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-46 - Psychiatric Hospital Services › Subsection 144-101-II-46.03 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
46.03-1 General
					 Eligibility
Individuals must meet the financial eligibility criteria
						as set forth in the MaineCare Eligibility Manual (10-144 CMR Chapter 332). Some
						members may have restrictions on the type and amount of services they are
						eligible to receive.
It is the responsibility of the provider to verify
						eligibility and benefit level. The following describes specific eligibility for
						the covered services set forth in this section.
The member's condition must be such that his or her needs
						cannot be met in a less restrictive setting.
46.03-2
Age Requirement: For Inpatient
					 Services
An individual must be under age twenty-one (21) or age
						sixty-five (65) or older to be eligible to receive inpatient psychiatric
						hospital services, except that if a member receives inpatient services
						immediately before he or she reaches age twenty-one (21), the member is
						eligible for continued service until he or she reaches age twenty-two (22) or
						the date when service is no longer required, whichever comes first.
46.03-3
Partial
					 Hospitalization Services and Outpatient Services
To be eligible for partial hospitalization and outpatient
						services, the member's condition must be such that his or her needs cannot be
						met in a less intensive or less restrictive and available setting.
For outpatient services to be covered by MaineCare the
						member must need treatment similar to or more active or inclusive than is
						available through a weekly visit to a mental health agency, psychologist or
						psychiatrist, but not need partial or full-time hospitalization.
To be eligible for partial hospitalization services the
						member must need more active and inclusive treatment than is provided in an
						outpatient service, but not need full-time hospitalization or
						institutionalization.
46.03-4
"Katie Beckett"
					 Eligibility
The Office of MaineCare Services will determine
						classification (or eligibility) for certain children with disabilities ("Katie
						Beckett" Eligibility Option) age eighteen (18) and under. "Katie Beckett"
						eligibility has medical criteria in addition to financial criteria. All of the
						following eligibility criteria must be met for a child to receive MaineCare
						services:
A.
Disability
The child must be determined disabled by Supplemental
						Security Income standards. A disability determination is made by the Medical
						Review Team (MRT) at the Office of Integrated Access and Support as part of the
						MaineCare application process or by the disability determination unit at the
						Social Security Administration.
B.
Level of Care
The child must require a level of care that is typically
						provided in a hospital, including psychiatric hospitals, ICF-MR, or a Nursing
						Facility, although the child does not have to be admitted, relocated nor have a
						history of admissions to such an institution.
If the child were in a medical institution, the child
						would be eligible for Medicaid.
C.
Psychiatric Hospital Level of
					 Care
The following describes the criteria for severely
						emotionally disturbed children to meet the Psychiatric Hospital Level of Care.
						These criteria are used for establishing levels of care for SED children living
						at home who otherwise would need to be admitted to a hospital or psychiatric
						hospital. NOTE: All of the criteria under 1, 2, 3, and 4 must be met.
1. The member must have a primary diagnosis
					 of a Serious Emotional Disturbance as defined in Section 46.01 that has been
					 diagnosed by a mental health clinician as defined in Section 46.01.
This diagnosis must include information on all five axes
						from the most current version of The Diagnostic and Statistical Manual of
						Mental Disorders (DSM) that apply; and
2. Documentation by a mental health clinician
					 must be entered in the medical record that evidences that the child has been
					 diagnosed as defined in 46.03-4 C 1. and the disorder has persisted for a
					 minimum of six (6) months and can be expected to persist for a year or longer:
					 and
3. The child must have
					 exhibited in the last three (3) months, as documented by a mental health
					 clinician, at least one of the following symptoms and/or behaviors or would
					 exhibit one of the following symptoms and/or behaviors without medical
					 intervention (e.g. medication):
a.
Psychotic symptoms
characterized by defective or lost contact with
					 reality, often with hallucinations or delusions.
b.
Suicidality
- The individual
					 must have made one attempt within the last three months or have significant
					 ideation about or have a plan for suicide within the past month.
c.
Violence
- The individual
					 must be at risk for causing injury to persons or significant damage to property
					 as a result of a neurobiological, emotional and/or behavioral
					 disorder.
d.
Anorexia
					 Nervosa
- (diagnosed by a physician) with a weight loss of at least 25%
					 of original body weight, signs of electrolyte imbalance, cardiac arrhythmias or
					 congestive heart failure.
e.
Withdrawal
- Removal of one's physical and/or emotional self from
					 activities of daily living (e.g. can't get out of bed or does not interact with
					 others)
f.
Severe
					 Hyperactivity
- Hyperactive behavior, including mania, that interferes
					 with the child's ability to participate in age-appropriate daily activities in
					 a safe manner; and
4.
					 The child must
a. demonstrate a serious
					 functional impairment that substantially interferes with age-appropriate
					 ability to function in family, school or community activities; or
b. evidence a persistent and pervasive
					 anxiety and depression; or
c.
					 present security risks; or
d.
					 persistently or frequently exhibit inappropriate behavior such as: physical
					 aggression, self-injurious behavior, hyperactive or impulsive behavior;
					 or
e. be at risk for health
					 problems due to inappropriate behavior, such as infections or other problems
					 caused by functional impairments in activities of daily living.
D.
Appropriateness of Community-Based Care
The child must be able to receive or currently be
						receiving appropriate care, in the least restrictive setting, outside a
						hospital or psychiatric inpatient setting. The parent and child will
						participate in making the decision as to where the child will receive care. The
						family home will be given first preference, if appropriate, as determined by
						the parent or guardian.
E.
Cost Limits of Community-Based Care
The total annual cost to MaineCare for community-based
						care for children eligible for MaineCare in this category must be no greater
						than the amount MaineCare would pay for the child's care in an
						institution.