MaineCare coverage of services under this Section
requires prior approval from the Department, or its Assessing Services Agency.
Beginning and end dates of a member's medical eligibility period correspond to
the beginning and end dates for MaineCare coverage of the services in the
Authorized Plan of Care. The Department reserves the right to request
additional information to evaluate medical necessity. Coverage will be denied
if the services provided are not included in the Authorized Plan of Care,
except as allowed for an acute/emergency episode as described in Section
19.04-4(A)(13).
19.03-1 Home and
Community Benefits (HCB)may be reduced, denied, suspended or terminated under
the following circumstances; only the Department may terminate HCB:
A. The member does not meet the eligibility
requirements of Section
19.02;
B. The member declines personal care,
Attendant or nursing services;
C.
An Authorized Plan of Care to maintain or delay significant deterioration in
the health and welfare of the member at home, or in the community, can no
longer be developed and implemented;
D. The member receives services under Chapter
II, Section
96, "Private Duty Nursing and
Personal Support Services"; Chapter II, Section
12, "Consumer-Directed Attendant
Services"; or Section
40, "Home Health Services". Only
Care Coordination Services may be provided under this Section to a member who
receives services under Chapter II, Section
96, "Private Duty Nursing and
Personal Support Services"; Section
40, "Home Health Services"; or
Chapter II, Section
12, "Consumer-Directed Attendant
Services", until HCB are in place for the member and a transition can be
made;
E. The member does not meet
the medical eligibility criteria for nursing facility level services as set
forth in Chapter II, Section
67.02 of this Manual,
as determined by the Assessing Services Agency;
F. The member is accessing another waiver
pursuant to Title XIX, § 1915(c) of the Social Security
Act, including any of the following Sections: Section
18, Home and Community Based
Services for Adults with Brain Injury; Section
20, Home and Community Based
Services for Adults with Other Related Conditions; Section
21, Home and Community Benefits
for Members with Intellectual Disabilities or Autism Spectrum Disorder; and
Section
29, Support Services for Adults
with Intellectual Disabilities or Autism Spectrum Disorder;
G. The member is not financially eligible to
receive MaineCare benefits;
H. The
member does not comply with the Authorized Plan of Care for services;
I. When the member's most recent MED
assessment, and the clinical judgment of the ASA, determines that the
Authorized Plan of Care must be changed or reduced to match the member's needs
as identified in the reassessment and subject to the limitations of the cap.
Even though the member's medical eligibility for HCB may not be affected, the
Authorized Plan of Care may be modified by the ASA to reflect the change in
needs or any change in policy that affects all members;
J. The member becomes an inpatient of a
hospital, a resident of a nursing facility (NF), or resident of an Intermediate
Care Facility for Individuals with Intellectual Disabilities
(ICF-IID);
K. The member becomes a
resident in an assisted living setting or in an Adult Family Care Home (as
defined in the MBM, Chapter II, Section 2) or other residential care setting
including a private non-medical institution (as defined in the MBM, Chapter II,
Section
97) , sometimes referred to as a
residential care facility or supported living, regardless of payment source
(i.e. private or MaineCare).
L. The
cost of services exceeds the program cap and limits set forth in the
Section;
M. The member has provided
fraudulent or repeatedly inaccurate information in connection with eligibility
or services;
N. The
federally-approved Waiver under which these rules were promulgated terminates,
expires or a future amendment is not approved;
O. The Department, the SCA or the ASA
documents that the member, or other person living in or visiting the member's
residence, harasses, threatens or endangers the safety of individuals
delivering services or the health and safety of individuals providing services
is otherwise endangered; or
P. The
member does not permit the ASA, SCA or Direct Care Provider access to
information from the member's physician or access to other health information
necessary to meeting the needs of the member.
19.03-2
Denial of Participant
Direction: The ASA, SCA or Department, as appropriate, may deny or
terminate the ability of a member to receive participant-directed services for
any of the reasons set forth below. Prior to and as part of denying or
terminating services specific to the Participant-Directed Option, the SCA will
work to transition the member to another Representative or to agency services,
as appropriate:
A. The Representative
provides fraudulent or repeatedly inaccurate information to the Department,
ASA, SCA or Fiscal Intermediary in connection with obtaining or receiving
services, including the submission of time sheets that are not accurate of the
services provided;
B. The
Department, the SCA or the ASA documents that the Representative harasses,
threatens or endangers the safety of the member or individuals delivering
services;
C. The SCA documents that
the member or the Representative fails to hire or manage an Attendant
consistent with the requirements of this Section, including directing an
Attendant to provide services that are inconsistent or not covered by the
Authorized Plan of Care or hiring an Attendant who does not have the ability to
provide Attendant Services as defined by the Authorized Plan of Care;
D. The member or the Representative fails to
successfully complete the initial Skills Training within the required time
frame from the date of the referral for Skills Training;
E. The member or the Representative a) fails
to hire an Attendant within sixty (60) days from the completion of Skills
Training or b) has not employed an Attendant for a consecutive (60) day period,
not counting days where services may have been suspended; or
F. The member no longer has Cognitive
Capacity and there is no willing and appropriate person meeting the
requirements of this Section to act as Representative.
19.03-3
Suspension: Services may
be suspended for up to sixty (60) days. If such circumstances extend beyond
sixty (60) days, the member's service coverage under this Section will be
terminated and the member will need to be reassessed to determine medical
eligibility for these services.
If a member enters a hospital or nursing facility, the
SCA may provide Care Coordination services to that member provided it is within
sixty (60) days of discharge from the institution. However, these services may
not be billed and cannot be reimbursed until the member is home under this
Section.
19.03-4
Out
of State Services: Personal care or Attendant Services provided to a
member while the member is out of state must be approved by the SCA and may not
exceed fourteen (14) consecutive days. The SCA will review the Authorized Plan
of Care and determine if all ADL and IADL services are needed by the member
while out of state. The member is allowed thirty (30) days total of out of
state services per fiscal year. This section applies only when the service is
being provided by an agency licensed or registered in Maine or provided by an
Attendant reimbursed under the Participant-Directed Option. The member must
continue to meet all other program requirements. All out of state services are
also governed by Chapter I of the MaineCare Benefits
Manual.
