MaineCare Benefits Manual, Chapter II, Section 96 - Private Duty Nursing and Personal Care Services, Subsection 96.04 (Covered Services)

What this rule requires your agency to do

• 1Personal care services may be provided only by a home health aide, certified nursing assistant, personal support specialist, or Certified Residential Medication Aide employed by a contracted licensed assisted living agency; they shall not be delivered by the Member's spouse, the parent/stepparent of a minor child, or a legally responsible relative.(MaineCare Benefits Manual, Chapter II, Section 96 - Private Duty Nursing and Personal Care Services, Subsection 96.04 (Covered Services))
• 2The task time allowances in Appendix 1 must be used by the ASA (Members 21+) or PDN provider (under 21) to authorize covered ADL task time, and authorized hours may not exceed the established limits for the Member's assessed level of care.(MaineCare Benefits Manual, Chapter II, Section 96 - Private Duty Nursing and Personal Care Services, Subsection 96.04 (Covered Services))
• 3IADL and health-maintenance tasks are covered only when authorized in the plan of care, performed in conjunction with direct ADL or medication administration care, only when no family member or other person is available, and are capped per week by level (Level I: 2 hrs; Level II: 3 hrs; Levels III and IX: 4 hrs); IADL services are not covered as stand-alone.(MaineCare Benefits Manual, Chapter II, Section 96 - Private Duty Nursing and Personal Care Services, Subsection 96.04 (Covered Services))
• 4Skills training providers must instruct each new eligible Member in management of personal support specialists prior to the start of services and document that initial skills training occurred within 30 calendar days of the Member electing the family provider service option.(MaineCare Benefits Manual, Chapter II, Section 96 - Private Duty Nursing and Personal Care Services, Subsection 96.04 (Covered Services))
• 5PDN services must be provided according to a written plan of care reviewed and signed by a licensed physician and available to the Department or Service Coordination Agency upon request; at least monthly nursing services must be delivered to all Level II and III Members and qualifying Level I Members.(MaineCare Benefits Manual, Chapter II, Section 96 - Private Duty Nursing and Personal Care Services, Subsection 96.04 (Covered Services))
• 6Covered services require prior approval by the Department or its Assessing Services Agency and must be reasonable and necessary, based on the medical record and MED form outcome scores, and consistent with the authorized plan of care; payment is denied and may be recouped for services inconsistent with the authorized plan of care.(MaineCare Benefits Manual, Chapter II, Section 96 - Private Duty Nursing and Personal Care Services, Subsection 96.04 (Covered Services))
• 7Personal care services must, for Members under 21 (excluding family provider service option), be ordered by a physician under a PDN-provider plan of care signed by the physician; for Members 21 and over they must be approved by the Department or its ASA and specified in the authorized plan of care.(MaineCare Benefits Manual, Chapter II, Section 96 - Private Duty Nursing and Personal Care Services, Subsection 96.04 (Covered Services))
• 8Nursing services generally may not be provided by the Member's specified relatives or persons sharing a common abode as a single family unit, except under "special circumstances nursing," which requires the relative to meet all licensing/training/reporting requirements, be employed by a licensed home health agency, and pass a criminal background check with no disqualifying convictions.(MaineCare Benefits Manual, Chapter II, Section 96 - Private Duty Nursing and Personal Care Services, Subsection 96.04 (Covered Services))