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-19 - Home and Community Benefits for the Elderly and Adults with Disabilities › Subsection 144-101-II-19.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
19.01-1
Activities of Daily
					 Living
(ADLs) are basic activities of self-care performed by individuals
					 on a daily or frequent basis necessary for independent living and may include
					 activities such as: bed mobility, transfer, locomotion, eating, toilet use,
					 bathing, and dressing. The specific ADL requirements for eligibility and
					 covered services are set forth elsewhere in this section.
19.01-2
Acute/Emergency Episode
is the unforeseen occurrence of an acute health episode that requires a change
					 in the member's Authorized Plan of Care, or the unforeseen circumstance where
					 the availability of the member's caregiver or informal support system is
					 compromised.
19.01-3
Assessing Services Agency (ASA)
is an Authorized Entity providing
					 services to the Department for medical eligibility determinations, Authorized
					 Plan of Care development and prior authorization of covered services under this
					 Section. The assessor at the ASA conducts face-to-face assessments, using the
					 Department's Medical Eligibility Determination (MED) form. A member's medical
					 eligibility is based upon a member's assessment outcome. If medical eligibility
					 is determined for this Section, the ASA develops the Authorized Plan of Care
					 with the member and specifies all services to be provided under this Section,
					 including type of services and number of hours for all provider
					 types.
19.01-4
Attendant
is an individual who meets the qualifications required
					 in Section 19.08-7(B)(5). The Attendant provides services specified in the
					 Authorized Plan of Care to a member utilizing the Participant-Directed
					 Option.
19.01-5
Authorized
					 Entity
is an independent entity providing services to the Department to
					 perform specified functions under a valid contract or other approved signed
					 agreement.
19.01-6
Authorized
					 Plan of Care
is authorized by the Assessing Services Agency, or the
					 Department, and which specifies all services to be delivered to a member under
					 this Section, including the number of hours for each covered service, and the
					 provider type to deliver each service. The Authorized Plan of Care shall be
					 based upon the member's assessment outcome scores recorded in the Department's
					 MED form, utilizing the time frames contained therein, and the professional
					 clinical judgment of the assessor.
The Authorized Plan of Care shall reflect the needs
						identified by the assessment, considering the member's goals, preferences,
						living arrangement, informal caregiving supports provided by family and
						friends, and services provided by other public and private funding sources.
						MaineCare shall not cover any service under this benefit that duplicates
						another service, regardless of payor or provider, including services such as
						Medicare and MaineCare hospice services, Private Non-Medical Institution (PNMI)
						services, and assisted housing services (see
						22 M.R.S.
						§7852 ).
19.01-7
Back Up Plan
is a part
					 of the service plan that addresses contingencies such as emergencies, including
					 the failure of a worker to appear as scheduled, when the absence of the service
					 presents a risk to the member's health and welfare.
19.01-8
Budget Authority
provides those members utilizing the Participant-Directed Option, the authority
					 to determine their Attendant's wages within the service cap.
19.01-9
Choice Letter
is a
					 document signed by the member or legal agent of the member indicating the
					 member's decision to select either Home and Community Benefits or institutional
					 services.
19.01-10
Cognitive
					 Capacity
is the mental function of knowing, including aspects of
					 awareness, perception, reasoning, and judgment, assessed for purposes of
					 determining a member's ability to self-direct his or her care.
19.01-11
Cueing
is any spoken
					 instruction or physical guidance that serves as a signal to do something.
					 Cueing is typically used when caring for members who are cognitively
					 impaired.
19.01-12
Direct
					 Care Provider
is a MaineCare provider that directly provides Personal
					 Care, Home Health or in-home Respite services under this Section.
19.01-13
Extensive Assistance
means although the individual performed part of the activity over the last
					 seven (7) days, or twenty-four (24) to forty-eight (48) hours if in a hospital
					 setting, help of the following type(s) was provided: 
					 
												Weight-bearing support three (3) or more times,
						  or
												Full staff performance of activity (three (3) or
						  more times) during part (but not all) of the last seven (7) days.
19.01-14
Extraordinary Care
means care exceeding the range of activities that a spouse would ordinarily
					 perform in the household on behalf of a person without a disability or chronic
					 illness of the same age, and which are necessary to assure the health and
					 welfare of the member and avoid institutionalization.
19.01-15
Fiscal Intermediary
is
					 a provider of Financial Management Services on behalf of members utilizing
					 Attendants through the Participant-Directed Option. The Fiscal Intermediary's
					 responsibilities include, but are not limited to, preparing payroll and
					 withholding taxes, making payments for Attendant services and ensuring
					 compliance with State and Federal tax and labor regulations and the
					 requirements under this Section. The Fiscal Intermediary acts as an agent of
					 the employer (i.e., the member or the member's Representative) in accordance
					 with Federal Internal Revenue Service codes and procedures.
19.01-16
Health and Welfare Tool
is an evaluation completed by the Service Coordination Agency to assess risks
					 and unmet needs of members as required by the Department.
19.01-17
Health Maintenance
					 Activities
assist the member with Activities of Daily Living and
					 Instrumental Activities of Daily Living, and additional activities specified in
					 this definition. These activities are performed by a designated caregiver for
					 an individual who would otherwise perform the activities if he or she were
					 physically or cognitively able to do so, and enable the member to live in his
					 or her home and community. These additional activities include, but are not
					 limited to catheterization, ostomy care, preparation of food and tube feedings,
					 bowel treatments, administration of medications, care of skin with damaged
					 integrity, and occupational and physical therapy activities such as assistance
					 with prescribed exercise regimes.
19.01-18
Instrumental Activities of
					 Daily Living
(IADLs) are tasks necessary for maintaining a member's
					 immediate environment, such as preparing and serving meals, washing dishes,
					 dusting, making bed, pick-up living space, sweeping, vacuuming and washing
					 floors, cleaning toilet, tub and sink, appliance care, changing linens, refuse
					 removal, shopping for groceries and prepared foods, storage of purchased
					 groceries, and laundry, either within the residence or at an outside laundry
					 facility. The specific IADL requirements for eligibility and covered services
					 are set forth elsewhere in this Section.
19.01-19
Limited Assistance
is a
					 term used to describe an individual's self-care performance in Activities of
					 Daily Living, as defined by the Minimum Data Set (MDS) assessment process. It
					 means that although the individual was highly involved in the activity over the
					 last seven (7) days, or twenty-four (24) to forty-eight (48) hours if in a
					 hospital setting, help of the following type(s) was provided: 
					 
												physical help in guided maneuvering of limbs or
						  other non-weight-bearing assistance three (3) or more times, or
												Limited Assistance three (3) or more times, plus
						  more help with weight-bearing support provided only one (1) or two (2)
						  times.
19.01-20
MeCare
is a
					 computerized long-term care medical eligibility system facilitating the entire
					 medical assessment and service authorization process, from intake through
					 information dissemination.
19.01-21
Medical Eligibility
					 Determination (MED) Form
is the Department's approved form for
					 determining a member's medical eligibility for services under this Section. The
					 MED form's definitions, scoring mechanisms and time frames provide the basis
					 for including services in the Authorized Plan of Care. The Department, or the
					 ASA, shall conduct the MED assessment on a face-to-face basis. Based upon the
					 member's outcome scores, an Authorized Plan of Care is then developed, which
					 specifies the services, numbers of hours, and provider types. The Care Plan
					 Summary section of the MED form documents the Authorized Plan of Care, and
					 identifies any other non-HCB services the member may be receiving, regardless
					 of payor.
19.01-22
Member
is an individual who meets the eligibility requirements of
					 this Section and is authorized to receive services. A member may be represented
					 by his or her "guardian," "agent," or "surrogate," as these terms are defined
					 in 18-A M.R.S. §5 - 801, or by a Representative as defined in this
					 Section.
19.01-23
One-Person
					 Physical Assist
requires one (1) person to provide either weight-bearing
					 or non-weight-bearing assistance for an individual who cannot perform the
					 activity independently over the last seven (7) days, or twenty-four (24) to
					 forty-eight (48) hours if in a hospital setting. This does not include
					 Cueing.
19.01-24
Participant-Directed Option
is a choice offered to members to
					 manage their Attendant Services. Specifically, the member hires, discharges,
					 trains, schedules and supervises the Attendant(s) providing services. A member
					 who chooses to engage in the Participant-Directed Option is considered the
					 employer of his or her Attendant(s).
19.01-25
Participant-Directed
					 Rate
is the reimbursement for Attendant Services under the Participant
					 Directed-Option which consists of two components: the Attendant provider wage
					 and the employer expense component:
(1)
					 Attendant portion of the rate that is designated as the Attendant's gross
					 hourly wage for authorized care provided;
(2) Participant-Directed Option expense
					 component that is the portion of the participant-directed Attendant rate for
					 any mandated employer's share of social security, federal and state
					 unemployment taxes, Medicare, and worker's compensation insurance
					 premiums.