C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-40, subsec. 144-101-II-40.02

Current through 2024-51, December 18, 2024

Subsection 144-101-II-40.02 - ELIGIBILITY FOR CARE

*The Department is seeking, and anticipates receiving, approval from CMS for this Section. Pending approval, the change will be effective.

40.02-1Authorization Process. The HHA must obtain authorization from the Department or its Authorized Entity for all members receiving services under this section except as provided in 40.02-5 subparagraph B.

A. Plans of Care must be submitted to the Department or its Authorized Entity within five (5) business days of the start of services. After the plans of care are reviewed for medical appropriateness, providers will receive a final authorization for the plan of care.

B. A member who qualifies under 40.02-4 and requires psychotropic medication administration or psychotropic medication monitoring as his/her only services, shall be exempt from the authorization process outlined above. If the member requires any additional Home Health Services, these shall follow the authorization process as outlined in 40.02-1 subparagraph A above.

The Department or its Authorized Entity must determine if the member continues to meet the eligibility for care requirements in Section 40.02.

C. Members receiving services under Section 19, Home and Community Benefits for the Elderly and for Adults with Disabilities may be eligible for nursing services under this Section if Section 19 nursing services have been deemed insufficient by the Department to meet the acute nursing needs of the Member. Section 40 providers must seek prior approval through the Office of MaineCare Services to provide Section 40, Home Health Nursing Services to Section 19 members.

40.02-2General and Specific Requirements

An individual may be found eligible to receive services as set forth in this Section, if he or she meets both the General MaineCare Eligibility Requirements and the Home Health Services Medical Eligibility Requirements.

40.02-3General MaineCare Eligibility Requirements. Individuals 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.

40.02-4Home Health Services Medical Eligibility Requirements. A member must meet the following requirements:

A. The patient must be under the care of a physician who is legally authorized to practice and is acting within the scope of their license.

B. The medical condition of the member must be such that it can be safely and appropriately treated by the Home Health Agency under a plan of care reviewed and signed by a physician every certification period; AND

C. The member must be in a place of residence and NOT in an institution that meets the definition of a hospital, nursing facility or ICF-IDD except as allowed under Section 40.01-13 and Section 40.06; AND

D. Home Health Services shall not be provided if services are available and safely accessible to the member on an outpatient basis. The plan of treatment signed by both the physician and the Home Health Agency must include a statement of the medical necessity for receiving services at home citing the specific reasons outpatient care is contraindicated (defined in 40.01-3) or not possible. The reasons must be listed and the likelihood of a bad outcome must be probable or definite as opposed to possible or rarely; AND

E. Observation and assessment by a nurse is not reasonable and necessary to the treatment of the illness/injury where these indications are part of a long standing pattern of the member's condition and there is no significant change in health status.

F.To qualify for skilled nursing services, the condition of the member must require skilled nursing care on a "part-time" (as defined in Section 40.01-20) or "intermittent" (as defined in Section 40.01-14) basis or otherwise no less than twice per month.

1. intraarterial, intravenous, intramuscular or subcutaneous injection, or intravenous feeding, all for treatment of unstable conditions requiring medical or nursing intervention. Daily insulin injections for an individual whose diabetes is under control do not meet the requirements of this Section; or

2. nasogastric tube, gastrostomy, or jejunostomy feeding, for a new/recent (within past thirty (30) days) or unstable condition; or

3. nasopharyngeal suctioning or tracheostomy care; however, care of a tracheostomy tube must be for a recent (within the past thirty (30) days) or unstable condition; or

4. treatment and/or application of dressings when the physician has prescribed irrigation, the application of prescribed medication, or sterile dressings of stage III and IV decubitus ulcers, other widespread skin disorders (except psoriasis and eczema), or care of wounds, when the skills of a registered nurse are needed to provide safe and effective services (including, but not limited to, ulcers, second or third degree burns, open surgical sites, fistulas, tube sites and tumor erosions); or

5. administration of oxygen on a regular and continuing basis when the member's medical condition warrants professional nursing observation for a new or recent (within past thirty (30) days) condition; or

6. professional nursing assessment, observation and management of an unstable medical condition (see Section 40.01-28); or

7. insertion and maintenance of a urethral or suprapubic catheter as an adjunct to the active treatment of a disease or medical condition may justify a need for skilled nursing care. In such instances, the need for a catheter must be documented and justified in the member's medical record; or

8. care to manage conditions requiring a ventilator/ respirator.

9. direct assistance from a professional nurse is required for the safe management of an uncontrolled seizure disorder (e.g.: grandmal); or

10. assessment and management for a new or recent medical condition (within the past thirty (30) days); or

11. professional nursing care and monitoring for administration of treatments, procedures, or dressing changes, which involve prescription medications, according to physician orders, at least twice per month. Treatments include:

a. administration of medication via a tube;

b. tracheostomy care;

c. urinary catheter change;

d. urinary catheter irrigation;

e. barrier dressings for Stage 1 or 2 ulcers;

f. chest PT by RN;

g. oxygen therapy by RN;

h. other physician ordered treatments; or

i. teaching and training activities for patient and family;

12. professional nursing care for Members receiving:

a. radiation therapy;

b. chemotherapy given intravenously or by injection; or

c. hemodialysis or peritoneal dialysis;

G.To qualify for therapy services, the member must require physicaltherapy services, or speech-language pathology services, or occupational therapy services as described below:

a. physical therapy or occupational therapy services as part of aplanned program that is designed, established and provided by,and requires the professional skills of a licensed or registered therapist. (Therapy services may be delivered by a qualified licensed or certified therapy assistant under the direction of a qualified professional therapist.) The findings of an initial evaluation and periodic reassessments must be documented in the member's medical record. Skilled therapeutic services must be ordered by a physician and be designed to achieve specific goals within a given time frame. The need for maintenance or preventative therapy does not meet the requirements of this Section.

b. in addition, all members seeking occupational or physical therapy services must have rehabilitation potential (defined in Section 40.01-23) documented by a physician;

c. speech-language pathology services as part of a planned program that is designed, established, and provided by and requires the professional skills of a licensed speech-language pathologist or speech-language pathology assistant supervised by a Board licensed speech-language pathologist.

All members must be assessed by a physician. The physician must provide documentation that the member has experienced a significant decline in his or her ability to communicate orally, safely swallow, or masticate and has rehabilitation potential (defined in Section 40.01-23). The documentation of the physician's assessment must be signed by the physician and be part of the member's record.

For continued eligibility beyond the initial certification period for all members the Home Health Agency must obtain a report completed by the speech-language pathologist documenting the member's progress and prognosis for improved speech, mastication, or swallowing functioning. The report must be forwarded to the member's physician for confirmation that rehabilitation potential still exists for the member. The report must be amended and signed by the physician to document the rehabilitation potential of the member. This report must be maintained in the member's medical record.

40.02-5Medical Eligibility Requirements for Psychotropic Medication Services

A member may receive in-home psychotropic medication services if he or she meets ALL of the following requirements:

A. The member has a Severe and Persistent Mental Illness that meets the eligibility requirements set forth in Section 17.02, Community Support Services for persons with Severe and Persistent Mental Illness. A copy of the Department's approved Section 17 assessment tool shall be completed pursuant to the requirements in Section 17.

The signed assessment shall be maintained in the member's medical record. A copy of the signed assessment must be submitted to the Department along with the start of care form; AND

B. The member requires psychotropic medication administration or monitoring for psychotropic medication; AND

C. The member is not receiving psychotropic medication services under any other Sections of the MBM (except physician services are allowed); AND

40.02-6* Medical Eligibility Requirements for Telemonitoring Services.

In order to be eligible for telemonitoring services, a member must:

A. Be eligible for Home Health Services under Chapter II, Section 40, HomeHealth Services;

B. Have a current diagnosis of a health condition requiring monitoring of clinical data at a minimum of five times per week, for at least one week;

C. Have a written opinion from a clinician, based on documented or reported history, stating that he/she is at risk of hospitalization or admission to an emergency room; OR

Have continuously received telemonitoring services during the past calendar year and have a continuing need for such services, as documented by an annual note from a licensed Health Care Provider;

D. Reside in a setting suitable to support telemonitoring equipment;

E. Have the physical and cognitive capacity to effectively utilize the telemonitoring equipment or have a caregiver willing and able to assist with the equipment; and

F. Have telemonitoring services included in the member's plan of care. A notation from a Health Care Provider, dated prior to the beginning of service delivery, must be included in the member's plan of care. If telemonitoring services begin prior to the date recorded in the provider's note, services shall not be reimbursed.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-40, subsec. 144-101-II-40.02