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Maine - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The Maine Department of Health and Human Services (DHHS) Office of Aging and Disability Services (OADS) certifies agencies to deliver Targeted Case Management (TCM) under MaineCare Benefits Manual Chapter II, Section 13. Prospective entities must pass a specific OADS certification review under 14-197 CMR Chapter 10 before they are permitted to execute a MaineCare Provider Agreement.

Agencies must strictly adhere to Conflict-Free Case Management mandates to be approved and maintain enrollment. An entity approved to bill Section 13 TCM cannot simultaneously provide direct waiver services, such as community supports or work supports, to the same individual, forcing providers to structurally separate their case management operations from direct care delivery.

1. Service Definition and Scope

Targeted Case Management in Maine encompasses assessment, person-centered service planning, referral, and monitoring across an individual's full service package. The service is designed to ensure individuals have choice of providers and that their options are not unduly influenced by the entities coordinating their care.

Recent rulemaking expanded the scope of populations eligible for these services, ensuring continuity of care for vulnerable groups navigating the MaineCare system.

2. Regulatory and Oversight Agencies

Oversight of Targeted Case Management is divided between programmatic certification and financial Medicaid enrollment. The Office of Aging and Disability Services (OADS) handles the programmatic certification for agencies serving adults with I/DD and Autism.

The Office of MaineCare Services (OMS) manages the provider enrollment process, claims processing, and reimbursement methodology.

3. Gatekeeping Prerequisites: Who Can Even Apply

Maine does not currently impose a Certificate of Need or a closed RFP procurement for Section 13 Targeted Case Management. However, strict structural firewalls exist regarding service delivery that block applications from non-compliant entities.

While OADS implemented a temporary pause on initial applications for waiver providers under MBM Sections 18, 20, 21, and 29 effective April 13, 2026, Section 13 TCM requires its own distinct certification prerequisite before Medicaid enrollment can begin.

4. Licensure and Certification Requirements

Maine does not issue a traditional facility "license" for case management agencies. Instead, providers must obtain agency certification directly from OADS.

Certification is the formal process whereby an applicant entity is determined to be qualified to provide case management services to adults with I/DD and Autism under the provisions of the MaineCare Manual.

5. Medicaid Provider Enrollment

Following OADS certification, agencies must enroll as billing providers through the Office of MaineCare Services. This process links the programmatic approval to the state's MMIS for claims payment.

Providers must use the state's designated portal to finalize their enrollment and define their specific service locations before they can accept waiver members.

6. Staffing, Training and Background Checks

TCM agencies must employ qualified personnel who meet MaineCare's educational and experience standards for case management. Staff must be trained on specific assessment tools mandated by the state.

Newly approved agencies are also required to participate in state-led onboarding to ensure they understand operational expectations.

7. Documentation, Policies and Records

Agencies must maintain comprehensive records of the Person-Centered Plan (PCP) and all monitoring activities. Documentation must clearly justify any requests for specialized funding.

Providers are required to use specific state forms for information release and funding requests, while maintaining their own internal release forms for standard operations.

8. Billing, Rates and Claims

TCM services are billed to MaineCare under Section 13 rules. Recent rulemaking has consolidated the reimbursement methodology directly into Chapter II of the MaineCare Benefits Manual.

When case managers request specific funds to mitigate health or safety concerns, those funds are strictly controlled and distributed only to state-approved vendors.

9. Approval Sequence and Timeline

The pathway to becoming a billable TCM provider in Maine follows a strict sequential order. Programmatic certification must be fully secured before Medicaid enrollment can be initiated.

Skipping steps or failing to attend mandatory onboarding will halt the approval process.

10. Common Denials and Survey Findings

Applications and ongoing certifications are most frequently jeopardized by failing to maintain the strict separation required by conflict-free rules.

Administrative errors during the enrollment phase also cause significant delays.

11. Key Contacts and Resources

Prospective providers should utilize the official DHHS portals and contact specific division email addresses for application support.

Monitoring the DHHS rulemaking page is essential for staying updated on changes to Section 13.

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