96.02-4Medical Eligibility RequirementsApplicants for services under this Section must meet the eligibility requirements as set forth in this Section and as documented on the Medical Eligibility Determination form. A Member meets the medical eligibility requirements for a particular level of care if he or she requires a combination of assistance with the following services: medication administration, the required numbers of Activities of Daily Living and/or Instrumental Activities of Daily Living and nursing services, as appropriate. The requirements for each level of care are defined below. The clinical judgment of the Department's Assessing Services Agency shall be the basis of the scores entered on the Medical Eligibility Determination form.
Medical eligibility and the scores for criteria: (l) extensive assistance or total dependence, (m) behavior and (n) cognition, as well as, the Activities of Daily Living and the Instrumental Activities of Daily Living, must be reviewed in the context of an individual's age-appropriate development. A child or infant shall not qualify for covered services by virtue of scoring high dependency requirements with the ADLs or IADLs, or the aforementioned criteria, when these dependency requirements are normal for the child's age. The clinical judgment of the Department's Assessing Services Agency, or the PDN provider as required (for individuals under age 21), shall be determinative of the scores on the medical eligibility determination assessment.
Determination of Eligibility
A registered nurse trained in conducting assessments with the Department's approved MED form, shall conduct the medical eligibility assessment. In the process of completing the assessment the nurse assessor shall use professional nursing judgement. The assessor shall, as appropriate within the exercise of professional nursing judgment, consider documentation, perform observations, and conduct interviews with the applicant/Member, family Members, direct care staff, the applicant's/Member's physicians, and other individuals and document in the record of the assessment all information considered relevant in his or her professional judgment.
A.Level IA Member meets the medical eligibility requirements for Level I if he or she requires:
1. cuing 7 days per week for eating, toilet use, bathing, and dressing; or2. limited assistance and a 1 person physical assist with at least 2 ADLs; or3. limited assistance and a one person physical assist with at least 1 ADL plus physical assistance with at least 2 IADLs; or4. any of the following nursing services, at least once per month, that are or otherwise would be performed by or under the supervision of a registered professional nurse: a. intraarterial, intravenous, intramuscular, or subcutaneous injection, or intravenous feeding, for treatment of unstable conditions requiring medical or nursing intervention; other than daily insulin injections for an individual whose diabetes is under control;b. nasogastric tube, gastrostomy, or jejunostomy feeding, for a new/recent (within past 30 days) or unstable condition;c. nasopharyngeal suctioning or tracheostomy care; however, care of a tracheostomy tube must be for a recent (within the last 30 days) or unstable condition;d. 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, 2nd or 3rd degree burns, open surgical sites, fistulas, tube sites, and tumor erosions);e. administration of oxygen on a regular and continuing basis when the Member's medical condition warrants professional nursing observations, for a new or recent (within past 30 days) condition;f. 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 Member's medical record;g. services to manage a comatose condition;h. care to manage conditions requiring a ventilator/respirator;i. direct assistance from others is required for the safe management of an uncontrolled seizure disorder, (i.e.grand mal);j. professional nursing assessment, observation, and management for problems including wandering, or physical abuse, or verbal abuse or socially inappropriate behavior;k. professional nursing assessment, observation and management for impaired memory, and impaired recall ability, and impaired cognitive ability;l. administration of treatments, procedures, or dressing changes which involve prescription medications, for post-operative or chronic conditions according to physician orders, that require nursing care and monitoring. Treatments include: (i) administration of medication via a tube;(iii) urinary catheter change;(iv) urinary catheter irrigation;(v) barrier dressings for stage 1 or 2 ulcers;(vii) oxygen therapy by RN;(viii) other physician ordered treatments; or(ix) teaching and training activities for patient and family; orm. professional nursing for physician ordered radiation therapy, chemotherapy, or dialysis.B.Level IIA person meets the medical eligibility requirements for Level II, if he or she meets the criteria for requiring (B)(1) nursing services and assistance with (B)(2) activities of daily living as described below:
1.Nursing ServicesTo meet the nursing services criteria, a person must need any of the following services, at least once per month, that are or otherwise would be performed by or under the supervision of a registered professional nurse, as described below:
a. intraarterial, intravenous, intramuscular, or subcutaneous injection, or intravenous feeding, for treatment of unstable conditions requiring medical or nursing intervention; other than daily insulin injections for an individual whose diabetes is under control;b. nasogastric tube, gastrostomy, or jejunostomy feeding, for a new/recent (within past 30 days) or unstable condition;c. nasopharyngeal suctioning or tracheostomy care; however, care of a tracheostomy tube must be for a recent (within the last 30 days) or unstable condition;d. 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, 2nd or 3rd degree burns, open surgical sites, fistulas, tube sites, and tumor erosions);e. administration of oxygen on a regular and continuing basis when the Member's medical condition warrants professional nursing observations, for a new or recent (within past 30 days) condition;f. professional nursing assessment, observation and management of a medical condition;g. 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 Member's medical record;h. services to manage a comatose condition;i. care to manage conditions requiring a ventilator/respirator;j. direct assistance from others is required for the safe management of an uncontrolled seizure disorder, (i.e. grand mal);k. professional nursing assessment, observation, and management for problems including wandering, or physical abuse, or verbal abuse or socially inappropriate behavior;l. professional nursing assessment, observation and management for impaired memory, and impaired recall ability, and impaired cognitive ability;m. administration of treatments, procedures, or dressing changes which involve prescription medications, for post-operative or chronic conditions according to physician orders, that require nursing care and monitoring; (i) administration of medication via a tube;(iii) urinary catheter change;(iv) urinary catheter irrigation;(v) barrier dressings for stage 1 or 2 ulcers;(vii) oxygen therapy by RN;(viii) other physician ordered treatments; or(ix) teaching and training activities for patient and family; orn. professional nursing for physician ordered radiation therapy, chemotherapy, or dialysis.2.Activities of Daily LivingAn individual must require daily (7 days per week) cuing for all of the following ADLs: eating, toilet use, bathing, dressing; or, at least limited assistance and a one person physical assist is needed with at least any 2 activities of daily living.
C.Level III1. A person meets the medical eligibility requirements for Level III if he or she requires at least limited assistance and a one person physical assist with 2 of the following ADLs: bed mobility, transfer, locomotion, eating, or toileting, and if he or she meets the criteria for nursing services below.2. To meet the nursing services criteria, a person must need any of the following services, at least once per month, that are or otherwise would be performed by, or under the supervision of, a registered professional nurse, as described below:a. intraarterial, intravenous, intramuscular, or subcutaneous injection, or intravenous feeding, for treatment of unstable conditions requiring medical or nursing intervention, other than daily insulin injections for an individual whose diabetes is under control;b. nasogastric tube, gastrostomy, or jejunostomy feeding, for a new/recent (within the last 30 days) or unstable condition;c. nasopharyngeal suctioning or tracheostomy care; however, care of a tracheostomy tube must be for a recent, (within the last 30 days) or unstable condition;d. 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, 2nd or 3rd degree burns, open surgical sites, fistulas, tube sites, and tumor erosions);e. administration of oxygen on a regular and continuing basis when the Member's medical condition warrants professional nursing observations, for a new or recent (within last 30 days) condition;f. professional nursing assessment, observation and management of a medical condition;g. 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 Member's medical record;h. services to manage a comatose condition;i. care to manage conditions requiring a ventilator/respirator;j. direct assistance from others is required for the safe management of an uncontrolled seizure disorder, (i.e. grand mal);k. professional nursing assessment, observation, and management for problems including wandering, or physical, or verbal abuse, or socially inappropriate behavior;l. professional nursing assessment, observation and management for impaired memory, and impaired recall ability, and impaired cognitive ability;m. administration of treatments, procedures, or dressing changes that involve prescription medications for post-operative or chronic conditions according to physician orders and require nursing care and monitoring; orn. professional nursing for physician ordered radiation therapy, chemotherapy, or dialysis.D.Level IVAn individual who is under 21 years of age is eligible for Level IV, if he or she meets the medical eligibility requirements set forth in Section 67.02-3, "Nursing Facility Services", of the MaineCare Benefits Manual.
E.Level VA person meets the medical eligibility requirements for Level V if he or she requires either (1) or (2) below.
1. Daily (7 days per week) nursing services and ventilator support for a person who is ventilator-dependent; Or
2.a. Daily (7 days per week), 24-hour nursing care for at least one of the following treatments and procedures: 96.02-4(B)(1)(a); (b); (c); (d); (h) or (j); required every 8 hours (or all 3 shifts), which are, or otherwise would be, performed by an RN or LPN; And
b. Daily (7 days per week) nursing care for at least any 2 of the following professional nursing services: 96.02-4(B)(1)(a); (b); (c); (d); (h); or (j).F.Level VI Medication and Venipuncture Services for Members who are Severely Mentally Disabled. An individual meets the medical eligibility requirements for Level VI if the following are met:
1. The individual meets the eligibility requirements for services under Section 17, "Community Support Services for Persons with Severe and Persistent Mental Illness", and requires medication administration or monitoring services for the treatment of mental illness. The Member's eligibility shall be established by a completed "verification of eligibility form" described in Section 17, or otherwise by a signed certification by a physician that the Member is eligible/covered under Section 17. Dated copies of this form/certification must be maintained in the Member's record to verify eligibility for covered services; and
2. A physician must sign and certify a statement that the Member's medical condition prevents the safe use of outpatient services and outpatient services are contraindicated for specific reasons. The reasons must be listed and the likelihood of such a bad result must be probable or definite as opposed to possible or rare. Reasons may include lack of services within a 20 mile radius of the Member's residence. MaineCare covers transportation to all MaineCare covered services, therefore, lack of transportation does not qualify as an exemption.G.Level VII Venipuncture Only Services An individual meets the medical eligibility requirements for Level VII if the following are met:
1. The individual requires only venipuncture services on a regular basis, as ordered by a physician; and
2. A physician must sign and certify a statement that the Member's medical condition prevents the safe use of outpatient services and outpatient services are contraindicated for specific reasons. The reasons must be listed and the likelihood of such a bad result must be probable or definite as opposed to possible or rare. Reasons may include lack of services within a 20 mile radius of the Member's residence. MaineCare covers transportation to all MaineCare covered services, therefore, lack of transportation does not qualify as an exemption.H.Level VIII Nursing Services Only for Members receiving Personal Care Services under other Sections of the MBM. A Member meets the requirements for Level VIII if he or she is receiving personal care services under any of the following Sections: Section 2, "Adult Family Care Services"; Section 12, "Consumer Directed Attendant Care Services"; Section 97, "Private Non-Medical Institution Services"; and Section 21, "Home and Community-Based Waiver Services for Members with Intellectual Disabilities or Autism Spectrum Disorder ", or Level IX under this Section and requires any of the following nursing services, at least once per month, 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, for treatment of unstable conditions requiring medical or nursing intervention; other than daily insulin injections for an individual whose diabetes is under control;2. nasogastric tube, gastrostomy, or jejunostomy feeding, for a new/recent (within past 30 days) or unstable condition;3. nasopharyngeal suctioning or tracheostomy care; however, care of a tracheostomy tube must be for a recent (within the last 30 days) 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, 2nd or 3rd degree burns, open surgical sites, fistulas, tube sites, and tumor erosions);5. administration of oxygen on a regular and continuing basis when the Member's medical condition warrants professional nursing observations, for a new or recent (within past 30 days) condition;6. 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 Member's medical record;7. services to manage a comatose condition;8. care to manage conditions requiring a ventilator/respirator;9. direct assistance from others is required for the safe management of an uncontrolled seizure disorder, (i.e. grand mal);10. professional nursing assessment, observation, and management for problems including wandering, or physical abuse, or verbal abuse or socially inappropriate behavior;11. professional nursing assessment, observation and management for impaired memory, and impaired recall ability, and impaired cognitive ability;12. administration of treatments, procedures, or dressing changes which involve prescription medications, for post-operative or chronic conditions according to physician orders, that require nursing care and monitoring. Treatments include: a. administration of medication via a tube;c. urinary catheter change;d. urinary catheter irrigation;e. barrier dressings for stage 1 or 2 ulcers;h. other physician ordered treatments; ori. teaching and training activities for patient and family.13. professional nursing for physician ordered radiation therapy, chemotherapy, or dialysis.I.Level IX Personal Care Services for Members with Daily Medication Needs. An individual meets the medical eligibility requirements for Level IX if the following are met:
1. The individual requires daily assistance with medication administration for routine prescription medications delivered by a CRMA and physical assistance with at least 2 IADLs, Or2. The individual requires daily assistance with medication administration for routine prescription medications delivered by a CRMA and physical assistance with at least 1 ADL.