C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-89, subsec. 144-101-II-89.03

Current through 2024-51, December 18, 2024

Subsection 144-101-II-89.03 - MEMBER ELIGIBILITY

To receive MaineMOM services, members must meet the eligibility requirements set forth in this section.

89.03-1General Eligibility

Members must meet the eligibility criteria described in Chapter I, Section 1 of the MBM and in the MaineCare Eligibility Manual, 10-144 Chapter 332.

89.03-2Specific Requirements

All diagnoses and qualifying risk factors must be documented in the member's Care Plan.

Members must be diagnosed with an OUD, in accordance with the current version of the DSM; AND have a second chronic condition OR be at risk of having a second chronic condition.

A. Eligible Chronic Conditions as Second Chronic Condition:

1. mental health condition;

2. additional SUD (other than OUD);

3. tobacco use;

4. diabetes;

5. heart disease;

6. overweight or obesity as evidenced by a body mass index over 25;

7. chronic obstructive pulmonary disease (COPD);

8. hypertension;

9. hyperlipidemia;

10. developmental and intellectual disorder;

11. circulatory congenital abnormality;

12. asthma;

13. acquired brain injury; or

14. seizure disorder.

B. Definition of at Risk of another Chronic Condition

A member is deemed to be at risk of another chronic condition if the member has high risk behaviors and other factors that may contribute to chronic conditions such as, but not limited to:

1. smoking;

2. obesity;

3. poor nutrition;

4. childhood trauma;

5. risky sexual practices;

6. intravenous drug use;

7. history of or current substance use other than opioids; and

8. family health issues.

89.03-3Eligibility Certification

Providers must submit certification requests to the Department or its authorized entity. Each member's eligibility shall be based on a diagnosis rendered within the past year from the date of the certification request, as documented by a professional whose scope of practice includes the ability to diagnose. Reassessments shall occur at least annually in order to ensure ongoing eligibility for services provided herein.

Providers shall maintain a member's eligibility verification in the member's record.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-89, subsec. 144-101-II-89.03