Section 197-11-04 - COVERED SERVICESCovered services are available for individuals meeting the eligibility requirements set forth in Section 11.02. All covered services require prior authorization by the Department, or its Authorized Agent, consistent with these rules, and are subject to the limits in Section 11.03. The Authorized Plan of Service shall be based upon the consumer's assessment outcome scores recorded on the Department's Medical Eligibility Determination (MED) form, and its definitions.
Services provided must be required for meeting the identified needs of the individual, based upon the outcome scores on the MED form, and as authorized in the plan of service. Coverage will be denied if the services provided are not consistent with the consumer's authorized plan of service. The Department may also recoup payment from the Authorized Agent, pursuant to 22 MRSA §1714-A, if applicable, for inappropriate service provision or overpayment, as determined through post payment review.
Covered Services are:
(A)Administration Costs of the overall administration of this program are built into the hourly rate for Personal Assistance Services. The Authorized Agent is responsible for overall administration including consumer assessment, monitoring, assistance, instruction, and assistant payment processing. Registered Nurses, Occupational Therapists and Certified Occupational Therapy Assistants are staff qualified to carry out these functions. Such tasks include: (1) initiating eligibility assessments and re-assessments to determine medical eligibility and the consumer's ability to self-direct;(2) determining the need for additional non-scheduled reassessments or additional skills training;(3) providing skills training and testing;(4) monitoring, through face-to-face contact, unless the consumer has previous experience with another personal assistance program, at least twice in the first six (6) months and annually thereafter to coincide with reassessment, documenting and taking appropriate action concerning any changes in the general health and welfare of the consumer;(5) providing consumer instruction services as needed by the individual consumer to demonstrate competency in the direction and management of the PA for initially instructing the consumer in the management of Personal Assistants and additional instruction as needed.(a) Consumer instruction services must be provided to each new eligible consumer prior to the start of services. The Authorized Agent must document that the consumer has successfully completed the training within thirty (30) calendar days of the date of determination of medical eligibility.(b) Instruction in PA management includes: instruction in recruiting, interviewing, selecting, training, scheduling and directing a competent assistant in the activities identified in the authorized plan of service and if necessary terminating the PA's employment.(c) Consumer instruction also includes instructing the consumer in his or her rights and responsibilities, including the obligations under the Consumer Directed Home Based Care policy.(6) assessing the consumer/assistant relationship, including whether assistant duties are being performed satisfactorily, whether assistant training is adequate or if additional training is needed;(7) issuing a notice of intent to reduce, deny or terminate services as defined in Section 11.03. (B)Consumer Directed Personal Assistance Servicesconsumer's who qualify for Assistance Services are eligible for the following services:
(1) Bed mobility, transfer, and locomotion activities to get in and out of bed, wheelchair or motor vehicle;(2) Using the toilet and maintaining continence;(3) Health maintenance activities as defined in 11.01 (R)(4) Bathing, including transfer;(5) Personal hygiene which may include combing hair, brushing teeth, shaving, applying makeup, washing and drying face, hands, and perineum;(8) Household tasks for the consumer only, when authorized and specified in the Authorized Plan of Service. These tasks must be furnished in conjunction with direct service to the consumer and directed by the consumer;(a) grocery and prepared food shopping, assistance with obtaining medication, to meet the consumer's health and nutritional needs;(b) routine housework, including sweeping, washing and/or vacuuming of floors, cleaning of plumbing fixtures (toilet, tub, sink), appliance care, changing of linens, refuse removal;(c) laundry done within the residence or outside of the home at a laundry facility;(d) money management, as directed by the consumer, for the consumer, and(e) meal preparation and clean up.(C)Transportation. Transportation services may be provided only when a consumer is unable to be transported alone. consumer's shall first attempt to locate other resources beforeutilizing transportation services under this program. Travel time of the assistant shall be assessed only in the course of delivering a covered service and in support of IADLs as determined during the assessment. Additional time for transportation may not be added to the plan of service. A consumer may, however, substitute their existing hours of other activities necessary for independent living for transportation time. Any individual providing transportation must hold a valid State of Maine driver's license for the type of vehicle being operated. All providers of transportation services shall maintain adequate liability insurance coverage for the type of vehicle being operated(D)Personal Emergency Response System (PERS). A Personal Emergency Response System is an electronic device which enables individuals to secure help in the event of an emergency. PERS services may be authorized for individuals who live alone, or who are alone for significant parts of the day, who are capable of using the system, and have no regular assistant for extended periods of time, and who would otherwise require extensive routine supervision. The use of the PERS will result in a reduction of authorized hours that are equal to the cost of the service.14- 197 C.M.R. ch. 11, § 04