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-29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-29.04 - PERSONAL PLAN

Current through 2024-29, July 17, 2024
Whenever significant changes occur that alter level of
						care, the case manager will submit an updated Assessment Form to DHHS. The case
						manager must complete and submit all waiver documents including the BMS 99, or
						current functional assessment approved by the Department and the updated
						Personal Plan to the Resource Coordinator thirty (30) days in advance of the
						annual redetermination date.
If the member or guardian chooses services under this
						Section, the request for services must be submitted to DHHS or its Authorized
						Entity. As part of the planning process, the member's needs are identified and
						documented in the Personal Plan. Except for residential services, other
						services shall be provided to the member within ninety (90) days.
29.04-1
Prior Authorization for
					 Reimbursable Services
Medically necessary services and units of services must
						be identified in the Personal Plan. Requests for services must be submitted to
						DHHS or its Authorized Agent for Prior Authorization in order for the services
						to be reimbursed. Requests will be reviewed by DHHS or its Authorized Entity,
						and may be examined and evaluated by DHHS or its Authorized Entity, before
						units of service are authorized. All Prior Authorizations are time-limited, and
						the length of the authorization may vary by member and service as documented in
						the Personal Plan. Upon expiration of an authorization, a new authorization
						must be obtained before reimbursement may be provided for the service.
DHHS and its Authorized Entity reserve the right to
						conduct Utilization Review of any service authorized under this Section,
						applying the service-specific eligibility standards set forth in this Section.
						DHHS and its Authorized Entity may terminate or revise a service authorization
						upon finding that the member no longer satisfies the eligibility standards for
						the service or level of service authorized.
29.04-2
Personal Plan
					 Requirements
The case manager will ensure that a Planning Team is
						convened to initiate development of the Personal Plan prior to services being
						initiated. Case Managers must meet with the member absent of current providers
						to ensure conflict free planning and informed choice. The planning process must
						reflect cultural conventions of the member. The planning process must be
						conducted by providing information in plain language and in a manner that is
						accessible to the member and when applicable, their legal
						representative.
The effective plan date must be current and less than six
						(6) months old at the time of the member's eligibility determination or
						redetermination. The planning process must comply with the requirements
						described in
						42 CFR §
													441.301(c)(1), and 34 -B
						M.R.S.A. §5470- B(2).. The Personal Plan must contain at a minimum:
A. All MaineCare Home and Community waiver
					 benefit services determined medically necessary by the team including all other
					 services that may not be covered under this section but that the member
					 identifies and may pursue;
B. The
					 frequency of provision of the services, including transportation
					 services;
C. How services
					 contribute to the member's health and well-being and the member's ability to
					 reside in a community setting;
D.
					 The member's goals for strengthening and cultivating personal, community,
					 family, and professional relationships;
E. The role and responsibility of the
					 member's service providers in supporting the member's goals, including goals
					 for strengthening natural and supportive personal, family, community and
					 professional relationships;
F.
					 Members who chose to receive Home Support- Remote Support must have a
					 safety/risk plan, which shall describe the potential risks to the member's
					 health and welfare while receiving Home Support- Remote Support and the
					 reasonable steps to alleviate those risks; and
G. In order for the Personal Plan to be
					 approved, the Personal Plan must include signatures of
1. The member,
2. The guardian, if applicable,
3. The case manager, and
4. Per
					 34-B MRSA
					 §5470-B and
					 42 CFR §
														441.301, the individuals and providers
					 responsible for the implementation of the plan.
The Personal Plan will be used by DHHS or its Authorized
						Entity to identify the type and units of authorized services the member may
						receive under this Section. If more than one provider is reimbursed for the
						same category of direct supports, an explanation of the differences in roles
						and responsibilities of each provider and how services will not be duplicated
						is required.
All providers must ensure that notice of the Grievance
						process outlined in 14-197 CMR Chapter 8 is regularly provided to members
						served by the provider. Providing notice includes, at a minimum, ensuring that
						written notice of the grievance process is provided to the member and/or their
						guardian at any planning meeting; posting notice of the grievance process in an
						appropriate common area of all facilities operated by the provider; and posting
						notice of the grievance process on any website maintained by the provider. In
						addition, the provider must ensure that all staff are trained in the grievance
						process.