C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-67, subsec. 144-101-II-67.02

Current through 2024-51, December 18, 2024

Subsection 144-101-II-67.02 - ELIGIBILITY FOR CARE

67.02-1General and Specific Requirements

MaineCare coverage of NF services requires prior approval from the Department or its Authorized Entity. NF services are covered for an approved eligibility period for each MaineCare member. Beginning and end dates of the individual's eligibility period correspond to beginning and end dates for MaineCare reimbursement. MaineCare coverage shall end on the eligibility end date unless a new eligibility period has been authorized. A person is eligible to receive covered services if he or she meets: general MaineCare financial eligibility requirements and other eligibility requirements set forth in the MaineCare Eligibility Manual, medical eligibility requirements, as set forth in Section 67.02-3 and as documented on the MED form completed by the Department or its Authorized Entity, and other specific requirements for NF services.

67.02-2General Requirements. A person must meet the MaineCare financial eligibility requirements and other eligibility requirements set forth in the MaineCare Eligibility Manual, as determined by the Office of Integrated Access and Support.

67.02-3Medical Requirements

In order to receive services under this Section applicants must meet the eligibility requirements as set forth in this Section and as documented on the MED form. An applicant for services or a resident under this Section meets the medical eligibility requirements for admission to a nursing facility if he or she requires the services specified in 67.02-3(A) OR (B) OR (C), as determined or otherwise verified by the Department or its Authorized Entity and documented on the approved MED form. The timeframes used to determine medical eligibility are incorporated in the MED form. If an applicant or member is placed in a NF facility out of state, then the MED form that is completed by the Department or its Authorized Entity must be submitted as part of the out of state prior authorization process that is described in Chapter I, Section 1.14-2 of the MBM.

A. A person meets the medical eligibility requirements for NF services if he or she needs at least one (1) of the following services seven (7) days per week (unless otherwise specified) that are or otherwise would be performed by or under the supervision of a registered professional nurse:

1. intraarterial, intravenous, intramuscular, or subcutaneous injection, or intravenous feeding, all for treatment of unstable conditions requiring medical or nursing intervention. Daily insulin injections for an individual whose diabetes is under control do not meet the requirements of this Section;

2. nasogastric tube, gastrostomy, or jejunostomy feeding, for a new/recent (within past thirty (30) days) or unstable condition;

3. nasopharyngeal suctioning or tracheostomy care; however, care of a tracheostomy tube must be for a recent or unstable condition;

4. treatment and/or application of dressings when the physician has prescribed irrigation, the application of prescribed medication, or sterile dressings of stage III and IV decubitus ulcers, other widespread skin disorders (except psoriasis and eczema), or care of wounds, when the skills of a registered nurse are needed to provide safe and effective services (including, but not limited to, ulcers, second or third degree burns, open surgical sites, fistulas, 5. administration of oxygen on a regular and continuing basis when the person's medical condition warrants professional nursing observation, for a new or recent (within past thirty (30) days) condition;

5. administration of oxygen on a regular and continuing basis when the person's medical condition warrants professional nursing observation, for a new or recent (within past thirty (30) days) condition;

6. professional nursing assessment, observation and management of an unstable medical condition (observation must, however, be needed at least once per shift throughout the twenty-four (24) hours);

7. insertion and maintenance of a urethral or suprapubic catheter as an adjunct to the active treatment of a disease or medical condition may justify a need for skilled nursing care.

In such instances, the need for a catheter must be documented and justified in the person's medical record;

8. physical, speech/language, occupational, or respiratory therapy provided at least five (5) days per week as part of a planned program that is designed, established by, and provided by, and requires the professional skills of, a licensed or registered therapist. (Therapy services may be delivered by a qualified licensed or certified therapy assistant under the direction of a qualified professional therapist.) The findings of an initial evaluation and periodic reassessments must be documented in the person's medical record. Skilled therapeutic services must be ordered by a physician and be designed to achieve specific goals within a given time frame. With the exception of speech/language criteria outlined under 67.05-13 (E), maintenance or preventative therapy does not meet the requirements of this Section. A Continuous Positive Airway Pressure (CPAP) or Bilevel Positive Airway Pressure (BIPAP) system or the wearing of an airway clearance system vest does not meet the requirements of this Section;

9. services to manage a comatose condition;

10. care to manage conditions requiring a ventilator/ respirator at least three (3) days per week;

11. direct assistance from others is required for the safe management of an uncontrolled seizure disorder, (i.e.: grandmal) at least weekly; or

12. extensive assistance or total dependence with three (3) of the following five (5) activities of daily living:

(a) bed mobility;

(b) transfer;

(c) locomotion;

(d) eating; and

(e) toilet use (refer to 67.02-3(B)(2) below).

B. A person meets the medical eligibility requirements for NF services if he or she needs a combination of at least three (3) of the following services described in 67.02-3(B) below, including at least one (1) of the nursing services described in 67.02-3(B)(1), that are or otherwise would be performed by or under the supervision of a registered professional nurse.

1. Nursing Services

Nursing services include any of the following on a frequent basis of a minimum of three (3) days a week unless otherwise specified:

a. any physician-ordered services specified in 67.02-3(A) but provided on a frequent rather than daily basis;

b. professional nursing assessment, observation and management for impaired memory, and impaired recall ability, and impaired cognitive ability;

i. If an individual meets the threshold for deficits in cognition as defined in Sec. 67.01-19, but otherwise does not require professional nursing intervention at least three (3) days per week, then the individual shall be assessed in accordance with Section 67.02-3(C) below.

c. professional nursing assessment, observation, and management for problems including wandering, physical abuse, verbal abuse or socially inappropriate behavior;

i. If an individual meets the threshold for deficits in behavior as defined in Section 67.01-2 0, but otherwise does not require professional nursing intervention at least three (3) days per week, then the individual shall be assessed in accordance with Section 67.02-3(C) below.

d. physician-ordered occupational, physical, or speech-language therapy provided at least three (3) days a week as part of a planned program that is designed by, established by, provided by, and requires the professional skills of, a licensed or registered therapist. (Therapy services may be delivered by a qualified licensed or certified therapy assistant, under the direction of a qualified professional therapist.) The findings of an initial evaluation and periodic reassessments must be documented in the member's medical record. Therapeutic services must be ordered by a physician for individuals twenty-one (21) years of age or older.

Rehabilitation potential (see Section 67.01-2 6) must be documented by the physician for these speech-language services for individuals twenty-one (21) years of age or older.

With the exception of speech/language criteria outlined under 67.05-13 (E), maintenance or preventative services do not meet the requirements of this Section.

e. administration of treatments (excluding: nebulizers, CPAP or BIPAP systems, and airway clearance system vest), procedures, or dressing changes which involve prescription medications, for post-operative or chronic conditions according to physician orders, that require nursing care and monitoring; or

f. professional nursing for physician ordered radiation therapy, chemotherapy, or dialysis.

2.Activities of Daily Living

At least "limited assistance" (defined in 67.01) and a "one person physical assist" (defined in 67.01) is needed with the following activities of daily living:

a.Bed Mobility: how person moves to and from lying position, turns side to side, and positions body while in bed;

b.Transfer: how person moves between surfaces to/from: bed, wheelchair, standing position (excluding to/from bath/toilet and dressing);

c.Locomotion: how person moves between locations on the same floor, in room and other areas. If in wheelchair, self-sufficiency once in chair;

d.Eating: how person eats and drinks (regardless of skill); and

e.Toilet Use: how person uses the toilet room (or commode, bedpan, urinal): transfers on/off toilet, cleanses, changes pad, manages ostomy or catheter, adjusts clothes.

C. An individual who meets the threshold for deficits in criteria 67.02-3 (B)(1)(b) cognition and/or (B)(1)(c) behavior, as defined in Section 67.01-1 9 and 67.01-20 respectively, but otherwise does not require professional nursing intervention at least three (3) days per week, then the individual shall be assessed using the criteria below. The individual shall be eligible for NF services if he or she has a qualifying score on the Cognitive Screen and/or Behavioral Screen, in combination with a need for at least "limited assistance" with an activity(ies) of daily living described in Section (B)(2), for a total of three (3) service needs. (e.g. Cognitive score =thirteen (13) points and two (2) ADL's; OR Cognitive score = thirteen (13) points and Behavioral score = fourteen (14) points and one (1) ADL; OR Behavioral score = fourteen (14) points and two (2) ADL's)

1.Cognition Screen Sixteen (16) points available, thirteen (13) required

a.Memory for Events

0 Can recall details and sequences of recent experiences and remember names of meaningful acquaintances.

1 Cannot recall details or sequences of recent events or remember names of meaningful acquaintances.

2 Cannot recall entire event or names of close friends or relatives (e.g., recent outings, visits of relatives or friends) without prompting.

3 Cannot recall entire event or name of spouse or other living partner even with prompting.

b.Memory and Use of Information

0 Does not have difficulty remembering and using information. Does not require directions or reminding from others.

1 Has minimal difficulty remembering and using information. Requires direction and reminding from others one (1) to three (3) times per day. Can follow written instructions.

2 Has difficulty remembering and using information. Requires direction and reminding from others four (4) or more times per day. Cannot follow written instructions.

4 Cannot remember or use information. Requires continual verbal reminding.

c. Global Confusion

0 Appropriately responsive to environment.

1 Nocturnal confusion on awaking.

2 Periodic confusion during daytime.

3 Nearly always confused.

d. Spatial Orientation

0 Oriented, able to find and keep his/her bearings.

1 Spatial confusion when driving or riding in local community.

2 Gets lost when walking in neighborhood.

3 Gets lost in own home or present environment.

e. Verbal Communication

0 Speaks normally.

1 Minor difficulty with speech or word-finding difficulties.

2 Able to carry out only simple, uncomplicated conversations.

3 Unable to speak coherently or make needs known.

2.Behavior Screen Twenty (20) points available, fourteen (14) required

a. Sleep Patterns

0 Unchanged from "normal" for the individual.

1 Sleeps, noticeably more or less "normal".

2 Restless, nightmares, disturbed sleep, increased awakenings.

4 Up wandering for all or most of the night, inability to sleep.

b. Wandering

0 Does not wander.

1 Does not wander. Is chair bound or bed bound.

2 Wanders within the facility or residence and may wander outside, but does not jeopardize health and safety.

3 Wanders within the facility or residence. May wander outside; health and safety may be jeopardized. Does not have history of getting lost and is not combative about returning.

4 Wanders outside and leaves grounds. Has a consistent history of leaving grounds, getting lost or being combative about returning. Requires a treatment plan that may include the use of psychotropic drugs for management and safety.

c. Behavioral Demands on Others

0 Attitudes, habits and emotional states do not limit the individual's type of living arrangement and companions.

1 Attitudes, habits and emotional states limit the individual's type of living arrangement and companions.

3 Attitudes, disturbances and emotional states create consistent difficulties that are modifiable to manageable levels. The individual's behavior can be changed to reach the desired outcome through respite, in-home services, or existing facility staffing.

4 Attitudes, disturbances and emotional states create consistent difficulties that are not modifiable to manageable levels. The individual's behavior cannot be changed to reach the desired outcome through respite, in-home services, or existing facility staffing, even with training for the caregiver.

d. Danger to Self and Others

0 Is not disruptive or aggressive, and is not dangerous.

1 Is not capable of harming self or others because of mobility limitations (is bed bound or chair bound).

2 Is sometimes (one (1) to three (3) times in the last seven (7) days) disruptive or aggressive, either physically or verbally, or is frequently extremely agitated or anxious, even after proper evaluation and treatment.

3 Is frequently (four (4) or more times during the last seven (7) days) disruptive or aggressive, or is frequently extremely agitated or anxious, and professional judgment is required to determine when to administer prescribed medication.

4 Is dangerous or physically abusive, and even with proper evaluation and treatment, may require physician's orders for appropriate interventions.

e. Awareness of Needs/Judgment

0 Understands those needs that must be met to maintain self care.

1 Sometimes (one (1) to three (3) times in the last seven (7) days) has difficulty understanding those needs that must be met, but will cooperate when given direction or explanation.

2 Frequently (four (4) or more times during the last seven (7) days) has difficulty understanding those needs that must be met, but will cooperate when given direction or explanation.

3 Does not understand those needs that must be met for self care and will not cooperate even though given direction or explanation.

67.02-4Other Specific Requirements

Nursing facility services are covered under the MaineCare program if an applicant is determined to be medically eligible, according to 67.02-3(A) OR (B) OR (C), and when all of the following conditions are met:

A. An applicant who meets the NF medical eligibility criteria in 67.02-3 has been informed of, and offered the choice of, available, appropriate, and cost-effective home and community-based services and alternatives to NF placement. The relative costs to the applicant of each option must be explained.

B. The Assessment Form and the preadmission screening (PASARR) for mental illness and intellectual disability have been completed, or the applicant is otherwise exempt (see Section 67.05-1 ).

C. The applicant (or applicant's guardian, or applicant's agent or surrogate, as defined in 18-A MRSA Sec.5 - 801 and evidenced by a valid, signed document on file at the NF, available upon request) selected placement in the nursing facility as documented by a signed choice letter.

D. The nursing facility to be reimbursed has the signed orders for NF services by the physician responsible for the care of the resident. The medical care of each resident must be supervised by a physician.

E. No Medicare or other third-party payment is available for the services, in accordance with Chapter I, MaineCare Benefits Manual.

67.02-5Medical Requirements for Acquired Brain Injury (ABI) Services

A person meets the medical eligibility requirements for NF ABI services if he or she has been determined to meet the NF eligibility requirements of the following ABI criteria as determined or otherwise verified by the Department or its Authorized Entity.

A. Has a diagnosis of Acquired Brain Injury; and

B. The individual has received an assessment by a qualified neuropsychologist (as defined in the MBM, Rehabilitative Services, Section 102.08-5 B) and/or a licensed physician who is Board certified, or otherwise Board eligible in Physical Medicine and Rehabilitation; and

The assessment must at least:

1. Positively indicate the individual: is not in a persistent vegetative state, is able to demonstrate potential for physical and/or behavioral and/or cognitive rehabilitation; and shows evidence of moderate to severe behavioral and/or cognitive and/or functional disabilities; and

2. Result in specific rehabilitation goals, based upon the findings of the assessment, describing types and frequencies of therapies and expected outcomes and timeframes.

In order for services to be covered under the ABI rate of reimbursement, the assessment as described in 67.02-5(B) must be completed and a rehabilitation plan of care based upon the findings of the assessment must be in place. An assessment conducted up to no more than three (3) months prior to admission will be accepted.

C. Has completed a Health and Safety Assessment, Revised: 02/25/14 (the assessment can be found at the Department's Brain Injury Services website:http://www.maine.gov/dhhs/oads/disability/bi/index.shtml) administered by the Department or its Authorized Entity with an overall score of 0.1 or higher. An assessment conducted up to no more than three (3) months prior to admission will be accepted; and

D. Has completed a Mayo-Portland Adaptability Inventory - 4 administered by the Department or its Authorized Entity with an item score of 3 or higher for two of the following items. An assessment conducted up to no more than three (3) months prior to admission will be accepted:

a. Novel Problem Solving

b. Impaired Self-Awareness

c. Irritability, Anger, Aggression

d. Inappropriate Social Interactions

e. Fund of Information or Attention/Concentration or Memory

67.02-6Medical Requirements for Members requiring Ventilator Care Services

A. Effective 7/1/15, if CMS approves, in order for a member to be 15 medically eligible for Ventilator Care Services in a Nursing Facility, the Member must be ventilator dependent and may be admitted from the following locations:

1. An Intensive Care Unit if the Member is no longer in need of ICU level of care; or

2. An Acute Care Facility if the Member is clinically stable; or

3. From their residence if they are receiving ventilator support in the home and the conditions in the home environment are such that the Member may no longer be able to maintain a stable respiratory status.

B. Additionally, the Member must:

1. Have current documentation from a physician certifying the medical necessity of ventilator support; and

2. Be unable to meet his/her respiratory needs via non-invasive ventilation (CPAP, BiPAP, etc.)

67.02-7Extraordinary Circumstances (EC)

A. A nursing facility must request and receive written approval for a member's continued stay under "extraordinary circumstances." (Please refer to 67.05-4.). A NF MaineCare member whose length of stay has been reimbursed by MaineCare for more than one hundred-twenty (120) consecutive days may continue to stay in the NF due to "extraordinary circumstances" if it has been determined after documented discharge planning that:

1. There is no available, appropriate placement within a sixty (60) mile radius of the member's residence; AND

2. Discharge from the NF would pose serious risk to the individual's health, welfare, or safety.

The counting of one hundred-twenty (120) consecutive days may include short-term hospital stays (ten (10) or fewer days), but may not include any days accrued during an appeal process, which begins on the day the member requests an appeal with the Department (see Section 67.05-1 8).

B. MaineCare coverage for "extraordinary circumstances" shall be for a specified period approved by the Department. For coverage to continue beyond the approved period, the NF must submit a completed request form to the Department at least five (5) calendar days prior to the end date of the member's approved EC period. If appropriate, the Department will approve a new EC certification period. When a member is admitted to a hospital, the EC period ends on the date of admission. A member must be assessed by the Department or its Authorized Entity prior to the member's return to the NF as required under Section 67.05-2(B).

67.02-8Frequent Change in Care Settings

A. In order to promote the health and well-being of a member who has experienced frequent changes in health status, resulting in frequent changes in care settings (defined in 67.01-23), coverage for NF services may continue even though the member's health status has improved such that he or she no longer meets the Section 67.02-3 medical eligibility requirements for NF level care, and would otherwise be discharged, if the following additional criteria are met:

1. The member has lost medical eligibility for NF services at least twice, while receiving covered services in the NF, during the past nine (9) month period; and

2. The member has a chronic or unstable medical condition that would likely result in re-admission to the NF within three (3) months of discharge; and

3. The various settings (including home), within the last nine (9) months, must be listed, each facility identified with admission and discharge dates documented; and

4. The member (or member's guardian, or member's agent or surrogate, as defined in 18-A MRSA Sec.5 - 801 and evidenced by a valid, signed document on file at the NF, available upon request) chooses to continue to stay in the NF, as documented by a signed Choice Letter.

B. The member will be determined eligible pursuant to the requirements of this Section by the Department. The NF shall submit the above required information to the Department with a request for classification under this Section. If approved, a classification period will be established. The member must be reassessed within five (5) calendar days prior to the end date of the member's approved classification period, if an additional classification period is requested under this Section. The Department shall consider the member's recent history of frequent changes in care settings, as well as health status, and may continue to classify him/her for NF coverage under this Section as appropriate.

67.02-9Significant Change Assessment

A. If the NF believes the member has become medically eligible for NF services during a certified EC period, during an appeal or while awaiting placement for residential care, then the NF shall request a significant change eligibility assessment from the Department or its Authorized Entity. A significant change (see Section 67.01-2 5) MDS assessment and the most recent quarterly MDS assessment, prior to this change, must be submitted to the Department or its Authorized Entity. In order for the Department or its Authorized Entity to complete an Assessment Form, the significant change areas must impact on this Section's eligibility.

B. The significant change assessment process applies to current residents, whom the facility believes meet the medical eligibility criteria and are under appeal for denial of medical eligibility or have within the past year had an Assessment Form appealed and upheld as accurate by the Commissioner's final ruling in the appeal. It also applies to members receiving extraordinary circumstances or frequent change eligibility as exceptions to medical eligibility.

67.02-10Days Awaiting Placement for Residential Care Facility

Current nursing facility residents who have no federal third party coverage or long term care insurance coverage and who have been determined not medically eligible for MaineCare nursing facility benefits may continue to stay in the nursing facility subject to all of the following conditions:

A. The resident has received notice that he/she is not medically eligible for NF MaineCare benefits, the facility has initiated the discharge process, and has determined that there is no safe and appropriate placement currently available.

B. The individual meets the medical and financial eligibility requirements for MaineCare coverage in a cost reimbursed residential care facility, as determined by the regional Office of Integrated Access and Support.

C. The member met the MaineCare medical eligibility criteria for NF in effect at the time of admission to the nursing facility.

D. The nursing facility continually pursues discharge of the member. The nursing facility shall continue to document in the member's record all efforts to locate appropriate placement.

E. The member accepts the first available, appropriate placement within a sixty (60) mile radius of the facility or the member's home, if applicable.

The member may accept a placement beyond the sixty (60) mile radius. However, this is not required. The nursing facility must notify the Department if a member refuses a placement meeting these criteria. If the member refuses this placement, the Department will issue a thirty (30) day notice to the nursing facility that reimbursement will terminate.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-67, subsec. 144-101-II-67.02