12.03-1
Determination of Eligibility
A.
Members must meet the financial eligibility criteria as set forth in the
MaineCare Eligibility Manual. Some members may have
restrictions on the type and amount of services they are eligible to receive.
It is the responsibility of the provider to verify a member's eligibility for
MaineCare prior to providing services, as described in MaineCare
Benefits Manual (MBM) Chapter I;
B. Applicants for services under this Section
must meet the eligibility requirements as set forth in this Section and as
documented on the Medical Eligibility Determination form. A member meets the
medical eligibility requirements if he or she requires a combination of
assistance with the required activities of daily living, as defined in Section
12.03-1(D) and as set forth elsewhere in this Section. The clinical judgment of
the Department's ASA is the basis of the scores entered on the Medical
Eligibility Determination form. The clinical judgment of the Department's ASA
is determinative of the scores on the medical eligibility determination
assessment;
C. The member must have
a disability with functional impairments, which interfere with his/her own
capacity to provide self-care and daily living skills without assistance. The
member's disability must be permanent or chronic in nature as verified by the
member's physician.
D. A registered
nurse trained in conducting assessments with the Department's approved MED form
must conduct the medical eligibility assessment. The assessor must, as
appropriate within the practice of professional nursing judgment, consider
documentation, perform observations, and conduct interviews with the
applicant/member, family members, direct care staff, the applicant's/member's
physicians, and other individuals and document in the record of the assessment
all information considered relevant in his or her professional judgment. The
following levels of eligibility are determined at assessment:
Level I A member meets the medical
eligibility requirements for Level I if he or she requires at least limited
assistance plus a one person physical assist with at least two (2) of the
following ADLs: bed mobility, transfer, locomotion, eating, toilet use,
dressing, and bathing.
Level II A member meets the medical
eligibility requirements for Level II if he or she requires at least limited
assistance and a one person physical assist with at least three (3) of the
following ADLs: bed mobility, transfer, locomotion, eating, toilet use,
dressing, and bathing.
Level III A member meets the medical
eligibility requirements for Level III if he or she requires at least extensive
assistance and a one person physical assist with two (2) of the following five
ADLs: bed mobility, transfer, locomotion, eating, or toileting; and limited
assistance and a one person physical assist with two (2) of the following
additional ADLS: bed mobility, transfer, locomotion, eating, toilet use,
dressing, and bathing.
E.
The member must agree to complete initial member instruction and testing within
thirty (30) days of completion of the MED form to determine medical eligibility
in order to develop and verify that he or she has attained the skills needed to
hire, train, schedule, discharge, and supervise attendants and document the
provision of personal care services identified in the authorized plan of care.
Members who do not complete the course of instruction or do not demonstrate to
the Service Coordination Agency that they have attained the skills needed to
self-direct are not eligible for services under this Section;
F. The member must not be residing in a
hospital, nursing facility, or Intermediate Care Facility for the Individuals
with Intellectual Disabilities (ICF-IID) as an inpatient;
G. The member must not reside in an Adult
Family Care Home(as defined in MaineCare Benefits Manual,
Chapters II and III, Section 2,) or other residential setting including a
Private Non-Medical Institution (MBM, Chapters II and III, Section
97) , sometimes referred to as a
residential care facility or supported living, regardless of payment source,
(i.e. private or MaineCare);
H. The
member must not be receiving personal care services under Private Duty
Nursing/Personal Care Services, Section
96, or be receiving any In-home
Community and Support Services for Elderly and Other Adults, Section 63, or
participating in other MaineCare programs where personal care services are a
covered service.
I. The member must
have the cognitive capacity, as measured on the MED form to be able to
"self-direct" the attendant. The ASA will assess cognitive capacity as part of
each member's eligibility determination using the MED findings. The Service
Coordination Agency will assess cognitive capacity as part of consumer
instruction. Minimum MED form scores are:
(a)
decision making skills: a score of 0 or 1;
(b) making self understood: a score of 0, 1,
or 2;
(c) ability to understand
others: a score of 0, 1, or 2;
(d)
self performance of managing finances: a score of 0, 1, or 2; and
(e) support for managing finances, a score of
0, 1, 2, or 3.
An applicant not meeting the specific scores above during
his or her eligibility determination will be presumed not able to self-direct
and ineligible for benefits under this Section.
J. Applicants who meet these eligibility
criteria for personal care attendant services shall:
i. Receive an authorized plan of care based
upon the scores, timeframes, findings and covered services recorded in the MED
assessment. The covered services to be provided in accordance with the
authorized plan of care must not exceed the established limits and must be
authorized by the Department or its ASA;
ii. The ASA must approve an eligibility
period for the Member, based upon the scores, timeframes and needs identified
in the MED assessment for the covered services, and the assessor's clinical
judgment. An eligibility period cannot exceed twelve (12) months;
iii. The ASA forwards the completed
assessment packet to the Service Coordination Agency of the Member's choice
within three (3) business days of the medical eligibility determination and
authorization of the plan of care;
iv. The Service Coordination Agency must
contact the Member within twenty-four (24) hours of receipt of the MED
assessment and authorized plan of care. The Service Coordination Agency must
implement skills training and coordinate services with the Member as well as
monitor service utilization and assure compliance with this policy;
and
v. The Service Coordination
Agency will complete the service plan and initiate skills instruction within
thirty (30) days of the medical eligibility assessment date. The Service
Coordination Agency will notify the Department, using the transmittal form
approved by the Department, when the Member has successfully completed this
requirement and an attendant has been hired. Provision of attendant services
can begin only after the Department is notified that the Member has
successfully completed this training and the service plan has been
received.
12.
03-2
Redetermination of Eligibility
A. For all Members under this Section, in
order for the reimbursement of services to continue uninterrupted beyond the
approved medical eligibility period, a reassessment to determine medical
eligibility and authorization of services by the ASA is required. MaineCare
payment ends with the reassessment date, also known as the medical eligibility
end date.
Step #1: The Service Coordination Agency
must submit a reassessment request to the ASA. The ASA must complete a
reassessment at least five (5) calendar days prior to the end date of the
member's current medical eligibility period to establish continued eligibility
for MaineCare coverage of attendant Services. If the need for additional
consumer skills instruction has been identified by the ASA or the Service
Coordination Agency, it will be documented in the Member's service plan.
Step #2: The ASA's findings and scores
recorded in the MED form shall be determinative for establishing eligibility
for services and the authorized plan of care. The service plan shall not be
completed until medical eligibility has been determined and services
authorized, as allowed under this Section, in the care plan summary of the MED
form.
Step #3: The ASA shall review, face-to-face
with the Member at the Member's residence, the medical eligibility for services
at least annually based on clinical judgment.
Each member is eligible for attendant services, as
identified, documented, and authorized on the MED form, within the following
limitations as described below and in Chapter III, Section 12.
