Subsection 144-101-II-28.04 - COVERED SERVICES A covered service is a service provided to a member for which payment may be made under the MaineCare Program, and through contract with DHHS. Assessment and treatment are covered services when provided to an eligible member by an approved staff so long as the services are medically necessary as defined in this section. Treatment is provided in the home and/or community in either individual or group settings and requires prior authorization and utilization review.
28.04-1Treatment Services for Children with Cognitive Impairments and Functional Limitations are medically necessary treatment services for members under the age of twenty one (21). Treatment services are designed to retain or improve functional abilities which have been negatively impacted by the effects of cognitive or functional impairment and are focused on behavior modification and management, social development, and acquisition and retention of developmentally appropriate skills. Services include problem solving activities in order to help the member develop and maintain skills and abilities necessary to manage his or her behavioral health treatment needs, learning the social skills and behaviors necessary to live with and interact with other community members and independently, and to build or maintain satisfactory relationships with peers or adults, learning the skills that will improve a member's self-awareness, environmental awareness, social appropriateness and support social integration, and learning awareness of and appropriate use of community services and resources.28.04-2Specialized Services for Children with Cognitive Impairments and Functional Limitations are medically necessary, evidence based treatment services for members under the age of twenty one (21), that utilize behavioral interventions designed to improve socially significant behaviors and developmentally appropriate skills to a measurable degree. Services include problem solving activities in order to help the member develop and maintain skills and abilities necessary to manage his or her behavioral health treatment needs, learning the social skills and behaviors necessary to live with and interact with other community members and independently, and to build or maintain satisfactory relationships with peers or adults, learning the skills that will improve a member's self-awareness, environmental awareness, social appropriateness and support social integration, and learning awareness of and appropriate use of community services and resources. *The Department is seeking, and anticipates receiving, approval from CMS for this Section. Pending approval, these changes will be effective.
28.04-3 *BCBA Services are services performed by a BCBA in connection with Specialized Services for Children with Cognitive Impairments and Functional Limitations (Specialized Services). The BCBA is responsible for the supervision and delivery of the Specialized Services. BCBA services are defined as the following: 1. Conduct Functional Behavioral Assessments (FBA). FBAs are a process of gathering information from multiple sources to hypothesize and understand what reliably predicts and maintains a problem behavior. The FBA evaluates behavior to analyze the antecedent and consequence as a reinforcement of a problem behavior. Behaviors are defined in measurable terms. The FBA uses a validated assessment which may also include interview, direct and/or indirect observation in the member's natural environment, functional analysis, preference assessment, assessment of reinforcement effectiveness, data collection, and reporting. An initial FBA is limited to fifteen (15) hours. One update is allowed per year, limited to ten (10) hours;2. Conduct Individual Treatment Plan development, positive behavior support planning, and periodic reviews/revision of the ITP and positive behavior support plan. Planning services are limited to six(6) hours for developing the initial treatment plan, and up to one (1) hour per month to review, and update as necessary, the treatment plan;3. Conduct summary and analysis of data on Member progress, and review data trends with staff to refine Member treatment. Summary and data analysis services are limited to one (1) hour per Member per month;4. Conduct evidence-based practices congruent with Specialized Services with Members in accordance with the Member's Individualized Treatment Plan. Specialized Services are limited to two (2) hours per Member per month. 5. Conduct coordination of Member care with other providers. Coordination Services are limited to two (2) hours per Member per month;6. Conduct parent training on behavioral principles and interventions specific to the Member. Parent training services are limited to six (6) hours per Member per quarter;7. Conduct monthly Member treatment team meetings. There is a limit of one (1) hour per Member per month for monthly Member treatment team meetings; Providers may request additional hours/units beyond the stated limitations above when deemed medically necessary through supported documentation and Prior Authorization through the Department or its Authorized entity.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-28, subsec. 144-101-II-28.04