C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-93, subsec. 144-101-II-93.03

Current through 2025-02, January 8, 2025

Subsection 144-101-II-93.03 - MEMBER ELIGIBILITY

Members must meet the eligibility requirements set forth in this section.

93.03-1General 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.

93.03-2Specific Requirements

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

Members must be diagnosed with Substance Use Disorder, Opioid (as set forth in the Diagnostic and Statistical Manual of Mental Disorders (5th ed. DSM-5)); 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. a mental health condition;

2. an additional substance use disorder (other than OUD);

3. tobacco use;

4. diabetes;

5. heart disease;

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

7. Chronic Obstructive Pulmonary Disease (COPD);

8. hypertension;

9. hyperlipidemia;

10. developmental and intellectual disorders;

11. circulatory congenital abnormalities;

12. asthma;

13. acquired brain injury; and

14. seizure disorders.

B.Definition of at Risk of another Chronic Condition

Members shall be assessed by the OHH providers for high risk behaviors and other risk factors that may contribute to chronic conditions such as, but not limited to: smoking; obesity; poor nutrition; childhood trauma; risky sex practices; intravenous drug use; history of or current substance use other than opioids; and family health issues.

93.03-3Eligibility 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-93, subsec. 144-101-II-93.03