Subsection 144-101-II-19.01 - DEFINITIONS19.01-1Activities of Daily Living (ADLs) are basic activities of self-care performed by individuals on a daily or frequent basis necessary for independent living and may include activities such as: bed mobility, transfer, locomotion, eating, toilet use, bathing, and dressing. The specific ADL requirements for eligibility and covered services are set forth elsewhere in this section. 19.01-2Acute/Emergency Episode is the unforeseen occurrence of an acute health episode that requires a change in the member's Authorized Plan of Care, or the unforeseen circumstance where the availability of the member's caregiver or informal support system is compromised.19.01-3Assessing Services Agency (ASA) is an Authorized Entity providing services to the Department for medical eligibility determinations, Authorized Plan of Care development and prior authorization of covered services under this Section. The assessor at the ASA conducts face-to-face assessments, using the Department's Medical Eligibility Determination (MED) form. A member's medical eligibility is based upon a member's assessment outcome. If medical eligibility is determined for this Section, the ASA develops the Authorized Plan of Care with the member and specifies all services to be provided under this Section, including type of services and number of hours for all provider types.19.01-4Attendant is an individual who meets the qualifications required in Section 19.08-7(B)(5). The Attendant provides services specified in the Authorized Plan of Care to a member utilizing the Participant-Directed Option.19.01-5Authorized Entity is an independent entity providing services to the Department to perform specified functions under a valid contract or other approved signed agreement.19.01-6Authorized Plan of Care is authorized by the Assessing Services Agency, or the Department, and which specifies all services to be delivered to a member under this Section, including the number of hours for each covered service, and the provider type to deliver each service. The Authorized Plan of Care shall be based upon the member's assessment outcome scores recorded in the Department's MED form, utilizing the time frames contained therein, and the professional clinical judgment of the assessor. The Authorized Plan of Care shall reflect the needs identified by the assessment, considering the member's goals, preferences, living arrangement, informal caregiving supports provided by family and friends, and services provided by other public and private funding sources. MaineCare shall not cover any service under this benefit that duplicates another service, regardless of payor or provider, including services such as Medicare and MaineCare hospice services, Private Non-Medical Institution (PNMI) services, and assisted housing services (see 22 M.R.S. §7852) .
19.01-7Back Up Plan is a part of the service plan that addresses contingencies such as emergencies, including the failure of a worker to appear as scheduled, when the absence of the service presents a risk to the member's health and welfare.19.01-8Budget Authority provides those members utilizing the Participant-Directed Option, the authority to determine their Attendant's wages within the service cap. 19.01-9Choice Letter is a document signed by the member or legal agent of the member indicating the member's decision to select either Home and Community Benefits or institutional services.19.01-10Cognitive Capacity is the mental function of knowing, including aspects of awareness, perception, reasoning, and judgment, assessed for purposes of determining a member's ability to self-direct his or her care.19.01-11Cueing is any spoken instruction or physical guidance that serves as a signal to do something. Cueing is typically used when caring for members who are cognitively impaired.19.01-12Direct Care Provider is a MaineCare provider that directly provides Personal Care, Home Health or in-home Respite services under this Section. 19.01-13Extensive Assistance means although the individual performed part of the activity over the last seven (7) days, or twenty-four (24) to forty-eight (48) hours if in a hospital setting, help of the following type(s) was provided: Weight-bearing support three (3) or more times, or Full staff performance of activity (three (3) or more times) during part (but not all) of the last seven (7) days. 19.01-14Extraordinary Care means care exceeding the range of activities that a spouse would ordinarily perform in the household on behalf of a person without a disability or chronic illness of the same age, and which are necessary to assure the health and welfare of the member and avoid institutionalization.19.01-15Fiscal Intermediary is a provider of Financial Management Services on behalf of members utilizing Attendants through the Participant-Directed Option. The Fiscal Intermediary's responsibilities include, but are not limited to, preparing payroll and withholding taxes, making payments for Attendant services and ensuring compliance with State and Federal tax and labor regulations and the requirements under this Section. The Fiscal Intermediary acts as an agent of the employer (i.e., the member or the member's Representative) in accordance with Federal Internal Revenue Service codes and procedures.19.01-16Health and Welfare Tool is an evaluation completed by the Service Coordination Agency to assess risks and unmet needs of members as required by the Department.19.01-17Health Maintenance Activities assist the member with Activities of Daily Living and Instrumental Activities of Daily Living, and additional activities specified in this definition. These activities are performed by a designated caregiver for an individual who would otherwise perform the activities if he or she were physically or cognitively able to do so, and enable the member to live in his or her home and community. These additional activities include, but are not limited to catheterization, ostomy care, preparation of food and tube feedings, bowel treatments, administration of medications, care of skin with damaged integrity, and occupational and physical therapy activities such as assistance with prescribed exercise regimes.19.01-18Instrumental Activities of Daily Living (IADLs) are tasks necessary for maintaining a member's immediate environment, such as preparing and serving meals, washing dishes, dusting, making bed, pick-up living space, sweeping, vacuuming and washing floors, cleaning toilet, tub and sink, appliance care, changing linens, refuse removal, shopping for groceries and prepared foods, storage of purchased groceries, and laundry, either within the residence or at an outside laundry facility. The specific IADL requirements for eligibility and covered services are set forth elsewhere in this Section.19.01-19Limited Assistance is a term used to describe an individual's self-care performance in Activities of Daily Living, as defined by the Minimum Data Set (MDS) assessment process. It means that although the individual was highly involved in the activity over the last seven (7) days, or twenty-four (24) to forty-eight (48) hours if in a hospital setting, help of the following type(s) was provided: physical help in guided maneuvering of limbs or other non-weight-bearing assistance three (3) or more times, or Limited Assistance three (3) or more times, plus more help with weight-bearing support provided only one (1) or two (2) times. 19.01-20MeCare is a computerized long-term care medical eligibility system facilitating the entire medical assessment and service authorization process, from intake through information dissemination. 19.01-21Medical Eligibility Determination (MED) Form is the Department's approved form for determining a member's medical eligibility for services under this Section. The MED form's definitions, scoring mechanisms and time frames provide the basis for including services in the Authorized Plan of Care. The Department, or the ASA, shall conduct the MED assessment on a face-to-face basis. Based upon the member's outcome scores, an Authorized Plan of Care is then developed, which specifies the services, numbers of hours, and provider types. The Care Plan Summary section of the MED form documents the Authorized Plan of Care, and identifies any other non-HCB services the member may be receiving, regardless of payor.19.01-22Member is an individual who meets the eligibility requirements of this Section and is authorized to receive services. A member may be represented by his or her "guardian," "agent," or "surrogate," as these terms are defined in 18-A M.R.S. §5 - 801, or by a Representative as defined in this Section.19.01-23One-Person Physical Assist requires one (1) person to provide either weight-bearing or non-weight-bearing assistance for an individual who cannot perform the activity independently over the last seven (7) days, or twenty-four (24) to forty-eight (48) hours if in a hospital setting. This does not include Cueing.19.01-24Participant-Directed Option is a choice offered to members to manage their Attendant Services. Specifically, the member hires, discharges, trains, schedules and supervises the Attendant(s) providing services. A member who chooses to engage in the Participant-Directed Option is considered the employer of his or her Attendant(s).19.01-25Participant-Directed Rate is the reimbursement for Attendant Services under the Participant Directed-Option which consists of two components: the Attendant provider wage and the employer expense component: (1) Attendant portion of the rate that is designated as the Attendant's gross hourly wage for authorized care provided;(2) Participant-Directed Option expense component that is the portion of the participant-directed Attendant rate for any mandated employer's share of social security, federal and state unemployment taxes, Medicare, and worker's compensation insurance premiums.19.01-26Person-Centered Planning is a member-directed process through which each member's needs, goals and preferences are identified, and strategies are developed to address those needs, goals and preferences. The process ensures that the member's assessment, service plan development, and services and supports are directed by the member, to the extent they wish.19.01-27Personal Support Specialist (PSS), also known as Personal Care Assistant (PCA), is an individual who provides Personal Care Services. The PSS/PCA has completed a Department approved training course of at least fifty (50) hours, unless otherwise exempt under this Section, which includes, but is not limited to, instruction in basic personal support procedures, first aid, handling of emergencies, and review of the mandatory reporting requirement under the Adult Protective Services Act(Title 22, Ch. 958-A of the Maine Revised Statutes).19.01-28Representative means an individual responsible for managing Attendant Services on behalf of a member using the Participant-Directed Option. The Representative must meet the qualifications and requirements as described in the provision for Policies and Procedures, Other Qualified Staff.19.01-29Risk Assessment is an evaluation to assess potential risks to members and the development of strategies to mitigate such risks that are integral to enabling members to live in the community while ensuring their health and welfare. 19.01-30Service Coordination Agency (SCA) is an organization that has the statewide capacity to provide Care Coordination and Skills Training to eligible members under this Section, and has met the MaineCare provider enrollment requirements of the Department. In addition to Care Coordination and Skills Training, the SCA is responsible for administrative functions, including but not limited to, maintaining member records, submitting claims, conducting internal utilization and quality assurance activities, and meeting the reporting requirements of the Department. The SCA shall refer to the Department's contracted Waiver Service Provider when a member is determined eligible for any of the following services: Assistive Technology (including devices, remote monitoring and transmissions), Personal Emergency Response System (PERS), Environmental Modifications and Respite Services delivered in an institution. In order to prevent a potential conflict of interest, the SCA providing Care Coordination Services to a member may not be a provider of direct care services.19.01-31Service Order is the document provided by the SCA to the Direct Care Provider that includes information on the type, amount and frequency of services to be provided to the member. The Service Order specifies the tasks authorized by the ASA in the Authorized Plan of Care.19.01-32Signature of the Registered Nurse (RN) assessor from the ASA and the care coordinator from the SCA equates with the "login" onto the MeCare eligibility determination computer system.19.01-33Significant Service Change is defined as a major change in the member's status that is not self-limiting, impacts on more than one (1) area of his or her health status, and requires multidisciplinary review or revision of the Authorized Plan of Care.19.01-34Total Dependence means full staff performance of the activity during the entire last seven (7) day period, i.e., complete non-participation by the member in all aspects of the ADLs.19.01-35Unstable Medical Condition exists when the member's condition is fluctuating in an irregular way and/or is deteriorating and affects the member's ability to function independently. The fluctuations are to such a degree that medical treatment and professional nursing observation, assessment and management at least once every eight (8) hours is required. An Unstable Medical Condition requires increased physician involvement and should result in communication with the physician for adjustments in treatment and medication. Evidence of fluctuating vital signs, lab values, and physical symptoms and Authorized Plan of Care adjustments must be documented in the medical record. Not included in this definition is the loss of function resulting from a temporary disability from which full recovery is expected.19.01-36Waiver Services Provider (WSP) is an agency contracted by the Department's Office of Aging and Disability Services (OADS), responsible for coordinating the following services: Respite Services delivered in an institution, Assistive Technology (including devices, remote monitoring and transmissions), PERS, and Environmental Modifications. This provider enters into agreements with subcontractors and ensures that these services are delivered according to the Authorized Plan of Care, oversees and assures compliance with policy requirements, and conducts required internal and external utilization review activities with regard to these services. This provider is responsible to bill the Department and reimburse the subcontractors for delivering these services. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-19, subsec. 144-101-II-19.01