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-21 - Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder
Subsection 144-101-II-21.14 - APPENDIX I- Shared Living and Family-Centered Per Diem Criteria for increased level of support
Universal Citation: 10 ME Code Rules ยง 144-101-II-21.14
Current through 2024-38, September 18, 2024
21.14-1 General
Members who receive services through this Benefit and Members applying to receive services through this Benefit may submit a Request for Exceptions. The purpose of submitting a Request for Exceptions is to ensure that Members receive adequate and appropriate services and supports in the most integrated setting appropriate to their needs, consistent with Title II of the Americans with Disabilities Act, 42 U.S.C. §§ 12131-12134, and consistent with Section 21 health and safety requirements. To achieve that outcome, Members may submit a Request for Exceptions to seek services in excess of otherwise-applicable Section 21 waiver monetary and/or unit caps. Members or their Representatives may seek Exceptions by submitting a written request.
Filing a Request for Exceptions is neither a waiver of nor a substitute for the Member's right to an administrative hearing on an appeal under Chapter I, Section 1; to file a grievance under 14-197 C.M.R. ch. 8; or to file a complaint pursuant to 34-B M.R.S. §5611.
21.14-2 Applications
A. Requests for Exceptions must be submitted
in writing on a form provided by the Department by the Member, the Member's
Representative, or the Member's Case Manager.
B. For those Members seeking an Exception
when applying to receive Section
21 services, the Member, the
Member's Representative, or the Member's Case Manager shall submit the Request
for Exceptions with the materials required under the Section
21 regulation for a determination
of the Member's medical eligibility for Section
21 services. A Member must satisfy
all Section
21 eligibility requirements,
including wait list priorities, if applicable, and obtain a funded offer of
Section
21 services prior to the
Department's consideration of a Request for Exceptions.
C. For those Members who have received a
funded offer of Section
21 services or are already
receiving Section
21 Services, Requests for
Exceptions shall be submitted to the Department via email to
HCBSwaiverexceptions.DHHS@maine.gov, or via US Mail to the Clinical Review Team
at the Office of Aging and Disability Services, 11 State House Station, Augusta
ME 04333. The Department will acknowledge receipt of a Request for Exceptions
from a Section
21 Member within five (5) business
days.
D. The Member bears the
burden of establishing that the Member needs an Exception to:
(i) ensure the Member receives adequate and
appropriate services and supports in the most integrated setting appropriate to
their needs and to avoid an undue risk of segregation in an institution; and
(ii) that natural supports are not
available to meet the needs the Exceptions are intended to address.
E. A Request for Exceptions shall
include the following information when known to the Member:
1. The name, address, telephone number, email
address, and MaineCare number of the Member and the name, address, telephone
number, and email address, of the person who submitted the Request for the
Member, if applicable;
2. The
specific provision(s) in MBM Chapters II or III, Section
21 from which an Exception is
requested;
3. The specific
Exception(s) requested, the proposed level of service that would result from
approval of the Request for Exceptions, and the anticipated duration of the
proposed Exception(s);
4. Any
relevant facts;
5. A history of the
Department's action on the issue including prior communications with the
Department on this issue, if applicable;
6. The name, address, and telephone number of
any person inside or outside the Department with knowledge of the matter with
respect to which the Exception is requested; and
7. Signed releases of information authorizing
persons with relevant knowledge or records to furnish the Department with
information pertaining to the request, if
desired.
21.14-3 Department Review and Decision
A. The Department may ask for
additional information from the Member. The Member has ten (10) business days
from the date of the request to submit additional documents or information. The
Department may deny a Request for Exceptions if the Member refuses or fails to
provide documents or information requested by the Department.
B. The Department shall apply some or all of
the Criteria set forth below in § 21.14-4 and issue a written decision
("Decision") on the Request for Exceptions within sixty (60) days of receipt of
all materials submitted by the Member or requested by the Department.
C. The Department may deny a
Member's Request for Exceptions if the Department has previously denied a
substantially similar Request for Exceptions from the Member, or if the Member
has previously been denied a reasonable modification under the Americans with
Disabilities Act for a substantially similar request, unless new information is
available regarding the Member's need for the requested Exception.
D. The Department's Decision shall state:
1. The name of the Member on whose behalf the
Request for Exceptions was made, and the Exceptions sought;
2. A list of documents reviewed, and a
summary of other information obtained to review the Request for
Exceptions;
3. Whether the
Department has granted, granted in part, or denied the Request for
Exceptions;
4. Alternative services
or Exceptions offered to the Member;
5. The nature of any Exceptions granted to
the Member, their duration, any conditions, and the reasons for the imposition
of any limits on the duration of or conditions for the Exceptions;
6. The reasons for the Department's Decision;
and
7. Notice of the Member's
appeal rights.
E. All
Exceptions are subject to Utilization Review.
F. All Exceptions must be written into the
Member's Person-Centered Service Plan.
21.14-4 Criteria for Decisions
A. The Department, or its Authorized Entity,
can only approve a Request for Exceptions if the Member has demonstrated all of
the below criteria:
1. The requested service
is a Covered Service;
2. The Member
reasonably requires the Exception to receive services in the community, or
failure to grant the Exception will place the Member at serious risk of
institutionalization or segregation;
3. The Member lacks natural supports to meet
the needs that the requested Exception is intended to address;
4. The need for Exception could not be met
with other services or combination of services available in the
MaineCare Benefits Manual; and
5. The Exception will ensure the Member's
needs will be met in the most integrated setting appropriate to their
needs.
B. The Department
may deny a Request for Exceptions (even if the Member demonstrates the Member
needs the Exception to live in the most integrated setting appropriate to the
Member's needs) if the Department determines that any or all of the below
applies:
1. The Member's proposed community
placement is not appropriate;
2.
The Member's health and safety cannot be assured in the community even if the
Exception is granted; or
3. The
Exception, if granted, would fundamentally alter this Benefit.
21.14-5 Duration; Re-Assessment
A. The Member's Case
Manager, the Member, or the Member's Representative shall note approved
Exception(s) and their duration in the Member's Person-Centered Service
Plan.
B. Exceptions granted to a
Member under this section shall expire as set forth in the Decision.
C. At least sixty (60) days prior to the
expiration of an Exception, if the Member wishes to renew the Exception, the
Member, the Member's Representative, or the Member's Case Manager shall submit
a request to renew the Exception in conformance with § 21.11-2. The
Department will evaluate the request to renew the Exception applying the
criteria set forth in § 21.11-4.
21.14-6 Appeals
A Member may appeal the Department's Decision on a Request for Exceptions, or a request to renew an Exception, through the Department's MaineCare appeals process pursuant to Chapter I, Section 1, within sixty (60) calendar days.
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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