C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-13, subsec. 144-101-II-13.03

Current through 2024-51, December 18, 2024

Subsection 144-101-II-13.03 - ELIGIBILITY FOR SERVICES

An individual may be found eligible to receive MaineCare Targeted Case Management services if the following requirements are met:

13.03-1General Eligibility Requirements

Individuals must meet the eligibility criteria as set forth in the MaineCare Eligibility Manual, Chapter I, Section 1. Some members may have restrictions on the type and amount of services they are eligible to receive.

Designated case management agencies shall be responsible for confirming the member's eligibility for case management services. If the individual is not currently receiving MaineCare, he or she will be referred to a district office of the Department of Health and Human Services, Office of Integrated Access and Support, to determine eligibility for MaineCare.

13.03-2Specific Eligibility Requirements

In order to receive Targeted Case Management Services, members must meet criteria for one of the four following target groups:

A. Members must meet the eligibility criteria for one of the following targeted population groups:

1. Case Management Services for Children with one of the following:

a. Behavioral Health Disorders,

b. Developmental Disabilities, and/or

c. Chronic Medical Conditions.

2. Case Management Services for Adults with one of the following:

a. Developmental Disabilities,

b. Substance Abuse Disorders, and/or

c. HIV.

3. Case Management Services for Members Experiencing Homelessness AND

B. Render a diagnosis, if a diagnosis is a requirement of a Targeted Case Management Eligibility Group.The diagnosis must be rendered, within the scope of the individual's license, by a physician, a physician assistant or an independently licensed clinician (as defined in state statute or rule). Functional limitations, as set forth below, must be identified, supported, and documented in assessments using accepted standardized instruments that are developmentally appropriate to the members being assessed.

Functional Limitations mean:

Vocational

Impairment in vocational functioning as manifested by (1) an inability to be consistently employed at a self-sustaining level or (2) an ability to be employed only with extensive supports (A person who is able to earn sustaining income, but is recurrently unemployed because of acute episodes of mental illness or addictions does not meet this functional limitations requirement).

Education

Impairment in educational functioning as manifested by an inability to establish and pursue educational goals within a normal time frame or without extensive supports.

Instrumental Activities of Daily Living (IADL)

Impairment in IADL functioning as manifested by an inability to consistently and independently accomplish home management tasks, including household meal preparation, washing clothes, grocery shopping and budgeting.

Social or Interpersonal

Impairment in social or interpersonal functioning as manifested by an inability to independently develop or maintain social relationships, or to independently participate in social or recreational activities. This may be evidenced by:

- Repeated inappropriate or inadequate social behavior (defined as aninability to behave appropriately or adequately without extensive or consistent support or coaching; or only in special contexts or situations such as social groups organized by the provider), or

- Consistent participation in activities only with extensive support or coaching, and when involvement is mostly limited to special activities established for persons with interpersonal impairments.

Community

Impairment in community functioning as manifested by a pattern of significant community disruption, including family disruption or social unacceptability or inappropriateness, which may not recur often but is of such magnitude that it results in severe consequences (including exclusion from the member's primary social group) or in severe impediments to securing basic needs such as housing.

Self-care, Independent Living or Activities of Daily Living

Impairment in self-care or independent living as manifested by an inability to consistently perform the range of practical daily living tasks required for basic functioning in the community, including:

- Bed mobility, transfer, locomotion, eating, toilet use, bathing, and dressing

- Grooming, hygiene, and meeting nutritional needs

- Care of personal business affairs

- Transportation and care of residence

- Procurement of medical, legal, and housing services

- Recognition and avoidance of common dangers or hazards to self and possessions.

13.03-3Case Management Services for Children

A.Eligibility Criteria for Children with Behavioral Health Disorders

Acceptable standardized instruments means, for behavioral health, Child/Adolescent Functional Assessment Scale (CAFAS) (ages 6 through 20), Child and Adolescent Needs and Strength assessment Preschool Comprehensive (CANS-PC) (ages 0-5), Child and Adolescent Needs and Strengths assessment Mental Health (CANS-MH) (ages 5-17), the Child/Adult Needs and Strengths Assessment Transition Mental Health (CANSAT-MH) (18-21), Preschool and Early Childhood Functional Assessment Scale (PECFAS) (ages 3 through 6), and Ages and Stages (and Ages and Stages Social Emotional scales) (up through age 5).

Children must meet the criteria listed below in subsections 1 OR 2. In addition children must meet the criteria listed in subsection 3a or 3b to be eligible for TCM Services.

1. A child with a completed multi-axial evaluation of an Axis I or Axis II mental health diagnosis(es) as described in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), or a diagnosis described in the most recent version of the Diagnostic Classification of Mental Health and Developmental Disabilities of Infancy and Early Childhood

(DC: 0-3). Axis I mental health diagnoses do not include the following: Learning Disabilities (LD) in reading, mathematics, written expression, Motor Skills Disorder, and LD NOS (Learning Disabilities Not Otherwise Specified); Communication Disorders (Expressive Language Disorders, Mixed Receptive Expressive Language Disorder, Phonological Disorder, Stuttering, and Communication Disorder NOS); OR

2. A child under five (5) years of age who:

a. is determined by a professional approved by the Department as being at risk of developing a mental health disorder due to known environmental or biological risks using DHHS adopted tools, AND

b. has significant impairment or limitation in adaptive behavior or functioning according to criteria as established by the Department (See 13.03-2 B), and determined by a qualified professional approved by the Department.

3. Level of Care Criteria

a. Level of care criteria for services assessed through the CAFAS:

(1) Case management service is authorized for up to thirty (30) days from the date of the first billed encounter if the eight (8) scale composite CAFAS score is fifty (50) or less.

(2) Case management services may continue beyond thirty (30) and up to ninety (90) days from the date of the first billeden counter if the eight (8) scale composite CAFAS score is at least between fifty-one (51) and seventy (70).

(3) Clinical information will be considered in addition to the composite CAFAS scores above as the scores are not the solecriteria for eligibility and review.

(4) Case management services may continue beyond 90 days if the 8 scale CAFASscore is above (70). Service continuation will be dependent upon clinical information submitted

b. Level of care criteria for services assessed through the CANS:

(1) Case management service is authorized for up to ninety (90) days from the date of the first billed encounter if the assessment scores are 2 or higher for both the "Behavioral/Emotional needs" AND "Life domain Functioning" sections of the CANS-PC, the CANS-MH or the CANSAT-MH.

(2) Clinical information will be considered in addition to the CANS scores as the scores are not the sole criteria for eligibility and review.

(3) Case management service may continue beyond ninety (90) days dependent on clinical information submitted.

B.Eligibility Criteria for Children with Developmental Disabilities

Acceptable standardized instruments means, for developmental disabilities, CHAT (ages 6 through 20), Child and Adolescent Needs and Strengths assessment-Preschool Comprehensive (CANS-PC) (ages 0-5), Child and Adolescent Needs and Strengths assessment-Mental Health (CANS-MH) (5-17), Child and Adolescent Needs and Strengths assessment Autism Spectrum Profile (CANS-ASP) (0-18), Child/Adult Needs and Strengths Assessment Transition Developmental Disabilities (CANSAT-DD) (18-21), Vineland Adaptive Behavior Scales (up through age 20), Battelle Developmental Inventory (up through age 7), Bayley Scales of Infant and Toddler Development (age 1 month through 2 years), and Ages and Stages (and Ages and Stages Social Emotional scales) (up through age 5).

Children must meet the criteria listed below in subsection 1 OR 2 OR 3. In addition children must meet the criteria listed in 4a. OR 4b.to be eligible for TCM Services.

1. Meet the definition of developmental disabilities as defined in 22 M.R.S.A. §3573 or have an Axis II diagnosis of mental retardation as described in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders; OR

2. Have an Axis I diagnosis of pervasive developmental disorder as described in the most recent Diagnostic and Statistical Manual of Mental Disorders; OR

3. For children between birth and five (5) years of age:

a. Are determined by a professional approved by the Department as being at risk of developing a Pervasive Developmental Disorder due to known environmental or biological risks using DHHS adopted tools, AND

b. Have significant impairment or limitation in adaptive behavior or functioning according to criteria established by the Department (See Section 13.03-2(B)) and as determined by a qualified professional approved by the Department.

4. Level of Care Criteria

a. Level of care criteria for services assessed through the CHAT:

(1)Case management service is authorized for up to thirty (30) days from the date of the first billed encounter if the CHAT score is twenty (25) or less.

(2) Case management services may continue beyond thirty (30) and up to ninety (90) days from the date of the first billed encounter if the CHAT score is at least between twenty-six (26) and thirty-five (35).

(3) Clinical information will be considered in addition to the CHAT scores above as the scores are not the sole criteria for eligibility and review.

(4) Case management services may continue if the CHAT score is above 35. Service continuation will be dependent upon clinical information submitted.

b. Level of care criteria for services assessed through the CANS:

(1) Case management service is authorized for up to ninety (90) days from the date of the first billed encounter if the assessment scores are 2 or higher for:

i. Both the "Behavioral/EmotionalNeeds" and "Life Domains" sections of the CANS-PC;

ii. The "Maladaptive Behaviors" section of the CANS-ASP;

OR

iii. The "Needs" section of the CANSAT-DD.

(2) Clinical information will be considered in addition to the CANS scores as the scores are not the sole criteria for eligibility and review.

(3) Case management service may continue beyond ninety (90) days dependent on clinical information submitted.

C. Eligibility Criteria for Children with Chronic Medical Conditions

1. A child who is infected with the human immunodeficiency virus (HIV), as determined by a positive HIV antibody or antigen test, or who has a diagnosis of HIV disease or AIDS; OR

2. A child who has:

a. been diagnosed with an autoimmune disease, diabetes, respiratory disorder, a neurological disorder, brain injury or other chronic condition specifically recognized by the Department or its authorized agent; AND

b. three (3) or more documented functional limitations as defined in 13.03-2(B) (Functional Limitations); OR

3. A child who has:

a. a diagnosed physical condition or the presence of a documented history by a professional approved by the Department of prenatal, perinatal, neonatal, or early physical developmental events or conditions suggestive of damage to the central nervous system or of later atypical physical development, such as, but not limited to, cerebral palsy, meningitis, heart defects, or bronchiopul monary dysplasia which, without intervention, has a high probability of resulting in physical developmental delay, AND

b. significant impairment or limitation in adaptive functioning according to criteria as established by the Department and determined by a qualified professional approved by the Department.

4. Level of Care Criteria for services for Children Chronic Medical Conditions

a. Case management service is authorized for up to thirty (30) days from the date of the first billed encounter if one of the assessed functional limitations is severe and two or more are moderate in severity as evidenced by approved standardized instruments completed by a specialist in adaptive functioning and there is a documented need for TCM service to provide referral services for the member.

b. Case management services may continue beyond thirty (30) and up to ninety (90) days from the date of the first billed encounter if two of the assessed functional limitations are severe and 1 or more functional limitations are moderate in severity as evidenced by approved accepted standardized instruments completed by a specialist in adaptive functioning and there is a documented need for TCM service to provide referral services with limited monitoring and follow up for the member.

c. Case management services may continue if 3 or more of the assessed functional limitations are severe as evidenced by approved accepted standardized instruments completed by a specialist in adaptive functioning and there is a documented need for TCM service to provide referral services with monitoring and follow up of those services, for the member. Service continuation will be dependent upon clinical information submitted

13.03-4Case Management Services for Adults

Adults must meet the following criteria to be eligible for TCM Services.

A.Eligibility Criteria for Adults with Developmental Disabilities

An individual is eligible for case management services if he or she is age eighteen (18) or older and meets the eligibility requirements of Title 34B M.R.S.A.§3573, which defines developmental disabilities, or Title 34B M.R.S.A. §6002, which defines autism. A person who has reached his or her eighteenth (18^th) birthday and is under age twenty-one (21) may choose to receive case management services as an adult.

B.Eligibility Criteria for Adults with Substance Abuse Disorders

1. An adult who has an Axis I diagnosis(es) of substance abuse disorder(s) described in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) AND

2. Who is currently seeking substance abuse treatment services by a DHHS approved substance abuse treatment provider; AND

3. Who is pregnant, who is living with his or her minor children, and/or who is an intravenous drug user, AND

4. Who is enrolled in a substance abuse program which receives funding by the Substance Abuse Prevention Treatment Block Grant as provided by 42 U.S.C. section 300x - 22(b).

C.Eligibility Criteria for Adults with HIV

An adult who is infected with the human immunodeficiency virus (HIV), as determined by a positive HIV antibody or antigen test, or who has a diagnosis of HIV disease or AIDS.

A designated case management agency shall be responsible for confirming the person's eligibility for case management services. Case management services for persons with HIV infection are covered services only when provided by approved staff of agencies designated by the Department's Center for Disease Control, Division of Infectious Disease, HIV, STD and Viral Hepatitis Program Administrator.

13.03-5Case Management Services for Members Experiencing Homelessness

Members experiencing homelessness but who otherwise are not eligible for TCM must meet the following Eligibility Criteria to be eligible for TCM under this Section;

A. A member must be either:

1. Currently residing or has in the past ninety (90) days resided in an emergency shelter in the State of Maine, OR

2. An individual who does not otherwise have a permanent address, residence, or facility in which they could reside

B. In addition to meeting the criteria in (A) above, an individual must meet ALL of the following:

1. require treatment or services from a variety of agencies and providers to meet the individual's medical, social, educational, and other needs; AND

2. will access needed services only if assisted by a qualified targeted comprehensive case manager who, in accordance with the individual plan of care, locates, coordinates, and regularly monitors the services; AND

3. The member must meet at least one of the following criteria:

a. is in need of immediate medical care; OR

b. is in need of an immediate crisis evaluation or mental health assessment to address a behavioral health issue; OR

c. has a current medical or mental health condition and is at risk of losing or has lost access to medically necessary services; OR

d. has an immediate need for medications to address an existing medicaland/or behavioral health condition;OR

e. is demonstrating physical or mental impairment such that services are necessary to improve, restore or maintain health and well-being; OR

f. has experienced immediate or recent trauma and is demonstrating a need for assistance with gaining and coordinating access to necessary care and services appropriate to their needs.

13.03-6Eligibility Procedures

Eligibility for case management services will be determined by either a case manager of the Department or a comprehensive case manager of a designated provider. Eligibility procedures are specific to the targeted case management groups and/or program offices within the Department. The procedure for determining eligibility for case management services is as follows:

A. Individuals who may be eligible for case management services may be referred by any source, such as a physician, psychologist, other health or mental health provider, school, parent, guardian, or public and private community agency. (Written permission from the applicant or legal guardian is required whenever a referral is made by any person or agency acting on behalf of the applicant.)

B. Documentation of eligibility must be in a format approved by the Department or its Authorized Agent. Eligibility information from case management agencies may be used in planning, management and quality assurance activities.

C. If the individual is not currently receiving MaineCare, the comprehensive case manager will refer the individual to a district office of the Department of Health and Human Services, Office of Integrated Access and Support to determine eligibility for MaineCare.

D. All members who are eligible for case management will be assigned a comprehensive case manager with reasonable promptness after initial referral. For children ages birth through twenty (20) a comprehensive case manager must be assigned within one hundred and eighty (180) days after initial referral.

E. If it is determined that the individual does not meet the established criteria for targeted case management services, the applicant shall be informed in writing and given notice of his or her right to appeal that decision. (For more information regarding Appeal Rights, refer to Chapter I of the MaineCare Benefits Manual.)

F. Additional requirements specific to the targeted case management groups and/or program offices within the Department, as applicable.

13.03-7 Quality Assurance

Providers must cooperate with the Department or its authorized agent in conducting quality assurance activities including, but not limited to the following:

1. Periodic review of cases to assure quality and appropriateness of care conducted in accordance with the quality assurance protocols specific to each target group.

2. Review of all records to assure that documentation is signed and dated by the reviewers, and included in the member's record, or kept in a separate and distinct file parallel to the member's record.

3. Providers are subject to all guidelines in MaineCare Benefits Manual, Chapter I.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-13, subsec. 144-101-II-13.03