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-21.07 - LIMITS

Current through 2024-29, July 17, 2024
21.07-1 MaineCare Members can receive
					 services under only one Home and Community Waiver Benefit at any one time.
21.07-2 Effective January 1, 2021,
					 when the Member receives Community Support services in addition to Work
					 Support-Group and/or Work Support-Individual services, the combined cost of
					 Community Support, Work Support-Individual and Work Support-Group may not
					 exceed $39,875.32 annually.
21.07-3
Home Accessibility Adaptations
are limited to a ten
					 thousand-dollar ($10,000.00) limit in a five (5) year period with an additional
					 annual allowance up to three hundred dollars ($300.00) for repairs and
					 replacement per year. Home Accessibility Adaptions that exceed five hundred
					 dollars ($500) require documentation from a physician or other appropriate
					 professional such as an OT, PT, or Speech Therapist, indicating that the
					 purchase is appropriate to meet the Member's need.
21.07-4
Specialized Medical Equipment
					 and Supplies
are limited to only specialized medical equipment and
					 supplies that cannot be obtained as a covered service under other sections of
					 the
MaineCare Benefits Manual.
. Proof of attempts to obtain
					 requested services under other MaineCare sections may be required for approval.
					 These services are to be considered the property of the Member.
For purchases of Specialized Medical Equipment and
						Supplies costing more than five hundred dollars ($500), the Member must obtain
						documentation from a physician or other appropriate professional such as an
						occupational, physical, or speech therapist assuring that the purchase is
						appropriate to meet the Member's need and is medically necessary.
21.07-5
Communication
					 Aids
costing more than five hundred dollars ($500), the Member must
					 obtain documentation from a licensed speech-language pathologist, Licensed
					 Audiologist or a Certified Assistive Technology Professional (ATP) assuring
					 that the purchase is appropriate to meet the Member's need and assuring the
					 medical necessity of the devices or services. Only Communication Aids that
					 cannot be obtained as a covered service under other sections of the
MaineCare Benefits Manual
will be reimbursed under this
					 Section.
21.07-6
Consultation
					 Services
are limited to those providers not already reimbursed for
					 consultation as part of another service. Personnel who provide services under
					 targeted case management may not be reimbursed for Consultation Services.
					 Consultation is limited to sixty-six (66) units or sixteen and a half (16.5)
					 hours annually, per type of consultation (Occupational Therapy, Physical
					 Therapy, Speech, Behavioral and Psychological).
21.07-7
Non-traditional Communication
					 Consultation
is limited to sixty (60) hours annually.
21.07-8
Crisis Intervention
					 Services
that have not been included on the Person-Centered Service Plan
					 are limited to a period not to exceed two weeks and must be authorized by the
					 DHHS or its Authorized Entity. Crisis Intervention Services may not extend past
					 two (2) weeks without a recommendation from the Member's Person-Centered
					 Service Team and additional approval from DHHS.
21.07-9
Crisis Assessment
					 Services
are limited to one (1) assessment in a three-year (3) period,
					 with a maximum allowance of $2,250.00, and includes all related follow-up
					 activities.
21.07-10
Occupational Therapy (Maintenance)
provided by an Occupational
					 Therapist, Registered, Licensed (OTR/L) is limited to forty-eight (48) quarter
					 hour units per year. Occupational Therapy (Maintenance) provided by an
					 Occupational Therapist Assistant/Licensed (OTA/L) is limited to forty (40)
					 quarter hour units per year. When a OTA/L is providing Occupational Therapy
					 (Maintenance), it must be under the supervision of an OTR.
21.07-11
Enrollment in High School
A Member may not receive Community Support while enrolled in high
					 school.
21.07-12
Place of
					 Employment
A Member may not receive Community Support or Home Support at
					 his or her place of employment.
21.07-13
Family-Centered Support
					 Providers
No additional Family-Centered Support providers will be
					 approved and enrolled after 12/20/2007.
21.07-14
Nursing Facility or Hospital
If a Member enters a nursing facility or a hospital, payment under
					 Section
					 21 will be temporarily suspended.
					 If the Member remains in the nursing facility or hospital for more than thirty
					 (30) consecutive days, enrollment in this waiver will be terminated unless
					 there is a written request to DHHS to continue holding the funded opening.
After six (6) continuous months in a nursing facility or
						hospital, if the Member does not resume services, the Member will be terminated
						from the waiver.
21.07-15
Work Support-Individual
services are limited to one DSP per Member
					 at a time.
21.07-16
Home
					 Support- Agency Per Diem
as of December 24, 2012, Home Support- Agency
					 Per Diem placements will only be approved at provider controlled homes where a
					 minimum of two (2) Members reside.
21.07-17
Home Support Quarter Hour
may not exceed three hundred and thirty-six (336) quarter hour units or
					 eighty-four (84) hours a week. Units of service that were not provided to a
					 Member in any week cannot be carried over into subsequent weeks.
21.07-18
Out of State Services
Authorizations for services to be provided out of state will not exceed sixty
					 (60) days of service within a given fiscal year and not exceed sixty (60) days
					 within any six (6) month period except as provided in
					 42 C.F.R. §
												431.52(b).
21.07-19
Annual MaineCare
					 Expenditures
for services under this waiver for an individual Member are
					 limited to two hundred percent (200%) of the state-wide average annual cost of
					 care for an individual in an Intermediate Care Facility for Individuals with
					 Intellectual Disabilities (ICF/IID), as determined by DHHS.
21.07-20
Assistive Technology
					 Services
are not covered under this rule if they are available under
					 another MaineCare rule.
The components above are subject to the following
						limits:
1. Assistive Technology-
					 Assessments are subject to a limit of 32 units, per state fiscal
					 year.
2. Assistive Technology-
					 Devices and services are subject to a combined limit $6,000 annually, per state
					 fiscal year.
3. Assistive
					 Technology- Transmission (Utility Services) are limited to $50.00 per
					 month.