Notice to MaineCare Providers Regarding MaineCare Reimbursement when Restraint is Utilized in Outpatient Behavioral Health Settings, Including Schools

Mar 06, 2023

This notice clarifies that MaineCare does not reimburse providers for time periods when a provider subjects a member to a restraint in outpatient behavioral health settings, including school settings.  Department rules, in particular the Rights of Recipients of mental health services (RoR) for adults and children (14-193 C.M.R. ch. 1 and 14-472 C.M.R. ch. 1), limit the ability of providers of behavioral health services to use restraint interventions in outpatient settings, including offices, schools, clinics, outpatient hospital sites, homes, and community-based settings.  This guidance applies to the following providers and settings, for the specified (italicized) services:

• Behavioral Health Providers

Section 17 – Community Support Services: Community Integration Services, Community Rehabilitation Services, Assertive Community Treatment, Daily Living Support Services, Skills Development Services, and Day Support Services

Section 28 – Rehabilitative and Community Support (RCS) Services for Children with Cognitive Impairments and Functional Limitations: RCS standard, RCS Specialized, Board Certified Behavior Analyst services

Section 46 – Psychiatric Hospital Services: Outpatient Behavioral Health services only – Individual/Family/Group Therapy, Partial Hospitalization, IOP

Section 65 – Behavioral Health Services: Outpatient (Comprehensive Assessment and Individual/Family/Group Therapy), Family Psychoeducational Treatment, Intensive Outpatient (IOP), Neurobehavioral Status Exam, Psychological Testing, Adaptive Assessments, Medication Management, Medication Assisted Treatment with Methadone (Opioid Treatment Programs), Home and Community Based Treatment, Children’s Assertive Community Treatment, Children's Behavioral Health Day Treatment, Mental Health Psychosocial Clubhouse Services, Specialized Group Services, Tobacco Cessation Treatment, and Behavioral Therapies for Children with Disruptive Behavior Disorders.

• Medical Providers delivering Behavioral Health services

Section 3 – Ambulatory Care Clinic Services: School-based Health Centers: Behavioral Health services

Section 9 – Indian Health Services: Behavioral Health services

Section 31 – Federally Qualified Health Center Services: Behavioral Health services

Section 45 – Hospital Services: Outpatient Behavioral Health services only – Individual/Family/Group Therapy, Partial Hospitalization, IOP

Section 90 – Physician Services: Outpatient Behavioral Health services

Section 103 – Rural Health Clinic Services: Behavioral Health Services

If a MaineCare provider seeks prior authorization for treatment and the service plan includes the use of restraint during the provision of an outpatient behavioral health service, DHHS or its Authorized Entity will request additional information, and will consider whether the request is consistent with Department rules such as the RoR and other governing law, including MaineCare Benefits Manual (MBM) provisions. In determining whether a service is reimbursable, MaineCare or its Authorized Entity considers the nature and components of the service being delivered and the role of the individual provider during service delivery. This includes reviewing the member’s treatment goals and methods employed to support the member in accomplishing their goals. Restraint is a safety intervention utilized as a last resort when all attempts of medical services have failed. Thus, the use of restraint is inconsistent with medically necessary covered services in the MBM. When a restraint is initiated, delivery of the covered service as described in the MBM will necessarily end or pause until such time that the restraint has ended, a member has resolved their safety concerns, and they are able to re-engage in medically necessary treatment in accordance with their treatment plan.  MaineCare will not reimburse for any time a provider is administering a restraint, or for any services delivered while the MaineCare member is being restrained.  The fact that an individual provider may be involved in a restraint outside the scope of this guidance (service and/or time not billed to MaineCare; inpatient or residential service) does not disqualify that provider from being reimbursed by MaineCare for MaineCare-covered services delivered in an outpatient setting when delivered consistent with this guidance.  

This guidance is specific to MaineCare behavioral health services provided in an outpatient setting and does not dictate what practices may or may not be appropriate in other settings, or for activities for which a provider is not seeking MaineCare reimbursement.  In particular, this guidance does not dictate what may or may not be permissible in a school setting regulated by the Maine Department of Education (DOE) for activities that MaineCare does not reimburse. DOE and entities subject to its regulatory authority are governed by DOE’s rules. Regardless of whether restraints may be employed in school settings under narrowly prescribed circumstances pursuant to DOE rules, MaineCare may not reimburse providers for services utilizing restraint that do not meet DHHS rules and/or MaineCare service delivery requirements.

For additional information there is a Frequently Asked Questions document now posted on MaineCare’s School Health-Related Services webpage.

For questions regarding MaineCare, please contact your Provider Relations Specialist (PDF) at the Office of MaineCare Services.

For questions related to question #2 above, please contact Gaye Erskine, at the Department of Education, Office of Special Services and Inclusive Education, at 207-624-6628.