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-21 - Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder › Subsection 144-101-II-21.03 - DETERMINATION OF ELIGIBILITY

Current through 2024-29, July 17, 2024
Eligibility for this benefit is based on meeting all
						three of the following criteria:
1) the
					 eligibility criteria for a funded opening based on priority,
2) medical eligibility, and
3) eligibility for MaineCare as determined by
					 the DHHS, Office for Family Independence (OFI).
21.03-1
Funded Opening
The number of MaineCare Members that can receive services
						under this Section is limited to the number, or "funded openings," and point in
						time approved by the Centers for Medicare and Medicaid Services (CMS). Persons
						who would otherwise be eligible for services under this Section are not
						eligible to receive services if all of the funded openings are filled.
21.03-2
Reserved
					 Capacity
The DHHS reserves a portion of Member capacity of the
						waiver for specified purposes in order to:
Meet the needs of incapacitated or dependent adults
						  who require adult protective services to alleviate the risk of serious harm
						  resulting from abuse, neglect and/or exploitation; and
													Meet the needs of those individuals who choose to
						  leave an ICF/IID, long term nursing home placement, state psychiatric hospital,
						  or hospital and
													Meet the needs of Members under age 21 in out of
						  state residential placements funded by MaineCare or State funds.
The number reserved associated with Section 21.03-2 above
						is an average based on the DHHS's data for those in need of adult protective
						services in recent years. The number reserved for ICF/IID, long term nursing
						home placement, state psychiatric hospital or hospital residents is based on
						currently known referrals. The number reserved for Members in out-of-state
						residential placements is based on the number of current out of state
						residential placements funded by MaineCare or State funds.
21.03-3
General Eligibility
					 Criteria
Consistent with Subsection 21.03-1, a person is eligible
						for services under this Section if the person:
A. Is age eighteen (18) or older ;
					 and
B. Has an Intellectual
					 Disability as defined in the Definitions Section above, or Autism Spectrum
					 Disorder also defined in the Definitions Section above, or Rett Syndrome as
					 defined by the DSM; and
C. Meets
					 the medical eligibility criteria for admission to an ICF/IID as set forth under
					 the
MaineCare Benefits Manual
, Chapter II, Section
					 50; and
D. Does not receive services under any other
					 federally approved MaineCare home and community-based waiver program;
					 and
E. Meets all MaineCare
					 eligibility requirements as set forth in the
MaineCare Eligibility
					 Manual
; and
F. The
					 estimated annual cost of the Member's services under the waiver is equal to or
					 less than two hundred percent (200%) of the state-wide average annual cost of
					 care for an individual in an ICF/IID, as determined by the DHHS.
21.03-4
Establishing Medical
					 Eligibility
In order to determine medical eligibility, the Member and
						Case Manager must provide to DHHS the following:
A. A completed copy of the assessment form
					 (BMS 99) or current functional assessment approved by the DHHS; and
B. A copy of the Member's Person-Centered
					 Service Plan approved and signed by the Member, guardian and the Case Manager
					 within the preceding six months; and
C. Any other relevant material indicating the
					 Member's service needs.
Based on review of the Assessment Form and the Member's
						Person-Centered Service Plan, a QIDP designated by DHHS will determine the
						Member's medical eligibility for services under this Section.
DHHS shall notify each Member or the Member's guardian in
						writing of any decision regarding the Member's medical eligibility, and the
						availability of benefit openings under this Section. The notice will include
						information about the Member's right to appeal any of these decisions. Rights
						for notice and appeal are further described in Chapter I of the
MaineCare Benefits Manual
.
If the Member is found to be eligible, DHHS must send the
						Member or guardian written notice that the Member can receive ICF/IID services
						or services under this Section. The Member or guardian must submit to the Case
						Manager a signed choice letter documenting the Member's choice to receive
						services under this section.
21.03-5
Calculating the Estimated
					 Annual Cost
Prior to formal determination of eligibility for services
						under this section, each applicant and the applicant's planning team must
						identify the required mix of services to meet the applicant's needs and to
						assure the applicant's health and welfare. The applicant and the applicant's
						planning team shall submit a detailed estimate of the total annual cost for
						waiver services identified in the Person-Centered Service Plan, including the
						specific services and the number of units for each service.
21.03-6
Priority
When a Member is found to meet MaineCare eligibility
						criteria and medical eligibility criteria for these services, the priority for
						a funded opening shall be established in accordance with the following:
A.
Priority 1:
Any Member on the
					 waiting list shall be identified as Priority 1 if:
1. The Member has been determined by DHHS to
					 be in need of adult protective services in accordance with
					 22 M.R.S.
					 §§3470
et seq.
,
					 and if the Member continues to meet the financial and medical eligibility
					 criteria at the time that need for adult protective services is determined.
OR
2.
Although DHHS has not determined the Member to be in
						need of adult protective services, the Member is at risk for abuse, neglect, or
						exploitation because the Member meets the following criteria:
a. The Member resides with his or her Primary
					 Caregiver and the Primary Caregiver has reached age sixty-five (65) or has a
					 terminal illness, and is having difficulty providing the necessary supports to
					 the Member; AND
b. The Member has
					 no other responsible or willing caregiver; AND
c. The Member meets at least one of the
					 following criteria, and is at risk of one other:
i. Within the last 12 months, the Member has
					 demonstrated a significant medical/behavioral need, as evidenced and documented
					 by: 
					 
																	Increased functional needs and required supports as
						  a result of a mental health or medical condition; OR,
																	Criminal behavior resulting in involvement with the
						  criminal justice system (not dependent upon conviction) that impacts or results
						  in the harm or threat to others; OR
ii. Prolonged and unresolved crisis
					 involvement resulting in high-risk for institutionalization; OR
iii. Three or more hospital admissions over
					 the last 12 months due to a medical or behavioral decline that is expected to
					 continue; OR
iv. The health, safety
					 or welfare of the Member or others is at imminent danger.
B.
Priority 2:
Any Member on the waiting list shall be identified as
					 Priority 2 if the Member does not satisfy Priority 1 criteria, yet has been
					 determined to be at risk for abuse, neglect, or exploitation in the absence of
					 the provision of benefit services identified in his or her service plan.
					 Examples of Members who shall be considered Priority 2 include:
1. a Member whose Primary Caregiver has
					 reached age sixty (60) and is having difficulty providing the necessary
					 supports to the Member in the family home; or
2. a Member living in unsafe or unhealthy
					 circumstances but who is not yet in need of adult protective services, as
					 determined by DHHS Adult Protective Services.
C.
Priority 3:
Any Member on the
					 waiting list shall be identified as Priority 3 if the Member is not at risk of
					 abuse, neglect, or exploitation in the absence of the provision of the benefit
					 identified in the service plan. Examples of Members who shall be considered
					 Priority 3 include:
1. a Member living with
					 family, who has expressed a desire to move out of the family home;
2. a Member whose medical or behavioral needs
					 are changing and who may not be able to receive appropriate services in the
					 current living situation;
3. a
					 Member who resides with family, if the family must be employed to maintain the
					 household but cannot work in the absence of the benefit being provided to the
					 Member; or
4. A Member who has
					 graduated from high school in the State of Maine, has no continuing support
					 services outside of the school system, but is in need of such
					 services.
D. Annual
					 Waiting List Confirmation: The Member must confirm on an annual basis his/her
					 interest in remaining on the Section
					 21 waiting list in accordance with
					 the following process:
1. The Office of Aging
					 and Disability Services will notify the Member, his/her guardian, and the
					 Member's Case Manager of the need to complete the Section
					 21 Waiver Information Form to
					 confirm the Member's continued interest in remaining on the waiting
					 list.
2. The Member, his/her
					 guardian, and the Member's Case Manager will complete the Section
					 21 Waiver Information Form and
					 submit the form to the Department.
3. If the Section
					 21 Waiver Information Form is not
					 received within forty-five (45) days of notice to the Member, his/her guardian,
					 and Case Manager, then the Department will issue a second reminder
					 notice.
4. In the event that the
					 Section
					 21 Waiver Information Form is not
					 received by the Department within six (6) months of the initial notice to the
					 Member, his/her guardian, and Case Manager, then the Department will notify the
					 Member of his/her removal from the waiting list. The Member can reapply for
					 Section
					 21 services
					 thereafter.
E.
					 Reconsideration of Priority: If the Member would like the Department to
					 consider new information and re-evaluate priority level, then a Section
					 21 Waiver Information Form must be
					 submitted to the Department. This can be done at any time, or at the time of
					 the annual waiting list confirmation.
21.03-7
Choosing Whom to Serve Within
					 the Same Priority
If the number of openings is insufficient to serve all
						Members on the waiting list who have been determined, at the time that any
						opening is determined to be available, to be within the same priority group,
						DHHS shall first determine whether each Member continues to meet the financial
						and medical eligibility criteria to be served through this benefit. For those
						who continue to meet such criteria, the DHHS will utilize the most current
						assessment that is entered into the Enterprise Information System (EIS), or
						current database, and submitted by the individual Member, guardian or Case
						Manager. Upon review of information concerning all Members within the same
						priority group who continue to meet financial and medical eligibility criteria
						and for whom current service plans are in place, DHHS shall determine which
						Members to serve. The determination will be based on a comparison of the
						Members' known needs and the comparative degree of abuse, neglect or
						exploitation or risk of abuse, neglect or exploitation that each Member will
						likely experience in the absence of the provision of the benefit.
21.03-8
Waiting List and
					 Offers for Funded Opening
DHHS will maintain a waiting list of eligible MaineCare
						Members who cannot access Home and Community Benefits because a funded opening
						is not available. Members who are on the waiting list for the benefit services
						shall be served in accordance with the priorities identified above. At the time
						a Member is offered a funded opening the Member will be removed from the
						waiting list.
A Member has sixty days from the receipt of notification
						by DHHS of a funded opening to respond with intent to accept waiver services. A
						Member has six (6) months from the receipt of notification to start services.
						If the Member fails to respond to DHHS with intent to accept the funded opening
						within sixty (60) days of this notice or fails to begin services within six (6)
						months, the waiver offer will then be withdrawn. A Member may reapply at any
						time for waiver services.
21.03-9
Redetermination of
					 Eligibility
Every twelve (12) months from the date of initial
						eligibility approval, the Member's Case Manager will submit to OADS: a Current
						Person-Centered Service Plan based on the effective plan date that is less than
						six (6) months old and an updated assessment form (BMS 99) or current
						assessment approved by the Department.
If the updated Assessment Form and Person-Centered
						Service Plan are not received by OADS, by the due date, reimbursement for
						services will be denied until receipt of the assessment form and
						Person-Centered Service Plan. Reimbursement for services will resume upon
						receipt of the Assessment Form and a signed Person-Centered Service Plan.