Subsection 144-101-II-17.02 - ELIGIBILITY FOR CARE17.02-1Requirements for Eligibility. A person is eligible to receive covered services if he or she meets both general MaineCare eligibility requirements and specific eligibility requirements for Community Support Services. Eligibility for services under theMaineCare Benefits Manual, Chapter II, Section 13, Targeted Case Management Services, Section 65, Behavioral Health Services, Section 91, Health Home Services and Section 92, Behavioral Health Home Services may not preclude eligibility for covered services under this Section. However, services must be coordinated and not duplicated.17.02-2General Requirements. Individuals must meet the 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.17.02-3Specific Requirements. A member meets the specific eligibility requirements for covered services under this section if: A. The person is age eighteen (18) or older or is an emancipated minor and meets criteria for a Serious and Persistent Mental Illness as follows: 1. A primary diagnosis of Schizophrenia or Schizo affective disorder in accordance with the Diagnostic and Statistical Manual, 5th edition (DSM 5) criteria; or2. Another primary DSM 5 diagnosis or DSM 4 equivalent diagnosis with the exception of Neurocognitive Disorders, Neurodevelopmental Disorders, Antisocial Personality Disorder and Substance Use Disorders who: a) has a written opinion from a clinician, based on documented or reported history, stating that he/she is likely to have future episodes, related to mental illness, with a non-excluded DSM 5 diagnosis, that would result in or have significant risk factors of homelessness, criminal justice involvement or require a mental health inpatient treatment greater than seventy-two (72) hours, or residential treatment unless community support program services are provided; based on documented or reportedhistory; for the purposes of this section, reported history shall mean an oral or written history obtained from the member, a provider, or a caregiver; orb) has received treatment in a state psychiatric hospital, within the past twenty-four (24) months, for a non-excluded DSM 5 diagnosis; orc) has been discharged from a mental health residential facility, within the past twenty-four (24) months, for a non-excluded DSM 5 diagnosis; ord) has had two or more episodes of inpatient treatment for mental illness, for greater than seventy-two (72) hours per episode, within the past twenty-four (24) months, for a non-excluded DSM 5 diagnosis; ore) has been committed by a civil court for psychiatric treatment as an adult; orf) until the age of twenty-one (21), the recipient was eligible as a child with severe emotional disturbance, and the recipient has a written opinion from a clinician, in the last twelve (12) months, stating that the recipient had risk factors for mental health inpatient treatment or residential treatment, unless ongoing case management or community support services are provided. AND
B. Has significant impairment or limitation in adaptive behavior or functioning directly related to the primary diagnosis and defined by the LOCUS or other acceptable standardized assessment tools approved by the Department. If using the LOCUS, the member must have a LOCUS score, as determined by a LOCUS Certified Assessor, of seventeen (17) (Level III) or greater, except that to be eligible for Community Rehabilitation Services (17.04-2) and ACT (17.04-3), the member must have a LOCUS score of twenty (20) (Level IV) or greater.C. Eligible members who are eighteen (18) to twenty-one (21) years of age shall elect to receive services as an adult or as a child. Those members electing services as an adult are eligible for services under this Section. Those electing services as a child may be eligible for services under Chapter II, Section 65, Behavioral Health Services or Section 13 or both.D. The LOCUS or other approved tools must be administered, at least annually, or more frequently, if DHHS or an Authorized Entity requires it.17.02-4Determination of Eligibility. For each member seeking Community Support Services, a Community Support Provider will: A. Verify the member's eligibility for MaineCare; andB. Determine the member's eligibility, initially and annually, for Community Support Services. The annual eligibility verification must include a recent diagnosis that is supported by evidence of symptoms as defined in the current version of the Diagnostic and Statistical Manual of Mental Disorders, completed within the past year, as documented by an appropriately licensed clinician.C. For Community Integration Services only, verify that a member meets specific Eligibility Requirements under 17.02-3 within thirty (30) days of the start date of services. If eligibility verification is not submitted by close of business on day thirty (30), MaineCare will cease payment for services under this section on day thirty-one (31). Requests for a waiver of 17.02-3 Specific Requirements for eligibility must be made in accordance with 17.09-2(A).
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-17, subsec. 144-101-II-17.02