C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-107, subsec. 144-101-II-107.04

Current through 2024-51, December 18, 2024

Subsection 144-101-II-107.04 - MEMBER ELIGIBILITY

107.04-01General Eligibility

To access PRTF services, members must meet all the following criteria:

A. Be under the age of 21.

B. Meets Clinical Certification of Need (CCON) requirements, as set forth in 107.04-02.

C. The parent or legal guardian, when applicable has approved of this level of service; and

D. The member meets all other MaineCare eligibility requirements.

107.04-02Clinical Certification of Need (CCON) for PRTF Services

A. CCON Team

1. An independent team consisting of the following individuals must complete the CCON for each member seeking care in a PRTF. No member of the team may be employed by or have a consultant relationship with the admitting PRTF. The team must consist of the following individuals:

a. A physician;

b. A licensed master's level clinician with clinical experience in child psychiatry. Eligible provider types include:

i. LCSW;

ii. LCPC;

iii. Psychiatric Mental Health Nurse Practitioner;

iv. Physician's Assistant;

c. An individual with specific knowledge of the member's situation. The parent/guardian (when applicable) or designee must fill this role. This individual may be a current provider, family or community member, case manager, or other individual with relevant knowledge. In the event of multiple providers, only one individual may be designated to serve this role. The parent/guardian will have the opportunity to select this individual to serve on their behalf; and

d. A representative of the Office of Child and Family Services.

B. Certification Requirements

1. The CCON team must unanimously certify all the following:

a. The member has an active psychiatric condition and functional deficits qualifying as a Serious Emotional Disturbance (SED) meeting the criteria below. The member must be reassessed annually at minimum (within twelve (12) months of the last determination) by licensed mental health professional acting within the scope of their licensure to determine if the member continues to qualify as having an SED:

i. Have a primary diagnosis listed in Appendix A with a severity specifier of moderate to severe (when applicable) when applied to the current condition of the youth, as determined by a licensed mental health professional acting within the scope of their licensure, for the previous six (6) month period or must be reasonably predicted to last six (6) months; and

ii. The member must also consistently and persistently demonstrate behavioral abnormalities to a significant degree, well outside the normative developmental expectations for the previous six (6) month period or must be reasonably predicted to last six (6) months. Behavioral abnormalities cannot be attributed to intellectual, sensory, or health factors.

iii. The member must additionally display at a minimum, four (4) of the following conditions:

a. failure to establish or maintain developmentally and culturally appropriate relationships with adult caregivers or authority figures;

b. failure to demonstrate or maintain developmentally and culturally appropriate peer relationships;

c. failure to demonstrate a developmentally appropriate range and expression of emotion or mood;

d. disruptive behavior sufficient to lead to isolation in or from school, home, therapeutic, or recreation settings;

e. behavior that is seriously detrimental to the youth's growth, development, safety, or welfare, or to the safety or welfare of others; or

f. behavior resulting in substantial documented disruption to the family including, but not limited to, adverse impact on the ability of family members to secure or maintain gainful employment.

b. Ambulatory (community-based) resources available in the community, including Private Non-Medical Institutions (PNMI), do not meet the treatment needs of the member, as evidenced by one of the following:

i. The youth has behavior that puts the youth at substantial documented risk of harm to self;

ii. The youth has persistent, pervasive, and frequently occurring oppositional defiant behavior, aggression, or impulsive behavior related to the SED diagnosis which represents a disregard for the wellbeing or safety of self or others; or

iii. There is a need for continued treatment beyond the reasonable duration of an acute care hospital and documented evidence that appropriate intensity of treatment cannot be provided in a community setting.

The member need not have accessed or exhausted all other available services; however, the team must make a determination that these other services are inadequate to meet the member's needs.

c. Treatment of the member's psychiatric condition requires medical supervision seven days per week and 24 hours per day, on an inpatient basis and under the direction of a physician.

d. Services can reasonably be expected to improve the member's condition or prevent further regression so that the services will no longer be needed.

2. Additionally, the CCON team must provide documentation of the following:

a. Member's diagnosis or diagnoses;

b. Summary of present medical finding;

c. Relevant medical, psychiatric, and behavioral history;

d. Mental and physical functional capacity;

e. Prognoses, to the extent determinable;

f. The member's created or updated CANS assessment; and

g. Documentation describing any community based services previously accessed by the member as well as their efficacy and challenges faced.

3. Prior Authorization

a. The CCON documentation must contain relevant information as described in Sections 107.04-02.B (1-2) above, which must be submitted for Prior Authorization (PA) to the Department or the Department's third-party administrator. Prior Authorization is required for all PRTF services.

4. Copies of the CCON documentation must be submitted to the PRTF upon the member's admission, and every 60 days thereafter in accordance with the CCON process.

C. Duration of Care

1. PRTF services may continue to be provided as long as medically necessary as determined by the Treatment Plan and described in the CCON.

2. The CCON process must be completed every 60 days to meet federal utilization control requirements.

3. A continued stay Prior Authorization (PA) must be completed every 60 days.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-107, subsec. 144-101-II-107.04