Subsection 144-101-II-9.04 - COVERED SERVICESThe following services are covered if provided by or at an Indian Health Services clinic and are medically necessary.
A. Services provided by physicians, physician assistants, certified nurse midwives, nurse practitioners, psychologists, licensed alcohol and drug counselors, licensed clinical social workers, licensed clinical professional counselors and licensed professional counselors;B. Services and supplies furnished as incident to services of physicians, physician assistants, certified nurse midwives, nurse practitioners, psychologists, licensed alcohol and drug counselors, licensed clinical social workers, licensed clinical professional counselors and licensed professional counselors;C. Any other medically necessary services provided by the Indian Health Center that is included in the State's Medicaid Plan. (These services must be provided in accordance with all applicable sections of the MaineCare Benefits Manual in order to be reimbursable.)D. Pharmacy and ambulance services, provided that the Indian Health Center enrolls and receives reimbursement as prescribed under the applicable sections of the MaineCare Benefits Manual.E. Home Health Services provided under the Maine Medicaid home health benefit as described in Chapter II, Section 40 of the MaineCare Benefits Manual. No other services provided under Section 40 will be reimbursable under this section.F. Asthma self-management services are reimbursable if they are asthma management programs developed in accordance with the National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Each program must have:
b. a primary instructor (a licensed health professional or a health educator with a baccalaureate degree. Note: licensed practical nurses may only reinforce, not initiate, teaching.);c. a pre and post assessment for each participant which shall be kept as part of the member's record in accordance with this Section and Chapter I of the MaineCare Benefits Manual;d. an advisory committee which may be part of an overall patient education advisory committee; ande. a physician referral for all members.G. Reimbursement for Diabetes Self-Management Training Education (DSMT) and Follow-Up Services will be allowed when a provider is enrolled with the Maine Diabetes Prevention and Control Program administered by Maine Center for Disease Control and Prevention and based on the individualized plan; The services include:
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 Prevention and Control Program 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 assessment interview to assess and document what the member has learned during the program, and to develop a plan for follow-up sessions to address the components and 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, a follow-up visit one year after the last class is required to complete the member's participation in the program unless otherwise determined in the client's plan of care. All encounters provided in the Diabetes Self-Management Training (DSMT) sessions are billed separately. These types of education are reimbursable due to the didactic nature of their content. A total of up to 10 hours of DSMT may be billed, and up to three additional hours of Medical Nutritional Therapy (MNT) may be billed. Follow-up is not required if the provider and client determine that the client learned what they can given their participation, at which point that client would be defined as completed. A written referral must be given by the client's provider for DSMT or MNT to be billed.
When the Medicaid member is under the age of 21, this service will also be reimbursed when provided to the person/people who provide the member's daily care.
H. Off-site delivery of services furnished by health center staff is reimbursable when services are provided away from the center and when the member's chart documents that the delivery site is the most clinically appropriate setting for the provision of services. Examples of off-site services locations include: a nursing facility, an emergency room, an inpatient hospital, or a patient's home. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-9, subsec. 144-101-II-9.04