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-19.07 - GENERAL ELIGIBILITY PROCEDURES

Universal Citation: 10 ME Code Rules § 144-101-II-19.07

Current through 2024-38, September 18, 2024

The procedure for determining eligibility, in accordance with the criteria outlined in §19.02 above, for Home and Community Benefits (HCB) is as follows:

A. Medical eligibility: A complete, standardized referral, or verbal/written request by the member, or designated representative, for a medical eligibility assessment shall be submitted to the Department or the Assessing Services Agency (ASA). The ASA shall conduct a medical eligibility assessment within five (5) business days of receipt of a request, except when the member is receiving acute level of care services. In such cases, the assessment is delayed until twenty-four (24) hours before discharge, or when continued acute level services are denied.

The Department or its Authorized Entity shall conduct a face-to-face medical eligibility assessment at the member's residence using the Medical Eligibility Determination (MED) assessment form. The individual conducting the assessment shall be a registered nurse and shall be trained in conducting assessments and developing an Authorized Plan of Care using the Department's approved tool. The RN assessor's findings and scores recorded in the MED form shall be determinative in establishing eligibility for services and the Authorized Plan of Care. Applicants who meet the eligibility criteria set forth in Section 19.02, or their guardian, agent or surrogate as appropriate, shall receive an Authorized Plan of Care based upon the scores, time frames and findings recorded in the MED assessment and level of care for which they are eligible. The covered services to be provided in accordance with the Authorized Plan of Care shall:

1) not exceed the established financial caps;

2) be subject to prior approval by the Department or the ASA; and

3) the nursing or therapy treatment plan shall be under the direction of the member's physician, when applicable.

The ASA shall be responsible to:

1. Offer the applicant at the time of assessment a choice of available Service Coordination Agencies from the list of enrolled MaineCare providers for this service.

2. Inform the applicant (guardian, agent, or surrogate) of the options stated in the Choice Letter. The applicant (guardian, agent, or surrogate) will need to indicate his or her choice of either Nursing Facility Services or HCB on the Choice Letter and state his or her wish to initiate services by signing the Choice Letter. The Choice Letter must be signed annually.

3. If the applicant or member chooses nursing facility care, the individual shall be placed in accordance with existing placement procedures as set forth in this Manual, Chapter II, Section 67. In the event a nursing facility bed is not available, the member may choose HCB within ninety (90) days of the assessment date unless otherwise specified in the assessment. A new Choice Letter must be signed.

4. If the financial eligibility process has not been initiated, the ASA assessor will provide an application for financial eligibility determination and refer the applicant to the Office for Family Independence (OFI).

5. The ASA assessor shall approve an initial eligibility period for up to one (1) year, based upon the scores and needs identified in the MED assessment. A shorter eligibility period may be authorized for an individual member when supported by documented clinical judgment of the assessor.

6. Based on the member's needs and preferences, the ASA assessor shall discuss alternative home and community resources available to the member.

7. The ASA shall forward the completed MED form to the Department's Service Coordination Agency (SCA)of choice within three business days of its completion.

8. When the member is placed on a wait list under this Section, the ASA will discuss other funding service options during the assessment process. The ASA will initiate any necessary referrals on the member's behalf to access home care options. The member will be informed that his or her name has been referred to the HCB wait list, when applicable.

B. Financial Eligibility: Financial eligibility is determined by the local office of the Office for Family Independence (OFI) as outlined in the MaineCare Eligibility Manual. The ASA's pre-screen intake process may instruct the applicant and/or designated representative to initiate the financial eligibility process at the local OFI office. For SSI members, no financial determination process is necessary. The RN assessor will verify SSI status.

C. Implementation of the Authorized Plan: On receipt of the eligibility packet the SCA shall:

1. contact the member within two (2) business days;

2. assist the member with locating providers and obtaining authorized services or making appropriate referrals for Skills Training and Financial Management Services (FMS);

3. implement and coordinate services with the Direct Care Provider using Service Orders;

4. monitor service utilization and assure compliance with this policy; and

5. send a copy of the Authorized Plan of Care to the attending physician, with a cover letter inviting the physician to participate and comment on the Authorized Plan of Care.

In addition to the above, the SCA shall be responsible for submitting provider service authorizations through MeCare to the Department's MaineCare claims system according to Department procedures. When the services are terminated the SCA will be responsible for entering service end-dates by the next business day.

D. Redetermination of Eligibility

1. For all Members receiving services under this Section, in order for the reimbursement of services to continue uninterrupted beyond the approved eligibility period, a reassessment and prior approval of services is required. The SCA is responsible for making a referral to the ASA twenty-one (21) days prior to the end of the eligibility end date. The ASA must conduct the reassessment and prior approval no earlier than twenty-one days prior to the eligibility end date, and must complete the reassessment and prior approval before the eligibility end date and in accordance with the requirements and timelines outlined in Section 19.07. A.

2. The SCA will provide relevant information to the ASA, prior to the reassessment due date. The information shall be shared with the ASA as part of the referral for re-determination of medical eligibility and development of the Authorized Plan of Care.

3. The SCA shall make referrals for reassessments based upon a Significant Service Change in the member's health status or service needs.

4. If a service plan is under appeal and services are being maintained during that process, a member will not be reassessed while the appeal process is ongoing except as authorized by the Office of Aging and Disability Services (OADS) for reasons of health and welfare.

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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