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-50 - ICF-MR Services
Subsection 144-101-II-50.05 - ELIGIBILITY FOR CARE
Universal Citation: 10 ME Code Rules ยง 144-101-II-50.05
Current through 2024-38, September 18, 2024
50.05-1 General and Specific Requirements
In order to be eligible for ICF-MR services, all the following standards must be met:
A.
General MaineCare Eligibility Requirement. Individuals must meet
the eligibility criteria as set forth in the MaineCare Eligibility Manual. The
eligibility determination process is administered by the Office of Integrated
Access and Support.
B.
Specific MaineCare Requirements.
1. The Department or the Department's
authorized agent must determine the individual's medical eligibility, as
described in Section 50.06; and
2.
Individuals must be diagnosed by a physician as having mental retardation or a
related condition, which is manifested before the person reaches age twenty-two
(22); and
3. Individuals must
require active treatment of ICF-MR services, as defined in this Section. An
individual's eligibility cannot be based merely on his/her diagnosis. General
and specific requirement determinations are processed concurrently in order to
expedite the decision of the applicant's overall eligibility for ICF-MR
services. Once an applicant is found eligible, the Department will review
eligibility requirements on an annual basis.
50.05-2 Eligibility for Care in an ICF-MR Nursing Facility
A. All
MaineCare eligible members admitted to an ICF-MR Nursing Facility must have the
medical necessity for ICF-MR care certified by a physician on admission and
re-certified annually. There must be documented evidence of nursing needs that
require at least eight (8) hours per day of licensed nurse
supervision.
B. Before admission to
an ICF-MR Nursing Facility or before authorization for payment, there must be a
medical, psychological, and social evaluation and a plan of care. An Individual
Program Plan (IPP) developed by the Inter-Disciplinary Team (IDT), must be
established in accordance with State licensing and Federal certification
requirements.
C. In addition to
meeting one (1) or more of the criteria described under 50.05-3(B), one (1) or
more of the following criteria must apply to a member in order for the member
to be eligible to receive care in an ICF-MR Nursing Facility:
1. Plan of care requires the skills of a
licensed nurse; and/or
2. Tube
feedings that require professional nursing judgment, observation and care;
and/or
3. Medical needs that
require constant licensed nursing evaluations, judgments, and interventions,
i.e. suctioning; and/or
4. Certain
injectable medicines that require licensed nursing observation, supervision, or
administration; and/or
5.
Uncontrolled seizures that require licensed nursing observation, supervision,
or administration.
50.05-3 Eligibility for Care in an ICF-MR Group Home Facility
A. All
MaineCare eligible members admitted to an ICF-MR Group Home Facility must have
the medical necessity for ICF-MR care certified by a physician on admission and
re-certified annually. The physician must certify that the member is
not in need of eight (8) hours or more per day of nursing care. An
IPP developed by the IDT must be established in accordance with State licensing
and Federal certification requirements.
B. A member must require the services
provided in an ICF-MR Group Home Facility, but cannot have care needs that
require the presence of a licensed nurse for supervision for eight (8) hours or
more per day. One (1) or more of the following criteria must apply to the
member in order for the member to be eligible to receive care in an ICF-MR
Group Home Facility. The member must:
1. Need
assistance in personal care such as oral hygiene, care of skin, personal
grooming and bathing; or
2. Exhibit
or has exhibited deviation from acceptable behavior; or
3. Require some personal supervision;
or
4. Require some protection from
environmental hazards; or
5.
Require supervision while participating in diversional and motivational
activities both in the facility and in the community; or
6. Require assistance with medications that
are of a routine nature and can be administered by qualified group home
facility personnel; or
7. Require
assistance due to aphasia.
C. If a member residing in an ICF-MR Group
Home Facility has medical needs that require twenty-four (24) hour nursing
supervision, he or she may continue to reside in the facility if the following
conditions are met. The member must:
1. Have a
medical care plan developed in accordance with State licensing and Federal
certification regulations; and
2.
Be in a facility where twenty-four (24) hour licensed nurse in-house coverage
is provided; and
3. Obtain approval
from the DHHS before twenty-four (24) hour nursing services are provided;
and
4. The member's medical
condition must be expected to be temporary.
50.05-4 Continued Eligibility
A. Each MaineCare member must be reviewed by
authorized representatives of DHHS to verify the continued need for ICF-MR
level of care on an annual basis.
B. The Division of Licensing and Regulatory
Services independent professional team shall review the quality, quantity, and
necessity of the services being delivered to a MaineCare member at the
following intervals:
1. a record review shall
be performed every six (6) months; and
2. a site visit and records review shall be
performed annually.
C.
The IPP must be reviewed by all or a portion of the IDT at least every ninety
(90) days.
D. Physician
re-certification shall be considered in compliance if:
(1) it is completed not later than ten (10)
calendar days after the required date, and
(2) the physician establishes good cause why
the required date was not met.
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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