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-12 - Consumer Directed Attendant Services
Subsection 144-101-II-12.04 - AMOUNT AND DURATION OF SERVICES

Universal Citation: 10 ME Code Rules § 144-101-II-12.04

Current through 2024-38, September 18, 2024

The Department or its ASA, consistent with these rules, determines the plan of care and the number of hours of covered services for each new member prior to the start of services, and for each established member, as his or her scheduled re-assessment comes due. The services provided must be reflected in the service plan and based upon the authorized covered services documented in the care plan summary of the MED form.

MaineCare coverage of services under this Section is contingent upon eligibility determination prior to service delivery and consistent with these rules. Beginning and end dates of a member's medical eligibility period must correspond to the beginning and end dates for MaineCare coverage for these services.

The ADL Task Time Allowances in the attached Appendix A reflect the time normally allowed to accomplish the listed tasks. The ASA will use these allowances when authorizing a member's authorized plan of care on the care plan summary in the MED form and this plan will be reflected in the service plan. If these times are not sufficient, when considered in light of a member's unique circumstances, as identified and documented by the ASA, the ASA may make an adjustment as long as authorized hours do not exceed the limits established for the member's assessed level of care.

Services under this Section will be reduced, terminated, suspended or denied by the Department, the ASA or the Service Coordination Agency if any of the following situations occur:

A. Termination/Denial of Services

1. The member exceeds the applicable Level I, II or III established limits.

2. The member declines these services;

3 A significant change occurs in the member's medical, functional, or cognitive status and the ASA or the Service Coordination Agency determines that appropriate services can no longer be provided under this Section;

4. The ASA or the Service Coordination Agency determines that the health and welfare of the member is endangered should he or she remain at home receiving services under this Section;

5. The Service Coordination Agency documents that the member fails to manage an attendant consistent with requirements of this Section;

6 The member enters a hospital, nursing facility, private non-medical institution, or Intermediate Care Facility for Individuals with Intellectual Disabilities as an inpatient;

7. The member is receiving personal care services under Section 96, "Private Duty Nursing and Personal Care Services"; Section 19, "Home and Community- Benefits for the Elderly and Adults with Disabilities"; Section 63 "In-Home and Community Support Services for Elderly and Other Adults" (HBC); or any other section of the MaineCare Benefits Manual where personal care services are a covered service;

8. The member resides in assisted housing, a residential care facility, PNMI or supported living arrangement where personal care services are already provided;

9. The member is not medically or financially eligible to receive Title XIX or XXI benefits;

10. The Service Coordination Agency documents the member does not comply with the authorized plan of care;

11. The member gives fraudulent information to the Department, ASA or Service Coordination Agency;

12. The Department, ASA, or the Service Coordination Agency documents the member or someone living in or frequently visiting the household harasses, threatens, or endangers the safety of individuals delivering services;

13. The ASA or Service Coordination Agency documents the member is directing the personal attendant to complete tasks not included as covered services in Section 12.05;

14. The member does not meet the eligibility criteria under Section 12.03; or

15. Services have been suspended for more than sixty (60) days. At that time the member's eligibility for these services will be terminated and will require a new assessment by the ASA and determined medically eligible prior to services restarting.

B. Reduction of Services

Based upon the member's most recent MED assessment, the authorized plan of care shall be reduced, according to the clinical judgment of the Department, the ASA, or the Service Coordination Agency and is subject to the limitations and caps of this Section and the approved authorized plan of care.

C. Suspension of Services

Services will be suspended up to sixty (60) days because the member has been admitted to an institution, such as a Hospital, Nursing Facility or ICF-IID, or Private Non-Medical Institution (PNMI).

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.

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