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-19 - Home and Community Benefits for the Elderly and Adults with Disabilities
Subsection 144-101-II-19.06 - LIMITS

Universal Citation: 10 ME Code Rules § 144-101-II-19.06

Current through 2024-38, September 18, 2024

A. Except as otherwise provided in this Section, effective April 1, 2020, the program cap established by the Department is $6,565. 00 per member per month.

B. Skills Training Services shall not exceed 14. 25 hours per annual eligibility period including the hours needed for initial instruction. These costs will not be included as part of the member's monthly program cap.

C. FMS is not included as part of the monthly program cap.

D. Environmental Modifications may not exceed $3,000 per annual eligibility period per member. These costs will not be included as part of the member's monthly program cap.

E. Assistive Technology Devices and Services may not exceed $1,000 per member per annual eligibility period. These costs are excluded from the member's monthly program cap noted above.

F. Assistive Technology-Transmission: These services may not exceed $600 per member per annual eligibility period. These costs are excluded from the member's monthly program cap noted above.

G. Assistive Technology- Remote Monitoring: These services may not exceed $6,000 per member per annual eligibility period. These costs are excluded from the member's monthly program cap noted above.

H. Respite Services shall not exceed the allowed maximum, which is based on the cost of thirty (30) days of Nursing Facility Services at the rate as established in Chapter III, Section 19 (Respite Care Services, not in the home), per member per annual eligibility period. These costs are included as part of the member's monthly program cap.

I. Home Delivered Meals has a limit of one meal per member, per day up to seven days per week. The cost of this service shall be included in the monthly program cap for the member.

J. Living Well for Better Health: The program has a lifetime limit; a member may attend this service up to three (3) times but no more than once per calendar year. The cost of this service shall be included in the monthly program cap for the member.

K. Matter of Balance (Falls Prevention): The program has a lifetime limit; a member may participate in this program up to three (3) times but no more than once per calendar year. The cost of this service shall be included in the monthly program cap for the member.

L. An individual who receives Attendant or Personal Care Services as a member under this Section or other MaineCare or State-funded long-term care programs may not be reimbursed as an Attendant or Personal Support Specialist.

M. Attendant or Personal Care Services: Delivery of these services to an individual member (or household) may not exceed forty (40) hours per week from one individual staff member.

A member who is at risk of institutionalization may seek an exception to this limit. The criteria the Department shall consider in evaluating the request include:

1. Availability of workers in the member's area;

2. Number of hours needed above the cap;

3. Whether the member's condition is unique as compared to other Section 19 members;

4. The length of time for which the exception is requested; and

5. The agency's or member's efforts to find other workers.

The Department's decision shall be in writing and shall be provided to the Member.

N. Personal Care or Attendant Services: The monthly program cap may be exceeded by no more than 20% for personal care or Attendant Services for members who meet either of the following qualifications, provided that in no case shall a member receive more than eighty-six and a quarter (86. 25) hours per week of personal care and/or Attendant Services:

The member needs Extensive Assistance with the following Activities of Daily Living:

a. Bed Mobility: how person moves to and from lying position, turns side to side, and positions body while in bed;

b. Transfer: how person moves between surfaces to/from: bed, wheelchair, standing position (excluding to/from bath/toilet and dressing);

c. Locomotion: how person moves between locations on the same floor, in room and other areas. If in wheelchair, self-sufficiency once in chair;

d. Eating: how person eats and drinks (regardless of skill); and

e. Toilet Use: how person uses the toilet room (or commode, bedpan, urinal): transfers on/off toilet, cleanses, changes pad, manages ostomy or catheter, and adjusts clothes;

2. The Department or the Department's Authorized Entity determines based on medical necessity that the member faces significant risk to health, welfare and safety; is at imminent risk of institutionalization; and there is no ability to meet the member's needs through other resources or supports such that extraordinary measures are warranted.

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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