Subsection 144-101-I-1.06 - COVERED AND NON-COVERED SERVICES1.06-1Covered ServicesAll covered services reimbursable by MaineCare must be medically necessary and described in the MBM. MaineCare members are eligible for as many covered services as are medically necessary and within the limitations outlined in applicable sections of this Manual. The Department reserves the right to require additional medical opinions or evaluations by appropriate professionals of its choice concerning medical necessity or expected therapeutic benefit of any requested service.
Covered services include those services described in other Chapters of this Manual and other medically necessary health care, diagnostic services, treatment, and other measures, as required by the Omnibus Reconciliation Act of 1989.
These services are intended to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services described in the Manual sections applicable to EPSDT for members under age twenty-one (21), whether or not such services are (otherwise) covered under the Medicaid State Plan as long as they would otherwise be federally allowable under the State Plan.
1.06-2Interpreter ServicesA. Providers must ensure that MaineCare members are able to communicate effectively with them regarding their medical needs. MaineCare will reimburse providers for interpreters required for limited and non-English speaking members and/or deaf/hard of hearing members, when these services are necessary and reasonable to communicate effectively with members regarding health needs. Interpreter services can only be covered in conjunction with another covered MaineCare service or medically necessary follow-up visit(s) to the initial covered service. MaineCare will pay for two (2) interpreters for deaf MaineCare members who use a sign language other than American Sign Language or who use a unique non-spoken method of communication and require a relay interpreting team including a deaf interpreter working with a hearing interpreter.
B. Family members or personal friends may be used as interpreters, but cannot be paid. "Family" means any of the following: 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. Family members or friends, with the exception of those individuals under the age of 18, may be used as non-paid interpreters if:
1. requested by the member; and 2. the use of this friend or family member does not compromise the effectiveness of services or violate the member'sconfidentiality; and3. the member is advised that an interpreter is available at no charge to the member.C. If a paid interpreter is hired, providers can select the interpreter. However, should the interpreter provide transportation to the member, MaineCare will not reimburse the interpreter for transporting the member while concurrently billing for interpreter services. All interpreter services must be provided in accordance with the Americans with Disabilities Act.D. A provider may not bill MaineCare for an interpreter service supplied by an entity in which the provider, any owner of the provider, or an immediate family member of the provider or any of its owners has any direct or indirect ownership or financial interest, unless: 1. The provider also reimburses other entities for the provision of interpreter services; and 2. The entity providing the interpreting service makes those services commercially available to MaineCare providers or other businesses that do not share a direct or indirect familial ownership interest with the interpreting entity.E. When providers request reimbursement for any interpreter services, the services must be included in the member record. Documentation must include a statement verifying the interpreter qualifications, date, time and duration of service, language used, the name of the interpreter, and the cost of performing the service.F. Providers are responsible for ensuring that interpreters protect patient confidentiality and adhere to an interpreter code of ethics. Providers shall document that interpreters have provided evidence of having read and signed a code of ethics for interpreters equivalent to the model included as Appendix #1. This shall be deemed as compliance with this requirement.G. Providers of interpreter services must be licensed by the Maine Department of Professional and Financial Regulation as Certified Interpreters/Transliterators, Certified Deaf Interpreters, Limited Interpreters/Transliterators, or as Limited Deaf Interpreters.H. Providers must use the following code when billing for interpreter services for deaf/hard of hearing members and non-English speaking members: T1013 Sign language or oral interpreter services per fifteen minutes.
The actual billable amount should be the lesser of the interpreter's usual and customary charge and the rate authorized by the Department.
Any other codes for interpreter services listed in the specific service sections of the MBM are no longer valid.
I. Providers may use language interpreter services conducted via telephone or other audio/video means. These services may come from local resources, national language interpreter services such as LanguageLine Solutions or comparable services. Wherever feasible, providers should use local and more cost-effective interpreter services. When billing for language interpreter services conducted via telephone or other audio/video means, providers should use the T1013 procedure code with a GT modifier and include copies of the invoice with the claim. Reimbursement is by invoice.
J.Exceptions and Limitations1. Hospitals, ICF/IID Intermediate Care Facility for Individuals with Intellectual Disabilities, and nursing facilities may not bill separately for either language or deaf/hard of hearing interpreter services. For hospitals, ICF/IIDs, and nursing facilities, these costs will be allowable and are included in the calculation of reimbursement.2. The Department will not pay for interpreter services when there is a primary third party payer if the primary third party payer is required to cover the interpreter services.3. The Department will not reimburse for interpreter travel time or wait time. 1.06-3Presumptive Eligibility for Services for Pregnant WomenA. Presumptive eligibility can only be determined by qualified providers. The term "qualified provider" is defined in 42 U.S.C. § 1396r-1. Examples of qualified providers to determine eligibility are: Federally Qualified Health Centers; Indian Health Centers; Rural Health Clinics; Family Planning Agencies; WIC Agencies. B. Pregnancy-related services are those services that are necessary for the health of the pregnant woman or fetus, or that have become necessary as a result of the woman having been pregnant. 1.06-4Non-Covered ServicesA. MaineCare will not reimburse for non-covered services. Providers may bill members for non-covered services only if, prior to the provision of the service, the provider has clearly explained to the member that MaineCare does not cover the service and that the member will be responsible for the payment. Providers must document in the member's record that the member was told, prior to provision, that the service was not a MaineCare covered service and that the member is responsible for the payment.B. The following services are considered non-covered services. Costs for these non-covered services are not reimbursable by MaineCare, or by the member unless the notification requirements described in Section 1.06-4(A) have been met. MaineCare does not reimburse for:
1. Services not described in the MBM, or related Principles of Reimbursement; 2 Experimental procedures or drugs not approved by the Food and Drug Administration (FDA);3. Services that are primarily custodial care, respite care, socialization, academic, religious, vocational, or educational, unless specifically permitted elsewhere in this Manual including: a.Custodial ServicesCustodial Services are any services, or components of services, of which the basic nature is to provide custodial care.
b.Socialization or Recreational ServicesSocialization or recreational services are any services, or components of services, of which the basic nature is to provide opportunities for socialization, or those activities that are solely recreational in nature. These non-covered services include, but are not limited to picnics, dances, ball games, parties, field trips, and social clubs.
c.Academic/Educational Services Any services or components of service provided to members that are academic or educational in nature. Academic services include, but are not limited to, those traditional subjects such as science, history, literature, foreign languages, and mathematics.
d.Vocational Services Vocational services include organized programs such as vocational skills training, or sheltered employment, that prepare individuals for paid or unpaid employment.
4. Services that have prerequisites that have not been met as defined in the appropriate section of the MBM, including prior authorization and medical eligibility requirements;5. Any items or services that have been purchased elsewhere that are required to be purchased through a volume purchase agreement between the state and a provider;6. Services provided without a pre-admission screening and/or concurrent review as required by the Department;7. Services provided by a psychiatric facility, institution for mental diseases, or institutional service provided for members age twenty-one (21) to sixty-five (65). No federal financial participation is available for these services or this population; 8. Administrative tasks, including verification of MaineCare eligibility, updating member contact information, scheduling of appointments, tasks performed for the provider's own administrative purposes, and similar activities. Certain administrative tasks may be covered when described in the appropriate Section of the MBM; and 9. Any other services not provided in conformance with the requirements of this Manual.C.Coverage Limitations Associated with Managed Care MaineCare will not cover the cost of services denied by a managed care plan when the service was denied because the member did not comply with the plan's requirements. When a member receives services not in compliance with the managed care plan, the member is responsible for paying for those services. Examples of member non-compliance include but are not limited to, failure to obtain the necessary referral from the managed care plan or receiving services from a provider that does not participate in the managed care plan. This applies both to MaineCare managed care benefits and private managed care plans. There is an exception for members with emergency medical conditions that are screened, stabilized, and transferred as required by federal law.
Providers of MaineCare Managed Care services, as noted in Chapter VI Primary Care Case Management, must have a referral from the member's primary care provider site prior to the member visit. Certain services are exempt from needing a referral from the primary care provider and are outlined under Chapter VI, Section 1, Primary Care Case Management, Section 1.05.
D.Request for Rule Change or New Rules for MaineCare Coverage of Non-Covered Services1. When a member or provider requests authorization for MaineCare coverage of a service not currently covered by MaineCare, that request will be denied (see exception in Section E, for members with EPSDT). The individual or group making the request may contact MaineCare Services, Director, Division of Policy, to request a formal review of a proposed new service. Appropriate staff will then review the request. 2. MaineCare Services will consider, but is not obligated to cover, health interventions within the specified service sections if they meet all of the following outcome criteria: a. The intervention is for a medical condition;b. There is sufficient evidence to draw conclusions about the effects of the intervention on health outcomes;c. The evidence demonstrates that the intervention can be expected to produce its intended effects on health outcomes;d. The intervention's expected beneficial effects on health outcomes outweigh its expected harmful effects; ande. The intervention is the most cost-effective method available to address the medical condition.3. Key definitions to support the above statements are: a. Medical Condition: A disease, an illness, or an injury. A biological or psychological condition that lies within the range of normal human variation is not considered a disease, illness, or injury.b. Health Outcomes: Outcomes of medical conditions that directly affect the length or quality of a person's life.c. Sufficient Evidence: Evidence is considered to be sufficient to draw conclusions if it is peer reviewed, is well controlled, directly or indirectly relates the intervention to health outcomes, and is reproducible both within and outside of research settings.d. Health Intervention An activity undertaken for the primary purpose of preventing, improving, or stabilizing a medical condition. Activities that are not considered health interventions include those that are primarily custodial, or part of normal existence, or undertaken primarily for the convenience of the patient, family, or practitioner.e. Cost: An intervention is considered cost effective if there is no other available intervention that offers a clinically appropriate benefit at a lower cost.E. As described in Section 1.14, the Department shall take all reasonable and necessary steps to ensure that all requests for prior authorization of services for MaineCare members receiving EPSDT that are determined to be non-covered under this Manual, be considered for coverage under EPSDT, prior to being denied as non-covered.1.06-5Broken AppointmentsProviders may not bill members for broken appointments, even if providers advised members prior to the service. However, providers may refuse to continue to see members who have repeatedly broken appointments without prior notice. In such situations, providers must provide prior notice of office policies concerning no-shows to members before refusing to continue to see those members.
1.06-6Rental Equipment Members for whom the Department is renting medical equipment (for example, certain wheelchairs or C-PAPs) are required to return the equipment following the end of the authorization period.
10-144 C.M.R. ch. 101, I-1.06