C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-46, subsec. 144-101-II-46.03
Individuals must meet the financial eligibility criteria as set forth in the MaineCare Eligibility Manual (10-144 CMR Chapter 332). 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 eligibility and benefit level. The following describes specific eligibility for the covered services set forth in this section.
The member's condition must be such that his or her needs cannot be met in a less restrictive setting.
An individual must be under age twenty-one (21) or age sixty-five (65) or older to be eligible to receive inpatient psychiatric hospital services, except that if a member receives inpatient services immediately before he or she reaches age twenty-one (21), the member is eligible for continued service until he or she reaches age twenty-two (22) or the date when service is no longer required, whichever comes first.
To be eligible for partial hospitalization and outpatient services, the member's condition must be such that his or her needs cannot be met in a less intensive or less restrictive and available setting.
For outpatient services to be covered by MaineCare the member must need treatment similar to or more active or inclusive than is available through a weekly visit to a mental health agency, psychologist or psychiatrist, but not need partial or full-time hospitalization.
To be eligible for partial hospitalization services the member must need more active and inclusive treatment than is provided in an outpatient service, but not need full-time hospitalization or institutionalization.
The Office of MaineCare Services will determine classification (or eligibility) for certain children with disabilities ("Katie Beckett" Eligibility Option) age eighteen (18) and under. "Katie Beckett" eligibility has medical criteria in addition to financial criteria. All of the following eligibility criteria must be met for a child to receive MaineCare services:
The child must be determined disabled by Supplemental Security Income standards. A disability determination is made by the Medical Review Team (MRT) at the Office of Integrated Access and Support as part of the MaineCare application process or by the disability determination unit at the Social Security Administration.
The child must require a level of care that is typically provided in a hospital, including psychiatric hospitals, ICF-MR, or a Nursing Facility, although the child does not have to be admitted, relocated nor have a history of admissions to such an institution.
If the child were in a medical institution, the child would be eligible for Medicaid.
The following describes the criteria for severely emotionally disturbed children to meet the Psychiatric Hospital Level of Care. These criteria are used for establishing levels of care for SED children living at home who otherwise would need to be admitted to a hospital or psychiatric hospital. NOTE: All of the criteria under 1, 2, 3, and 4 must be met.
This diagnosis must include information on all five axes from the most current version of The Diagnostic and Statistical Manual of Mental Disorders (DSM) that apply; and
The child must be able to receive or currently be receiving appropriate care, in the least restrictive setting, outside a hospital or psychiatric inpatient setting. The parent and child will participate in making the decision as to where the child will receive care. The family home will be given first preference, if appropriate, as determined by the parent or guardian.
The total annual cost to MaineCare for community-based care for children eligible for MaineCare in this category must be no greater than the amount MaineCare would pay for the child's care in an institution.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-46, subsec. 144-101-II-46.03