Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter II - Specific Policies By Service
Section 144-101-II-102 - Rehabilitative Services
Subsection 144-101-II-102.03 - ELIGIBILITY FOR CARE

Universal Citation: 10 ME Code Rules § 144-101-II-102.03

Current through 2024-38, September 18, 2024

A member is eligible to receive services under this Section if he or she meets both the General Eligibility Requirements for MaineCare and the Specific Eligibility Requirements detailed in this Section. It is the responsibility of the provider to verify a member's eligibility for MaineCare prior to providing services, as described in Chapter I.

102.03-1 General Eligibility Requirements for MaineCare

Individuals must meet the financial eligibility criteria as set forth in the MaineCare Eligibility Manual (MEM). Some members may have restrictions on the type and amount of services they are eligible to receive, based on the MEM.

102.03-2 Specific Eligibility Requirements

A member must meet the following criteria:

A. Has a diagnosis of brain injury, as defined in Section 102.02-2 and confirmed by a clinical evaluation as defined in Section 102.05-1; and

B. Is not receiving acute hospital rehabilitation services; and

C. Is not receiving intensive rehabilitation NF services for individuals with a Brain Injury as defined in Section 102.02-8; and

D. If the member is currently receiving services in a nursing facility setting that are not intensive rehabilitative NF services, then the member must meet all of the following criteria:

i) The member's clinical evaluation documents rehabilitation potential (defined Section 102.02-9); and

ii) The member requires licensed/certified services to continue improvement; and

iii) The member has limited or no other access to rehabilitative services; and

iv) The member expresses a desire to move to a less restrictive setting; and

v) Discharge to a less restrictive living arrangement has been identified in the discharge potential section of the Minimum Data Set (MDS) (which is conducted by the NF) and active planning for discharge is documented in the member's NF plan of care.

E. Meets the requirements of one of the following three Covered Services:

1. Intensive Integrated Neuro-rehabilitation. A member meets the medical eligibility requirements for Intensive Integrated Neuro-rehabilitation if he or she:

Scores at least "3" on one item, in two or more domains in the Department's authorized Brain Injury Assessment Tool, (see Section 102.03-3); and

Has documented rehabilitation potential (defined in Section 102.02-9).

2. Neurobehavioral Rehabilitation. A member meets the medical eligibility requirements for Neurobehavioral Rehabilitation if he or she

Scores at least "2" on one item, in any two or more domains in the Department's authorized Brain Injury Assessment Tool, (see Section 102.03-3); and

Scores at least a "2" one any one item on questions 14, 15, 18, 19, 21 22, 23, 24, 41, 42 or 43 in the Department's authorized Brain Injury Assessment tool and

Has documented rehabilitation potential (defined in Section 102.02-9).

3. Community/Work Reintegration or Self Care/Home Management Reintegration.

Scores at least "2" on one item, in two or more domains in the Department's authorized Brain Injury Assessment Tool, (see Section 102.03-3); and

Requires this level of service to achieve documented rehabilitation potential or maintain function.

102.03-3 Brain Injury Assessment Tool Criteria

The member must have each item below rated by clinicians (any of the following, as appropriate: physician, neuropsychologist, registered nurse, occupational therapist, physical therapist, speech-language pathologist, social worker, professional counselor, or therapeutic recreation specialist) who have evaluated the member, are familiar with the member and the member's history, including the clinical assessment, and have

experience in the treatment of brain injury. Each item must be rated on the Department's Brain Injury Assessment Tool (BIAT) to indicate the level at which the member being evaluated experienced problems during the last two (2) weeks. The number of hours authorized to match the individual member's needs must be included on the Start of Care (SOC) and Utilization Review (UR) Form (see Section 102.08-3). The Brain Injury Assessment Tool is available to view and copy on the Department's website. The Department or its Authorized Agent may conduct an assessment as a part of utilization review.

The following scale, or variations set forth within the BIAT, is used for rating.

0 None

1 Mild problem but does not interfere with activities, or interferes less than 5% of the time; may use assistive device or medication

2 Mild problem; interferes with activities 5-24% of the time

3 Moderate problem; interferes with activities 25-75% of the time

4 Severe problem: interferes with activities more than 75% of the time

The BIAT measures the following domains and elements:

A. Physical Function

Mobility

Use of hands

Dizziness

Vision

Audition

B. Language/Cognition

Attention/Concentration

Motor speech

Verbal communication

Nonverbal communication

Visuospatial abilities

Memory

Novel problem solving

Executive function/prospective memory

Initiation

Impaired self-awareness

C. Emotional Adjustment

Anxiety

Depression

Inappropriate social interaction

Irritability, anger, aggression

Sensitivity to mild symptoms

Psychotic symptoms

Problem behaviors

Danger to self or others

D. Independence

Eating/Self-care

Dressing/Self-care

Bathing/Self-care

Hygiene/Self-care

Toileting/Self-care

Information management and self-advocacy

Residence

Constructive roles

Managing money and finances

E. Medical

Pain and headache

Fatigue

Sleep disturbance

Medical self-care

Medication management and compliance

F. Substance Use

Alcohol use

Drug use

Nicotine use

G. Scoring

Please refer to 102.03-2 for specific eligibility requirements for pertinent scoring information.

Note: BIAT items adapted from the Mayo-Portland Adaptability Inventory-4 (MAPI). Original MAPI available on line at http://www.tbindsc.org

Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.