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-19 - Home and Community Benefits for the Elderly and Adults with Disabilities › Subsection 144-101-II-19.07 - GENERAL ELIGIBILITY PROCEDURES

Current through 2024-29, July 17, 2024
The procedure for determining eligibility, in accordance
						with the criteria outlined in §
											19.02 above, for Home
						and Community Benefits (HCB) is as follows:
A.
Medical eligibility
: A complete, standardized
					 referral, or verbal/written request by the member, or designated
					 representative, for a medical eligibility assessment shall be submitted to the
					 Department or the Assessing Services Agency (ASA). The ASA shall conduct a
					 medical eligibility assessment within five (5) business days of receipt of a
					 request, except when the member is receiving acute level of care services. In
					 such cases, the assessment is delayed until twenty-four (24) hours before
					 discharge, or when continued acute level services are denied.
The Department or its Authorized Entity shall conduct a
						face-to-face medical eligibility assessment at the member's residence using the
						Medical Eligibility Determination (MED) assessment form. The individual
						conducting the assessment shall be a registered nurse and shall be trained in
						conducting assessments and developing an Authorized Plan of Care using the
						Department's approved tool. The RN assessor's findings and scores recorded in
						the MED form shall be determinative in establishing eligibility for services
						and the Authorized Plan of Care. Applicants who meet the eligibility criteria
						set forth in Section
						19.02, or their
						guardian, agent or surrogate as appropriate, shall receive an Authorized Plan
						of Care based upon the scores, time frames and findings recorded in the MED
						assessment and level of care for which they are eligible. The covered services
						to be provided in accordance with the Authorized Plan of Care shall:
1) not exceed the established financial caps;
2) be subject to prior approval by
					 the Department or the ASA; and
3)
					 the nursing or therapy treatment plan shall be under the direction of the
					 member's physician, when applicable.
The ASA shall be responsible to:
1.  Offer the applicant at the time of
					 assessment a choice of available Service Coordination Agencies from the list of
					 enrolled MaineCare providers for this service.
2.  Inform the applicant (guardian, agent, or
					 surrogate) of the options stated in the Choice Letter. The applicant (guardian,
					 agent, or surrogate) will need to indicate his or her choice of either Nursing
					 Facility Services or HCB on the Choice Letter and state his or her wish to
					 initiate services by signing the Choice Letter. The Choice Letter must be
					 signed annually.
3.  If the
					 applicant or member chooses nursing facility care, the individual shall be
					 placed in accordance with existing placement procedures as set forth in this
					 Manual, Chapter II, Section 67. In the event a nursing facility bed is not
					 available, the member may choose HCB within ninety (90) days of the assessment
					 date unless otherwise specified in the assessment. A new Choice Letter must be
					 signed.
4.  If the financial
					 eligibility process has not been initiated, the ASA assessor will provide an
					 application for financial eligibility determination and refer the applicant to
					 the Office for Family Independence (OFI).
5.
					  The ASA assessor shall approve an initial eligibility period for
					 up to one (1) year, based upon the scores and needs identified in the MED
					 assessment. A shorter eligibility period may be authorized for an individual
					 member when supported by documented clinical judgment of the assessor.
6.  Based on the member's needs
					 and preferences, the ASA assessor shall discuss alternative home and community
					 resources available to the member.
7.
					  The ASA shall forward the completed MED form to the Department's
					 Service Coordination Agency (SCA)of choice within three business days of its
					 completion.
8.  When the member is
					 placed on a wait list under this Section, the ASA will discuss other funding
					 service options during the assessment process. The ASA will initiate any
					 necessary referrals on the member's behalf to access home care options. The
					 member will be informed that his or her name has been referred to the HCB wait
					 list, when applicable.