C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-21, subsec. 144-101-II-21.03

Current through 2024-44, October 30, 2024

Subsection 144-101-II-21.03 - DETERMINATION OF ELIGIBILITY

Eligibility for this benefit is based on meeting all three of the following criteria:

1) the eligibility criteria for a funded opening based on priority,

2) medical eligibility, and

3) eligibility for MaineCare as determined by the DHHS, Office for Family Independence (OFI).

21.03-1Funded Opening

The number of MaineCare Members that can receive services under this Section is limited to the number, or "funded openings," and point in time approved by the Centers for Medicare and Medicaid Services (CMS). Persons who would otherwise be eligible for services under this Section are not eligible to receive services if all of the funded openings are filled.

21.03-2Reserved Capacity

The DHHS reserves a portion of Member capacity of the waiver for specified purposes in order to:

Meet the needs of incapacitated or dependent adults who require adult protective services to alleviate the risk of serious harm resulting from abuse, neglect and/or exploitation; and Meet the needs of those individuals who choose to leave an ICF/IID, long term nursing home placement, state psychiatric hospital, or hospital and Meet the needs of Members under age 21 in out of state residential placements funded by MaineCare or State funds.

The number reserved associated with Section 21.03-2 above is an average based on the DHHS's data for those in need of adult protective services in recent years. The number reserved for ICF/IID, long term nursing home placement, state psychiatric hospital or hospital residents is based on currently known referrals. The number reserved for Members in out-of-state residential placements is based on the number of current out of state residential placements funded by MaineCare or State funds.

21.03-3General Eligibility Criteria

Consistent with Subsection 21.03-1, a person is eligible for services under this Section if the person:

A. Is age eighteen (18) or older ; and

B. Has an Intellectual Disability as defined in the Definitions Section above, or Autism Spectrum Disorder also defined in the Definitions Section above, or Rett Syndrome as defined by the DSM; and

C. Meets the medical eligibility criteria for admission to an ICF/IID as set forth under the MaineCare Benefits Manual, Chapter II, Section 50; and

D. Does not receive services under any other federally approved MaineCare home and community-based waiver program; and

E. Meets all MaineCare eligibility requirements as set forth in the MaineCare Eligibility Manual; and

F. The estimated annual cost of the Member's services under the waiver is equal to or less than two hundred percent (200%) of the state-wide average annual cost of care for an individual in an ICF/IID, as determined by the DHHS.

21.03-4Establishing Medical Eligibility

In order to determine medical eligibility, the Member and Case Manager must provide to DHHS the following:

A. A completed copy of the assessment form (BMS 99) or current functional assessment approved by the DHHS; and

B. A copy of the Member's Person-Centered Service Plan approved and signed by the Member, guardian and the Case Manager within the preceding six months; and

C. Any other relevant material indicating the Member's service needs.

Based on review of the Assessment Form and the Member's Person-Centered Service Plan, a QIDP designated by DHHS will determine the Member's medical eligibility for services under this Section.

DHHS shall notify each Member or the Member's guardian in writing of any decision regarding the Member's medical eligibility, and the availability of benefit openings under this Section. The notice will include information about the Member's right to appeal any of these decisions. Rights for notice and appeal are further described in Chapter I of the MaineCare Benefits Manual.

If the Member is found to be eligible, DHHS must send the Member or guardian written notice that the Member can receive ICF/IID services or services under this Section. The Member or guardian must submit to the Case Manager a signed choice letter documenting the Member's choice to receive services under this section.

21.03-5Calculating the Estimated Annual Cost

Prior to formal determination of eligibility for services under this section, each applicant and the applicant's planning team must identify the required mix of services to meet the applicant's needs and to assure the applicant's health and welfare. The applicant and the applicant's planning team shall submit a detailed estimate of the total annual cost for waiver services identified in the Person-Centered Service Plan, including the specific services and the number of units for each service.

21.03-6Priority

When a Member is found to meet MaineCare eligibility criteria and medical eligibility criteria for these services, the priority for a funded opening shall be established in accordance with the following:

A.Priority 1: Any Member on the waiting list shall be identified as Priority 1 if:

1. The Member has been determined by DHHS to be in need of adult protective services in accordance with 22 M.R.S. §§3470et seq., and if the Member continues to meet the financial and medical eligibility criteria at the time that need for adult protective services is determined.

OR

2.

Although DHHS has not determined the Member to be in need of adult protective services, the Member is at risk for abuse, neglect, or exploitation because the Member meets the following criteria:

a. The Member resides with his or her Primary Caregiver and the Primary Caregiver has reached age sixty-five (65) or has a terminal illness, and is having difficulty providing the necessary supports to the Member; AND

b. The Member has no other responsible or willing caregiver; AND

c. The Member meets at least one of the following criteria, and is at risk of one other:

i. Within the last 12 months, the Member has demonstrated a significant medical/behavioral need, as evidenced and documented by: Increased functional needs and required supports as a result of a mental health or medical condition; OR, Criminal behavior resulting in involvement with the criminal justice system (not dependent upon conviction) that impacts or results in the harm or threat to others; OR

ii. Prolonged and unresolved crisis involvement resulting in high-risk for institutionalization; OR

iii. Three or more hospital admissions over the last 12 months due to a medical or behavioral decline that is expected to continue; OR

iv. The health, safety or welfare of the Member or others is at imminent danger.

B.Priority 2: Any Member on the waiting list shall be identified as Priority 2 if the Member does not satisfy Priority 1 criteria, yet has been determined to be at risk for abuse, neglect, or exploitation in the absence of the provision of benefit services identified in his or her service plan. Examples of Members who shall be considered Priority 2 include:

1. a Member whose Primary Caregiver has reached age sixty (60) and is having difficulty providing the necessary supports to the Member in the family home; or

2. a Member living in unsafe or unhealthy circumstances but who is not yet in need of adult protective services, as determined by DHHS Adult Protective Services.

C.Priority 3: Any Member on the waiting list shall be identified as Priority 3 if the Member is not at risk of abuse, neglect, or exploitation in the absence of the provision of the benefit identified in the service plan. Examples of Members who shall be considered Priority 3 include:

1. a Member living with family, who has expressed a desire to move out of the family home;

2. a Member whose medical or behavioral needs are changing and who may not be able to receive appropriate services in the current living situation;

3. a Member who resides with family, if the family must be employed to maintain the household but cannot work in the absence of the benefit being provided to the Member; or

4. A Member who has graduated from high school in the State of Maine, has no continuing support services outside of the school system, but is in need of such services.

D. Annual Waiting List Confirmation: The Member must confirm on an annual basis his/her interest in remaining on the Section 21 waiting list in accordance with the following process:

1. The Office of Aging and Disability Services will notify the Member, his/her guardian, and the Member's Case Manager of the need to complete the Section 21 Waiver Information Form to confirm the Member's continued interest in remaining on the waiting list.

2. The Member, his/her guardian, and the Member's Case Manager will complete the Section 21 Waiver Information Form and submit the form to the Department.

3. If the Section 21 Waiver Information Form is not received within forty-five (45) days of notice to the Member, his/her guardian, and Case Manager, then the Department will issue a second reminder notice.

4. In the event that the Section 21 Waiver Information Form is not received by the Department within six (6) months of the initial notice to the Member, his/her guardian, and Case Manager, then the Department will notify the Member of his/her removal from the waiting list. The Member can reapply for Section 21 services thereafter.

E. Reconsideration of Priority: If the Member would like the Department to consider new information and re-evaluate priority level, then a Section 21 Waiver Information Form must be submitted to the Department. This can be done at any time, or at the time of the annual waiting list confirmation.

21.03-7Choosing Whom to Serve Within the Same Priority

If the number of openings is insufficient to serve all Members on the waiting list who have been determined, at the time that any opening is determined to be available, to be within the same priority group, DHHS shall first determine whether each Member continues to meet the financial and medical eligibility criteria to be served through this benefit. For those who continue to meet such criteria, the DHHS will utilize the most current assessment that is entered into the Enterprise Information System (EIS), or current database, and submitted by the individual Member, guardian or Case Manager. Upon review of information concerning all Members within the same priority group who continue to meet financial and medical eligibility criteria and for whom current service plans are in place, DHHS shall determine which Members to serve. The determination will be based on a comparison of the Members' known needs and the comparative degree of abuse, neglect or exploitation or risk of abuse, neglect or exploitation that each Member will likely experience in the absence of the provision of the benefit.

21.03-8Waiting List and Offers for Funded Opening

DHHS will maintain a waiting list of eligible MaineCare Members who cannot access Home and Community Benefits because a funded opening is not available. Members who are on the waiting list for the benefit services shall be served in accordance with the priorities identified above. At the time a Member is offered a funded opening the Member will be removed from the waiting list.

A Member has sixty days from the receipt of notification by DHHS of a funded opening to respond with intent to accept waiver services. A Member has six (6) months from the receipt of notification to start services. If the Member fails to respond to DHHS with intent to accept the funded opening within sixty (60) days of this notice or fails to begin services within six (6) months, the waiver offer will then be withdrawn. A Member may reapply at any time for waiver services.

21.03-9Redetermination of Eligibility

Every twelve (12) months from the date of initial eligibility approval, the Member's Case Manager will submit to OADS: a Current Person-Centered Service Plan based on the effective plan date that is less than six (6) months old and an updated assessment form (BMS 99) or current assessment approved by the Department.

If the updated Assessment Form and Person-Centered Service Plan are not received by OADS, by the due date, reimbursement for services will be denied until receipt of the assessment form and Person-Centered Service Plan. Reimbursement for services will resume upon receipt of the Assessment Form and a signed Person-Centered Service Plan.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-21, subsec. 144-101-II-21.03