C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-29, subsec. 144-101-II-29.04
Whenever significant changes occur that alter level of care, the case manager will submit an updated Assessment Form to DHHS. The case manager must complete and submit all waiver documents including the BMS 99, or current functional assessment approved by the Department and the updated Personal Plan to the Resource Coordinator thirty (30) days in advance of the annual redetermination date.
If the member or guardian chooses services under this Section, the request for services must be submitted to DHHS or its Authorized Entity. As part of the planning process, the member's needs are identified and documented in the Personal Plan. Except for residential services, other services shall be provided to the member within ninety (90) days.
Medically necessary services and units of services must be identified in the Personal Plan. Requests for services must be submitted to DHHS or its Authorized Agent for Prior Authorization in order for the services to be reimbursed. Requests will be reviewed by DHHS or its Authorized Entity, and may be examined and evaluated by DHHS or its Authorized Entity, before units of service are authorized. All Prior Authorizations are time-limited, and the length of the authorization may vary by member and service as documented in the Personal Plan. Upon expiration of an authorization, a new authorization must be obtained before reimbursement may be provided for the service.
DHHS and its Authorized Entity reserve the right to conduct Utilization Review of any service authorized under this Section, applying the service-specific eligibility standards set forth in this Section. DHHS and its Authorized Entity may terminate or revise a service authorization upon finding that the member no longer satisfies the eligibility standards for the service or level of service authorized.
The case manager will ensure that a Planning Team is convened to initiate development of the Personal Plan prior to services being initiated. Case Managers must meet with the member absent of current providers to ensure conflict free planning and informed choice. The planning process must reflect cultural conventions of the member. The planning process must be conducted by providing information in plain language and in a manner that is accessible to the member and when applicable, their legal representative.
The effective plan date must be current and less than six (6) months old at the time of the member's eligibility determination or redetermination. The planning process must comply with the requirements described in 42 CFR § 441.301(c)(1), and 34 -B M.R.S.A. §5470- B(2).. The Personal Plan must contain at a minimum:
The Personal Plan will be used by DHHS or its Authorized Entity to identify the type and units of authorized services the member may receive under this Section. If more than one provider is reimbursed for the same category of direct supports, an explanation of the differences in roles and responsibilities of each provider and how services will not be duplicated is required.
All providers must ensure that notice of the Grievance process outlined in 14-197 CMR Chapter 8 is regularly provided to members served by the provider. Providing notice includes, at a minimum, ensuring that written notice of the grievance process is provided to the member and/or their guardian at any planning meeting; posting notice of the grievance process in an appropriate common area of all facilities operated by the provider; and posting notice of the grievance process on any website maintained by the provider. In addition, the provider must ensure that all staff are trained in the grievance process.
Each member or guardian will determine the composition of the Planning Team. Planning will occur in a manner that is respectful and reflective of the member's preference. The member will lead the person-centered planning process where possible. The member's representative should have a participatory role, as needed and as defined by the member, unless State law confers decision-making authority to the legal guardian.
The Case Manager is responsible for convening the planning team and facilitating the Person Centered Planning process. The Case Manager or Case Management Supervisor has sole authority for scheduling and rescheduling the planning team at the request of the member or their legal representative. In addition to the Case Manager,
The planning team must include the following members, if applicable:
The planning team may include the following members, if applicable:
The member's Personal Plan must be revised and updated at least annually, based on the plan's effective date or at the request of the member or guardian, and in addition when other significant changes occur relating to the member's physical, social, behavioral, medical, communication, or psychological needs, or the member's significant progress toward his or her goals. The Case Manager must reconvene the Planning Team to revise and update the Personal Plan as service needs change, including the location where services are received. Planning meetings must be held both prior to 30 days and subsequent to the planned move of a member to a new service in order to coordinate and to evaluate the member's satisfaction with the change.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-29, subsec. 144-101-II-29.04