Section 144-332-14-3 - MEDICAL NEED CLASSIFICATIONIn order for Medicaid to pay for nursing facility care the person must be in medical need of that level of care. This decision is made by the Department of Health and Human Services or its designee.
Section 3.1:Individuals ineligible due to a transfer of assetsIf the individual meets the medical need criteria but is ineligible for help with long term care costs due to a transfer of assets, the Categorically Needy Income Limit in Chart 4.1 is used to determine Medicaid eligibility.
Section 3.2:Individuals who are not in need of nursing facility level of careI. If an individual in a Nursing Facility does not meet the medical need criteria, that person may still be eligible for Medicaid coverage if the individual would be eligible if they were living in the community. Coverage is determined using the rules in Parts 6, 7 and 10 for an individual in the living arrangement, "living alone or with others". In this situation, Medicaid will not pay for nursing care costs nor can they be used toward meeting a deductible.II. Awaiting Placement for Residential Care (DAP or APRC). If an individual is in need of residential care but there are no beds available the individual may remain in the nursing facility as awaiting placement to a residential care facility. This coverage is for individuals converting from private pay including Medicare to Medicaid and found not in need of nursing facility level of care. MaineCare may help the individual with the cost of care if they meet eligibility criteria below. The Office of MaineCare Services sets the APRC rates (Chart 3.8). A. The Office of Aging and Disability Services (OADS) must establish that the individual meets non-financial criteria as identified in the MaineCare Benefits Manual.B. The following financial criteria must be met: 1. the asset and all non-financial criteria are the same as for an individual residing in a Residential Care Facility (RCF). See Part 12;2. countable income is determined using the same rules as for an individual residing in a RCF; and 3. the individual's countable income must be less than the APRC amount. A cost of care to be paid to the nursing facility is determined using the same rules as for an individual in a RCF. SSI and State Supplement benefits are counted when determining the cost of care. If countable income is equal to or over the APRC amount, the daily rate can be used as the cost incurred for medical expenses in determining a "spend-down" (deductible).
C. If countable income is equal to or less than the Community Medicaid income limit for the individual's coverable group, they can get Medicaid coverage in addition to help with the cost of room and board under APRC.D. If countable income is over this amount, but less than the APRC amount, the individual is eligible for APRC only (not Medicaid).E. Coverage under APRC ends when: 1. the Office of Aging and Disability Services (OADS) determines the individual no longer meets the non financial criteria as identified in the MaineCare Benefits Manual; or2. the individual becomes financially ineligible.10- 144 C.M.R. ch. 332, § 14-3