C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-50, subsec. 144-101-II-50.05

Current through 2024-51, December 18, 2024

Subsection 144-101-II-50.05 - ELIGIBILITY FOR CARE

50.05-1General and Specific Requirements

In order to be eligible for ICF-MR services, all the following standards must be met:

A.General MaineCare Eligibility Requirement. Individuals must meet the eligibility criteria as set forth in the MaineCare Eligibility Manual. The eligibility determination process is administered by the Office of Integrated Access and Support.

B.Specific MaineCare Requirements.

1. The Department or the Department's authorized agent must determine the individual's medical eligibility, as described in Section 50.06; and

2. Individuals must be diagnosed by a physician as having mental retardation or a related condition, which is manifested before the person reaches age twenty-two (22); and

3. Individuals must require active treatment of ICF-MR services, as defined in this Section. An individual's eligibility cannot be based merely on his/her diagnosis. General and specific requirement determinations are processed concurrently in order to expedite the decision of the applicant's overall eligibility for ICF-MR services. Once an applicant is found eligible, the Department will review eligibility requirements on an annual basis.

50.05-2Eligibility for Care in an ICF-MR Nursing Facility

A. All MaineCare eligible members admitted to an ICF-MR Nursing Facility must have the medical necessity for ICF-MR care certified by a physician on admission and re-certified annually. There must be documented evidence of nursing needs that require at least eight (8) hours per day of licensed nurse supervision.

B. Before admission to an ICF-MR Nursing Facility or before authorization for payment, there must be a medical, psychological, and social evaluation and a plan of care. An Individual Program Plan (IPP) developed by the Inter-Disciplinary Team (IDT), must be established in accordance with State licensing and Federal certification requirements.

C. In addition to meeting one (1) or more of the criteria described under 50.05-3(B), one (1) or more of the following criteria must apply to a member in order for the member to be eligible to receive care in an ICF-MR Nursing Facility:

1. Plan of care requires the skills of a licensed nurse; and/or

2. Tube feedings that require professional nursing judgment, observation and care; and/or

3. Medical needs that require constant licensed nursing evaluations, judgments, and interventions, i.e. suctioning; and/or

4. Certain injectable medicines that require licensed nursing observation, supervision, or administration; and/or

5. Uncontrolled seizures that require licensed nursing observation, supervision, or administration.

50.05-3Eligibility for Care in an ICF-MR Group Home Facility

A. All MaineCare eligible members admitted to an ICF-MR Group Home Facility must have the medical necessity for ICF-MR care certified by a physician on admission and re-certified annually. The physician must certify that the member is not in need of eight (8) hours or more per day of nursing care. An IPP developed by the IDT must be established in accordance with State licensing and Federal certification requirements.

B. A member must require the services provided in an ICF-MR Group Home Facility, but cannot have care needs that require the presence of a licensed nurse for supervision for eight (8) hours or more per day. One (1) or more of the following criteria must apply to the member in order for the member to be eligible to receive care in an ICF-MR Group Home Facility. The member must:

1. Need assistance in personal care such as oral hygiene, care of skin, personal grooming and bathing; or

2. Exhibit or has exhibited deviation from acceptable behavior; or

3. Require some personal supervision; or

4. Require some protection from environmental hazards; or

5. Require supervision while participating in diversional and motivational activities both in the facility and in the community; or

6. Require assistance with medications that are of a routine nature and can be administered by qualified group home facility personnel; or

7. Require assistance due to aphasia.

C. If a member residing in an ICF-MR Group Home Facility has medical needs that require twenty-four (24) hour nursing supervision, he or she may continue to reside in the facility if the following conditions are met. The member must:

1. Have a medical care plan developed in accordance with State licensing and Federal certification regulations; and

2. Be in a facility where twenty-four (24) hour licensed nurse in-house coverage is provided; and

3. Obtain approval from the DHHS before twenty-four (24) hour nursing services are provided; and

4. The member's medical condition must be expected to be temporary.

50.05-4Continued Eligibility

A. Each MaineCare member must be reviewed by authorized representatives of DHHS to verify the continued need for ICF-MR level of care on an annual basis.

B. The Division of Licensing and Regulatory Services independent professional team shall review the quality, quantity, and necessity of the services being delivered to a MaineCare member at the following intervals:

1. a record review shall be performed every six (6) months; and

2. a site visit and records review shall be performed annually.

C. The IPP must be reviewed by all or a portion of the IDT at least every ninety (90) days.

D. Physician re-certification shall be considered in compliance if:

(1) it is completed not later than ten (10) calendar days after the required date, and

(2) the physician establishes good cause why the required date was not met.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-50, subsec. 144-101-II-50.05