Subsection 144-101-II-92.03 - MEMBER ELIGIBILITYMembers must meet the eligibility requirements set forth in this section.
92.03-1General Eligibility. Members must meet the eligibility criteria as set forth in the MaineCare Eligibility Manual, Chapter 1, Section 1. 92.03-2Specific RequirementsA.Serious and Persistent Mental Illness (SPMI).Adult members must meet the following criteria. Eligibility must be supported by written diagnosis(es), rendered by a physician, a physician assistant, or an independently licensed clinician, within the scope of the professional's license, and the diagnosis(es) shall be documented in the member's record. (1) Members must have a primary mental health diagnosis under the most current edition of the Diagnostic and Statistical Manual of Mental Disorders, except that the following diagnoses may not be primary diagnoses for purposes of this eligibility requirement: (a) Delirium, dementia, amnestic, and other cognitive disorders;(b) Mental disorders due to a general medical condition, including neurological conditions and brain injuries;(c) Substance use or dependence;(d) Intellectual disability;(e) Adjustment disorders;(g) Antisocial personality disorder. AND
(2) Has a LOCUS score, as determined by staff certified for LOCUS assessment by DHHS upon successful completion of prescribed LOCUS training, of seventeen (17) (Level III) or greater. The LOCUS assessment must be administered annually and documented in the member's record. B.Serious Emotional Disturbance (SED). Children members must meet the following criteria. Eligibility must be supported by written diagnosis(es), rendered by a physician, a physician assistant, or an independently licensed clinician, within the scope of the professional's license, and the diagnosis(es) shall be documented in the member's record. (1) Members must have a mental health diagnosis under the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders,or a diagnosis described in the current version of theDiagnostic Classification of Mental Health and Developmental Disabilities of Infancy and Early Childhood, except that the following diagnoses are not eligible for services in this section: (a) Learning Disabilities in reading, mathematics, written expression;(b) Motor Skills Disorder;(c) Learning Disabilities Not Otherwise Specified;(d) Communication Disorders (Expressive Language Disorders, Mixed Receptive Expressive Language Disorder, Phonological Disorder, Stuttering, and Communication Disorder Not Otherwise Specified; AND
(2) After the initial month of BHH enrollment, members must also have a significant impairment or limitation in adaptive behavior or functioning as evidenced by a CANS score of a two (2) or higher in both of the following sections: "Child Behavioral/Emotional Needs" and "Life Functioning Domain." The CANS must be reviewed and updated by the BHH a minimum of every one hundred and eighty days (180) days or sooner when major changes occur. The CANS, including all age relevant domains, must be entered into the Maine ASO database, or approved equivalent data system, for tracking and reporting purposes. Information gathered via the CANS must be used to inform and guide the development of the Plan of Care, described in 92.05-1. C.Eligibility Verification. Member eligibility is determined by the Department or its authorized entity, which must provide pre-authorization for services. Each member's eligibility must be based on a diagnosis rendered within the past year, as documented by an appropriately licensed professional. Reassessments shall occur at least annually in order to ensure ongoing eligibility for services provided herein. Eligibility verification shall be included in the member's record. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-92, subsec. 144-101-II-92.03