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 § 144-101-II-21.14

Current through 2025-13, March 26, 2025

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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