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-26 - Day Health Services
Subsection 144-101-II-26.02 - ELIGIBILITY FOR CARE

Universal Citation: 10 ME Code Rules § 144-101-II-26.02

Current through 2024-38, September 18, 2024

26.02-1 General Requirements

A member is eligible to receive services as set forth in this Section if he or she meets the general MaineCare eligibility requirements and the specific MaineCare eligibility requirements. Members must meet the financial eligibility criteria as set forth in the MaineCare Eligibility Manual. Some members may have restrictions on the type and amount of services they are eligible to receive.

26.02-2 Specific Day Health Services Eligibility Requirements

The member must be assessed by the Department or the Department's authorized agent, using the Department's approved medical eligibility assessment form. A member must require assistance with a combination of activities of daily living and nursing at specific levels in order to meet eligibility for specific levels of care. A member is medically eligible for day health services under this section if he or she meets the criteria set forth in (A), (B) or (C) below:

A. Level I: A member meets the eligibility requirements for Level I if the following are met:

1. Member requires daily (seven (7) days per week) "Cuing" (defined in Section 26.01) for all items: 26.02-2 (A) (2), (d), (e), (f) and (g) listed below;

2. At least "limited assistance" (defined in 26.01) and a "one-person physical assist" (defined in 26.01) are needed with at least two (2) of 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);

c. Locomotion: How person moves between locations, in room and other areas. If in wheelchair, self-sufficiency once in chair;

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

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

f. Bathing: How person takes full-body bath/shower, sponge bath and transfers in/out of tub/shower (exclude washing of back and hair); and

g. Dressing: How person puts on, fastens, and takes off all items of street clothing, including donning/removing prosthesis.

B. Level II: A member meets the eligibility requirements for Level II if the following are met:

1. At least "extensive assistance" (defined in 26.01) and a "one-person physical assist" (defined in 26.01) are needed for at least two (2) of the following five (5) activities of daily living listed in 26.02-2 (A) (2) above: bed mobility, transfer, locomotion, eating, toilet use.

2. Member meets two (2) of the following three (3) criteria:

a. Cognition Threshold:

i. Scores a one (1) on Section C.1a of the MED form on short-term memory (recall after five (5) minutes). A score of one (1) indicates memory problems; and

ii. Can recall no more than two (2) of the following items from Section C.2 of MED form, Memory/Recall Ability: current season, location of own room, names/faces, where he/she is; and

iii. Scores a two (2) or three (3) under Section C.3 of MED form, Cognitive Skills for Daily Decision-Making. Moderately impaired (decisions poor; cues/supervision required) will be scored as two (2) and severely impaired (never/rarely made decisions) will be scored as three (3).

b. Behavior threshold: member must score a two (2) or three (3) under Section D.1 of the MED form, Problem Behavior. This behavior includes wandering, being verbally abusive, physically abusive, and/or demonstrating socially inappropriate behavior four (4) or more days per week.

c. At least "limited assistance" (defined in 26.01) and a "one-person physical assist" (defined in 26.01) is needed for at least one (1) of the following five (5) activities of daily living listed in 26.02-2(A)(2) above: bed mobility, transfer, locomotion, eating, toilet use.

C. Level III: A member must meet the medical eligibility requirements detailed in Chapter II, Section 67.02, "Nursing Facility Services".

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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