MaineCare Policy E-Message - March 22, 2016
Maine Department of Health & Human Services sent this bulletin at 03/22/2016 08:41 AM EDT
The Division of Policy posts all proposed and recently adopted rules on MaineCare’s Policy and Rules webpage. This website keeps the proposed rules on file until they are finalized and until the Secretary of State website is updated to reflect the changes. The MaineCare Benefits Manual is available on-line at the Secretary of State’s website.
Below, please find a Notice of Agency Rule-making Adoption. You can access the complete rule at http://www.maine.gov/dhhs/oms/rules/index.shtml
Notice of Agency Rule-making Adoption
AGENCY: Department of Health and Human Services, Office of MaineCare Services
CHAPTER NUMBER AND TITLE: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapters II & III, 101, Section 17, Community Support Services and Allowances for Community Support Services
ADOPTED RULE NUMBER:
CONCISE SUMMARY: The Department adopts this rule to effectuate the following changes:
- The Table of Contents has been updated to reflect new page numbers and includes 17.01-18, Primary Diagnosis.
- List of Definitions now includes:
a. Primary Diagnosis, 17.01-18 which now reads “for the purposes of this policy, primary diagnosis shall mean the diagnosis that results in qualifying functional deficits.” In response to public comments, Primary Diagnosis has been added to clarify 17.02-3 Specific Requirements for eligibility.
b. 17.01-5, Clinician now reads “is an individual appropriately licensed or certified in the state or province in which he or she practices, practicing within the scope of that licensure or certification, and qualified to deliver treatment under this section. A clinician includes the following: Licensed Clinical Professional Counselor (LCPC); Licensed Clinical Professional Counselor-conditional (LCPC-conditional); Licensed Clinical Social Worker (LCSW); Licensed Master Social Worker conditional (LMSW-conditional clinical); physician; psychiatrist; Advance Practice Registered Nurse Psychiatric and Mental Health Practitioner (APRN-PMH-NP); Advance Practice Registered Nurse Psychiatric and Mental Health Practitioner (APRN-PMH-CNS); Physician Assistant (PA); or licensed psychologist.” Clinical has been removed from Licensed Clinical Psychologist as it appeared in proposed language, as suggested by a commenter.
c. 17.01-21, Substance Abuse Counselor now reads “means an individual who is licensed by the Maine State Board of Alcohol and Drug Counselors as a Certified Alcohol and Drug Counselor (CADC), Licensed Alcohol and Drug Counselor (LADC); or an Advanced Practice Registered Nurse (APRN), Licensed Physician (MD or DO), Physician Assistant (PA), Licensed Psychologist, Licensed Clinical Social Worker (LCSW), Licensed Clinical Professional Counselor (LCPC), or Licensed Marriage and Family Therapist (LMFT), who has a minimum of one (1) year of clinical experience providing substance abuse treatment.” Physician Assistant has been added to this definition based on public comment.
- 17.02-3(A)(2) Specific Requirements for Eligibility now reads “has a written opinion from a clinician, based on documented or reported history, stating that he/she is likely to have future episodes, related to mental illness, with a non-excluded DSM 5 diagnosis, that would result in or have significant risk factors of homelessness, criminal justice involvement or require mental health inpatient treatment greater than 72 hours, or residential treatment unless community support program services are provided; based on documented or reported history; for the purposes of this section, reported history shall mean an oral or written history obtained from the member, a provider or caregiver; or…” The additional language of “significant risk factors: and “reported history” have been included to clarify eligibility criteria based on comments received.
- 17.02-3(A)(2)(f), As a result of comments, the Department changed the eligibility criteria to make it a less restrictive criteria (more generous to recipients). The changed provision now reads “until the age of 21, the recipient was eligible as a child with severe emotional disturbance, and the recipient has a written opinion from a clinician, in the last 12 months, stating that the recipient had risk factors for mental health inpatient treatment or residential treatment, unless ongoing case management or community support services are provided.” The proposed language read “and the recipient has a written opinion from a clinician, in the last 12 months, stating that he/she is reasonably likely to have future episodes requiring mental health inpatient or residential treatment, unless ongoing case management or community support services are provided,” and thus was more restrictive.
- 5. 17.02-3(B), now reads: “Has significant impairment or limitation in adaptive behavior or functioning directly related to the primary diagnosis and defined by the LOCUS or other acceptable standardized assessment tools approved by the Department.” This language was added to clarify the need for significant impairment or limitation in adaptive behavior or functioning as it relates to the primary diagnosis.
- 17.02-4(C), now reads: “For Community Integration Services, only, verify that a member meets specific Eligibility Requirements under 17.02-3 within thirty (30) days of the start date of services. If Eligibility Verification is not submitted by close of business on day thirty (30), MaineCare will cease paying for services, under this section, on day thirty one (31).” In response to public comments indicating that the proposed language was confusing, additional language has been included.
- 17.04-3, Assertive Community Treatment (Medication services), now reads: “capacity to administer medications daily in a member’s home or community by an appropriately licensed/certified ACT team professional.” In response to public comment “CRMAs are allowed to administer medications as delegated by the RN or other licensed medical providers” has been removed.
- 17.07-1(B), now reads: “A psychologist who is a licensed psychologist by the Maine Board of Examiners of Psychologists or by the state or province where services are provided, as documented by written evidence from that Board.” Proposed language read “a licensed clinical psychologist”. In response to public comment clinical has been removed.
- 17.07-1(J), now reads: “A registered nurse, under the direction of a psychiatrist, who is a graduate of an accredited nursing program and holds a valid license to practice in the state or province in which services are to be provided.” Proposed language read “a registered nurse, under the supervision of a psychiatrist”. In response to public comment “under the supervision” has been changed to “under the direction of”.
- Changing the eligibility so that individuals with a sole diagnosis of either autism or intellectual disability (“neurodevelopmental disorders”), are no longer eligible for Section 17 services. However, individuals with neurodevelopmental disorders who also have a qualifying or co-occurring diagnosis, would remain eligible for Section 17 services.
- Deletion of AMHI Consent Decree Class Member as a stand-alone criterion for eligibility to receive Community Integration Services.
- Deletion of Intensive Case Management as a covered service.
- Exceptions for face to face visit requirements through Assertive Community Treatment includes:
a. All attempts to reach and meet with the member, including if the member was unavailable or the contact occurred through a closed door.
b. Contacts to transition the member to another level of care.
c. Variations in the number of weekly face-to-face contacts i.e. two (2) contacts in one week and four (4) the next.
In response to public comment, “contacts assessed to be clinically inappropriate” has been removed as an exception.
Changes made to the eligibility for Section 17 services were made so that only those individuals for whom Section 17 was clinically appropriate would be eligible. Section 17 services are designed to serve those most in need of intensive support. The Department believes that some of the individuals currently receiving Section 17 services are more appropriately served under other sections of the MaineCare manual, such as Section 65 (Behavioral Health Services), or Section 21 (Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorder), Section 29 (Support Services for Adults with Intellectual Disabilities or Autistic Disorder), or Section 92 (Behavioral Health Homes).
The Department carefully evaluated the need for changes to Section 17 rule and spent nearly a year meeting with a group that included a psychiatrist and other clinicians. The Department spent a great deal of time reviewing and discussing clinical criteria for the appropriate treatment of individuals with severe mental illness and concluded that treating individuals with mild or moderate mental illness (individuals with conditions such as anxiety, mild or moderate depression, and PTSD) with the types of community supports provided in Section 17 is not clinically appropriate and can even be counter indicated. These individuals are better served with counseling and/or medication, and those services are available in Section 65, or through the holistic support provided in the Behavioral Health Home model, Section 92. Individuals with severe and persistent mental illness do benefit from intensive community supports, and they will remain eligible for these Section 17 services. The Department determined that it was in the best interest of the MaineCare population to make these changes to the eligibility criteria. As such, the Department tailored the eligibility criteria to meet the needs of the individuals for whom Section 17, is clinically appropriate.
Intensive Case Management services were deleted because the Department determined after conducting studies, that this service was not being utilized. Case Management services continue to be available under Section 13.
The Department deleted the status of an AMHI Consent Decree class member as a stand-alone criterion for eligibility for Section 17 Community Integration services, because that is not a standard recognized or authorized in federal Medicaid law or regulation. It is likely that there will be many Consent Decree class members who will remain eligible for Section 17 Community Integration services. For those class members who will no longer be eligible for Section 17 Community Integration services, the Department acknowledges its duty to provide services required under the Consent Decree, as provided and funded through non-MaineCare state contracts.
The fiscal impact of this rulemaking is largely indeterminable. While the Department is unable to estimate how many recipients will no longer be eligible for Section 17 services because of these rule changes, the Department also cannot accurately predict how many of those recipients will seek out other services most notably Section 92, Behavioral Health Homes and Section 65, Behavioral Health Services, or Section 29 Community Support Services for Adults with Intellectual Disabilities or Autistic Disorders. In addition, regarding the Consent Decree, if individuals in this group do not meet Section 17 Community Integration eligibility criteria, they will no longer be eligible for Section 17 Community Integration services. However, they would remain eligible to receive Community Integration services, as required by the Consent Decree, and as provided and funded through non-Medicaid state contracts.
It is anticipated that this rulemaking will not impose any costs on municipal or county governments, or on small businesses employing fewer than twenty employees.
See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
EFFECTIVE DATE: March 22, 2016
AGENCY CONTACT PERSON: Heidi Bechard, Health Planner
AGENCY NAME: Division of Policy
ADDRESS: 242 State Street
11 State House Station
Augusta, Maine 04333-0011
TELEPHONE: (207) 624-4074 FAX: (207) 287-1864
TTY: 711 (Deaf/Hard of Hearing)