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-12 - Consumer Directed Attendant Services › Subsection 144-101-II-12.03 - ELIGIBILITY FOR SERVICES

Current through 2024-29, July 17, 2024
12.03-1
Determination of Eligibility
A.
					 Members must meet the financial eligibility criteria as set forth in the
MaineCare Eligibility Manual
. Some members may have
					 restrictions on the type and amount of services they are eligible to receive.
					 It is the responsibility of the provider to verify a member's eligibility for
					 MaineCare prior to providing services, as described in
MaineCare
					 Benefits Manual
(MBM) Chapter I;
B. Applicants for services under this Section
					 must meet the eligibility requirements as set forth in this Section and as
					 documented on the Medical Eligibility Determination form. A member meets the
					 medical eligibility requirements if he or she requires a combination of
					 assistance with the required activities of daily living, as defined in Section
					 12.03-1(D) and as set forth elsewhere in this Section. The clinical judgment of
					 the Department's ASA is the basis of the scores entered on the Medical
					 Eligibility Determination form. The clinical judgment of the Department's ASA
					 is determinative of the scores on the medical eligibility determination
					 assessment;
C. The member must have
					 a disability with functional impairments, which interfere with his/her own
					 capacity to provide self-care and daily living skills without assistance. The
					 member's disability must be permanent or chronic in nature as verified by the
					 member's physician.
D. A registered
					 nurse trained in conducting assessments with the Department's approved MED form
					 must conduct the medical eligibility assessment. The assessor must, as
					 appropriate within the practice of professional nursing judgment, consider
					 documentation, perform observations, and conduct interviews with the
					 applicant/member, family members, direct care staff, the applicant's/member's
					 physicians, and other individuals and document in the record of the assessment
					 all information considered relevant in his or her professional judgment. The
					 following levels of eligibility are determined at assessment:
Level I
A member meets the medical
						eligibility requirements for Level I if he or she requires at least limited
						assistance plus a one person physical assist with at least two (2 ) of the
						following ADLs: bed mobility, transfer, locomotion, eating, toilet use,
						dressing, and bathing.
Level II
A member meets the medical
						eligibility requirements for Level II if he or she requires at least limited
						assistance and a one person physical assist with at least three (3) of the
						following ADLs: bed mobility, transfer, locomotion, eating, toilet use,
						dressing, and bathing.
Level III
A member meets the medical
						eligibility requirements for Level III if he or she requires at least extensive
						assistance and a one person physical assist with two (2) of the following five
						ADLs: bed mobility, transfer, locomotion, eating, or toileting; and limited
						assistance and a one person physical assist with two (2) of the following
						additional ADLS: bed mobility, transfer, locomotion, eating, toilet use,
						dressing, and bathing.
E.
					 The member must agree to complete initial member instruction and testing within
					 thirty (30) days of completion of the MED form to determine medical eligibility
					 in order to develop and verify that he or she has attained the skills needed to
					 hire, train, schedule, discharge, and supervise attendants and document the
					 provision of personal care services identified in the authorized plan of care.
					 Members who do not complete the course of instruction or do not demonstrate to
					 the Service Coordination Agency that they have attained the skills needed to
					 self-direct are not eligible for services under this Section;
F. The member must not be residing in a
					 hospital, nursing facility, or Intermediate Care Facility for the Individuals
					 with Intellectual Disabilities (ICF-IID) as an inpatient;
G. The member must not reside in an Adult
					 Family Care Home(as defined in
MaineCare Benefits Manual
,
					 Chapters II and III, Section 2,) or other residential setting including a
					 Private Non-Medical Institution (MBM, Chapters II and III, Section
					 97 ), sometimes referred to as a
					 residential care facility or supported living, regardless of payment source,
					 (i.e. private or MaineCare);
H. The
					 member must not be receiving personal care services under Private Duty
					 Nursing/Personal Care Services, Section
					 96, or be receiving any In-home
					 Community and Support Services for Elderly and Other Adults, Section 63, or
					 participating in other MaineCare programs where personal care services are a
					 covered service.
I. The member must
					 have the cognitive capacity, as measured on the MED form to be able to
					 "self-direct" the attendant. The ASA will assess cognitive capacity as part of
					 each member's eligibility determination using the MED findings. The Service
					 Coordination Agency will assess cognitive capacity as part of consumer
					 instruction. Minimum MED form scores are:
(a)
					 decision making skills: a score of 0 or 1;
(b) making self understood: a score of 0, 1,
					 or 2;
(c) ability to understand
					 others: a score of 0, 1, or 2;
(d)
					 self performance of managing finances: a score of 0, 1, or 2; and
(e) support for managing finances, a score of
					 0, 1, 2, or 3.
An applicant not meeting the specific scores above during
						his or her eligibility determination will be presumed not able to self-direct
						and ineligible for benefits under this Section.
J. Applicants who meet these eligibility
					 criteria for personal care attendant services shall:
i. Receive an authorized plan of care based
					 upon the scores, timeframes, findings and covered services recorded in the MED
					 assessment. The covered services to be provided in accordance with the
					 authorized plan of care must not exceed the established limits and must be
					 authorized by the Department or its ASA;
ii. The ASA must approve an eligibility
					 period for the Member, based upon the scores, timeframes and needs identified
					 in the MED assessment for the covered services, and the assessor's clinical
					 judgment. An eligibility period cannot exceed twelve (12) months;
iii. The ASA forwards the completed
					 assessment packet to the Service Coordination Agency of the Member's choice
					 within three (3) business days of the medical eligibility determination and
					 authorization of the plan of care;
iv. The Service Coordination Agency must
					 contact the Member within twenty-four (24) hours of receipt of the MED
					 assessment and authorized plan of care. The Service Coordination Agency must
					 implement skills training and coordinate services with the Member as well as
					 monitor service utilization and assure compliance with this policy;
					 and
v. The Service Coordination
					 Agency will complete the service plan and initiate skills instruction within
					 thirty (30) days of the medical eligibility assessment date. The Service
					 Coordination Agency will notify the Department, using the transmittal form
					 approved by the Department, when the Member has successfully completed this
					 requirement and an attendant has been hired. Provision of attendant services
					 can begin only after the Department is notified that the Member has
					 successfully completed this training and the service plan has been
					 received.