APPENDIX IIA Weekly Authorized per Facility Home Support Agency per diem Provider Location Address MaineCare Provider ID Instructions Regular Medical Total Support Hours Support Hours in excess Support (sum total of all types MaineCare Member up to 168 of 168 Hours of support hours) A the weekly authorized support hours under each type by MaineCare B member for this facility C D Sum of total weekly authorized support hours for all members in facility by type E of support and total facility. F TOTAL weekly authorized support hours by each type The range of allowable weekly hours is based on authorized hours with the Lowest - 92.5% total weekly of lowest hours in range at 92.5% of total Authorized Hours authorized hours and the highest hours in Highest - 105% total weekly of the range at 105% of the total authorized Authorized Hours hours.
APPENDIX IIA Weekly Authorized per Facility Home Support Agency per diem Provider Location Address MaineCare Provider ID Instructions MaineCare Member Regular Support Hours up to 168 in excess of 168 Medical Support Hours Total Support Hours (sum total of all types of support hours) A the weekly authorized support hours under each type by MaineCare member for this facility B C D Sum of total weekly authorized support hours for all members in facility by type of support and total facility. E F TOTAL weekly authorized support hours by each type The range of allowable weekly hours is based on authorized hours with the lowest hours in range at 92.5% of total authorized hours and the highest hours in the range at 105% of the total authorized hours. Lowest - 92.5% total weekly of Authorized Hours Highest - 105% total weekly of Authorized Hours