Subsection 144-101-II-18.03 - DETERMINATION OF ELIGIBILITY18. 03-1 Approved OpeningThe number of MaineCare members who can receive services under this section is limited to the number of openings approved by the Centers for Medicare and Medicaid Services (CMS). Persons who would otherwise be eligible for services under this section are not eligible to receive services if all of the approved openings are filled.
18. 03-2 General Eligibility CriteriaConsistent with Subsection 18. 03-1, a person is eligible for services under this section if the person:
A. Is age eighteen (18) or older; andB. Has a diagnosis of acquired brain injury. Acquired Brain Injury means an insult to the brain resulting directly or indirectly from trauma, anoxia, or vascular lesions, or infection, which is not of a degenerative or congenital nature, can produce a diminished or altered state of consciousness resulting in impairment of cognitive abilities and/or physical functioning, can result in the disturbance of behavioral or emotional functioning, can be either temporary or permanent, and can cause partial or total functional disability or psychosocial maladjustment. (Title 22 §3086); and C. The individual has received an assessment by a qualified neuropsychologist (as defined in the MaineCare Benefits Manual, Rehabilitative Services, Section 102. 08-5 B) and/or a licensed physician who is Board certified or Board eligible in Physical Medicine and Rehabilitation, which: 1. positively indicates the individual: is not in a persistent vegetative state; is able to demonstrate potential for physical and/or behavioral and/or cognitive rehabilitation; shows evidence of moderate to severe behavioral and/or cognitive and/or functional disabilities; and2. results in specific rehabilitation goals, based upon the findings of the assessment, describing types and frequencies of therapies and expected outcomes and time frames; and D. Has a completed Department-approved Health and Safety Assessment administered by the Department with an overall score of 0. 1 or higher. The Department approved Health and Safety Assessment evaluates cognitive, physical, and behavioral needs related to a person's brain injury. It assesses whether a person needs support for the three areas. Additionally, it assesses if the person needs cueing, direct support, or a behavioral support. Scores range from 0-1. The assessment can be found at the Department's Brain Injury Services website: http://www. maine. gov/dhhs/oads/disability/bi/index. shtmlThe assessment was last revised: 02/25/14. The Department will only accept assessments conducted no more than three months prior to application; andE. Has completed Mayo-Portland Adaptability Inventory - 4 (or current Department approved version of the MPAI) with an item score of 3 or higher for two of the following items: b. Impaired Self-Awarenessc. Irritability, Anger, Aggressiond. Inappropriate Social Interactione. Fund of Information or Attention/Concentration or Memory The Department will only accept assessments conducted no more than three months prior toapplication; and
F. Does not receive services under any other federally-approved MaineCare home and community-based waiver program; andG. Meets all MaineCare eligibility requirements as set forth in the MaineCare Eligibility Manual; andH. The estimated annual cost of the member's services under the waiver is equal to or less than one hundred percent (100%) of a blended rate of the statewide average annual cost of care for individuals in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID) and Nursing Facility Brain Injury units, as determined by DHHS (the blended rate being the sum of 20% of the statewide average annual cost of care in an ICF/IID and 80% of the statewide average annual cost of care in a Nursing Facility Brain Injury unit); andI. Can have his or her health and welfare needs assured in the community setting as stated in § 18. 04-2(D). 18. 03-3 Establishing Medical EligibilityDetermination of the member's medical eligibility for services under this Section requires the following:
A. Completion of a Medical Eligibility Determination (MED) assessment by the Assessing Services Agency (ASA); B. Completion of the Mayo Portland Adaptability Inventory (MPAI) or current functional assessment, as approved by DHHS, by DHHS or its Authorized Entity; C. Completion of the Department approved Health and Safety Assessment (HSA); andD. Documentation from a qualified neuropsychologist (as defined in the MaineCare Benefits Manual, Rehabilitative Services, Chapter II, Section 102. 08-5 (B)) and/or a licensed physician who is Board certified or Board eligible in Physical Medicine and Rehabilitation that the waiver services are medically necessary as described in Section 18. 03-2(C) . The member and Care Monitor are responsible for working with DHHS to ensure that each of these items is completed. DHHS shall notify each member or the member's guardian in writing of any decision regarding the member's medical eligibility, and the availability of benefit openings under this section. The notice will include information about the member's right to appeal any of these decisions. Rights fornotice and appeal are further described in Chapter I of the MaineCare Benefits Manual.
18. 03-4 PriorityWhen a member is found to meet MaineCare financial eligibility and medical eligibility for these services, the priority for an approved opening shall be established in accordance with the following:
A. Priority 1: A member shall be identified as Priority 1 if the member is currently residing in afacility of more than 8 beds that is engaged in providing diagnosis, treatment or care, which typically includes: medical attention; nursing care and related services; 24-hour supervision; and coordination and integration of health or rehabilitative services; and the member continues to meet the financial and medical eligibility criteria at the time that an approved opening becomes available. Order of enrollment will be based on date of application; an application will be considered complete on the date upon which items (A) through (D) from Section 18. 04-1, Procedures for Developing the Care Plan, have been completed to DHHS satisfaction and DHHS has received all documents. If there are two applications received on the same day, the applicant with the longest continuous stay in institutional care will be prioritized first.
B.Priority 2: A member shall be identified as Priority 2 if the member has been determined to be residing in the community. A higher priority will be given to those members who are at imminent risk of abuse, neglect or exploitation followed by those at anticipated risk of abuse, neglect or exploitation or homelessness and institutionalization with the next year. If applications exceed approved openings in any given year, a waiting list will be established. The list will be prioritized, as specified above, such that when there is a funded opening an individual will be selected from priority one first and then immediately from priority two if there are not any completed and approved applicants from priority one.
18. 03-5 Redetermination of EligibilityEligibility for services under this section must be redetermined annually. When determining continuing eligibility, the Care Coordinator will initiate an updated MED assessment, updated Mayo Portland Adaptability Inventory or current functional assessment, as approved by DHHS, and an updated Department approved Health and Safety Assessment. The MED Assessment and Mayo Portland Adaptability Inventory or current functional assessment will be conducted by DHHS or its Authorized Entity. The Department approved Health and Safety Assessment will be completed by the Department or its Authorized Entity. Updated assessments must be completed twelve (12) months from the date of initial approval, and every twelve (12) months thereafter. Once the assessment has been updated, the Care Plan will be updated annually. If the updated Assessment Referral is received after the due date, reimbursement for services will resume upon completion of the assessment. Whenever there is a significant change in the member condition that requires an alteration in the level of care,the Care Coordinator will provide notice to DHHS or its Authorized Entity and request an updated assessment. See 18. 04-3 regarding updating of the Care Plan.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-18, subsec. 144-101-II-18.03