C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-50, subsec. 144-101-II-50.06

Current through 2024-51, December 18, 2024

Subsection 144-101-II-50.06 - POLICIES AND PROCEDURES

50.06-1Admissions to an ICF-MR Facility

MaineCare coverage of ICF-MR services must begin only after an applicant is determined eligible by the Department's Office of Integrated Access and Support, determined medically eligible by the Department or the Department's authorized agent, and classified by the Department as needing an ICF-MR level of care.

A.Admission from a Hospital

The following criteria must be met if a member is to be admitted from a hospital:

1. If the applicant is not a MaineCare member, the hospital's discharge planner or other designated person must refer the individual, family member, or guardian to the regional office of the Office of Integrated Access and Support for MaineCare eligibility determination.

2. The hospital must complete the Department's designated assessment form (currently BMS-85) and fax it to the Department. The hospital must complete the assessment form no less than twenty-four (24) hours prior to the denial of acute level of care or discharge from a hospital.

B.Admission from a Nursing Facility (NF)

The following criteria must be met if a member is to be admitted from a nursing facility:

1. If the individual is not a MaineCare member, the NF will refer the applicant, family member, or guardian to the regional office of the Office of Integrated Access and Support.

2. The Department's designated assessment form must be completed by the NF and sent to the Department or the Department's authorized agency. The Department will determine medical eligibility for the member to enter an ICF-MR. If the member is found medically and financially eligible, the member can be transferred to the ICF-MR. When the resident is admitted to an ICF-MR, the NF will send copies, if applicable, of the MDS assessment, the most recent MED form, and all Preadmission Screening (PAS) and Change In Condition (CIC) review records (Level I, Level II, IDT, and Annual Resident Reviews) to the ICF-MR.

C.Admission From Other Settings

The following criteria must be met when members are to be admitted from other settings:

1. Concurrent with the MaineCare eligibility determination process, the Department or its authorized agent must arrange for an assessment at the applicant's residence.

2. The Department or its authorized agent must conduct the medical eligibility assessment using the Department's designated assessment form. The assessment form must be completed within five (5) calendar days of the request for an assessment. Faxed request forms are acceptable.

D.Admission Certification

On admission to an ICF-MR, all Title XIX and XXI eligible members must be certified by a physician for medical necessity for ICF-MR Services.

If the member is to be admitted to an ICF-MR Group Home Facility, a physician must certify that the member is not in need of more than eight (8) hours per day of nursing care, and that the member in an ICF-MR Group Home Facility is in need of active treatment for at least one (1) of the conditions listed under Section 50.05-3(B).

If the member is to be admitted to an ICF-MR Nursing Facility a physician must certify that there is a need for at least eight (8) hours per day of nursing care and that the member is in need of active treatment for at least one (1) of the conditions listed under Section 50.05-2. In addition, there must be a medical care plan identifying the care needs of the member based on his or her medical condition.

E.Admissions Discrimination

Each facility must have a written policy, consistent with State licensing and Federal certification requirements that must define the medical services that are provided in the facility.

Each facility must have a written anti-discrimination policy consistent with State licensing and Federal certification requirements.

If the facility has a policy provision so stating, a facility may preferentially admit certain members, but only on the following grounds:

1. A facility that is owned and operated by a religious or denominational group may preferentially admit any member of that religion or denomination.

2. A facility may preferentially admit any member who, for at least three (3) years, has been a resident in the area where the facility is located.

3. A facility may preferentially admit any member who is referred by a specific hospital with which the facility has a transfer agreement.

4. A facility must preferentially admit any member who is referred by DHHS on an emergency basis.

A facility may not accept or receive payment in addition to MaineCare reimbursement, and must accept the MaineCare rate as payment in full.

50.06-2Discharges

A.Discharge Planning Procedure

Each ICF-MR must maintain written discharge planning procedures that describe who will have operational responsibility for discharge planning; and, the manner and methods by which such staff members will function, including that person's relationship with the facility staff.

At the time of the member's discharge, the ICF-MR must provide to those persons responsible for post-discharge care such information as will insure the optimal continuity of care. In addition, the ICF-MR must submit a member transfer form to DHHS.

B.To Another ICF-MR or to a Nursing Facility (NF)

If a Title XIX or XXI member is transferred from an ICF-MR to another ICF-MR, a copy of the most current assessment form, which established medical eligibility and approval, must be transferred with the member. If the member is transferred to a NF, the member must be reclassified. The member must be determined to meet the medical criteria described in Section 67 of the MaineCare Benefits Manual by the Department or the Department's authorized agent.

50.06-3Utilization Review Plan

Each ICF-MR must have in effect a written utilization plan. The plan must include but not be limited to requirements for:

A. Certification of members by a physician prior to admission and re-certification annually;

B. Classification of members prior to admission and annually thereafter;

C. Independent professional continued stay reviews of each member's ongoing eligibility for the ICF-MR level of care performed by DHHS every six (6) months;

D. Medical records;

E. Procedure when continued stay is not necessary, however the member is awaiting discharge; and

F. Re-certification/reclassification schedule for medical eligibility for all MaineCare members.

50.06-4Independent Professional Reviews

The Department must conduct an annual on-site review. An independent professional review team must consist of one (1) or more health services consultants, a medical social work consultant, and a physician, if appropriate. At least one team member must be a Qualified Mental Retardation Professional (QMRP). The following criteria must also be met:

A. Annually, the independent professional review team must conduct an exit conference with the administrator and such staff as may be designated by the administrator to discuss the findings of the team relative to quality of services, appropriateness of services, over- or under-utilization of services, and changes in classification and/or level of care.

B. A notification letter (BMSLC-14) must be prepared for any member who no longer requires the same level of care.

C. If the member's condition undergoes a significant change prior to the scheduled reclassification date, the facility must reassess the member and complete a new assessment form to demonstrate on-going and continued eligibility for the ICF-MR level of care. A copy must be submitted to the Department.

D. If a member in an ICF-MR is reclassified as no longer meeting the criteria for the ICF-MR level of care, the member must be be given written notice by the facility and provided their appeal rights, pursuant to Chapter I of the MaineCare Benefits Manual. MaineCare will not reimburse for that member effective the date the member's appeal rights have expired (in the event of no appeal) or when the member's appeal rights have been exhausted, and there is a safe and appropriate place to discharge the member.

50.06-5Payment of Bed Holds for Short-Term Hospitalizations

A.Hospitalization

An ICF-MR must provide a member with the opportunity for readmission following hospitalization, if the individual remains a MaineCare member.

B.Payment of Bed Holds

Payment of bed holds for a semi-private room for a short-term hospitalization must not exceed twenty-five (25) calendar days per admission, as long as the member is expected to return to the ICF-MR.

If a member leaves the hospital and does not return to the ICF-MR, MaineCare will not reimburse for the bed hold as of the date of discharge from the hospital.

C.Excess Days

Any member whose hospitalization exceeds the authorization period that is paid by MaineCare must be permitted to be readmitted to the facility immediately upon the first availability of a bed in the ICF-MR as long as the member requires the level of care provided by the facility.

D.Procedure

The facility must receive authorization from a physician for a hospitalization and notify the Department of the date of hospitalization and expected date of return by submitting an assessment form.

E.Payment for Bed Holds by Member's Family and Friends

The ICF-MR must give written notice to the member, legal guardian, and/or family in those instances where the member will exceed the number of days that MaineCare will reimburse for a bed hold.

In those instances where the member does not meet the criteria for bed hold, the ICF-MR must advise the member and his or her representative in writing that the bed hold limit is exceeded, and that family or friends have the option of holding the bed by making payment not to exceed the MaineCare rates.

50.06-6Leave of Absence

All ICFs-MR are responsible for informing members in writing of the limit of fifty-two (52) overnight leaves of absence per calendar year. Payment may be made to a facility to reserve a bed for a member on an overnight leave of absence if the following conditions are met:

1. The member's IPP, as developed by the IDT, provides for such absence; and

2. The leave of absence is reported in accordance with the Department's billing instructions.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-50, subsec. 144-101-II-50.06