C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-97, subsec. 144-101-II-97.02
The following individuals are eligible for medically necessary covered Private Non-Medical Institution services as set forth in this Manual:
Individuals must meet the basic eligibility criteria as set forth in Part 2 of theMaineCare Eligibility Manual, 10-144 CMR Chapter 332. There are restrictions on the type and amount of services that members are eligible to receive and they must meet specific eligibility criteria detailed below.
Services in PNMIs must be medically necessary, as evidenced by meeting the medical eligibility criteria set forth in this section. A physician or primary care provider must also document in writing that this model of service is medically necessary for the member, and both the physician and the PNMI provider must keep this documentation in the member's file. For all PNMI services, this documentation must be completed as part of the prior authorization process conducted by the Department and/or its Authorized Agent.
Members must require residential substance use treatment as assessed by the provider and documented in the individual service plan and member's file using the following criteria: American Society of Addiction Medicine, ASAM Patient Criteria for the Treatment of
Disorder, Second Edition, revised (2001), Level III, Residential/Inpatient Treatment Criteria. Members must continue to meet Level III for continued eligibility.
The Department or its Authorized Agent will conduct utilization review to assure medical necessity of these services.
Appendix C facilities must contact the Department's Office of Aging and Disability Services, who must verify that members meet the medical eligibility requirements for residential care as indicated by the Medical Eligibility Determination (MED) tool assessment.
A member meets the medical eligibility and admission criteria for Appendix C PNMI only if that person meets one or more of the following eligibility requirements:
Requires cuing seven (7) days per week for eating, toilet use, bathing, and dressing; OR Requires limited assistance and a one (1) person physical assist with at least two (2) of the seven (7) activities of daily living (ADLs) including bed mobility, transfer, locomotion, eating, toilet use, bathing, or dressing; OR Requires preparation and administration of regularly scheduled prescribed medications two (2) or more times per day that is or otherwise would be performed by a person legally qualified to administer prescribed medications; OR Requires any of the following nursing services, at least once per month, that are or otherwise would be performed by or under the supervision of a registered professional nurse, as described below: administration of treatments, procedures, or dressing changes which involve prescribed medications, for post-operative or chronic conditions according to physician orders, that require nursing care and monitoring. These treatments include: administration of medication via a tube; tracheostomy care; urinary catheter change; urinary catheter irrigation; barrier dressings for Stage 1 or 2 ulcers; chest Physical Therapy (PT) by RN; oxygen therapy by RN; or other physician-ordered treatments; OR Professional nursing assessment, observation, and management for problems including wandering, physical or verbal abuse or socially inappropriate behavior; OR Professional nursing assessment, observation and management for impaired memory, and impaired recall ability, and impaired cognitive ability; OR Exhibits moderately to significantly impaired decision-making ability that will result in reasonably foreseeable unsafe behavior when not appropriately supervised as measured by the cognition section of the MED tool; OR Presents an imminent risk of harm or a probable risk of significant deterioration, as determined by the Department or the Department's Authorized Agent, of the individual's physical, mental or cognitive condition if the individual resides or would reside outside of a licensed facility.All children's services under this Section with the exception of crisis services require prior authorization using eligibility criteria set forth in these rules.
Providers must submit all documentation required for prior authorization according to the guidelines of this Section and Chapter I of this Manual to the appropriate Department Regional Office of the Office of Child and Family Services.
All required assessment tools must be completed within the last ten (10) days prior to submission of the prior authorization request. The DHHS Intensive Temporary Residential Treatment Team (ITRT) in each Region will review the information submitted to determine whether the child meets the criteria set forth below. The Team will determine the child's level of severity and recommend appropriate providers who can meet the needs of the child.
Providers must obtain prior authorization for current residents using these same assessments at the next continuing stay review. Reassessment is required to assure that medical necessity criteria are met for continuing stay in either Level I or Level II programs. Each prior authorization letter sent to the provider and the child/guardian shall indicate the model of service the child is eligible for.
Children must be assessed using the tools mentioned below and providers must submit all requested documentation to the appropriate Department Regional Office of Child and Family Services. Failure to submit requested information will result in disapproval of the prior authorization request. The Department will not reimburse for services that have not been prior approved.
Crisis service providers must contact the Department within 48 hours of initiation of service to begin the prior authorization process for continued provision of services.
Any change in a child's location or program within an agency or to another agency requires prior authorization.
The following assessment tools are used in assessing eligibility for Children's PNMI services, though none of the tools are used as the sole determinant of eligibility.
Children's Habilitation Assessment Tool (CHAT) assesses functioning in three domains: behavior, social skills, and life skills using interviews for individuals 6 to 18 years of age diagnosed with intellectual disabilities or pervasive developmental disorders.
Child and Adolescent Functional Assessment Scale (CAFAS) assesses the functioning due to emotional, behavioral, psychological, psychiatric, or substance use problems in individuals 6 through 17 years of age. A trainedrater completes the scale.
Global Assessment Functioning (GAF) is a numeric scale (0 through 100) used by mental health clinicians and physicians to subjectively rate social, occupational and psychological functioning, e.g., how well or adaptively one is meeting various problems-in-living. Children and adolescents under the age of 18 may be evaluated on the Children's Global Assessment Scale, or C-GAS.
There are four models of PNMI services for Appendix D Child Care Facilities:
There are two levels of PNMI services for children with intellectual disabilities and/or PDD and other symptoms requiring this intensity of service. A child is eligible for only one level of service at a time. Initial priorauthorization will not be given for more than thirty days at a time and continuing stay will be assessed at a minimum of every ninety days thereafter.
All of the following criteria set forth below must be met, in addition to criteria for either Level I or Level II services, as detailed below. The child must have:
An Axis I or II diagnosis from the most current version of the DSM, and A disorder that has lasted for at least six (6) months or is expected to last for at least one (1) year in the future, and A current need for therapeutic treatment or availability of a therapeutic on-site staff response on a twenty-four hour basis, and A disorder that is amenable to treatment in a residential setting, and even with intensive community intervention, including services and supports, there is significant potential that the child will be hospitalized, or there is a clear indication that the child's condition would significantly deteriorate and would require a higher model of service than can be provided in the home and community.In addition to the above criteria, the child must meet the following criteria for either Level I or Level II services:
Level I Criteria
Significant recent aggression across multiple environments or severe enough within one environment to have caused serious injury or there is significant potential of serious injury to self or others; or Recent homicidal ideation with risk of harm to others, or Recent suicidal ideation with risk of harm to self; or Symptoms of intellectual disabilities or Pervasive Developmental Disorder so severe that it results in an inability to care for oneself to a developmentally appropriate level even with home and community supports and services; or Has not responded to less restrictive level of care or would have a significant risk of harm to self or others if a less restrictive setting were attempted; and An assessment using the Children's Habilitation Assessment Tool (CHAT) with a score of 30 or higher or Global Assessment Functioning (GAF) tool score of 50 or lower with description of specific symptoms justifying the score.Level II Criteria
The Child must meet all the level I service criteria and in addition: Frequency, intensity and duration of intervention required to address daily repeated aggression and potential for harm to self or others, or Frequency, intensity and duration of assistance required to address activities of daily living and potential for harm to self or others either directly or as a consequence of being unable to maintain ADL's and Children's Habilitation Assessment Tool (CHAT) score of 35 or higher, or a Global Assessment Functioning (GAF) score of 40 or lower with description of specific symptoms justifying the score.There are two levels of PNMI services for children and adolescents with Mental Health Conditions.
The child must meet all of the criteria set forth below:
The child must have either an Axis I or II diagnosis from the most current version of the DSM, and The child's disorder has lasted for at least six (6) months or is expected to last for at least one year in the future, and The child has a current need for therapeutic treatment or availability of a therapeutic on-site staff response on a twenty-four hour basis, and The child's disorder is amenable to treatment in a residential setting, and Even with intensive community intervention, including services and supports, there is significant potential that the child will be hospitalized, or there is a clear indication that the child's condition would significantly deteriorate and would require a higher model of service than can be provided in the home and community.In addition, the child must meet the criteria below for Level I or Level II services:
Level I Criteria
Significant recent aggression across multiple environments or severe enough within one environment to have caused injury or there is significant potential of injury to self or others; or Recent homicidal ideation with risk of harm to others, or Recent suicidal ideation with risk of harm to self; or Symptoms of mental illness so severe that it results in an inability to care for oneself in a developmentally appropriate manner, even with home and community supports or services; or Has not responded to less restrictive model of service or would have a significant risk of harm to self or others if a less restrictive setting were attempted; and A Child and Adolescent Functional Assessment Scale (CAFAS) score of 100 or higher or Global Assessment Functioning (GAF) score of 50 or lower with description of specific symptoms justifying the score.Level II Criteria
Frequency, intensity and duration of intervention required to address daily repeated aggression and potential for harm to self or others, or Frequency, intensity and duration of assistance required to address Activities of Daily Living and potential for harm to self or others either directly or as a consequence of being unable to maintain ADL's and A Child and Adolescent Functional Assessment Scale (CAFAS) 8 scale score of 120 or higher, or Global Assessment Functioning (GAF) score of 40 or lower with description of specific symptoms justifying the score.The purpose of this temporary service is to stabilize a child who is currently residing in an Appendix D PNMI and experiences an escalation in behavioral discontrol in order to avoid the need to hospitalize the child. This service, provided only in an Appendix D PNMI for the express purpose of maintaining a child in the PNMI program, must be Prior Authorized and will be subject to Continuing Stay Review no later than every seven (7) calendar days. An Individualized Treatment Plan detailing the issue that has caused this request to be made must be submitted to the OCFS regional Intensive Treatment Review Team with the request for Prior Authorization that demonstrates why the child or others are not safe without this level of service, changes in treatment in an effort to decrease the unsafe behaviors, and documents a discharge plan with specific discharge criteria from this level of service.
The typical length of service is no more than seven (7) days and should not exceed thirty (30) days. In situations where this Level is sought for thirty (30) days or more, a Continuing Stay Review will be required and a new program considered that would more appropriately meet the child's needs.
The child must meet all eligibility criteria set forth below. The child must meet eligibility criteria for
AND
Brief hospitalizations for medication and behavioral stabilization are not grounds for seeking this level of care.
Crisis Stabilization services are individualized therapeutic interventions provided to a child during a psychiatric emergency 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. Psychiatric emergency is when the child is in imminent risk of serious harm to self or others and even with intensive community intervention, including services and supports, there is significant potential that the member will be hospitalized.
Components of crisis stabilization include assessment, monitoring behavior and the member's response to therapeutic interventions; participating and assisting in planning for and implementing crisis and post stabilization activities, and supervising the child to assure personal safety.
While crisis services do not require prior authorization, providers must contact the Department within forty-eight (48) hours to get approval of continued reimbursement for this service using the prior approval process detailed in this Section.
Intensive Temporary Behavioral Health Treatment in a Residential Setting
Therapeutic Foster Care is a family-based service delivery approach providing treatment to children with moderate to severe mental health, behavioral health and developmental needs. Treatment is delivered through services integrated with key interventions and supports provided by therapeutic foster parents who are trained supervised and supported by qualified therapeutic foster care program staff. The delivery of treatment is a shared responsibility between the independently licensed clinical staff, the independently licensed social work staff and the therapeutic foster parents. Therapeutic foster care is designed to allow children receiving treatment to reside in a family like setting as opposed to institutional settings, while receiving treatment.
To be eligible for these services, the child must be in DHHS or Department of Corrections custody and must require therapeutic intervention detailed above.
The child must meet the following criteria:
A Child and Adolescent Functional Assessment Scale (CAFAS) 8 scale score of 50 higher, and an Axis I or II diagnosis from the most current version of the DSM, and The child's disorder must have lasted for at least six (6) months or is expected to last for at least one year in the future, and A current need for therapeutic treatment or availability of a therapeutic on-site staff response on a twenty-four-hour basis, and Even with intensive community intervention, including services and supports, significant potential that the child will be hospitalized, or there is a clear indication that the child's condition would significantly deteriorate and would require a higher model of service than can be provided in the home and community.Appendix E services require prior authorization and utilization review.
Providers must submit all eligibility documentation required for prior authorization according to the guidelines of this Section and Chapter I of the MaineCare Benefits Manual to the Office of Behavioral Health. No PNMI provider may admit a member into an Appendix E facility without prior authorization. To be eligible, members must meet the following eligibility criteria, with documentation of all of the following information in the member's care plan:
Providers must use the Department's approved assessment tool, the Level of Care Utilization System for Psychiatric and Addiction Services, Adult Version 2010, of the American Association of Community Psychiatrists (LOCUS) as a tool in assessing eligibility.
Members must meet the following eligibility criteria, with documentation of all of the following information in the member's plan:
The person is age eighteen (18) or older or is an emancipated minor;
AND
Has a primary diagnosis on Axis I or Axis II of the multiaxial assessment system of the current version of the Diagnostic and Statistical Manual of Mental Disorders, other than one of the following diagnoses: Delirium, dementia, amnesia, and other cognitive disorders; Mental disorders due to a general medical condition, including neurological conditions and brain injuries; Substance use or dependence; developmental disabilities; Adjustment disorders; V-codes; or Antisocial personality disorder;
AND
demonstrates a need for residential care as assessed by the LOCUS with a score on the LOCUS of at least 23 or greater and a Level V or more.
Non-Case Mixed Medical and Remedial Facilities specialize in the treatment of adults with ID/DD, brain injury, mental illness, or other disabilities.
No PNMI provider may admit a member into an Appendix F mental health facility without prior authorization. Appendix F Non-Case Mixed facilities must contact the Department of Health and Human Services as detailed below to obtain prior authorization for services:
Those facilities serving public wards must contact the Office of Aging and Disability Services Adult Protective Services Regional Offices for authorization for placement of any member in an Appendix F facility serving public wards. For all other Appendix F facilities contact the Office of Aging and Disability Services to assure that services are prior authorized.
Facilities serving members with mental illness in an Appendix F facility must submit all eligibility documentation required for prior authorization according to the guidelines of this Section and Chapter I of the MaineCare Benefits Manual to the DHHS Office of Behavioral Health. To be eligible, members must meet the following eligibility criteria, with documentation of all of the following information in the member's care plan:
Providers must use the Department's approved assessment tool in assessing eligibility, the LOCUS, which is the Level of Care Utilization System for Psychiatric and Addiction Services of the American Association Services. The Adult Version 2000 will be utilized until DHHS has authorization to use the Adult 2010 version.
Members must meet the following eligibility criteria, with documentation of all of the following information in the member's plan:
The person is age eighteen (18) or older or is an emancipated minor;
AND
Has a primary diagnosis on Axis I or Axis II of the multiaxial assessment system of the current version of the Diagnostic and Statistical Manual of Mental Disorders, other than one of the following diagnoses: Delirium, dementia, amnesia, and other cognitive disorders; Mental disorders due to a general medical condition, including neurological conditions and brain injuries; Substance use or dependence; developmental disabilities; Adjustment disorders; V-codes; or Antisocial personality disorder;
AND
demonstrates a need for residential care as assessed by the LOCUS with a score on the LOCUS of at least 23 or greater and a Level V or more.
To be eligible for services in facilities specializing in treatment of brain injury, members must meet the following eligibility criteria, with documentation of all of the following information in the member's individual service plan:
The person must be age eighteen (18) or older AND Have a primary diagnosis of head injury, defined as "an insult to the brain resulting directly or indirectly from trauma, anoxia, vascular lesions or infection, which is not of a degenerative or congenital nature; can produce a diminished or altered stated of consciousness resulting in impairment of cognitive abilities or physical functioning; can result in the disturbance of behavioral or emotional functioning; can be either temporary or permanent; and can cause partial or total functional disability or psychosocial maladjustment" confirmed by a qualified neuropsychologist or a licensed physician who is Board certified or otherwise Board eligible, in either physical medicine and rehabilitation or neurology;
AND
Have cognitive, physical, emotional and behavioral needs resulting in a score of at least three (3) on one item in at least two (2) domains on the Brain Injury Assessment Tool (BIAT) administered by a qualified neuropsychologist or occupational therapist or speech/language pathologist or a licensed physician who is Board certified or otherwise Board eligible in either physical medicine and rehabilitation or neurology or other licensed professional authorized by Brain Injury Services;
AND
Have a demonstrated need for twenty-four (24) hour supervision and support as indicated on the Brain Injury Health and Safety Assessment (BIHSA) administered by a qualified neuropsychologist or occupational therapist or speech/language pathologist or a licensed physician who is Board certified or otherwise Board eligible in either physical medicine and rehabilitation or neurology or other licensed professional authorized by Brain Injury Services.
Members with brain injuries receiving these services will be reassessed annually using the BIAT and BIHSA to determine continuing need for services. Members currently receiving these services will be assessed within 180 days of the implementation date of this rule.
Members no longer eligible for these services will be discharged only to a safe, appropriate residential arrangement.
In order to be eligible for services under this sub-section specializing in treatment for members with intellectual disabilities and/or Pervasive Developmental Disabilities, members must be at least eighteen (18) years old
AND
meet the eligibility requirement for persons with intellectual disabilities/pervasive developmental disorders as defined in 34-B M.R.S.A. Section5001(3) and 6002. "Intellectual disability" means a condition of significantly sub-average intellectual functioning resulting in or associated with concurrent impairments in adaptive behavior and manifested during the developmental period."
AND
be in jeopardy of not having a place to live, or not adequate supervision necessary to assure their health and safety. This determination will be made based on the results of a risk assessment and supported by the member's planning team,
AND
Require that supervision be available and on-site at all times;
AND using the Department's Developmental Services Needs Inventory tool, have identified needs at the C, D, or E level in at least three of the categories. Providers may contact the Department to obtain this assessment tool.
Some providers of Medical and Remedial Facilities treat members with a variety of medical needs not detailed above. To be reimbursed for services, providers must assure that members meet medical eligibility for at least one of the above Medical and Remedial Facility eligibility criteria detailed above including at a minimum the eligibility criteria for Appendix C or Appendix F above or eligibility as a public ward for Adult Protective Services as defined in 22 M.R.S.A Chapter 958-A.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-97, subsec. 144-101-II-97.02