Renew Your Membership

FY25 Membership Renewal Form Due – July 31, 2024
Your MACSP Membership Renewal Form is due by July 31, 2024. Please fill out the form below and note the “*” required fields. When complete, use the submit button at the bottom of the page. After you submit the renewal form you will receive a confirmation email. Within seven business days, an invoice will be sent via email from “Accounts ” to the agency contact for invoicing, with a cc to the designated voting representative, listed on the renewal form. Questions? – Contact Becca Emmons, Membership Coordinator e: [email protected] o: 207.563.1883
Agency Name:*
Address*
Street Address Address Line 2 City State ZIP Code
Website:*
Telephone:*
Fax Number:*
Corporate Status:*
- For Profit – Corporation
- For Profit – Individual
- For Profit – Partnership
- Non Profit – Corporation
- Non Profit – Other
Agency Provider ID (NPI):*
NPI +3 locations numbers NOT needed.
Year Agency Established Services in Maine:
Designated Voting Representative Name:*
The individual designated by your organization to vote on MACSP business.
Title:*
Designated Voting Member Email:*
Designated Voting Member Telephone:*
Proxy Voting Representative Name:*
The individual who may vote on behalf of your organization when the designated voting member is not available. This proxy voting member may onle vote when consent is given by the voting member.
Title:*
Proxy Voting Member Email:*
Please complete the following information for the person who is responsible for billing and financial management in your organization.
Contact Person for Invoicing:*
Title:*
Contact for Invoicing Email:*
Address:*
Street Address Address Line 2 City State ZIP Code
Contact for Invoicing Telephone:*
Name of individual(s) listed as Administrators on the Agency’s Provider Agreement and any licenses held by the organization.*
Does the agency hold any of the following licenses? (check all that apply)*
- Agency does not hold any of these licenses
- ICF-ID
- Assisted Housing
- Behavioral Health Section 65
- Children’s Services Section 28
- Childcare
- Other
Has anyone in the management of this organization been involved in a license revocation or forced to close any other organization delivering similar services?*
- Yes
- No
If yes, please describe:
Select the counties your agency provides services in:*
- Select All
- Androscoggin
- Aroostook
- Cumberland
- Franklin
- Hancock
- Kennebec
- Knox
- Lincoln
- Oxford
- Penobscot
- Piscataquis
- Sagadahoc
- Somerset
- Waldo
- Washington
- York
Agency Provided Covered Services
Please describe the covered services provided by your agency, including number of individuals served and number of employees.
Please select the Covered Services under Section #13 provided by agency:
- Adult Case Management
- Children’s Case Management
- Adult and Child Case Management
Number of ADULTS served under Section #13:
Number of CHILDREN served under Section #13:
Number of employees performing covered services under Section #13:
Please select the Covered Services under Section #18 provided by your agency:
- Select All
- Assistive Technology Device and Services
- Care Coordination Services
- Career Planning
- Community/Work Reintegration
- Employment Specialist Services
- Home Support Services
- Non-Medical Transportation Services
- Self-Care/Home Management Reintegration
- Work Ordered Day Club House
- Work Support Services
Number of individuals served under Section #18:
Number of employees performing covered services under Section #18:
Please select the Covered Services under Section #19 provided by your agency:
- Select All
- Assistive Technology Device and Services
- Assistive Technology-Remote Monitoring
- Assistive Technology-Transmission
- Care Coordination Services
- Environmental Modifications
- Financial Management Services
- Home Delivered Meals
- Home Health Services
- Personal Care Services
- Attendant Services
- Living Well for Better Health
- Matter of Balance
- Per Diem Residential Services
- Transportation Services
- Respite Services
- Skills Training
Number of individuals served under Section #19:
Number of employees performing covered services under Section #19:
Please select the Covered Services under Section #20 provided by your agency:
- Select All
- Assistive Technology Device and Services
- Assistive Technology-Remote Monitoring
- Assistive Technology-Transmission
- Care Coordination Services
- Environmental Modifications
- Financial Management Services
- Home Delivered Meals
- Home Health Services
- Personal Care Services
- Attendant Services
- Living Well for Better Health
- Matter of Balance
- Per Diem Home Support Services
- Personal Emergency Response System Services
- Transportation Services
- Respite Services
- Skills Training
Number of individuals served under Section #20:
Number of employees performing covered services under Section #20:
Please select the Covered Services under Section #21 provided by your agency:
- Select All
- Assistive Technology
- Career Planning
- Community Support – Individual
- Community Support – Group (1:2, 1:3)
- Consultation Services
- Crisis Assessment
- Crisis Intervention Services
- Home Accessibility Adaptations
- Home Support-Agency Per Diem (group home)
- Home Support-Family-Centered Support
- Home Support-Quarter Hour
- Home Support-Remote Support
- Non-Traditional Communication Assessments
- Non-Traditional Communication Consultation
- Occupational Therapy (Maintenance)
- Physical Therapy (Maintenance)
- Shared Living
- Speech Therapy (Maintenance)
- Work Support-Group
- Work Support-Individual
Number of individuals served under Section #21:
Number of employees performing covered services under Section #21:
Number of employees working in Agency Group Homes:
Number of Agency Group Home locations (as of July 1, 2024):
# of agency group home locations that are open and actively providing Section 18 or Section 21 services as of July 1, 2024.
Number of Individuals/Residents living in Agency Group Home locations (as of July 1, 2024):
# of individuals/residents living in agency group home locations that are open and actively providing Section 18 or Section 21 services as of July 1, 2024.
Number of Shared Living Individuals Supported (as of July 1, 2024):
# of individuals supported by Section 21 Shared Living Services as of July 1, 2024.
Number of Shared Living Providers-unrelated as of July 1, 2024:
# of contracted Shared Living Providers that are NOT related to the individual supported.
Number of Shared Living Providers-related as of July 1, 2024:
# of contracted Shared Living Providers that are related to the individual supported.
Please select the Covered Services under Section #28 provided by your agency:
- Select All
- Treatment Services
- Specialized Services
- BCBA Services
Number of children served under Section #28:
Number of employees performing covered services under Section #28:
Please select the Covered Services under Section #29 provided by your agency:
- Select All
- Assistive Technology
- Career Planning
- Community Support – Group
- Community Support – Comm Membership
- Home Accessibility Adaptations
- Home Support-Family-Centered Support
- Home Support-Quarter Hour
- Respite Services
- Shared Living
- Transportation
- Work Support-Group
- Work Support-Individual
Number of individuals served under Section #29:
Number of employees performing covered services under Section #29:
Number of Shared Living Individuals Supported (as of July 1, 2024):
# of individuals supported by Section 21 Shared Living Services as of July 1, 2024.
Number of Shared Living Providers-unrelated as of July 1, 2024:
# of contracted Shared Living Providers that are NOT related to the individual supported.
Number of Shared Living Providers-related as of July 1, 2024:
# of contracted Shared Living Providers that are related to the individual supported.
Please select the Covered Services under Section #50 provided by your agency:
- Select All
- ICF-MR Development Training (Community Supports/Day) Program
- Per Diem Residential Services
- Pharmacy Services
- Physical Therapy and Occupational Therapy
- Speech and Hearing Services
- Supplies and Equipment Billed by Supplier or Pharmacy
- Other Services
Number of individuals served under Section #50:
Number of employees performing covered services under Section #50:
Please select the Covered Services under Section #65 provided by your agency:
- Select All
- Children’s Home and Community Based Treatment
- Children’s Behavioral Health Day Treatment
Number of individuals served under Section #65:
Number of employees performing covered services under Section #65:
Please select the Covered Services under Section #92 (Behavioral Health Home) provided by your agency:
- Select All
- Children’s Behavioral Health Home
Number of children served under Section #92:
Number of employees performing covered children's services under Section #92:
Please select the Covered Services under Section #97 – Appendix F provided by your agency:
- Select All
- Per Diem Residential Services
- Pharmacy Consultation
- RN Consultation
- Dietary Consultation
Number of individuals served under Section #97 – Appendix F:
Number of employees performing covered services under Section #97 – Appendix F:
Number of per diem residential locations under Section #97 – Appendix F:
Please select the Covered Services under Section #102 provided by your agency:
- Select All
- Clinical Assessment and Reassessment
- Intensive Integrated Neuro-rehabilitation
- Neuro-behavioral Rehabilitation
- Home and Community Reintegration
- Self-Care/Home Management
Number of individuals served under Section #102:
Number of employees performing covered services under Section #102:
Special Purpose Pre-School (SPPS):
- Yes
- No
Does your organization provide DOE-funded SPPS services?
Number of employees in your SPPS program?
# of staff working in special purpose pre-school programming as of July 1, 2024.
Number of students in your SPPS program?
Other IDD Services:
Please list the Mainecare Section # and service type for other IDD services agency provides.
Number of individuals served under other IDD services:
Number of employees performing covered services under other IDD services:
Membership Dues
Please complete all applicable information requested regarding total revenue your organization or business receives for providing services to children and adults with intellectual disabilities, Autism and Brain Injuries in the State of Maine. MACSP defines qualifying revenue as revenue generated by the agency from the provision of any of the services listed in the Mainecare Benefits Manual (MBM) Chapters 2 and 3 under Sections 13, 18, 19, 20, 21, 28, 29, 50, 97-Appendix F, and 102. Additionally, as of July 1, 2024; revenue generated by Department of Education (DOE) supported Special Purpose Pre-School (SPPS) programming and Section 92 Behavioral Health Homes for Children should be included when calculating the organization’s qualifying revenue.
What is your total MACSP qualifying revenue from FY '24, or calendar year-end 2023, or your last completed audited financial statement?*
Include revenues from Section 13, 18, 19, 20, 21, 28, 29, 50 (ICF), 65, 97-F (PNMI), 102, Special Purpose Pre-School programming and IDD revenue from any related entities.
Dues Level*
Select the corresponding dues level for your agency. An invoice for this amount will be sent to the invoicing contact listed on this application, with a cc to the designated voting member for your organization. Payment – Payment is due within 30 days of invoice receipt or no later than August 31, 2024. Details will be provided in the invoice sent within seven business days of submitting this renewal form.
Dues Level FY 2024-2025*
- Level I 0-$249,999 Dues: $703
- Level II $250,000-$499,999 Dues: $1,312
- Level III $500,000-$999,999 Dues: $1,819
- Level IV $1,000,000-$1,499,999 Dues: $2,229
- Level V $1,500,000-$1,999,999 Dues: $2,931
- Level VI $2,000,000-$3,499,999 Dues: $3,224
- Level VII $3,500,000-$4,999,999 Dues: $3,459
- Level VIII $5,000,000-$6,999,999 Dues: $3,811
- Level IX $7,000,000-$8,999,999 Dues: $4,104
- Level X $9,000,000-$11,499,999 Dues: $4,456
- Level XI $11,500,000-$13,999,999 Dues: $4,807
- Level XII $14,000,000-$17,999,999 Dues: $5,217
- Level XIII $18,000,000-$24,999,999 Dues: $5,687
- Level XIV $25,000,000-$39,999,999 Dues: $6,156
- Level XV $40,000,000 + Dues: $6,995
MACSP Members commit to the following prescribed standards and principles of quality, which apply to the supports provided in the professional relationship with persons served, parents and guardians of persons served, colleagues, related agencies and professions, and the community at large.

AS A MEMBER OF MACSP, THIS ORGANIZATION PLEDGES TO:
- Provide supports and services in a manner which exemplifies integrity, compassion, and respect for individual differences and choice;
- Provide supports and services designed to meet the needs of the individual supported with emphasis on promoting choice, self-determination, inclusion, growth, and development;
- Respect the privacy of the individual supported and protect the rights of confidentiality;
- Give preference to professional responsibility over any personal interest;
- Advocate for standards that promote outcomes of quality;
- Advocate for and provide supports and services that best assure the health and safety of the individual supported;
- Encourage and advocate for the protection of the individual supported and the community at-large against unethical and/or illegal practices or actions by other individuals or organizations engaged in providing supports;
- Not discriminate because of race, color, religion, age, sex, sexual orientation, disability, or national ancestry and work to eliminate or prevent such discrimination;
- Promote inclusion and equitable treatment of all people including those receiving supports, staff, friends, families, and the community at-large;
- Serve as a responsible steward for public and private funds;
- Contribute to MACSP Membership ideas, findings, concepts, understanding, knowledge, and practice which further develop education and expanded knowledge of leading practices in providing high quality supports and services to individuals with disabilities;
- Keep MACSP information and materials confidential without further dissemination or distribution to employees without a need or to any third parties without the express written permission of MACSP; and
- Be accountable for statements made with respect to individuals with disabilities and distinguish clearly statements and actions made as an individual and, when authorized by the MACSP Board of Directors, those made as a representative of MACSP.
CERTIFICATION SIGNATURE (sign in the box below)*
I certify that the information provided in this application is accurate and complete to the best of my knowledge. The undersigned hereby agrees that it will in all respects conform to and abide by MACSP’s Quality Pledge and Bylaws, and all amendments hereafter made thereto.
Date:*
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Name:*
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Renew Your Membership

FY25 Membership Renewal Form Due – July 31, 2024

Agency Provided Covered Services

Membership Dues