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Maine Administrative Code
Department 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICESDivision 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERALChapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)Chapter VI
Section 144-101-VI-01 - Primary Care Case Management (replaced by Section 03 on June 21, 2022)
Subsection 144-101-VI-01.05 - EXEMPT SERVICES

C.M.R. 10, 144, ch. 101, ch. VI, 144-101-VI-01, subsec. 144-101-VI-01.05

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Current through 2024-51, December 18, 2024
Subsection 144-101-VI-01.05 - EXEMPT SERVICES
1.05-1Services Not Managed by PCPs

Certain services contained within the service categories listed in Section 1.04 may be accessed directly by members, i.e., without a PCP's referral. The particular services for which a member may self-refer are:

a. Family planning services. The following services may be obtained by a member without a PCP referral:
(i) health education and counseling necessary to make informed choices and understand contraceptive methods;
(ii) distribution of information on family planning;
(iii) consultation, examination and medical treatment including, but not limited to, treatment of urinary tract infection or "UTI".
(iv) diagnosis and treatment of sexually transmitted diseases (STDs), including lab tests;
(v) screening, testing and counseling for human immunodeficiency virus (HIV);
(vi) provision of contraceptive pills, devices, and supplies; and
(vii) diagnosis of infertility;
b. Obstetrical services. Members may self-refer for obstetrical services for the duration of pregnancy, and up to sixty (60) calendar days postpartum. At sixty (60) calendar days postpartum, the member's PCP must resume treatment/management of member's care. During pregnancy, non-obstetrical services and treatment must also be managed and coordinated by the member's PCP;
c Annual gynecological examinations, that may include, but are not limited to: a pelvic examination, a PAP smear, clinical breast examination, mammogram, CBC and routine urinalysis;
d. Mental health and substance abuse services;
e. Annual routine eye examinations, however, services must be provided by an optometrist or ophthalmologist; and
f. Medical care provided in school-based centers or well child clinics.
1.05-2Sections of MaineCare Benefits Manual Not Managed By PCPs

The member's PCP will not manage the following services defined in Chapter II of this Manual. These services do not require a PCP referral in order to be payable by MaineCare, although they may require prior authorization by providers of that service and are subject to the requirements of the respective section of the MBM. Reimbursement for provision of these services will be made in accordance with the policies set forth in Chapters II and III of this Manual and will only be made to providers enrolled with MaineCare, in accordance with Chapter I of this Manual.

a.Ambulance Services, Section 5.
b.Community Support Services, Section 17.
c.Consumer Directed Attendant Services, Section 12.
d.Day Habilitation Services for Persons with Mental Retardation, Section 24.
e.Day Health Services, Section 26.
f.Day Treatment Services, Section 41.
g.Dental Services, Section 25.
h.Early Intervention Services, Section 27.
i.Family Planning Agency Services, Section 30.
j.Home and Community Benefits for the Elderly and for Adults with Disabilities, Section 19.
k.Home and Community Based Waiver Services for Persons with Mental Retardation or Autistic Disorder, Section 21.
l.Home and Community Benefits for the Physically Disabled, Section 22.
m.Hospice Services, Section 43.
n.ICF-MR Services, Section 50.
o.Laboratory Services, Section 55.
p.Licensed Clinical Social Worker, Licensed Clinical Professional Counselor and Licensed Marriage and Family Therapist Services, Section 58.
q.Medical Imaging Services, Section 101.
r.Behavioral Health Services, Section 65.
s.Nursing Facility Services, Section 67.
t.Organ Transplant Services, Sections 45 and 90.
u.Pharmacy Services, Section 80.
v.Private Duty Nursing and Personal Care Services, Section 96.
w.Private Non-Medical Institution Services, Section 97.
x.Psychiatric Facility Services, Section 46.
y.Rehabilitative Services, Section 102.
z.Targeted Case Management Services, Section 13.
aa.Transportation Services, Section 113.
bb.V.D. Screening Clinic Services, Section 150.
cc.School-Based Rehabilitation Services, Section 104.
dd.New MaineCare Benefits Manual, Chapter II Sections. Any new sections added to Chapter II of the MaineCare Benefits Manual will automatically be incorporated as part of Section 1.05 on the date the MaineCare policy becomes effective unless these rules are revised to include the service(s) as a Managed Service in Section 1.04.

C.M.R. 10, 144, ch. 101, ch. VI, 144-101-VI-01, subsec. 144-101-VI-01.05