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-102 - Rehabilitative Services › Subsection 144-101-II-102.03 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
A member is eligible to receive services under this
						Section if he or she meets both the General Eligibility Requirements for
						MaineCare and the Specific Eligibility Requirements detailed in this Section.
						It is the responsibility of the provider to verify a member's eligibility for
						MaineCare prior to providing services, as described in Chapter I.
102.03-1
General Eligibility
					 Requirements for MaineCare
Individuals must meet the financial eligibility criteria
						as set forth in the MaineCare Eligibility Manual (MEM). Some members may have
						restrictions on the type and amount of services they are eligible to receive,
						based on the MEM.
102.03-2
Specific Eligibility Requirements
A member must meet the following criteria:
A. Has a diagnosis of brain injury, as
					 defined in Section 102.02-2 and confirmed by a clinical evaluation as defined
					 in Section 102.05-1; and
B. Is not
					 receiving acute hospital rehabilitation services; and
C. Is not receiving intensive rehabilitation
					 NF services for individuals with a Brain Injury as defined in Section 102.02-8;
					 and
D. If the member is currently
					 receiving services in a nursing facility setting that are not intensive
					 rehabilitative NF services, then the member must meet all of the following
					 criteria:
i) The member's clinical evaluation
					 documents rehabilitation potential (defined Section 102.02-9); and
ii) The member requires licensed/certified
					 services to continue improvement; and
iii) The member has limited or no other
					 access to rehabilitative services; and
iv) The member expresses a desire to move to
					 a less restrictive setting; and
v)
					 Discharge to a less restrictive living arrangement has been identified in the
					 discharge potential section of the Minimum Data Set (MDS) (which is conducted
					 by the NF) and active planning for discharge is documented in the member's NF
					 plan of care.
E. Meets
					 the requirements of one of the following three Covered Services:
1.
Intensive Integrated
					 Neuro-rehabilitation
. A member meets the medical eligibility
					 requirements for
Intensive Integrated Neuro-rehabilitation
if he
					 or she:
Scores at least "3" on one item, in two or more domains
						in the Department's authorized Brain Injury Assessment Tool, (see Section
						102.03-3); and
Has documented rehabilitation potential (defined in
						Section 102.02-9).
OR
2.
Neurobehavioral
					 Rehabilitation
. A member meets the medical eligibility requirements for
Neurobehavioral Rehabilitation
if he or she
Scores at least "2" on one item, in any two or more
						domains in the Department's authorized Brain Injury Assessment Tool, (see
						Section 102.03-3); and
Scores at least a "2" one any one item on questions 14,
						15, 18, 19, 21 22, 23, 24, 41, 42 or 43 in the Department's authorized Brain
						Injury Assessment tool and
Has documented rehabilitation potential (defined in
						Section 102.02-9).
OR
3.
Community/Work Reintegration or Self
					 Care/Home Management Reintegration
.