Attention Section 67, Nursing Facility Services: Bariatric Care Reimbursement

Nov 21, 2022

MaineCare is issuing this guidance to nursing facilities regarding the process for facilities to request durable medical equipment (DME) and/or authorization for reimbursement to meet extra staffing needs for residents with bariatric care needs. 

To request reimbursement for extra staffing for bariatric care needs, the facility must submit a prior authorization (PA) request via the HealthPAS online portal, or by fax at 1-866-598-3963, or U.S. Mail: PA Unit, Office of MaineCare Services, 11 State House Station, Augusta, ME 04333. The request must include a supporting letter of medical necessity and clinical documentation from the treating provider. The letter of medical necessity must document:  

1) The extent of the member's ability to participate in their own care (e.g. can the member weight-bear or perform any of their own activities of daily living independently or with assistance)​. 

2) Whether the member requires a one-, two-, or three-person assist and why this level of assist is necessary.​ 

3) The unique physical characteristics of the member that require the additional assistance (e.g. distribution of member’s weight).​ 

4) The hourly rate being requested, including documentation of employee type and anticipated wages and labor hours that justify the requested rate​. 

To request DME to meet a resident’s bariatric care needs, nursing facilities should contact a DME provider. If providers need assistance finding a DME dealer, contact the DME Provider Relations Specialist Shannon Beggs by email or phone at (207) 624-4012. The DME provider will submit a PA request to MaineCare via the HealthPAS online portal, or by fax at 1-866-598-3963, or U.S. Mail: PA Unit, Office of MaineCare Services, 11 State House Station, Augusta, ME 04333. MaineCare may approve bariatric equipment for a member residing in a Nursing Facility at an amount higher than the facility’s rate of reimbursement if the member meets the two criteria below. Any DME that MaineCare approves for a resident is that resident’s property. 

1) The member meets the definition of being bariatric size specific to the requested equipment.​ 

2) The DME provider can demonstrate that the requested equipment meets medical necessity requirements for the member.  

For more information, please contact Provider Relations Specialist Bruce Cosgrove.