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-45 - Hospital Services
Subsection 144-101-II-45.07 - POLICIES AND PROCEDURES

Universal Citation: 10 ME Code Rules ยง 144-101-II-45.07

Current through 2024-38, September 18, 2024

45.07-1 Discharge Planning

Medicaid patients denied continued hospitalization as a result of utilization review, or denied Medicare or other third party coverage on the basis of no longer having medical necessity for hospitalization, shall be denied Medicaid coverage unless approved for days awaiting NF placement, as described in Section 45.07-2. A copy of the denial letter indicating the last day of third party coverage must be submitted to: Program Integrity, SHS 11, Augusta, ME, 04333.

Each hospital shall maintain a written record of discharge planning procedures, setting forth at least the following:

A. The name of the staff member of the hospital who has operational responsibility for discharge planning.

B. The manner and methods by which such staff member will function, including his or her authority and relationship with the facility's staff.

C. The time period in which each eligible individual's need for discharge planning will be determined (which period may not be later than seven days after the day of admission).

D. The local agencies and individuals available to the facility as discharge planning resources, and a requirement that the attending physician assist a multidisciplinary team in developing discharge plans. Responsibilities for implementation shall be a team decision.

E. A provision for periodic review and re-evaluation of the facility's discharge planning program.

Hospital Discharge Instructions. Hospital Emergency Departments are required to provide discharge instructions that include contact information for appropriate Health Home providers (including Opioid Health Home, Behavioral Health Home, and Health Home Services - Community Care Team providers) to eligible individuals with chronic conditions, including opioid use disorder, serious and persistent mental illness, and serious emotional disturbance.

45.07-2 Medical Eligibility Determination for Nursing Facility (NF) Care

Prior to discharge, the hospital must notify members who will require nursing facility care services that a preadmission long-term care assessment is required for each applicant, regardless of source of payment, including private pay individuals. The Department or its Authorized Agent shall conduct the assessment using the approved eligibility assessment form. For a member transferring from a hospital to a NF under Medicare or any other private insurance coverage, the long-term care assessment may be delayed until the exhaustion of his or her insurance covered NF stay. To receive MaineCare coverage for days awaiting placement, or nursing facility level services, a member must meet the medical eligibility requirements as set forth in Chapter II, Section 67.

When it is expected that a patient will convert from Medicare, private pay or other third party coverage to MaineCare coverage, the hospital, on behalf of the member, must request, a nursing facility eligibility assessment prior to the exhaustion of the individual's current coverage. The Department or Authorized Agent must conduct this assessment when these third-party benefits are exhausted. In the cases of Medicare denials, a copy of the hospital's Medicare denial letter, indicating the last day of covered services, must be submitted to the Department or its Authorized Agent.

45.07-3 General Procedures for Medical Eligibility Determination

Eligible members who no longer require acute care and are to be transferred from a hospital to a NF, skilled NF level swing-bed, or days awaiting NF placement status must be determined medically eligible, pursuant to the criteria set forth in Chapter II, Section 67 of this Manual, by the Department or its Authorized Agent, prior to this transfer.

An individual may be admitted directly to a skilled NF level swing-bed without prior acute inpatient services, if determined medically eligible by the Department or its Authorized Agent.

1. The hospital shall request an assessment by submitting a complete referral form to the Authorized Agent. An incomplete form will be returned to the hospital and the assessment delayed until receipt of a complete form. Forms may be faxed. The Authorized Agent shall complete the medical eligibility assessment form within twenty-four (24) hours of the request for an assessment and the eligibility assessment shall not be conducted sooner than twenty-four (24) hours prior to the denial of acute level of care or discharge from a hospital.

2. If the patient is not a MaineCare member, the hospital's discharge planner or other designated person shall explore MaineCare eligibility and refer the patient, family member or guardian to the Office for Family Independence.

3. The hospital's discharge planner or other designated person must request that the Department or its Authorized Agent complete the eligibility assessment forms as specified in Chapter II, Section 67 of this Manual.

4. The Department or its Authorized Agent will inform the member and offer the choice of available, appropriate and cost-effective, home and community-based services and alternatives to NF placement. The relative costs to the member of each option must be explained.

5. If the member does not select community-based services, he/she must accept the first available, appropriate nursing facility placement within a sixty (60)-mile radius of his/her home, or MaineCare reimbursement will cease. If the member refuses to accept the placement, the hospital discharge planner must notify the Department. The Department will issue a ten (10) day notice of intent to terminate services. The member may accept a placement beyond the sixty (60) miles from home radius, however, this cannot be required of the member.

The discharge planner shall document in the medical record all efforts to obtain appropriate placement.

6. If the member is eligible for both MaineCare and Medicare and is eligible for Medicare nursing facility services, the member shall be admitted to a Medicare-certified NF bed, except in the following circumstances:
a. The member has been a resident in a NF and desires to return to that NF and can receive appropriate care; or

b. An appropriate Medicare-certified NF bed is not available within a sixty (60)-mile radius of the member's home.

Once a NF bed is secured, the hospital must notify the Department or its Authorized Agent, on the approved form, of the member's placement.

7. Prior to a member's return to a NF, following a hospital stay that exceeds bed hold limitations in Chapter II, Section 67, the member must be assessed by the Department or its Authorized Agent using the medical eligibility determination form to determine whether he/she continues to meet the medical eligibility criteria set forth in Chapter II, Section 67 for NF services, and whether or not community-based services are an appropriate option.

8. When a member is found financially eligible retroactively, MaineCare will reimburse for covered services that the hospital provides only during the period for which the member has been found to be both medically and financially eligible.

45.07-4 Program Integrity

Program Integrity monitors the services provided and determines the appropriateness and necessity of services. See Chapter I for further information.

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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