C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-109, subsec. 144-101-II-109.07
A covered service is a service for which the member is eligible and payment can be made by the Department. All covered services provided under this Section must be ordered or requested in writing by a practitioner of the healing arts as allowed by the respective licensing authority and his or her scope of practice. Covered services are also limited to the following:
The following services are covered for all members:
A direct encounter between a licensed speech-language pathologist and the member to determine the status of both receptive and expressive communication skills.
The process of producing behavioral change in the member with a communication disorder involving a one-to-one relationship by a licensed speech-language pathologist or a registered speech-language pathology assistant and following a plan of care.
The process of producing behavioral change in the member with a communication disorder involving other than a one-to-one relationship by a licensed speech-language pathologist or a registered speech-language pathology assistant and following a plan of care.
A direct encounter between member and speech-language pathologist to determine current status with periodicity determined by plan of care. At minimum, re-evaluations will occur and plans shall be updated within six (6) months of the date of the plan of care.
Specialty testing by speech-language-pathologist to assist in diagnosis and development of a medical plan of care. Report will include speech-language pathologist's recommendations. Currently acceptable medical tests and procedures are to be utilized as medically necessary.
Pure tone air conduction testing by a speech-language pathologist as part of a hearing screening program.
Speech, voice and/or language screening performed by a licensed speech-language pathologist or a registered speech-language pathology assistant as part of screening.
The scope of augmentative and alternative communication evaluation services including: diagnostic, screening, preventive, and corrective services provided by a licensed speech-language pathologist or, as appropriate, a registered speech-language pathology assistant. Specific activities include: evaluation for, recommendations of, design, set-up, customization, reprogramming, maintenance, and training related to the use of an AACD. Refer to Chapter II, Section 60, "Durable Medical Equipment", of the MaineCare Benefits Manual for criteria for augmentative communication devices.
This shall include customizing the operational characteristics of an AACD in order to meet the needs of the individual member and to maximize the use and effectiveness of the device.
This service shall be performed by a licensed speech-language pathologist who is familiar and has experience with augmentative communication devices.
This shall include any necessary reprogramming of AACD equipment when performed by a licensed speech-language pathologist or registered speech-language pathology assistant who is familiar and has experience with augmentative communication devices.
A direct encounter between a member and an audiologist to determine the member's hearing status.
Based on a written plan of care serial evaluation for persons difficult to test in order to obtain reliable audiologic information necessary for case management.
A direct encounter between a member and an audiologist which determines site of lesion; this may include, but is not limited to, the following tests: pure tone air, pure tone bone, speech audiometry, Bekesy, tonedecay, short increment sensitivity index (SISI), impedance, alternate binaural loudness balance tests (ABLB).
Audiologic evaluation necessitated by an observed or suspected change in a member's hearing status because of disease or injury, on referral from a physician or PCP.
Specialty testing performed by an audiologist to assist in diagnosis and developing a medical plan of care. The report shall include audiologist's recommendations.
The process of producing behavioral change in the member presenting communication disorders related to auditory function, involving a one-to-one relationship, and following a plan of care. This includes cochlear implant follow-up aural rehabilitation services.
The process of producing behavioral change in the member presenting a communication disorder related to auditory function involving other than a one-to-one relationship and following a plan of care.
Covered services must be provided by an audiologist, and include evaluating members for hearing aid and demonstrating the basic features of hearing aids to the member. For each evaluation of a member, the audiologist will write a written report.
Members are eligible for one hearing aid or one replacement hearing aid every five years, through Section 60 (Medical Supplies and Durable Medical Equipment). Providers must submit prior authorization request and documentation for hearing aids, as required in Section 60.
Covered services must be provided by an audiologist and include re-evaluating members in accordance with a written plan of care.
NOTE : "Group" is defined as two to four individuals with one clinician. When services are provided, a brief notation must be made for each individual in his/her medical record.
*The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services of these changes.
Coverage of the following services is limited to members under the age of twenty-one (21):
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-109, subsec. 144-101-II-109.07