensure the safety of a member or society and can be provided in an office or on scene. "On scene" can mean a variety of locations including member homes, school, street, emergency shelter, and emergency rooms.
Services include all components of screening, assessment, evaluation, intervention, and disposition commonly considered appropriate to the provision of emergency and crisis mental health care, to include co-occurring mental health and substance use conditions. Crisis Resolution Services are individualized therapeutic intervention services available on a twenty-four (24) hour, seven (7) day a week basis and provided to eligible members by providers that have a contract with DHHS to provide these services.
Covered services include direct telephone contacts with both the member and the member's Parent or Guardian or adult's member's guardian when at least one face-to-face contact is made with the member within seven (7) days prior to the first contact related to the crisis resolution service. The substance of the telephone contact(s) must be such that the member is the focus of the service, and the need for communication with the Parent or Guardian without the member present must be documented in the member's record.
Staff providing Crisis Services include Clinicians, Mental Health Rehabilitation Technicians (MHRT), Behavioral Health Professionals (BHP), or Direct Support Professionals (DSP) with certification at the level appropriate for the services being delivered and for the population being served. Supervisors of MHRT, BHP, and DSP staff must be Clinicians, within the scope of their licensure.
To provide Children's Crisis Resolution Services as a BHP, the employee must meet the education requirement and complete the required BHP training within the prescribed time frames, as described in 65.05-9(D) and 65.05-9(E).
A treatment episode includes face-to-face visits and related follow up phone calls, as clinically indicated, up to a sixty (60) day period after the first face-to-face visit.
Crisis Residential Services are individualized therapeutic interventions provided to a member during a psychiatric emergency, and/or crises originating from problems associated with an intellectual disability, autism, or other related condition to address mental health and/or co-occurring mental health and substance use conditions for a time-limited post-crisis period, in order to stabilize the member's condition. These services may be provided in the member's home or in a temporary out-of-home setting and include the development of a crisis stabilization plan. Components of crisis residential services include assessment; monitoring behavior and the member's response to therapeutic interventions; participating and assisting in planning for and implementing crisis and post-crisis stabilization activities; and supervising the member to assure personal safety. Services include all components of screening, assessment, evaluation, intervention, and disposition commonly considered appropriate to the provision of emergency and crisis mental health care.
Staff providing Crisis Residential Services for members with mental health as a primary condition include Clinicians, MHRTs, BHPs and DSPs with certification at the level appropriate for the services being delivered and the population being served. To provide Children's Crisis Resolution Services as a BHP, the employee must meet the education requirement and complete the required BHP training within the prescribed time frames, as described in 65.05-9(D) and 65.05-9(E).
Staff who have not completed certification requirements in full within six (6) months of the date of hire, or within twelve (12) months for staff who are employed at the time this rule goes into effect, are not eligible to perform reimbursable services with any provider until certification is complete.
Supervisors of MHRT, BHP, and DSP staff must be a Clinician, practicing within the scope of their licensure.
For children's Crisis Residential Services determination of the appropriate level of care shall be based on tools approved by DHHS and clinical assessment information obtained from the member and Family.
Outpatient Services are professional assessment, counseling and therapeutic Medically Necessary Services provided to members, to improve functioning, address symptoms, relieve excess stress and promote positive orientation and growth that facilitate increased integrated and independent levels of functioning. Services are delivered through planned interaction involving the use of physiological, psychological, and sociological concepts, techniques and processes of evaluation and intervention.
Services include a Comprehensive Assessment, diagnosis, including co-occurring mental health and substance use disorder diagnoses, individual, Family and group therapy, and may include Affected Others and similar professional therapeutic services as part of an integrated Individualized Treatment Plan.
Services must focus on the developmental, emotional needs and problems of members and their families, as identified in the Individualized Treatment Plan.
These services may be delivered during a regularly scheduled appointment or on an emergency after hours basis either in an agency, home, or other community-based setting, such as a school, street or emergency shelter.
Coordination of treatment with all included parties (as appropriate to the outpatient role), including PCP's, or other medical practitioners, and state or other community agencies, is well documented.
Children's Outpatient Services offer ways to improve or to stabilize the member's Family living environment in order to minimize the necessity for out-of-home placement of the member, to assist Parents or Guardians and Family members to understand the effects of the member's disabilities on the member's growth and development and on the Family's ability to function, and to assist Parents and Family members to positively affect their member's development.
For children's Outpatient Services determination of the appropriate level of care shall be based on clinical assessment information obtained from the member and Family.
These services may be provided by a Clinician or Substance Use Qualified Staff practicing within the scope of their licensure.
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The Department shall submit to CMS and anticipates approval for a State Plan Amendment related to the following provisions.
Family Psychoeducational Treatment is an Evidenced Based Practice provided to eligible members in multi-Family groups and single-Family sessions. Clinical elements include engagement sessions, psychoeducational workshops and on-going treatment sessions focused on solving problems that interfere with treatment and rehabilitation, including co-occurring mental health and substance use disorder diagnoses.
Providers must have a contract to provide this service as described in 65.02-2. For children's Family Psychoeducational Treatment Services determination of the appropriate level of care shall be based on the Child/Adolescent's Level of Functional Assessment Score (CAFAS) or Preschool and Early Childhood Functional Assessment Scale (PECFAS), other tools approved by DHHS and clinical assessment information obtained from the member and Family.
The Department shall submit to CMS and anticipates approval for a State Plan Amendment related to the following provisions.
Intensive Outpatient Program (IOP) Services are short-term, time-limited, intensive, multidisciplinary approaches designed to treat clinically significant issues in a structured environment. IOP Services shall be consistent with existing Evidence-Based Practices, Promising and Acceptable Treatment or Best Practice parameters in type, staffing, frequency, and duration. Where Evidence-Based Practices do not exist, the treatment shall be consistent with Promising and Acceptable Treatment or Best Practice treatment parameters.
Members must receive Prior Authorization from the Department or its Authorized Entity for IOP services. Length of stay and program intensity, including the number of hours of service per day, is based on the individual member's treatment needs as determined by a Comprehensive Assessment and service intensity tools/level of care assessments the provider administers and documents in the member's Individualized Treatment Plan (ITP). Service method, approach, frequency, and duration must be adequate to effectively treat the identified presenting problem(s).
DD/BH, ED, and DBT IOP providers must additionally meet the following requirements as outlined below:
Providers must utilize Applied Behavior Analysis (ABA) principles to include:
Providers must utilize physician, nursing, and dietician services, as clinically indicated, to include:
Providers must utilize the DBT principles to include:
Members seeking IOP services must be:
All diagnoses and disorders referred to below are as defined by the DSM.
SU-IOP is a program for Child and adult members who have a primary substance use disorder or a substance use disorder with a co-occurring mental health disorder and meet ASAM Level 2 placement criteria.
The MH-IOP is a program for Child and adult members who have a primary mental health disorder or a mental health disorder with a co-occurring substance use disorder and exhibit moderate to severe psychiatric symptoms.
The DD/BH-IOP is a program for Child and adult members who have an Autism Spectrum Disorder (ASD) or an Intellectual Disability and exhibit functional limitations, verbal and/or physical aggression, self-injurious behaviors, severe emotional dysregulation, and other serious problem behaviors.
The G-IOP is a program for members who have a primary mental health disorder or a co-occurring mental health and substance use disorder and exhibit moderate to severe psychiatric symptoms and have reached at least sixty-five (65) years of age.
The ED-IOP is a program for Child and adult members who have an Eating Disorder, to include Otherwise Specified Feeding or Eating Disorder and Unspecified Feeding or Eating Disorder, Avoidant/Restrictive Food Intake Disorder, Anorexia Nervosa, Binge Eating Disorder, and/or Bulimia Nervosa.
The (DBT-IOP) is a program for Child and adult members who have a primary mental health diagnosis or mental health disorder with a co-occurring substance use disorder and meet at least three (3) of the following criteria: exhibit severe emotional dysregulation, chronic suicidality, impulsivity, self-harm, strained interpersonal relationships, inability to engage in appropriate coping skills, and/or has a history of mental health crises and/or psychiatric hospitalizations.
Medication Management Services are services that are directly related to the psychiatric evaluation, prescription, administration, education and/or monitoring of medications intended for the treatment and management of mental health, substance uses, and/or co-occurring mental health and substance use disorders, including Medications for Opioid Use Disorder (MOUD).
Neurobehavioral Status Exam (Procedure Codes 96116 and 96121) and Psychological Testing (Procedure Codes 96130 and 96131)
Neurobehavioral Status Exam and Psychological Testing services include clinical assessment of thinking, reasoning and judgment, meeting face-to-face with the member, time interpreting test results and preparing the report of test results. Services also may include testing for diagnostic purposes to measure a member's emotions, intellectual functioning, personality characteristics, and psychopathology, through the use of standardized test instruments or projective tests.
Neuropsychological Testing (e.g., Halstead-Reitan Neuropsychological Battery Wechsler Memory Scales and Wisconsin Card Sorting) and Psychological Testing by a Psychologist or Physician (Procedure Codes 96132, 96133, 96136, 96137)
When performed by a Psychologist or Physician,Neuropsychological and Psychological Testing services includes both face-to-face time administering tests to the member and time interpreting these test results and preparing the report. Testing focuses on thinking, reasoning, judgment, and memory to evaluate the member's neurocognitive abilities. In addition to the administration, scoring, interpretation, and report writing, this code also allows reimbursement for additional time necessary to integrate other sources of clinical data, including previously completed and reported technician and computer administered tests. Procedure codes 96132 and 96133 are reported when administering Neuropsychological testing evaluation. Procedure codes 96136 and 96137 are used when administering two or more psychological or neuropsychological tests.
Neuropsychological Testing (e.g., Halstead-Reitan Neuropsychological Battery Wechsler Memory Scales and Wisconsin Card Sorting) and Psychological Testing by a Psychological Examiner (Procedure Codes 96138 and 96139)
When provided by a Psychological Examiner, Neuropsychological and Psychological Testing services includes interview/test administration, report preparation, and interpretation. The test is administered by a Psychological Examiner (i.e. technician) and includes any reportable amount of time the technician spent with the client to assist them in completing the assessment. Procedure codes 96138 and 96139 are used when administering two or more psychological or neuropsychological tests by an examiner/technician.
The Department shall submit to CMS and anticipates approval for a State Plan Amendment related to the following provisions.
Adaptive Assessments (Procedure codes 96112 and 96113)
When provided by a licensed Clinician acting within their scope of practice, Adaptive Assessments services includes administration of the assessment, report preparation, and interpretation. The test includes any reportable amount of time the technician spent with the client to assist them in completing the assessment. Adaptive Assessments include the Vineland Adaptive Behavior Scale, Adaptive Behavior Assessment System (ABAS), Bayley Scales of Infant and Toddler Development, and the Battelle Developmental Inventory.
Neurobehavioral Status Exam, Neuropsychological Testing, Psychological Testing, and Adaptive Assessments do not require Prior Authorization nor do they require the completion of a Comprehensive Assessment or Individualized Treatment Plan. However, if the services are provided in a school the need for the evaluation must be documented in the member's written notice and maintained in the member's record.
Please see Appendix I for a list of qualified professionals.
Children's Assertive Community Treatment (ACT) service is a twenty-four (24) hour, seven (7) days a week intensive service provided in the home, community and office, designed to facilitate discharge from inpatient psychiatric hospitalization or to prevent imminent admission to a psychiatric hospital. Services may also be utilized to facilitate discharge from a psychiatric residential facility or prevent the need for admission to a crisis stabilization unit.
Children's ACT services shall include all of the following:
Be at clear risk for psychiatric hospitalization or residential treatment or admission to a crisis stabilization unit;
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Has been discharged from a psychiatric hospital, residential treatment facility or crisis stabilization unit within the past month, with documented evidence that he or she is highly likely to experience clinical decompensation resulting in readmission to the hospital, crisis unit or residential treatment in the absence of Children's ACT Service.
Children's ACT services are provided by a multidisciplinary team on a twenty-four (24) hour per day, seven days a week basis.
These teams operate under the direction of an independently licensed Clinician. The team will assume comprehensive clinical responsibility for the eligible member.
Children's ACT Service may be provided to an eligible member for up to six (6) continuous months with Prior Authorization. Services beyond the initial six (6) months must be reauthorized by DHHS or an Authorized Entity. Requests for reauthorization must be submitted in writing at least fourteen (14) days prior to the six (6) month anniversary date and documented in the member's record. This service may be utilized concurrently with MaineCare Benefits Manual Section 28, "Rehabilitation and Community Support Services for Children with Cognitive Impairments and Functional Limitations", or other services under this Section for a period not to exceed thirty (30) days. The specific purpose of this thirty (30) day interval must be for transition to a less intensive or restrictive modality of treatment. Any concurrent services must be Prior Authorized by DHHS or an Authorized Entity . Concurrent services will only be approved when the Children's ACT team provider is able to clearly demonstrate that the member would not be able to be discharged from this level of care without concurrent services.
Providers must submit request for Prior Authorization and reauthorization using DHHS approved forms for this service to DHHS or an Authorized Entity, who will use information in the member's record and clinical judgment to consider the need for this service. The DHHS staff or an Authorized Entity will consider Prior Authorization for any admission of a member into the Children's ACT service considering diagnosis, functioning level, clinical information, and DHHS approved tools to verify need for this level of care. The setting in which the Children's ACT service is to be provided must also be Prior Authorized. Documentation of this Prior Authorization must appear in the member's record. See also Chapter I, Section 1, of the MaineCare Benefits Manual for Prior Authorization timelines.
This treatment is for members in need of mental health treatment based in the home and community who need a higher intensity service than Outpatient Services but a lower intensity than Children's ACT Services.
Services include providing treatment to members living with their families. Services also may include members who are not currently living with a parent or guardian. Services include providing individual and/or family therapy or counseling, as written in the ITP. The services assist the member and parent or caregiver to understand the member's behavior and developmental level including co-occurring mental health and substance use, teaching the member and family or caregiver how to appropriately and therapeutically respond to the member's identified treatment needs, supporting and improving effective communication between the parent or caregiver and the member, facilitating appropriate collaboration between the parent or caregiver and the member, and developing plans and strategies with the member and parent or caregiver to improve and manage the member's and/or family's future functioning in the home and community.
Services include therapy, counseling or problem-solving activities in order to help the member develop and maintain skills and abilities necessary to manage his or her mental health treatment needs, learning the social skills and behaviors necessary to live with and interact with the community members and independently, and to build or maintain satisfactory relationships with peers or adults, learning the skills that will improve a member's self-awareness, environmental awareness, social appropriateness and support social integration, and learning awareness of and appropriate use of community services and resources.
The goals of the treatment are to develop the member's emotional and physical capability in the areas of daily living, community inclusion and interpersonal functioning, to support inclusion of the member into the community, and to sustain the member in his or her current living situation or another living situation of his or her choice.
The member must meet all of the following criteria:
To receive services due to Imminent Risk the member must meet the following criteria:
Behavioral Health: Where there has been a risk assessment and determination by a crisis provider or other licensed Clinician that the member is at risk for impending admission, within forty-eight (48) hours, to a Psychiatric Hospital, Crisis Stabilization Unit or Homeless Shelter, or other out of home behavioral health treatment facility, unless services are initiated, or
Child Welfare: Where Child Welfare Services (CWS) of DHHS is involved with the Family, Imminent Risk of removal is the stage at which CWS has completed its assessment, and has determined that the Family must participate in a safety plan requiring that services start immediately or the member will be removed from the home or foster care setting (not including a Treatment Foster Care setting), or
Corrections: Where the Juvenile Community Corrections Officer, law enforcement officer or court recommends or determines that the member will be detained or committed within forty-eight (48) hours unless services are initiated, and
The Parent/Guardian must participate in the member's treatment, consistent with the ITP.
Eligibility criteria as stated in Children's Home and Community Based Treatment must be clearly documented,
Providers must fax a referral form to the offices of DHHS or an Authorized Entity the same day of the start of service,
Providers must forward documentation of the risk of removal from crisis provider, licensed Clinician, Child welfare worker, juvenile community corrections officer, law enforcement officer or court to DHHS within thirty (30) days of the start of service, and
Providers must ensure that the one of the criteria for Imminent Risk is met, to include Behavioral Health, Child Welfare, or Corrections, Providers must begin the Comprehensive Assessment process with the member immediately and initiate treatment with the Family and Child within forty-eight (48) hours, and
Providers must contact DHHS or an Authorized Entity for Prior Authorization to be entered into the computer system within forty-eight (48) hours.
Staff allowed to provide this treatment include a Clinician and, when appropriate, a staff certified as a Behavioral Health Professional.
To provide Home and Community Based Treatment the employee must meet the educational requirement and complete the required Behavioral Health Professional (BHP) training within the prescribed time frames, as described in 65.05-9(E).
Educational requirement to deliver the Home and Community Based Treatment services can be one (1) of the following:
A staff meeting the educational requirement in 65.05-9.D must begin receiving the Behavioral Health Professional training within thirty (30) days from the date of hire. The provisional candidate must complete the training and obtain certification within one (1) year from the date of hire.
Approvals must be maintained in the agency's personnel file and the length of provisional status documented in the employee's file. Provisional candidates who have not completed certification requirements within one (1) year from the date of hire are not eligible to perform reimbursable services with any provider until certification is complete.
DHHS or an Authorized Entity may approve exceptions for staff to be qualified as clinicians under this section beyond the effective date of these rules. DHHS or an Authorized Entity will consider information such as attempts at recruiting qualified clinicians, availability of qualified clinicians in geographic areas, supervision to be provided, clinical competency of the individual, and wage/salary offered by the agency.
Understand the member's diagnosis and the particular challenges it presents to the member's Family;
Be knowledgeable about and capable of delivering the appropriate treatment for the diagnosis and symptoms;
Coordinate with DHHS or an Authorized Entity to ensure each member who gets the service has a medical need for the service and that the member's Parent(s) or caregiver is involved.
Members of the treatment team will provide information, support and/or intervention, whenever possible and clinically appropriate to the members and families they serve appropriate to ensuring continuity and consistency of treatment. The treatment team will coordinate and communicate with the local crisis agency when necessary.
Providers must refer the member for psychiatric consultation when necessary.
The treatment team must include:
The Office of Child and Family Services Medical Director may approve exceptions to the number of staff required for treatment teams to provide service for this Section. The Medical Director will consider information including but not limited to whether the provider is using an approved Evidence-Based Practice or whether the alternative treatment model has been tested with randomized or controlled outcome studies.
Provide individual and Family, if appropriate, treatment in the home and community, as written in the ITP;
Teach the member how to appropriately and therapeutically manage his or her mental health treatment and particular mental health challenges;
Support development of effective communication between the member and significant others in their lives (Family, employers, teachers, friends, etc.);
Facilitate appropriate collaboration between the member and significant others;
Support the member in utilizing the new skills in his or her living situation and community that have been described in the ITP;
Develop plans and strategies with the member to improve his or her ability to function in his or her living situation and community after treatment is complete;
Meet with other service providers to plan and coordinate treatment to ensure the integration of the treatment across the member's home, school, and community and to achieve the desired outcomes and goals identified in the ITP (see collateral contacts, Section 65.05-10); and
Review the ITP at least every ninety (90) days to determine whether or not the ITP will be continued, revised or discontinued. The Clinician, and Parent or caregiver, and member, if appropriate must sign and date the ITP.
Children's Home and Community Based Treatment shall be consistent with existing Evidence-Based Practices, Promising and Acceptable Treatment or Best Practice parameters in type, staffing, frequency, duration, and service provider setting. Where Evidence Based Practices do not exist, the treatment shall be consistent with Promising and Acceptable Treatment or Best Practice treatment parameters.
Children's Home and Community Based Treatment services must meet requirements for Central Enrollment and will be subject to Prior Authorization and ongoing Utilization Review.
Children's Home and Community Based Treatment requires Prior Authorization and Utilization Review every ninety (90) days of treatment. DHHS will evaluate effectiveness before authorizing continuation of treatment. The duration of care will typically be up to six (6) months, subject to Prior Authorization and DHHS Utilization Review. Subject to medical necessity and Utilization Review, treatment may be approved beyond six (6) months on a case-by-case basis.
Utilization Review must ensure that:
The ITP is reviewed every ninety (90) days;
Each member has a medical need for the service;
The member's Parent/caregiver is participating in the treatment planning process and in the treatment, if appropriate;
Measurable progress is being made on the goals and objectives identified in the ITP and that this progress is expected to continue; and
A discharge plan addresses the Natural Supports and treatment needs that will be necessary for the member and Family to sustain their progress at the end of this treatment.
The purpose of the treatment and measure of effectiveness will be demonstrated improvement for the member and Family in one or more of the following areas:
Functioning and skill development;
Adaptive behavior;
Member's ability to live within the Family and larger community.
Collateral Contact is a face-to-face contact on behalf of a member by a mental health professional to seek or share information about the member in order to achieve continuity of care, coordination of services, and the most appropriate mix of services for the member.
Discussions or meetings between staff of the same agency (or contracted agency) are considered to be collateral contacts only if such discussions are face-to-face and are part of a team meeting that includes professionals and caregivers from other agencies who are included in the development of the Individualized Treatment Plan (ITP).
This subsection shall apply only to Opioid Treatment Program (OTP) Services with methadone that are certified. Certified OTP Programs must comply with all federal regulations under 42 C.F.R. 8. OTPs using other medications are not covered under this subsection.
OTP facilities must make available adequate medical, counseling, educational and other assessment and treatment services as part of a packaged combined service.
Staff Credentials
All clinical staff providing OTP services with methadone must have sufficient education, training, and experience, or any combination thereof, to perform assigned functions.
Medical Director
The medical director's responsibilities must include but are not limited to the following:
Within five (5) days of the resignation or replacement of the medical director, the facility must notify the Office of MaineCare Services.
Assessment
Assessments provided according to this subsection shall be considered to meet the requirements for Comprehensive Assessments as described in Section 65.08-4.
All individuals participating in OTP facilities must undergo a complete medical exam by a physician, physician assistant, or nurse practitioner within fourteen (14) days following admission. OTPs must develop policies and demonstrate policy compliance in addressing the needs of pregnant women. Such policies will be based on current Best Practices and reflect the special needs of patients who are pregnant. All individuals admitted to an OTP facility shall be assessed initially and periodically by qualified personnel for treatment planning purposes. The initial assessment must address the following elements in the preparation and development of treatment planning goals: the educational, vocational rehabilitation, employment needs of the member, and the member's needs for medical, psychosocial, economic, legal, and other support services.
Individualized Treatment Plan (ITP)
ITPs for OTP services with methadone must be in compliance with requirements outlined in Section 65.08-4(B).
Counseling
OTP facilities must provide adequate substance use disorder counseling to each member, as clinically indicated, and shall include the following:
Substance Use Testing
OTP facilities must provide adequate testing and analysis for substance use, including at least eight (8) random substance use tests per year, per patient in maintenance treatment, in accordance with generally accepted clinical practice.
For members in short-term withdrawal management treatment, the OTP shall perform at least one initial substance use test. For members receiving long-term withdrawal management treatment, the program shall perform initial and monthly random tests on each patient.
Results and any follow-up action must be documented in the member record.
Testing should follow federal and state guidelines including Chapter II, Section 55, "Laboratory Services", of the MaineCare Benefits Manual.
Medication Administration
OTP facilities must ensure that opioid agonist treatment medications are administered or dispensed only by a practitioner licensed under the appropriate State law and registered under the appropriate State and Federal laws to administer or dispense opioid agonist medications, or by an agent of such a practitioner, supervised by and under the order of the licensed practitioner. This agent is required to be a pharmacist, registered nurse, or licensed practical nurse, or any other healthcare professional authorized by Federal and State law to administer or dispense opioid medications.
OTP facilities must have policies in place and followed that reflect applicable State and federal rules regarding take-home use and align with 42 C.F.R. § 8.12. All prescribers of OTPs are required to consult the Prescription Monitoring Program (PMP) prior to initial treatment, and as clinically indicated. All OTP facilities must develop and implement a Diversion Control Plan with measures to reduce the possibility of diversion of controlled substances.
For each new member enrolled in a program, the initial dose of methadone shall not exceed thirty (30) milligrams and the total dose for the first day shall not exceed forty (40) milligrams, unless the program physician documents in the member's record that forty (40) milligrams did not suppress opioid abstinence symptoms.
Facility Operation
OTP facilities must ensure adequate coverage and accessibility for the treatment needs of each member and be available at least six (6) days per week throughout the calendar year.
Medical Records
In addition to the requirements set out above and in Section 65.08-4 of this policy, OTPs must comply with the following documentation requirements:
Interpreter Services are described in Chapter I, Section 1 of the MaineCare Benefits Manual.
A covered service is a specificservice determined to be medically necessary by qualified staff licensed to make such a determination and subsequently specified in the Individualized Treatment Plan (ITP) and for which payment to a provider is permitted under the rules of this Section. This qualified staff must assume clinical responsibility for medical necessity and the ITP development. The Behavioral Health Day Services described below are covered when (1) provided in an appropriate setting as specified in the ITP, (2) supervised by an appropriate professional as specified in the ITP, (3) performed by a qualified provider, and (4) billed by that provider. Behavioral Health Day Treatment Services must be delivered in conjunction with an educational program in a School as defined in 65.02-4.
Behavioral Health Day Treatment Services are structured therapeutic services designed to improve a member's functioning in daily living and community living.
Programs may include a mixture of individual, group, and activities therapy, and also include therapeutic treatment oriented toward developing a Child's emotional and physical capability in area of interpersonal functioning. This may include behavioral strategies and interventions. Services will be provided as prescribed in the ITP. Involvement of the member's Family will occur in treatment planning and provision. Behavioral Health Day Treatment Services may be provided in conjunction with a residential treatment program. Services are provided based on time designated in the ITP but may not exceed six (6) hours per day, Monday through Friday, up to five days per week. Medically Necessary Services must be identified in the ITP.
The member must be aged twenty (20) or under, and must be referred by the Qualified Staff, as defined below. Additionally, the member must need treatment that is more intensive and frequent than Outpatient but less intense than hospitalization.
Within thirty (30) days of the start of service, the member must have received an evaluation and must have a primary mental health diagnosis in accordance with the current Diagnostic and Statistical Manual of Mental Disorders or a diagnosis based on the current Diagnostic Classification of Mental Health or Developmental Disorders of Infancy and Early Childhood Manual (DC-05); and
In addition, based on an evaluation using the Battelle, Bayley, Vineland, or other tools approved by DHHS, as well as other clinical assessment information obtained from the member and Family, the member must either have a significant functional impairment (defined as a substantial interference with or limitation of a member's achievement or maintenance of one or more developmentally appropriate, social, behavioral, cognitive, or adaptive skills); or
Have a competed evaluation establishing that the member has two (2) standard deviations below the mean in one domain of development or 1.5 standard deviations below the mean in at least two areas of development on the Battelle, Bayley, Vineland, or other tools approved by DHHS and other clinical assessment information obtained from the member and Family.
Staff qualified to provide this treatment include the following Clinicians (Psychiatrist, Psychologist, LCSW, LCPC, LMFT) and staff certified as a Behavioral Health Professional (BHP) who has completed ninety (90) documented college credit hours or Continuing Education Units (CEUs). Staff qualified to determine medical necessity to develop the ITP are Psychologists, LCSWs, LCPCs, or LMFTs. Board Certified Behavioral Analysts (BCBAs) are allowed to provide supervision to BHP staff.
To provide Behavioral Health Day Treatment as a BHP, the employee must meet the education requirement and complete the required BHP training within the prescribed time frames, as described in 65.05-13.C.
All staff must begin receiving the Behavioral Health Professional training within thirty (30) days from the date of hire. The provisional candidate must complete the training and obtain certification within one (1) year from the date of hire.
Approvals must be maintained in the agency's personnel file and the length of provisional status documented in the employee's file. Provisional candidates who have not completed certification requirements within one (1) year from the date of hire are not eligible to perform reimbursable services with any provider until certification is complete.
Tobacco cessation treatment shall be a covered service for all MaineCare members who currently use tobacco products and who wish to cease the use of tobacco products. Tobacco cessation treatment includes both counseling and products.
Tobacco cessation counseling services are provided to educate and assist members with tobacco cessation. During counseling, providers must educate members about the risks of tobacco use, the benefits of quitting, and assess the member's willingness and readiness to quit. Providers should identify barriers to cessation, provide support, and use techniques to enhance motivation to quit for each member. These services 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 65.
In addition to counseling, tobacco cessation treatment services include the provision of all pharmacotherapy approved by the Federal Food and Drug Administration for tobacco dependence treatment, including, but not limited to, buproprion. Tobacco cessation products are "Covered Drugs," reimbursable pursuant to Ch. II, Section 80 of the MaineCare Benefits Manual. As Covered Drugs, tobacco cessation products are included on the Department's Preferred Drug List (PDL), as set forth in Ch. II, Section 80. The PDL may be accessed via the Department's website.
MaineCare members are not required to participate in tobacco cessation counseling to receive tobacco cessation products.
Section 65.07-5(B) (Limitations, Individual Outpatient Therapy) and Section 65.07-5(C) (Limitations, Group Outpatient Therapy) are inapplicable to tobacco cessation treatment services. Members shall be provided with tobacco cessation treatment services with no annual or lifetime dollar limits, and no annual or lifetime limits on attempts to cease tobacco use.
Section 65.11 (Co-Payment) is inapplicable to tobacco cessation treatment services. In addition, Section 80 (Co-Payment) is inapplicable to tobacco cessation products.
Providers may bill these services alone or in addition to other Section 65 covered services provided on the same date of service. Documentation of tobacco cessation treatment services must be contained in the member's record.
Mental Health Psychosocial Clubhouse Services refers to services delivered through a community-based International Center for Clubhouse Development (ICCD) accredited clubhouse setting in which the member, with staff assistance, engages in operating all aspects of the program. Member choice is a key feature of the model. Through a structured environment that is referred to as the work-ordered day, supports and services related to employment, education, housing, Community Inclusion, wellness, community resources, advocacy, and recovery are provided.
Members participate in the program's day-to-day decision making and governance. Through Clubhouse involvement, members achieve or regain the confidence and skills necessary to lead satisfying, meaningful lives and successfully manage their mental illness.
Covered services include activities to increase employment related skills, wellness skills, and community living skills necessary for independent self-management. Clubhouse objectives promote access to preferred living, learning, working, and socialization roles for members in their communities. Services offer members organized, effective strategies for moving into and maintaining gainful integrated, competitive employment. Services improve social role functioning, employment, recreation, and quality of life. Services are delivered in the community and at the Clubhouse and are in alignment with the Individualized Treatment Plan that is developed through a member-driven process.
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Specialized Group Services consist of education, peer, and Family support, provided in a group setting, to assist the members to focus on recovery, wellness, meaningful activity, and community tenure. When cofacilitated by two non-licensed mental health professionals, a licensed mental health professional must supervise the co-facilitators.
Specialized Group Services fall into the following four (4) groups:
Copeland Center for Wellness & Recovery
P.O. Box 6471
Brattleboro, VT 05302
Phone: (802) 254-5335
In order to be eligible for Specialized Group Services, the member must meet the same criteria specified in Section 65.05-15.A (Eligibility for Mental Health Psychosocial Clubhouse Services). Specialized Group Services must be Prior Authorized by the Department or its Authorized Entity.
Behavioral Therapies are evidence-based Parent training models focused on teaching Parents and other caregivers the skills needed to help the Child member better manage his or her disruptive behavior disorder. Overseen by a Clinician, in accordance with the evidence-based model, the model helps Parents understand how the member's diagnosis affects the member, and helps change challenging behaviors by building parenting skills, improving relationships between Parent and member, and by helping the member manage his or her own behaviors.
Eligible members must be aged birth to twelve, and have clinically significant disruptive behaviors that lead to functional impairment in one or more domains as determined by Comprehensive Assessment and standardized assessment tools, such as the ECBI, Vanderbilt, CBCL/ CASII, CAFAS, CANS, YOQ etc.; OR
Parent Stress Index (PSI) scores indicate significant Parent distress, dysfunctional Parent-Child relationship, and/or difficult Child behavior in the clinical range; AND
Eligible members must have one (1) of the following qualifying diagnoses to include: ADHD (inattentive, hyperactive, or combined subtype); Oppositional Defiant Disorder; Conduct Disorder; Intermittent Explosive Disorder; Other Specified Disruptive, Impulse-Control, and Conduct Disorder; and Unspecified Disruptive, Impulse-Control, and Conduct Disorder.
Members must be referred by their physician or other Clinicians working within the scope of their practice.
Members meeting the criteria above may be eligible for any of the following behavioral therapies:
Triple P's suite of interventions is organized into five (5) levels of intervention intensity in order for services to be rendered according to a Family's need, time constraints, and desire for support. Each level of intervention has with a choice of delivery methods to allow for flexibility to meet the needs of individuals in their communities. All interventions are considered as brief, time-limited, and highly efficacious.
Triple P Level 4 is the program designated as an appropriate intervention for a Child with a disruptive behavior disorder where behavior problems are present.
Triple P Level 4 is covered under this section. Level 4 interventions include the following:
The Incredible Years is broken up into five (5) parenting programs that target key developmental stages. The appropriate stage must be chosen based on the developmental age of the Child. Each program consists of groups up to fourteen (14) participants and two (2) leaders. Each session meets weekly and is two to two and one-half (2-2.5) hours long.
Designed for infants from birth to twelve (12) months. This program consists of nine (9) to twelve (12) sessions.
Designed for toddlers aged one (1) to three (3) years. This program is twelve (12) to thirteen (13) sessions.
Designed for children aged three (3) to six (6) years. This program is eighteen (18) to twenty (20) sessions.
Designed for children aged six (6) to twelve (12) years. This program is twelve (12) to twenty (20) sessions.
Designed for children aged four (4) to twelve (12) years, this program focuses on parental interpersonal problems such as depression and anger management. This program is nine (9) to eleven (11) sessions, intended for Parents who have completed a basic program only.
PCIT uses a combination of behavior therapy, play therapy, and Parent training to improve the Parent-Child relationship, and aims to teach Parents/caregivers effective, positive discipline skills. PCIT is a short-term intervention, completed in approximately fourteen to twenty (14-20) sessions, depending on the needs of the Child. Consistent attendance along with daily home practice is important for successful outcomes.
PCIT can be used to treat behavioral problems associated with disruptive behavior disorders, aggressive behaviors, temper tantrums, negative attention seeking behaviors, and whining. Treatment is broken into two phases, each with teaching live coaching sessions.
Completion of treatment is based on the Parent/caregiver's mastery of CDI and PDI skills.
https://www.triplep.net/glo-en/home/
http://www.incredibleyears.com/
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-65, subsec. 144-101-II-65.05