This section governs the delivery and reimbursement of Targeted Case Management (TCM) services under Maine's Medicaid program (MaineCare), covering comprehensive assessment, service planning, referral, and monitoring activities for eligible members. It sets provider requirements for case management agencies and case managers, including qualifications, documentation, and quality assurance standards. The rule covers multiple eligibility populations including children with behavioral health disorders or developmental disabilities, adults with developmental disabilities, substance use disorders, or HIV, and members experiencing homelessness. It does not license or set operating standards for any specific facility-based level of care.
View official sourceTABLE OF CONTENTS An asterisk (*) denotes provisions for which the Department is seeking and anticipates approval from the Centers for Medicare & Medicaid Services of a State Plan Amendment related to this rule. PAGE 13.01 PURPOSE 1 13.02 DEFINITIONS 1 13.02-1 Adult 1 13.02-2 Ages and Stages Questionnaire (ASQ) 1 13.02-3 Ages and Stages Questionnaire: Social-Emotional (ASQ-SE) 1 13.02-4 Authorized Entity 1 13.02-5 Case Management Agencies 1 13.02-6 Case Management Services 1 13.02-7 Case Manager 1 13.02-8 Child or Children 1 13.02-9 Child and Adolescent Needs and Strengths (CANS) 2 13.02-10 Child and Family Team 2 13.02-11 Clinician 2 13.02-12 Department 3 13.02-13 Diagnostic Classification of Mental Health and Development Disorders of Infancy and Early Childhood (DC 0-3) 3 13.02-14 Diagnostic and Statistical Manual of Mental Health Disorders (DSM) 3 13.02-15 Emergency Shelter 3 13.02-16 Functional Limitations 3 13.02-17 Human Immunodeficiency Virus (HIV) 4 13.02-18 Member 4 13.02-19 Natural Supports 4 13.02-20 Out-of-Home-Placement 4 13.02-21 Prior Authorization 4 13.02-22 Service Prioritization Decision Assistance Tool (SPDAT) 4 13.02-23 Utilization Review 5 13.03 COVERED SERVICES 5 13.03-1 Comprehensive Assessment and Periodic Reassessment 5 13.03-2 Development and Periodic Revision of the Individual Service Plan 6 13.03-3 Referral and Related Activities 9 13.03-4 Monitoring and Follow-Up Activities 10 13.04 ELIGIBILITY FOR SERVICES 10 13.04-1 Eligibility Criteria for Children with Behavioral Health Disorders 11 13.04-2 Eligibility Criteria for Children with Developmental Disabilities 11 13.04-3 Eligibility Criteria for Children with Chronic Medical Conditions 12 13.04-4 Eligibility Criteria for Members in Carceral Settings 13 13.04-5 Eligibility Criteria for Adults with Developmental Disabilities 13 13.04-6 Eligibility Criteria for Adults with Substance Use Disorders 13 13.04-7 Eligibility Criteria for Adults with HIV 13 13.04-8 Eligibility Criteria for Members Experiencing Homelessness 13 13.05 LIMITATIONS 14 13.05-1 One Case Management Agency 14 13.05-2 Prior Authorization and Utilization Review 15 13.06 NON-COVERED SERVICES AND ACTIVITIES 15 13.07 PROVIDER REQUIREMENTS 16 13.07-1 Case Management Agency Requirements 15 13.07-2 Case Manager and Supervisor Requirements 19 13.07-3 Additional Supervisor Requirements 20 13.07-4 Quality Assurance 21 13.08 CASE MANAGER AND SUPERVISOR QUALIFICATIONS 21 13.08-1 Case Manager Qualifications 21 13.08-2 Supervisor Qualifications 22 13.09 DOCUMENTATION REQUIREMENTS 23 13.10 REIMBURSEMENT 25 13.10-1 Reimbursement Methodology 25 13.10-2 Cost of Living Adjustment 26 13.11 BILLING 26 13.01 PURPOSE This Section governs the delivery and reimbursement of Targeted Case Management services in accordance with applicable law. Targeted Case Management services are furnished to assist eligible Members in gaining access to needed medical, social, educational, and other services. Targeted Case Management service providers must provide services in conformance with this rule and with other applicable sections of the MaineCare Benefits Manual. 13.02 DEFINITIONS 13.02-1 An Adult is any person who is twenty-one (21) years of age or older. 13.02-2 Ages and Stages Questionnaires (ASQ) is a series of questionnaires which parents, caregivers, and providers can use to evaluate a child’s development from birth through five (5) years of age. The ASQ is used to help professionals identify delays and areas that may need support. 13.02-3 Ages and Stages Questionnaires: Social-Emotional (ASQ-SE) is a series of questionnaires which parents, caregivers, and providers can use to evaluate a child’s social-emotional development from birth through five (5) years of age. The ASQ-SE is used to help professionals understand what to expect for social-emotional development for a child’s age and to identify areas where the child may need support. 13.02-4 Authorized Entity is an 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. 13.02-5 Case Management Agency is a firm, partnership, association, corporation, or an organization approved by the Department or its Authorized Entity to provide Case Management Services. 13.02-6 Case Management Services are covered services under this Section provided by a Case Manager working for a Case Management Agency to assist eligible Members who reside in a community setting, or are transitioning to a community setting, in gaining access to needed medical, social, educational, and other services. Case Management Services consist of comprehensive assessment and periodic reassessment, development and periodic revision of the Individual Service Plan (ISP), referral and related activities, and monitoring and follow-up activities. Case Management Services are “Care Coordination” as contemplated in and when delivered to children covered by United States v. State of Maine, No. 1:24-cv-00315-SDN (D. Me. Dec. 20, 2024)(Order on Mot. Dismiss and Retain Jurisdiction, Ex. A, Settlement Agreement Between the United States of America and the State of Maine). 13.02-7 Case Manager is an individual who delivers Case Management Services and is employed or contracted by a Case Management Agency. 13.02-8 Child or Children is a person or people between the ages of birth through twenty (20) years or age. Children who are ages eighteen (18) through twenty (20) or are emancipated minors may choose to receive children’s services or adult services, both of which are covered under this Section, whichever best meets their individual needs. -574675177800 00 13.02-9 Child and Adolescent Needs and Strengths Assessment (CANS) 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. The CANS is structured into domains which are tailored to particular age ranges. 13.02-10 Child and Family Team refers to a group of individuals, chosen by the eligible Member, in conjunction with the Member’s family/guardian, which develops and implements an ISP for Members under twenty-one (21) years of age, except for Members between eighteen (18) and twenty (20) years of age choosing to receive adult Case Management Services. The team is connected to the Member and the Member’s family/guardian through natural, community, and formal support relationships. The team consists of the following: A. The eligible Member, unless clinically contraindicated; B. The eligible Member’s parent(s) or other legally responsible party, such as a guardian; C. The Case Manager; D. Other key service providers, chosen by the Child and Family Team to address the eligible Member's specific needs (e.g., physician, psychiatrist, psychologist, social worker, nurse, crisis intervention worker, child protection or substitute care worker, rehabilitation counselor, physical, speech, occupational or recreational therapist, child development worker, substance use disorder counselor, criminal justice worker); E. If chosen by the Child and family, Natural Supports and others who provide informal support; and F. As appropriate, a special education or other education professional. 13.02-11 Clinician is an individual appropriately licensed or certified, practicing within the scope of that licensure or certification, and qualified to deliver treatment under this Section. A Clinician includes the following: Licensed Clinical Professional Counselor (LCPC); Licensed Clinical Professional Counselor-Conditional (LCPC-C); Licensed Clinical Social Worker (LCSW); Licensed Master Social Worker- Conditional Clinical (LMSW-CC); Licensed Marriage and Family Therapist (LMFT); Licensed Marriage and Family Therapist-Conditional (LMFT-C); Licensed Alcohol and Drug Counselors (LADC), Certified Alcohol and Drug Counselors (CADC); Physician; Psychiatrist; Advanced Practice Registered Nurse Psychiatric and Mental Health Practitioner (APRN-PMH-NP); Advanced Practice Registered Nurse Psychiatric and Mental Health Clinical Nurse Specialist (APRN-PMH-CNS); Psychological Examiner; Physician Assistant (PA); Registered Nurse (RN) or Licensed Clinical Psychologist. 13.02-12 Department means the Maine Department of Health and Human Services, also referred to as DHHS. 13.02-13 Diagnostic Classification of Mental Health and Development Disorders of Infancy and Early Childhood (also known as DC: 0-3) is a publication that 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. 13.02-14 Diagnostic and Statistical Manual of Mental Health Disorders (DSM) is the current version published by the American Psychiatric Association. The DSM is used to classify mental health disorders and provide standard categories for definition of mental health disorders. 13.02-15 Emergency Shelter means a facility, the primary purpose of which is to provide a temporary place for a person experiencing homelessness to sleep and which meets the Emergency Shelter requirements established by the Maine State Housing Authority at 99-346 C.M.R. ch. 19. 13.02-16 Functional Limitations may be comprised of the following: Vocational. For Members of working age, impairment in vocational functioning is manifested by an inability to be consistently employed at a self-sustaining level or an ability to be employed only with extensive supports (A person who is able to earn sustaining income but is recurrently unemployed because of acute episodes of mental illness or addictions does not meet this Functional Limitations requirement). For Children, impairment in vocational functioning is manifested by limitations in communication skills, task initiation, prioritization, problem solving, and/or time management which impair the Child’s ability to be a candidate for future employment or continuing educational opportunities. B. Educational. Impairment in educational functioning is manifested by an inability to pursue age-appropriate educational goals within a normal time frame or without extensive supports. C. Instrumental Activities of Daily Living (IADL). Impairment in IADL functioning is manifested by an inability to consistently and independently accomplish home management tasks, including but not limited to household meal preparation, washing clothes, grocery shopping, and budgeting; or for Children, impairments may be manifested by an inability to perform developmentally appropriate activities for their age, such as learning to make basic meals and make simple transactions, including allowances, understanding how sending mail works, or understanding the name and purpose of their medications. D. Social or Interpersonal. Impairment in social or interpersonal functioning is manifested by an inability to independently develop or maintain social relationships or to independently participate in social or recreational activities. This may include, but is not limited to: Repeated inappropriate or inadequate social behavior (defined as an inability to behave appropriately or adequately without extensive or consistent support or coaching; or only in special contexts or situations such as social groups organized by the provider); or Consistent participation in activities only with extensive support or coaching and when involvement is mostly limited to special activities established for persons with interpersonal impairments. E. Community. Impairment in community functioning is manifested by a pattern of significant community disruption, including family disruption or social unacceptability or inappropriateness, which may not recur often but is of such magnitude that it results in severe consequences (including but not limited to exclusion from the Member’s primary social group) or in severe impediments to securing basic needs such as housing. F. Self-care, Independent Living or Activities of Daily Living. Impairment in self-care or independent living is manifested by an inability to consistently perform the range of practical daily living tasks required for basic functioning in the community, including, but not limited to: 1. Bed mobility, transfer, locomotion, eating, toilet use, bathing, and dressing; 2. Grooming, hygiene, and meeting nutritional needs; 3. Care of personal business affairs; 4. Transportation and care of residence; 5. Procurement of medical, legal, and housing services; and 6. Recognition and avoidance of common dangers or hazards to self and possessions. 13.02-17 Human Immunodeficiency Virus (HIV) is the virus which causes AIDS (Acquired Immune Deficiency Syndrome). 13.02-18 Member is a MaineCare member. 13.02-19 Natural Supports means the relatives, friends, neighbors, and community resources that a family goes to for support. 13.02-20 Out-of-Home Placement is a residential setting other than a family home where a Child receives services primarily to address a mental illness or a developmental disability. Out-of-Home Placements include, but are not limited to, children’s residential care facilities (CRCFs), psychiatric residential treatment facilities (PRTFs), hospitals, and psychiatric hospitals. Emergency departments, therapeutic foster care homes, and therapeutic intensive homes are not Out-of-Home Placements. 13.02-21 Prior Authorization is the process of obtaining prior approval as to the medical necessity and eligibility for a service. See Chapter I, Section 1, of the MaineCare Benefits Manual for general prior authorization requirements. 13.02-22 Service Prioritization Decision Assistance Tool (SPDAT) is a risk assessment tool for professionals working with homeless people to prioritize who should receive assistance first. The SPDAT was designed to help guide Case Management Services and improve housing stability outcomes. 13.02-23 Utilization Review is a formal assessment, completed by the Department or its Authorized Entity, of the medical necessity, efficiency and appropriateness of services and treatment plans on a prospective, concurrent or retrospective basis. 13.03 COVERED SERVICES* The following Case Management Services are covered services when provided to an eligible Member by a Case Management Agency via a qualified Case Manager: *The Department is seeking and anticipates approval from the Centers for Medicare & Medicaid Services of a State Plan Amendment related to this provision. 13.03-1 Comprehensive Assessment and Periodic Re-assessment Comprehensive Assessment and Periodic Re-assessment consist of initial and follow-up assessments that determine an eligible Member’s medical, behavioral, mental health, social, residential, educational, vocational, and other related needs, as well as the Member’s strengths and goals. For Members under age twenty-one (21), the Comprehensive Assessment and Periodic Re-assessment must also determine the strengths and goals of the Member’s parents, guardians, caregivers, or other family members to the extent these goals relate to the Member’s service needs. For Members under age twenty-one (21), the Comprehensive Assessment and Periodic Re-assessment must be conducted in-person with the Child and Family Team and include, at a minimum, a visit to the Member’s home, as appropriate, and observation of family interactions. For all Members, the Comprehensive Assessment and Periodic Re-assessment must include at least the following: A. Taking the Member’s medical, developmental, and mental health history; B. Identification of the needs of the Member and completion of related documentation, including any assessments required by the Department and, for Members who are Children with behavioral health needs, referral to the Single Assessment if so required by Chapter I, Section 7, Children’s Behavioral Health Services Global Rule; C. Gathering information through interviews with the Member, family members, Natural Supports, and, as applicable to form a complete assessment, interviews with medical providers, social workers, and educators; D. Review of relevant medical and other records with the applicant or legal representative’s written consent; E. Review of providers currently delivering medical, social, and other support services to the Member; and F. Identification and/or assessment of the following, when applicable to the Member: Current medications; Nutritional status; Emotional and behavioral status; Health care coverage; Living situation; Personal support systems; Member’s goals and preferences; Environmental, social, and functional status; Educational history; Employment status; Health education needs; Social supports; The most integrated setting appropriate to meet the Member’s needs; and The need for professional evaluations and assessments necessary to document and recommend eligibility. G. The Member’s name, address, and birth date; H. The Member’s history, including physical and social environment, past service use, and a detailed social and family history to identify behavioral health risk factors, child welfare involvement, and developmental trauma; health/medical status, including chronic or severe medical and substance use disorder problems; educational status; developmental status; and habilitative skills, including social and daily living skills; I. The Member’s needs, including current functional level and level of risk, available strengths and supports, including family and social networks and preferences; J. Documentation of an evaluation by a psychiatrist, physician, physician assistant, psychologist, advanced practice psychiatric nurse, advanced practice registered nurse, LCSW, LMSW, LMFT, or an LCPC, which includes diagnosis; and K. Signature and credential of the Case Manager completing the assessment and the date the assessment was completed. A Comprehensive Assessment must be completed within the first thirty (30) days of enrollment in Case Management Services, and Periodic Re-assessments must occur at least annually, and whenever changes in the Member’s needs warrant review. For Children with behavioral health needs, a Re-assessment must be done at the request of the Child or family and after any significant change in circumstance, including but not limited to a crisis event, a hospitalization as a result of the Child’s behavioral health needs, the Child’s arrest and referral to the Maine Department of Corrections pursuant to 15 M.R.S.A. § 3203-A, an admission for in-patient psychiatric care, a child welfare placement, a placement in an alternative school, or an incident endangering self or others at the Child’s school. 13.03-2 Development and Periodic Revision of the Individual Service Plan (ISP) The ISP must be developed and revised based on information collected through the Comprehensive Assessment and Periodic Re-assessment. Because the assessment of the Member’s needs must be comprehensive, the ISP must also be comprehensive to address all identified needs. The ISP must be completed within thirty (30) days of enrollment in Case Management Services. Except for Adults with HIV, the ISP must be reviewed, and updated as necessary, every ninety (90) days, or more frequently as a change in the Member’s needs occurs, by the Case Manager and the Member/legal guardian (when applicable) to determine if the plan requires updating. For Adults with HIV, the ISP must be reviewed every six (6) months or more frequently as a change in the Member’s needs occurs. For Children with behavioral health needs, the ISP must be reviewed after any significant change in circumstance, including but not limited to a crisis event, a hospitalization as a result of the Child’s behavioral health needs, the Child’s arrest and referral to the Maine Department of Corrections pursuant to 15 M.R.S.A. § 3203-A, an admission for in-patient psychiatric care, a child welfare placement, a placement in an alternative school, or an incident endangering self or others at the Child’s school. The ISP must be updated at least every six (6) months. For Children, the ISP must be developed with the Child and Family Team. Every one hundred eighty (180) days for Children with behavioral health needs, as part of the ISP review, the Case Manager must visit the Member’s home, as appropriate, and observe family interactions and interview the Member, family, and natural supports; the Case Manager must document any updates to the Member’s social history related to behavioral health risk factors, child welfare involvement, and developmental trauma in the ISP. Providers of Case Management Services for Adults with Developmental Disabilities must utilize the current version of the OADS Person Centered Planning Process Instruction Manual, available at https://www.maine.gov/dhhs/oads/providers/adults-with-intellectual-disability-and-autism/person-centered-planning, when developing the ISP. A Member may decline to receive services that have been identified as necessary in the ISP. If the Member declines services listed in the ISP, this must be documented in the Member’s record. The ISP must include the below components unless the provider determines a specific component is not applicable because the Member is a Child or Adult. Children who need behavioral health services and any Member if appropriate based on their needs, a crisis plan with the goal of stabilizing the Member and diverting the Member, whenever possible, from receiving services in an Out-of-Home-Placement or making an emergency department visit due to a behavioral health need by identifying and furnishing appropriate services in the home and community; Member and family strengths; needs and preferences, including cultural needs and preferences; short- and long-term goals and desired outcomes; supports including Natural Supports and psychiatric, medical, social, educational, and family supports; and resources identified to address each identified need; All services, including community-based options, required to address the Member’s and family’s needs, as applicable to the Member’s ISP, and the duration, frequency, and intensity of those needed services. The ISP must document which, if any, listed services the Member declines, which services the Member receives and their effectiveness, and, if applicable, adjustments to services and justification for any adjustments. For Children who need behavioral health services, the ISP will document whether the Child has received a Single Assessment as described in Chapter I, Section 7, the date of that Single Assessment, and whether the Child and Family Team have reviewed the results of that Single Assessment; The procedures, instruments, and assessment tools used to evaluate the Member’s progress in the chosen services; if the Member is already receiving a service, whether that service is effective, and a record of service delivery; and target dates for completion. The ISP must also identify the provider who will deliver each service, any barriers that may prevent the Member from receiving services, and how the Case Manager or Child and Family Team will address those barriers. A plan for reviewing the ISP following a crisis or significant event involving the Member. Updates to the ISP must include whether services are received, whether services are effective, and, if applicable, any needed adjustments to services with justification for the adjustments; Documentation of a determination, as applicable, that the Member needs one (1) or more services that are only offered in an Out-of-Home Placement. If such a determination is made, the ISP must document that the Case Manager discussed barriers to the Member receiving services in a family home and must document when the Member or the Member’s parents or guardians choose to receive services in an Out-of-Home Placement. A plan to return a Member to their home when receiving services in an Out-of-Home Placement. The ISP must document the specific steps that will be taken so the Member can return home and continue to receive necessary services and must include a planned discharge date. A plan for significant transitions in the Member’s life, including transitions to a new school or to adult services; Reference to and coordination with other written plans relevant to a Member’s needs, such as an individualized education plan, a 504 plan, an individualized plan for employment, and a positive behavioral support plan; Documentation of measures taken to afford the Member and, if applicable, their parent/legal guardian, with informed choice as to service setting and measures taken to address any concerns about receiving services in a family home, and documentation of the Member’s or, if applicable, their parent/legal guardian’s written consent for services and the settings in which those services will be delivered; J. A plan for ensuring the active participation of the Member and, as appropriate, the Member’s parent(s), legal guardian(s), or other caregiver(s); K. Documentation of Member and/or family involvement in the development and/or review of the plan, including their signatures; L. The problems to be resolved, measurable goals and objectives to be attained, and/or outcomes to be realized through provision of identified services; M. Referral to appropriate providers of services and follow-up documentation; N. Plans for coordination with other agencies and providers, as appropriate; O. Identification of any other Case Management Agencies under this Section and similar services, such as under Chapter II, Section 92, “Behavioral Health Home Services” and what services they are currently providing. Case Managers must give Members a document explaining these services; P. Documentation that the Member or their guardian or legal representative has been offered a choice of Case Management Agencies and Case Managers, and documentation of the Member’s choice; and Q. The signature and credential of the staff completing the ISP, including the Case Manager and the Case Manager’s supervisor, and the date the plan was completed. 13.03-3 Referral and Related Activities The Case Manager must help the eligible Member obtain needed services, including by linking the Member with medical, social, educational providers or other programs and services that address identified needs and achieve goals specified in the ISP. Referral and related activities include: A. Making referrals to providers for needed services and helping obtain documentation required for those referrals; B. Scheduling appointments for the Member; Assisting with applications for services and programs, including services and programs offered by public agencies; D. Providing contacts or other information about services provided by self-advocacy groups, recreation organizations, or social groups; E. Assisting with transitions to new services, providers, or supports; and F. Educating Members and their families regarding: 1. The range of services and settings that may be appropriate to meet the Member’s needs and preferences; 2. How to access services; and 3. How to coordinate and advocate for services. Referral and related activities do not include providing transportation to or from the service to which the Member is referred, escorting the individual to or from the service, or providing child care so that an individual may access the service. However, referral and related activities do include arranging transportation for Members who need it to access medically necessary services. 13.03-4 Monitoring and Follow-Up Activities are comprised of activities and contacts that are necessary to ensure that the ISP is effectively implemented and adequately addresses the needs of the Member. This includes contact with the Member as needed to monitor objectives and, if appropriate, periodic contact with the Member’s family, providers, or other entities. Case Managers may conduct monitoring activities in-person or via telehealth. Services delivered via telehealth must comply with Chapter I, Section 4. These services must be conducted as frequently as necessary, but not less than monthly. Case Managers must: A. Determine if services are being furnished in accordance with the ISP; B. Determine if services in the ISP are adequate to address the needs of the Member; C. Determine if the needs or status of the Member have changed and require adjustments to the ISP and service arrangements with providers or service termination; Assess progress toward goals and intended outcomes outlined in the ISP; Monitor the status of referrals; Assess the Member’s needs for MaineCare, MaineCare waiver programs, State funded services, and any other relevant benefits or services, and support the Member in maintaining eligibility for such programs, benefits and services; Identify new services and resources which may more effectively meet the Member’s needs and only facilitate transitions to these services when it is the Member’s choice; and H. Assist with applications and re-applications for necessary programs or services. 13.04 ELIGIBILITY FOR SERVICES Members must meet the eligibility criteria as set forth in the MaineCare Eligibility Manual. Some Members may have restrictions on the type and amount of services they are eligible to receive. It is the responsibility of the provider, as described in MaineCare Benefits Manual, 10-144 C.M.R. ch.1, Section 1, to verify a Member’s eligibility for MaineCare prior to providing services. Children aged eighteen (18) through twenty (20) years of age and Children who are emancipated minors may choose to receive children’s services or adult services, whichever best meets their individual needs. Providers must also verify Members meet one (1) of the eligibility categories below prior to delivering services. Reassessments of eligibility shall occur at least annually. Case Management Agencies shall document the eligibility verification in the Member’s record. Some of the specific eligibility categories below require Members to have Functional Limitations. These Functional Limitations, as defined in 13.02-15, must be identified, supported, and documented in assessments using accepted standardized instruments that are developmentally appropriate to the Members being assessed. 13.04-1 Eligibility Criteria for Children with Behavioral Health Disorders* A. Members six (6) through twenty (20) years of age are eligible for Case Management Services if: 1. The Member has a mental health or substance use disorder diagnosis as described in the most recent version of the DSM. Eligible mental health diagnoses do not include the following: communication disorders, specific learning disorder, medication induced movement disorders and other adverse effects of medication; and 2. The Member received a CANS score of two (2) or higher in at least two (2) of the following domains: “Behavioral Emotional Needs,” “Life Functioning,” and “Risk Behaviors.” B. Members birth through five (5) years of age are eligible for Case Management Services if: 1. A Clinician determines that the Member is at risk of developing a mental health disorder due to a specific social, environmental, or biological determinant of health, such as housing insecurity, malnutrition, exposure to toxins, social exclusion, and/or genetic predispositions; and 2. The Member receives either: A CANS score of two (2) or higher in at least two (2) of the following domains: “Behavioral Emotional Needs,” “Risk Factors and Behaviors,” and “Life Functioning;” or b. An ASQ-SE overall score that is “above cutoff.” *The Department is seeking and anticipates approval from the Centers for Medicare & Medicaid Services of a State Plan Amendment related to this provision. 13.04-2 Eligibility Criteria for Children with Developmental Disabilities* A. Members six (6) through twenty (20) years of age are eligible for Case Management Services if: 1. The Member meets the definition of developmental disabilities as defined in 22 M.R.S.A. §3573 or has a diagnosis of Autism Spectrum Disorder (ASD) as described in the most recent version of the DSM; and 2. The Member has received a CANS score of two (2) or higher on two of the following domains: “Behavioral Emotional Needs,” “Life Functioning,” and “Risk Behaviors.” B. Members birth through five (5) years of age are eligible for Case Management Services if: A Clinician determines that the Member is at risk of developing a developmental delay due to a specific social, environmental, or biological determinant of health, such as housing insecurity, malnutrition, exposure to toxins, social exclusion, and/or genetic predispositions; and 2. The Member has at least one (1) Functional Limitation as determined by a Clinician; and 3. The Member has received either: A CANS score of two (2) or higher in at least two (2) of the following domains: “Functioning and Development,” “Infant and Children,” “Life Functioning,” and “Risk Factors and Behaviors.” or ii. An ASQ score “below cutoff” in at least two (2) domains. *The Department is seeking and anticipates approval from the Centers for Medicare & Medicaid Services of a State Plan Amendment related to this provision. 13.04-3 Eligibility Criteria for Children with Chronic Medical Conditions* To be eligible for Case Management Services, the Member must be a Child who: Is living with HIV, as determined by a positive HIV antibody or antigen test, or who has a diagnosis of HIV disease or AIDS; or Has been: 1. Diagnosed with an autoimmune disease, diabetes, respiratory disorder, a neurological disorder, brain injury or other chronic condition specifically recognized by the Department or its Authorized Entity; and 2. Determined by a Clinician to have three (3) or more Functional Limitations; or C. Meets the following criteria: 1. Has one (1) of the following: a. A diagnosis of a physical condition that is indicative of damage to the central nervous system; b. A documented history by a Clinician of prenatal, perinatal, neonatal, or early physical developmental events or conditions suggestive of damage to the central nervous system; or c. Atypical physical development or a condition, such as, but not limited to, cerebral palsy, meningitis, heart defects, or bronchopulmonary dysplasia, which, without intervention, has a high probability of resulting in physical developmental delay; and 2. Has a Functional Limitation as determined by a Clinician. *The Department is seeking and anticipates approval from the Centers for Medicare & Medicaid Services of a State Plan Amendment related to this provision. 13.04-4 Eligibility Criteria for Members in Carceral Settings* A Member who is a Child or Adult under 26 years old is eligible for Case Management Services if they meet the definition of “eligible juvenile” as set forth in Section 1902(nn)(2) of the Social Security Act, at 42 U.S.C. § 1396a(nn)(2); provided, however, that Eligible Juveniles are eligible for Case Management Services only for the period thirty (30) days prior to their release from a public institution, as defined at 42 U.S.C. § 1396a(nn)(3) and excluding a medical institution, and for at least thirty (30) days after such release. *The Department is seeking and anticipates approval from the Centers for Medicare & Medicaid Services of a State Plan Amendment related to this provision. 13.04-5 Eligibility Criteria for Adults with Developmental Disabilities A Member who is an Adult diagnosed with a developmental disability, as defined in 34-B M.R.S. § 3573, or with ASD, as defined in Title 34-B M.R.S. § 6002, is eligible for Case Management Services. 13.04-6 Eligibility Criteria for Adults with Substance Use Disorders* An Adult Member is eligible for Case Management Services if the Adult: A. Has a Substance Use Disorder (SUD) diagnosis as described in the most recent version of the DSM; B. Is currently seeking or receiving substance use treatment services; and C. Is pregnant, is living with his or her minor children, and/or is an intravenous drug user. *The Department is seeking and anticipates approval from the Centers for Medicare & Medicaid Services of a State Plan Amendment related to this provision. 13.04-7 Eligibility Criteria for Adults with HIV An Adult Member living with HIV, as determined by a positive HIV antibody or antigen test, or who has a diagnosis of HIV or AIDS is eligible for Case Management Services. 13.04-8 Eligibility Criteria for Members Experiencing Homelessness Members experiencing homelessness are eligible for Case Management Services if they meet the criteria in all of the following subparts: A. Meet at least one (1) of the following: 1. Currently reside or have in the past ninety (90) days resided in an Emergency Shelter in the State of Maine; 2. Have a history of homelessness and a Service Prioritization Decision Assistance Tool (SPDAT) score of twenty (20) to sixty (60); or 3. Do not have a permanent address, residence, or facility in which they reside or could reside; and B. Meet all of the following: Require treatment or services from a variety of agencies and providers to meet their medical, social, educational, and other needs; and 2. In order to successfully access needed services, require assistance by a qualified Case Manager who, in accordance with the ISP, locates, coordinates, and regularly monitors the services; and C. Meet at least one (1) of the following: 1. Need immediate medical care; 2. Need an immediate crisis evaluation or mental health assessment to address a behavioral health issue; 3. Have a current medical or mental health condition and are at risk of losing or have lost access to medically necessary services; 4. Have an immediate need for medications to address an existing medical and/or behavioral health condition; 5. Are demonstrating physical or mental impairment such that services are necessary to improve, restore or maintain health and well-being; or 6. Have experienced immediate or recent trauma and are demonstrating a need for assistance with gaining and coordinating access to necessary care and services appropriate to their needs. 13.05 LIMITATIONS 13.05-1 One Case Management Agency A. Members must choose only one (1) approved Case Management Agency from which to receive services, except as provided in 13.05-1(D) and (E). B. The Department will reimburse only for Case Management Services provided by the Case Management Agency chosen by the Member, except as provided in 13.05-1(D) and (E). C. A Member may choose a new Case Management Agency at any time. D. Subject to prior authorization, two (2) Case Management Agencies may provide services concurrently for a period of thirty (30) days to a Member transitioning from one (1) eligibility category to another (e.g., child to adult). E. Pursuant to Chapter I, Section 7, and to the greatest extent allowed by state and federal law, more than one (1) Case Management Agency may deliver Case Management Services to one (1) eligible Child if one (1) Case Management Agency cannot meet the Child’s needs. 13.05-2 Prior Authorization and Utilization Review A. Case Management Services require Prior Authorization. Case Management Agencies are responsible for obtaining Prior Authorizations from the Department or its Authorized Entity. B. The Department or its Authorized Entity reserves the right to approve continuation of any covered services as described in this Section, applying the standards established by this Section for eligibility and for continuation of services. All Case Management Services may be subject to Utilization Review. 13.06 NON-COVERED SERVICES A. Reimbursement for Case Management Services must not duplicate reimbursement made to public agencies or private entities under other program authorities for Case Management Services or coordination services. B. Reimbursement for Case Management Services under this Section must not duplicate reimbursement for similar services made under other Sections of the MaineCare Benefits Manual or other funding sources including, but not limited to, Chapter II, Section 18, “Home and Community-Based Services for Adults with Brain Injury”; Chapter II, Section 19, “Home and Community Benefits for the Elderly and Adults with Disabilities”; Chapter II, Section 20, “Home and Community Services for Adults with Other Related Conditions”; Chapter II, Section 89, “MaineMOM Services and Reimbursement”; Chapter II, Section 91, “Health Homes Services – Community Care Teams”; Chapter II, Section 92, “Behavioral Health Home Services”; and Chapter II, Section 93, “Opioid Health Home Services”. C. Reimbursement for Case Management Services under this Section must not duplicate reimbursement for similar services delivered to Members residing in and receiving services from an institution, including, but not limited to, hospitals, nursing facilities, intermediate care facilities for individual with intellectual disabilities, children’s residential care facilities, and other private non-medical institutions, except for a period of no more than 180 days from a planned discharge date or if there’s a written opinion from a clinician that discharge will occur within 180 days if a specific discharge date has not been selected yet. Case Managers delivering Case Management Services to a Member residing in an institution during this 180-day period must coordinate with the institution to ensure that no duplicative case management activities occur, such as making duplicative referrals to the same providers.* *The Department is seeking and anticipates approval from the Centers for Medicare & Medicaid Services of a State Plan Amendment related to this provision. D. Case Management Services do not include and Case Management Agencies may not bill for activities outside the scope of the covered services. Such activities include, but are not limited to, the following: 1. Representative payee services and other financial services, meaning any services, or components of services, for which the basic nature is to provide economic services to the Member, including but not limited to financial or credit counseling; 2. Housekeeping, homemaking, or services delivered for the convenience of a Member receiving covered services, including, but not limited to, shopping, child care, and laundry service; 3. Direct delivery of an underlying medical, educational, social, or other service to which an eligible Member has been referred; and 4. Costs associated with and/or time spent on progress notes, transportation, internal meetings, data entry, appointment reminders associated with the delivery of covered services. These activities are built into the rates and are not separately reimbursable. 13.07 PROVIDER REQUIREMENTS 13.07-1 Case Management Agency Requirements Case Management Agencies must: A. Promote effective operation of the agency in a manner consistent with applicable State and Federal laws, regulations, and policies; B. Maintain clear written policies and guidelines for decision making, program operations, and provisions for monitoring the same; C. Provide orientation and continuing education, and communicate when appropriate with all applicable licensing boards and other professional regulation governing boards; D. Have policies and procedures to protect the rights of Members; E. Have a comprehensive set of personnel policies and procedures; F. Have job descriptions and qualifications, including licensure, for all staff employed either directly or by contract with the provider; G. Have a review process to ensure that Case Managers and Supervisors possess the minimum qualifications required by this Section. The review process must occur upon hiring new employees or contracted staff, and additionally on an annual basis to assure that credentials remain valid; H. Maintain documentation of staff qualifications in staff personnel files. Such documentation includes but is not limited to transcripts, licenses, and certificates; I. Ensure that employed staff and contractors possess the skills, attitudes, and knowledge needed to perform job functions and maintain and comply with policies for performing regular staff evaluations and working with volunteers; J. Exhibit effective inter-agency coordination that demonstrates a working knowledge of other community agencies. This means the provider and its contracting agencies must be aware of information regarding the types of services offered and limitations on these services. Similarly, providers must ensure that other human service agencies are provided with accurate, up-to-date information regarding the provider's services, service limitations, and priorities within those services; K. Comply with all additional requirements as defined in any contract between the Department and the Case Management Agency; L. Plan staff development and continuing education activities for their employees and contractors that broaden their existing knowledge in the fields of, as applicable, developmental disabilities, mental health, substance use disorder, long term care, chronic medical conditions and related areas; M. Provide staff orientation for Case Managers prior to their delivering Case Management Services. Orientation and training must include topics relevant to the service and population served. Additionally, orientation for all staff must include the following subject matter: 1. Overall operation of the program and agency 2. Job duties/responsibilities 3. Agency policies and procedures 4. Confidentiality 5. Code of ethics 6. Professional boundaries 7. Introduction to local resources and programs 8. Review of client eligibility and intake process 9. Required documentation in client files 10. Training needs and annual training requirements 11. Quality management 12. Coping with job related stress/preventing burnout 13. Crisis management N. Maintain in personnel files documentation of the continuing education and staff development training completed by Case Managers; O. Ensure Case Managers for Children deliver Case Management Services in accordance with the following principles: 1. Family voice and choice – The Child and Family Team gathers family and Member perspectives to determine priorities throughout the ISP development and care coordination processes. 2. Child and Family Team based care – The Child and Family Team of individuals is agreed upon by the family and Member, and committed to them through informal, formal, and community support and service relationships. 3. Involvement of Natural Supports – Child and Family Team members actively seek out and encourage the full participation of team members drawn from the Member’s family and others in the Member’s networks of relationships chosen by the Member. 4. Collaboration – Child and Family Team members work cooperatively and share responsibility for developing, implementing, monitoring, and evaluating a single ISP. 5 Community-based – The Case Management Agency implements service and support strategies that take place in the most inclusive, most responsive, most accessible, and least restrictive settings possible, and that safely promote the Member and family integration into home and community life. 6. Culturally competent – The service delivery model demonstrates respect for and builds on the values, preferences, beliefs, culture, and identity of the Member, family, and their community. 7. Individualized – To achieve the goals laid out in the ISP, the Child and Family Team develops and implements a customized set of strategies, supports, and services. 8. Strengths based – The Child and Family Team identifies, builds on, and enhances the capabilities, knowledge, skills, and assets of the Member and family, their community, and other Child and Family Team members. 9. Persistence – Despite challenges, the Child and Family Team persists in working toward the goals included in the ISP. 10. Outcomes based – The Case Management Agency ties the goals and strategies of the ISP to observable or measurable indicators of success, monitors progress in terms of these indicators, and revises the plan accordingly. P. Case Management Agencies delivering services to Children with Behavioral Health Disorders and Adults with Substance Use Disorders must be licensed pursuant to 10-144 C.M.R. ch. 123. Case Management Agencies delivering services to other eligibility groups must be licensed by the Department if so required by Department regulation or statute; Q. Case Management Agencies delivering Case Management Services to Children with Behavioral Health Disorders or to Children with Developmental Disabilities must receive program approval from the Office of Behavioral Health Services; Case Management Agencies delivering Case Management Services to Adults with Developmental Disabilities must receive program approval from the Office of Aging and Disability Services. Case Management Agencies delivering Case Management Services to Adults with HIV must receive program approval from the Office of MaineCare Services; and Case Management Agencies delivering Case Management Services to Children with Chronic Medical Conditions, Members in Carceral Settings, Adults with Substance Use Disorder, or Members Experiencing Homelessness are subject to program approval as determined by the Department; and R. Ensure the following requirements for Case Management Services for Adults with Developmental Disabilities are met: 1. As required by 34-B M.R.S. §5201(6)(B), unless otherwise specified in the ISP, Case Managers shall maintain monthly contact with the Member and must visit the Member’s home at least twice per year. Additionally, Case Managers must have at least one (1) in-person contact with each Member quarterly. 2. All provisions in 14-197 C.M.R. ch. 10, including but not limited to all staffing and caseload requirements and ratios. 13.07-2 Case Manager and Supervisor Requirements Case Managers and Supervisors must: A. Ensure that Members and their family members, as applicable, know how to raise issues with existing services or lack of services, including, as applicable, by filing a grievance with the Department, by requesting the Case Manager raise an issue with the provider, with the Department, or with an oversight board, or by requesting the Case Manager make referrals to alternate or additional providers; B. Identify risks that may lead to an Out-of-Home Placement and barriers that prevent a Member from living in a family home and, when serving Children, discuss, when applicable, how services may be furnished in a family home other than a parental home; C. For Case Managers serving Children who receive a Single Assessment for Medium to High Intensity Behavioral Health Services described at Ch. I, Section 7, promptly review with the Child and Family Team the Child’s service options as determined by the Single Assessment; D. Meet in places and at times convenient for and preferred by Members and/or their parent(s)/guardian(s)/caregiver(s); To the greatest degree possible considering certain workforce, financial, or other systemic constraints that may be outside their control, ensure that Members receive timely services and notify the Department when Members do not receive timely services, including, for Children with Behavioral Health Disorders, by complying with timeliness requirements in Chapter I, Section 7; Develop a process to ensure decisions can be made if, and implement that process when, the group involved in the development or revision of the ISP cannot reach consensus; Coordinate with other relevant entities, including school staff, medical providers, juvenile justice staff, and other state service program staff or contractors to ensure those programs support the ISP; In the event the Case Manager determines that the Member needs one (1) or more services which MaineCare only covers in an Out-of-Home Placement, inform the Member and, when appropriate, the Member’s parents/guardians, of the option to submit or ask that the Case Manager submit, a request for an Americans with Disabilities Act (ADA) modification to the Department’s ADA Coordinator; I. Practice culturally competent care which demonstrates respect for and builds on the values, beliefs, culture, and identity of Members, their families, and their communities; J. Practice with persistence so that, despite challenges, the Case Manager persists towards the goals in the ISP; K. Comply with reportable events policy as required by 14-197 C.M.R. ch. 12; and L. If serving Children, enroll in a Department-approved wraparound planning principles training series within thirty (30) days from the date of hire and complete the training series within sixty (60) days from the date of hire. 13.07-3 Additional Supervisor Requirements The Case Management Agency must identify a supervisor who meets the requirements set forth in Section 13.08-2 for each staff member. Supervisors are responsible for supervising Case Managers, reviewing ISPs, and ensuring the provision of quality Case Management Services. Supervisors must give approval and provide signature for all ISPs. At a minimum, supervision of Case Managers must be provided according to the following standards: A. Supervision must be conducted at regularly scheduled times, no less frequently than once monthly for each Case Manager. B. Supervision may be conducted on an individual or group basis. Supervision must be measured and documented in hours and shall be subject to review by the Department. Supervisors must give approval and provide signature for all ISPs. C. Supervision shall include the following: Review of case records, including the ISP, and approval and signature of each ISP reviewed; Documentation in the case records, indicating the occurrence of the review; Review of case management activities, including adequacy and completeness of screenings, assessments, referrals, etc.; Participation in the development of the Case Manager’s individual, group and family support skills, as applicable; Maintenance of a record of supervision, including the dates, Case Manager(s) supervised, duration and content of supervision, signed by the supervisor; and Discussion of issues germane to the Case Management Services delivered. 13.07-4 Quality Assurance Providers must cooperate with the Department or its Authorized Entity in conducting quality assurance activities including, but not limited to, the following: A. Periodic review of cases to assure quality and appropriateness of care conducted in accordance with the quality assurance protocols specific to each target group; and B. Review of all records to assure that documentation is signed and dated by the reviewers and included in the Member’s record or kept in a separate and distinct file parallel to the Member’s record. 13.08 CASE MANAGER AND SUPERVISOR QUALIFICATIONS 13.08-1 Case Manager Qualifications A. Except for Case Managers delivering Case Management Services to individuals with HIV or to Members Experiencing Homelessness, Case Managers must have: 1. A bachelor’s degree from an accredited four (4) year institution of higher learning with a specialization in a field closely related to the population being served, including but not limited to psychology, mental health and human services, behavioral health, behavioral sciences, social work, substance use, human development, special education, counseling, rehabilitation, sociology, or nursing; or 2. A master’s degree in social work, education, psychology, counseling, nursing or closely related field from an accredited graduate school; or 3. A bachelor’s degree from an accredited four (4) year institution of higher learning in an unrelated field and at least one (1) year of full-time equivalent relevant human services experience. Case Managers must receive subsequent training and supervision relevant to the population served; or 4. Been employed on 8/1/2009 as a Case Manager providing services under the former Section 13 then in effect. A person so employed will be considered qualified for the purposes of this section. B. Case Managers delivering Case Management Services to individuals with HIV or to Members Experiencing Homelessness must meet at least one (1) of the Case Manager qualifications in 13.08-1(A) or must have a:* Combined five (5) years of education and experience in providing direct services in social, health, or behavioral health fields; or 2. Current Mental Health Rehabilitation Technician/Community (MHRT/C) Certification. *The Department is seeking and anticipates approval from the Centers for Medicare & Medicaid Services of a State Plan Amendment related to this provision. 13.08-2 Supervisor Qualifications The allowable provider types in subparts A through H may be fully or conditionally licensed and must act within their scope of practice. Supervisors of Case Management Services delivered to Children with Behavioral Health Disorders must be one (1) of the following: Licensed Psychologist; Licensed Clinical Social Worker (LCSW); Licensed Clinical Professional Counselor (LCPC); Licensed Marriage and Family Therapist (LMFT); Psychiatric Nurse; or Individuals who meet the criteria in 13.08-1(A)(4). B. Supervisors of Case Management Services delivered to Children with Developmental Disabilities must be one (1) of the following: 1. Licensed Psychologist; 2. Licensed Clinical Social Worker (LCSW); 3. Licensed Clinical Professional Counselor (LCPC); 4. Licensed Marriage and Family Therapist (LMFT); 5. Licensed Master of Social Work (LMSW); or 6. Individuals who meet the criteria in 13.08-1(A)(4). C. Supervisors of Case Management Services delivered to Children with Chronic Medical Conditions must be one of the following: 1. Licensed Physician; 2. Licensed Physician Assistant; 3. Advanced Practice Registered Nurse; 4. Psychiatric Nurse or Registered Nurse; 5. Licensed Clinical Professional Counselor (LCPC) 6. Licensed Clinical Social Worker (LCSW); or 7. Individuals who meet the criteria in 13.08-1(A)(4). D. Supervisors of Case Management Services delivered to Members in Carceral Settings must be one (1) of the following: Licensed Physician; Licensed Physician Assistant; Advanced Practice Registered Nurse; Psychiatric Nurse or Registered Nurse; Licensed Psychologist; Licensed Clinical Social Worker (LCSW); Licensed Clinical Professional Counselor (LCPC); Licensed Marriage and Family Therapist (LMFT); Licensed Master of Social Work (LMSW); or Individuals who meet the criteria in 13.08-1(A)(4). E. Supervisors of Case Management Services delivered to Adults with Developmental Disabilities must have at least four (4) years of experience with intellectual disabilities or autism spectrum disorder and be one of the following: Licensed Psychologist; Licensed Clinical Social Worker (LCSW); Licensed Clinical Professional Counselor (LCPC); Licensed Marriage and Family Therapist (LMFT); Licensed Master of Social Work (LMSW); Advanced Practice Registered Nurse; Psychiatric Nurse; Registered Nurse; or Individuals who meet the criteria in 13.08-1(A)(4). F. Supervisors of Case Management Services delivered to Adults with Substance Use Disorders must be one of the following: Licensed Physician; Licensed Psychologist; Licensed Clinical Social Worker (LCSW); Licensed Clinical Professional Counselor (LCPC); Licensed Marriage and Family Therapist (LMFT); Licensed Master of Social Work (LMSW); Licensed Alcohol and Drug Counselors (LADCs); Advanced Practice Registered Nurse; Psychiatric Nurse; or Individuals who meet the criteria in 13.08-1(A)(4). Supervisors of Case Management Services delivered to Adults with HIV must be one (1) of the following: Licensed Physician; Licensed Physician Assistant; Advanced Practice Registered Nurse; Psychiatric Nurse or Registered Nurse; Licensed Clinical Professional Counselor (LCPC) Licensed Clinical Social Worker (LCSW); Licensed Master of Social Work (LMSW); or Individuals who meet the criteria in 13.08-1(A)(4). H. Supervisors of Case Management Services delivered to Members Experiencing Homelessness must be one (1) of the following: Licensed Physician or Physician Assistant; Licensed Psychologist; Licensed Clinical Social Worker (LCSW); Licensed Clinical Professional Counselor (LCPC); Licensed Marriage and Family Therapist (LMFT); Licensed Master of Social Work (LMSW); Advanced Practice Registered Nurse; Psychiatric Nurse or Registered Nurse; or Individuals who meet the criteria in 13.08-1(A)(4). 13.09 DOCUMENTATION REQUIREMENTS The provider must complete and maintain documentation in accordance with the requirements set forth below: A. Content of Member Case Record The Case Management Agency must maintain a specific record for each Member, which must include but is not limited to: 1. Written progress notes and status reports, including dates of service; 2. For all records, including progress notes and status reports, the Case Manager’s signature and credential, as well as the date completed; 3. Relevant assessment and evaluation reports and correspondence from and to other providers; 4. Release of information authorizations as necessary, signed by the Member, or when necessary and as required by law, by a parent, guardian, or other individual permitted by law; and 5. Reviews of the ISP, which will include any applicable meeting notes, a reviewed/revised ISP with applicable signatures, and a signature sheet of all meeting attendees. B. Record Entries Providers must complete written or electronic entries in the Member record or electronic medical record for each Case Management Service provided. Any release of medical records containing information on HIV infection status shall be in compliance with 5 M.R.S.A. §19201 et seq. and other applicable state and federal law and regulation. Providers must complete all entries within seven (7) calendar days of the date of service delivery, and must include: 1. The dates of the Case Management Services; 2. The name of the provider agency (if relevant), the name of the Case Manager providing the Case Management Service, and the location of service delivery; 3. The nature, content, and units of the Case Management Services delivered, progress toward goals specified in the ISP, and/or if the goals have been achieved or modified; 4. Whether the Member declined services in the ISP; 5. A timeline for obtaining needed services; 6. A timeline for re-evaluation of the ISP; and 7. The Case Manager’s signature and credential. 13.10 REIMBURSEMENT 13.10-1 Reimbursement Methodology* Specific reimbursement rates are listed on the MaineCare Provider Fee Schedule, which is posted on the Department’s website in accordance with 22 MRSA Section 3173-J(7), at https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx Providers of services reimbursed on a quarter hour basis under this Section will be reimbursed for any substantive contact at a minimum of fifteen (15) minutes. Providers are subject to the rounding requirements in Chapter I, Section 1, of the MaineCare Benefits Manual. The table below includes the codes, modifiers, and unit of service for each covered service as of the effective date of this Section. Current codes, modifiers, and units of services can be found on the fee schedule linked above. Covered Service Code Modifier Unit Case Management Services for Adults with HIV T1017 15 Minutes Case Management Services for Children with Developmental Disabilities T1017 UD 15 Minutes Case Management Services for Children with Behavioral Health Disorders T1017 UC 15 Minutes Case Management Services for Children with Chronic Medical Care Needs T1017 UB 15 Minutes Case Management Services for Adults with Substance Use Disorders T1017 HF 15 Minutes Case Management Services for Members Experiencing Homelessness T1017 U5 15 Minutes Case Management Services for Members in Carceral Settings G9012 15 Minutes Case Management Services for Adults with Developmental Disabilities G9012 HI 15 Minutes *The Department is seeking and anticipates approval from the Centers for Medicare & Medicaid Services of a State Plan Amendment related to this provision. 13.10-2 Cost of Living Adjustment* Each January 1st the Department will apply an annual cost of living adjustment proportional to the percentage increase in the Maine minimum wage, as determined by the Maine Department of Labor, to all Section 13 services which did not receive a rate adjustment within the previous twelve (12) months. The Maine Department of Labor determines the percentage increase, if any, as of August of the previous year over the level as of August of the year preceding that year in the Consumer Price Index for Urban Wage Earners and Clerical Workers (CPI-W) for the Northeast Region, or its successor index, as published by the United States Department of Labor, Bureau of Labor Statistics, or its successor agency, with the amount of the minimum wage increase rounded to the nearest multiple of 5¢. These COLAs will satisfy 22 M.R.S. § 3173-J and will also satisfy the requirements set forth in 22 M.R.S § 7402(1). *The Department is seeking and anticipates approval from the Centers for Medicare & Medicaid Services of a State Plan Amendment related to this provision. 13.11 BILLING Provider billing documentation must demonstrate that only one (1) Case Manager's time is billed for any specific activity provided to the Member. Costs included in the reimbursement methodology set forth in Section 13.10-1, such as relevant expenses for administrative and program support, are not separately reimbursed. Billing must be accomplished in accordance with the Department's billing instructions (https://mainecare.maine.gov/Billing%20Instructions/Forms/Publication.aspx). STATUTORY AUTHORITY: 22 M.R.S. Sections 42, 3173 ESTABLISHED: April 29, 1988 RULEMAKING HISTORY: Routine Technical Rule: March 20, 2014, Filing 2014-041 Emergency Rule: January 30, 2026, Filing 2026-030 Routine Technical Rule: April 28, 2026 APAO ACCESSIBILITY CHECK (Word): April 28, 2026 REPEALED AND REPLACED: April 28, 2026 – Filing 2026-093