Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 332 - MAINECARE ELIGIBILITY MANUAL › Part 14 - INDIVIDUALS IN MEDICAL INSTITUTIONS › Section 144-332-14-3 - MEDICAL NEED CLASSIFICATION

Current through 2024-29, July 17, 2024
In order for Medicaid to pay for nursing facility care the
					 person must be in medical need of that level of care. This decision is made by
					 the Department of Health and Human Services or its designee.
Section 3.1:
Individuals ineligible due
				  to a transfer of assets
If the individual meets the medical need criteria but is
					 ineligible for help with long term care costs due to a transfer of assets, the
					 Categorically Needy Income Limit in Chart 4.1 is used to determine Medicaid
					 eligibility.
Section 3.2:
Individuals who are not in need of nursing facility level of care
I. If an individual in a Nursing Facility
				  does not meet the medical need criteria, that person may still be eligible for
				  Medicaid coverage if the individual would be eligible if they were living in
				  the community. Coverage is determined using the rules in Parts 6, 7 and 10 for
				  an individual in the living arrangement, "living alone or with others". In this
				  situation, Medicaid will not pay for nursing care costs nor can they be used
				  toward meeting a deductible.
II.
				  Awaiting Placement for Residential Care (DAP or APRC). If an individual is in
				  need of residential care but there are no beds available the individual may
				  remain in the nursing facility as awaiting placement to a residential care
				  facility. This coverage is for individuals converting from private pay
				  including Medicare to Medicaid and found not in need of nursing facility level
				  of care. MaineCare may help the individual with the cost of care if they meet
				  eligibility criteria below. The Office of MaineCare Services sets the APRC
				  rates (Chart 3.8).
A. The Office of Aging and
				  Disability Services (OADS) must establish that the individual meets
				  non-financial criteria as identified in the
MaineCare Benefits
				  Manual
.
B. The following
				  financial criteria must be met:
1. the asset
				  and all non-financial criteria are the same as for an individual residing in a
				  Residential Care Facility (RCF). See Part 12;
2. countable income is determined using the
				  same rules as for an individual residing in a RCF; and 3. the individual's
				  countable income must be less than the APRC amount. A cost of care to be paid
				  to the nursing facility is determined using the same rules as for an individual
				  in a RCF. SSI and State Supplement benefits are counted when determining the
				  cost of care.
If countable income is equal to or over the APRC amount,
					 the daily rate can be used as the cost incurred for medical expenses in
					 determining a "spend-down" (deductible).
C. If countable income is equal to or less
				  than the Community Medicaid income limit for the individual's coverable group,
				  they can get Medicaid coverage in addition to help with the cost of room and
				  board under APRC.
D. If countable
				  income is over this amount, but less than the APRC amount, the individual is
				  eligible for APRC only (not Medicaid).
E. Coverage under APRC ends when:
1. the Office of Aging and Disability
				  Services (OADS) determines the individual no longer meets the non financial
				  criteria as identified in the
MaineCare Benefits Manual
;
				  or
2. the individual becomes
				  financially ineligible.