The purpose of this Appendix is to detail guidelines for Office of Aging and Disability Services in approving a Medical Add-On to the established published rate. All current statutes, regulations, decree provisions, policies, and licensing standards regarding medical services are unaffected by these guidelines. This Appendix develops criteria that warrant an adjustment to the DHHS's established published rate for Community Support, Employment Specialist Services and Work Support Services.
The Clinical Review Team (CRT) is the entity within OADS that is responsible for review and approval, of all Medical Add-On rate increases for services under this section.
The rate is designed to support Members with intermittent or longer duration medical conditions. Changes or needs that may be considered for Medical Add-On include but are not limited to: support over and beyond routine services such as ventilators, nebulizers, diabetes management-insulin dependent, suctioning, seizure management-uncontrolled, chronic eating disorders, or persons with co-existing conditions that significantly affect physical movement and require near total physical assistance on a daily basis. Conditions related to surgeries, procedures, injuries and other short term conditions are also considered for the Medical Add-On rate increase.
The following standards and practices must be demonstrated in order for the CRT to approve a Medical Add-On:
A.Physician Order1. There must be a written physician or physician's assistant's order, less than three (3) months old for the member. This order must specify: a. The specific illness or condition to be addressed;b. The specific procedure(s) that will be utilized;c. The time span over which the treatment or intervention is expected to be needed. If the treatment or intervention is expected to be needed for an indefinite period of time then this expectation should be specified;d. The anticipated frequency of treatment or intervention on a daily, weekly, or monthly basis;e. Where applicable and possible: i. The approximate length of time required for each episode of the treatment or intervention andii. The degree of licensure or certification required for those who carry out the treatment, and those who provide training and oversight relative to its application.B.Planning Team1. The team must meet or otherwise confer for the following purposes: a. To review and complete the request for Medical Add-On and any additional documentation required for submission to the CRT.b. To determine whether the setting where the member is served is appropriate to carry out the physician's recommended treatment or intervention; andc. To determine how the member's needs shall be met and what the staffing requirements are.2. All of these determinations and recommendations must be noted in the Personal Plan.C.Provider Requirements1. The provider must be an enrolled MaineCare provider.2. For any physician or physician's assistant order specifying a skilled medical professional who shall train, monitor, or deliver treatment, the provider must have regular access to the professional, either as an employee, or via a contract, or via an established relationship; or alternatively, the provider must be able to gain this access in a time frame commensurate with the treatment requirements.D.Approval Process1. The CRT will review the information submitted with the request, the Personal Plan, information in the electronic record such as reportable events, crisis notes, as well as any applicable assessments or evaluations in the member's record.2. The CRT will issue a written decision for the Medical Add-On, within twenty (20) working days of receipt of all required documentation. If additional information is required, a written request will be issued. Upon receipt of the additional information the CRT will approve or deny the request within ten (10) working days.3. Approvals will include a specification of the duration of the Medical Add-On, as well as authorized daily or weekly units of service which require the Medical Add-On.4. Treatments or interventions that are anticipated to be needed for an extended or indefinite period of time must be reviewed annually or more frequently as determined by the CRT. Verification of this continued need must be provided to the CRT within a year of the original approval, in order for the Medical Add-On to continue. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-29, subsec. 144-101-II-29.14