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-67 - Nursing Facility Services › Subsection 144-101-II-67.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
67.02-1
General and Specific Requirements
MaineCare coverage of NF services requires prior approval
						from the Department or its Authorized Entity. NF services are covered for an
						approved eligibility period for each MaineCare member. Beginning and end dates
						of the individual's eligibility period correspond to beginning and end dates
						for MaineCare reimbursement. MaineCare coverage shall end on the eligibility
						end date unless a new eligibility period has been authorized. A person is
						eligible to receive covered services if he or she meets: general MaineCare
						financial eligibility requirements and other eligibility requirements set forth
						in the MaineCare Eligibility Manual, medical eligibility requirements, as set
						forth in Section 67.02-3 and as documented on the MED form completed by the
						Department or its Authorized Entity, and other specific requirements for NF
						services.
67.02-2
General Requirements
. A person must meet the MaineCare financial
					 eligibility requirements and other eligibility requirements set forth in the
					 MaineCare Eligibility Manual, as determined by the Office of Integrated Access
					 and Support.
67.02-3
Medical
					 Requirements
In order to receive services under this Section
						applicants must meet the eligibility requirements as set forth in this Section
						and as documented on the MED form. An applicant for services or a resident
						under this Section meets the medical eligibility requirements for admission to
						a nursing facility if he or she requires the services specified in 67.02-3(A)
						OR (B) OR (C), as determined or otherwise verified by the Department or its
						Authorized Entity and documented on the approved MED form. The timeframes used
						to determine medical eligibility are incorporated in the MED form. If an
						applicant or member is placed in a NF facility out of state, then the MED form
						that is completed by the Department or its Authorized Entity must be submitted
						as part of the out of state prior authorization process that is described in
						Chapter I, Section 1.14-2 of the MBM.
A. A person meets the medical eligibility
					 requirements for NF services if he or she needs at least one (1) of the
					 following services seven (7) days per week (unless otherwise specified) that
					 are or otherwise would be performed by or under the supervision of a registered
					 professional nurse:
1. intraarterial,
					 intravenous, intramuscular, or subcutaneous injection, or intravenous feeding,
					 all for treatment of unstable conditions requiring medical or nursing
					 intervention. Daily insulin injections for an individual whose diabetes is
					 under control do not meet the requirements of this Section;
2. nasogastric tube, gastrostomy, or
					 jejunostomy feeding, for a new/recent (within past thirty (30) days) or
					 unstable condition;
3.
					 nasopharyngeal suctioning or tracheostomy care; however, care of a tracheostomy
					 tube must be for a recent or unstable condition;
4. treatment and/or application of dressings
					 when the physician has prescribed irrigation, the application of prescribed
					 medication, or sterile dressings of stage III and IV decubitus ulcers, other
					 widespread skin disorders (except psoriasis and eczema), or care of wounds,
					 when the skills of a registered nurse are needed to provide safe and effective
					 services (including, but not limited to, ulcers, second or third degree burns,
					 open surgical sites, fistulas, 5. administration of oxygen on a regular and
					 continuing basis when the person's medical condition warrants professional
					 nursing observation, for a new or recent (within past thirty (30) days)
					 condition;
5. administration of
					 oxygen on a regular and continuing basis when the person's medical condition
					 warrants professional nursing observation, for a new or recent (within past
					 thirty (30) days) condition;
6.
					 professional nursing assessment, observation and management of an unstable
					 medical condition (observation must, however, be needed at least once per shift
					 throughout the twenty-four (24) hours);
7. insertion and maintenance of a urethral or
					 suprapubic catheter as an adjunct to the active treatment of a disease or
					 medical condition may justify a need for skilled nursing care.
In such instances, the need for a catheter must be
						documented and justified in the person's medical record;
8. physical, speech/language, occupational,
					 or respiratory therapy provided at least five (5) days per week as part of a
					 planned program that is designed, established by, and provided by, and requires
					 the professional skills of, a licensed or registered therapist. (Therapy
					 services may be delivered by a qualified licensed or certified therapy
					 assistant under the direction of a qualified professional therapist.) The
					 findings of an initial evaluation and periodic reassessments must be documented
					 in the person's medical record. Skilled therapeutic services must be ordered by
					 a physician and be designed to achieve specific goals within a given time
					 frame. With the exception of speech/language criteria outlined under 67.05-13
					 (E), maintenance or preventative therapy does not meet the requirements of this
					 Section. A Continuous Positive Airway Pressure (CPAP) or Bilevel Positive
					 Airway Pressure (BIPAP) system or the wearing of an airway clearance system
					 vest does not meet the requirements of this Section;
9. services to manage a comatose
					 condition;
10. care to manage
					 conditions requiring a ventilator/ respirator at least three (3) days per
					 week;
11. direct assistance from
					 others is required for the safe management of an uncontrolled seizure disorder,
					 (i.e.: grandmal) at least weekly; or
12. extensive assistance or total dependence
					 with three (3) of the following five (5) activities of daily living:
(a) bed mobility;
(b) transfer;
(c) locomotion;
(d) eating; and
(e) toilet use (refer to 67.02-3(B)(2)
					 below).