C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-12, subsec. 144-101-II-12.03

Current through 2024-51, December 18, 2024

Subsection 144-101-II-12.03 - ELIGIBILITY FOR SERVICES

12.03-1Determination of Eligibility

A. Members must meet the financial eligibility criteria as set forth in the MaineCare Eligibility Manual. Some members may have restrictions on the type and amount of services they are eligible to receive. It is the responsibility of the provider to verify a member's eligibility for MaineCare prior to providing services, as described in MaineCare Benefits Manual (MBM) Chapter I;

B. Applicants for services under this Section must meet the eligibility requirements as set forth in this Section and as documented on the Medical Eligibility Determination form. A member meets the medical eligibility requirements if he or she requires a combination of assistance with the required activities of daily living, as defined in Section 12.03-1(D) and as set forth elsewhere in this Section. The clinical judgment of the Department's ASA is the basis of the scores entered on the Medical Eligibility Determination form. The clinical judgment of the Department's ASA is determinative of the scores on the medical eligibility determination assessment;

C. The member must have a disability with functional impairments, which interfere with his/her own capacity to provide self-care and daily living skills without assistance. The member's disability must be permanent or chronic in nature as verified by the member's physician.

D. A registered nurse trained in conducting assessments with the Department's approved MED form must conduct the medical eligibility assessment. The assessor must, as appropriate within the practice of professional nursing judgment, consider documentation, perform observations, and conduct interviews with the applicant/member, family members, direct care staff, the applicant's/member's physicians, and other individuals and document in the record of the assessment all information considered relevant in his or her professional judgment. The following levels of eligibility are determined at assessment:

Level I A member meets the medical eligibility requirements for Level I if he or she requires at least limited assistance plus a one person physical assist with at least two (2) of the following ADLs: bed mobility, transfer, locomotion, eating, toilet use, dressing, and bathing.

Level II A member meets the medical eligibility requirements for Level II if he or she requires at least limited assistance and a one person physical assist with at least three (3) of the following ADLs: bed mobility, transfer, locomotion, eating, toilet use, dressing, and bathing.

Level III A member meets the medical eligibility requirements for Level III if he or she requires at least extensive assistance and a one person physical assist with two (2) of the following five ADLs: bed mobility, transfer, locomotion, eating, or toileting; and limited assistance and a one person physical assist with two (2) of the following additional ADLS: bed mobility, transfer, locomotion, eating, toilet use, dressing, and bathing.

E. The member must agree to complete initial member instruction and testing within thirty (30) days of completion of the MED form to determine medical eligibility in order to develop and verify that he or she has attained the skills needed to hire, train, schedule, discharge, and supervise attendants and document the provision of personal care services identified in the authorized plan of care. Members who do not complete the course of instruction or do not demonstrate to the Service Coordination Agency that they have attained the skills needed to self-direct are not eligible for services under this Section;

F. The member must not be residing in a hospital, nursing facility, or Intermediate Care Facility for the Individuals with Intellectual Disabilities (ICF-IID) as an inpatient;

G. The member must not reside in an Adult Family Care Home(as defined in MaineCare Benefits Manual, Chapters II and III, Section 2,) or other residential setting including a Private Non-Medical Institution (MBM, Chapters II and III, Section 97) , sometimes referred to as a residential care facility or supported living, regardless of payment source, (i.e. private or MaineCare);

H. The member must not be receiving personal care services under Private Duty Nursing/Personal Care Services, Section 96, or be receiving any In-home Community and Support Services for Elderly and Other Adults, Section 63, or participating in other MaineCare programs where personal care services are a covered service.

I. The member must have the cognitive capacity, as measured on the MED form to be able to "self-direct" the attendant. The ASA will assess cognitive capacity as part of each member's eligibility determination using the MED findings. The Service Coordination Agency will assess cognitive capacity as part of consumer instruction. Minimum MED form scores are:

(a) decision making skills: a score of 0 or 1;

(b) making self understood: a score of 0, 1, or 2;

(c) ability to understand others: a score of 0, 1, or 2;

(d) self performance of managing finances: a score of 0, 1, or 2; and

(e) support for managing finances, a score of 0, 1, 2, or 3.

An applicant not meeting the specific scores above during his or her eligibility determination will be presumed not able to self-direct and ineligible for benefits under this Section.

J. Applicants who meet these eligibility criteria for personal care attendant services shall:

i. Receive an authorized plan of care based upon the scores, timeframes, findings and covered services recorded in the MED assessment. The covered services to be provided in accordance with the authorized plan of care must not exceed the established limits and must be authorized by the Department or its ASA;

ii. The ASA must approve an eligibility period for the Member, based upon the scores, timeframes and needs identified in the MED assessment for the covered services, and the assessor's clinical judgment. An eligibility period cannot exceed twelve (12) months;

iii. The ASA forwards the completed assessment packet to the Service Coordination Agency of the Member's choice within three (3) business days of the medical eligibility determination and authorization of the plan of care;

iv. The Service Coordination Agency must contact the Member within twenty-four (24) hours of receipt of the MED assessment and authorized plan of care. The Service Coordination Agency must implement skills training and coordinate services with the Member as well as monitor service utilization and assure compliance with this policy; and

v. The Service Coordination Agency will complete the service plan and initiate skills instruction within thirty (30) days of the medical eligibility assessment date. The Service Coordination Agency will notify the Department, using the transmittal form approved by the Department, when the Member has successfully completed this requirement and an attendant has been hired. Provision of attendant services can begin only after the Department is notified that the Member has successfully completed this training and the service plan has been received.

12. 03-2Redetermination of Eligibility

A. For all Members under this Section, in order for the reimbursement of services to continue uninterrupted beyond the approved medical eligibility period, a reassessment to determine medical eligibility and authorization of services by the ASA is required. MaineCare payment ends with the reassessment date, also known as the medical eligibility end date.

Step #1: The Service Coordination Agency must submit a reassessment request to the ASA. The ASA must complete a reassessment at least five (5) calendar days prior to the end date of the member's current medical eligibility period to establish continued eligibility for MaineCare coverage of attendant Services. If the need for additional consumer skills instruction has been identified by the ASA or the Service Coordination Agency, it will be documented in the Member's service plan.

Step #2: The ASA's findings and scores recorded in the MED form shall be determinative for establishing eligibility for services and the authorized plan of care. The service plan shall not be completed until medical eligibility has been determined and services authorized, as allowed under this Section, in the care plan summary of the MED form.

Step #3: The ASA shall review, face-to-face with the Member at the Member's residence, the medical eligibility for services at least annually based on clinical judgment.

Each member is eligible for attendant services, as identified, documented, and authorized on the MED form, within the following limitations as described below and in Chapter III, Section 12.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-12, subsec. 144-101-II-12.03