Section 197-11-03 - DURATION OF SERVICESEach Consumer Directed Home Based Care consumer may receive as many covered services as identified, documented and authorized on the MED form, as required, within the limitations and exceptions described below. Home Based Care coverage of services under this Section requires prior authorization from the Department or its Authorized Agent. Beginning and end dates of an individual's medical eligibility determination period correspond to the beginning and end dates for Home Based Care coverage of the plan of service authorized by the Authorized Agent or the Department. The services provided must be reflected in the Service Plan and based upon the authorized covered services documented in the care plan summary of the MED form. The Maximum Authorized Service amount is 40 hours of services per week.
(A)The total monthly cost of services may not exceed the lesser of the monthly plan of service authorized by the Authorized Agent or the monthly cap, established by the Department.(B) Suspension. Services will be suspended if the consumer is hospitalized or using institutional care. If such circumstances extend beyond thirty (30) days the consumer must be reassessed to determine appropriate services. Upon discharge from a hospital or institutional care facility, the consumer's previous level of service will resume until a reassessment is conducted. The reassessment will be conducted within two weeks following the consumer's discharge from the hospital or institutional care facility.(C) Services under this Section may be suspended, reduced, denied or terminated by the Department or the Authorized Agent, as appropriate depending on the nature and severity of the situation, for the following reasons:(1) The consumer does not meet eligibility requirements;(2) The consumer declines services;(3) The consumer is eligible to receive services under a MaineCare program, including any MaineCare Home or Community Based waiver program or a State funded long term care services program;(4) Based on the consumer's most recent MED assessment, the plan of service is reduced to match the consumer's needs as identified in the reassessment and subject to the limitations of the program cap;(5) The health or safety of the consumer or of individuals providing services is endangered;(6) Consumer refuses personal assistance services;(7) Consumer has failed to make his/her calculated monthly co-payment within thirty (30) days of receipt of the co-pay bill;(8) When the consumer gives fraudulent information, including, but not limited to assessment information and reporting, payroll records, and all other recordkeeping documents to theDepartment of Health and Human Services or the Authorized Agent;(9) The consumer fails to personally manage an assistant;(10) The consumer is using program funds to pay the Personal Assistant to complete tasks outside the covered services described in Section 11.04;(11) Failure of a consumer to demonstrate the skills necessary to successfully manage his/her personal-health maintenance, including management of the PA in compliance with these rules;(14) The consumer endorses or attempts to endorse a check that is made payable to the PA;(15) The consumer fails to carryout his/her responsibilities for FICA withholding, unemployment insurance or worker's compensation insurance;(16) In the event that a consumer is found to have used program funds in violation of the requirements of this section, the consumer must reimburse the Authorized Agent for all such funds before being subsequently considered for services under this Chapter.(17) In the event that services have been denied or terminated by the Authorized Agent or the Department for any of the reasons included in this section, such actions will be afactor in determining eligibility in any subsequent application for services under this rule. Notice of intent to reduce, deny, or terminate services under this section will be done in accordance with Section 11.13 of this rule.
14- 197 C.M.R. ch. 11, § 03