18. 03-1
Approved Opening
The number of MaineCare members who can receive services
under this section is limited to the number of openings approved by the Centers
for Medicare and Medicaid Services (CMS). Persons who would otherwise be
eligible for services under this section are not eligible to receive services
if all of the approved openings are filled.
18. 03-2
General Eligibility
Criteria
Consistent with Subsection 18. 03-1, a person is eligible
for services under this section if the person:
A. Is age eighteen (18) or older;
and
B. Has a diagnosis of acquired
brain injury. Acquired Brain Injury means an insult to the brain resulting
directly or indirectly from trauma, anoxia, or vascular lesions, or infection,
which is not of a degenerative or congenital nature, can produce a diminished
or altered state of consciousness resulting in impairment of cognitive
abilities and/or physical functioning, can result in the disturbance of
behavioral or emotional functioning, can be either temporary or permanent, and
can cause partial or total functional disability or psychosocial maladjustment.
(Title 22 §3086); and
C. The
individual has received an assessment by a qualified neuropsychologist (as
defined in the MaineCare Benefits Manual, Rehabilitative Services, Section 102.
08-5 B) and/or a licensed physician who is Board certified or Board eligible in
Physical Medicine and Rehabilitation, which:
1. positively indicates the individual: is
not in a persistent vegetative state; is able to demonstrate potential for
physical and/or behavioral and/or cognitive rehabilitation; shows evidence of
moderate to severe behavioral and/or cognitive and/or functional disabilities;
and
2. results in specific
rehabilitation goals, based upon the findings of the assessment, describing
types and frequencies of therapies and expected outcomes and time frames; and
D. Has a completed
Department-approved Health and Safety Assessment administered by the Department
with an overall score of 0. 1 or higher. The Department approved Health and
Safety Assessment evaluates cognitive, physical, and behavioral needs related
to a person's brain injury. It assesses whether a person needs support for the
three areas. Additionally, it assesses if the person needs cueing, direct
support, or a behavioral support. Scores range from 0-1. The assessment can be
found at the Department's Brain Injury Services website:
http://www.
maine. gov/dhhs/oads/disability/bi/index. shtmlThe assessment was last
revised: 02/25/14. The Department will only accept assessments conducted no
more than three months prior to application; and
E. Has completed Mayo-Portland Adaptability
Inventory - 4 (or current Department approved version of the MPAI) with an item
score of 3 or higher for two of the following items:
a. Novel Problem Solving
b. Impaired Self-Awareness
c. Irritability, Anger, Aggression
d. Inappropriate Social Interaction
e. Fund of Information or
Attention/Concentration or Memory
The Department will only accept assessments conducted no
more than three months prior toapplication; and
F. Does not receive services under any other
federally-approved MaineCare home and community-based waiver program;
and
G. Meets all MaineCare
eligibility requirements as set forth in the MaineCare Eligibility Manual;
and
H. The estimated annual cost of
the member's services under the waiver is equal to or less than one hundred
percent (100%) of a blended rate of the statewide average annual cost of care
for individuals in Intermediate Care Facilities for Individuals with
Intellectual Disabilities (ICFs/IID) and Nursing Facility Brain Injury units,
as determined by DHHS (the blended rate being the sum of 20% of the statewide
average annual cost of care in an ICF/IID and 80% of the statewide average
annual cost of care in a Nursing Facility Brain Injury unit); and
I. Can have his or her health and welfare
needs assured in the community setting as stated in § 18. 04-2(D).
18. 03-3
Establishing Medical Eligibility
Determination of the member's medical eligibility for
services under this Section requires the following:
A. Completion of a Medical Eligibility
Determination (MED) assessment by the Assessing Services Agency (ASA);
B. Completion of the Mayo Portland
Adaptability Inventory (MPAI) or current functional assessment, as approved by
DHHS, by DHHS or its Authorized Entity;
C. Completion of the Department approved
Health and Safety Assessment (HSA); and
D. Documentation from a qualified
neuropsychologist (as defined in the MaineCare Benefits Manual, Rehabilitative
Services, Chapter II, Section 102. 08-5 (B)) and/or a licensed physician who is
Board certified or Board eligible in Physical Medicine and Rehabilitation that
the waiver services are medically necessary as described in Section 18. 03-2(C)
.
The member and Care Monitor are responsible for working
with DHHS to ensure that each of these items is completed. DHHS shall notify
each member or the member's guardian in writing of any decision regarding the
member's medical eligibility, and the availability of benefit openings under
this section. The notice will include information about the member's right to
appeal any of these decisions. Rights fornotice and appeal are further
described in Chapter I of the MaineCare Benefits Manual.
18. 03-4
Priority
When a member is found to meet MaineCare financial
eligibility and medical eligibility for these services, the priority for an
approved opening shall be established in accordance with the following:
A.
Priority 1: A member shall
be identified as Priority 1 if the member is currently residing in afacility of
more than 8 beds that is engaged in providing diagnosis, treatment or care,
which typically includes: medical attention; nursing care and related services;
24-hour supervision; and coordination and integration of health or
rehabilitative services; and the member continues to meet the financial and
medical eligibility criteria at the time that an approved opening becomes
available. Order of enrollment will be based on date of application; an
application will be considered complete on the date upon which items (A)
through (D) from Section 18. 04-1,
Procedures for Developing the Care Plan, have been
completed to DHHS satisfaction and DHHS has received all documents. If there
are two applications received on the same day, the applicant with the longest
continuous stay in institutional care will be prioritized first.
B.
Priority 2: A
member shall be identified as Priority 2 if the member has been determined to
be residing in the community. A higher priority will be given to those members
who are at imminent risk of abuse, neglect or exploitation followed by those at
anticipated risk of abuse, neglect or exploitation or homelessness and
institutionalization with the next year.
If applications exceed approved openings in any given
year, a waiting list will be established. The list will be prioritized, as
specified above, such that when there is a funded opening an individual will be
selected from priority one first and then immediately from priority two if
there are not any completed and approved applicants from priority one.
18. 03-5
Redetermination of Eligibility
Eligibility for services under this section must be
redetermined annually. When determining continuing eligibility, the Care
Coordinator will initiate an updated MED assessment, updated Mayo Portland
Adaptability Inventory or current functional assessment, as approved by DHHS,
and an updated Department approved Health and Safety Assessment. The MED
Assessment and Mayo Portland Adaptability Inventory or current functional
assessment will be conducted by DHHS or its Authorized Entity. The Department
approved Health and Safety Assessment will be completed by the Department or
its Authorized Entity. Updated assessments must be completed twelve (12) months
from the date of initial approval, and every twelve (12) months thereafter.
Once the assessment has been updated, the Care Plan will be updated annually.
If the updated Assessment Referral is received after the due date,
reimbursement for services will resume upon completion of the assessment.
Whenever there is a significant change in the member condition that requires an
alteration in the level of care,the Care Coordinator will provide notice to
DHHS or its Authorized Entity and request an updated assessment. See 18. 04-3
regarding updating of the Care Plan.
