C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-29, subsec. 144-101-II-29.03

Current through 2024-44, October 30, 2024

Subsection 144-101-II-29.03 - DETERMINATION OF ELIGIBILITY

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

1) the member must require Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) level of care as set forth under the MaineCare Benefits Manual, Chapter II, Section 50. 2) the member must have eligibility for MaineCare as determined by the DHHS Office for Family Independence (OFI), and 3) a funded opening is available.

29.03-1Funded Opening- The number of MaineCare members that can receive services under this Section is limited to the number, or "funded openings," approved by the Centers for Medicare and Medicaid Services (CMS) and the appropriation of sufficient funding by the Maine Legislature. 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 or if there is not sufficient funding.

29.03-2General Eligibility Criteria

Consistent with Subsection 29.03-1, 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 or Autism Spectrum Disorder or Rett Syndrome; 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 fifty percent (50%) of the state-wide average annual cost of care for an individual in an ICF/IID, as determined by the DHHS.

29.03-3Establishing 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 (BMS99) or current functional assessment approved by the DHHS and

B. A copy of the member's Personal Plan approved and signed by the member or guardian and the case manager within the preceding six months of the effective plan date and any other relevant material indicating the member's service needs.

Based on review of the Assessment Form, the Personal Plan, a QID 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 medically 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.

29.03-4Calculating the Estimated Annual Cost

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

29.03-5Waiting List and Offers for Funded Openings

DHHS will maintain a waiting list of eligible MaineCare members who cannot get access to Section 29 Services because a funded opening is not available. Members who are on the waiting list for the benefit services shall be served chronologically based on the date the Designated Representative determines eligibility for the waiver. At the time when 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 to DHHS with intent to accept waiver services. A member has six months from the receipt of notification to start receipt of services. If the member fails to respond with intent to accept the funded opening within 60 days of this notice or fails to begin services within 6 months, the waiver offer will then be withdrawn. A member may reapply at any time for waiver services.

29.03-6Redetermination of Eligibility

When making a determination of continuing eligibility, every 12 months from the date of initial approval and every 12 months thereafter, the member's case manager will submit to OADS a current Personal Plan that is less than six (6) months old, and an updated Assessment Form (BMS 99) or current functional assessment approved by the Department.

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

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-29, subsec. 144-101-II-29.03