This Maine Medicaid (MaineCare) rule governs covered behavioral health services under Section 65, establishing definitions, provider qualifications, eligibility, covered services, limitations, billing, and reimbursement requirements. Covered services include outpatient therapy, intensive outpatient programs (IOP), opioid treatment program (OTP) services with methadone, children's day treatment, crisis resolution, and other mental health and substance use services. Providers—including independent practitioners, mental health agencies, and substance use agencies—must meet specified licensing, credentialing, and supervision requirements. The rule applies to both adult and children/adolescent members with mental health, substance use, or co-occurring diagnoses.
View official sourceTABLE OF CONTENTS PAGE 65.01 DEFINITIONS 1 65.01-1 American Society of Addiction Medicine Criteria (ASAM) 1 65.01-2 Affected Other 1 65.01-3 Authorized Entity 1 65.01-4 Best Practices 1 65.01-5 Central Enrollment 1 65.01-6 Certified Clinical Supervisor (CCS) 1 65.01-7 Certified Intentional Peer Support Specialist (CIPSS) 1 65.01-8 Child or Children 1 65.01-9 Child and Adolescent Functional Assessment Scale (CAFAS) 1 65.01-10 Clinician 2 65.01-11 Community Inclusion 2 65.01-12 Comprehensive Assessment 2 65.01-13 Continuing Education Units (CEU) 2 65.01-14 Co-occurring Capable 2 65.01-15 Co-occurring Disorders 2 65.01-16 Co-occurring Services 2 65.01-17 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC-05) 3 65.01-18 Diagnostic and Statistical Manual of Mental Health Disorders (DSM) 3 65.01-19 Evidence-Based Practices 3 65.01-20 Family 3 65.01-21 Functional Behavior Assessment (FBA) 3 65.01-22 Imminent Risk 4 65.01-23 Individualized Treatment Plan (ITP) 4 65.01-24 Kinship Care 4 65.01-25 Level of Care/Service Intensity Tool 4 65.01-26 Medically Necessary Services 4 65.01-27 MHRT/C 4 65.01-28 NTA/Psychometrician 4 65.01-29 Natural Supports 4 65.01-30 Opioid Treatment Program (OTP) Services with Methadone 4 65.01-31 Parent or Guardian 5 65.01-32 Parental Participation 5 65.01-33 Permanency 5 65.01-34 Positive Behavior Support Plan (PBSP) 5 65.01-35 Practice Methods 5 65.01-36 Preschool and Early Childhood Functional Assessment Scale (PECFAS) 5 65.01-37 Prior Authorization 5 65.01-38 Promising and Acceptable Treatment 5 65.01-39 Serious Emotional Disturbance (SED) 6 65.01-40 Serious Mental Illness 6 65.01-41 Strengths-Based Approach 7 65.01-42 Substance Use Qualified Staff 7 65.01-43 Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) 7 65.01-44 Trauma Informed Care 7 65.01-45 Utilization Review 8 65.01-46 V-9 Extended Care or Status 8 65.02 PROVIDER QUALIFICATIONS 9 65.02-1 Independent Practitioner 9 65.02-2 Mental Health Agencies 9 65.02-3 Substance Use Agencies 9 65.02-4 School 9 65.03 ELIGIBILITY 10 65.04 DURATION OF CARE 10 65.05 COVERED SERVICES 10 65.05-1 Crisis Resolution 10 65.05-2 Outpatient Services 11 65.05-3 Family Psychoeducational Treatment 13 65.05-4 Intensive Outpatient Program Services (IOP) 13 65.05-5 Medication Management Services 18 65.05-6 Neurobehavioral Status Exam, Psychological Testing, and Adaptive Assessments 19 65.05-7 Children’s Assertive Community Treatment 20 65.05-8 Children’s Home and Community Based Treatment 24 65.05-9 Multisystemic Therapy 31 65.05-10 Functional Family Therapy 32 65.05-11 Opioid Treatment Program (OTP) Services with Methadone 33 65.05-12 Interpreter Services 36 65.05-13 Children’s Behavioral Health Day Treatment 36 65.05-14 Tobacco Cessation Treatment Services 38 65.05-15 Mental Health Psychosocial Clubhouse Services 38 65.05-16 Specialized Group Services 41 65.05-17 Behavioral Therapies 42 65.06 NON-COVERED SERVICES 48 65.06-1 Homemaking or Individual Convenience Services 49 65.06-2 Transportation Costs for Providers 49 65.06-3 Case Management Services 49 65.06-4 Adult Community Support/Adult Day Treatment Services 49 65.06-5 Financial Services 49 65.06-6 Driver Education and Evaluation Program (DEEP) Evaluations 49 65.06-7 Comparable or Duplicative Services 49 65.07 LIMITATIONS 50 65.07-1 Services in the Individualized Treatment Plan (ITP) 50 65.07-2 Prior Authorization and Utilization Review 50 65.07-3 Crisis Resolution 51 65.07-4 Outpatient Services 51 65.07-5 Intensive Outpatient Program Services (IOP) 55 65.07-6 Medication Management Services 55 65.07-7 Psychological Testing and Adaptive Assessments 55 65.08 POLICIES AND PROCEDURES 56 65.08-1 Supervision of Direct Care Staff 56 65.08-2 Behavioral Health Professional Certification 57 65.08-3 Direct Support Professional (DSP) 57 65.08-4 Member Records 58 65.08-5 Program Integrity (PI) Unit 64 65.08-6 Protections for Adults with Serious Mental Illness 64 65.08-7 Background Check Requirements 64 65.08-8 Additional Requirements for Providers of Children’s Services 65 65.08-9 Quality Assurance Review Requirements 66 65.09 APPEALS 66 65.10 REIMBURSEMENT 66 65.10-1 Cost-of-Living Adjustment 70 65.10-2 Pay-for-Performance for HCT 70 65.10-3 Services for Members Who are Deaf or are Hard of Hearing 72 65.11 BILLING INSTRUCTIONS 72 65.12 APPENDIX I 73 65.13 APPENDIX II 76 65.01 DEFINITIONS Definitions for the purposes of Section 65 are as follows: 65.01-1 American Society of Addiction Medicine Criteria (ASAM) is level of care criteria establishing what services are medically necessary for a member. 65.01-2 Affected Other is an individual with a demonstrated Family relationship with a member whose substance use has led to clinically significant impairment or distress for the individual. In order for an Affected Other to participate in Family therapy, there must be a family relationship with a MaineCare eligible member. Affected Others seeking individual therapy must have MaineCare coverage themselves. 65.01-3 Authorized Entity is an organization authorized by the Department of Health and Human Services (Department or DHHS) to perform specified functions pursuant to a signed contract or other approved signed agreement. 65.01-4 Best Practices are treatment techniques, procedures and protocols described in detail where the effectiveness of these practices has been established through consensus among experts in the field. Key portions of these practices have been documented in research studies to be effective in selected treatment settings. 65.01-5 Central Enrollment is a process of determining baseline eligibility for behavioral health treatment. 65.01-6 Certified Clinical Supervisor (CCS) is a Clinician who is credentialed by the Maine State Board of Alcohol and Drug Counselors, 02-384 C.M.R. ch. 6, and must conduct supervision as defined in the regulations for Licensing/Certifying of Substance Use Disorder Treatment Programs or Integrated Mental Health and Substance Use Disorder Treatment Programs, 10-144 C.M.R. ch. 123, in the State of Maine. 65.01-7 Certified Intentional Peer Support Specialist (CIPSS) means an individual who has completed the DHHS Office of Behavioral Health (OBH) curriculum for CIPSS and receives and maintains certification. 65.01-8 Child or Children means a person or people between the ages of birth through twenty (20) years of age. Children aged eighteen (18) through twenty (20) years of age and Children who are emancipated minors may choose to receive children’s mental health services or adult mental health services, both of which are covered under this Section, whichever best meets their individual needs. 65.01-9 Child and Adolescent Functional Assessment Scale (CAFAS) is a multi-dimensional rating scale, which assesses a member’s degree of impairment in day-to-day functioning due to emotional, behavioral, psychological, psychiatric, or substance use problems. 65.01-10 Clinician is an individual appropriately licensed or certified in the state or province in which he or she practices, 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 (MD or DO); 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. 65.01-11 Community Inclusion means the participation of a member in typical community activities that are both age and developmentally appropriate and are identified in the Individualized Treatment Plan (ITP). 65.01-12 Comprehensive Assessment is an integrated evaluation by the service provider of the member's medical and psycho-social needs, including co-occurring mental health and substance use needs to determine the need for treatment and/or referral, and to establish the appropriate intensity and level of care. 65.01-13 Continuing Education Unit (CEU) is a measure used in continuing education programs, particularly those required in a licensed profession. The Maine Department of Education (DOE) recognizes CEUs as approved continuing education credits that teachers, education technicians and others can apply to licensure or certification requirements. DOE recognizes 4.5 CEUs as equal to 3 semester hours. 65.01-14 Co-occurring Capable Providers are organized to welcome, identify, engage, and serve members with co-occurring mental health and substance use disorders, and to incorporate attention to these issues in all aspects of Co-occurring Services including linkage with other providers, staff competency and training. Clinicians must practice within the scope of their individual license(s) and follow all applicable mental health and substance use regulations in regard to member records including, but not limited to Comprehensive Assessments, ITP and progress notes. 65.01-15 Co-occurring Disorders are any combination of a mental health and substance use disorder diagnosis. 65.01-16 Co-occurring Services are integrated services provided to a member who has both a mental health and a substance use disorder diagnosis. This includes persistent disorders of either type in remission; a substance related or induced mental health disorder and a diagnosable disorder that co-occurs with interacting symptoms of the other disorder. When mental health and substance use disorder diagnoses occur together, each is considered primary and is assessed, described and treated concurrently. Co-occurring Services consist of a range of integrated, appropriately matched interventions that may include Comprehensive Assessment, treatment and relapse prevention strategies that may be combined, when possible within the context of a single treatment relationship. Co-occurring Services also include addressing Family therapy or counseling issues involving mental health, substance use or other disorders where MaineCare services cover Family therapy or counseling. -12573002038350065.01-17 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (also known as DC 0-5), is the current version published by Zero To Three National Center for Infants, Toddlers and Families. The publication formulates categories for the classification of mental health and development disorders manifested early in life. 65.01-18 Diagnostic and Statistical Manual of Mental Health Disorders (DSM) is the current version published by the American Psychiatric Association. The manual is used to classify mental health diagnoses and provide standard categories for definition of mental health disorders. 65.01-19 Evidence-Based Practices (Practices Based on Scientific Evidence) are prevention or treatment practices that are based on consistent scientific evidence demonstrating that the treatment improves member outcomes. Elements of the practice are standardized, replicable and effective within a given setting and for particular populations and diagnosis or behavior. The practice is sufficiently documented through research to permit the assessment of fidelity to the model. As a result, the degree of successful implementation of the service can be measured by the use of a standardized fidelity tool that operationally defines the essential elements of practice. There must be no clinical or empirical evidence or theoretical basis indicating that the treatment constitutes a substantial risk of harm to those receiving the treatment, compared to its likely benefits. 65.01-20 Family, unless otherwise defined in this Section, means the primary caregiver(s) in a member's daily life (which may include a biological or adoptive Parent, foster Parent, legal guardian or designee), a spouse or significant other, biological or adoptive Child, foster Child, stepchild, significant other’s Child, sibling, stepparent, stepbrother or stepsister, brother-in-law, sister-in-law, grandparent, spouse of grandparent or grandchild, a person who provides Kinship Care, or any person sharing a common abode as part of a single-Family unit. 65.01-21 Functional Behavior Assessment (FBA) is a process of gathering information from multiple sources to hypothesize and understand what reliably predicts and maintains a problem behavior. The FBA evaluates behavior to analyze the antecedent and consequence as a reinforcement of a problem behavior. Behaviors are defined in measurable terms. The FBA uses a validated assessment which may also include interview, direct and/or indirect observation in the member’s natural environment, functional analysis, preference assessment, assessment of reinforcement effectiveness, data collection, and reporting. The FBA will be used for the purpose of developing individualized Positive Behavior Support Plans for members receiving Developmental Disability and Behavioral Health Intensive Outpatient Program (DD/BH-IOP) Services. 65.01-22 Imminent Risk is the immediate risk of a Child’s removal from the home and/or community due to the specific circumstances as described in Children’s Home and Community Based Treatment. 65.01-23 Individualized Treatment Plan (ITP) is a plan of treatment based on a Comprehensive Assessment developed by a Clinician. 65.01-24 Kinship Care is the full-time care, nurturing, and protection of members by relatives, members of their tribes or clans, godparents, stepparents, or any adult who has a kinship bond with a Child. 65.01-25 Level of Care/Service Intensity Tool is an assessment and placement instrument which evaluates the intensity of service needs and guides level of care placement decisions. The appropriate tool depends on the member’s age. The age-appropriate Level of Care/Service Intensity tool is the Early Childhood Service Intensity Instrument (ECSII) for ages zero (0) to five (5), the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII) for ages six (6) to eighteen (18), and the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) for ages eighteen (18) to twenty-one (21). 65.01-26 Medically Necessary Services are services provided as described in Section 65.05 Covered Services and as defined in Chapter I, Section 1 of the MaineCare Benefits Manual. 65.01-27 MHRT/C means an individual who has received Mental Health Rehabilitation Technician/Community certification from DHHS. 65.01-28 NTA/Psychometrician is a Neurobehavioral Testing Assistant/Psychometrician. Psychometrics is the field of study concerned with the theory and technique of psychological measurement, which includes the measurement of knowledge, abilities, attitudes, personality traits, and education. 65.01-29 Natural Supports include the relatives, friends, neighbors, and community resources that a member or Family goes to for support. They may participate in the treatment team but MaineCare does not reimburse Natural Supports for their time spent participating in services as part of a treatment team. 65.01-30 Opioid Treatment Program (OTP) Services with Methadone are services provided by a program or practitioner engaged in opioid use disorder treatment of individuals that include the dispensing of an opioid agonist treatment medication (i.e., methadone), along with a comprehensive range of medical and rehabilitative services, when clinically necessary, to an individual to treat the adverse medical, psychological, or physical effects related to opiate addiction. Compliance with Federal and State laws and regulations that govern treatment, including, but not limited to, DHHS, OBH, the Center for Substance Abuse Treatment (Division of the Substance Abuse and Mental Health Services Administration), the US Drug Enforcement Agency, the US Food and Drug Administration, and the State Pharmacy Board is required in the provision of services. 65.01-31 Parent or Guardian may be the biological, adoptive, or foster Parent or the legal guardian. They may participate in the treatment team but MaineCare does not reimburse Parents and Guardians for their time spent participating in services as part of a treatment team. 65.01-32 Parental Participation means that the Parent or caregiver is involved in the treatment team; participates in the assessment process; and helps develop the ITP for the purpose of the design, delivery, and evaluation of treatment specific to the member’s mental health needs. The Parent or caregiver participates in treatment and models and reinforces skills learned. 65.01-33 Permanency means that a member lives in a planned living arrangement either with a Parent or other caregiver and can return to the Parent or caregiver from a stay in a hospital, a residential treatment or correctional facility. 65.01-34 Positive Behavior Support Plan (PBSP) includes individualized, strengths-based strategies based on positive reinforcement techniques that are designed to increase a member’s use of prosocial and positive behaviors and decrease negative or detrimental behaviors. The PBSP summarizes the findings of the FBA and is used for the purpose of developing individualized strategies for members receiving DD/BH IOP Services. 65.01-35 Practice Methods shall mean treatment techniques, procedures, therapeutic modalities, and protocols. For example, a practice method is Dialectical Behavior Therapy or Cognitive Behavioral Therapy. 65.01-36 Preschool and Early Childhood Functional Assessment Scale (PECFAS) is a multi-dimensional rating scale that assesses the psychosocial functioning of members aged three (3) to seven (7) years. 65.01-37 Prior Authorization (PA) is the process of obtaining prior approval as to the medical necessity and eligibility for a service. 65.01-38 Promising and Acceptable Treatment is defined as treatment that has a sound theoretical basis in generally accepted psychological principles. There must be substantial clinical literature to indicate the value of the treatment with members who experience the diagnostic problems and behaviors for which this treatment is needed. The treatment is generally accepted in clinical practice as appropriate for use with members who experience these diagnostic problems and behaviors. There must be no clinical or empirical evidence or theoretical basis indicating that the treatment constitutes a substantial risk of harm to those receiving it, compared to its likely benefits. The treatment must have a book, manual, or other available writing that specifies the components of the treatment protocol and describes how to administer it. An individual, who has been certified in the provision of the Promising and Acceptable treatment, if such certification exists, must provide services. The existence of a certification standard for a treatment does not, by itself, indicate that the treatment meets the standard for a Promising and Acceptable treatment. 65.01-39 Serious Emotional Disturbance (SED) is when a member has a mental, emotional or behavioral health diagnosis within the past year in accordance with the current version of the DSM or DC 0-5, and which has resulted in functional impairment that substantially interferes with or limits the member’s role or functioning in family, school, or community activities. Members with SED may be at risk for more restrictive placement, including but not limited to psychiatric hospitalization, as a result of this condition for which other less intensive levels of service have not been effective (e.g. traditional outpatient services). 65.01-40 Serious Mental Illness is when a person who is age eighteen (18) or older, or who is an emancipated minor has: A. A primary diagnosis of Schizophrenia or Schizoaffective disorder in accordance with the current version of the DSM; or B. Another primary mental health diagnosis in accordance with the current version of the DSM, with the exception of Neurocognitive Disorders, Neurodevelopmental Disorders, Antisocial Personality Disorder and Substance Use Disorders, who: 1. has a written opinion from a Clinician, based on documented or reported history, stating that he/she is likely to have future episodes, related to mental illness, with a non-excluded DSM diagnosis, that would result in or have significant risk factors of homelessness, criminal justice involvement or require a mental health inpatient treatment greater than seventy-two (72) hours, or residential treatment unless community support services and/or evidence based outpatient treatment is provided; based on documented or reported history (an oral or written history obtained from the member, a provider, or a caregiver); or 2. has received treatment in a state psychiatric hospital, within the past 24 months, for a non-excluded DSM diagnosis; or 3. has been discharged from a mental health residential facility, within the past 24 months, for a non-excluded DSM diagnosis; or 4. has had two or more episodes of inpatient treatment for mental illness, for greater than seventy-two (72) hours per episode, within the past twenty-four (24) months, for a non-excluded DSM diagnosis; or 5. has been committed by a civil court for psychiatric treatment as an adult; or 6. until the age of twenty-one (21), was eligible as a Child with SED, and has a written opinion from a Clinician, in the last twelve (12) months, stating that he/she has risk factors for mental health inpatient treatment or residential treatment, unless ongoing case management or community support services are provided; AND C. A significant impairment or limitation in adaptive behavior or in functioning directly related to the primary diagnosis as assessed by the Level of Care Utilization System (LOCUS, as defined in Chapter II, Section 17 of the MaineCare Benefits Manual), or by other acceptable standardized assessment tool adopted by the Department through rulemaking which is administered at least annually. If using the LOCUS, the member must have a LOCUS score, as determined by a LOCUS Certified Assessor, of Level 3 or greater. 65.01-41 Strengths-Based Approach is defined as a way to assess, plan, and deliver treatment incorporating the identified strengths and capabilities of the member and Family. 65.01-42 Substance Use Qualified Staff in order to provide substance use outpatient therapy, staff must be a LADC, a CADC, or a MD or DO, a Licensed Clinical Psychologist, a LCSW, a LMSW-CC, a LCPC, a LCPC-C, a LMFT, a LMFT-C, a Registered Professional Nurse certified as a Psychiatric Nurse, or an Advanced Practice Psychiatric and Mental Health Registered Nurse (APRN), who meet the education and experience requirements set forth in the regulations for the licensing of Substance Use Disorder Treatment Programs or Integrated Mental Health and Substance Use Disorder Treatment Programs under Section 23 and 24, respectively, in 10-144 C.M.R. ch. 123. All services must be provided under the direction of a MD or DO, APRN, or Psychologist and supervised by a Certified Clinical Supervisor (CCS). 65.01-43 Trauma Focused Cognitive Behavioral Therapy (TF-CBT) is a modality of outpatient therapy. TF-CBT is a targeted psychotherapeutic approach that helps address the negative effects of traumatic stress. TF-CBT is a structured therapy model that incorporates psychoeducation, affect regulation techniques, cognitive-behavioral techniques, coping skill development, reprocessing of traumatic memories, and Family therapy. TF-CBT incorporates the opportunity for conjoint therapy with Parents/caregivers and the Child, in which Parents/caregivers can learn about the impact of trauma on children, learn how to support positive coping and affect regulation skills in their Child, develop effective communication with their Child, support the Child in processing traumatic memories, and enhance the Child’s sense of safety. 65.01-44 Trauma Informed Care is the provision of behavioral health services that include: An understanding of psychological trauma, symptoms, feelings and responses associated with trauma and traumatizing relationships, and the development over time of the perception of psychological trauma as a potential cause and/or complicating factor in medical or psychiatric illnesses. Familiarity with current research on the prevalence of psychological (childhood and adult) trauma in the lives of members with serious mental health and substance use disorders and possible sequelae of trauma (e.g., post-traumatic stress disorder (PTSD), depression, generalized anxiety, self-injury, substance use, flashbacks, dissociation, eating disorder, revictimization, physical illness, suicide, aggression toward others). Providing physical and emotional safety; maximizing member choice and control; maintaining clarity of tasks and boundaries; ensuring collaboration in the sharing of power; maximizing empowerment and skill building. Consideration of all members as potentially having a trauma history, understanding as to how such members can experience re-traumatization and ability to interact with members in ways that avoid re-traumatization. An ability to maintain personal and professional boundaries in ways that are informed and sensitive to the unique needs of a member with a history of trauma. An understanding of unusual or difficult behaviors as potential attempts to cope with trauma and respect for member’s coping attempts and avoiding a rush to negative judgments. 65.01-45 Utilization Review is a formal assessment of the medical necessity, efficiency and appropriateness of services and ITPs on a prospective, concurrent or retrospective basis. The provider is required to notify DHHS or an Authorized Entity upon initiation of all services provided under Section 65 in order for the Authorized Entity to begin Utilization Review. 65.01-46 V-9 Extended Care or Status is a written agreement for continued care allowing a member eighteen (18) through twenty (20) years of age to continue to be under the care and custody of DHHS. Normally, a member who reaches the age of eighteen (18) is automatically dismissed from custody and achieves full adult rights and responsibilities. The member may negotiate a written agreement with DHHS, Office of Child and Family Services for the following reasons: A. To obtain a high school diploma or general equivalency diploma, or obtain post-secondary educational or specialized post-secondary education certification; B. To participate in an employment skills support service; C. To access mental health or other counseling support, including Co-occurring Services; D. To meet specialized placement needs; E. The member is pregnant and needs parenting support; or F. The member has medical and special health conditions or needs. G. No member in care may be accepted for continuing services after his or her eighteenth (18th) birthday unless an “Application and Agreement of Responsibility for Continued Care” (V-9) has been signed by both the member and the member’s caseworker prior to the member’s eighteenth (18th) birthday. Most members having this status must participate in full time secondary or post-secondary education approved by the DHHS caseworker and that caseworker’s supervisor. 65.02 PROVIDER QUALIFICATIONS The following providers are qualified to provide Behavioral Health Services. 65.02-1 Independent Practitioner is a Licensed Psychologist, Psychological Examiner, LCPC, LCSW or LMFT who practices independently, has a Provider Agreement with DHHS, is Co-occurring Capable, knowledgeable in Trauma Informed Care, practices within the scope of his or her licensure and adheres to all state and federal rules and regulations concerning confidentiality and the Americans with Disabilities Act. 65.02-2 Mental Health Agencies are providers licensed by the Division of Licensing and Certification pursuant to 34-B M.R.S.A. §1203-A and enrolled as MaineCare Providers to operate mental health programs in accordance with 10-144 C.M.R. ch. 123, Behavioral Health Organizations Licensing Rule. Agencies must adhere to the Rights of Recipients of Mental Health Services (14-193 C.M.R. ch. 1) and the Rights of Recipients of Mental Health Services Who are Children in Need of Treatment (14-472 C.M.R. ch. 1). Providers must maintain all appropriate Licensing and Credentialing and must notify DHHS, including the Office of MaineCare Services, OCFS and/or OBH of any changes in Licensing or Credentialing status. Only Mental Health Agencies that have a contract for specific covered services may provide covered mental health services for members in the care or custody of DHHS, Office of Child and Family Services. Those agencies licensed by DHHS as an ambulatory health care unit, allied health care facility, or as a residential childcare facility must also have a mental health agency license to be reimbursable under this Section. 65.02-3 Substance Use Agencies are providers who are licensed by the Division of Licensing and Certification and are enrolled as MaineCare providers to operate substance use disorder treatment programs in accordance with 10-144 C.M.R. ch. 123, Behavioral Health Organizations Licensing Rule. Providers must maintain all appropriate Licensing and Credentialing and must notify DHHS, including the Office of MaineCare Services and OBH of any changes in Licensing or Credentialing status. 65.02-4 School is a program that has been approved by the DOE, as either a Special Purpose Private School or a Regular Education Public School Program under 05-071 C.M.R., ch. 101, §XII and 20-A M.R.S.A. §7204 (4), 7252-A and 7253, or a program operated or contracted by the Child Development Services System 20-A M.R.S.A. §7001(1-A) that has enrolled as a provider and entered into a provider agreement, as required by MaineCare. For the purposes of this rule, a school may provide the following services: A. Neurobehavioral Status Exam, Neuropsychological Testing and Psychological Testing, as described in 65.05-6; B. Children’s Behavioral Health Day Treatment, as described in 65.05-13; C. Outpatient Services, as described in 65.05-1; and D. Behavioral Therapies, as described in 65.05-17. All services must be provided by qualified staff, as described in the corresponding sections of this policy. Additional provider qualifications requirements are stated in the descriptions of services in Section 65.05. 65.03 ELIGIBILITY Individuals 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 to verify a member’s eligibility for MaineCare, as described in MaineCare Benefits Manual, Chapter I, Section 1, prior to providing services. Additional specific eligibility criteria are set forth for each service. 65.04 DURATION OF CARE Each eligible Member may receive covered services that are medically necessary within the limitations of this section. DHHS reserves the right to request additional information to evaluate medical necessity and review utilization of services. DHHS requires PA for some services reimbursed under this section. DHHS may require Utilization Review for all services reimbursed under this section. 65.05 COVERED SERVICES 65.05-1 Crisis Resolution Services* This service will only be provided under Section 65 through June 30, 2026. This provision will not be legally effective after June 30, 2026. Effective July 1, 2026, MaineCare will cover this service under Section 66 (Crisis Services), and the service will be known as “Site-Based Crisis Stabilization Services”. Services are immediate crisis-oriented services provided to a member with a serious problem of disturbed thought, behavior, mood or social relationships, and/or crises originating from problems associated with an intellectual disability, autism, or other related condition. Services are oriented toward the amelioration and stabilization of these acute emotional disturbances to ensure the safety of a member or society and can be provided in an office or on scene. "On scene" can mean a variety of locations including member homes, school, street, emergency shelter, and emergency rooms. Services include all components of screening, assessment, evaluation, intervention, and disposition commonly considered appropriate to the provision of emergency and crisis mental health care, to include co-occurring mental health and substance use conditions. Crisis Resolution Services are individualized therapeutic intervention services available on a twenty-four (24) hour, seven (7) day a week basis and provided to eligible members by providers that have a contract with DHHS to provide these services. Covered services include direct telephone contacts with both the member and the member’s Parent or Guardian or adult’s member’s guardian when at least one face-to-face contact is made with the member within seven (7) days prior to the first contact related to the crisis resolution service. The substance of the telephone contact(s) must be such that the member is the focus of the service, and the need for communication with the Parent or Guardian without the member present must be documented in the member’s record. Staff providing Crisis Services include Clinicians, Mental Health Rehabilitation Technicians (MHRT), Behavioral Health Professionals (BHP), or Direct Support Professionals (DSP) with certification at the level appropriate for the services being delivered and for the population being served. Supervisors of MHRT, BHP, and DSP staff must be Clinicians, within the scope of their licensure. To provide Children’s Crisis Resolution Services as a BHP, the employee must meet the education requirement and complete the required BHP training within the prescribed time frames, as described in 65.05-9(D) and 65.05-9(E). A treatment episode includes face-to-face visits and related follow up phone calls, as clinically indicated, up to a sixty (60) day period after the first face-to-face visit. 65.05-2 Outpatient Services -1371600240030 00 Outpatient Services are professional assessment, counseling and therapeutic Medically Necessary Services provided to members, to improve functioning, address symptoms, relieve excess stress and promote positive orientation and growth that facilitate increased integrated and independent levels of functioning. Services are delivered through planned interaction involving the use of physiological, psychological, and sociological concepts, techniques and processes of evaluation and intervention. To receive Outpatient Services, Children members must have a SED or a mental health, substance use, or co-occurring mental health and substance use diagnosis in accordance with the DSM or DC 0-5. Adult members must have a diagnosis from the DSM. To receive Outpatient Services for substance use disorders or co-occurring mental health and substance use disorders, members must meet ASAM Level 0.5 or Level 1 placement criteria. Services include a Comprehensive Assessment as described in 65.08-4(A), diagnosis, including co-occurring mental health and substance use disorder diagnoses, individual, Family and group therapy, and may include Affected Others and similar professional therapeutic services as part of an integrated ITP. DHHS may reimburse providers for an Outpatient Diagnostic Assessment as described in 65.07-4(C) to determine eligibility for Outpatient Services. Services must focus on the developmental, emotional needs and problems of members and their Families, as identified in the ITP. These services may be delivered during a regularly scheduled appointment or on an emergency after hours basis in an office or community-based setting, such as a member’s home, street, or emergency shelter. Providers traveling to the Member to deliver Outpatient Services should bill with the appropriate “community” Outpatient Services code. Providers not traveling to the Member to deliver Outpatient Services should bill with the appropriate “office” Outpatient Services code. Coordination of treatment with all included parties (as appropriate to the outpatient role), including PCPs, or other medical practitioners, and state or other community agencies, must be well documented. Children’s Outpatient Services offer ways to improve or to stabilize the member’s Family living environment in order to minimize the necessity for out-of-home placement of the member, to assist Parents or Guardians and Family members to understand the effects of the member’s disabilities on the member’s growth and development and on the Family’s ability to function, and to assist Parents and Family members to positively affect the member's development. For Children’s Outpatient Services determination of the appropriate level of care shall be based on clinical assessment information obtained from the member and Family. If a Child receives Outpatient Services, providers may only deliver Outpatient Services to that Child’s Parents, Guardians, or Family without the Child present if they are clinically indicated and are identified in the Child’s ITP. These services may be provided by a Clinician or Substance Use Qualified Staff practicing within the scope of their licensure. Providers delivering Outpatient Therapy utilizing Trauma Focused Cognitive Behavioral Therapy (TF-CBT) must: A. Be a licensed or conditionally-licensed Psychologist, Psychiatrist, LCPC, LCPC-C), LCSW, LMSW-CC, LMFT, or LMFT-C who is knowledgeable in Trauma Informed Care, and practices within the scope of his or her licensure; B. Have current certification as a TF-CBT therapist from, and maintain recertification per the criteria and rules set forth by, the TF-CBT National Therapist Certification Program. Information on certification and recertification requirements can be found at tfcbt.org. The therapist must retain documentation of certification and recertification; and C. Participate with the Department in fidelity monitoring according to the Department-determined process. 65.05-3 Family Psychoeducational Treatment Family Psychoeducational Treatment is an Evidenced Based Practice provided to eligible members in multi-Family groups and single-Family sessions. Clinical elements include engagement sessions, psychoeducational workshops and on-going treatment sessions focused on solving problems that interfere with treatment and rehabilitation, including co-occurring mental health and substance use disorder diagnoses. Providers must have a contract to provide this service as described in 65.02-2. For children’s Family Psychoeducational Treatment Services determination of the appropriate level of care shall be based on the Child/Adolescent’s Level of Functional Assessment Score (CAFAS) or Preschool and Early Childhood Functional Assessment Scale (PECFAS), other tools approved by DHHS and clinical assessment information obtained from the member and Family. 65.05-4 Intensive Outpatient Program (IOP) Services Intensive Outpatient Program (IOP) Services are short-term, time-limited, intensive, multidisciplinary approaches designed to treat clinically significant issues in a structured environment. IOP Services shall be consistent with existing Evidence-Based Practices, Promising and Acceptable Treatment or Best Practice parameters in type, staffing, frequency, and duration. Where Evidence-Based Practices do not exist, the treatment shall be consistent with Promising and Acceptable Treatment or Best Practice treatment parameters. Members must receive PA from the Department or its Authorized Entity for IOP services. Length of stay and program intensity, including the number of hours of service per day, is based on the individual member’s treatment needs as determined by a Comprehensive Assessment and service intensity tools/level of care assessments the provider administers and documents in the member’s ITP. Service method, approach, frequency, and duration must be adequate to effectively treat the identified presenting problem(s). A. IOP Service and Staff Requirements 1. IOP qualified staff must deliver, at a minimum, three (3) hours per day, three (3) days per week of services to a member, except for Substance Use IOP Level II and Eating Disorder Level II which have more intensive time requirements below. Services must be performed under the direction of a Physician or Psychiatrist to assure the program design is adequate to meet the needs of the members served, and ensure appropriate supervision and medical review of the IOP covered services described in the following subtypes: a. Substance Use IOP (SU-IOP) Level I ii. Level II Mental Health IOP (MH-IOP) Developmental Disability and Behavioral Health IOP (DD/BH-IOP) Geriatric IOP (G-IOP) Dialectical Behavior Therapy IOP (DBT-IOP) Eating Disorder IOP (ED-IOP) i. Level I ii. Level II 2. IOP services must include, at a minimum: Intake and service assessment; ITP; Medical evaluation, as clinically indicated; Psychiatric services, including medication management, as clinically indicated; Weekly individual therapy; Daily group therapy; Daily group psychoeducation and skills training groups; Family therapy, support, and education, as clinically indicated; Ongoing assessment of clinical status and recovery needs; Care coordination, as needed; and Discharge, aftercare, and safety planning. 3. IOP qualified staff must have adequate training and/or experience specific to the treatment model utilized and population served. Providers who utilize Evidence-Based Practices shall have record of any training appropriate to the model delivered. IOP qualified staff include: Clinicians; and For DD/BH IOP only: Board-Certified Behavior Analysts (BCBA) IOP qualified staff may also include (when clinically indicated and practicing within the scope of licensure or certification): Licensed Social Workers (LSX, LSW) Mental Health Rehabilitation Technicians/Community (MHRT/C) BHP Direct Support Professionals (DSP) Board-Certified Assistant Behavior Analysts (BCaBA) Registered Behavior Technicians (RBT) Alcohol and Drug Counseling Aids (ADCA) Licensed Occupational Therapists Licensed Speech and Language Pathologists Certified Therapeutic Recreational Specialists Licensed Dieticians Peer Support Specialists (CIPSS or other certified peers as approved by the Department) B. Additional IOP Service and Staff Requirements for DD/BH, ED, DBT and SU-IOP Level II IOP Providers DD/BH, ED, and DBT IOP providers must additionally meet the following requirements as outlined below: 1. For DD/BH-IOP Services: Providers must utilize Applied Behavior Analysis (ABA) principles to include: a. A FBA, as part of the service assessment, and completed by a BCBA; b. A Positive Behavior Support Plan (PBSP) based on the FBA, that includes strategies and interventions designed to modify interfering behavior. The PBSP must be individualized, respectful, developmentally appropriate, focused on positive reinforcement of desired behavior, and designed to help the member master age and developmentally appropriate skills; and c. Family psychoeducation and behavioral training for Parents and/or caregivers. 2. For ED-IOP Services: Providers must utilize physician, nursing, and dietician services, as clinically indicated, to include: a. Assessment by a Clinician; and evaluation by a physician (MD/DO) as clinically indicated, as part of the service assessment; b. Routinely weighing the member, unless clinically indicated to the contrary. Providers may use open or blind weighing methods; and c. Determination of the severity of a member’s eating disorder symptoms and level of care treatment needs as follows: i. ED-IOP Level I: Medical intervention (if clinically indicated); and At least one (1) meal per program day completed with clinical support. ii. ED-IOP Level II: Medical intervention and stabilization required based on the severity of eating disorder symptoms; At least two (2) meals per program day completed with clinical support; and Deliver a minimum of six (6) hours per day of services, five (5) days per week, per member. 3. For DBT-IOP Services: Providers must utilize the DBT principles to include: a. Skills training groups provided weekly; b. Skills coaching available twenty-four (24) hours, seven (7) days per week; and c. Clinician and other qualified staff participation in weekly consultation by a professional who is DBT-trained and certified. 4. For SU-IOP Level II Services:* Providers must deliver a minimum of twenty (20) hours of services per member per week. Providers must deliver at least eleven (11) hours of service per week in-person. Providers may deliver the remaining hours of service via telehealth or in-person. Providers must not bill for more than five (5) days per week per member for SU-IOP Level II services. * The Department is seeking and anticipates approval from the Centers for Medicare and Medicaid Services of a State Plan Amendment related to this provision. C. IOP Member General Eligibility Criteria Members seeking IOP services must be: 1. Transitioning from a higher level of care (e.g., residential treatment or inpatient psychiatric hospitalization) to a lower level of care when discharge is imminent within thirty (30) days or less; OR 2. At risk of: a. Placement in a residential treatment setting, or b. Involvement in the criminal justice or juvenile justice system, or c. Inpatient psychiatric hospitalization, or d. Homelessness; AND 3. Present with a level of clinical acuity that cannot be safely and successfully treated in an outpatient level of care. Determination of clinical acuity shall include the use of clinically indicated service intensity tools/level of care assessments. 4. Except for SU-IOP Levels I and II, to receive IOP services Children must receive a score of Level 4 or higher on the age-appropriate Level of Care/Service Intensity tool completed by the Department or its Authorized Entity. D. Specific IOP Member Eligibility Criteria All diagnoses and disorders referred to below are as defined by the DSM. Substance Use IOP (SU-IOP): a. SU-IOP Level I is a program for Child and adult members who have a primary substance use disorder or a substance use disorder with a co-occurring mental health disorder and meet ASAM Level 2.1 placement criteria. Services may be delivered in-person or via telehealth. b. SU-IOP Level II is a program for Child and adult members who have a primary substance use disorder, or a substance use disorder with a co-occurring mental health disorder, and meet ASAM Level 2.5 placement criteria. To be eligible for SU-IOP Level II services, the member must need more active and inclusive treatment than is provided in an outpatient service, but not need full-time hospitalization or institutionalization. This program is delivered in person, though telehealth may be used to meet the minimum requirements as described in 65.05-4(B)(4). Mental Health IOP (MH-IOP) The MH-IOP is a program for Child and adult members who have a primary mental health disorder or a mental health disorder with a co-occurring substance use disorder and exhibit moderate to severe psychiatric symptoms. Services may be delivered in-person or via telehealth. Developmental Disability and Behavioral Health IOP (DD/BH-IOP) The DD/BH-IOP is a program for Child and adult members who have an Autism Spectrum Disorder (ASD) or an Intellectual Disability and exhibit functional limitations, verbal and/or physical aggression, self-injurious behaviors, severe emotional dysregulation, and other serious problem behaviors. Services must be delivered in-person. Geriatric IOP (G-IOP) The G-IOP is a program for members who have a primary mental health disorder or a co-occurring mental health and substance use disorder and exhibit moderate to severe psychiatric symptoms and have reached at least sixty-five (65) years of age. Services must be delivered in-person. Eating Disorder Intensive Outpatient Program (ED-IOP) The ED-IOP is a program for Child and adult members who have an Eating Disorder, to include Otherwise Specified Feeding or Eating Disorder and Unspecified Feeding or Eating Disorder, Avoidant/Restrictive Food Intake Disorder, Anorexia Nervosa, Binge Eating Disorder, and/or Bulimia Nervosa. ED-IOP Level I and ED-IOP Level II services must be delivered in-person. Dialectical Behavior Therapy IOP (DBT-IOP) The (DBT-IOP) is a program for Child and adult members who have a primary mental health diagnosis or mental health disorder with a co-occurring substance use disorder and meet at least three (3) of the following criteria: exhibit severe emotional dysregulation, chronic suicidality, impulsivity, self-harm, strained interpersonal relationships, inability to engage in appropriate coping skills, and/or has a history of mental health crises and/or psychiatric hospitalizations. Services may be delivered in-person or via telehealth. 65.05-5 Medication Management Services Medication Management Services are services that are directly related to the psychiatric evaluation, prescription, administration, education and/or monitoring of medications intended for the treatment and management of mental health, substance use, and/or co-occurring mental health and substance use disorders, including Medications for Opioid Use Disorder (MOUD). 65.05-6 Neurobehavioral Status Exam, Neuropsychological Testing, Psychological Testing, and Adaptive Assessments Neurobehavioral Status Exam (Procedure Codes 96116 and 96121) and Psychological Testing (Procedure Codes 96130 and 96131) Neurobehavioral Status Exam and Psychological Testing services include clinical assessment of thinking, reasoning and judgment, meeting face-to-face with the member (either in-person or via interactive telehealth), time interpreting test results and preparing the report of test results. Services also may include testing for diagnostic purposes to measure a member’s emotions, intellectual functioning, personality characteristics, and psychopathology, through the use of standardized test instruments or projective tests. Neuropsychological Testing (e.g., Halstead-Reitan Neuropsychological Battery Wechsler Memory Scales and Wisconsin Card Sorting ) and Psychological Testing by a Psychologist or Physician (Procedure Codes 96132, 96133, 96136, 96137) When performed by a Psychologist or Physician, Neuropsychological Testing and Psychological Testing services include both face-to-face time administering tests to the member (either in-person or via interactive telehealth) and time interpreting these test results and preparing the report. Testing focuses on thinking, reasoning, judgment, and memory to evaluate the member’s neurocognitive abilities. In addition to the administration, scoring, interpretation, and report writing, this code also allows reimbursement for additional time necessary to integrate other sources of clinical data, including previously completed and reported technician and computer administered tests. Procedure codes 96132 and 96133 are reported when administering Neuropsychological Testing evaluation. Procedure codes 96136 and 96137 are used when administering two or more psychological or neuropsychological tests. Neuropsychological Testing (e.g., Halstead-Reitan Neuropsychological Battery Wechsler Memory Scales and Wisconsin Card Sorting) and Psychological Testing by a Psychological Examiner (Procedure Codes 96138 and 96139) When provided by a Psychological Examiner, Neuropsychological Testing and Psychological Testing services include interview/test administration, report preparation, and interpretation. The test is administered by a Psychological Examiner (i.e. technician) and includes any reportable amount of time the technician spent with the client to assist them in completing the assessment. Procedure codes 96138 and 96139 are used when administering two or more psychological or neuropsychological tests by an examiner/technician. Adaptive Assessments (Procedure codes 96112 and 96113) When provided by a licensed Clinician acting within their scope of practice, Adaptive Assessment services include administration of the assessment, report preparation, and interpretation. The test includes any reportable amount of time the technician spent with the client to assist them in completing the assessment. Adaptive Assessments include the Vineland Adaptive Behavior Scale, Adaptive Behavior Assessment System (ABAS), Bayley Scales of Infant and Toddler Development, and the Battelle Developmental Inventory. Neurobehavioral Status Exam, Neuropsychological Testing, Psychological Testing, and Adaptive Assessments do not require PA nor do they require the completion of a Comprehensive Assessment or ITP. However, if the services are provided in a school the need for the evaluation must be documented in the member’s written notice and maintained in the member’s record. Please see Appendix I for a list of qualified professionals. 65.05--1440180-5447030007 Children’s Assertive Community Treatment (ACT) Services A. Service Description Children’s Assertive Community Treatment (ACT) service is available twenty-four (24) hours a day, seven (7) days a week, three hundred and sixty-five (365) days a year as an intensive service provided in the home, community, and office that is designed to facilitate discharge from and prevent admission to inpatient psychiatric hospitalizations as described in Chapter II, Section 46, Psychiatric Hospital Services, children’s residential care facilities as described in Chapter II, Section 97, Private Non-Medical Institution Services, psychiatric residential treatment facilities as described in Chapter II, Section 107, Psychiatric Residential Treatment Facility Services, and crisis residential facilities as described in Chapter II, Section 66, Crisis Services. 1. Children’s ACT services shall include all of the following: a. Individualized Treatment Planning; b. Development and implementation of a comprehensive crisis management plan and providing follow-up services to assure services are delivered and the crisis is resolved; c. Follow-along service, defined as a Medically Necessary Service that assures flexibility in providing services on an as needed basis in accordance with a member’s ITP; d. Contacts with the member’s Parent or Guardian, other Family members, providers of services or supports to ensure continuity of care and coordination of services within and between inpatient and community settings; e. Family involvement, education and consultation in order to help Family members develop support systems and manage the member’s mental illness and co-occurring substance use disorders; f. Individual and Family outpatient therapy, supportive counseling or problem-solving activities, including interactions with the member and his/her immediate Family support system in order to maintain and support the member’s development and provide the support necessary to help the member and Family manage the member’s mental illness and co-occurring substance use. Children’s ACT services may also include group therapy; g. Linking, monitoring, and evaluating services and supports; and h. Medication services, including medication management and administration, which minimally includes: i. One (1) in-person contact per month with the psychiatrist, the advanced practice registered nurse (APRN), nurse practitioner or clinical nurse specialist with advanced training in children’s psychiatric mental health; and ii. Capacity to administer medications daily, as applicable, in a member’s home or community by an appropriately licensed or certified Children’s ACT team professional. 2. Children’s ACT teams must provide a monthly average of three (3) in-person contacts with each member per week, of which at least one contact is a clinical intervention with the clinician. Qualifying contacts are interventions provided by a multidisciplinary treatment team member which directly address the youth’s identified goals and may include collateral contacts. Family-only contacts must be clearly documented in the member’s record. Group treatment will not count towards the three (3) required in-person contacts per week. Telehealth may be utilized to provide services designated to meet the member’s individualized treatment needs when clinically indicated, but may not count towards the three (3) required in-person contacts per week. There may be exceptions to the three (3) in-person contact requirements and the member’s record must clearly document why the contacts did not occur. The Department does not support any exceptions which are standard weekly occurrences and/or which occurred due to provider convenience. Allowable exceptions may include: i. When the provider did not contact the member but made multiple, distinct attempts to reach and meet with the member, including if the member was unexpectedly unavailable, or the contact occurred through a closed door; ii. The member transitioned to another level of care and required fewer than three (3) contacts to complete this transition; iii. If the monthly average of qualifying in-person contacts is at least three (3) per week, variations in the number of in-person contacts in a particular week, i.e. two (2) contacts in one week and four (4) the next; or iv. If extenuating circumstances, such as bad weather or illness, requires what would normally be an in-person contact to occur via telehealth. Providers may deliver two (2) separate and distinct in-person contacts provided on the same date of service when services are: i. Provided by different multidisciplinary team members; ii. Directly related to the member’s identified goals; iii. Delivered based on the best interest of the member and the member’s family; and iv. Clinically justified, medically necessary, and clearly documented. B. Specific Eligibility Requirements for Members Ages Zero (0) Through Twenty (20) for Children’s ACT Service 1. Eligible members must need treatment that is more intensive and frequent than Outpatient or Children’s Home and Community Based Treatment. 2. Members receiving Children’s ACT Services must have a SED and must have received a score of Level 4 or higher on the age-appropriate Level of Care/Service Intensity tool completed by the Department or its Authorized Entity. 3. In addition, the member must meet at least one (1) of the following criteria: a. Be at clear risk for psychiatric hospitalization or residential treatment or admission to a crisis stabilization unit; or b. Has been discharged from a psychiatric hospital, residential treatment facility or crisis stabilization unit within the past month, with documented evidence that he or she is highly likely to experience clinical decompensation resulting in readmission to the hospital, crisis unit or residential treatment in the absence of Children’s ACT Service. C. Provider Requirements Children’s ACT services are provided by a multidisciplinary team, available on a twenty-four (24) hour per day, seven (7) days a week basis. The multidisciplinary team must include: a. a psychiatrist, or an advanced practice registered nurse (APRN), nurse practitioner or clinical nurse specialist with advanced training in children’s psychiatric mental health and with the approval of the Office of Child and Family Services Medical Director, and -3429008763000b. a LCSW, LCPC, or LMFT. 2. The multidisciplinary team may also include any of the following: -1485900-68580000a. a Psychologist, b. a PA with advanced training in children’s psychiatric mental health, c. an APRN, Nurse Practitioner (NP) or Clinical Nurse Specialist with advanced training in children’s psychiatric mental health, if the team includes a Psychiatrist, d. a Registered Nurse with advanced training in children’s psychiatric mental health, e. a LMSW-CC, f. a LCPC-C, g. a LMFT-C, h. a LADC, i. a CADC, j. a vocational counselor and/or an educational counselor, k. a bachelor level Other Qualified Mental Health Professional (OQMHP), l. a Peer Support Specialist, or* m. a Family Support Specialist.* These teams operate under the direction of an independently licensed Clinician. The team will assume comprehensive clinical responsibility for the eligible member. * The Department is seeking and anticipates approval from the Centers for Medicare and Medicaid Services of a State Plan Amendment related to this provision. D. Duration/Prior Authorization/Utilization Review -1371600110299500Children’s ACT Service may be provided to an eligible member for up to six (6) continuous months with PA. Services beyond the initial six (6) months must be reauthorized by DHHS or an Authorized Entity. Requests for reauthorization must be submitted in writing at least fourteen (14) days prior to the six (6) month anniversary date and documented in the member’s record. This service may be utilized concurrently with MaineCare Benefits Manual Section 28, “Rehabilitation and Community Support Services for Children with Cognitive Impairments and Functional Limitations”, or other services under this Section for a period not to exceed thirty (30) days. The specific purpose of this thirty (30) day interval must be for transition to a less intensive or restrictive modality of treatment. Any concurrent services must be prior authorized by DHHS or an Authorized Entity. Concurrent services will only be approved when the Children’s ACT team provider is able to clearly demonstrate that the member would not be able to be discharged from this level of care without concurrent services. Providers must submit request for PA and reauthorization using DHHS approved forms for this service to DHHS or an Authorized Entity, who will use information in the member’s record and clinical judgment to consider the need for this service. The DHHS staff or an Authorized Entity will consider PA for any admission of a member into the Children’s ACT service considering diagnosis, functioning level, clinical information, and DHHS approved tools to verify need for this level of care. The setting in which the Children’s ACT service is to be provided must also be prior authorized. Documentation of this PA must appear in the member’s record. See also Chapter I, Section 1, of the MaineCare Benefits Manual for PA timelines. 65.05-8 Children’s Home and Community Based Treatment (HCT) Services A. Service Description This treatment is for members in need of mental health treatment based in the home and community who need a higher intensity service than Outpatient Services but a lower intensity than Children’s ACT Services. HCT services delivered to a member are based on level of care needs, not on a minimum amount of time spent with the member per contact. Providers must deliver HCT primarily in-person. HCT services are designed to meet the member’s individualized treatment needs delivered through a combination of medically necessary clinical interventions and may include the following: Individual therapy session(s); Family therapy session(s); 3. Treatment team/stakeholder meetings; and 4. Collateral contacts. The HCT treatment team (Clinician or BHP) provides services that include a monthly average of three (3) in-person or telehealth contacts per week, at least one (1) of which is a clinical intervention with a Clinician. Qualifying contacts are interventions provided by a treatment team member which directly address the youth’s identified treatment goals and may include collateral contacts, which are not separately billable, as they are incorporated into the weekly rate of reimbursement. A collateral contact is a contact on behalf of a member by a mental health professional to seek or share information about the member in order to achieve continuity of care, coordination of services, and the most appropriate mix of services for the member. Discussions or meetings between staff of the same agency (or contracted agency) are considered to be collateral contacts only if such discussions are part of a team meeting that includes professionals and caregivers from other agencies who are included in the development of the ITP. There may be exceptions to the three (3) contact requirement and the member’s record must clearly document why the contacts did not occur. The Department does not support any exceptions which are standard weekly occurrences and/or which occurred due to provider convenience. Allowable exceptions may include: a. When the provider did not contact the member but made multiple, distinct attempts to reach and meet with the member, including if the member was unexpectedly unavailable, or the contact occurred through a closed door; b. The member transitioned to another level of care and required fewer than three (3) contacts to complete this transition; or c. If the monthly average of qualifying contacts is at least three (3) per week, variations in the number of contacts in a particular week may occur, i.e. two (2) contacts in one week and four (4) the next. Services include providing treatment to members living with their families. Services also may include members who are not currently living with a parent or guardian. Family participation is required in treatment services to the greatest degree possible given the individual needs as well as family circumstances. Services include providing individual and/or family therapy or counseling, as written in the ITP. The services assist the member and Parent or caregiver to understand the member’s behavior and developmental level including co-occurring mental health and substance use. If a Child receives HCT Services, providers may only deliver HCT Services to that Child's Parents or Guardians without the Child present if it is clinically indicated and identified in the Child’s ITP. The services assist in teaching the member and Family or caregiver how to appropriately and therapeutically respond to the member’s identified treatment needs, supporting and improving effective communication between the parent or caregiver and the member, facilitating appropriate collaboration between the parent or caregiver and the member, and developing plans and strategies with the member and parent or caregiver to improve and manage the member’s and/or Family’s future functioning in the home and community. Services include therapy, counseling or problem-solving activities in order to help the member develop and maintain skills and abilities necessary to manage his or her mental health treatment needs, learning the social skills and behaviors necessary to live with and interact with the community members and independently, and to build or maintain satisfactory relationships with peers or adults, learning the skills that will improve a member's self-awareness, environmental awareness, social appropriateness and support social integration, and learning awareness of and appropriate use of community services and resources. The goals of the treatment are to develop the member’s emotional and physical capability in the areas of daily living, community inclusion and interpersonal functioning, to support inclusion of the member into the community, and to sustain the member in his or her current living situation or another living situation of his or her choice. -13716009271000B. General Eligibility Requirements for Children’s Home and Community Based Treatment The member must meet all of the following criteria: Treatment that is a higher intensity service than Outpatient Services but a lower intensity service than Children’s ACT Services must be medically necessary for the member, demonstrated as follows: 1. The member has a completed evaluation with a mental health diagnosis in accordance with the DSM or a diagnosis from the DC 0-5 within thirty (30) days of the start of service. Mental health diagnoses do not include the following: Learning Disabilities (LD) in reading, mathematics, written expression, Motor Skills Disorder, and Unspecified LD ;-171450012446000-137160035306000 Communication Disorders (Expressive Language Disorders, Mixed Receptive Expressive Language Disorder, Phonological Disorder, Stuttering, and Unspecified Communication Disorder); 2. The member has a significant functional impairment (defined as a substantial interference with, or limitation of, a member’s achievement or maintenance of one or more developmentally appropriate, social, behavioral, cognitive, or adaptive skills); 3. The member has a SED; 4. To receive Children’s HCT services, the member must receive a score of Level 3 or higher on the age-appropriate Level of Care/Service Intensity tool completed by the Department or its Authorized Entity; and 5. Have Parental Participation. C. Specific Imminent Risk Eligibility Requirements to waive Central Enrollment and Prior Authorization for Children’s Home and Community Based Treatment To receive services due to Imminent Risk the member must meet the following criteria: Behavioral Health: Where there has been a risk assessment and determination by a crisis provider or other licensed Clinician that the member is at risk for impending admission, within forty-eight (48) hours, to a psychiatric hospital, crisis stabilization unit or homeless shelter, or other out of home behavioral health treatment facility, unless services are initiated, or Child Welfare: Where Child Welfare Services (CWS) of DHHS is involved with the Family, Imminent Risk of removal is the stage at which CWS has completed its assessment, and has determined that the Family must participate in a safety plan requiring that services start immediately or the member will be removed from the home or foster care setting (not including a Treatment Foster Care setting), or Corrections: Where the Juvenile Community Corrections Officer, law enforcement officer or court recommends or determines that the member will be detained or committed within forty-eight (48) hours unless services are initiated, and The Parent/Guardian must participate in the member’s treatment, consistent with the ITP. D. Waiver of Central Enrollment and Prior Authorization for services provided due to Imminent Risk is valid only under the following conditions: 1. Eligibility criteria as stated in HCT must be clearly documented, 2. Providers must fax a referral form to the offices of DHHS or an Authorized Entity the same day of the start of service, 3. Providers must forward documentation of the risk of removal from crisis provider, licensed Clinician, Child welfare worker, juvenile community corrections officer, law enforcement officer or court to DHHS within thirty (30) days of the start of service, and 4. Providers must ensure that the one of the criteria for Imminent Risk is met, to include Behavioral Health, Child Welfare, or Corrections, 5. Providers must begin the Comprehensive Assessment process with the member immediately and initiate treatment with the Family and Child within forty-eight (48) hours, and 6. Providers must contact DHHS or an Authorized Entity for PA to be entered into the computer system within forty-eight (48) hours. E. Provider Requirements for Children’s Home and Community Based Treatment 1. Staff allowed to provide this treatment include a Clinician and, when appropriate, a staff certified as a BHP. To provide Home and Community Based Treatment the employee must meet the educational requirement and complete the required BHP training within the prescribed time frames, as described in 65.05-7(F) in addition to the following educational requirement to deliver the Home and Community Based Treatment services, which can be met with one (1) of the following: a. A minimum of sixty (60) higher education credit hours in a related field of social services, human services, health or education; b. A minimum of ninety (90) higher education credit hours in an unrelated field with the provider required to have a specific plan for supervision and training documented in the personnel file of the employee; c. A minimum of three (3) years of direct experience working with Children in a behavioral health children’s services program with the provider required to have a specific plan for supervision and training documented in the personnel file of the employee. The provider shall facilitate family participation in the Child’s treatment program, if it is in the Child’s best interest. 3. The provider shall facilitate family outreach, document how this outreach is made, and maintain contact information for any known biological family and fictive kin of the Child. F. Provisional Approval of Providers of Children’s Home and Community Based Treatment: A staff meeting the educational requirement in 65.05-8(E) must begin receiving the BHP training within thirty (30) days from the date of hire. The provisional candidate must complete the training and obtain certification within one hundred and eighty (180) days from the date of hire. Approvals must be maintained in the agency’s personnel file and the length of provisional status documented in the employee’s file. Provisional candidates who have not completed certification requirements within one hundred and eighty (180) days from the date of hire are not eligible to perform reimbursable services with any provider until certification is complete. DHHS or an Authorized Entity may approve exceptions for staff to be qualified as clinicians under this section beyond the effective date of these rules. DHHS or an Authorized Entity will consider information such as attempts at recruiting qualified clinicians, availability of qualified clinicians in geographic areas, supervision to be provided, clinical competency of the individual, and wage/salary offered by the agency. G. The provider of Children’s Home and Community Based Treatment must: Understand the member's diagnosis and the particular challenges it presents to the member's Family; Be knowledgeable about and capable of delivering the appropriate treatment for the diagnosis and symptoms; Coordinate with DHHS or an Authorized Entity to ensure each member who gets the service has a medical need for the service and that the member’s Parent(s) or caregiver is involved. Members of the treatment team will provide information, support and/or intervention, whenever possible and clinically appropriate to the members and families they serve appropriate to ensuring continuity and consistency of treatment. The treatment team will coordinate and communicate with the local crisis agency when necessary. Providers must refer the member for psychiatric consultation when necessary. H. Provider Requirements: Treatment Teams The treatment team must include: 1. A Clinician who will provide therapy or counseling directly to the member and/or Family in the home or community; and when clinically appropriate. 2. A BHP who will provide intervention services to the member and Family under the direct supervision of a Clinician. Clinical justification for the inclusion or exclusion of the BHP must be documented in the member record. Excluding a BHP may not be solely due to inadequate staffing. The Department may approve exceptions to the number of staff required for treatment teams to provide service for this Section. The Department will consider information including but not limited to whether the provider is using an approved Evidence-Based Practice or whether the alternative treatment model has been tested with randomized or controlled outcome studies. I. The treatment team shall: Provide individual and Family, if appropriate, treatment in the home and community, as written in the ITP; Teach the member how to appropriately and therapeutically manage his or her mental health treatment and particular mental health challenges; Support development of effective communication between the member and significant others in their lives (Family, employers, teachers, friends, etc.); Facilitate appropriate collaboration between the member and significant others; Support the member in utilizing the new skills in his or her living situation and community that have been described in the ITP; Develop plans and strategies with the member to improve his or her ability to function in his or her living situation and community after treatment is complete; Meet with other service providers to plan and coordinate treatment to ensure the integration of the treatment across the member’s home, school, and community and to achieve the desired outcomes and goals identified in the ITP; and -1257300825500Review the ITP at least every ninety (90) days to determine whether or not the ITP will be continued, revised or discontinued. The Clinician, and Parent or caregiver, and member, if appropriate must sign and date the ITP.-14859004699000 HCT shall be consistent with existing Evidence-Based Practices, Promising and Acceptable Treatment or Best Practice parameters in type, staffing, frequency, duration, and service provider setting. Where Evidence-Based Practices do not exist, the treatment shall be consistent with Promising and Acceptable Treatment or Best Practice treatment parameters. J. Duration of Care/Prior Authorization/Utilization Review HCT services must meet requirements for Central Enrollment and will be subject to PA and ongoing Utilization Review. HCT requires PA and Utilization Review every ninety (90) days of treatment. DHHS will evaluate effectiveness before authorizing continuation of treatment. The duration of care will typically be up to six (6) months, subject to PA and DHHS Utilization Review. Subject to medical necessity and Utilization Review, treatment may be approved beyond six (6) months on a case-by-case basis. 1. Utilization Review must ensure that: a. The ITP is reviewed every ninety (90) days; b. Each member has a medical need for the service; c. The member’s Parent/caregiver is participating in the treatment planning process and in the treatment, if appropriate; -13716005524500 d. Measurable progress is being made on the goals and objectives identified in the ITP and that this progress is expected to continue; and e. A discharge plan addresses the Natural Supports and treatment needs that will be necessary for the member and Family to sustain their progress at the end of this treatment. 2. The purpose of the treatment and measure of effectiveness will be demonstrated improvement for the member and Family in one or more of the following areas: a. Functioning and skill development; b. Adaptive behavior; and c. Member’s ability to live within the Family and larger community. 65.05-9 Multisystemic Therapy (MST) Multisystemic Therapy (MST) is an intensive Family-based treatment that addresses the determinants of serious disruptive behavior in members and their families. It is a short-term treatment approach that usually takes three (3) to six (6) months. The treatment typically includes three (3) to six (6) hours/week of clinical treatment. MST is a manualized intervention with a strong evidence base: the MST therapist must be highly accessible to members and services must be available twenty-four (24) hours a day, seven (7) days a week, which may include collateral contacts. The MST therapist continually evaluates treatment outcomes. MST services must maintain treatment integrity and meet the fidelity criteria developed by MST Services, Inc. MST therapists and supervisors must be a master’s level clinician and must be certified by MST Services, Inc. (http://www.mstservices.com). MST-Problem Sexualized Behavior (MST-PSB) services must meet additional training and supervision requirements set forth below in addition to standard MST protocols. B. To be eligible for MST, members must receive a score of Level 3 or higher on the age-appropriate Level of Care/Service Intensity tool completed by the Department or its Authorized Entity. C. MST providers must meet a minimum contact standard with the member. For the purposes of meeting the minimum contact standard, contacts must occur on separate days except in rare circumstances when the provider is testing the sustainability of the member’s progress in preparation for discharge. The member’s record must clearly document if and why two contacts were delivered on the same day. Exceptions to the minimum contact standard may include, but are not limited to, when the member transitions to another service and needs fewer contacts or when attempts to meet with the member fail. Exceptions to the minimum contact standard cannot occur on a weekly basis and are not permitted only for the provider’s convenience. The minimum contacts standards for each of the services are: 1. Multisystemic Therapy: MST therapists must deliver a minimum monthly average of two (2) in-person or telehealth contacts per week to each member they serve. Services administered via telehealth must comply with Chapter I, Section 4, “Telehealth Services”, of the MaineCare Benefits Manual. Contacts may include individual therapy session(s) for the identified Child, Family therapy session, or clinically necessary team or stakeholder meetings. 2. Multisystemic Therapy for Problem Sexualized Behaviors: MST therapists must deliver a minimum monthly average minimum of three (3) in-person or telehealth contacts per week to each member they serve. Contacts may include individual therapy session(s) for the identified Child, Family therapy session(s), or clinically necessary team or stakeholder meetings. 65.05-10 Functional Family Therapy (FFT) FFT is a Family strengths-based clinical assessment and intervention model built on a foundation of acceptance and respect. FFT addresses risk and protective factors within and outside of the Family that impact adolescents and their adaptive development from the ages of eleven (11) through eighteen (18). FFT consists of five major components: engagement, motivation, relational assessment, behavior change, and generalization. The intervention averages eight (8) to twelve (12) sessions for mild to moderate needs and up to thirty (30) sessions for members with complex needs. Services include in-person or telehealth sessions with the member and/or Family members, telephone outreach and team meetings that include the member and/or Family members. FFT providers must maintain treatment integrity and meet fidelity criteria developed by FFT, LLC. FFT therapists and supervisors must be a master’s level Clinician and be certified by FFT, LLC. B. To be eligible for FFT, members must receive a score of Level 3 or higher on the age-appropriate Level of Care/Service Intensity tool completed by the Department or its Authorized Entity. C. FFT therapists must deliver a minimum of one (1) in-person Family session (the member and at least one (1) Family member) per week in which the treatment goals are addressed. The FFT therapist must utilize interventions, the intensity and frequency of which are based on the member’s risk and protective factors. FFT also provides collateral contacts. Contacts may include outreach, service coordination, crisis calls, or team meetings where client and/or a Parent or Guardian are present. 65.05-11 Opioid Treatment Program (OTP) Services with Methadone This subsection shall apply only to Opioid Treatment Program (OTP) Services with Methadone that are certified. Certified OTPs must comply with all federal regulations under 42 C.F.R. Part 8. OTPs using other medications are not covered under this subsection. OTPs must make available adequate medical, counseling, educational and other assessment and treatment services as part of a packaged combined service. Harm Reduction Principles OTP staff must incorporate and have adequate training in harm reduction principles, meaning practical and legal evidence-based strategies like overdose education; testing and intervention for infectious diseases, including counseling and risk mitigation activities forming part of a comprehensive, integrated approach to address human immunodeficiency virus (HIV), viral hepatitis, sexually transmitted infections, and bacterial and fungal infections; distribution of opioid overdose reversal medications; linkage to other public health services; and connecting those who have expressed interest in additional support to peer services. Mobile OTP Requirements Mobile OTP Services with Methadone providers must license mobile OTP sites as required by the Division of Licensing and Certification. Providers that will deliver OTP Services in a mobile setting must comply with requests from DHHS for supplemental information. Providers must follow all applicable state and federal regulations and guidelines. C. Staff Credentials All clinical staff providing OTP services with methadone must have sufficient education, training, and experience, or any combination thereof, to perform assigned functions. D. Medical Director The medical director’s responsibilities must include but are not limited to the following: Administering of all medical services performed by the program, either by performing them directly or by delegating specific responsibility to authorized program physicians and healthcare professionals functioning under the medical director’s direct supervision. 2. Reviewing and approving in writing all treatment plans at least once annually. 3. Determining admission eligibility, diagnosis and prescribing of medication. Within five (5) days of the resignation or replacement of the medical director, the program must notify the Office of MaineCare Services. E. Assessment Assessments provided according to this subsection shall be considered to meet the requirements for Comprehensive Assessments as described in 65.08-4. All members participating in OTPs must receive an initial screening and a complete medical exam by a physician, physician assistant, or nurse practitioner in compliance with 42 C.F.R. Part 8. The initial screening must occur prior to admission and the complete medical exam must occur within fourteen (14) days following admission. The initial screening and complete medical exam may be delivered via telehealth in compliance with 42 C.F.R. Part 8. OTPs must develop policies and demonstrate policy compliance in addressing the needs of pregnant members. Such policies will be based on current Best Practices and reflect the special needs of pregnant members. All individuals admitted to an OTP shall be assessed initially and periodically by qualified personnel for treatment planning purposes. The initial assessment must address the following elements in the preparation and development of treatment planning goals: the educational, vocational rehabilitation, employment needs of the member, and the member’s needs for medical, psychosocial, economic, legal, and other support services. F. Individualized Treatment Plan ITPs for OTP services with methadone must be in compliance with requirements outlined in 65.08-4(B). G. Counseling OTPs must provide adequate substance use disorder counseling and psychoeducation to each member, as clinically indicated and mutually agreed-upon, including harm reduction education and recovery-oriented counseling. This counseling shall be provided by a program counselor, qualified by education, training, or experience to assess the psychological and sociological background of members, to contribute to the appropriate care plan for the member and to monitor and update member progress. Member refusal of counseling alone shall not preclude them from receiving MOUD. OTP counseling shall also include the following: 1. Counseling related to preventing exposure to, and the transmission of, HIV disease for each member admitted or readmitted to continuous medication or withdrawal management treatment; and 2. Coordination of services and referral, if indicated, to adequate and reasonably accessible community resources, vocational rehabilitation, education, and employment services for members who either request such services or who have been determined by the program staff to be in need of such services; and 3. Group counseling sessions including, but not limited to, any of the following: psychoeducational groups, skills development groups, cognitive behavioral therapy groups, or support groups. H. Substance Use Testing OTPs must provide adequate testing and analysis for substance use, including at least eight (8) random substance use tests per year, per member in continuous medication treatment, in accordance with generally accepted clinical practice. For members in short-term withdrawal management treatment, the OTP shall perform at least one initial substance use test. For members receiving long-term withdrawal management treatment, the program shall perform initial and monthly random tests on each member. Results and any follow-up action must be documented in the member record. Testing should follow federal and state guidelines including Chapter II, Section 55, “Laboratory Services”, of the MaineCare Benefits Manual. I. Medication Administration OTPs must ensure that opioid agonist treatment medications are administered or dispensed only by a practitioner licensed under the appropriate State law and registered under the appropriate State and Federal laws to administer or dispense opioid agonist medications, or by an agent of such a practitioner, supervised by and under the order of the licensed practitioner. This agent is required to be a pharmacist, RN, or licensed practical nurse, or any other healthcare professional authorized by Federal and State law to administer or dispense opioid medications. OTPs must have policies in place and followed that reflect applicable State and federal rules regarding take-home use and align with 42 C.F.R. § 8.12. All prescribers of OTPs are required to consult the Prescription Monitoring Program (PMP) prior to initial treatment, and as clinically indicated. All OTPs must develop and implement a Diversion Control Plan with measures to reduce the possibility of diversion of controlled substances. For each new member enrolled in a program, the initial dose of methadone shall be individually determined and shall include consideration of the type(s) of opioid(s) involved in the member’s opioid use disorder, other medications or substances being taken, medical history, and severity of opioid withdrawal. The total dose for the first day shall not exceed fifty (50) milligrams, unless an appropriately-licensed OTP practitioner documents in the member's record that fifty (50) milligrams did not suppress opioid abstinence symptoms. J. Program Operation OTP programs must ensure adequate coverage and accessibility for the treatment needs of each member and be available at least six (6) days per week throughout the calendar year. K. Medical Records In addition to the requirements set out above and in Section 65.08-4 of this policy, OTPs must comply with the following documentation requirements: The program must monitor and document the member’s progress in the member’s record as it relates to the ITP. Each member visit must reflect progress towards goals identified in the ITP. Results of substance use tests shall be documented in the member’s record. The member’s record must also include documentation that the results of substance use testing have been reviewed and considered as part of the treatment planning process, dosing, and decisions for take-home medication. 65.05-12 Interpreter Services Interpreter Services are described in Chapter I, Section 1 of the MaineCare Benefits Manual. 65.05-13 Children’s Behavioral Health Day Treatment Service Description This covered service is a specific service determined to be medically necessary by qualified staff licensed to make such a determination and subsequently specified in the ITP and for which payment to a provider is permitted under the rules of this Section. This qualified staff must assume clinical responsibility for medical necessity and the ITP development. The Behavioral Health Day Services described below are covered when (1) provided in an appropriate setting as specified in the ITP, (2) supervised by an appropriate professional as specified in the ITP, (3) performed by a qualified provider, and (4) billed by that provider. Behavioral Health Day Treatment Services must be delivered in conjunction with an educational program in a School as defined in 65.02-4. Behavioral Health Day Treatment Services are structured therapeutic services designed to improve a member’s functioning in daily living and community living. Programs may include a mixture of individual, group, and activities therapy, and also include therapeutic treatment oriented toward developing a Child’s emotional and physical capability in the area of interpersonal functioning. This may include behavioral strategies and interventions. Services will be provided as prescribed in the ITP. The provider must involve the member’s Family in planning and providing treatment when clinically appropriate. Behavioral Health Day Treatment Services may be provided in conjunction with a residential treatment program. Services are provided based on time designated in the ITP but may not exceed six (6) hours per day, Monday through Friday, up to five days per week. Medically Necessary Services must be identified in the ITP. B. Eligibility for Behavioral Health Day Treatment The member must be aged twenty (20) or under, and must be referred by the Qualified Staff, as defined below. Additionally, the member must need treatment that is more intensive and frequent than Outpatient but less intense than hospitalization. Within thirty (30) days of the start of service, the member must have received an evaluation and must have a primary mental health diagnosis in accordance with the DSM or a diagnosis based on the DC-05; and In addition, based on an evaluation using the Battelle, Bayley, Vineland, or other tools approved by DHHS, as well as other clinical assessment information obtained from the member and Family, the member must either have a significant functional impairment (defined as a substantial interference with or limitation of a member’s achievement or maintenance of one or more developmentally appropriate, social, behavioral, cognitive, or adaptive skills); or Have a completed evaluation establishing that the member has two (2) standard deviations below the mean in one domain of development or 1.5 standard deviations below the mean in at least two areas of development on the Battelle, Bayley, Vineland, or other tools approved by DHHS and other clinical assessment information obtained from the member and Family. C. Provider Requirements for Behavioral Health Day Treatment Staff qualified to provide this treatment include the following Clinicians (Psychiatrist, Psychologist, LCSW, LCPC, LMFT, LMSW-CC, LCPC-C, and LMFT-C) and staff certified as a BHP who has completed ninety (90) documented college credit hours or Continuing Education Units (CEUs). Staff qualified to determine medical necessity to develop the ITP are Psychologists, LCSWs, LCPCs, or LMFTs. Board Certified Behavioral Analysts (BCBAs) are allowed to provide supervision to BHP staff. To provide Behavioral Health Day Treatment as a BHP, the employee must meet the education requirement and successfully complete the required BHP training within the prescribed time frames, as described in 65.05-12(D) in addition to having completed ninety (90) documented college credit hours or Continuing Education Units (CEUs) D. Provisional Approval of Providers of Behavioral Health Day Treatment: All staff must begin receiving the BHP training within thirty (30) days from the date of hire. The provisional candidate must successfully complete the training and obtain certification within one hundred and eighty (180) days from the date of hire. Approvals must be maintained in the agency’s personnel file and the length of provisional status documented in the employee’s file. Provisional candidates who have not completed certification requirements within one hundred and eighty (180) days from the date of hire are not eligible to perform reimbursable services with any Behavioral Day Health Treatment provider until certification is complete. 65.05-14 Tobacco Cessation Treatment Services Tobacco Cessation Treatment shall be a covered service for all MaineCare members who currently use tobacco products, including electronic cigarettes or vapes, and who wish to cease the use of tobacco products. Tobacco Cessation Treatment includes both counseling and products. Tobacco cessation counseling services are provided to educate and assist members with tobacco cessation. During counseling, providers must educate members about the risks of tobacco use and the benefits of quitting, and assess the member’s willingness and readiness to quit. Providers should identify barriers to cessation, provide support, and use techniques to enhance motivation to quit for each member. These services may be provided in the form of individual or group counseling. Both forms of counseling may be provided by licensed practitioners within the scope of licensure as defined under State law and who are eligible to provide other coverable services in Section 65. In addition to counseling, Tobacco Cessation Treatment services include the provision of all pharmacotherapy approved by the Federal Food and Drug Administration for tobacco dependence treatment, including, but not limited to, bupropion. Tobacco cessation products are “Covered Drugs,” reimbursable pursuant to Chapter II, Section 80 of the MaineCare Benefits Manual. As Covered Drugs, tobacco cessation products are included on the Department’s Preferred Drug List (PDL), as set forth in Chapter II, Section 80. The PDL may be accessed via the Department’s website. MaineCare members are not required to participate in tobacco cessation counseling to receive tobacco cessation products. The limitations in 65.07-4do not apply to Tobacco Cessation Treatment services. Members shall be provided with Tobacco Cessation Treatment services with no annual or lifetime dollar limits, and no annual or lifetime limits on attempts to cease tobacco use. Providers may bill these services alone or in addition to other Section 65 covered services provided on the same date of service. Documentation of Tobacco Cessation Treatment Services must be contained in the member’s record. 65.05-15 Mental Health Psychosocial Clubhouse Services A. Service Description Mental Health Psychosocial Clubhouse Services refers to services delivered through a community-based International Center for Clubhouse Development (ICCD) accredited clubhouse setting in which the member, with staff assistance, engages in operating all aspects of the program. Member choice is a key feature of the model. Through a structured environment that is referred to as the work-ordered day, supports and services address behavioral health related barriers that impact employment, education, housing, Community Inclusion, wellness, community resources, advocacy, and recovery are provided. Members participate in the program’s day-to-day decision making and governance. Through Clubhouse involvement, members achieve or regain the confidence and skills necessary to lead satisfying, meaningful lives and successfully manage their mental illness. Covered services include activities to increase wellness skills, community living skills necessary for independent self-management, and skills that may help obtain and maintain employment. In alignment with clubhouse objectives, services improve members’ engagement in and access to all preferred social roles, including roles related to learning, working, and community engagement, which improves members’ quality of life and well-being. . Services are delivered in the community and at the Clubhouse and are in alignment with the ITP that is developed through a member-driven process. B. Eligibility for Mental Health Psychosocial Clubhouse Services 1. In order to be eligible for services, the member must: be age eighteen (18) or older or an emancipated minor; AND have a primary mental health diagnosis in accordance with the current version of the DSM, except that the following diagnoses may not be primary diagnoses for purposes of this eligibility requirement: Neurocognitive Disorders, Delirium, dementia, amnestic, and other cognitive disorders; Mental disorders due to a general medical condition, including neurological conditions and brain injuries; Substance Related and Addictive Disorders, Substance use or dependence; Neurodevelopmental Disorders ; Intellectual disability Adjustment disorders; V-codes; or Antisocial personality disorders; AND Have significant impairment or limitation in adaptive behavior or functioning according to an acceptable standardized assessment tool. If using the LOCUS, the member must have a LOCUS score, as determined by a LOCUS Certified Assessor, of seventeen (17) (Level III) or greater. 2. Determination of Eligibility Eligibility for services must be supported initially, and then annually, for Mental Health Psychosocial Clubhouse Services. The annual eligibility verification must include a recent diagnosis that is supported by evidence provided of symptoms defined in the most current version of the Diagnostic and Statistical Manual of Mental Disorders, completed within the past year, as documented by an appropriately licensed Clinician. The LOCUS or other approved tools must be administered at least annually, or more frequently, if DHHS or an Authorized Entity requires it. C. Provider Requirements for Mental Health Psychosocial Clubhouse Services The provider shall be a Mental Health Agency. 2. To ensure fidelity to the Evidence-Based Practice of the psychosocial rehabilitation model, clubhouses must acquire and maintain Clubhouse International Accreditation through the International Center for Clubhouse Development. Additional information regarding Clubhouse International accreditation is available on the ICCD website at http://www.iccd.org/certification.html . 3. All new clubhouses must participate in Clubhouse International’s New Clubhouse Development Training. 4. Provider staff must be certified as Mental Health Rehabilitation Technician/ Community (MHRT/C) and must complete continuing education training through Clubhouse International. 65.05-16 Specialized Group Services Specialized Group Services consist of education and peer and Family support, provided in a group setting, to assist the members to focus on recovery, wellness, meaningful activity, and community tenure. When cofacilitated by two non-licensed mental health professionals, a licensed mental health professional must supervise the co-facilitators. Specialized Group Services fall into the following four (4) groups: A. Wellness Recovery Action Planning (WRAP). Wellness Recovery Action Planning is a curriculum-based self-management and recovery system developed, trademarked, and maintained by the Copeland Center for Wellness and Recovery. WRAP explores the foundational concepts of recovery and wellness, including hope, personal responsibility, and education; increases the understanding of personal experiences; encourages the use of Natural Supports; and helps individuals develop a personal plan that promotes an improved quality of life focusing on relapse prevention, personal growth, and recovery. The group meets for a maximum of twelve (12) sessions of two (2) hours each. WRAP services are co-facilitated by peers who are CIPSS certified and who must have successfully completed the Copeland Center's "Mental Health Recovery WRAP: Facilitator Certification" program or any equivalent successor Copeland Center program for certifying WRAP facilitators. More information about WRAP training and certification is available by contacting the Copeland Center directly at: Copeland Center for Wellness & Recovery P. O. Box 6471 Brattleboro, VT 05302 Phone: (802) 254-5335 http://www.copelandcenter.com B. Recovery Workbook Group. Recovery Workbook Group is a co-facilitated, curriculum-based recovery group designed to increase awareness and understanding of the recovery process. This service includes the development of coping and empowerment strategies, skills for rebuilding connections with self or others, and skills needed to strengthen and maintain the recovery process and to create opportunities for living fuller lives. The group meets for a maximum of thirty (30) weekly two (2) hour sessions for a total of sixty (60) hours. The service is facilitated by individuals who have received a certificate for successful completion of the course “PDP 703-REC: Facilitating a Recovery Workshop” through the Boston University Center for Psychiatric Rehabilitation. The Recovery Workbook Group is co-facilitated and requires at least one (1) peer facilitator who is CIPSS certified. The second co-facilitator may be a peer, mental health professional, or other qualified individual. C. Trauma Recovery and Empowerment Group (TREM). Trauma Recovery and Empowerment Group utilizes a skills-based group treatment approach to address issues of sexual, physical, and emotional abuse. The co-facilitated group meets for a maximum of thirty-three (33) sessions offered over a nine (9) month period for trauma survivors. Thirty (30) sessions focus on empowerment, trauma recovery, and advanced trauma recovery issues. The remaining three (3) sessions serve as the conclusion, or termination, for the group. Each session is seventy-five (75) minutes long and includes a combination of discussion and experiential exercises. Format for the group is based upon the book “Trauma Recovery and Empowerment – A Clinician’s Guide for Working with Women in Groups” by Maxine Harris, Ph.D., and based upon The Community Connections’ Trauma Work Group. Format for the group may also include utilization of the workbook entitled “Healing the Trauma of Abuse” by Mary Ellen Copeland, M.A., M.S., and Maxine Harris, Ph.D. D. Dialectical Behavior Therapy (DBT). Dialectical Behavior Therapy is a skills training group conducted in a psychoeducational format. The co-facilitated group focuses on the acquisition and strengthening of skills. Skills training consists of four (4) modules: mindfulness, distress tolerance, interpersonal effectiveness in conflict situations, and emotional regulation. Groups meet weekly for two (2) to two and a half (2 1/2) hour sessions for up to one (1) year but may meet more frequently for a shorter duration. Format for the group is based upon “Skills Training Manual for Treating Border-Line Personality Disorder” by Marsha M. Linehan. Providers delivering this service must be DBT-trained and certified. E. Eligibility for Specialized Group Services In order to be eligible for Specialized Group Services, the member must meet the same criteria specified in Section 65.05-15(B) (Eligibility for Mental Health Psychosocial Clubhouse Services). Members do not have to meet the eligibility criterion in Section 65.05-15(B)(1)(a) to be eligible for DBT. Specialized Group Services must be prior authorized by the Department or its Authorized Entity. 65.05-17 Behavioral Therapies A. Service Description Behavioral Therapies are evidence-based Parent training models focused on teaching Parents and other caregivers the skills needed to help Children members better manage their disruptive behavior disorder. Overseen by a Clinician, in accordance with the Evidence-Based Practice, the model helps Parents understand how the member’s diagnosis affects the member, and helps change challenging behaviors by building parenting skills, improving relationships between Parent or Guardian and member, and by helping the member manage his or her own behaviors. B. Eligibility for Behavioral Therapies Eligible members must: 1. Be sixteen (16) years old or younger. Not all Behavioral Therapies are for all ages and additional age requirements are specified below; 2. Be referred by a licensed provider working within the scope of their practice; 3. Have clinically significant disruptive behaviors that lead to functional impairment in one or more domains as determined by Comprehensive Assessment and standardized assessment tools, such as the ECBI, Vanderbilt, CBCL/ CASII, CAFAS, CANS, YOQ etc.; OR have Parent Stress Index (PSI) scores indicate significant Parent distress, dysfunctional Parent-Child relationship, and/or difficult Child behavior in the clinical range; AND 4. Have a SED. C. Behavioral Therapies Members meeting the criteria above may be eligible for any of the following Behavioral Therapies: 1. The Triple P – Positive Parenting Program is a parenting and Family support system designed to prevent and treat social, emotional and behavioral problems in Children. Triple P interventions are organized into five (5) levels of intervention intensity and are based upon social learning, cognitive-behavioral, and developmental theories, and research on risk factors associated with social and behavioral problems in Children. The program aims to equip Parents and Guardians with the skills and confidence they need to be able to successfully manage Family issues self-sufficiently within a self-regulatory model (i.e. without ongoing support). Triple P aims to prevent problems in the Family, school, and community while helping to create Family environments that encourage Children to reach their potential. Triple P Staff Requirements Staff providing Triple P must be certified by the developer of the model (located at https://www.triplep.net/glo-en/home/) and have, at minimum, a bachelor’s degree in health, education, childcare, or social services. Uncertified staff may not perform this service until all certification requirements are met. Providers delivering services to members thirteen to sixteen (13-16) years old must be appropriately credentialed for Triple P-Teen. Qualified staff shall deliver services consistent with the Evidence-Based Practice and material made available by the developer of the Evidence-Based Practice and adhere to the fidelity requirements. Triple P staff must: Use session checklists. Each intervention has a session checklist which assists practitioners in implementing the service as intended. These checklists are integrated into the training protocol and are found in all Triple P manuals; and Attend two (2) hours of Peer Assisted Support Supervision (PASS) quarterly. During PASS sessions, practitioners present cases, obtain feedback from other qualified practitioners, and continue to supplement their skills with continuing education. Practitioners learn the PASS model at training, and the PASS manual and checklist are available to trained practitioners through the Triple P Provider Network. b. Covered Triple P Interventions Triple P’s suite of interventions is organized into five (5) levels of intervention intensity in order for services to be rendered according to a Family’s need, time constraints, and desire for support. Each level of intervention has with a choice of delivery methods to allow for flexibility to meet the needs of individuals in their communities. All interventions are considered as brief, time-limited, and highly efficacious. Covered interventions include the following: i. Group Triple P (Level 4): Groups of no more than twelve (12) Parents attend at least four (4) sessions and are supported with three (3) phone counseling/catch-up sessions at home. Group Triple P is for Parents and Guardians of a member who meets eligibility for Behavioral Therapies who is up to twelve (12) years old, or up to sixteen (16) years old for Group Teen Triple P (Level 4). Groups follow the clinical method of assessment, treatment planning (i.e., developing a parenting plan), and follow up and use a variety of teaching methods such as videos, role-playing, discussion, homework assignments, and a Parent workbook to engage Parents, help Parents learn self-regulatory skills, and reinforce positive parenting strategies. Standard Triple P (Level 4): Intended for Parents and Guardians of a member who meets eligibility for Behavioral Therapies who is up to twelve (12) years old, or up to sixteen (16) years old for Standard Teen Triple P, who need intensive support. Individual counseling is typically delivered over ten (10) one (1)-hour sessions. Individual Parent sessions also follow the clinical method of assessment, treatment planning (i.e., developing a parenting plan), and follow up and use a variety of teaching methods such as videos, role-playing, discussion, homework assignments, and a Parent workbook to engage Parents, help Parents learn self-regulatory skills, and reinforce positive parenting. Standard and Group Stepping Stones Triple P (Level 4): Standard and Group Stepping Stones are for Parents and Guardians of a member who meets eligibility for Behavioral Therapies who is up to twelve (12) years old. Standard Stepping Stones is typically delivered over ten (10) one and a half (1.5) hour weekly sessions. Group Stepping Stones is typically delivered over six (6) two and a half (2.5) hour group sessions and includes three (3) phone consultations. Triple P Pathways (Level 5): Developed as an intensive intervention program for Parents and Guardians of a member who meets eligibility for Behavioral Therapies who is up to sixteen (16) years old. Triple P Pathways covers five (5) additional sessions of extended Triple P modules, which must either follow or be incorporated into a Level 4 intervention. A Triple P practitioner must have approved Triple P Pathways for the member to be eligible. Providers delivering Triple P Pathways must be certified in Triple P Pathways, in addition to Level 4 interventions. 2. The Incredible Years Series is a set of interlocking and comprehensive training programs for Parents, teachers, and Children with the goals of treating aggressive behavior and disruptive behavior disorders. The program aims to prevent conduct problems, delinquency, violence, and substance use through promotion of child social competence, emotional regulation, positive attributions, academic readiness, and problem solving. The Incredible Years is broken up into five (5) parenting programs that target key developmental stages. The appropriate stage must be chosen based on the developmental age of the Child. Each program consists of groups of ten to fourteen (10-14) participants and two (2) leaders. Each session meets weekly and is two to two and one-half (2-2.5) hours long. a. Incredible Years Programs i. Baby Program: Designed for infants from birth to twelve (12) months. This program consists of nine (9) to twelve (12) sessions. ii. Toddler Basic Program Designed for toddlers aged one (1) to three (3) years. This program is twelve (12) to thirteen (13) sessions. iii. Preschool Program Designed for children aged three (3) to six (6) years. This program is eighteen (18) to twenty (20) sessions. iv. School Age Basic Program Designed for children aged six (6) to twelve (12) years. This program is twelve (12) to twenty (20) sessions. v. Advanced Parenting Program Designed for children aged four (4) to twelve (12) years, this program focuses on parental interpersonal problems such as depression and anger management. This program is nine (9) to eleven (11) sessions, intended for Parents who have completed a basic program only. b. Incredible Years Staff Requirements Staff providing Incredible Years must be accredited by the developer of the model (located at http://www.incredibleyears.com/). Additionally, one (1) leader must have a Master of Arts or comparable educational background. Group leaders may come from many disciplines, including counseling, social work, psychology, psychiatry, nursing, and education. It is recommended that potential group leaders have prior training in child development, and cognitive social learning theory. They must have a minimum of two (2) years of experience with young Children, parenting skills, and family interactions. Group leaders must possess excellent interpersonal skills, leadership skills, have facilitated or led group activities, and have a strong awareness of group dynamics. Qualified staff shall deliver services consistent with the Evidence-Based Practice and material made available by the developer of the Evidence-Based Practice and adhere to the fidelity requirements, specifically: Accredited group leaders shall lead at least one (1) group every nineteen (19) months; and Accredited group leaders shall participate in a fidelity check every eighteen (18) months (this could be a coaching session with an accredited peer coach, a video review of a group by a mentor or trainer, or an in-person or online video consultation with a mentor or trainer). 3. Parent-Child Interaction Therapy (PCIT) is an evidence-based treatment for children twelve (12) and younger with disruptive behavior disorders that places emphasis on improving the quality of the Parent-Child relationship and changing Parent-Child interaction patterns. Children and their Parents/caregivers are seen together in PCIT. Most of the session time is spent coaching caregivers in the application of specific therapy skills. Clinicians typically coach from an observation room with a one-way mirror into the playroom, using a “bug-in-the-ear” system for communicating to the Parents as they play with their Child. Concluding each session, the Clinician and caregiver together decide which skill to focus on most during daily 5-minute home practice sessions the following week. PCIT uses a combination of behavior therapy, play therapy, and Parent training to improve the Parent-Child relationship, and aims to teach Parents/caregivers effective, positive discipline skills. PCIT is a short-term intervention, completed in approximately fourteen to twenty (14-20) sessions, depending on the needs of the Child. Consistent attendance along with daily home practice is important for successful outcomes. a. PCIT Phases PCIT can be used to treat behavioral problems associated with disruptive behavior disorders, aggressive behaviors, temper tantrums, negative attention seeking behaviors, and whining. Treatment is broken into two (2) phases, each with teaching live coaching sessions. i. Phase 1 - Child-Directed Interaction (CDI): During the first (1st) phase of treatment, Parents/caregivers are taught play therapy skills as a way to interact with their children in a positive and consistent manner. ii. Phase 2 - Parent Directed Interaction (PDI): During the second (2nd) phase of treatment, Parents/caregivers are taught specific discipline techniques, such as time-out procedures, that are consistent and predictable. Children learn to obey their Parents/caregivers and problematic behaviors are reduced. Completion of treatment is based on the Parent/caregiver’s mastery of CDI and PDI skills. PCIT Staff Requirements Staff providing PCIT shall be accredited by the developer of the model (located at http://www.pcit.org/) and: i. Have a master’s degree or higher, or an international equivalent of a master’s degree, in a mental health field; ii. Be one of the following: (a) An independently licensed mental health service provider (for example, licensed psychologist, psychiatrist, licensed marital and family therapist, licensed practicing counselor, licensed clinical social worker, etc.) or be working under the supervision of a licensed mental health service provider; or (b) A psychology doctoral student who has completed the third year of training and be conducting clinical work under the supervision of a licensed mental health service provider. Uncertified staff may not perform this service until all certification requirements are met. Qualified staff shall be consistent with the evidence and material made available by the developer of the Evidence-Based Practice and adhere to the fidelity requirements outlined by the developer, specifically: Utilize the 2011 PCIT Protocol and 2013 Clinical Manual for DPICS-IV as disseminated by PCIT International; iv. Obtain at least three (3) hours of PCIT Continuing Education credit every two (2) years through education activities sponsored by the PCIT International Task Force on Continuing Education; and v. Complete the re-certification process every two (2) years to include submitting a brief application for re-certification and documentation of successful completion of three (3) hours of PCIT Continuing Education. Certification experience scores are required only for the initial certification process. D. Additional Requirements for Behavioral Therapies 1. All members will have an ITP as defined in 65.01-23 and described in 65.08-4(B). 2. Only one (1) type of Behavioral Therapy under 65.05-17(C) may be authorized for and delivered to a member at any one (1) time. 3. Providers shall participate with the Department in fidelity monitoring according to the Department determined process. 65.06 NON-COVERED SERVICES Please refer to the MaineCare Benefits Manual, Chapter I, Section 1, “General Administrative Policies and Procedures”, for a general listing of non-covered services including academic, vocational, socialization or recreational services and custodial services and associated definitions that are applicable to all Sections of the MaineCare Benefits Manual. MaineCare does not reimburse Natural Supports, or Parents or Guardians, for their time spent participating in services as part of a treatment team. Additional non-covered services related to the delivery of mental health services are as follows: 65.06-1 Homemaking or Individual Convenience Services: Any services or components of services of which the basic nature is to maintain or supplement the housekeeping, homemaking or basic services for the convenience of the member are not reimbursable under this policy. These non-covered services include, but are not limited to, housekeeping, shopping, Child day care, or respite and laundry service. 65.06-2 Transportation Costs for Providers: Provider costs related to transportation (e.g., mileage involved in providing services) are built into the rates for services that include transportation of Members. Therefore, separate billings to the MaineCare Program for provider travel time are not reimbursable. Member transportation services to and from Section 65 services are covered by MBM Section 113 and are not reimbursable under Section 65. 65.06-3 Case Management Services: Any services, or components of services of which the basic nature is to provide case management services are not reimbursable under these Behavioral Health Services rules unless otherwise indicated. Please refer to Chapter II, Section 13, “Targeted Case Management Services”, Chapter II, Section 17, “Community Support Services”, Chapter II, Section 92, “Behavioral Health Home Services”, and Chapter II, Section 93, “Opioid Health Home Services” of the MaineCare Benefits Manual for a description of the coverage of such services. 65.06-4 Adult Community Support/Adult Day Treatment Services: Any services, or components of services of which the basic nature is to provide Adult Community Support Services, or Adult Day Treatment Services are not reimbursable under this Section. Please refer to Chapter II, Section 17, “Community Support Services”, of the MaineCare Benefits Manual for a description of the coverage of such services. 65.06-5 Financial Services: Any services, or components of services of which the basic nature is to provide economic services to the member, such as financial or credit counseling are not covered under this Section. 65.06-6 Driver Education and Evaluation Program (DEEP) Evaluations: Any program, services or components of services of which the basic nature is to provide DEEP evaluations are not reimbursable under this Section. 65.06-7 Comparable or Duplicative Services: Services as defined under this Section are not covered if the member is receiving comparable or duplicative services under this or another Section of the MaineCare Benefits Manual. A. Any Services provided as a Covered Service under Section 65 are not covered and are not reimbursable if the member is receiving another service under Section 65, except as set forth in the specific Covered Services and as follows: 1. Such concurrent services require PA for a specified duration and amount by DHHS or an Authorized Entity, and 2. Such exceptions are documented in the member’s ITP, and 3. Concurrent services are consistent with the provisions in the MaineCare services described in this Section and other MaineCare Benefits Manual Sections, and 4. There is a clear, documented clinical justification as to why concurrent treatment under this service is needed, as follows: a. During the course of provision of a service the Clinician uncovers an issue requiring referral to specialized treatment (e.g., trauma, sexual abuse issue, substance use), or b. The service is necessary for a successful transition of the member to a different level of care. B. Other such comparable or duplicative services include, but are not limited to, services covered under MaineCare Benefits Manual, Section 40, “Home Health Services”, and Section 96, “Private Duty Nursing Services”; services that are duplicated by a Private Non-Medical Institution providing services under Section 97; services that are duplicated by a Section 13, “Targeted Case Management Services” provider; services that are duplicated by a Section 17, “Community Support Services” provider; services that are duplicated by a Section 92, “Behavioral Health Home Services” provider; services that are duplicated by a Section 93, “Opioid Health Home Services” provider; and other services described in this Section. Refer to Appendix II for further detail on comparable or duplicative services. 65.07 LIMITATIONS 65.07-1 Services in Individualized Treatment Plan Only services included in the ITP will be reimbursed. Reimbursement will be allowed for covered services prior to the approval of the initial ITP, when the provider obtains subsequent approval of those services within thirty (30) days of the date the member begins treatment. 65.07-2 Prior Authorization and Utilization Review Some services in this section require PA, including, but not limited to, Children’s ACT and HCT. In accordance with 22 M.R.S. §3174-EEE, PA is not required for certain services for members with an Opioid Use Disorder including, but not limited to, OTP Services with Methadone and SU-IOP. PA criteria can be found at: https://mainecare.maine.gov/ProviderHomePage.aspx After submitting a PA request the provider will receive PA with a description of the type, duration and costs of the services authorized. The provider is responsible for providing services in accordance with the Prior Authorization letter. The PA number is required on the CMS 1500 claim form. All extensions of services beyond the original authorization must be prior authorized by this same procedure. All other services in this section require notification of initiation of services for Utilization Review purposes. 65.07-3 Crisis Resolution* *This provision regarding Crisis Resolution Services is effective until June 30th, 2026. Beginning July 1, 2026, MaineCare will cover this service, which will be known as Mobile Crisis Intervention Response Services, under Chapter II, Section 66. -5715002794000A treatment episode includes face-to-face visits and related follow up phone calls, as clinically indicated, up to (60) days after the first face to face visit. DHHS Office of Child and Family Services (OCFS) or OBH Medical Director or Designee may approve additional time, if medically necessary and clinical documentation supports the need for the service. Crisis resolution services will cover the time necessary to accomplish appropriate crisis intervention, collateral contact, stabilization and follow-up. When increased staffing is necessary to ensure that a member receives necessary services while the safety of that member is maintained, MaineCare reimbursement for these services will be made to more than one (1) Clinician and/or other qualified staff at a time. Providers must maintain documentation of the necessity of this treatment. More than one agency may be reimbursed for crisis contacts and respective face-to-face follow-up contacts for children and adult crisis resolution services only when the two agencies have a formal agreement or sub-contract stipulating one (1) or more agencies deliver phone services and the other agency (or agencies) provide follow-up, and face-to-face services. 65.07-4 Outpatient Services A. There is a limit on Children’s mental health, substance use and co-occurring mental health and substance use Outpatient Services of seventy-two (72) quarter-hour units of service per year. For a member to receive services beyond seventy-two (72) quarter-hour units of service in a service year for Children’s mental health, substance use, or co-occurring mental health and substance use Outpatient Services, the following conditions must be satisfied: 1. Any member receiving Children’s mental health, substance use, or co-occurring mental health and substance use Outpatient Services must have a Serious Emotional Disturbance or a mental health, substance use or co- occurring mental health and substance use diagnosis in accordance with the DSM or the DC 0-5; 2. Documented evidence in the member’s file that continued treatment is necessary to correct or ameliorate a mental health, substance use or co-occurring condition. Documentation must include prior treatment, progress, if any, and clinical justification that additional treatment is medically necessary. For substance use and co-occurring mental health and substance use services, members must meet ASAM Level 0.5 or Level 1 placement criteria for individual, family or group outpatient services; and 3. The member must be participating in treatment and making progress toward goals or, if the member is not making progress, there must be an active strategy in place to improve progress toward goals. B. There is a limit on Adult’s mental health, substance use, and co-occurring mental health and substance use Outpatient Services of seventy-two (72) quarter-hour units of service per year. For a member to receive services beyond seventy-two (72) quarter-hour units of service in a service year for Adult’s Mental Health, substance use, or co-occurring mental health and substance use Outpatient Services, the following conditions must be satisfied: 1. Any member receiving Adult Mental Health, substance use, or co-occurring mental health and substance use Outpatient Services must have a diagnosis from the DSM and for substance use and co-occurring mental health and substance use services, members must meet ASAM Level 0.5 or Level 1 placement criteria for individual, family, or group outpatient services; 2. There must be documented evidence in the member’s file that continued outpatient treatment: a. Is reasonably expected to bring about significant improvement in symptoms and functioning; and b. Is medically necessary to prevent the mental health, substance use or co-occurring mental health and substance use condition from worsening, such that the member would likely need continued outpatient treatment; and 3. The member must be participating in treatment and making progress toward goals supporting his or her ongoing recovery, or, if the member is not making progress, there must be an active strategy in place to improve progress toward goals. C. Outpatient Diagnostic Assessment Outpatient Diagnostic Assessments are used to determine whether a member has a behavioral health diagnosis in accordance with the DSM or DC: 0-5. The assessment may include all standard components of a diagnostic assessment, including, but not limited to, a biopsychosocial assessment, a mental status exam, evaluation of risk factors, and discussion of their behavioral health history. . Reimbursement for Outpatient Diagnostic Assessments do not include psychological testing. Reimbursement for Outpatient Diagnostic Assessments shall not exceed two (2) hours or eight (8) units annually. An additional one (1) hour or four (4) units will be authorized if the member chooses to switch providers and the new provider needs additional units to conduct an Outpatient Diagnostic Assessment. D. Individual Outpatient Therapy For Members, individual and Family mental health or co-occurring Individual Outpatient Therapy is limited to two (2) hours per week except when a member requires services for an emergency or crisis situation or when a service is medically necessary to prevent hospitalization. For Members, individual and Family outpatient for those needing interpreter services will be limited to three (3) hours per week. For Members, substance use individual and family outpatient is limited to three (3) hours per week. MaineCare reimbursement for Individual Outpatient Therapy will be made to only one (1) provider at any given time unless temporary coverage is provided in the absence of the usual provider. A member may receive mental health individual outpatient and substance use individual outpatient services concurrently from two (2) separate providers in accordance with the individual service limits. If a member is receiving integrated Co-occurring Services with one (1) provider for a mental health and a substance use diagnosed condition; the member may not also receive separate mental health or substance use Individual Outpatient Therapy services under Section 65 Behavioral Health Services. E. Group Outpatient Therapy 1. Members receiving Group Outpatient Therapy must be eight (8) years of age or older, unless members less than eight (8) years of age receive Family therapy or receive outpatient therapy in a group to specifically address a severe childhood trauma that may include, but is not limited to, a serious threat to one's life or physical integrity, a serious threat or harm to a Parent, or sudden destruction of one's home or community. 2. Reimbursement for Group Outpatient Therapy is limited to ninety (90) minutes per week except for: a. Members in an inpatient psychiatric facility for whom services shall be provided in accordance with the plan of care; or b. Members who are in Group Outpatient Therapy that is designated for the purpose of trauma treatment; or c. Members who are sex offenders or victims of sexual abuse, and are in Group Outpatient Therapy designated for treatment of sex offenders or victims of sexual abuse; or d. Members aged twenty (20) years or less, whose ITP documents the need for weekly outpatient therapy in excess of ninety (90) minutes per week. e. Members who receive Dialectical Behavior Therapy (DBT) meet for two (2) to two and a half (2 ½) hours per week for up to one (1) year but may meet more frequently for a shorter duration than one (1) year. f. Members who receive Differential Substance Abuse Treatment (DSAT) meet for two (2) three (3) hour groups per week for up to eight (8) weeks during the intensive phase of this Evidence-Based Practice. The DSAT maintenance phase follows the intensive DSAT treatment and members attend one (1) two (2) hour group per week for up to twenty-three (23) weeks. 3. Group Outpatient Therapy for mental health, substance use, and Co-occurring Services requires a minimum of three (3) members and is limited to no more than ten (10) members in a group when one (1) Clinician is conducting the group. No more than two (2) members of the same Family shall receive services in the same group, unless it is a Family outpatient therapy group. When Group Outpatient Therapy is provided to a group of more than four (4) members, it can be provided by up to two (2) therapists at one time. If more than ten (10) members attend, two (2) Clinicians must conduct the group. Reimbursement for Group Outpatient Therapy is allowed if more than three (3) members are scheduled for the session but only three (3) or fewer members attend due to unavoidable circumstances. 4. When Group Outpatient Therapy is delivered by two (2) Clinicians, both Clinicians may not bill for providing the same services to the same members at the same time. When Group Outpatient Therapy is provided by both professionals at the same time, they can bill as follows: a. One provider seeks reimbursement for the provision of services to the total number of members in the group; or b. Each therapist bills for services provided to a portion of the total number of members in the group. Each co-therapist may bill only for the portion of members for which the other co-therapist has not billed. The total amount submitted by both therapists for MaineCare reimbursement must not exceed the total number of members in the group. For example, if there are eight (8) members in Group Outpatient Therapy, each provider may bill the group rate for the session, accounting for four (4) members each. The provider billing for the member is responsible for maintaining all clinical records relating to that member. 65.07-5 Intensive Outpatient Program Services (IOP) Intensive Outpatient Program Services must be delivered for a minimum of three (3) hours per day, three (3) days a week. A provider may not be reimbursed for delivering more than one (1) outpatient service to a member at the same time. An outpatient service is Outpatient Services as described in (65.05-1), Intensive Outpatient Program Services (IOP) as described in (65.05-4), or (OTP) Services with Methadone as described in (65.05-10). IOP group services require a minimum of three (3) members. If more than ten (10) members attend, two (2) qualified staff must conduct the group. Reimbursement for IOP group services is allowed if more than three (3) members are scheduled for the group but only three (3) or fewer members attend due to unavoidable circumstances. Members may receive additional outpatient services as medically necessary when the treating condition(s) is distinct from the condition(s) addressed by the IOP. 65.07-6 Medication Management Services Medication Management limits for reimbursement are as follows: A. For adults, up to one (1) hour is allowed for the Comprehensive Assessment of Medication Management. B. For Children, up to two (2) hours is allowed for the Comprehensive Assessment of Medication Management. All subsequent sessions for Medication Management and evaluation are limited to thirty (30) minutes. Any additional time beyond the thirty (30) minutes is considered outpatient counseling and is only reimbursable if it is prior authorized and covered as an Outpatient Service, as defined in this Section. Providers must have documentation in their records to support those billings. Providers may bill for only one (1) encounter of Medication Management Services with a member per day, which may consist of both Medication Management and Outpatient Services on the same day. 65.07-7 Psychological Testing and Adaptive Assessments -148590016573500Psychological testing includes the administration of the test, the interpretation of the test, and the preparation of test reports. Psychometric testing does not include preliminary diagnostic interviews or subsequent consultation visits. Reimbursement for psychological testing will be limited to testing administered at such intervals indicated by the testing instrument and as clinically indicated. Psychological testing is limited to no more than four (4) hours for each test except for the tests listed below. Providers must maintain documentation that clearly supports the hours billed for administration and associated paperwork. Each Halstead-Reitan Battery or any other comparable neuropsychological battery is limited to no more than seven (7) hours (including testing and assessment). This is to be used only when there is a question of a neuropsychological and cognitive deficit. Testing for intellectual level is limited to no more than two (2) hours for each test. Each self-administered test is limited to thirty (30) minutes. Only the testing for the eligible member is reimbursable. This includes self- administered tests completed for the benefit of the member as indicated by the testing instrument. The following tests are considered self-administered, and include but are not limited to: A. Achenbach Child Behavior Checklist; B. Adult Adolescent Parenting Inventory; C. Child Abuse Potential Survey; D. Connor’s Rating Scales; E. Parenting Stress Index; F. Piers-Harris Self Concept Scale; G. Reynolds Children’s Depression Scale; H. Rotter Incomplete Sentences Blank; I. Shipley Institutes of Living Scale; and J. Fundamental Interpersonal Relations Orientation Scale-Behavior (FIROB). Adaptive assessments are limited to no more than two (2) hours per assessment. One assessment is allowable per member per calendar year. Providers must maintain documentation that clearly supports the hours billed for administration and associated paperwork. 65.08 POLICIES AND PROCEDURES -45720012700065.08-1 Supervision of Direct Care Staff* Any direct care staff that deliver services, but are not Clinicians, are required to meet supervision requirements in accordance with 10-144 C.M.R. ch. 123, Behavioral Health Organizations Licensing Rule. * The Department is seeking and anticipates approval from the Centers for Medicare & Medicaid Services of a State Plan Amendment related to this provision. -45720012700065.08-2 Behavioral Health Professional Certification* A. To qualify for the BHP certification, individuals must meet the following criteria: 1. Be 18 years of age or older; 2. Have a high school diploma or equivalent; 3. Obtain BHP certification within one hundred and eighty (180) days of hire; and 4. Must not be annotated pursuant to 10-144 C.M.R. ch. 128, Certified Nursing Assistant and Direct Care Worker Registry Rule. The provisional candidate must begin receiving BHP training within thirty (30) days from the date of hire and must complete the training and obtain certification within one hundred and eighty (180) days of the date of hire. Records of BHP training and certifications, and the length of provisional status must be maintained in the agency’s personnel files. Provisional candidates who have not completed certification requirements in full within one hundred and eighty (180) days of the date of hire are not eligible to perform reimbursable services with any provider until certification is complete. Additional requirements for BHP certification may apply for some services in this rule and are clarified in the specific sub-section. * The Department is seeking and anticipates approval from the Centers for Medicare & Medicaid Services of a State Plan Amendment related to this provision. 65.08-3 Direct Support Professional (DSP) A DSP is a person who: A. Successfully completed the Direct Support Professional curriculum as adopted by DHHS, or demonstrated proficiency through DHHS’s approved Assessment of Prior Learning, or has successfully completed the curriculum from the Maine College of Direct Support within six (6) months of date of hire. Prior to providing services to a member alone, a DSP must have completed the following four modules from the College of Direct Support, including computer based and live sessions: 1. Introduction to Developmental Disabilities 2. Professionalism 3. Individual Rights and Choice 4. Maltreatment Documentation of completion must be retained in the personnel record. Completed the following Department-approved trainings, within the first six (6) months from date of hire and thereafter every thirty-six (36) months: Reportable Events System (14-197, ch. 12) Regulations Governing Behavioral Support, Modification and Management for People with Intellectual Disabilities or Autism in Maine (14-197, ch. 5) Rights and Basic Protections of a Person with an Intellectual Disability or Autism (Title 34-B §5605) Grievance Training (must be completed before working with members). Has a background check consistent with Section 65.08-8; Has an adult protective and Child protective record check; E. Is at least eighteen (18) years of age; F. Graduated from high school or acquired a GED; G. Has current CPR and First Aid Certification. H. Prior to administering medication, is legally authorized to assist with the administration of medication if the DSP is certified as a Certified Nursing Assistant-Medications (CNA-M), as a Certified Residential Medication Aide (CRMA), or a Registered Nurse (RN), or otherwise has been trained to administer medications through a training program specifically for Family-Centered or Shared Living model homes and authorized, certified, or approved by DHHS. All new staff or subcontractors shall have six (6) months from their date of hire to obtain DSP certification. Evidence of date of hire and enrollment in the training must be documented in writing in the employee’s personnel file or a file for the subcontractor. Services provided during this time are reimbursable as long as the documentation exists in the personnel file. A person who provides Direct Support must be a DSP regardless of his or her status as an employee or subcontractor of a provider . A DSP can supervise another DSP. 65.08-4 Member Records A member’s record must contain written documentation of a Comprehensive Assessment, an ITP and progress notes. The Comprehensive Assessment process determines the intensity and frequency of Medically Necessary Services and includes utilization of instruments as may be approved or required by DHHS. ITPs are the plans of care developed by the treatment team with the member and in consultation with the Parent, guardian, and/or natural supports, if appropriate, based on a Comprehensive Assessment of the member. Individualized plans include the ITP, the Crisis/Safety Plan (as clinically indicated) and the Discharge Plan. A. Comprehensive Assessment 1. A Clinician must complete a Comprehensive Assessment that integrates co-occurring mental health and substance use issues within thirty (30) days of the day the member begins services. The Comprehensive Assessment must be included in the member’s record. The Comprehensive Assessment process must include a direct encounter with the member and if appropriate, Family members, Parents, friends, and guardian. The Comprehensive Assessment must be updated at a minimum, when there is a change in level of care, or when major life events occur, and annually. The Comprehensive Assessment must contain documentation of the member’s current status, history, strengths and needs in the following domains: personal, Family, social, emotional, psychiatric, psychological, medical, drug and alcohol (including screening for Co-occurring Services), legal, housing, financial, vocational, educational, leisure/recreation, potential need for crisis intervention, physical/sexual and emotional abuse. The Comprehensive Assessment may also contain documentation of developmental history, sources of support that may assist the member to sustain treatment outcomes including natural and community resources and state and federal entitlement programs, physical and environmental barriers to treatment and current medications. Domains addressed must be clinically pertinent to the service being provided. Additionally, for a Comprehensive Assessment for a member with substance use, the documentation must also contain age of onset of alcohol and drug use, duration, patterns and consequences of use, Family usage, types and response to previous treatment. 2. The Comprehensive Assessment must be summarized and include a diagnosis in accordance with the DSM or the DC 0-5, as appropriate. The Comprehensive Assessment must be signed, credentialed, and dated by the Clinician conducting the Comprehensive Assessment. A Comprehensive Assessment for a member with a substance use diagnosis must also contain ASAM level of care criteria. If the Comprehensive Assessments for a member receiving integrated treatment for Co-occurring Disorders, the Comprehensive Assessment must contain both the DSM and ASAM Criteria. 3. If a provisional diagnosis is made by an MHRT or CADC providing the direct service, the diagnosis will be reviewed within five (5) working days by the supervising licensed Clinician and documented in the record. 4. The Comprehensive Assessment must contain documentation if information is missing and the reason the information cannot be obtained or is not clinically applicable to the service being provided. 5. For members receiving Family Psychoeducation, Neurobehavioral Status Exam, Neuropsychological Testing, Psychological Testing, and Adaptive Assessments, no Comprehensive Assessment is required. B. Individualized Treatment Plan The Clinician, member and other participants (service providers, Parents or guardian) must develop an ITP, based on the Comprehensive Assessment that is appropriate to the developmental level of the member. 2. When an ITP is required it must contain the following, unless there is an exception: a. The member’s diagnosis and reason for receiving the service; b. Measurable long-term goals with target dates for achieving the goals; c. Measurable short-term goals with target dates for achieving the goals, objectives that allow for measurement of progress, and the tasks the member must perform to complete goals; d. Specific services to be provided with amount, frequency, duration and Practice Methods of services, and designation of who will provide the service, including documentation of Cooccurring Services and Natural Supports, when applicable; e. Measurable Discharge criteria; f. Special accommodations needed to address physical or other disabilities to provide the service; g. For OTP services, the dosage plan, as documented by a physician or physician extender advanced practice professional in the member’s record; h. -22860069215000Participant signatures, credential (if applicable) and date for the initial ITP. For OTP services, the initial ITP must also be signed by the medical director. The first thirty (30) or ninety (90) day period begins with date of the initial signed ITP. i. The Clinician, member and other participants if indicated (service providers, Parent(s) or Guardian(s)) must review the ITP at all major decision points but no less frequently than ninety (90) days, or as described in 65.08-4(B)(3). If clinically indicated, the member’s needs may be reassessed, and the ITP may be reviewed and amended more frequently than described in 65.08-4(B)(3). Changes to the ITP are in effect as of the date it is signed by the Clinician and member or, when appropriate, the Parent or Guardian. All participants must sign, credential (if applicable) and date the reviewed ITP. 3. The ITP must be completed and reviewed within the following schedule as applicable: a. Crisis Resolution - as clinically indicated. For members receiving Crisis Resolution Services, a written plan of care is substituted for the ITP. b. Outpatient Services - Mental Health, Co-occurring, and Medication Management Services completed within thirty (30) days from admission and reviewed every twelve (12) visits or annually, whichever comes first. c. Outpatient - Substance Use completed within three (3) outpatient sessions and reviewed every ninety (90) days. d. Intensive Outpatient Program Services completed within three (3) outpatient sessions from admission and reviewed every thirty (30) days. e. Children’s ACT, HCT completed within thirty (30) days from admission and reviewed every ninety (90) days. f. Opioid Treatment Program Services with Methadone completed within seven (7) calendar days from admission and reviewed every ninety (90) days. 4. For members receiving Family Psychoeducation, Neurobehavioral Status Exam, Neuropsychological Testing, Psychological Testing, and Adaptive Assessments, no ITP is required. 5. If a member receives covered “Case Management Services” under MaineCare Benefits Manual, to include Section 13, Section 17, Section 92, Section 93, or any similar case management services, the member’s mental health provider's ITP will coordinate with the appropriate portion of the member’s ITP described in the MaineCare Benefits Manual to include, but not limited to, Section 13, Section 17, Section 92, or Section 93. 6. MaineCare will reimburse for covered services provided before the ITP is approved as long as the ITP is completed within prescribed time frames from the day the member begins treatment. 7. If a member is assessed by appropriate staff, but an ITP is not developed because there is at least a sixty (60) day waiting list to enter into treatment, reimbursement may be made for the assessment only. Comprehensive Assessments must be updated before treatment begins if, in the opinion of the professional staff assigned to the case, this would result in more effective treatment. If an update is necessary, additional units for the Comprehensive Assessment may be authorized by DHHS or an Authorized Entity. 8. Crisis Plan The crisis plan must: a. Identify the precursors to the crisis; b. Identify the strategies and techniques that may be utilized to stabilize the situation and help ensure the safety of the member and others when a member experiences a crisis; c. Identify the individuals responsible for the implementation of the plan including any individuals whom the member (or Parents or Guardian, as appropriate) identifies as significant to the member’s stability and well-being; and d. Be reviewed every ninety (90) days or as part of the required review of the ITP. C. Documentation Providers must maintain written progress notes for all services, in chronological order. All entries in the progress note must include the service provided, the provider’s signature and credentials, the date on which the service was provided, the duration (including the beginning and end time) of the service, and the progress the member is making toward attaining the goals or outcomes identified in the ITP. For in-home services, the progress note must also contain the time the provider arrived and left. Additionally, the provider must ask the member or an adult responsible for the member to sign off on a time slip or other documentation documenting the date, time of arrival, and time of departure of the provider. In the case of co-therapists providing group psychotherapy, the provider who bills for the service for a specific member is responsible for maintaining records and signing entries for that member. Facsimile or electronic signatures will be considered valid by DHHS if in accordance with mental health licensing standards. Separate clinical records must be maintained for all members receiving group psychotherapy services. The records must not identify any other member or confidential information of another member. -148590063500 The clinical record shall also specifically include written information or reports on all medication reviews, medical consultations, psychometric testing, and collateral contacts made on behalf of the member (name, relationship to member, etc.). Documentation of cases where a member requires more than two (2) hours of outpatient services per week to prevent hospitalization must be included in the file. This documentation must be signed by the supervising Clinician. D. Discharge/Closing Summary A closing summary shall be signed, credentialed and dated and included in the clinical record at the time of discharge. This will include a summary of the treatment. The summary shall include: 1. The date of discharge, reason for discharge and, if applicable, the name, telephone number, address and relationship of the person(s) or provider to whom the member was discharged; 2. A summary of the services provided during the member’s treatment, including the member’s progress during treatment and any unmet needs; 3. The member’s diagnosis at discharge, using the DSM or DC 0-5; and 4. Disposition of the member’s care, including services recommended and the plan for follow-up services, including identification of who is responsible for continued services. The closing summary shall be provided to the member and/or their parent/guardian, as applicable. All service authorizations must be closed by the date of discharge. E. Quality Assurance Periodic review of cases to assure quality and appropriateness of care will be conducted in accordance with the quality assurance (QA) protocols established by DHHS. Reviews will be in writing, 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. 65.08-5 Program Integrity (PI) Unit Program Integrity Unit requirements apply as defined in the MaineCare Benefits Manual, Chapter I, Section 1, “General Administrative Policies and Procedures”. 65.08-6 Protections for Adults with Serious Mental Illness If the member with a Serious Mental Illness is receiving Behavioral Health services reimbursed under Section 65 identified in the member’s ITP, then the provider must: Obtain written approval from the Director of the OBH or designee prior to terminating Mental Health Psychosocial Clubhouse Services as defined in 65.05-15, Medication Management Services as defined in 65.05-5, and Specialized Group Services as defined in 65.05-16. Written approval is not required in cases where the terminating provider has successfully facilitated a member’s transfer, with the member’s consent, to a new provider. If approved by OBH, issue a thirty (30) day advanced written termination notice to the member prior to termination of member’s services. In cases where the member poses a threat of imminent harm to persons employed or served by the provider, the Director of OBH, or designee may approve a shorter notification for termination of services; Assist the member in obtaining clinically necessary services from another provider prior to discharge or termination; Accept Department referrals through the Department-defined referral process within seven calendar days for members deemed eligible for Medication Management Services. Only in cases where providers have received written approval from OBH, may a referral be declined. 65.08-7 Background Check Requirements Behavioral Health Services providers must conduct background checks every five (5) years on all prospective and current employees, persons contracted or hired, consultants, volunteers, students, and other persons who may be providing direct support services under this Section. Background checks on persons professionally licensed by the State of Maine will include a confirmation that the licensee is in good standing with the appropriate licensing board or entity. The provider shall contact child and adult protective services (including OADS and the Office of Child and Family Services) units within State government to obtain any record of substantiated allegations of abuse, neglect, or exploitation against an employment applicant before hiring the same. The provider shall follow the requirements set forth in 22 M.R.S. ch. 1961, The Maine Background Check Center Act, and 10-144 C.M.R. ch. 60, Maine Background Check Center Rule, for requirements on conducting and evaluating employee background checks. All background checks must be completed every five (5) years thereafter in accordance with 10-144 C.M.R. ch. 60. Costs for background checks are the provider’s responsibility. 65.08-8 Additional Requirements for Providers of Children’s Services A. Demonstrate utilization of the Federal Substance Abuse and Mental Health Services Administration’s (SAMHSA) System of Care Principles to include: Documentation of policies and procedures that incorporate System of Care Principles; and Documentation of System of Care Principles training for all staff to be completed within ninety (90) days of hire, and as requested by the Department. Adhere to the Rights of Recipients of Mental Health Services (14-193 C.M.R. ch. 1) and the Rights of Recipients of Mental Health Services Who are Children in Need of Treatment (14-472 C.M.R. ch. 1). Providers must maintain all appropriate Licensing and Credentialing and must notify the Department of any changes in licensing or credentialing status. Complete required disclosures and informed consents prior to delivering services and on an annual basis thereafter. Service providers must: Acquire informed consent for services from the member and their parent or legal guardian, when applicable. Informed consent means communicating in writing a description of services being provided, service goals, service expectations, disclosure of potential risks and benefits of services, and the roles and responsibilities of the provider. Informed consent also includes communication in writing of the family’s/caregiver’s role and responsibilities in the treatment process. Proof of informed consent must be documented in writing and signed by the provider and the parent/legal guardian; and For applicable services, inform the member, and in the case of a minor, the member’s parents or legal guardian(s), of the provider’s policy regarding the use of restraints during an emergency safety situation and provide a written copy of the policy to the member and their legal guardian as applicable, and the provider must communicate its restraint policy in a language that the member and their parent(s) or legal guardian(s) understand, and when necessary, provide interpreters to ensure that the member and/or their family understand the policy; and 3. Review with the member and their parent/legal guardian, the provider’s role and responsibility as a mandated reporter of abuse and/or neglect pursuant to 22 M.R.S. §3477 and 22 M.R.S. §4011-A and document this disclosure in the member’s record. 65.08-9 Quality Assurance Review Requirements Providers delivering services to Children under Section 65 shall participate in quality assurance reviews conducted by the Department to include on-site and/or document quality reviews which may result in quality improvement recommendations. 65.09 APPEALS In accordance with Chapter I, Section 1, of the MaineCare Benefits Manual, members have the right to appeal in writing or verbally any decision made by DHHS to reduce, deny or terminate services provided under this benefit. 65.10 REIMBURSEMENT *The Department will seek, and anticipates approval, from CMS, related to this provision. Specific reimbursement rates for services are listed on the MaineCare Provider Fee Schedule, which is posted on the Department’s website in accordance with 22 M.R.S.A. Section 3173-J(7), at https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx 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. All providers must append the appropriate modifiers identified in billing instructions to claim lines for covered services that are required by an individualized education program (IEP) or individualized family service plan (IFSP). Providers should not use the same modifiers when billing for MaineCare covered services that are listed as optional in an IEP or IFSP. Covered Service Code Modifier Unit Outpatient Diagnostic Assessment Psychologist – Office H2000 AH 15 minutes APRN-PMH-NP/APRN-PMH-CNS/LCSW/LCPC/LMFT – Office H2000 HO 15 minutes Deaf – Office H2000 15 minutes LADC – Office H2000 HN 15 minutes CADC – Office H2000 HM 15 minutes Psychologist – Community H2000 AH U2 15 minutes APRN-PMH-NP/APRN-PMH-CNS/LCSW/LCPC/LMFT – Community H2000 HO U2 15 minutes Deaf – Community H2000 U2 15 minutes LADC – Community H2000 HN U2 15 minutes CADC – Community H2000 HM U2 15 minutes Outpatient Services – Individual/Family – Office Psychologist, One-to-One – Office H0004 AH 15 minutes APRN-PMH-NP/APRN-PMH-CNS/LCSW/LCPC/LMFT – Office H0004 HO 15 minutes Deaf, One-to-One – Office H0004 15 minutes LADC, One-to-One – Office H0004 HN 15 minutes CADC, One-to-One – Office H0004 HM 15 minutes Trauma-Focused Cognitive Behavioral Therapy – Office H0004 ST 15 minutes Outpatient Services – Individual/Family – Community Psychologist – Community H0004 AH U2 15 minutes APRN-PMH-NP/APRN-PMH-CNS/LCSW/LCPC/LMFT – Community H0004 HO U2 15 minutes Deaf – Community H0004 U2 15 minutes LADC – Community H0004 HN U2 15 minutes CADC – Community H0004 HM U2 15 minutes Trauma-Focused Cognitive Behavioral Therapy – Office H0004 ST U2 15 minutes Outpatient Services – Group Therapy Psychologist, Group – Office H0004 AH HQ 15 minutes APRN-PMH-NP/APRN-PMH-CNS/LCSW/ LCPC/ LMFT, Group – Office H0004 HO HQ 15 minutes LADC, Group – Office H0004 HN HQ 15 minutes CADC, Group – Office H0004 HM HQ 15 minutes Intensive Outpatient Program (IOP) Services Substance Use H0015 Per Diem Substance Use – Level II H0015 CG Per Diem Mental Health H0015 HE Per Diem Dev. Disabilities / Behavioral Health H0015 HI Per Diem Geriatric H0015 HC Per Diem Dialectical Behavior Therapy H0015 HK Per Diem Eating Disorder – Level I H0015 HT Per Diem Eating Disorder – Level II H0015 HT AT Per Diem Medication Management Services Adult Services H2010 15 minutes Children’s Services H2010 HA 15 minutes Neurobehavioral Status Exam, Neuropsychological Testing, Psychological Testing, and Adaptive Assessments Neurobehavioral Status Exam, Psychologist or Physician (includes face-to-face time with the member, time interpreting test results, and preparing the report) – First Hour 96116 HE 1 hour Neurobehavioral Status Exam, Psychologist or Physician (includes face-to-face time with the member, time interpreting test results, and preparing the report) – Each Additional Hour 96121 HE 1 hour Psychological testing, Psychologist or Physician (includes face-to-face time administering tests to the member and time interpreting these results and preparing the report) – First Hour 96130 HE 1 hour Psychological testing, Psychologist or Physician (includes face-to-face time administering tests to the member, time interpreting these results, and preparing the report) – Each Additional Hour 96131 HE 1 hour Neuropsychological testing (e.g., Halstead Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), Psychologist or Physician (includes face-to-face time administering tests to the member, time interpreting these test results, and preparing the report) – First Hour 96132 HE 1 hour Neuropsychological testing (e.g., Halstead Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), Psychologist or Physician (includes face-to-face time administering tests to the member, time interpreting these test results, and preparing the report) – Each Additional Hour 96133 HE 1 hour Psychological or Neuropsychological test administration – two or more tests –Psychologist or Physician (includes face-to-face time administering tests to the member, time interpreting these test results, and preparing the report) - First 30 Minutes 96136 HE 30 minutes Psychological or Neuropsychological test administration – two or more tests –Psychologist or Physician (includes face-to-face time administering tests to the member, time interpreting these results, and preparing the report) – Each Additional 30 Minutes 96137 HE 30 minutes Neuropsychological and Psychological testing – Psychological Examiner (interpretation and report, administered by a technician, face-to-face) – First 30 Minutes 96138 HE 30 minutes Neuropsychological and Psychological testing – Psychological Examiner (interpretation and report, administered by a technician, face-to-face) – Each Additional 30 Minutes 96139 HE 30 minutes Adaptive Assessment – First Hour 96112 HE 1 hour Adaptive Assessment – Each Add. 30 min 96113 HE 30 minutes Children’s Assertive Community Treatment (ACT) Children’s ACT H0040 HA Weekly Children’s Comprehensive Community Support Services - Home and Community Based Treatment (HCT) HCT H2021 HA Weekly HCT – (OCFS-Funded) H2021 HU Weekly HCT – (TF-CBT) H2021 ST Weekly Children’s Comprehensive Community Support Services – Functional Family Therapy (FFT), Multi-Systemic Therapy (MST) and MST for Problem Sexualized Behaviors (MST-PSB) FFT H2021 HE Weekly MST H2033 Weekly MST-PSB H2033 HK Weekly Opioid Treatment Program Services Opioid Treatment Program Services (based on 72.4% of Medicare G2067) H0020 Weekly Children’s Behavioral Health Day Treatment BHP Level H2012 HN 15 minutes BHP Level – Two patients served H2012 HN UN 15 minutes BHP Level – Three patients served H2012 HN UP 15 minutes BHP Level – Four patients served H2012 HN UQ 15 minutes Master’s Level H2012 HO 15 minutes Master’s Level – Two patients served H2012 HO UN 15 minutes Master’s Level – Three patients served H2012 HN UP 15 minutes Master’s Level – Four patients served H2012 HO UQ 15 minutes Tobacco Cessation Treatment Services Smoking and Tobacco Cessation Counseling, individual, intermediate 99406 3-10 minutes Smoking and Tobacco Cessation Counseling, individual, intensive 99407 >10 minutes Preventive Medicine, Tobacco Cessation Group Counseling 99411 30 minutes Preventive Medicine, Tobacco Cessation Group Counseling 99412 60 minutes Mental Health Psychosocial Clubhouse Services Mental Health Clubhouse Services H2030 15 minutes Specialized Group Services Wellness Recovery Action Planning H2019 HH Session Recovery Workbook H2019 HE Session Trauma Recovery and Empowerment H2019 ST Session Dialectical Behavior Therapy H2019 HK Session Behavioral Therapies Triple P 1:1 – Bachelor's T1027 HN HA Session Triple P – Group 2-4 members – Bachelor's T1027 HN HA UN Session Triple P – Group 5-7 members – Bachelor's T1027 HN HA UR Session Triple P – Group 8+ members – Bachelor's T1027 HN HA US Session Triple P 1:1 – Master's T1027 HO HA Session Triple P – Group 2-4 members – Master's T1027 HO HA UN Session Triple P – Group 5-7 members – Master's T1027 HO HA UR Session Triple P – Group 8+ members – Master's T1027 HO HA US Session Incredible Years – Group 2-4 members T1027 TJ UN Session Incredible Years – Group 5-7 members T1027 TJ UR Session Incredible Years – Group 8+ members T1027 TJ US Session Parent-Child Interaction Therapy (PCIT) T1027 HA 15 minutes Crisis Resolution Services* Crisis Resolution H2011 15 minutes Crisis Resolution -Children H2011 HA 15 minutes *This service will only be provided under Section 65 through June 30, 2026. This provision will not be legally effective after June 30, 2026. Effective July 1, 2026, MaineCare will cover this service under Section 66 (Crisis Services), and the service will be known as “Site-Based Crisis Stabilization Services”. 65.10-1 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 65 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). 65.10-2 Pay-for-Performance for HCT* * The Department is seeking and anticipates approval from the Centers for Medicare & Medicaid Services of a State Plan Amendment related to this provision. Performance Thresholds Upon setting applicable performance thresholds within this provision, the Department will withhold four (4) percent of HCT payments. The remaining four (4) percent of the rate will be paid to providers every three (3) months if the provider satisfies the Minimum Performance Threshold. Subject to the availability of appropriations, the Department will reimburse providers that meet the Excellence Performance Threshold an additional 1% of the total PMPM payments every three (3) months. Minimum and Excellence Performance Thresholds are based on a composite score of the performance measures. Performance thresholds are set in advance of performance periods. If the performance threshold(s) change, HCT providers will not be scored on an adjusted threshold until six (6) months after the change is implemented. The Department shall set the performance thresholds so that no less than 70% of eligible providers are expected to be above the Minimum Performance Threshold and no less than 20% of providers are expected to be above the Excellence Performance Threshold. This means that 30% of eligible providers, at baseline, are not expected to meet the Minimum Performance Threshold and thus will not receive the four (4) percent payment. The Department cannot anticipate the exact percentage of providers that will, during the performance period, satisfy either or neither of the performance thresholds. B. Pay-for-Performance Reporting Beginning July 2026, all HCT providers, regardless of performance, will receive a quarterly report with the performance assessment, indicating whether they satisfied the Minimum or Excellence Performance Threshold standards and what their reimbursement will be. The report will contain instructions for the HCT provider to appeal and/or rebut the report’s data if the HCT provider disagrees with the report and the reimbursement they are set to receive. The Department will provide a thirty (30) day rebuttal period prior to issuing reimbursement. C. Performance Measures HCT providers are eligible for the pay-for-performance provision if at least 10% of their member panel is eligible for inclusion in the performance measures and if there is a sufficient quality measure-eligible population to allow for appropriate assessment. The sufficient quality measure-eligible population for each quality measure will be listed on: www.maine.gov/dhhs/oms/providers/valuebased-purchasing. If the HCT provider does not have the minimum number of required members, it will automatically receive the full rate. The HCT performance measures include the following: 1. Quality of Life / Patient Experience Denominator: MaineCare members who received HCT for a minimum of nine (9) weeks during the twelve- (12) month assessment period. Numerator: MaineCare members who meet the denominator criteria and completed the most recent questionnaire issued by the Department or its Authorized Entity during the twelve- (12) month assessment period. 2. Evidence-Based Practice Denominator: MaineCare members who received HCT for a minimum of nine (9) weeks during the twelve- (12) month assessment period. Numerator: MaineCare members who meet the denominator criteria and received services based on evidence-based practices according to the most recent questionnaire issued by the Department or its Authorized Entity during the twelve- (12) month assessment period. 65.10-3 Services for Members Who are Deaf or are Hard of Hearing A provider who is fluent in American Sign Language (ASL) or is a credentialed deaf interpreter and who delivers Outpatient Services in ASL to a member who is deaf or hard of hearing may bill for the applicable enhanced rate. Credentialed providers must be licensed as ASL Interpreters under the Department of Professional and Financial Regulation Rules for American Sign Language Interpreters, or other credential as approved by the Department. ASL fluent speakers must be able to attest to and/or document proficiency, as requested by the Department. Providers must submit documentation to MaineCare enrollment for eligibility verification. Information on licensing can be found at: https://www.maine.gov/pfr/professionallicensing/professions/american-sign-language-interpreters/licensing/conditional-interpreter-conditional-deaf-interpreter-certified-interpreter-certified-deaf-interpreter. 65.11 BILLING INSTRUCTIONS A. Providers must bill in accordance with DHHS’ billing requirements for the CMS 1500 claim form. B. In order to receive full MaineCare reimbursement for claims submitted for a service that is defined as an exemption in Chapter I, Section 1, of the MaineCare Benefits Manual, providers must follow the appropriate MaineCare provider billing instructions. C. All services provided on the same day must be submitted on the same claim form for MaineCare reimbursement. D. For billing purposes, the unit is based on member time rather than staff time. E. Providers must document appropriate and current ICD diagnostic codes for members receiving Medically Necessary Services in order to be reimbursed. 65.12 APPENDIX I PROFESSIONAL STAFF CHILDREN’S BEHAVIORAL HEALTH SERVICE The following tables show the provider types that are qualified to deliver each behavioral health service covered under this section, either as Independent Practitioners or under a Mental Health Agency or Substance Use Agency. Provider Crisis Resolution Services Outpatient Services Intensive Outpatient Program Services Family Psychoeducation Medication Services Neurobehavioral Status Exam/ Psychological Testing Adaptive Assessments Children’s ACT Children’s Home and Community Based Treatment Children’s Behavioral Health Day Treatment Tobacco Cessation Counseling Physician X X X X X X X X Psychiatrist X X X X X X X X X X Psychologist X X X X X X X X Physician Assistant X X X X X X X Psychological Examiner X LCSW/LMFT/LCPC/ LMSW-CC/LCPC-C/ LMFT-C X X X X X X X X X LADC/CADC X X X X APRN-PMH-NP/CNS X X X X X X X RNBC/RNC X X X X X X MHRT X X X X BHP X X X X X BCBA (supervision only) X BCBA (DD/BH only) X BCaBA/RBT (DD/BH only) X LSW, LSX X Occupational Therapist X Speech Therapist X Dietician X Rec. Specialist X Peer Specialist X Mental Health Agency X X X X X X X X X X X NTA/Psycho-metrician X APPENDIX I PROFESSIONAL STAFF ADULT BEHAVIORAL HEALTH SERVICE Provider Crisis Resolution Services Outpatient Services Intensive Outpatient Program Services Family Psychoeducation Medication Services Neurobehavioral Status Exam/ Psychological Testing Tobacco Cessation Counseling Physician X X X X X X X Psychiatrist X X X X X X X Psychologist X X X X X X Physician Assistant X X X X X Psychological Examiner X LCSW/LMFT/ LCPC/LMSW-CC/LCPC-C/ LMFT-C X X X X X LADC/CADC X X X APRN-PMH-NP/CNS X X X X X X RNBC/RNC X X X X X MHRT X X X DSP X X BCBA (DD/BH only) X BCaBA/RBT (DD/BH only) X LSW, LSX X Occupational Therapist X Speech Therapist X Dietician X Rec. Specialist X Peer Specialist X Mental Health Agency X X X X X X NTA/Psycho-metrician X PROFESSIONAL STAFF SUBSTANCE USE SERVICES Provider Outpatient Services IOP Services OTP with Methadone Medication Services Tobacco Cessation Counseling Physician (MD/DO) X X X X X Psychiatrist X X X X X Physician Assistant X X X X Psychologist X X X X APRN-PMH-NP/CNS X X X X X RNBC/RNC X X X X LADC/CADC X X X X ADCA X X LCSW/LCPC/LMFT/ LMSW-CC/LCPC-C /LMFT-C X X X X LSW, LSX X Occupational Therapist X Speech Therapist X Dietician X Rec. Specialist X Peer Specialist X Substance Use Agency X X X X X 65.13 APPENDIX II Service Services not allowed Concurrently Crisis Resolution Children’s Assertive Community Treatment (ACT) Outpatient Services Children’s Assertive Community Treatment (ACT) Children’s Home and Community Based Treatment Multisystemic Therapy (MST) Functional Family Therapy (FFT) OTP with Methadone (OTP with Methadone is not allowed concurrently only if the Outpatient Services are for Substance Use; if the Outpatient Services is for Mental Health, OTP with Methadone is allowed concurrently) Intensive Outpatient Program (IOP) Family Psychoeducation Children’s Assertive Community Treatment (ACT) Children’s Home and Community Based Treatment/ Collateral Contacts Behavioral Therapies for Disruptive Behavior Disorders SU-IOP Level I SU-IOP Level II Outpatient Services Medication Management of MOUDs Children’s Assertive Community Treatment (ACT) Children’s Home and Community Based Treatment Multisystemic Therapy (MST) Functional Family Therapy (FFT) OTP with Methadone Behavioral Therapies MH-IOP DD/BH-IOP G-IOP ED-IOP Level I ED-IOP Level II DBT-IOP Outpatient Services Medication Management of medications to treat mental health disorders Children’s Assertive Community Treatment (ACT) Children’s Home and Community Based Treatment Multisystemic Therapy (MST) Functional Family Therapy (FFT) OTP with Methadone Behavioral Therapies Medication Management of MOUDs Children’s Assertive Community Treatment (ACT) SU-IOP Level I SU-IOP Level II Medication Management of medications to treat mental health disorders Children’s Assertive Community Treatment (ACT) MH-IOP DD/BH-IOP G-IOP ED-IOP Level I ED-IOP Level II DBT-IOP Neurobehavioral Status Exam N/A Psychological Testing N/A Children’s Assertive Community Treatment (ACT) Crisis Resolution Crisis Residential Aftercare in Mobile Crisis Intervention Response Outpatient Services Intensive Outpatient Program (IOP) Family Psychoeducational Treatment Medication Management Children’s Home and Community Based Treatment (HCT) Multisystemic Therapy (MST) Functional Family Therapy (FFT) Behavioral Therapies Children’s Home and Community Based Treatment (HCT) Outpatient Services Intensive Outpatient Program (IOP) Family Psychoeducational Treatment Children’s Assertive Community Treatment (ACT) Behavioral Therapies Multisystemic Therapy (MST) Functional Family Therapy (FFT) Multisystemic Therapy (MST) Outpatient Services Intensive Outpatient Program (IOP) Children’s Assertive Community Treatment (ACT) Children’s Home and Community Based Treatment (HCT) Functional Family Therapy (FFT) Behavioral Therapies Functional Family Therapy (FFT) Outpatient Services Intensive Outpatient Program (IOP) Children’s Assertive Community Treatment (ACT) Children’s Home and Community Based Treatment (HCT) Multisystemic Therapy (MST) Behavioral Therapies OTP with Methadone Outpatient Services - Substance Use Intensive Outpatient Program (IOP) Children’s Behavioral Health Day Treatment N/A Behavioral Therapies Intensive Outpatient Program (IOP) Children’s Assertive Community Treatment (ACT) Family Psychoeducational Treatment Children’s Home and Community Based Treatment (HCT) Multisystemic Therapy (MST) Functional Family Therapy (FFT) STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173, 3173-J RULEMAKING HISTORY: ESTABLISHED DATE: August 1, 2008 RULEMAKING EFFECTIVE April 8, 2015: filing no. 2015-065 RULEMAKING EFFECTIVE November 23, 2016: filing no. 2016-198 RULEMAKING EFFECTIVE May 26, 2016: filing no. 2016-098 RULEMAKING EFFECTIVE November 19, 2018: filing no. 2018-246 RULEMAKING EFFECTIVE February 11, 2019: filing no. 2019-031 EMERGENCY RULEMAKING EFFECTIVE: January 30, 2026, filing nos. 2026-037 APAO ACCESSIBILITY CHECK (Word): April 28, 2026 RULEMAKING EFFECTIVE April 28, 2026 – filing 2026-095 NONSUBSTANTIVE CORRECTIONS (two errors made in the preparation of the adopted rule (at § 65.05-8(F) and § 65.08-2(A)(3))): May 28, 2026 NONSUBSTANTIVE CORRECTION (an error made in the preparation of the adopted rule (at § 65.08-2(A)(3))): May 29, 2026