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-19.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
MaineCare coverage of services under this Section
						requires prior approval from the Department, or its Assessing Services Agency.
						Beginning and end dates of a member's medical eligibility period correspond to
						the beginning and end dates for MaineCare coverage of the services in the
						Authorized Plan of Care. The Department reserves the right to request
						additional information to evaluate medical necessity. Coverage will be denied
						if the services provided are not included in the Authorized Plan of Care,
						except as allowed for an acute/emergency episode as described in Section
						19.04-4(A)(13).
19.03-1 Home and
					 Community Benefits (HCB)may be reduced, denied, suspended or terminated under
					 the following circumstances; only the Department may terminate HCB:
A. The member does not meet the eligibility
					 requirements of Section
					 19.02;
B. The member declines personal care,
					 Attendant or nursing services;
C.
					 An Authorized Plan of Care to maintain or delay significant deterioration in
					 the health and welfare of the member at home, or in the community, can no
					 longer be developed and implemented;
D. The member receives services under Chapter
					 II, Section
					 96, "Private Duty Nursing and
					 Personal Support Services"; Chapter II, Section
					 12, "Consumer-Directed Attendant
					 Services"; or Section
					 40, "Home Health Services". Only
					 Care Coordination Services may be provided under this Section to a member who
					 receives services under Chapter II, Section
					 96, "Private Duty Nursing and
					 Personal Support Services"; Section
					 40, "Home Health Services"; or
					 Chapter II, Section
					 12, "Consumer-Directed Attendant
					 Services", until HCB are in place for the member and a transition can be
					 made;
E. The member does not meet
					 the medical eligibility criteria for nursing facility level services as set
					 forth in Chapter II, Section
					 67.02 of this Manual,
					 as determined by the Assessing Services Agency;
F. The member is accessing another waiver
					 pursuant to Title XIX, § 1915(c) of the
Social Security
					 Act
, including any of the following Sections: Section
					 18, Home and Community Based
					 Services for Adults with Brain Injury; Section
					 20, Home and Community Based
					 Services for Adults with Other Related Conditions; Section
					 21, Home and Community Benefits
					 for Members with Intellectual Disabilities or Autism Spectrum Disorder; and
					 Section
					 29, Support Services for Adults
					 with Intellectual Disabilities or Autism Spectrum Disorder;
G. The member is not financially eligible to
					 receive MaineCare benefits;
H. The
					 member does not comply with the Authorized Plan of Care for services;
I. When the member's most recent MED
					 assessment, and the clinical judgment of the ASA, determines that the
					 Authorized Plan of Care must be changed or reduced to match the member's needs
					 as identified in the reassessment and subject to the limitations of the cap.
					 Even though the member's medical eligibility for HCB may not be affected, the
					 Authorized Plan of Care may be modified by the ASA to reflect the change in
					 needs or any change in policy that affects all members;
J. The member becomes an inpatient of a
					 hospital, a resident of a nursing facility (NF), or resident of an Intermediate
					 Care Facility for Individuals with Intellectual Disabilities
					 (ICF-IID);
K. The member becomes a
					 resident in an assisted living setting or in an Adult Family Care Home (as
					 defined in the MBM, Chapter II, Section 2 ) or other residential care setting
					 including a private non-medical institution (as defined in the MBM, Chapter II,
					 Section
					 97 ), sometimes referred to as a
					 residential care facility or supported living, regardless of payment source
					 (i.e. private or MaineCare).
L. The
					 cost of services exceeds the program cap and limits set forth in the
					 Section;
M. The member has provided
					 fraudulent or repeatedly inaccurate information in connection with eligibility
					 or services;
N. The
					 federally-approved Waiver under which these rules were promulgated terminates,
					 expires or a future amendment is not approved;
O. The Department, the SCA or the ASA
					 documents that the member, or other person living in or visiting the member's
					 residence, harasses, threatens or endangers the safety of individuals
					 delivering services or the health and safety of individuals providing services
					 is otherwise endangered; or
P. The
					 member does not permit the ASA, SCA or Direct Care Provider access to
					 information from the member's physician or access to other health information
					 necessary to meeting the needs of the member.