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-96 - Private Duty Nursing and Personal Care Services › Subsection 144-101-II-96.07 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
96.07-1
Eligibility Determination
Applicants for services under this Section must meet the
						eligibility requirements set forth in Section
						96.02. An eligibility
						assessment, using the Department's approved MED assessment form, shall be
						conducted by the Department, the ASA, or the PDN provider, as
						applicable.
Eligibility for individuals under the age of 21, and for
						medication services or venipuncture services, and excluding all seeking
						services under the family provider services option, shall be determined by the
						PDN provider, in accordance with the requirements of Section
						96.02 and the MED
						form.
These services require prior approval by the Department.
						All other PDN/PCS services, for Members age 21 and over, and those requesting
						services under the family provider service option, require eligibility
						determination and prior approval by the ASA.
Applicants ages 18 and over who meet the NF medical
						eligibility criteria also qualify for Home and Community Benefits. These
						benefits may provide a greater array and quantity of services than otherwise
						available under this Section
						96; therefore, applicants must be
						assessed to determine whether they qualify for NF level of care.
Members are prohibited from receiving Home and Community
						Benefits and services under this Section simultaneously, except as described in
						Section
						96.05(L).
A. If financial eligibility for MaineCare has
					 not been determined, the applicant, family Member or guardian, must be referred
					 to the regional Office for Family Independence, concurrent with the relevant
					 medical eligibility determination process.
B. The Department, or its ASA, shall conduct
					 a medical eligibility assessment using the Department's approved MED assessment
					 form. The individual conducting the assessment shall be a registered nurse and
					 will be trained in conducting assessments and developing an authorized plan of
					 care with the Department's approved tool. The RN assessor's findings and scores
					 recorded in the MED form shall be determinative in establishing eligibility for
					 services and the authorized plan of care.
C. The PDN provider shall develop a nursing
					 plan of care, which shall be reviewed and signed by the Member's physician. It
					 shall include the personal care and nursing services authorized by the ASA or
					 the Department, and the nursing plan signed by the Member's
					 physician.
D. The anticipated costs
					 of services under this Section to be provided under the authorized plan of care
					 must conform to the limits set forth in Section
					 96.03 and
					 96.06.
E. An individual's specific needs for medical
					 services must be reviewed and approved by the Member's physician at least every
					 62 days, and so documented in the medical record and nursing plan of care by
					 the RN.
1. Applicants, age 21 and over, and
					 Members requesting services under the family provider service option, who meet
					 the eligibility criteria for PDN services, as set forth in Section
					 96.02, and as
					 documented by the Department's approved MED assessment form, shall:
a. Be assigned, by the ASA, to the
					 appropriate level of care, and receive an authorized plan of care based upon
					 the scores, timeframes, findings and covered services recorded in the MED
					 assessment. The covered services to be provided in accordance with the
					 authorized plan of care shall:
1) not exceed
					 the established financial caps;
2)
					 be authorized by the Department or its ASA; and
3) be under the direction of the Member's
					 physician for the nursing plan of care.
b. The assessor shall approve an eligibility
					 period for the Member, based upon the scores, timeframes and needs identified
					 in the MED assessment for the covered services, and the assessor's clinical
					 judgment. The eligibility period shall not exceed 12 months.
c. Except for those Members who qualify under
					 Level IX, the assessor shall notify the Service Coordination Agency within two
					 business days of the medical eligibility determination and authorization of the
					 plan of care. For those Members who are eligible under Level IX, the assessor
					 shall forward the completed assessment and plan of care to the Licensed
					 Assisted Living Agency, as defined in § 96.01-28.
2. Members under age 21, excluding those
					 requesting services under the family provider service option.
a. Services require prior approval by the
					 Department. The Department shall approve an eligibility period, not to exceed
					 one year.
b. An individual under
					 age 21, who does not meet the eligibility criteria for PDN services as set
					 forth in Section
					 96.02, may be
					 reviewed under Prevention, Health Promotion, and Optional Treatment Services.
					 If the provider determines that services are medically necessary pursuant to
					 the criteria of Prevention, Health Promotion, and Optional Treatment Services,
					 then services shall be provided in accordance with a plan of care and billed
					 under this Section, adhering to all applicable financial caps unless
					 authorization to exceed that cap has been granted by the Department as outlined
					 under Section
					 96.03(A).
c. If a provider determines that any of the
					 requested services, for an individual under age 21, are medically necessary,
					 but are not available from that provider, the provider shall notify the family
					 in writing (in the Department's approved notice format) which services are not
					 available from that provider. A copy of the letter shall be sent to the
					 Department's Prevention, Health Promotion, and Optional Treatment Services
					 staff, and Prevention, Health Promotion, and Optional Treatment Services staff
					 shall offer to assist the Member in locating other providers.
d. If the provider determines that the
					 PDN/PCS services are not medically necessary, then the provider shall notify
					 (using a notice format approved by the Department) the family in writing of
					 which services will be provided and which services will not be provided, or
					 provided only on a reduced basis. The notice shall contain an understandable
					 explanation of the reasons and inform them of their appeal rights and of
					 Prevention, Health Promotion, and Optional Treatment Services. A copy of any
					 denial/reduction notice shall be sent to the Prevention, Health Promotion, and
					 Optional Treatment Services. Prevention, Health Promotion, and Optional
					 Treatment Services will then offer to assist the family to see what other
					 services may be provided to meet the child's needs.
e. The private duty nursing services provider
					 shall develop a nursing plan of care and an authorized plan of care.
f. The anticipated costs of services to be
					 provided under the plan of care must conform to the limits set forth in Section
					 96.03. The costs of
					 physical therapy, occupational therapy, speech and hearing services shall not
					 be included in the calculation of either the average annual cost of
					 institutional services or the cost of PDN services required by the
					 individual.
g. The PDN/Personal
					 care services provider shall obtain the signature of the physician on the plan
					 of care or a physician's order for private duty nursing and personal care
					 services and for the medical treatment plan. This shall be made available to
					 the Department or its Authorized Entity upon request. Services must also be
					 authorized by the Department or its Authorized Entity.
h. For services to individuals under age 21,
					 as well as individuals classified for venipuncture services and medication
					 services, but excluding those receiving services under the family provider
					 service option, the eligibility assessment form and the plan of care shall be
					 maintained in the Member's medical record, available upon request for review by
					 the Department. The provider must submit a copy of the medical eligibility
					 determination form to the Department.
i. The provider shall be responsible for
					 assuring that the plan of care shall not exceed the financial cap established
					 by the Department.