C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-46, subsec. 144-101-II-46.07

Current through 2024-51, December 18, 2024

Subsection 144-101-II-46.07 - DETERMINATION OF ELIGIBLITY

All members requesting eligibility must be determined to be in need of the psychiatric hospital services provided by providers enrolled under this Section. The determination of medical eligibility is made concurrently with the determination of financial eligibility in order to expedite the determination of the member's overall eligibility for psychiatric hospital services.

46.07-1Financial Eligibility Determination Procedure

Financial eligibility will be determined by the DHHS's Office of Integrated Access and Support.

46.07-2Medical Eligibility Determination Procedure

Before authorization for reimbursement may be made, a complete evaluation of the member must be made, a plan of care established, a certification of need of service completed, and Central Enrollment as defined in Section 46.08 completed.

A.Medical, Psychiatric, and Social Evaluations

An attending physician or staff physician must make a medical evaluation of each member's need for care and appropriate professional personnel must make a psychiatric and social evaluation. This evaluation must include all requirements detailed in Hospital Licensing regulations. In addition, each medical evaluation must include:

1. Diagnosis

2. Summary of present medical findings

3. Medical history

4. Mental and physical functional capacity

5. Prognosis

6. Measurable short and long term goals

7. Specific treatment modalities to be utilized

8. The responsibilities of each team member

9. Treatment received by the member shall be documented to justify the diagnosis and the treatment and rehabilitation activities carried out; and

10. A physician's recommendation of inpatient, partial hospitalization or outpatient services for the member. In the case of an individual who applies for MaineCare while receiving inpatient, partial hospitalization or outpatient services, a recommendation by a physician for continued care must be made as part of the medical evaluation.

B.Individual Written Plan of Care

The attending staff physician must establish and sign a written plan of care for each member, which must at minimum include the items described at Section 46.10.

46.07-3Coordination With Medicare

Medicare provides a lifetime limit of one hundred and ninety (190) inpatient days of care in a psychiatric hospital. In general, MaineCare benefits are limited to payment of the Medicare coinsurance and deductible for MaineCare-eligible Medicare beneficiaries as stated in Chapter I of the MaineCare Benefits Manual.

The following describes the additional requirements for authorization of MaineCare coverage in the event that a member applies for inpatient psychiatric hospital coverage after the one hundred and ninety (190) day lifetime limit or ninety (90) day spell-of-illness limit is exhausted or after the member's Medicare benefits are terminated for any other reason.

A.If Medicare's Lifetime Limit of One Hundred and Ninety (190) Days or Spell-Of-Illness Limit of Ninety (90) Days is Exhausted

A copy of the Medicare Exhaustion of Benefits notice must be included in the member's record.

B.Termination of Medicare Coverage Before the One Hundred and Ninety (190^th) Day of Benefits

1. If the Department believes that a reasonable basis for appeal exists:

a. The member must request reconsideration of the Medicare denial of benefit coverage.

b. The provider must assist the member in requesting reconsideration of the Medicare denial and submit a copy of the reconsideration request.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-46, subsec. 144-101-II-46.07