Remote Patient Monitoring Maine

Maine Medicaid provides coverage for remote patient monitoring services (which may or may not take place in real-time) under certain circumstances.

Covered telemonitoring services include:

• Evaluation of the member to determine if telemonitoring services are medically necessary
• Evaluation of Member to ensure cognitively and physically capable of operating equipment
• Evaluation of residence to determine suitability for telemonitoring services
• Education and training
• Remote monitoring and tracking of data by an RN, NP, PA or physician and response with appropriate clinical interventions
• Monthly telephonic services
• Maintenance of equipment
• Removal/disconnection of equipment

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.04. p. 4-5. (Accessed Apr. 2019). 

Home and Community Benefits for the Elderly and for Adults with Disabilities

Real-time remote support monitoring is covered under Home and Community Benefits for the Elderly and for Adults with Disabilities. Services may include a range of technological options including in-home computers, sensors and video camera linked to a provider that
enables 24/7 monitoring and/or contact as necessary.

Source: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19, p. 13 (Jan. 7, 2019). (Accessed Sept. 2019). 

In order to be eligible for telemonitoring a member must:

• Be eligible for home health services;
• Have a diagnosis of a health condition requiring monitoring of clinical data at a minimum of five times per week, for at least one week;
• Have documentation in the patient’s medical record that the patient is at risk of hospitalization or admission to an emergency room or have continuously received Telemonitoring Services during the past calendar year and have a continuing need for such services, as documented by an annual note from a health care provider;
• Have telemonitoring services included in the Member’s plan of care;
• Reside in a setting suitable to support telemonitoring equipment; and
• Have the physical and cognitive capacity to effectively utilize the telemonitoring equipment or have a caregiver willing and able to assist with the equipment.

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.02. p. 2-3 & Mainecare Benefits Manual. Ch. 11. Home Health Services. Sec. 40.05. Final Adoption 8/1//19. (Accessed Sept. 2019). 

Final approval must be obtained from the Department, Office of Aging and Disability Services while considering:

• Number of hospitalizations in the past year
• Use of an emergency room in the past year
• History of falls in the last six months resulting from injury
• Member lives alone or is home alone for significant periods of time
• Service access challenges and reasons for those challenges
• History of behavior indicating that a member’s cognitive abilities put them at significant risk of wandering
• Other relevant information

Source: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19, p. 13 (Jan. 7, 2019). (Accessed Sept. 2019). 

Provider Limitations

Telemonitoring only reimbursed when provided by a certified Home Health Agency. See regulations for specific requirements of Home Health Agencies utilizing telemonitoring services.

Source: MaineCare Benefits Manual. Ch. 11. Home Health Services. Sec. 40.05. Final Adoption 8/1//19. (Accessed Sept. 2019). 

In order to be reimbursed for services, Health Care providers

• Must be enrolled as MaineCare providers in order to be reimbursed for services
• Be a certified Home Health Agency pursuant to the MaineCare Benefits Manual Ch. II Section 40 (“Home Health Services”)
• The Provider ordering the service must be a Provider with prescribing privileges (physician, nurse practitioner or physician’s assistant)
• Must document that they have had a face-to-face encounter with the member before a physician may certify eligibility for services under the home health benefit. This may be accomplished through interactive telehealth services, but not by telephone or e-mail

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.01. (Accessed Sept. 2019). 

Other Restrictions

Telemonitoring services are intended to collect a member’s health-related data, such as pulse and blood pressure readings, that assist healthcare providers in monitoring and assessing the member’s medical conditions.

A note, dated prior to the beginning of service delivery, and demonstrating the necessity of home telemonitoring services, must be included in the member’s file. In the event that services begin prior to the date recorded on the provider’s note, services delivered in that month will not be covered.

Source: MaineCare Benefits Manual. Ch. 11. Home Health Services. Sec. 40.05. Final Adoption 8/1//19. (Accessed Sept. 2019). 

Services shall not be duplicate of any other services. See regulation for examples of duplication.

Source: MaineCare Benefits Manual. Ch. 11. Home Health Services. Sec. 40.06. Final Adoption 8/1//19. (Accessed Sept. 2019). 

See regulation for a list of non-covered services.

Source: MaineCare Benefits Manual. Ch. 11. Home Health Services. Sec. 40.07. Final Adoption 8/1//19. (Accessed Sept. 2019). 

• The department required to adopt regulations that comply with the following
  May not include any requirement that a patient has a certain number of ER visits or hospitalizations related to the patient’s diagnosis in the criteria for a patient’s eligibility for telemonitoring services
• Must include qualifying criteria for a patient’s eligibility of telemonitoring services that include documentation in a patient’s medical record that the patient is at risk of hospitalization or admission to an ER
• Must provide that group therapy for behavioral health or addiction services covered by the MaineCare program may be delivered through telehealth
• Must include requirements for individual providers and the facility or organization in which the provider works for providing telehealth and telemonitoring services.

Source: ME Statute Sec. 3173-H. (Accessed Sept. 2019).

A health care provider must document that a face-to-face encounter with the member occurred before they are eligible for a home health benefit. This can occur through interactive telehealth services, but not by telephone or e-mail.

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.03. p. 4 (Accessed Sept. 2019). 

ME established the ME Telehealth and Telemonitoring advisory group to evaluate difficulties related to telehealth and telemonitoring services and make recommendations to the department to improve it statewide.

Source: ME Statute Sec. 3173-I. (Accessed Sept. 2019).

The use of remote monitoring requires sufficient Back-Up Plans and the SCA will be responsible for ensuring that the member has at least two adequate back-up plans prior to making a referral for this service.

Source: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19, p. 13 (Jan. 7, 2019). (Accessed Mar. 2019