Subsection 144-101-II-20.03 - DETERMINATION OF ELIGIBILITY20.03-1Approved 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.
20.03-2General Eligibility CriteriaConsistent with Subsection 20.03-1, a person is eligible for services under this section if the person:
A. Is age twenty one (21) or older; andB. Has a Related Condition within the meaning of 42 C.F.R. § 435.1010. A "Related Condition" must meet all of the following conditions:
1. It is attributable to; a. Cerebral Palsy or Epilepsy; orb. Any other condition, other than mental illness, found to be closely related to Intellectual Disabilities because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with Intellectual Disabilities and requires treatment or services similar to those required for these persons. These conditions include but are not limited to Neurofibromatosis, Other Choreas, Anoxic Brain Damage, Cerebral Laceration and Contusion, Subarachnoid- Subdural and Extradural Hemorrhage following injury, Other and Unspecified Intracranial Hemorrhage following injury or Intracranial injury and unspecified nature, Muscular Dystrophy, Huntington's, Spina Bifida or other rare developmentally- based conditions.2. It is manifested before the person reaches age twenty two (22).3. It is likely to continue indefinitely.4. It results in substantial functional limitation in three (3) or more of the following areas of major life activity: b. Understanding and use of language.f. Capacity for independent living; andC. Meets the medical eligibility criteria for admission to an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) as set forth under the MaineCare Benefits Manual, Chapter II, Section 50; andD. Does not receive services under any other federally approved MaineCare home and community based waiver program; andE. Meets all MaineCare eligibility requirements as set forth in the MaineCare Eligibility Manual; andF. The estimated annual cost of the member's services under the waiver is equal to or less than one hundred percent (100%) of the state-wide average annual cost of care for a member in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), as determined by DHHS; andG. Can have his or her health and welfare needs assured in the community setting as stated in § 20.08-2(E) (1) and (2).20.03-3Establishing 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 BMS 99 or current functional assessment, as approved by DHHS, by the Care Monitor; and C. Documentation from a physician that the waiver services are medically necessary. 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 for notice and appeal are further described in Chapter I of the MaineCare Benefits Manual.
20.03-4PriorityWhen 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: (1) if the member is currently residing in a facility of more than 16 beds that is engaged in providing diagnosis, treatment or care of persons with related conditions, which typically includes: medical attention; nursing care and related services: 24-hour supervision: and coordination and integration of health or rehabilitative services, and(2) 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 20.04-1, 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: All other members shall be identified as Priority 2. 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.
20.03-5Redetermination of EligibilityEligibility for services under this section must be redetermined annually. When determining continuing eligibility, the Care Coordinator will initiate an updated Medical Assessment tool and updated BMS 99 form or current functional assessment, as approved by DHHS. This assessment will be conducted by DHHS 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 20.04-3 regarding updating of the Care Plan.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-20, subsec. 144-101-II-20.03