C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-13, subsec. 144-101-II-13.01

Current through 2024-51, December 18, 2024

Subsection 144-101-II-13.01 - DEFINITIONS

13.01-1An adult is any person who is eighteen (18) years of age or older or who is a legally emancipated minor. Adults aged eighteen (18) through twenty (20) years of age and children who are emancipated minors may choose to receive children's behavioral health or developmental disabilities services oradult behavioral health or developmental disabilities services, whichever best meets their individual needs.

13.01-2Antibody is a protein belonging to a class of proteins called immunoglobulins. Antibodies are produced by the body to counteract specific antigens as a response to the infection.

13.01-3Authorized Agent: shall mean the organization authorized by the Department of Health and Human Services (DHHS) to perform specified functions pursuant to a signed contract or other approved signed agreement.

13.01-4Case Management Agencies are a firm, partnership, association, corporation, or an organization approved to provide case management services by the Department or its Authorized Agent.

In order for these agencies to provide case management services they must execute a MaineCare Provider Agreement, and any other contract required by the Department of Health and Human Services. They must also be able to meet DHHS policy and contract requirements for case management services.

13.01-5Case Management Services are those covered services provided by a social services or health professional, or other qualified staff, to identify the medical, social, educational and other needs (including housing and transportation) of the eligible member, identify the services necessary to meet those needs, and facilitate access to those services. Case management consists of intake/assessment, plan of care development, coordination/advocacy, monitoring, and evaluation.

13.01-6Childis a person between the ages of birth to eighteen (18) years of age. Adults aged eighteen (18) through twenty (20) years of age and children who are emancipated minors may choose to receive children's behavioral health or developmental disabilities services oradult behavioral health or developmental disabilities services, whichever best meets their individual needs.

13.01-7Child and Adolescent Functional Assessment Scale (CAFAS) is a multi-dimensional rating scale, which assesses a member's degree of impairment in day-to-day functioning due to emotional, behavioral, psychological, psychiatric, or substance use problems.

13.01-8Child and Adolescent Needs and Strengths (CANS) assessment is a multipurpose tool that assesses the needs and strengths of children and adolescents with mental illness, developmental disabilities/intellectual disabilities, and autism spectrum disorders. The CANS may be used to support decision making (including level of care and service planning), to facilitate quality improvement initiatives, and to allow for the monitoring of outcomes of services. There are multiple versions of the CANS tool tailored to particular age ranges, including the Child and Adolescent Needs and Strength assessment-Preschool Comprehensive (CANS-PC) (ages 0-5), the Child and Adolescent Needs and Strengths assessment-Mental Health (CANS-MH) (ages 5-17), the Child and Adult Needs and Strengths assessment Transition Mental Health (CANSAT-MH) (ages 18-21), the Child and Adolescent Needs and Strengths assessment Autism Spectrum Profile (ASP) (0-18) and the Child and Adult Needs and Strengths assessment Transition Developmental Disabilities (CANSAT-DD) (18-21).

13.01-9Child and Family Teamrefers to a group of individuals who develop an Individualized Service Plan (ISP) for the eligible child. The team shall consist of the following persons:

a. The eligible child or adolescent, unless clinically contraindicated; and/or

b. The eligible child or adolescent's parent(s) or other legal or designated representative, such as guardian or advocate; and

c. The comprehensive case manager; and

d. at least one (1) of the following individuals:

i. A health/mental health care professional (physician, psychiatrist, psychologist, social worker, nurse, crisis intervention worker, according to the needs of the child or adolescent);

ii. Other key providers, deemed appropriate by the Child and Family Team to address the eligible child or adolescent's specific needs (e.g., child protection or substitute care worker, rehabilitation counselor, physical, speech, occupational or recreational therapist, child development worker, substance abuse counselor, criminal justice worker);

iii. Other persons identified and approved by the family, such as extended family members, neighbors, friends, and others who provide informal support;

iv. A special education or other education professional.

13.01-10Children's Habilitation Assessment Tool (CHAT) assesses functioning in three domains: behavior, social skills, and life skills using interviews for individuals 6 to 18 years of age diagnosed with mental retardation or a pervasive developmental disorder.

13.01-11Collateral Contact is a contact on behalf of a member by a comprehensive case manager to seek or share information about the member in order to achieve continuity of care, coordination of services, and the most appropriate mix of services for the member. Discussions or meetings between staff of the same agency (or contracted agency) are considered to be collateral contacts only if such discussions are included in the development of the Care Plan. Collateral contacts occur as a component under covered services (13.02).

13.01-12Comprehensive Case Manager is the one reimbursable case manager per member beginning 11/1/09. Comprehensive Case Managers must focus on coordinating and overseeing the effectiveness of all providers and benefits in responding to the member's assessed needs. Comprehensive Case Managers ensure that the individual care plan is effectively implemented and adequately addresses the assessed needs of the member.

13.01-13Contracted Services are Comprehensive Targeted Case Management Services provided by private agencies.

13.01-14Danger: A situation or condition of abuse, neglect, or exploitation as defined in 22 M.R.S.A. §3472, or the inability to give informed consent when there is no responsible substitute decision-maker.

13.01-15Department means the State of Maine, Department of Health and Human Services, also referred to as DHHS.

13.01-16Diagnostic Classification of Mental Health and Development Disorders of Infancy and Early Childhood: (also known as DC 0-3), formulates categories for the classification of mental health and development disorders manifested early in life. The DC: 0-3 is published by Zero To Three: National Center for Infants, Toddlers and Families.

13.01-17Diagnostic and Statistical Manual of Mental Health Disorders (DSM) is published by the American Psychiatric Association. The most recently published manual is used to classify mental health diagnoses and provide standard categories for definition of mental health disorders grouped in five axes.

13.01-18Emergency Sheltermeans a facility, the primary purpose of which is to provide a temporary place for homeless persons to sleep and which meets the criteria established by the Maine State Housing Authority for Emergency Shelter Funds.

13.01-19Homeless Person means an individual who lacks a fixed, regular and adequate nighttime residence and whose primary nighttime residence is an emergency shelter or public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings.

13.01-20Human Immunodeficiency Virus (HIV) is the virus which causes AIDS (Acquired Immune Deficiency Syndrome).

13.01-21Informed consent is a decision made with all relevant information about the issue, with an understanding of the consequences of a decision, and in the absence of duress.

13.01-22Memberis a MaineCare member.

13.01-23Primary Care Provider (PCP) is a provider who has contracted with the Department to provide primary care case management services.

13.01-24Prior Authorizationis the process of obtaining prior approval as to the medical necessity and eligibility for a service; see also Chapter I of the MaineCare Benefits Manual.

13.01-25Professional Approved by The Department refers to a professional who satisfies the same qualifications as are set forth in Section 13.07-2(B)(3).

13.01-26Utilization Review is a formal assessment of the medical necessity, efficiency and appropriateness of services and treatment plans on a prospective, concurrent or retrospective basis.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-13, subsec. 144-101-II-13.01