Section 197-11-01 - DEFINITIONS(A)Consumer-Directed Personal Assistance Services program, hereinafter referred to as Consumer-Directed Home Based Care (CDHBC), is a state funded program to provide long term care services to assist eligible consumer's to avoid or delay inappropriate institutionalization. State funds furnished through 34-B M.R.S.A. §5438 may not be used to supplant the resources available from families, neighbors, agencies and/or the consumer or from other Federal, State programs unless specifically provided for elsewhere in this section. State CDHBC funds shall be used to purchase only those covered services that are essential to assist the consumer to avoid or delay inappropriate institutionalization and which will foster independence, consistent with the consumer's circumstances and the authorized plan of service.(B)Activities of daily living (ADLs) ADLs include the following as defined in Section 11.02(B)(1)(a): bed mobility, transfer, locomotion, eating, toileting, bathing, hygiene, and dressing. The list of ADLs may be modified by the Authorized Agent, with the approval of the Department.(C)Assessing Services Agency (ASA) ASA means an organization authorized through a written agreement with the Department to conduct face-to-face assessments, using the Department's Medical Eligibility Determination (MED) form, and the timeframes and definitions contained therein, to determine medical eligibility and need for covered services. Based upon a consumer's assessment outcome scores recorded in the MED form, the ASA is responsible for authorizing a plan of service, which shall specify all services to be provided under this Section, including the number of hours for services, and the Authorized Agent types. The ASA is the Department's Authorized Agent for medical eligibility determinations and service plan development, and authorization of covered services as allowed under this Section.(D)Authorized Agent means an organization authorized by the Department under a valid contract or other approved, signed agreement to conduct a range of activities, which includes some or all of the following: accept referrals; assess consumer service needs; monitor the implementation of the service plan; train the consumer; serve as a resource to consumer's and their families; and assist with resolving problems. The Authorized Agent is also responsible for administrative functions, including maintaining consumer records; processing claims; final determination of the consumer copayment on receipt of the required information and collection of consumer co-payments; conducting the functions of an employer of record; and conducting required utilization review activities.(E)Authorized Plan of Service is a plan of service that is determined by the Assessing Services Agency, or the Department, and that specifies all services to be delivered to a consumer as allowed under this Section, including the number of hours for all covered services under this section. The Authorized Plan of Serviceshall be based upon the consumer's assessment outcome scores, and the timeframes contained therein, recorded in the Department's medical eligibility determination (MED) form. The Authorized Plan of Servicemust be completed on the Department's MED form and must not exceed the services required to provide necessary assistance with ADLs, IADLs, and identified Health Maintenance Activities on the MED form. The Authorized Agent has the authority to determine and authorize the plan of service. All authorized covered services provided under this Section must be listed in service Plan summary on the MED form. The Authorized Plan of Servicemust reflect the needs identified by the assessment, giving consideration to the consumer's living arrangement, informal supports, and services provided by other possible public or private funding sources to ensure non duplication of services. In no case will the amount of service authorized exceed the Maximum Authorized Service amount established by the Department. In the event the Maximum Authorized Service amount is amended, all Authorized Plans of Service will immediately be amended to reflect the amended Maximum.(F)Department means the Department of Health and Human Services.(G)Service Plan Summary is the section of the MED form that documents the Authorized Plan of Serviceand services provided by other public or private program funding sources or support, service category, reason codes, duration, unit code, number of units per month, rate per unit, and total cost per month. (H)Cognitive capacity: The consumer must have the cognitive capacity to perform all of the tasks and responsibilities of an employer in order to competently direct and manage the assistant. The consumer's cognitive capacity will be determined by an assessment conducted by the Authorized Agent.(I)Complete Medical Eligibility Determination packet includes a signed release of information, the fully completed medical eligibility determination (MED) form, the eligibility notification, hearing and appeal rights, service plan, complete financial assessment. Packets submitted that do not meet Department specifications will be returned to the AA.(J) Consumer, is the individual qualified for the program who will direct and control the Personal Assistant (PA). The consumer is someone with a disability who has functional limitations, which interfere with self-care and activities of daily living. The consumer must have the cognitive capacity to competently direct and manage the assistant on the job in order to assist and/or perform the ADLs, IADLs, and health maintenance activities. The consumer must be determined eligible for services under this section.(K)Consumer-Directed Home Based Care Services, also known as Personal Assistance Services (PAS), or Assistance Services, enable eligible people with disabilities to re-enter or remain in the community and to maximize their independent living opportunity at home. Consumer Directed Home Based Care Services includes a range of assistance with Activities of Daily Living (ADL), Instrumental Activities of Daily Living and Health Maintenance activities. The eligible consumer hires his/her own assistant, trains the assistant, supervises the provision of covered services, completes the necessary written documentation, and if necessary, terminates services or directs the termination of the assistant. The Department or the Assessing Services Agency, consistent with these rules, shall determine medical eligibility for services under this Section, prior authorize all covered services as allowed under this section, and authorize a plan of service for each new and established consumer of services. (L)Covered Services are those services for which payment can be made by the Department, under these regulations.(M)Criminal Background Check is research into the history of a PA or potential PA to determine if there is any criminal conviction involving abuse, neglect or misappropriation of property in a health care setting, or a complaint involving abuse or neglect that was substantiated by the Department pursuant to its responsibility to license hospitals, nursing facilities, home health agencies and assisted housing programs and that was entered on the Maine Registry of Certified Nursing Assistants, or a complaint involving the misappropriation of property in a health care setting that was substantiated by the Department and entered on the Maine Registry of Certified Nursing Assistants. (N)Department means the Maine Department of Health and Human Services.(O)Dependent Allowances. Dependents and dependent allowances are defined and determined in agreement with the method used in the MaineCare program. The allowances are changed periodically and cited in the MaineCare Eligibility Manual, Chart II, AFDC Related Income Limits. Dependents are defined as individuals who may be claimed for tax purposes under the Internal Revenue Code and may include a minor or dependent child, dependent parents, or dependent siblings of the consumer or consumer's spouse. A spouse may not be included.(P)Disability-related expenses: Disability-related expenses are out-of-pocket costs incurred by the consumer's for their disability, which are not reimbursed by any third-party sources. They include:(1) Home access modifications: ramps, tub/shower modifications and accessories, power door openers, shower seat/chair, grab bars, door widening, environmental controls;(2) Communication devices: adaptations to computers, speaker telephone, TTY, Personal Emergency Response Systems;(3) Wheelchair (manual or power) accessories: lap tray, seats and back supports;(4) Vehicle adaptations: adapted carrier and loading devices, one communication device for emergencies (limited to purchase and installation), adapted equipment for driving;(5) Hearing Aids, glasses, adapted visual aids;(6) Assistive animals (purchase only); (7) Physician ordered medical services and supplies;(8) Physician ordered prescription and over the counter drugs;(9) Medical insurance premiums, co-pays and deductibles;(10) Unemployment and workers compensation expenses related to employing the PA: and(11) The actual paid costs of conducting criminal background checks(Q)Extensive Assistance means although the individual performed part of the activity over the last 7 days, or 24 to 48 hours if in a hospital setting, help of the following type(s) was required and provided:(1) Weight-bearing support three or more times, or(2) Full staff performance during part (but not all) of the last 7 days.(R)Health Maintenance Activities are those activities designed to assist the consumer with ADLs and IADLs and additional activities as specified in the definition. These activities are performed by a designated individual who provides formal and informal supports for a competent self-directing individual, who would otherwise perform the activities, if he or she were physically able to do so and enable the individual to live in his or her own home and community. These additional activities include catheterization, ostomy care, preparation of food and tube feedings, bowel treatments, administration of medications, care of skin with damaged integrity, ventilator care, occupational and physical therapy activities such as assistance with prescribed exercise regimes.(S)Income includes: (1) Wages from work, including payroll deductions, excluding state and Federal taxes and employer mandated or court ordered withholdings;(2) Benefits from Social Security, Supplemental Security Income (SSI), Social security Disability Insurance (SSDI), pensions, insurance, independent retirement plans, annuities, and Aid and Attendance;(3) Adjusted gross income from property and/or business, based on the consumer's most recent Federal income tax; and(4) Interest and dividends. Not included are benefits from: the Home Energy Assistance Program, Food Stamps, General Assistance, Property Tax and Rent Refund, emergency assistance programs, or their successors.
(T)Instrumental activities of daily living (IADLs) Instrumental Activities of Daily Living (IADL); For purposes of the eligibility criteria and covered services under this section of policy, IADLs are limited to the following: meal preparation: preparation or receipt of the meal; routine housework; grocery shopping, storage of purchased groceries; community access; and laundry either within the residence or at an outside laundry facility; and money management, as directed by the consumer, for the consumer. The list of IADLs may be modified by the Authorized Agent, with the approval of the Department.(U)Limited Assistance means the individual was highly involved in the activity over the past seven days, or 24 to 48 hours if in a hospital setting, but received and required guided maneuvering of limbs or other non-weight bearing physical assistance three or more times or with weight-bearing support one or two times.(V)Liquid asset is something of value available to the consumer that can be converted to cash in three months or less and includes:(2) Certificates of deposit;(3) Money market and mutual funds;(4) Cash value of life insurance policies;(5) Stocks and bonds; and(6) Lump sum payments and inheritances.(7) Funds from a home equity conversion mortgage that are in the consumer's possession whether they are cash or have been converted to another form. Funds which are available to the consumer but carry a penalty for early withdrawal will be counted minus the penalty. Exempt from this category are mortuary trusts and lump sum payments received from insurance settlements or annuities or other such assets named specifically to provide income as a replacement for earned income. The income from these payments will be counted as income.
(W)Maximum Authorized Service is the highest number of day and night hours of service available to a Consumer as currently established by the Department of Health and Human Services. In establishing these limits, the Department will consult with the members of its Quality Assurance Review Committee. The Maximum Authorized Service amount must be determined at a rate that will allow the program to operate through the end of the current budget period within available resources. (X)Personal Assistance Needs are those determined as a result of completion of the medical eligibility determination form, resulting from an individual's inability to manage ADLs and IADLs, as a result of physical, emotional, or developmental problems. (Y)Medical Eligibility Determination (MED) Form is the form approved by the Department for medical eligibility determinations and service authorization for the Authorized Plan of Service based upon the assessment outcome scores. The definitions, scoring mechanisms and time-framesrelating to this form are contained therein and provide the basis for services and the service plan authorized. The service plan summary contained in the MED form documents the Authorized Plan of Service approved by the Authorized Agent. It also includes the service category, reason codes, duration, unit codes, number of units per month and rate per unit.(Z) Multi-disciplinary team (MDT). The MDT includes the consumer, the Authorized Agency, designated Registered Nurse (RN), Occupational Therapist (OT), or Certified Occupational Therapy Aid (COTA) staff, and may also include other people who provide or have an interest in the consumer's well-being. (AA)One-person Physical Assist requires one person over last seven (7) days or 24-48 hours if in a hospital setting, to provide either weight-bearing or non-weight bearing assistance for an individual who cannot perform the activity independently. This does not include cueing.(BB)Personal Assistance Services are services provided by a personal assistant (PA), which are required by an adult with personal care needs to achieve greater physical independence, which are consumer directed and which are limited to assistance with:(1) Bed Mobility: How person moves to and from lying position, turns side to side, and positions body while in bed;(2) Transfer: How person moves between surfaces to/from: bed, wheelchair, standing position (excluding to/from bath/toilet);(3) Locomotion: How person moves between locations, in room and other areas. If in wheelchair, self-sufficiency once in chair;(4) Eating: How person eats and drinks (regardless or skill);(5) Toilet Use: How person uses the toilet room (or commode, bedpan, urinal): transfers on/off toilet, cleanses, changes pad, manages ostomy or catheter, adjusts clothes;(6) Bathing: How person takes full-body bath/shower, sponge bath and transfers in/out of tub/shower; (7) Dressing: How person puts on, fastens, and takes off all items of street clothing, including donning/removing.(8) Hygiene: How person combs hair, brushes teeth, shaves, applies make-up, and washes and dries one's face and perineum. (CC)Personal Assistant is an individual who provides support to a consumer as in (BB) above.(DD)Quality assurance review committee (QARC) is a group appointed by the Department of Health and Human Services, whose responsibility it is to make recommendations to the Department for policy changes and improving quality of care and outcomes for the consumer.(EE) Self-Direct means the consumer hires, trains, directs assistants, and when necessary terminates the assistant. The applicant's ability to self-direct must be documented on the Medical Eligibility Determination Form.(FF)Service Plan is the document used by the Authorized Agency to assist the consumer to direct their assistant services as specified in the authorized plan of service. The Department must approve the service plan in template form. The plan must outline the ADL and IADL tasks, the time required to complete the tasks, and the frequency of the tasks that will be the basis for the assistant's job description and weekly schedule. The service plan will show the total hours available each week for the consumer to manage and direct the assistant. The hours shall not exceed the hours authorized on the MED form service plan summary or the Maximum Authorized Service amount, whichever is lesser and must include only the covered services from Section 11.04. The service plan is prepared after and is based on the completed MED form.(GG)Significant change. A significant change is defined as a major change in the consumer's status that, impacts on one or more areas of their functional or health status, and requires review or revision of the plan of service. A significant change assessment is appropriate if there is a consistent pattern of changes, with either two or more areas of improvement, or two or more areas of decline, that requires a review of the service plan and potential for a level of care change.(HH)Total Dependence means full staff performance of the activity during the last seven (7) day period across all shifts, or during eacheight (8) hour period in the twenty-four (24) hours.14- 197 C.M.R. ch. 11, § 01