Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
149 - OFFICE OF AGING AND DISABILITY SERVICES
Chapter 5 - BUREAU OF ELDER AND ADULT SERVICES POLICY MANUAL
Section 149-5-61 - ADULT DAY SERVICES
Universal Citation: 10 ME Code Rules ยง 149-5-61
Current through 2024-13, March 27, 2024
61.01 DEFINITIONS.
(A)
Adult Day
Services means an appropriately licensed program that receives funding
assistance from Bureau of Elder and Adult Services for consumers who require
assistance in paying for this service.
(B)
Activities of daily living
(ADLs) ADLs shall only include the following as defined in Section
61.02: bed mobility, transfer, locomotion, eating, toileting, bathing and
dressing
(C)
Authorized
Agent means an organization authorized by the Department to perform
reimbursable functions as specified in this section. The Licensed Adult Day
Service provider is the Authorized Agent under this Section.
(D)
Authorized Service plan
means a plan which is authorized by the Adult Day Service provider, or
the Department, which shall specify all services to be delivered to a recipient
under this Section, including the number of hours for all covered services. The
service plan shall be based upon the recipient's assessment outcome scores and
the timeframes contained therein, recorded in the Department's medical
eligibility determination (MED) form. The Adult Day Services provider has the
authority to determine and authorize the service plan. All authorized covered
services provided under this Section must be listed in the care plan summary on
the MED form.
(E)
Care Plan
Summary is the section of the MED form that documents the Authorized
Service Plan and services provided by other public or private program funding
sources or support, service category, reason codes, duration, unit code, number
of units per month, rate per unit, and total cost per month.
(F)
Covered Services are those
services for which payment can be made by the Department, under Section 61 of
the Bureau of Elder and Adult Services policy manual.
(G)
Cueing shall mean any spoken
instruction or physical guidance, which serves as a signal to do something.
Cueing is typically used when caring for individuals who are cognitively
impaired.
(H)
Dependent
Allowances. Dependents and dependent allowances are defined and
determined in agreement with the method used in the MaineCare program. The
allowances are changed periodically and cited in the MaineCare Eligibility
Manual, TANF Standard of Need Chart. Dependents are defined as individuals who
may be claimed for tax purposes under the Internal Revenue Code and may include
a minor or dependent child, dependent parents, or dependent siblings of the
consumer or consumer's spouse. A spouse may not be included.
(I)
Disability-related expenses
: Disability-related expenses are out-of-pocket costs incurred by the consumers
for their disability, which are not reimbursed by any third-party sources. They
include:
(1) Home access modifications:
ramps, tub/shower modifications and accessories, power door openers, show
seat/chair, grab bars, door widening, environmental controls;
(2) Communication devices: adaptations to
computers, speaker telephone, TTY, Personal Emergency Response
Systems;
(3) Wheelchair (manual or
power) accessories: lab tray, seats and back supports;
(4) Vehicle adaptations: adapted carrier and
loading devices, one communication device for emergencies (limited to purchase
and installation), adapted equipment for driving;
(5) Hearing Aids, glasses, adapted visual
aids;
(6) Assistive animals
(purchase only);
(7) Physician
ordered medical services and supplies;
(8) Physician ordered prescription and over
the counter drugs; and
(9) Medical
insurance premiums, co-pays and deductibles.
(J)
Household members: means the
consumer and spouse
(K)
Household members' income includes:
(1) Wages from work, including payroll
deductions, excluding state and Federal taxes and employer mandated or court
ordered with holdings;
(2) Benefits
from Social Security, Supplemental Security Insurance, pensions, insurance,
independent retirement plans, annuities, and Aid and Attendance;
(3) Adjusted gross income from property
and/or business, based on the consumer's most recent Federal income tax;
and
(4) Interest and dividends.
Not included are benefits from: the Home Energy Assistance Program, Food Stamps, General Assistance, Property Tax and Rent Refund, emergency assistance programs, or their successors.
(L)
Limited Assistance means the
individual was highly involved in the activity over the past seven days, or 24
to 48 hours if in a hospital setting, but received and required
* guided maneuvering of limbs or other non-weight bearing physical assistance three or more times or
* guided maneuvering of limbs or other non-weight bearing physical assistance three or more times plus weight-bearing support provided only one or two times
(M)
Liquid asset is something of value available to the consumer that
can be converted to cash in three months or less and includes:
(1) Bank accounts;
(2) Certificates of deposit;
(3) Money market and mutual funds;
(4) Life insurance policies;
(5) Stocks and bonds;
(6) Lump sum payments and inheritances;
and
(7) Funds from a home equity
conversion mortgage that are in the consumer's possession whether they are cash
or have been converted to another form.
Funds which are available to the consumer but carry a penalty for early withdrawal will be counted minus the penalty. Exempt from this category are mortuary trusts and lump sum payments received from insurance settlements or annuities or other such assets named specifically to provide income as a replacement for earned income. The income from these payments will be counted as income.
(N)
Medical Eligibility Determination
(MED) Form shall mean the form approved by the Department for medical
eligibility determinations and service authorization for the service plan based
upon the assessment outcome scores. The definitions, scoring mechanisms and
time frames relating to this form as defined in Section 61 provide the basis
for authorized services and the service plan by the Adult Day Services
provider. The care plan summary contained in the MED form documents the
authorized service plan to be implemented by the Adult Day Services provider in
the service plan. The service plan summary also identifies other services the
recipient is receiving, in addition to the authorized services provided under
this Section.
(O)
One-person
Physical Assist requires one person over last seven (7) days or 24-48
hours if in a hospital setting, to provide either weight-bearing or non-weight
bearing assistance for an individual who cannot perform the activity
independently. This does not include cueing.
61.02 ELIGIBILITY
(A)
General and Specific Requirements.
To be eligible for adult day services reimbursed directly by Bureau of
Elder and Adult Services with state funds, a consumer must:
(1) Be at least 18;
(2) Live in Maine;
(3) Lack sufficient personal and/or financial
resources for Adult Day Services;
(4) For an individual have assets of no more
than $50,000 or for couples have assets no more than $75,000.
(5) Be ineligible for the MaineCare Private
Duty Nursing/Personal Care Services, Maine Care Home and Community-Based
Benefits MaineCare Adult Day Health and MaineCare Consumer Directed Attendant
Services programs.
(6) Not be
participating in Section
63: In Home and Community Based Support
Services, Section
68: Respite Care for People with
Alzheimer's Disease or Related Disorders or the Consumer-Directed Home Based
Care program enacted by
26
M.R.S.A. Section1412-G.
(7) If the assessment for continued
eligibility indicates medical eligibility for a MaineCare program and potential
financial eligibility for MaineCare, consumers will be given written notice,
that the consumer has up to thirty (30) days to file a MaineCare application.
If Adult Day services are currently being received, services shall be
discontinued if a Bureau of Family Independence notice is not received within
thirty (30) days of the assessment date indicating that a financial application
has been filed. Services shall also be discontinued if, after filing the
application within thirty (30) days the application requirements have not been
completed in the time required by MaineCare policy.
(8) Not be residing in a hospital, nursing
facility, a licensed residential care facility or assisted living
program.
(9) Consumer or legal
representative agrees to pay the monthly calculated consumer payment.
(B)
Medical and Functional
Eligibility Requirements
Applicants for services under this section must meet the eligibility requirements as set forth in Section 61.02-B and documented on the Medical Eligibility Determination (MED) form. Medical eligibility will be determined using the MED form as defined in Section 61.01.
(1)
Eligibility: A person meets
the medical eligibility requirements for Adult Day Services if he or she
requires the combination of criteria of Activities of Daily Living,
(a) Requires cueing 7 days per week for
eating, toilet use, bathing, and dressing as defined in Section 61.01;
or
(b) Requires limited assistance
plus a one person physical assist with at least one (1) ADLs from the
following: bed mobility, transfer, locomotion, eating, toilet use, dressing,
and bathing.
(2)
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, manages 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.
61.03 Duration of Services
(A) Each Adult Day Services
recipient may receive as many covered services as are required up to a maximum
of thirty (30) hours per week. Coverage of services under this Section requires
prior authorization for program funds from the Department based on the
availability of program funds. Beginning and end dates of an individual's
eligibility determination period correspond to the beginning and end dates for
coverage of the Adult Day Services plan authorized.
(B) Services under this Section may be
reduced, denied or terminated by the Department, or the Authorized Adult Day
Services provider, as appropriate, for the following reasons:
(1) The consumer does not meet eligibility
requirements;
(2) The consumer
declines services;
(3) The consumer
is eligible to receive long-term care services under MaineCare including any
MaineCare Special Benefits.
(4) The
consumer is eligible to receive services and funds are available for services
under In Home and Community Support Services (Section
63 ) or the Consumer-Directed Home
Based Care Program enacted by
26
M.R.S.A. Section1412-G and there is a waiting
list for services under Section 61.
(5) Services have been suspended for more
than thirty (30) days
(6) The
consumer has failed to make his/her calculated monthly co-payment
(7) There are insufficient funds to continue
to pay for services for all current consumers, which results in a change
affecting some or all consumers.
(C) Suspension. Services may be suspended for
up to thirty (30) days while the consumer is hospitalized or using
institutional care. If such circumstances extend beyond thirty (30) days, the
recipient may be reassessed to determine eligibility if the provider determines
there has been a significant change.
Notice of intent to reduce, deny, or terminate services under this section will be done in accordance with Section 40.01 of this policy manual.
61.04 Covered Services
Covered services are available for individuals meeting the eligibility requirements set forth in Section 61.02. All covered services require prior authorization by the Department, consistent with these rules, and are subject to the limits in Section 61.03. The Authorized Service Plan shall be based upon the recipient's assessment outcome scores recorded on the Department's Medical Eligibility Determination (MED) form, its definitions, and the timeframes therein and the absence of a caregiver or need of caregiver respite.
Services provided must be required for meeting the identified needs of the individual, based upon the outcome scores on the MED form, and as authorized in the service plan. Coverage will be denied if the services provided are not consistent with the consumer's authorized service plan. The Department may also recoup payment from the Adult Day Care provider for inappropriate services provision, as determined through post payment review. The Authorized Adult Day Services provider has the authority to determine the service plan, which shall specify all services to be provided, including the number of hours the recipient will attend for adult care.
Covered services are:
(1) Assistance with activities of daily
living while attending the day services program
(2) Provision of snacks and a meal while in
attendance at adult day service program
(3) Provision of activities, socialization
and stimulation
(4) Transportation
services necessary to perform activities and socialization services described
in a recipients' plan of care, such as medical appointments. Reimbursement
shall only be made for mileage in excess of ten (10) miles per single trip on a
one way trip.
(5) Transportation
services necessary to transport a consumer to the program and return home,
provided this is a service of last resort. Mileage reimbursement rate shall not
exceed an amount established by the Department.
(6) Any individual providing transportation
must hold valid State of Maine driver's license for the type of vehicle being
operated. All providers of transportation services shall maintain adequate
liability insurance coverage for the type of vehicle being operated
61.05 Non Covered Services
The Following services are not reimbursable under this Section:
(A) Services for which the
cost exceeds the limits described in Section 61.03;
(B) Adult Day Services for residents of
licensed residential care or assisted living program;
(C) Services provided by a personal care
assistant who has a notation on the CNA registry of
(1) Any criminal convictions, except for
Class D and E convictions over ten (10) years old that did not involve, as a
victim of the act, a patient, client, or resident of a health care entity;
or
(2) Any specified documented
findings by the State Survey Agency of abuse, neglect or misappropriation of
property of a resident, client or patient.
61.06 POLICIES and PROCEDURES
(A)
Eligibility Determination An
eligibility assessment, using the Department's approved MED assessment form,
shall be conducted by the Department, or the Authorized Adult Day Services
provider. All Adult Day Services require eligibility determination and prior
authorization by the Department.
(1) The
Authorized Adult Day Services provider will accept verbal or written referral
information on each prospective new consumer, to determine appropriateness for
an assessment. When funds are available, prospective consumers will receive a
face to face medical eligibility determination assessment. All requests for
assessments shall be documented indicating the date and time the assessment was
requested and all required information provided to complete the
request.
(2) The Authorized Adult
Day Services provider shall inform the consumer of available community
resources and authorize a service plan that reflects the identified needs
documented by scores and timeframes on the MED form, giving consideration to
the consumer's informal supports, and services provided by other public or
private funding sources.
(3) The
Adult Day Services provider shall authorize a service plan based upon the
scores and findings recorded in the MED assessment. The covered services to be
provided shall not exceed the weekly maximum number of hours established by
Bureau of Elder and Adult Services. The maximum eligibility period for the
consumer, shall not exceed twelve (12) months.
(4) The Adult Day Services provider will
provide a copy of the authorized service plan, in a format understandable by
the average reader, a copy of the eligibility notice, release of information to
the consumer at the completion of the assessment. The Adult Day Services
provider will inform the consumer of the calculated co-payment based on the
cost of services authorized.
(5)
The Adult Day Services provider is required to accept as payment in full the
allowances established by BEAS for covered services under this
section.
(B)
Waiting List
(1) When funds are
not available to serve new consumers who have been assessed and determined
eligible for services under this section, or to increase services for current
consumers, a waiting list will be established by the Adult Day Services
provider. As funds become available consumers will be taken off the list and
served on a first come, first served basis.
(2) For consumers found ineligible for Adult
Day Services under this section, the Adult Day Services provider will inform
each consumer of alternative services or resources, and offer to refer the
person to those other services.
(3)
The Department will maintain one statewide waiting list.
(4) If there is a waiting list the first come
first serve basis for selection may be waived by the Department if in it's
judgment it is necessary to respond to the emergency needs or special
circumstances of a caregiver.
(C) Suspension. Services may be suspended for
up to thirty (30) days while the consumer is hospitalized or using
institutional care. If such circumstances extend beyond thirty (30) days, the
recipient may be reassessed to determine eligibility if the provider determines
there has been a significant change.
(D) Reassessment and Continued Services
(1) For all recipients under this section, in
order for the reimbursement of services to continue uninterrupted beyond the
approved classification period, a reassessment and prior authorization of
services is required and must be conducted no later than the reassessment date.
Payment ends for Adult Day Services with the reassessment date, also known as
the end date.
(2) An individual's
specific needs for Adult Day Services shall be reassessed at least
annually.
61.07 Professional and Other Qualified Staff
(A) The Adult Day Services
Provider shall:
(1) Be open to serve
consumers at least two days a week;
(2) Determine eligibility of applicants using
the Medical Eligibility Determination (MED) form;
(3) Contact Bureau of Elder and Adult
Services to request prior authorization if the applicant is determined
eligible;
(4) Submit invoices for
payment to Bureau of Elder and Adult Services on a Bureau of Elder and Adult
Services approved billing form;
(5)
Not bill for more than thirty (30) hours of Adult day services per week for
each consumer.
(6) Manage requests
for waiver of consumer payments;
(7) Provide any consumer or designated
representative of any consumer with an unresolved complaint about the Adult Day
Services with information on how to contact the Long Term Care
Ombudsman;
(8) Refer consumers who
need additional services to the Assessing Services Agency for an
assessment.
61.08 Consumer Records and Program Reports
(A)
Content of Consumer
Records. The Adult Day Services provider must establish and maintain a
record for each consumer that includes at least:
(1) The consumer's name, address, mailing
address if different, and telephone number;
(2) The name, address, and telephone number
of someone to contact in an emergency;
(3) Complete medical eligibility
determination form and financial assessments and reassessments that include the
date they were done and the signature of the person who did them;
(4) A service plan summary that promotes the
consumer's independence matches needs identified by the scores and timeframes
on the MED form and on the care plan summary on the MED form, with
consideration of other formal and informal services provided and which is
reviewed no less frequently than semiannually. The service plan includes:
(a) Evidence of the consumer's
participation;
(b) Who will provide
what service, when and how often, the reason for the service and when it will
begin and end;
(c) The signature of
the person who determined eligibility and authorized a plan of care;
and
(5) A dated release
of information signed by the consumer that conforms with applicable law, is
renewed annually and that:
(a) Is in language
the consumer can understand;
(b)
Names the agency or person authorized to disclose information
(c) Describes the information that may be
disclosed;
(d) Names the person or
agency to whom information may be disclosed;
(e) Describes the purpose for which
information may be disclosed; and
(f) Shows the date the release will
expire.
(6)
Documentation that consumers eligible to apply for a waiver for consumer
payments, were notified, that a waiver may be available;
(7) Written progress notes that summarize any
contacts made with or about the consumer and:
(a) The date the contact was made;
(b) The name and affiliation of the person(s)
contacted or discussed;
(c) Any
changes needed and the reasons for the changes in the plan of care.
61.09 RESPONSIBILITIES OF THE BUREAU OF ELDER AND ADULT SERVICES
(A) The Bureau of Elder and Adult Services is
responsible for:
(1) Setting the weekly
individual service plan hour limit;
(2) Setting the maximum allowable, hourly
reimbursement rate;
(3) Conducting
monitoring visits;
(4) Providing
written notification to the provider and if applicable, its governing body, of
problems in the program and setting deadlines for corrections;
(5) Evaluating program data; and
(6) Reviewing randomly selected requests for
waivers of consumer payment.
61.10 Consumer Payments. Consumers will pay 20% of the cost of Adult Day Services, except when they are granted a waiver. Consumers in Adult Day Services programs which use Title III funds are exempt from a required consumer payment but may be asked to make a donation comparable to the consumer payment.
(A)
Waiver of Consumer Payment.
Consumers will be informed that they may apply for waiver of all or part of the
assessed payment when:
(1) Monthly income of
household, as defined in Section 61.01(J) and 61.01(K), is no more than 200% of
the federal poverty level; and
(2)
Household assets are no more than $15,000.
(3) Calculation of the waiver of the consumer
payment will be completed by the Adult day Services provider following the
process described in Section 63.12.
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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