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-29.03 - 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 member must require Intermediate Care Facility for Individuals with
					 Intellectual Disabilities (ICF/IID) level of care as set forth under the
MaineCare Benefits Manual
, Chapter II, Section 50. 2) the
					 member must have eligibility for MaineCare as determined by the DHHS Office for
					 Family Independence (OFI), and 3) a funded opening is available.
29.03-1
Funded Opening-
The
					 number of MaineCare members that can receive services under this Section is
					 limited to the number, or "funded openings," approved by the Centers for
					 Medicare and Medicaid Services (CMS) and the appropriation of sufficient
					 funding by the Maine Legislature. 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 or if there is not sufficient funding.
29.03-2
General Eligibility
					 Criteria
Consistent with Subsection 29.03-1, 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 or Autism Spectrum Disorder or Rett Syndrome; 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 fifty percent (50%) of the state-wide average annual cost of care for
					 an individual in an ICF/IID, as determined by the DHHS.
29.03-3
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
					 (BMS99) or current functional assessment approved by the DHHS and
B. A copy of the member's Personal Plan
					 approved and signed by the member or guardian and the case manager within the
					 preceding six months of the effective plan date and any other relevant material
					 indicating the member's service needs.
Based on review of the Assessment Form, the Personal
						Plan, a QID 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 medically 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.
29.03-4
Calculating the Estimated
					 Annual Cost
Prior to formal determination of eligibility for services
						under this section, each applicant and their planning team must identify the
						required mix of services to meet the applicant's needs and to assure their
						health and welfare. The applicant and their planning team shall submit a
						detailed estimate of the annual cost for waiver services identified in the
						Personal Plan, including the specific services and the number of units for each
						service.
29.03-5
Waiting List and Offers for Funded Openings
DHHS will maintain a waiting list of eligible MaineCare
						members who cannot get access to Section
						29 Services because a funded
						opening is not available. Members who are on the waiting list for the benefit
						services shall be served chronologically based on the date the Designated
						Representative determines eligibility for the waiver. At the time when 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 to DHHS with intent to accept waiver
						services. A member has six months from the receipt of notification to start
						receipt of services. If the member fails to respond with intent to accept the
						funded opening within 60 days of this notice or fails to begin services within
						6 months, the waiver offer will then be withdrawn. A member may reapply at any
						time for waiver services.
29.03-6
Redetermination of
					 Eligibility
When making a determination of continuing eligibility,
						every 12 months from the date of initial approval and every 12 months
						thereafter, the member's case manager will submit to OADS a current Personal
						Plan that is less than six (6) months old, and an updated Assessment Form (BMS
						99) or current functional assessment approved by the Department.
If the updated Assessment Form and Personal Plan are not
						received by OADS by the due date, reimbursement for services will be denied
						until receipt of the assessment form and Personal Plan. Reimbursement for
						services will resume upon receipt of the Assessment Form and a signed Personal
						Plan.