Subsection 144-101-II-96.03 - DURATION OF CAREEach Title XIX and XXI Member may receive as many covered services as are medically necessary within the following limitations and exceptions as described below. MaineCare coverage of services under this Section requires prior approval from the Department or its Assessing Services Agency. Beginning and end dates of an individual's medical eligibility determination period correspond to the beginning and end dates for MaineCare coverage of the plan of care approved by the ASA or the Department.
A.Exception to the Limit: For all individuals under the age of 21 years, the caps described in Sections 96.03(B), (C) and (D), may be exceeded if services beyond these levels are determined medically necessary pursuant to the criteria described in "Prevention, Health Promotion and Optional Treatment Services", formerly EPSDT, of the MaineCare Benefits Manual. A determination of medical necessity for PDN/PCS shall not be determinative of medical necessity under "Prevention, Health Promotion and Optional Treatment Services". These additional services require prior authorization by the Department as described in Chapter I, Section 1, "General Administrative Policies and Procedures" and Chapter II, Section 94, "Prevention, Health Promotion, and Optional Treatment Services". Limits (when applicable) for individuals under age 21 years shall be based upon a yearly cap to better serve children who have episodic service needs.
B. Except as described in (A) above, for individuals classified for Levels of care I, II, III, VIII, or IX, the total monthly cost of covered private duty nursing, and personal care services, either alone or in combination with home health services provided under Chapters II & III, Section 40 of the MaineCare Benefits Manual, may not exceed the monthly Level I, II, III, VIII and IX caps established by the Department and the plan of care authorized by the ASA on the MED form. The amount of services an individual Member is authorized to receive is based upon the Member's MED assessment outcome scores. The Level I, II, III, VIII and IX caps are tied to allowing coverage for a range of services to meet the medical and excluding Level VIII, personal care service needs of each level.C. Except as described in (A) above, for individuals classified for Level IV of care, the total cost of private duty nursing and personal care services, either alone or in combination with home health services provided under Chapters II & III, Section 40 of the MaineCare Benefits Manual, may not exceed 100% of the average MaineCare annual cost of NF institutional services.D. Except as described in (A) above, for all individuals who are determined medically eligible for Level V care, the total monthly cost of private duty nursing and personal care services, either alone or in combination with home health services provided under Chapters II & III, Section 40 of the MaineCare Benefits Manual, may not exceed the monthly Level V cap established by the Department. The Department reserves the right to request additional information to evaluate medical necessity.E. Members who are receiving any of the following MaineCare services may only access nursing services under this Section, and are prohibited from receiving duplicative personal care services under this Section, since personal care services are provided under these Sections: Section 2, "Adult Family Care Services"; Section 12, "Consumer Directed Attendant Care Services"; Section 97, "Private Non-Medical Institution Services"; Section 18, "Home and Community-Based Services for Adults with Brain Injury", Section 19, "Home and Community-Based Services for Elders and Adults with Disabilities", Section 20, "Home and Community-Based Services for Adults with Other Related Conditions", Section 21, "Home and Community-Based Waiver Services for Members with Intellectual Disabilities or Autism Spectrum Disorder", and Section 29, "Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder."F. Services under this Section may be denied, reduced, suspended, or terminated by the Department, its Authorized Entity, or the PDN provider, as appropriate, for the following reasons: 1. A significant change occurs in the Member's medical status such that an authorized plan of care under this Section can no longer be developed; or2. The Member becomes an inpatient of a hospital, nursing facility, ICF-IID; or3. The Member is not medically eligible to receive services under this Section or financially eligible to receive Title XIX or XXI benefits; or4. Based upon the most recent MED assessment, the plan of care service authorization may be reduced to match the Member's needs as identified in the reassessment and subject to the limitations of the service cap, as follows: a. for Members age 21 and over, and those under age 21 receiving care under the family provider services option, and excluding those classified for medication services or venipuncture services under this Section according to the clinical judgment of the Department, the ASA or Service Coordination Agency;b. for Members under age 21, as well as those classified for medication services or venipuncture services under this Section, by the Department or the PDN provider; but excluding those receiving care under the family provider services option; or5. The Member declines services; or6. The Member refuses personal care or nursing services; or7. The Department, ASA, or the provider documents that the Member, or someone living in or frequently visiting the household, harasses, threatens, or endangers the health or safety of individuals delivering services; or8. The Member begins receiving any of the following MaineCare services: Section 2, "Adult Family Care Services"; Section 12, "Consumer Directed Attendant Care Services"; Section 18, "Home and Community-Based Services for Adults with Brain Injury"; Section 19, "Home and Community Benefits for Elderly and Adults with Disabilities"; Section 20, "Home and Community-Based Services for Adults with Other Related Conditions"; Section 97, "Private Non-Medical Institution Services"; Section 21, "Home and Community-Based Waiver Services for Members with Intellectual Disabilities or Autism Spectrum Disorder"; and Section 29, "Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder", in which case the personal care services are not covered under this Section.G.Suspension. Services may be suspended for up to 60 days. If such circumstances extend beyond 60 days, the member's service coverage under this Section will be terminated and the member will need to be reassessed to determine medical eligibility for these services. As described in Section 96.03(B), (C), and (D) above, the monthly cost of private duty nursing and personal care services, in combination with home health services under Section 40, must not exceed the monthly cap for the approved PDN level. If a member has a skilled need for short-term nursing services, the PDN services may be suspended, for up to 60 days, if the cost of the Section 40 home health services in combination with private duty nursing and personal cares services would exceed the cost cap for the approved PDN level of care.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-96, subsec. 144-101-II-96.03