C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-19, subsec. 144-101-II-19.02

Current through 2025-02, January 8, 2025

Subsection 144-101-II-19.02 - ELIGIBILITY FOR CARE

19.02-1General and specific requirements

To be eligible for services under this section, a member must be eighteen (18) years or older and meet the general MaineCare eligibility requirements found in theMaineCare Eligibility Manual (10-144 C.M.R. Ch. 332), medical requirements, and other specific requirements for Home and Community Benefits (HCB) for the Elderly and Adults with Disabilities. Even if a member meets all criteria for eligibility for services under this section, the provision of these services is subject to available funding for this program, individual cost limitations as set forth in this Section and aggregate cost neutrality assurances required by 42 C.F.R. § 441.302. Some members may have restrictions on the type and amount of services they are eligible to receive. It is the responsibility of the Service Coordination Agency (SCA) to verify a member's eligibility for MaineCare, as described in Chapter I of the MaineCare Benefits Manual, prior to coordinating the provision of services authorized by the ASA.

19.02-2Medical requirements

A person meets the medical eligibility requirements for this Section if he or she meets the medical eligibility requirements specified in Chapter II, Section 67.02, Nursing Facility Services, of this Manual.

The Department, or its Assessing Services Agency, using the Medical Eligibility Determination (MED) Form must complete a face-to-face assessment. The clinical judgment of the ASA shall be determinative of the scores given on the MED assessment.

19.02-3Other specific requirements

A member meets the requirements of this Section when all of the additional following conditions are met:

A. The projected cost of services under this Section needed by the member on a monthly basis must be established within the limits set forth in Section 19.06; and

B. A member or applicant who meets the eligibility criteria for nursing facility level of care has been informed of, and offered the choice of available, appropriate and cost-effective HCB; and

C. The member selected HCB as documented by a signed Choice Letter; and

D. The health and welfare of the applicant/member would not be endangered receiving services at home or in the community; and

E. The particular services needed by the member are available in the geographic area and a willing provider is available; and

F. The member must make themselves available for any eligibility assessment; and

G. The member must have a permanent or chronic disability or functional impairment which interferes with his/her own capacity to provide self-care and daily living skills without assistance as verified by the member's MED form; and

H. Members will be accepted into the program on a first-come, first-served basis, based upon the availability of funding. The waitlist will be maintained by the Office of Aging and Disability Services.

19.02-4Additional requirements for accessing the Participant-Directed Option

For a member to direct his or her own services under the Participant-Directed Option without the use of a Representative, the member must have Cognitive Capacity, as assessed on the MED form, to be able to self-direct his or her Attendant(s). The ASA will assess Cognitive Capacity as part of each member's eligibility determination using the MED findings. Minimum MED form scores are:

A. decision making skills: a score of 0 or 1;

B. making self-understood: score of 0, 1 or 2;

C. ability to understand others: score of 0, 1 or 2;

D. self-performance of managing finances: a score of 0, 1, or 2; and E. support for managing finances: a score of 0, 1, 2 or 3.

A member not meeting the specific scores detailed above during his or her eligibility determination will be presumed not able to self-direct without the use of a Representative under this Section.

19.02-5Additional requirements for Home Delivered Meals

In order to be eligible for this service under this section, a member can not reside in an institution that meets the definition of a hospital or nursing facility. Members eligible for this service are unable to prepare their own meals and no one else is responsible to prepare the meals.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-19, subsec. 144-101-II-19.02