10-144 Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER III SECTION 21 MAJOR SUBSTANTIVE ALLOWANCES FOR HOME AND COMMUNITY BENEFITS FOR ADULTS WITH INTELLECTUAL DISABILITIES ESTABLISHED: 11/1/83 LAST UPDATED: 6/1/2018 TABLE OF CONTENTS PAGE 1000 PURPOSE.......................................................................................................................1 1050 DEFINITIONS...............................................................................................................1 1100 AUTHORITY.................................................................................................................1 1200 COVERED SERVICES..................................................................................................1 1300 REIMBURSEMENT METHODS..................................................................................1 1400 CALCULATION OF THE PER DIEM RATE FOR AGENCY HOME SUPPORTS.......................................................................................3 1500 AVERAGE BILLING METHOD...................................................................................4 1600 REQUIREMENTS FOR PARTICIPATION IN MAINECARE PROGRAM..................5 1700 RESPONSIBLITIES OF THE PROVIDER...................................................................5 1800 RECORD KEEPING AND RETENTION OF FINANCIAL RECORDS.......................5 1900 BILLING PROCEDURES..............................................................................................5 1910 WORK SUPPORT GROUP RATE.................................................................................5 2000 AUDIT OF SERVICES PROVIDED..............................................................................6 2100 RECOVERY OF PAYMENTS........................................................................................6 APPENDIX I............................................................................................................................................7 APPENDIX IIA........................................................................................................................................12 APPENDIX IIB........................................................................................................................................14 i 10-144 Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER III SECTION 21 MAJOR SUBSTANTIVE RULE ALLOWANCES FOR HOME AND COMMUNITY BENEFITS FOR ADULTS WITH INTELLECTUAL DISABILITIES OR AUTISM SPECTRUM DISORDER ESTABLISHED: 11/1/83 LAST UPDATED: 6/1/2018 GENERAL PROVISIONS 1000 PURPOSE The purpose of these regulations is to describe the reimbursement methodology for Home and Community Based Services waiver providers whose services are reimbursed in accordance with Chapters II and III, Section 21, “Home and Community Benefits for members with Intellectual Disabilities or Autism Spectrum Disorder” of the MaineCare Benefits Manual. These Principles govern reimbursement for services provided on or after December 30, 2007. All services reimbursed in this section are considered fee for service. 1050 DEFINITIONS Fee for service - is a method of paying providers for covered services rendered to members. Under this fee for service system, the provider is paid for each discrete service described in Appendix I to a member. Per Diem - A day is defined as beginning at midnight and ending twenty-four (24) hours later. However, per diem Home Support services may be provided by more than one entity in a twenty-four hour period. On days when a member is transitioning between providers of home support, only the provider providing home support services at 11:59 p.m. may bill for home support for that day. Per Diem reimbursement is allowable to a Home Support Provider who provides Direct support at some point during that day, if the member transfers to an environment that is not being reimbursed for Home Support for that same time period. Week – A week is equal to seven consecutive days starting with the same day of the week as the provider’s payroll records, usually Sunday through Saturday. Year-Services are authorized based on the state fiscal year, July 1 through June 30. 1100 AUTHORITY The authority of the Department to accept and administer any funds that may be available from private, local, State or Federal sources for services under this Chapter is established in 22 M.R.S.A.§§ 10, 12, and 3173. The authority of the Department to adopt rules to implement this Chapter is established under 22 M.R.S.A.§§ 12, 42(l), and 3173. 1200 COVERED SERVICES –Covered Services are defined in Chapter II, Section 21 of the MaineCare Benefits Manual. 1300 REIMBURSEMENT METHODS Services covered under this section will be reimbursed on a fee for service basis using one of these methods as follows: 1. Standard Unit rate A Standard unit rate is the rate paid per unit of time (an hour, a specified portion of an hour, or a day) for a specific service. Services paid for using a standard rate are as follows: 1 10-144 Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER III SECTION 21 ALLOWANCES FOR HOME AND COMMUNITY BENEFITS FOR ADULTS WITH INTELLECTUAL DISABILITIES OR AUTISM SPECTRUM DISORDER MAJOR SUBSTANTIVE RULE 1300 ESTABLISHED: 11/1/83 LAST UPDATED: 6/1/2018 REIMBURSEMENT METHODS (cont.) A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. P. Q. R. S. T. U. V. W. X. Assistive Technology-Assessment; Assistive Technology-Transmission (Utility Services); Career Planning; Community Support Services Communication Aids-Ongoing Visual-Gestural and Augmented Communications; Consultation Services; Counseling; Crisis Intervention; Crisis Assessment; Employment Specialist Services; Home Support-Agency; Home Support-Quarter Hour (1/4 hour); Home Support-Family-Centered Support; Home Support-Remote Support– Monitor Only; Home Support-Remote Support– Interactive Support; Non-Traditional Communication Consultation; Non-Traditional Communication Assessments; Occupational Therapy (Maintenance) Service; Physical Therapy (Maintenance) Service; Shared Living; Speech Therapy (Maintenance) Service-Individual; Speech Therapy (Maintenance) Service-Group; Work Support- Individual; Work Support-Group; The standard rates for these services are listed in Appendix I. 2. Prior Approved Price - The price of an item or piece of equipment being purchased for a member must be reviewed and approved by DHHS before it will be reimbursed. A. Home Accessibility Adaptations - The DHHS will determine the amount of reimbursement after reviewing a minimum of two written itemized bids from different vendors submitted by the provider. Prior to services being delivered, written itemized bids must be submitted to the DHHS for approval and must contain cost of labor and materials, including subcontractor amounts. The DHHS will issue an authorization for the approved amount based on the written bids to the provider. B. Specialized medical equipment and supplies and Communication Aids- Speech Amplifiers, Aids, Communicators, Assistive Devices - The amount of payment for specialized medical equipment and supplies, and communication aids equipment, Speech Amplifiers, Aids, Communicators, Assistive Devices or Assistive Technology Devices shall be the lowest of: 1. Maximum MaineCare amount listed by applicable corresponding HCPCS codes published at least annually on the Department’s website, 2 10-144 Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER III SECTION 21 ALLOWANCES FOR HOME AND COMMUNITY BENEFITS FOR ADULTS WITH INTELLECTUAL DISABILITIES OR AUTISM SPECTRUM DISORDER MAJOR SUBSTANTIVE RULE 1300 ESTABLISHED: 11/1/83 LAST UPDATED: 6/1/2018 REIMBURSEMENT METHODS (cont.) https://mainecare.maine.gov/Provider%20Fee %20Schedules/Forms/Publication.aspx and made available to providers; 3. 2. The provider’s usual and customary charges; or 3. The manufacturer’s suggested retail price for any medical supply or medical equipment. Per Diem reimbursement: This method of reimbursement is used for Home Support Services provided by an agency. For purposes of Paragraphs 1300 through 1500, an agency is a provider that routinely employs direct care staff to provide Home Support Services to members in a facility operated by the agency. The per diem rate is calculated using the number of Agency Home Support hours authorized or provided for each member served in the agency’s facility and the standard unit rates for Agency Home Support listed in Appendix I. The calculation includes a small range of permissible variance between the number of hours authorized and the number of hours actually provided. The standard unit rates listed in Appendix I will be reduced by $2.92 for each hour of Home Support Service provided to the member in excess of 168 hours per week. Paragraph 1400 explains the method of calculating the per diem rate, and Appendix IIA sets forth instructions and a chart for use in calculating the per diem rate. The authorized per diem rate for all members is based on the total weekly hours authorized by DHHS for all members in the facility. The amount of the agency’s per diem rate is calculated using the chart in Appendix II and the rates for Agency Home Supports set forth in Appendix I. In performing these calculations, the standard unit rates listed in Appendix I will be reduced by $2.92 for each hour of agency Home Support Service provided to the member in excess of 168 hours per week. Only hours of services that have been authorized and provided with a Medical Add On for Agency Home Support for a member will be reimbursed at the Medical Support reimbursement rate. 1400 CALCULATION OF THE PER DIEM RATE FOR AGENCY HOME SUPPORTS If the number of Agency Home Support hours provided by the facility in a week is no less than 92.5 % and no more than 105% of the total hours authorized for members in the facility, the provider will be paid at the per diem rate. If the amount of Agency Home Support hours actually provided to all members in the facility in a given week is less than 92.5% of the hours authorized for those members, the agency’s per diem rate will be adjusted to reflect the number of hours actually provided to the members in the facility in that week. In that case, the agency’s per diem rate for that week will be determined by adding all of the authorized weekly hours for members in the facility, multiplying by the Agency Home Support rate listed in Appendix I and dividing by seven. The result is then divided by the number of members in the facility to determine a per diem rate applicable to each member for that week. 3 10-144 Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER III SECTION 21 MAJOR SUBSTANTIVE RULE 1500 ALLOWANCES FOR HOME AND COMMUNITY BENEFITS FOR ADULTS WITH INTELLECTUAL DISABILITIES OR AUTISM SPECTRUM DISORDER ESTABLISHED: 11/1/83 LAST UPDATED: 6/1/2018 AVERAGE BILLING METHOD When billing, the Home Support Agency per diem services providers may choose to bill for services provided using the weekly billing method or the monthly average billing method. Weekly billing method - Providers bill at the end of the each week based on the actual number of hours of direct support provided in comparison to the hours authorized. If the actual total weekly direct support hours provided for the facility falls within the range of allowable total weekly authorized support hours for the facility then the facility bills at the authorized per diem rate. If the actual total weekly direct support hours provided for the facility is less than the range of allowable total weekly authorized support hours for the facility then the billable rate is determined by using the actual weekly total support hours provided for the facility. Providers may refer to the billable rate under the applicable table on http://www.maine.gov/dhhs/oads/disability/ds/MaineCare/index.shtml or use Appendix IIA or IIB to calculate the billable amount. Monthly Average Billing Method - Providers may calculate a monthly average of weekly direct support services hours provided at the end of each month. If a provider chooses to use the monthly average billing method then all days in the month must be billed using this method. To use this method a provider must submit claims after the last day of the month. To determine the actual total weekly direct support hours, the actual total hours of direct support provided in the month from 1st day of the month through the last day of the month are divided by number of weeks in the month. A. B. C. D If there are 31 days in the month, then the number of weeks in the month is 4.43. If there are 30 days in the month, then the number of weeks in the month is 4.29. If there are 29 days in the month, then the number of weeks in the month is 4.14. If there are 28 days in the month, then the number of weeks in the month is 4.00. The result determines the average actual total weekly direct support hours provided by the facility for the entire month. If the average actual total weekly direct support hours provided by the facility falls within the range of allowable total weekly support hours that was authorized then the provider must bill at the authorized per diem rate. If the average actual total weekly direct support hours provided by the facility is less than the range of allowable weekly support hours that was authorized then the billable rate will be determined by using the actual total support hours provided for the facility. Providers can determine the billable rate in the applicable table in Appendix IIB in Chapter III. Partial Week- There are situational changes, often unpredictable, that occur resulting in a change in the authorized hours of support in a facility mid-week. Examples include death of a member, unanticipated move or the startup of a new program mid-week. In these instances, if the Provider has chosen to bill on a monthly basis, services for the week in which the authorization change occurred must be billed on pro-rated basis to determine the actual total weekly support hours provided using the formula below: 4 10-144 Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER III SECTION 21 MAJOR SUBSTANTIVE RULE ALLOWANCES FOR HOME AND COMMUNITY BENEFITS FOR ADULTS WITH INTELLECTUAL DISABILITIES OR AUTISM SPECTRUM DISORDER ESTABLISHED: 11/1/83 LAST UPDATED: 6/1/2018 If services are provided for 1 day, then the number of actual hours provided is .1428. If services are provided for 2 days, then the number of actual hours provided is .2857. If services are provided for 3 days, then the number of actual hours provided is .4285. If services are provided for 4 days, then the number of actual hours provided is .5714. If services are provided for 5 days, then the number of actual hours provided is .7142. If services are provided for 6 days, then the number of actual hours provided is .8571. Refer to the rate schedule to select the appropriate rate to bill based on the hours provided. 1600 REQUIREMENTS FOR PARTICIPATION IN MAINECARE PROGRAM Providers must comply with all requirements as outlined in Chapter 1 and Chapter II, Section 21 of the MaineCare Benefits Manual. 1700 RESPONSIBILITIES OF THE PROVIDER Providers are responsible for maintaining adequate financial and statistical records and making them available when requested for inspection by an authorized representative of the DHHS, Maine Attorney General’s Office or the Federal government. Providers shall maintain accurate financial records for these services separate from other financial records. 1800 RECORD KEEPING AND RETENTION OF FINANCIAL RECORDS When fiscal records are requested, providers have ten (10) business days to produce the requested record to DHHS. Complete documentation shall mean clear written evidence of all transactions of the provider entities related to the delivery of these services, including but not limited to daily census data, invoices, payroll records, copies of governmental filings, staff schedules, time cards, and member service charge schedule, or any other record necessary to provide the Commissioner with the highest degree of confidence that such services have actually been provided. The provider shall maintain all such records for at least five (5) years from the date of reimbursement. 1900 BILLING PROCEDURES Providers will submit claims to MaineCare and be reimbursed at the applicable rate for the service in accordance with MaineCare billing instructions for the CMS 1500 claim form. 1910 WORK SUPPORT GROUP RATE When billing for Work Support Services-Group the per person rate is based on the number of members served as follows: When billing, use of the appropriate modifiers from Appendix I is necessary for payment. 5 10-144 Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER III SECTION 21 MAJOR SUBSTANTIVE RULE 1910 ALLOWANCES FOR HOME AND COMMUNITY BENEFITS FOR ADULTS WITH INTELLECTUAL DISABILITIES OR AUTISM SPECTRUM DISORDER ESTABLISHED: 11/1/83 LAST UPDATED: 6/1/2018 WORK SUPPORT GROUP RATE (cont.) The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services for these changes. Pending approval, the changes will be effective July 1, 2017. 2000 AUDIT OF 3 $2.30 2.54 4 $1.73 1.91 5 $1.38 1.53 6 $1.15 1.27 Members in Group The Department shall reimbursement by for services and provided by collecting Documentation will be correspond to dates of reimbursement as 2100 Rate per Unit 7/1/17 – 6/30/18 2 Rate per Unit Prior to 7/1/17 and after 7/1/18 $3.46 $3.83 SERVICES PROVIDED monitor provider’s claims for randomly reviewing the claim verifying hours actually documentation from providers. requested from providers that service on claims submitted for follows: a) Payroll Records – Documentation showing the number of hours paid to an employee that covers the period of time for which the Direct Care hours are being requested. b) Staffing Schedules per facility – Documentation showing the hours and the name of the direct care staff scheduled to work at the facility. c) Member Records - Documentation that supports the service delivery of services that a member received. RECOVERY OF PAYMENTS The Department may recover any amounts due the Department based on Chapter I of the MaineCare Benefits Manual. 6 10-144 Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER III SECTION 21 MAJOR SUBSTANTIVE RULE ALLOWANCES FOR HOME AND COMMUNITY BENEFITS FOR ADULTS WITH INTELLECTUAL DISABILITIES OR AUTISM SPECTRUM DISORDER ESTABLISHED: 11/1/83 LAST UPDATED: 6/1/2018 APPENDIX I PROCEDURE CODE MAXIMUM ALLOWANCE Prior to 7/1/17 and After 7/1/18 DESCRIPTION MAXIMUM ALLOWANCE Effective 7/1/17-6/30/18 HOME SUPPORT: AGENCY T2016 T2016 SC T2017 T2017 SC See Appendix II and IIB Per diem** AGENCY HOME SUPPORT (Habilitation, residential, waiver) with See Appendix II and IIB Per Medical Add On diem** HOME SUPPORT: QUARTER HOUR HOME SUPPORT (Habilitation, residential, waiver) $6.33 ¼ hr HOME SUPPORT (Habilitation, residential, waiver) with Medical Add $7.57 ¼ hr On AGENCY HOME SUPPORT (Habilitation, residential, waiver) See Appendix II and IIB Per diem** See Appendix II and IIB Per diem** $7.00 ¼ hr $8.37 ¼ hr HOME SUPPORT: REMOTE SUPPORT T2017 QC T2017 GT T2016 U5 T2016 TG U5 T2016 UN U5 T2016 UN TG U5 T2016 UP U5 T2016 UP TG U5 HOME SUPPORT (Habilitation, residential, waiver)-REMOTE $1.63 ¼ hr SUPPORT-Monitor Only HOME SUPPORT (Habilitation, residential, waiver)-REMOTE $6.33 ¼ hr SUPPORT-Interactive Support HOME SUPPORT: FAMILY CENTERED SUPPORT HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered $105.16 Per diem Support -One member served HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered $219.03 Per diem Support -One member served- increased level of support HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered $86.61 Per diem Support-Two members served HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered $198.65 Per diem Support-Two members served- increased level of support HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered $73.85 Per diem Support-Three members served HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered $180.09 Per diem Support-Three members served- increased level of support $1.80 ¼ hr $7.00 ¼ hr $105.16 Per diem $219.03 Per diem $86.61 Per diem $198.65 Per diem $73.85 Per diem $180.09 Per diem *The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services for these changes with a July 1, 2017 effective date. 7 PROCEDURE CODE DESCRIPTION HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered Support-Four members servedT2016 UQ TG HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered U5 Support-Four members served- increased level of support HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered T2016 UR U5 Support-Five or more members served HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered T2016 UR TG U5 Support-Five or more members served- increased level of support T2016 UQ U5 MAXIMUM ALLOWANCE Prior to 7/1/17 and After 7/1/18 MAXIMUM ALLOWANCE Effective 7/1/17-6/30/18 $62.58 Per diem $62.58 Per diem $163.71 Per diem $163.71 Per diem $55.82 Per diem $55.82 Per diem $154.88 Per diem $154.88 Per diem $127.39 Per diem $140.89 per diem $185.27 Per diem $204.91 per diem $63.71 Per diem $70.46 per diem $121.57 Per diem $134.46 per diem SHARED LIVING S5140 S5140 TG S5140 UN S5140 UN TG SHARED LIVING (Foster Care, adult)-Shared Living Model-One member served SHARED LIVING (Foster Care, adult)-Shared Living Model-One member served- increased level of support SHARED LIVING (Foster Care, adult)-Shared Living Model-Two members served SHARED LIVING (Foster Care, adult)-Shared Living Model-Two members served- increased level of support H2023 H2023 SC H2023 UN H2023 UP H2023 UQ H2023 UR H2023 US WORK SUPPORT (supported employment)-Individual WORK SUPPORT (supported employment)- with Medical Add On WORK SUPPORT (supported employment)-Group 2 members served WORK SUPPORT (supported employment)-Group 3 members served WORK SUPPORT (supported employment)-Group 4 members served WORK SUPPORT (supported employment)-Group 5 members served WORK SUPPORT (supported employment)-Group 6 members served $6.91 ¼ hr $8.08 ¼ hr up to $3.46 per ¼ hr up to $2.30 per ¼ hr up to $1.73 per ¼ hr up to $1.38 per ¼ hr up to $1.15 per ¼ hr $7.64 ¼ hr $8.94 ¼ hr $3.83 ¼ hr $2.54 ¼ hr $1.91 ¼ hr $1.53 ¼ hr $1.27 ¼ hr T2015 CAREER PLANNING (Habilitation, prevocational) $28.00 hr $30.97 hr *The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services for these changes with a July 1, 2017 effective date. 8 MAXIMUM ALLOWANCE Prior to 7/1/17 and After 7/1/18 MAXIMUM ALLOWANCE Effective 7/1/17-6/30/18 $7.42 ¼ hr $8.21 ¼ hr $8.58 ¼ hr $9.49 ¼ hr $5.33 ¼ hour $5.89 ¼ hr $6.57 ¼ hr $7.27 ¼ hr ASSISTIVE TECHNOLOGY-ASSESSMENT ASSISTIVE TECHNOLOGY –TRANSMISSION (Utility Services) ASSISTIVE TECHNOLOGY –DEVICES (Monitoring feature/device, stand alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified) $14.44 ¼ hr Up to $50.00 per month. $14.44 ¼ hr Up to $50.00 per month. Per invoice up to $6,000.00 per year Per invoice up to $6,000.00 per year T2029 SPECIALIZED MEDICAL EQUIPMENT AND SUPPLIES Per itemized invoice Per itemized invoice S5165 CG S5165 HOME ACCESSIBILITY ADAPTATIONS (Repairs) HOME ACCESSIBILITY ADAPTATIONS (Home Modifications) Per itemized invoice Per itemized invoice Per itemized invoice Per itemized invoice Per itemized invoice Per itemized invoice $5.40 ¼ hr $5.40 ¼ hr $9.00 ¼ hr $9.00 ¼ hr $9.00 ¼ hr $9.00 ¼ hr PROCEDURE CODE T2019 T2019 SC T2021 T2021 SC 97755 T2035 A9279 V5274 T1013 GN G9007 92507 DESCRIPTION EMPLOYMENT SPECIALIST SERVICES (Habilitation, supported employment waiver) EMPLOYMENT SPECIALIST SERVICES (Habilitation, supported employment waiver)- with Medical Add-On COMMUNITY SUPPORT (Day habilitation, waiver) COMMUNITY SUPPORT (Day habilitation, waiver) with Medical Add On COMMUNICATION AIDS - SPEECH AMPLIFIER, AIDS, COMMUNICATORS (INCLUDING REPAIR AND MAINTENANCE), ASSISTIVE DEVICES COMMUNICATION AIDS - ONGOING VISUAL-GESTURAL AND FACILITATED COMMUNICATIONS SERVICES NON-TRADITIONAL COMMUNICATION CONSULTATION NON-TRADITIONAL COMMUNICATION ASSESSMENT *The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services for these changes with a July 1, 2017 effective date. 9 G9007 HI G9007 GO G9007 GP H0031 G9007 GN H0004 SC CONSULTATIVE SERVICES - BEHAVIORAL CONSULTATIVE SERVICES - OCCUPATIONAL THERAPY CONSULTATIVE SERVICES - PHYSICAL THERAPY CONSULTATIVE SERVICES - PSYCHOLOGICAL CONSULTATIVE SERVICES - SPEECH THERAPY COUNSELING $14.85¼ hr $5.40 ¼ hr $5.40 ¼ hr. $19.80 ¼ hr $5.40 ¼ hr $13.50 ¼ hr MAXIMUM ALLOWANCE Effective 7/1/17-6/30/18 $14.85¼ hr $5.40 ¼ hr $5.40 ¼ hr. $19.80 ¼ hr $5.40 ¼ hr $13.50 ¼ hr T1023 T2034 CRISIS ASSESSMENT CRISIS INTERVENTION SERVICES $2250.00 Per Encounter $6.35 ¼ hr $2250.00 Per Encounter $7.02 ¼ hr S8990 GO OCCUPATIONAL THERAPY (MAINTENANCE) OT/L OCCUPATIONAL THERAPY (MAINTENANCE)- Licensed Occupational Therapy Assistant (OTA/L) under the supervision of an Occupational Therapist, Licensed (OT/L) $ 9.54 ¼ hr $ 9.54 ¼ hr $8.57 ¼ hr $8.57 ¼ hr S8990 GP PHYSICAL THERAPY (MAINTENANCE) $9.72 ¼ hr $9.72 ¼ hr S8990 GN S8990 GN HQ SPEECH THERAPY (MAINTENANCE)-Individual $12.48 1/4 hr $12.48 1/4 hr SPEECH THERAPY (MAINTENANCE)-Group $9.36 1/4 hr $9.36 1/4 hr **These rates are used in conjunction with Appendix IIA and IIB to calculate the Home Support Agency Per Diem rate. PROCEDURE CODE S8990 GO U1 MODIFIERS CG GN GO GP HQ HI GT QC U5 SC TG UN UP MAXIMUM ALLOWANCE Prior to 7/1/17 and After 7/1/18 DESCRIPTION DESCRIPTIONS Policy criteria applied Services delivered under an outpatient speech language pathology plan of care Service delivered under an outpatient occupational therapy plan of care Services delivered under an outpatient physical therapy plan of care Group Setting Behavioral Consultation Remote Support-Interactive Support Remote Support-Monitor Only Home Support-Family Centered Support Medically necessary service or supply Complex/high tech level of care Two members served Three members served *The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services for these changes with a July 1, 2017 effective date. 10 10-144 Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER III SECTION 21 MAJOR SUBSTANTIVE RULE UQ UR US U1 ALLOWANCES FOR HOME AND COMMUNITY BENEFITS FOR ADULTS WITH INTELLECTUAL DISABILITIES OR AUTISM SPECTRUM DISORDER ESTABLISHED: 11/1/83 LAST UPDATED: 6/1/2018 Four members served Five members served Six members served Other Qualified Staff *Provider calculated, in accordance with base rates listed at Appendices IIA & IIB. For assistances with calculations see Tables 1 & 2 accessible through the DHHS website: http://www.maine.gov/dhhs/oads/MaineCare/index.shtml or by calling 1-866-5585 (TTY): 711. *The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services for these changes with a July 1, 2018 effective date. 11 APPENDIX IIA Weekly Hours Authorized per Facility Home Support Agency per diem Provider Location Address MaineCare Provider ID Instructions MaineCare Member A B C D E F TOTAL weekly authorized support hours by each type Regular Support Hours up to 168 Hours in excess of 168 Medical Support Hours Total Support Hours (sum total of all types of support hours) Enter the weekly authorized support hours under each type by MaineCare member for this facility Sum of total weekly authorized support hours for all members in facility by type of support and total facility. The range of allowable weekly hours is based on authorized hours with the lowest hours in range at 92.5% of total authorized hours and the highest hours in the range at 105% of the total authorized hours. RANGE Lowest - 92.5% total weekly of Authorized Hours Highest - 105% total weekly of Authorized Hours The Department is seeking and anticipates receiving approval from the federal center for Medicare and Medicaid Services for these changes with a July 1, 2017 effective date. 12 Regular Support Hours up to 168 $22.64* Hourly Support reimbursement rates by type $25.04* * Hours In Excess of 168 $19.72* $21.81** Medical Support Hours $27.41* $30.32** Amount includes service provider tax expense. Total weekly authorized support hours multiplied by hourly support rate for each type Total Weekly Authorized amount for facility by type 7 7 7 7 7 7 Seven (7) days in a week Number of days per week Total number of members in facility that are authorized for service. For Medical Add on, it would only be the number of member in facility that are authorized for those types of services. Number of members in facility (1 to 6) Total Authorized Per Diem (Daily) rate amount Total Weekly Authorized amount divided by number of days per week and then by the number for members in the facility for each type. Total amount / Days) / # of Consumers *Maximum allowance prior to 7/1/17 and after 7/1/18. **Maximum allowance effective 7/1/17-6/30/18. The Department is seeking and anticipates receiving approval from the federal center for Medicare and Medicaid Services for these changes with a July 1, 2017 effective date. 13 Providers are responsible for calculating all amounts payable to them in accordance with the above-listed rates and rate calculation formula. As an assistive tool, OMS provides sample calculations for each rate based on the number of weekly service hours provided and the number of members served. Calculation Tables 1& 2 are accessible through the DHHS website http://www.maine.gov/dhhs/oads/MaineCare/index.shtml. Providers may request paper copies of calculation Appendices IIA & IIB by calling OMS at 1-866-690-5585. TTY 711 THE DEPARTMENT EXPRESSLY DISCLAIMS THE ACCURACY OF THE CALCULATIONS TABULATED IN Appendix IIA & IIB AND EXPRESSLY DISCLAIMS ANY AND ALL LIABILITY FOR LOSSES, INCURRED COSTS, OR OTHER DETRIMENT SUFFERED BY ANY PROVIDER AS A RESULT OF RELIANCE UPON INFORMATION CONTAINED IN Appendix IIA & IIB. Appendix IIA is for members Authorized with Regular service, Appendix IIB is for members authorized with Medical Add On service. MaineCare Member A B C D E F Regular Support Rate up to 168 Hours in excess of 168 Medical Support Rate The total authorized per diem (daily) rate by member The Department is seeking and anticipates receiving approval from the federal center for Medicare and Medicaid Services for these changes with a July 1, 2017 effective date. 14 APPENDIX IIB Weekly Hours Authorized & Billed per Facility Home Support Agency per diem Provider Location Address MaineCare Provider ID Authorized billable Rate Calculator MaineCare Member A B C D E F TOTAL weekly authorized support hours by each type Regular Support Hours up to 168 Hours in excess of 168 Medical Support Hours Total Support Hours (sum total of all types of support hours) Instructions Enter the weekly authorized support hours under each Sum of total weekly authorized support hours for all m The Department is seeking and anticipates receiving approval from the federal center for Medicare and Medicaid Services for these changes with a July 1, 2017 effective date. 15 RANGE Lowest - 92.5% total weekly of Authorized Hours Highest - 105% total weekly of Authorized Hours The range of allowable weekly hours is based on authorized hours with the lowest hours in range at 92.5% of total authorized hours and the highest hours in the range at 105% of the total authorized hours. Regular Support Hours up to 168 Hourly Support reimbursement rates by type Total Weekly Authorized amount for facility by type Number of days per week $22.64* Hours In Excess of 168 $25.04** $19.72* Medical Support Hours $21.81** $27.41* $30.32** Amount includes service provider tax expense Total weekly authorized support hours multiplied by Hourly support Rate for each type 7 7 7 7 7 7 Seven days in a week Total number of members in facility that are authorized for service. For Medical Add on, it would only be the number of members in facility that are authorized for those services. Total Weekly Authorized amount divide by number of days per week and then by the number for members in the facility for each type Number of members in facility(1 to 6) Total Authorized Per Diem (Daily) rate amount (Total amount / Days) / # of Consumers Providers are responsible for calculating all amounts payable to them in accordance with the above-listed rates and rate calculation formula. As an assistive tool, OMS provides sample calculations for each rate based on the number of weekly service hours provided and the number of members served. Providers may request paper copies of calculation Appendices IIA & IIB Tables 1 & 2 are accessible through the DHHS website http://www.maine.gov/dhhs/oads/disability/ds/MaineCare/index.shtml. Providers may request paper copies of the tables by calling OMS at 1-866-690-5585. TTY 711. *Maximum allowance prior to 7/1/17 and after 7/1/18 ** Maximum allowance effective 7/1/17-6/30/18 The Department is seeking and anticipates receiving approval from the federal center for Medicare and Medicaid Services for these changes with a July 1, 2017 effective date. 16 THE DEPARTMENT EXPRESSLY DISCLAIMS THE ACCURACY OF THE CALCULATIONS TABULATED IN TABLES 1 & 2 AND EXPRESSLY DISCLAIMS ANY AND ALL LIABILITY FOR LOSSES, INCURRED COSTS, OR OTHER DETRIMENT SUFFERED BY ANY PROVIDER AS A RESULT OF RELIANCE UPON INFORMATION CONTAINED IN Appendix IIA or IIB. Appendix IIA is for members Authorized with Regular service. Appendix IIB is for members authorized with Medical Add On services. MaineCare Member Regular Support Rate up to 168 Hours in excess of 168 Medical Support Rate Hours in excess of 168 Actual Medical Support Hours A B C D E F MaineCare Member Actual Regular Support Hours up to 168 Actual Total Support Hours (sum total of all types of support hours) A B C D E F Actual support hours provided in a week by Type The Department is seeking and anticipates receiving approval from the federal center for Medicare and Medicaid Services for these changes with a July 1, 2017 effective date. 17 Range of total Authorized support Hours Hours Authorized Lowest - 92.5% total weekly of Authorized Hours Highest - 105% total weekly of Authorized Hours If Actual weekly hours provided fails within or above the range or authorized total weekly support hours than the provider should bill at the authorized member Per Diem (daily) rate from above. If Actual weekly hours provided falls below the range of authorized total weekly support hours then the provider should bill actual number of hours provided times the reimbursement rate. See Calculator below Regular Support Hours up to 168 Hours in excess of 168 Medical Support Hours Actual support hours provided in a week by type Hourly Support reimbursement rates by type Total Weekly reimbursement amount for facility by type 18 Total Actual Support Hours (sum total of all types of support hours) 7 7 7 Regular Support Rate up to 168 Hours in excess of 168 Medical Support Rate Number of days per week Number of members in facility that were authorized and provided service by type Total Billable Per Diem(Daily) rate Amount (Total amount / Days) / # of Consumers MaineCare Member A B C D E F 19