Current through 2024-38, September 18, 2024
20.03-1
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.
20.03-2
General Eligibility
Criteria
Consistent with Subsection 20.03-1, a person is eligible
for services under this section if the person:
A. Is age twenty one (21) or older;
and
B. Has a Related Condition
within the meaning of
42 C.F.R. §
435.1010.
A "Related Condition" must meet all of the following
conditions:
1. It is attributable to;
a. Cerebral Palsy or Epilepsy; or
b. Any other condition, other than mental
illness, found to be closely related to Intellectual Disabilities because this
condition results in impairment of general intellectual functioning or adaptive
behavior similar to that of persons with Intellectual Disabilities and requires
treatment or services similar to those required for these persons. These
conditions include but are not limited to Neurofibromatosis, Other Choreas,
Anoxic Brain Damage, Cerebral Laceration and Contusion, Subarachnoid- Subdural
and Extradural Hemorrhage following injury, Other and Unspecified Intracranial
Hemorrhage following injury or Intracranial injury and unspecified nature,
Muscular Dystrophy, Huntington's, Spina Bifida or other rare developmentally-
based conditions.
2. It
is manifested before the person reaches age twenty two (22).
3. It is likely to continue
indefinitely.
4. It results in
substantial functional limitation in three (3) or more of the following areas
of major life activity:
a.
Self-care.
b. Understanding and use
of language.
c. Learning.
d. Mobility.
e. Self-direction.
f. Capacity for independent living;
and
C. Meets
the medical eligibility criteria for admission to an Intermediate Care Facility
for Individuals with Intellectual Disabilities (ICF/IID) as set forth under the
MaineCare Benefits Manual, Chapter II, Section 50;
and
D. Does not receive services
under any other federally approved MaineCare home and community based waiver
program; and
E. Meets all MaineCare
eligibility requirements as set forth in the MaineCare Eligibility
Manual; and
F. The
estimated annual cost of the member's services under the waiver is equal to or
less than one hundred percent (100%) of the state-wide average annual cost of
care for a member in an Intermediate Care Facility for Individuals with
Intellectual Disabilities (ICF/IID), as determined by DHHS; and
G. Can have his or her health and welfare
needs assured in the community setting as stated in § 20.08-2(E) (1) and
(2).
20.03-3
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 BMS 99
or current functional assessment, as approved by DHHS, by the Care Monitor; and
C. Documentation from a physician
that the waiver services are medically necessary.
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 for notice and appeal are further
described in Chapter I of the MaineCare Benefits
Manual.
20.03-4
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:
(1) if the member
is currently residing in a facility of more than 16 beds that is engaged in
providing diagnosis, treatment or care of persons with related conditions,
which typically includes: medical attention; nursing care and related services:
24-hour supervision: and coordination and integration of health or
rehabilitative services, and
(2)
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 20.04-1, 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: All other members shall be identified as Priority 2. 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.
20.03-5
Redetermination of Eligibility
Eligibility for services under this section must be
redetermined annually. When determining continuing eligibility, the Care
Coordinator will initiate an updated Medical Assessment tool and updated BMS 99
form or current functional assessment, as approved by DHHS. This assessment
will be conducted by DHHS 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 20.04-3 regarding updating of the Care Plan.
