Section 144-505-5 - GENERAL CRITERIAThe Maine Health Systems Agency, Inc. and the Department of Human Services shall use the following general criteria relating to the availability, accessibility, acceptability,. continuity, cost, and quality of the service in conducting appropriateness reviews. Criteria based upon the following general criteria specific to the service(s) being reviewed shall be developed and published along with the written request(s) for information needed by the MHSA and the Department to conduct any particular review. Specific standards relating to the criteria may also be developed and published prior to the formal commencement of a review by the MHSA or the Department. If a service compares unfavorably with one or more of the criteria, it may result in the MHSA and/or the Department finding that service to be inappropriate. However, if during the course of their respective reviews the MHSA or the Department determines any criterion published prior to their reviews to be inadequate, that criterion shall not be used in their development of findings on the service(s) in question. In the case of areawide reviews which result in institution-specific findings of services provided by or through HMO's, the considerations shall be limited to those set forth in paragraph (H) of this section.
A. The relationship of the health services being reviewed to the applicable health systems plan, annual implementation plan, and State health plan.B. The relationship of the services reviewed to the long-range development plan (if any) of the person providing the services.C. The need that the population served has for the services, and the extent to which low income persons, racial and ethnic minorities, women, handicapped persons, and other underserved groups have access to those services.D. The availability of less costly or more effective alternative methods of providing the services.E. The relationship of the services reviewed to the existing health care system of the area in which the services are provided.F. The availability of resources (including health manpower, management personnel and funds for capital and operating needs) for the provision of the services reviewed and the availability of alternative uses of these resources for the provision of other health services.G. The special needs and circumstances of those entities which provide a substantial portion of their services or resources or both, to individuals not residing in the health service areas in which the entities are located or in adjacent health services areas. These entities may include medical and other health professions schools, multidisciplinary clinics, and specialty centers.H. The special needs and circumstances of HMOs. In the case of areawide reviews which result in institution specific findings regarding services provided by or through an HMO, the needs and circumstances shall be limited to:1. The needs of enrolled members and reasonably anticipated new members of the HMO for the existing institutional health services provided by the organization.2. Whether the services could be obtained from non-HMO, or other HMO providers in a reasonable and cost-effective manner which is consistent with the basic method of operation of the HMO.3. Any other factors which the State Agency may propose and the Secretary of the Department of Health and Human Services may find to be consistent with the purpose of Title XIII of the Act.I. The special needs and circumstances of biomedical and behavioral research projects which are designed to meet a national need and for which local conditions offer special advantages.J. The importance of recognizing the public's choice of allopathic or osteopathic health services by considering the unique needs and circumstances of providers of allopathic and osteopathic health care.K. The contribution of the existing institutional health services in meeting the health related needs of Members of medically underserved groups and groups which have traditionally experienced difficulties in obtaining equal access to health services (for example, low income .persons, racial and ethnic minorities, women and handicapped persons) particularly those needs identified in the applicable health systems plan, annual implementation plan and State health plan as deserving of priority.L. The special circumstances of health service institutions with respect to the need for conserving energy.M. In accordance with Section 1502(b) of the Act, the effect of competition on the supply of the health services being reviewed.N. Improvements or innovations in the financing and delivery of health services which foster competition, in accordance with Section 1502(b) of the Act, and serve to promote quality assurance and cost effectiveness.O. The quality of care provided by the services or facilities in the past.10- 144 C.M.R. ch. 505, § 5