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-96.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each Title XIX and XXI Member may receive as many covered
						services as are medically necessary within the following limitations and
						exceptions as described below. MaineCare coverage of services under this
						Section requires prior approval from the Department or its Assessing Services
						Agency. Beginning and end dates of an individual's medical eligibility
						determination period correspond to the beginning and end dates for MaineCare
						coverage of the plan of care approved by the ASA or the Department.
A.
Exception to the Limit
: For
					 all individuals under the age of 21 years, the caps described in Sections
					 96.03(B), (C) and
					 (D), may be exceeded if services beyond these
					 levels are determined medically necessary pursuant to the criteria described in
					 "Prevention, Health Promotion and Optional Treatment Services", formerly EPSDT,
					 of the
MaineCare Benefits Manual
. A determination of medical
					 necessity for PDN/PCS shall not be determinative of medical necessity under
					 "Prevention, Health Promotion and Optional Treatment Services". These
					 additional services require prior authorization by the Department as described
					 in Chapter I, Section 1, "General Administrative Policies and Procedures" and
					 Chapter II, Section
					 94, "Prevention, Health Promotion,
					 and Optional Treatment Services".
Limits (when applicable) for individuals under age 21
						years shall be based upon a yearly cap to better serve children who have
						episodic service needs.
B.
					 Except as described in (A) above, for individuals classified for Levels of care
					 I, II, III, VIII, or IX, the total monthly cost of covered private duty
					 nursing, and personal care services, either alone or in combination with home
					 health services provided under Chapters II & III, Section
					 40 of the
MaineCare
					 Benefits Manual
, may not exceed the monthly Level I, II, III, VIII and
					 IX caps established by the Department and the plan of care authorized by the
					 ASA on the MED form. The amount of services an individual Member is authorized
					 to receive is based upon the Member's MED assessment outcome scores. The Level
					 I, II, III, VIII and IX caps are tied to allowing coverage for a range of
					 services to meet the medical and excluding Level VIII, personal care service
					 needs of each level.
C. Except as
					 described in (A) above, for individuals classified for Level IV of care, the
					 total cost of private duty nursing and personal care services, either alone or
					 in combination with home health services provided under Chapters II & III,
					 Section
					 40 of the
MaineCare
					 Benefits Manual
, may not exceed 100% of the average MaineCare annual
					 cost of NF institutional services.
D. Except as described in (A) above, for all
					 individuals who are determined medically eligible for Level V care, the total
					 monthly cost of private duty nursing and personal care services, either alone
					 or in combination with home health services provided under Chapters II &
					 III, Section
					 40 of the
MaineCare
					 Benefits Manual
, may not exceed the monthly Level V cap established by
					 the Department. The Department reserves the right to request additional
					 information to evaluate medical necessity.
E. Members who are receiving any of the
					 following MaineCare services may only access nursing services under this
					 Section, and are prohibited from receiving duplicative personal care services
					 under this Section, since personal care services are provided under these
					 Sections: Section 2, "Adult Family Care Services"; Section
					 12, "Consumer Directed Attendant
					 Care Services"; Section
					 97, "Private Non-Medical
					 Institution Services"; Section
					 18, "Home and Community-Based
					 Services for Adults with Brain Injury", Section
					 19, "Home and Community-Based
					 Services for Elders and Adults with Disabilities", Section
					 20, "Home and Community-Based
					 Services for Adults with Other Related Conditions", Section
					 21, "Home and Community-Based
					 Waiver Services for Members with Intellectual Disabilities or Autism Spectrum
					 Disorder", and Section
					 29, "Support Services for Adults
					 with Intellectual Disabilities or Autism Spectrum Disorder."
F. Services under this Section may be denied,
					 reduced, suspended, or terminated by the Department, its Authorized Entity, or
					 the PDN provider, as appropriate, for the following reasons:
1. A significant change occurs in the
					 Member's medical status such that an authorized plan of care under this Section
					 can no longer be developed; or
2.
					 The Member becomes an inpatient of a hospital, nursing facility, ICF-IID;
					 or
3. The Member is not medically
					 eligible to receive services under this Section or financially eligible to
					 receive Title XIX or XXI benefits; or
4. Based upon the most recent MED assessment,
					 the plan of care service authorization may be reduced to match the Member's
					 needs as identified in the reassessment and subject to the limitations of the
					 service cap, as follows:
a. for Members age
					 21 and over, and those under age 21 receiving care under the family provider
					 services option, and excluding those classified for medication services or
					 venipuncture services under this Section according to the clinical judgment of
					 the Department, the ASA or Service Coordination Agency;
b. for Members under age 21, as well as those
					 classified for medication services or venipuncture services under this Section,
					 by the Department or the PDN provider; but excluding those receiving care under
					 the family provider services option; or
5. The Member declines services; or
6. The Member refuses personal care or
					 nursing services; or
7. The
					 Department, ASA, or the provider documents that the Member, or someone living
					 in or frequently visiting the household, harasses, threatens, or endangers the
					 health or safety of individuals delivering services; or
8. The Member begins receiving any of the
					 following MaineCare services: Section 2, "Adult Family Care Services"; Section
					 12, "Consumer Directed Attendant
					 Care Services"; Section
					 18, "Home and Community-Based
					 Services for Adults with Brain Injury"; Section
					 19, "Home and Community Benefits
					 for Elderly and Adults with Disabilities"; Section
					 20, "Home and Community-Based
					 Services for Adults with Other Related Conditions"; Section
					 97, "Private Non-Medical
					 Institution Services"; Section
					 21, "Home and Community-Based
					 Waiver Services for Members with Intellectual Disabilities or Autism Spectrum
					 Disorder"; and Section
					 29, "Support Services for Adults
					 with Intellectual Disabilities or Autism Spectrum Disorder", in which case the
					 personal care services are not covered under this Section.