14-193 C.M.R. ch. 40, § 2 - Criteria for Specialized Out-of-state Treatment Funding

Current through 2022-14, April 6, 2022

1. Requests for funding specialized out-of-state mental health treatment will be considered only for adult clients of DMHMRSAS, as currently defined.
2. Requests for grant funding specialized out-of-state mental health treatment will only be considered when all other sources of funding have been exhausted (such as reciprocal Medicaid agreements, third party insurance, personal resources, etc.). Every effort must have been made to fund the treatment jointly with other responsible agencies involved.
3. The client must have a current psychiatric evaluation that reports findings of instability secondary to an Axis I major mental illness, as defined by the current edition of the Diagnostic and Statistical Manual. The current clinical picture must clearly demonstrate medical necessity for treatment, as defined by evidence of severe dysfunction in aspects of daily living or danger to self or others, which has existed for at least 6 months or longer.
4. Requests for specialized out-of-state mental health treatment will only be considered when it has been demonstrated that in-state treatment AND treatment at a lower level of care have reasonably been attempted and failed, OR that there is no appropriate, safe and effective treatment available in the state.
5. The specific treatment plan or program being requested must have proven efficacy in the treatment of the client's Axis I diagnosis, be consistent with best clinical practice and qualitatively different from a program available in the state of Maine. Specialized out-of-state treatment will be authorized only when the program and/or facility meets applicable licensing regulations and there is reason to expect the program requested will significantly improve the condition of the client, returning him/her to a former level of stability. At the Department's discretion, a Departmental staff person may be designated to conduct an on-site review of the program being considered.
6. Requests for specialized out-of-state treatment will be approved only when it can be demonstrated that without the requested treatment, the client will continue to be unstable or will deteriorate further.
7. The client must voluntarily accept the specialized out-of-state treatment and evidence some capacity to benefit from the treatment. The guardian, if applicable, must also approve the specialized out-of-state treatment plan.
8. The specialized out-of-state treatment plan must be cost effective, demonstrated by the reasonable expectation for reduced future behavioral or somatic medical care costs AND by favorable cost comparison to other similar treatments.
9. Every preauthorization of specialized out-of-state treatment shall be for a specific length of time. The client's clinical progress will be monitored during treatment, consistent with good utilization review practices. When it is clinically appropriate, or if the client's condition does not improve in a reasonable period of time, the authorization for continued treatment may be withdrawn and the client transferred to a less intensive level of care or an instate program. Such a withdrawal and transfer will be done with sufficient notice to the client, family and providers involved.
10. Before preauthorization will be granted, there must be a preliminary discharge or transition plan developed, for the client to return to an instate treatment program.


14-193 C.M.R. ch. 40, § 2

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