Covered services are available for individuals meeting the eligibility requirements set forth in Section 96.02. Covered services must be required in order to maintain the Member's current health status, or prevent or delay deterioration of a Member and/or delay long-term institutional care. These services require prior approval by the Department, or its Assessing Services Agency, and are subject to the limits in Section 96.03.
Services provided must be reasonable and necessary for meeting the medical needs of the individual, based upon the medical record, and upon the outcome scores on the MED form, and as authorized in the plan of care. Payment will be denied if the services provided are not consistent with the Member's authorized plan of care. The Department may also recoup payment for inappropriate service provision, as determined through post payment review.
For Members age 21 and over, and those under age 21 receiving care under the family provider service option, and excluding those classified for medication services or venipuncture services (Level VI) under this Section, the Assessing Services Agency has the authority to determine the plan of care, which shall specify all services to be provided, including the number of hours for each covered service.
For Members under age 21 at any level of service, as well as Level VI and Level VII Members, but excluding those receiving care under the family provider service option, the PDN provider shall establish a plan of care. The plan of care shall be based upon the Member's assessment outcome scores recorded in the Department's Medical Eligibility Determination form and the timeframes therein.
Section 40, "Home Health Services", shall not replace or be delivered and reimbursed in lieu of authorized Section 96 covered services. (Section 40, "Home Health Services", must be delivered and reimbursed pursuant to those rules.)
Covered services under this Section include the following:
96.04-1Private Duty Nursing Services (PDN)A. PDN services must be provided according to a written plan of care, reviewed and signed by a licensed physician, and available to the Department or the Service Coordination Agency upon request. At least monthly nursing services must be delivered to all Level II and III Members, as well as those Level I Members who are eligible for services based upon the need for monthly nursing services.B. For individuals age 21 and over, and those under age 21 receiving care under the family provider service option, and excluding those classified for medication services or venipuncture services (Level VI) under this Section, PDN services shall be authorized by the Assessing Services Agency, and ordered and monitored by the Service Coordination Agency, in accordance with the authorized plan of care for covered services under this Section.C. For individuals under age 21, as well as all individuals classified for venipuncture services or medication services for the severely mentally disabled (Level VI), and excluding those receiving care under the family provider service option, the Department shall classify the Member based on the plan of care developed by the provider, subject to the process described under Section 96.06. D. Nursing services may be provided by: 1. an independently practicing registered professional nurse;2. a registered professional nurse or licensed practical nurse employed by, or under contract with, a licensed home health agency.E. Except as allowed in Section 96.04-1(F) below, nursing services shall not be covered when provided by the Member's husband or wife, natural or adoptive parent, child, or sibling, stepparent, stepchild, stepbrother or stepsister, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, grandparent or grandchild, spouse of grandparent or grandchild or any person sharing a common abode as part of a single family unit.F. "Special circumstances nursing" allows a relative, including a spouse or the parent of a minor child, to be paid to provide nursing services to the Member under this Section. To qualify for this coverage the Member's relative must meet the requirements in (1) and (2) below. 1. The relative must: (all of the following are required) a. meet all licensing, training, reporting and other requirements otherwise specified in this Section; andb. be employed by a licensed home health agency; andc. abide by the requirement that an independent nurse or physician must conduct any required assessments and/or develop the plan of care; andd. implement the Member's authorized plan of care; ande. if applicable, expect to continue non-reimbursed family caregiver responsibilities; andf. pass a criminal background check. The family nursing provider must not have any criminal convictions, except for Class D and Class E convictions over 10 years old that did not involve as a victim of the act a patient, client, or resident of a health care entity; or any specific documented findings by the State Survey Agency of abuse, neglect, or misappropriation of property of a resident, client, or patient.2. The relative must: (one of the following is required) a. have resigned from full-time or part-time employment specifically to provide PDN services to the Member; orb. have changed from full-time employment to part-time employment resulting in less compensation in order to provide PDN services to the Member; orc. have taken a leave of absence without pay from employment in order to provide PDN services to the Member;d. have incurred substantial expenses by providing PDN services to the Member; ore. be needed to provide an adequate number of qualified nurses to meet the Member's plan of care because of labor conditions or intermittent hours of care. To apply for coverage under this Section, contact the Director, Office of Aging and Disability Services, 11 State House Station, Augusta, ME 04333-0011.
G. Multiple patient nursing services are for nursing services (RN, LPN, and Independent RN) throughout this Section. The multiple patient procedure codes and modifiers must be used whenever it is determined (by the home health agency, the Department, or the Department's authorized entity, whichever has authority to authorize the Member's plan of care) to be safe and appropriate for one nurse to provide nursing services to more than one patient in the same home or building, during the same visit and it is specified in each Member's plan of care. Providers must bill with the Chapter III procedure codes and modifiers designated for multiple patients.96.04-2Personal Care ServicesA. For Members under the age of 21, excluding those receiving care under the family provider service option, personal care services must be ordered by a physician and delivered under a plan of care prepared by the PDN provider and signed by the physician.B. For Members age 21 and over, and for those under age 21 receiving care under the family provider service option, personal care services must be approved by the Department, or its Assessing Services Agency, and specified in the authorized plan of care. As a general rule, there shall be no more than one personal care staff Member delivering services at a time. If the Department, or its ASA, (or the physician for individuals under age 21) determines that an individual, based upon his/her health status, requires more than one personal care staff Member to perform a specific ADL task (e.g. to transfer a large person), then this can be authorized and specified in the plan of care.
If a single provider of personal care services is providing this service to multiple Section 96 members in a single visit, then the two (2) or three (3) person modifier shall be used, as outlined in Chapter III, Section 96, Private Duty Nursing and Personal Care Services.
Personal care services include services related to a Member's physical requirements for assistance with the activities of daily living, including assistance with related health maintenance activities.
C. Additionally, when authorized and specified in the Department, or ASA authorized plan of care, personal care services may include IADL and related health maintenance tasks, which are directly related to the Member's plan of care. These tasks must be performed in conjunction with direct care to the Member. Health maintenance and IADL tasks are those that would otherwise be normally performed by the Member if he or she were physically or cognitively able to do so. It must also be established that there is no family Member or other person available to assist with these tasks. A child or infant shall not qualify for coverage of IADL tasks because an infant or child does not normally perform these tasks. Coverage of IADL tasks is provided to assist individuals with disabilities to live independently in the community. IADL services may be authorized and covered only if the Member also requires ADL or medication administration services. IADL services are not covered as stand-alone personal care services; these may be covered only in combination with ADL or medication administration services. 1. The maximum hours per week allowed for IADL tasks for Levels I, II, III and IX is as follows: Level I is two hours; Level II is three hours; and Level III and IX is four hours. ADL and IADL tasks, and the allotted hours, must be specified and authorized in the plan of care.D. Certified nursing assistants, home health aides, or personal support specialists may transport a Member only to carry out necessary covered services in the Member's plan of care. Escort services may be provided only when a Member is unable to be transported alone, there are no other resources (family or friends) available for assistance, and the transportation agency can document that the agency is unable to meet the request for service. Such documentation must be included in the Member's record. Coverage is not available to reimburse for mileage or vehicle usage under this Section. Only the provider's services are covered.
E. Personal care services shall be provided, as appropriate, by a: 2. Certified nursing assistant; or3. Personal support specialist; or4. Certified Residential Medication Aide employed by a licensed assisted living agency, as defined in § 96.01-28, that holds a valid contract with OADS and provides medication administration as allowable under certification.F. Personal care services shall not be covered when delivered by a spouse of the Member, the parents or stepparents of a minor child, or a legally responsible relative.G. The task time allowances set forth in Appendix 1 must be used to authorize the time covered to complete covered and authorized ADL tasks for the plan of care. For Members age 21 and over, and those receiving care under the family provider services option the ASA shall abide by Appendix 1. For Members under age 21, the PDN provider shall abide by Appendix 1. These allowances reflect the time normally allowed to accomplish the listed tasks. The ASA and the PDN provider will use these allowances when authorizing a Member's care plan. If these times are not sufficient when considered in light of a Member's unique circumstances as identified and documented by the ASA or the PDN Provider, the ASA or the PDN Provider may make an appropriate adjustment as long as the authorized hours do not exceed the established limits for the Member's assessed level of care.H. The PSS super visit is a one-hour visit to deliver personal care services and health maintenance activities to a Member, no more than once per day. This service may be authorized up to seven days per week. If the Member requires more than one hour of personal care services on a given day, then the regular PSS services must be billed with the appropriate unit procedure codes, and the one-hour visit procedure code shall not be used. This is not a covered service under the family provider services option defined in Section 96.01-23.
I. Medication services delivered by Certified Residential Medication Assistants, and unrelated to the medication services described under Level VI, are covered services for those Members meeting the eligibility criteria under Level IX.96.04-3Venipuncture Only services (Level VII)A. These services shall be covered when it is the only identified nursing need and is required on a regular basis, as ordered by the physician. An RN or LPN must deliver venipuncture services. Personal care services are not covered services under venipuncture services. If the Member requires additional services, then he/she must meet (at least) the eligibility requirements for Level II or III. If the Member qualifies for Level II or III then all services including venipuncture services shall be authorized and delivered under Level II or III.96.04-4Medication and venipuncture services (Level VI)A. Level VI services are directly related to the administration and/or monitoring of medications intended for the treatment and management of mental illness in the context of community support services for people with severe and persistent mental illness (Level VI under this Section).B. Monitoring services may include venipuncture services for Members under this Section.C. A psychiatric nurse or a registered professional nurse must deliver these services.D. Personal care services are not covered services under this Section 96.04(F).If the Member requires additional services, then he or she must meet (at least) the eligibility requirements for Level II care. If the Member qualifies for Level II or III then all services including medication services shall be authorized and delivered under the Level II or III. The following services are covered upon Centers for Medicare and Medicaid Services (CMS) approval.
96.04-5Care Coordination activities are guided by the Member's authorized plan of care. Care coordination services include the following functions: Care Coordination is provided through in-person contact in the Member's residence, or through telephone and other methods with the Member, his/her family and other responsible parties, providers of service, and others as appropriate.
For Members who choose to self-direct their services, Care Coordination includes assisting the Member in arranging for, directing and managing his/her self-directed services as allowed, and coordinating access to Skills Training as defined in this Section.
A.Responsibilities1. Making initial contact with the Member or the responsible party, by telephone or other appropriate method, within two (2) business days of notification of authorization of care coordination services to discuss choice of provider(s), service delivery options, clarify issues, and answer questions;2. Assisting with the implementation of the authorized plan of care and coordinating service providers who are responsible for delivering services, by making referrals and providing service authorizations to qualified service provider(s) the Member chooses; or if the Member chooses to self-direct, providing access to Skills Training;3. Visiting the Member at his/her residence within 30-45 days of receipt of notification of authorization of care coordination services to review needs and goals, and address unmet needs;4. Visiting the Member annually to monitor the Member's overall health status by following up on identified needs and issues;5. Making contacts with family Members, designated representatives, guardians, providers of services or supports, the assessing services agency, and the Department to ensure continuity of care and coordination of services;6. Monitoring the Member's receipt of services and reviewing the plan of care by contacting the Member at least once per month. Monitoring calls may be reduced to a lesser frequency but not less than quarterly if the Member requests less frequent calls and there is documentation in the record to support this choice. Monitoring may be done by telephone unless an in-person visit is needed to be effective;7. Responding timely to assist the Member with resolving problems and other concerns;8. Advocating on behalf of the Member for appropriate community resources and services by providing information, making referrals and otherwise facilitating access to these supports;9. Modifying the authorized plan of care, within the following parameters:a. In the event a Member experiences a change in the need for services, the care coordinator has the authority to adjust the frequency of services under the authorized plan of care, in order to address the needs. However, the total number of hours authorized for the eligibility period shall not be exceeded.b. In the event a Member experiences an emergency or acute episode as defined in this Section, the care coordinator may adjust the authorized plan of care up to fifteen (15) percent of the monthly authorized amount, not to exceed the monthly program cap. Services added or changed due to the emergency or acute episode may not continue beyond fourteen (14) days.10. Making referrals for reassessments prior to the end of the eligibility period, and based upon a significant change in the Member's health status or change in service needs;11. Issuing notices of intent to suspend, reduce or terminate, as appropriate, when the Member is ineligible for such services or the level of services are reduced. The care coordinator may not issue a notice to reduce or terminate services based on medical eligibility;B. Other activities include, but are not limited to:1. Comply with the Department's internal authorization protocols,2. Maintaining Member records,3. Providing information as required by the Department,4. Following requirements regarding mandated reporting.96.04-6Skills Training includes the following functions: A. Instructing the Member in the management of personal support specialists. Instruction in management of PSS includes instruction in recruiting, interviewing, selecting, training, scheduling, and directing a competent PSS in the activities in the authorized plan of care and obligations under this Section. Providers of skills training must instruct each new eligible Member prior to the start of services.B. The provider must document that initial skills training has occurred within thirty (30) calendar days of the Member electing the FPSO option.C. The Skills Training provider may substitute a competency-based assessment in lieu of repeat instruction for Members having previously completed such training under an earlier eligibility period or from another provider of like services. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-96, subsec. 144-101-II-96.04