SECTION 63: IN-HOME AND COMMUNITY SUPPORT SERVICES FOR ELDERLY AND OTHER ADULTS
63.01 DEFINITIONS
(A) In-Home and Community Support Services for Elderly and Other Adults, hereinafter referred to as Home Based Care (HBC), is a state funded program to provide long term care services to assist eligible consumers to avoid or delay inappropriate institutionalization. Provision of these services is based on the availability of funds. State funds furnished through 22 M.R.S.A. §7301-7306 and §7321-7323 may not be used to supplant the resources available from families, neighbors, agencies and/or the consumer or from other Federal, State programs unless specifically provided for elsewhere in this section. State HBC funds shall be used to purchase only those covered services that are essential to assist the consumer to avoid or delay inappropriate institutionalization and which will foster independence, consistent with the consumer's circumstances and the authorized plan of care.
(B) Activities of daily living (ADLs). For purposes of eligibility ADLs shall only include the following as defined in Section 63.02(B): bed mobility, transfer, locomotion, eating, toileting, bathing and dressing.
(C) Acute/Emergency. Acute/Emergency means an unscheduled occurrence of an acute episode that requires a change in the physician ordered treatment plan or an unscheduled occurrence where the availability of the consumer’s informal support or caregiver is compromised.
(D) Assessing Services Agency (ASA) Assessing Services Agency means an organization authorized through a written contract with Bureau of Elder and Adult Services to conduct face-to-face assessments, using the Department’s Medical Eligibility Determination (MED) form, and the timeframes and definitions contained therein, to determine medical eligibility for covered services. Based upon a recipient’s assessment outcome scores recorded in the MED form, the Assessing Services Agency is responsible for authorizing a plan of care, which shall specify all services to be provided under this Section, including the number of hours for services, and the provider types. The Assessing Services Agency is the Department’s Authorized Agent for medical eligibility determinations and care plan development, and authorization of covered services under this Section.
(E) Authorized Agent means an organization authorized by the Department to perform functions under a valid contract or other approved, signed agreement. The Assessing Services Agency and the Home Care Coordinating Agency are Authorized Agents under this Section.
(F) Authorized Plan of Care means a plan of care which is authorized by the Assessing Services Agency, or the Department, which shall specify all services to be delivered to a recipient under this Section, including the number of hours for all covered services. The plan of care shall be based upon the recipient’s assessment outcome scores, and the timeframes contained therein, recorded in the Department’s Medical Eligibility Determination (MED) form. The Assessing Services Agency has the authority to determine and authorize the plan of care. All authorized covered services provided under this Section must be listed in the care plan summary on the MED form.
(G) Behavior threshold. Problem behavior is wandering with no rationalpurpose; or verbal abuse; or physical abuse; or socially inappropriate/disruptive behavior. A “threshold” score for problem behavior on the Medical Eligibility Determination (MED) form is equal to a score of 2 or 3 on one of these four criteria and occurs at least 4 days per week.
(H) Care Plan Summary is the section of the MED form that documents the Authorized Plan of Care and services provided by other public or private program funding sources or support, and their service category, reason codes, duration, unit code, number of units per month, rate per unit, and total cost per month.
(I) Cognitive capacity: The consumer must have the cognitive capacity, as measured on the MED form, to be able to "self direct" the attendant in the self-directed option outlined in Section 63.02(B)(5). This capability will be determined by the Authorized Agent as part of the eligibility determination using the Medical Eligibility Determination (MED) findings. Minimum MED form scores are (a) decision making skills: a score of 0 or 1; (b) making self understood: a score of 0,1, or 2; (c) ability to understand others: a score of 0,1, or 2; (d) self performance in managing finances: a score of 0,1,or 2; and (e) support in managing finances, a score of 0,1,2, or 3. An applicant not meeting the specific scores will be presumed incapable of hiring, firing, training, and supervising the self-directed plan of care.
(J) Cognitive threshold. Cognition is the ability to recall what is learned or known and the ability to make decisions regarding tasks of daily life. Cognition is evaluated in terms of:
(1) Memory: short-term and long-term memory;
(2) Memory/recall ability during last seven (7) days, or 24-48 hours if in a hospital; and
(3) Cognitive skills for daily decision making on a scale including: independent; modified independence; moderately impaired; severely impaired;
A “threshold” score for “impaired cognition” on the Medical Eligibility Determination (MED) form is equal to a score of 1 for loss of short term memory and 2 of items A-D or E none for memory/recall ability and a score of 2 or 3 for cognitive skills for decision making.
(K) Covered Services are those services for which payment can be made by the Department, under Section 63 of the Bureau of Elder and Adult Services policy manual.
(L) Cueing shall mean any spoken instruction or physical guidance which serves as a signal to do an activity. Cueing is typically used when caring for individuals who are cognitively impaired.
(M) Dependent Allowances. Dependents and dependent allowances are defined and determined in agreement with the method used in the MaineCare. The allowances are changed periodically and cited in the MaineCare Eligibility Manual, TANF Standard of Need Chart. Dependents are defined as individuals who may be claimed for tax purposes under the Internal Revenue Code and may include a minor or dependent child, dependent parents, or dependent siblings of the consumer or consumer’s spouse. A spouse may not be included.
(N) Disability-related expenses: Disability-related expenses are out-of-pocket costs incurred by the consumers for their disability, which are not reimbursed by any third-party sources. They include:
(1) Home access modifications: ramps, tub/shower modifications and accessories, power door openers, shower seat/chair, grab bars, door widening, environmental controls;
(2) Communication devices: adaptations to computers, speaker telephone, TTY, Personal Emergency Response systems;
(3) Wheelchair (manual or power) accessories: lap tray, seats and back supports;
(4) Vehicle adaptations: adapted carrier and loading devices, one communication device for emergencies (limited to purchase and installation), adapted equipment for driving;
(5) Hearing Aids, glasses, adapted visual aids;
(6) Assistive animals (purchase only);
(7) Physician ordered medical services and supplies;
(8) Physician ordered prescription and over the counter drugs; and
(9) Medical insurance premiums, co-pays and deductibles.
(O) Extensive Assistance means although the individual performed part of the activity over the last 7 days, or 24 to 48 hours if in a hospital setting, help of the following type(s) was required and provided:
(1) Weight-bearing support three or more times, or
(2) Full staff performance during part (but not all) of the last 7 days.
(P)
Health Assessment shall be conducted by a
registered nurse for each Home Based Care consumer as authorized by the Assessing Services Agency in the careplan.
The assessment shall be used for the management of chronic, stable conditions.
The assessment must include the following components: physical vital signs,
weight (if the consumer is confined to a bed or the consumer’s weight or other
disability prevents the nurse from safely obtaining the weight, this
measurement may be postponed, observable weight changes should be noted),
comprehensive systems review, nutritional status, medication review and
compliance, health advice, environmental and social needs. The nurse shall communicate and follow-up
with the physician and/or other providers as necessary. The findings of the health assessment must
be forwarded to the Home Care Coordinating Agency.
(Q)
Health
Maintenance Activities are
activities designed to assist the consumer with Activities of Daily Living and
Instrumental Activities of Daily Living, and additional activities specified in
this definition. These activities are performed by a designated caregiver for a
competent self-directing individual that would otherwise perform the
activities, if he or she were physically able to do so and enable the
individual to live in his or her home and community. These additional activities include, but are not limited
to, catheterization, ostomy care, preparation of food and tube feedings, bowel
treatments, administration of medications, care of skin with damaged integrity,
occupational and physical therapy activities such as assistance with prescribed
exercise regimes.
(R) Home
Care Coordinating Agency. The Home Care Coordinating
Agency means an organization authorized, through a written contract with Bureau
of Elder and Adult Services to conduct a range of activities which includes the
following: coordinate and implement the services in the consumer’s plan of care
authorized by the Assessing Services Agency; ensure that authorized services in
the care plan summary are delivered according to the service authorizations;
reduce, deny, or terminate services under this section; serve as a resource to
consumers and their families to identify available service delivery options and
service providers; answer questions; and assist with resolving problems. The Home Care Coordinating Agency is also
responsible for administrative functions, including: maintaining consumer
records; processing claims; overseeing and assuring compliance with policy
requirements by any and all sub-contractors; final determination of the
consumer copayment on receipt of the required information and collection of
consumer co-payments: and conducting required utilization review activities.
(S) Income includes:
(1) Wages from work, including payroll deductions, excluding state and Federal taxes and employer mandated or court ordered withholdings;
(2) Benefits from Social Security, Supplemental Security Insurance, pensions, insurance, independent retirement plans, annuities, and Aid and Attendance;
(3) Adjusted gross income from property and/or business, based on the consumer's most recent Federal income tax; and
(4) Interest and dividends.
Not included are benefits from: the Home Energy Assistance Program, Food Stamps, General Assistance, Property Tax and Rent Refund, emergency assistance programs, or their successors.
(T) Instrumental
Activities of Daily Living (IADLs). For
purposes of the eligibility criteria
under this section of policy, IADLs
are defined in section 63.02 (B) and are limited to the following: main
meal preparation: preparation or
receipt of the main meal; routine housework; grocery shopping and storage of
purchased groceries; and laundry either within the residence or at an outside
laundry facility.
(U) Limited
Assistance means the individual was highly involved in
the activity over the past seven days, or 24 to 48 hours if in a hospital
setting, but received and required
· guided maneuvering of limbs or other non-weight bearing physical assistance three or more times or
· guided maneuvering of limbs or other non-weight bearing physical assistance three or more times plus weight-bearing support provided only one or two times
(V) Liquid asset is something of value available to the consumer that can be converted to cash in three months or less and includes:
(1) Bank accounts;
(2) Certificates of deposit;
(3) Money market and mutual funds;
(4) Life insurance policies;
(5) Stocks and bonds;
(6) Lump sum payments and inheritances; and
(7) Funds from a home equity conversion mortgage that are in the consumer’s possession whether they are cash or have been converted to another form.
Funds which are available to the consumer but carry a penalty for early withdrawal will be counted minus the penalty. Exempt from this category are mortuary trusts and lump sum payments received from insurance settlements or annuities or other such assets named specifically to provide income as a replacement for earned income. The income from these payments will be counted as income.
(W) Long term care needs are those needs determined as a result of completion of the Medical Eligibility Determination form, resulting from an individual's inability to manage ADLs and IADLs, as a result of physical, emotional, or developmental problems.
(X) A medical condition is unstable when it is fluctuating in an irregular way and/or is deteriorating and affects the client's ability to function independently. The fluctuations are to such a degree that medical treatment and professional nursing observation, assessment and management at least once every 8 hours is required. An unstable medical condition requires increased physician involvement and should result in communication with the physician for adjustments in treatment and medication. Evidence of fluctuating vital signs, lab values, and physical symptoms and plan of care adjustments must be documented in the medical record. Not included in this definition is the loss of function resulting from a temporary disability from which full recovery is expected.
(Y) Medical Eligibility Determination (MED) Form shall mean the form approved by the Department for medical eligibility determinations and service authorization for the plan of care based upon the assessment outcome scores. The definitions, scoring mechanisms and time-frames relating to this form as defined in Section 63 provide the basis for services and the care plan authorized by the Assessing Services Agency. The care plan summary contained in the MED form documents the authorized care plan to be implemented by the Home Care Coordinating Agency in the service order. The care plan summary also identifies other services the recipient is receiving, in addition to the authorized services provided under this Section.
(Z) Multi-disciplinary team (MDT). The MDT includes the consumer, the designated home care coordinating agency staff person as appropriate, the RN assessor, or a health professional and may also include other people who provide or have an interest in the consumer's services.
(AA) One-person Physical Assist requires one person over the last seven (7) days or 24-48 hours if in a hospital setting, to provide either weight-bearing or non-weight bearing assistance for an individual who cannot perform the activity independently. This does not include cueing.
(BB) Personal care assistance services are those covered ADL and IADL services provided by a home health aide, certified nursing assistant or personal care assistant, which are required by an adult with long-term care needs to achieve greater physical independence, in accordance with the authorized plan of care.
(CC) Personal
care assistant (PCA) is a person who has completed a
Department approved training course of
at least 40 hours, which includes, but is not limited to, instruction in basic
personal care procedures, such as those listed in Section 63.02(B)(1)(b), first aid, handling of emergencies and review of the
mandatory reporting requirement under the Adult Protective Services Act;.
(DD) A quality assurance review committee (QARC) is a group sponsored by the Bureau of Elder and Adult Services, whose responsibility it is to review randomly selected consumer cases to assess the appropriateness and quality of authorized care plans and services delivered and to make recommendations for improving quality of care, outcomes for the consumer, and policy changes.
(EE) Self-Directed Option: Self-directed means payments made directly to consumers or surrogates to enable them to purchase covered in–home community support services pursuant to section 63.02(B)(5).
(FF) Service order means the document used by the Home Care Coordinating Agency to engage and order the subcontractor or independent contractor to complete the tasks, authorized by the Assessing Services Agency on the care plan summary of the MED form. The hours on the service order shall not exceed the hours authorized on the MED form care plan summary and must include only the covered services from Section 63.04.
(GG) Significant change. A significant change is defined as a major change in the consumer’s status that is not self limiting, impacts on more than one area of their functional or health status, and requires multi-disciplinary review or revision of the plan of care. A significant change assessment is appropriate if there is a consistent pattern of changes, with either two or more areas of improvement, or two or more areas of decline, that requires a review of the care plan and potential for a level of care change.
(HH) Signature. Effective with the implementation of the computerization of the Medical Eligibility Determination (MED) form, signature of the RN assessor or the HCCA staff will equate with “login” onto the appropriate electronic system.
(II) Total Dependence means full staff person/caregiver performance of the activity during the entire last seven (7) day period across all shifts, or during each eight hour period in twenty four (24) hours.
(A) General and Specific Requirements. To be eligible for services a consumer must:
(1) Be at least 18;
(2) Live in Maine;
(3) Lack sufficient personal and/or financial resources for in-home services;
(4)
Be ineligible for the MaineCare Private
Duty Nursing/Personal Care Services except as otherwise provided in this
Section, MaineCare Home and Community Based Waiver, MaineCare Adult Day Health,
MaineCare Consumer-Directed Attendant Services programs. ;
(5) Not be participating in Section 61: Adult Day Services, Section 62: Congregate Housing Services Program, Section 68: Respite Care for People with Alzheimer’s Disease or Related Disorders, Section 69: Bureau of Elder and Adult Services Homemaker Services or Consumer-Directed Home Based Care program enacted by 26 MRSA 1412-G;
(6) Not be residing in an Adult Family Care Home setting or other licensed Assisted Housing Program that is reimbursed for providing personal care services unless the consumer meets the eligibility criteria for Level IV services under this section;
(7) Not be residing in a hospital, residential care, assisted living or nursing facility;
(8) Consumer or legal representative agrees to pay the monthly calculated consumer payment; and
(9) If the assessment for continued eligibility indicates medical eligibility for a MaineCare program and potential financial eligibility for MaineCare, consumers will be given written notice, that the consumer has up to thirty (30) days to file a MaineCare application. If HBC services are currently being received, services shall be discontinued if a Bureau of Family Independence notice is not received within thirty (30) days of the assessment date indicating that a financial application has been filed. Services shall also be discontinued if, after filing the application within thirty (30) days the application requirements have not been completed in the time required by MaineCare policy.
(B) Medical and Functional Eligibility Requirements
Applicants for services under this section must meet the eligibility requirements as set forth in this Section 63.02(B) and documented on the Medical Eligibility Determination (MED) form. Medical eligibility will be determined using the MED form as defined in Section 63.01. A person meets the medical eligibility requirements for Home Based Care if he or she requires a combination of items from Activities of Daily Living 63.02(B)(1)(b), Instrumental Activities of Daily Living Section 63.02(B)(1)(c) and Nursing Services 63.02(B)(1)(d) The levels of care define which combined items are required for each level of care. 63.02 (1) OR (2) OR (3) OR (4) below. The clinical judgment of the Department’s Assessing Services Agency shall be the basis of the scores entered on the Medical Eligibility Determination (MED) form.
(1) Level I A person meets the medical eligibility requirements for Level I of Home Based Care if he or she requires the combination of criteria of Activities of Daily Living, Instrumental Activities of Daily Living and Nursing Services, as described below:
(a) Eligibility items
(i) Requires cueing 7 days per week for eating, toilet use, bathing, and dressing as defined in Section 63.01(L); or
(ii) Requires limited assistance plus a one person physical assist with at least two (2) ADLs from the following: bed mobility, transfer, locomotion, eating, toilet use, dressing, and bathing and assistance/done with help plus physical assistance with at least one (1) IADL; or
(iii) Requires limited assistance plus a one person physical assist with at least one (1) ADL from the following: bed mobility, transfer, locomotion, eating, toilet use, dressing, and bathing and assistance/done with help plus physical assistance with at least two (2) IADLs from the following: main meal preparation, routine housework, grocery shopping, and laundry; or
(iv) Requires limited assistance plus a one person physical assist with at least three (3) ADLs from the following: bed mobility, transfer, locomotion, eating, toilet use, dressing, and bathing or
(v) Requires one of the nursing services items i – xi below, at least once per week, that are or otherwise would be performed by or under the supervision of a registered professional nurse, as described in Section 63.02(B)(1)(d) below and limited assistance plus a one person physical assist with at least two (2) ADLs from the following: bed mobility, transfer, locomotion, eating, toilet use, dressing, and bathing: or
(vi) Requires two (2) of the nursing services items i – xi below, at least once per week, that are or otherwise would be performed by or under the supervision of a registered professional nurse, as described in Section 63.02 (B)(1)(d) below and limited assistance plus a one person physical assist with at least one (1) ADL from the following: bed mobility, transfer, locomotion, eating, toilet use, dressing, and bathing or
(vii) Requires one of the nursing services items i – xi below, at least once per week, that are or otherwise would be performed by or under the supervision of a registered professional nurse, as described in Section 63.02 (B)(1)(d) below and limited assistance plus a one person physical assist with at least one (1) ADL from the following: bed mobility, transfer, locomotion, eating, toilet use, dressing, and bathing and assistance/done with help plus physical assistance with at least one (1) IADL from the following: main meal preparation, routine housework, grocery shopping, and laundry:
(b) Activities of Daily Living:
(i) Bed Mobility: How person moves to and from lying position, turns side to side, and positions body while in bed;
(ii) Transfer: How person moves between surfaces to/from: bed, wheelchair, standing position (excluding to/from bath/toilet);
(iii) Locomotion: How person moves between locations, in room and other areas. If in wheelchair, self-sufficiency once in chair;
(iv) Eating: How person eats and drinks (regardless of skill);
(v) Toilet Use: How person uses the toilet room (or commode, bedpan, urinal): transfers on/off toilet, cleanses, changes pad, manages ostomy or catheter, adjusts clothes;
(vi) Bathing: How person takes full-body bath/shower, sponge bath and transfers in/out of tub/shower (exclude washing of back and hair); and
(vii) Dressing: How person puts on, fastens, and takes off all items of street clothing, including donning/removing prosthesis.
(c) Instrumental activities of daily living.
(i) “Instrumental activities of daily living (IADLs)” are regularly necessary home management activities listed below:
(ii) Daily instrumental activities of daily living (within the last 7 days):
(aa) main meal preparation: preparation or receipt of main meal;
(iii) Other instrumental activities of daily living (within the last 14 days):
(aa) routine housework: includes, but is not limited to vacuuming, cleaning of floors, trash removal, cleaning bathrooms and appliances;
(bb) grocery shopping: shopping for groceries and storage of purchased food or prepared meals;
(cc) laundry: doing laundry in home or out of home at a laundry facility;
(d) Nursing Services
(i) 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;
(ii) nasogastric tube, gastrostomy, or jejunostomy feeding, for a new/recent (within past 30 days) or unstable condition;
(iii) nasopharyngeal suctioning or tracheostomy care; however, care of a tracheostomy tube must be for a recent (within past 30 days) or unstable condition;
(iv) 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);
(v) administration of oxygen on a regular and continuing basis when the recipient's medical condition warrants professional nursing observations, for a new or recent (within past 30 days) condition;
(vi) professional nursing assessment, observation and management of an unstable medical condition (observation must, however, be needed at least once every eight hours throughout the 24 hours);
(vii) 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 recipient's medical record;
(viii) services to manage a comatose condition;
(ix) care to manage conditions requiring a ventilator/respirator;
(x) direct assistance from others is required for the safe management of an uncontrolled seizure disorder, (i.e.: grandmal);
(xi) physical, speech/language, occupational, or respiratory therapy provided as part of a planned program that is designed, established, and directed by a qualified licensed therapist. The findings of an initial evaluation and periodic reassessments must be documented in the recipient's medical record. Skilled therapeutic services must be ordered by a physician and be designed to achieve specific goals within a given time frame;
(2) Level II. A person meets the medical eligibility requirements for Level II of Home Based Care if he or she requires any of the nursing services, items i to xvi below, 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 in Section 63.02(B)(2)(a)
(a) Nursing Services
(i) 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;
(ii). nasogastric tube, gastrostomy, or jejunostomy feeding, for a new/recent (within past 30 days) or unstable condition;
(iii) nasopharyngeal suctioning or tracheostomy care; however, care of a tracheostomy tube must be for a recent (within past 30 days) or unstable condition;
(iv) 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);
(v) administration of oxygen on a regular and continuing basis when the recipient’s medical condition warrants professional nursing observations, for a new or recent (within past 30 days) condition;
(vi) professional nursing assessment, observation and management of an unstable medical condition (observation must, however, be needed at least once every eight hours throughout the 24 hours);
(vii) 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 recipient's medical record;
(viii) services to manage a comatose condition;
(ix) care to manage conditions requiring a ventilator/respirator;
(x) direct assistance from others is required for the safe management of an uncontrolled seizure disorder, (i.e.: grandmal);
(xi) physical, speech/language, occupational, or respiratory therapy provided as part of a planned program that is designed, established, and directed by a qualified licensed therapist. The findings of an initial evaluation and periodic reassessments must be documented in the recipient's medical record. Skilled therapeutic services must be ordered by a physician and be designed to achieve specific goals within a given time frame; or
(xii) Professional nursing assessment, observation and management of a medical condition;
(xiii) administration of treatments (excluding nebulizers), procedures, or dressing changes which involve prescription medications, for post-operative or chronic conditions according to physician orders, that require nursing care and monitoring;
(xiv) professional nursing for physician ordered radiation therapy, chemotherapy, or dialysis;
(xv) professional nursing assessment, observation and management for impaired memory, and impaired recall ability, and impaired cognitive ability;
(xvi) professional nursing assessment, observation, and management for problems including wandering, or physical abuse, or verbal abuse or socially inappropriate behavior;
(b) In addition to above, one of the following:
(i) requires daily (7 days per week) "Cueing" (defined in Section 63.01(L)) for all of the following criteria: 63.02(B)(2)(c)(eating, toilet use, bathing, and dressing),
OR
(ii) At least "limited assistance" (defined in 63.01(U)) and a "one person physical assist" (defined in 63.01(AA) is needed with at least two of the following: bed mobility, transfer, locomotion, eating, toilet use, dressing, and bathing as defined below in Section 63.02(B)(2)(c):
(c) Activities of Daily Living:
(i) Bed Mobility: How person moves to and from lying position, turns side to side, and positions body while in bed;
(ii) Transfer: How person moves between surfaces to/from: bed, wheelchair, standing position (excluding to/from bath/toilet);
(iii) Locomotion: How person moves between locations, in room and other areas. If in wheelchair, self-sufficiency once in chair;
(iv) Eating: How person eats and drinks (regardless of skill);
(v) Toilet Use: How person uses the toilet room (or commode, bedpan, urinal): transfers on/off toilet, cleanses, changes pad, manages ostomy or catheter, adjusts clothes;
(vi) Bathing: How person takes full-body bath/shower, sponge bath and transfers in/out of tub/shower (exclude washing of back and hair); and
(vii) Dressing: How person puts on, fastens, and takes off all items of street clothing, including donning/removing prosthesis.
(c) Instrumental activities of daily living.
“Instrumental activities of daily living (IADLs)” are regularly necessary home management activities listed below:
(i) Daily instrumental activities of daily living (within the last 7 days)
(aa) main meal preparation: preparation or receipt of main meal;
(ii) Other instrumental activities of daily living (within the last 14 days):
(bb) routine housework: includes, but is not limited to vacuuming, cleaning of floors, trash removal, cleaning bathrooms and appliances;
(cc) grocery shopping: shopping for groceries and storage of purchased food or prepared meals;
(dd) laundry: doing laundry in home or out of home at a laundry facility;
(3) Level III A person meets the medical eligibility requirements for Level III of Home Based Care if he or she requires at least “limited assistance and a "one person physical assist" in two of the following five ADLs: and assistance/done with help plus physical assistance with at least three IADLs from the following:
(a) Activities of Daily Living:
(i) Bed Mobility: How person moves to and from lying position, turns side to side, and positions body while in bed;
(ii) Transfer: How person moves between surfaces to/from: bed, wheelchair, standing position (excluding to/from bath/toilet);
(iii) Locomotion: How person moves between locations, in room and other areas. If in wheelchair, self-sufficiency once in chair;
(iv) Eating: How person eats and drinks (regardless of skill);
(v) Toilet Use: How person uses the toilet room (or commode, bedpan, urinal): transfers on/off toilet, cleanses, changes pad, manages ostomy or catheter, adjusts clothes;
(b) Instrumental activities of daily living.
“Instrumental activities of daily living (IADLs)” are regularly necessary home management activities listed below:
(i) Daily instrumental activities of daily living (within the last 7 days)
(aa) main meal preparation: preparation or receipt of main meal;
(ii) Other instrumental activities of daily living (within the last 14 days):
(aa) routine housework: includes, but is not limited to vacuuming, cleaning of floors, trash removal, cleaning bathrooms and appliances;
(bb) grocery shopping: shopping for groceries and storage of purchased food or prepared meals;
(cc) laundry: doing laundry in home or out of home at a laundry facility;
(4) Level IV A person meets the medical eligibility requirements for this level IV of Home Based Care if he or she meets the medical eligibility requirements for nursing facility level of care set forth in Chapter 2, Section 67.02-3 Nursing Facility Services of the MaineCare Benefits Manual.
(5) Self-directed Option. Consumers or their surrogates may arrange for and self-direct their services authorized by the Assessing Services Agency. This responsibility includes the selection, training, supervising, hiring, firing and payment of all employment related state and federal taxes. Case coordination and payment to the consumer or surrogate for services are provided by the Home Care Coordinating Agency. Except as noted below, all other requirements of Section 63 apply to consumers using the self-directed option.
(a) Eligibility. To be eligible for the self-directed option consumers must meet the requirements listed in Section 63.02-A and B-1,2, 3,or 4 and the requirements in either this section (a) or (b) below. The consumer:
(i) must not have a guardian or conservator;
(ii) must have the cognitive capacity, measured on the MED form, as defined in Section 63.01(I) to be able to self-direct the services. The authorized agent as part of the assessment will determine this capability;
(iii) is willing to meet all program requirements including documentation of services delivered;
(iv)
agrees to complete a minimum of 4 hours
of instruction prior to beginning the self-directed option on the rights,
risks, and responsibilities of the self-directed option; and
(v) Agrees to verify for any certified nursing assistant hired whether there is a notation on the CNA Registry
(aa) Any criminal convictions, except for Class D and Class E convictions over 10 years old that did not involve as a victim of the act a patient, client or resident of a health care entity and/ or;
(bb) Any specific documented findings by the State Survey Agency of abuse, neglect or misappropriation of property of a resident, client or patient; and
(b) Eligibility for Surrogate. For a consumer who does not qualify under (a), a surrogate may request to act on behalf of the consumer. A consumer with cognitive capacity also may choose to designate a surrogate to act on his/her behalf. The Home Care Coordinating Agency may authorize a surrogate to act on behalf of the consumer if the surrogate:
(i) Is at least 18 years old;
(ii) Has the cognitive capacity to arrange for and direct services;
(iii) Is not the consumer’s paid caregiver;
(iv) Shows a strong personal commitment to the consumer;
(v) Shows knowledge about the consumer’s preferences;
(vi) Agrees to visit the consumer at least every two (2) weeks;
(vii) Is willing to meet all program requirements including documentation of services delivered and documentation of required visitations;
(viii) Agrees to verify for any certified nursing assistant hired whether there is a notation on the CNA Registry
(aa) Any criminal convictions, except for Class D and Class E convictions over 10 years old that did not involve as a victim of the act a patient, client or resident of a health care entity and/ or;
(bb) Any specific documented findings by the State Survey Agency of abuse, neglect or misappropriation of property of a resident, client or patient; and
(ix) Agrees to complete a minimum of 4 hours of instruction prior to beginning the self-directed option on the rights, risks, and responsibilities of the self-directed option.
(c) Home Care Coordination. The Home Care Coordination Agency (HCCA) will:
(i) Provide instruction to consumer or surrogate on the skills needed to hire, train, and schedule, supervise, and document the provision of services identified in the Assessing Services Agency authorized plan of care;
(ii) Establish a monthly cost limit based on the authorized plan of care;
(iii) Explain the payment method used in the self-directed option to the consumer or surrogate;
(iv) Reimburse the consumer monthly an amount that is not more than the actual cost of services provided, up to the cap established in the authorized plan of care, less any applicable consumer co-payment;
(v) Provide face-to-face care monitoring every six months;
(vi) Provide the consumer or surrogate with information about the Long-term Care Ombudsman Program and Adult Protective Services; and
(vii) If requested by the consumer or surrogate, the HCCA may manage professional and/or covered services (RN, ERS for example), other than personal care services.
(d) Competency in Lieu of Training. This section applies to the self-directed option as defined in Section 63.02(B)(5). In lieu of completing a training program, the competency of the PCA to carry out the assigned tasks must be determined by the consumer or his or her surrogate when using the self-directed option. The PCAs competency to perform the required tasks shall be verified by:
(i) Determining previous experience with the tasks to be done;
(ii) Discussing the details of the tasks to be carried out, as stated in the authorized care plan, by the Assessing Services Agency on the care plan summary and by the Home Care Coordinating Agency on the service order; and
(iii) When the nature of the tasks or the condition of the consumer warrant the specialized knowledge and skills of a health professional, as determined by the Medical Eligibility Determination (MED) form, the PCA shall be trained by the consumer and satisfactorily do a return demonstration of the skills.
(e) Termination. When there is documentation that a consumer or the consumer’s surrogate is no longer able to self-direct their services, chooses to end the self-directed option, or no longer meets the eligibility requirements for the Self-Directed Option, the Home Care Coordinating Agency will terminate the Self-Directed Option.Management and direction of services will then resume with the HCCA. Consumer may then return to the HCCA coordinating the consumer’s services.
63.03DURATION OF SERVICES
Each Home Based Care consumer may receive as many covered services as are required within the limitations and exceptions as described below. Home Based Care coverage of services under this Section requires prior authorization from the Department or its Assessing Services Agency. Beginning and end dates of a consumer’s medical eligibility determination period correspond to the beginning and end dates for Home Based Care coverage of the plan of care authorized by the Assessing Services Agency or the Department.
(A) Exception to the Limit: For consumers accessing Adult Day Services reimbursed by HBC funds, the caps may be exceeded by an amount determined by the Department
(B) Consumers classified for Level I level of care (see Section 63.02(B)(1)), the total monthly cost of services may not exceed the lesser of the monthly plan of care authorized by the Assessing Services Agency or the "Level I" cap, established by the Department.
(C) Consumers classified for Level II level of care (see Section 63.02(B)(2)), the total monthly cost of services may not exceed the lesser of the monthly plan of care authorized by the Assessing Services Agency or the "Level II" cap established by the Department.
(D) Consumers classified for Level III level of care (see Section 63.02(B)(3)), the total monthly cost of services may not exceed the lesser of the monthly plan of care authorized by the Assessing Services Agency or the "Level III" cap established by the Department.
(E) Consumers
classified for Level IV level of care (see Section 63.02(B)(4)), the total
monthly cost of services may not exceed the lesser of the monthly plan of care
authorized by the Assessing Services Agency or 85% 80% of the average
cost of nursing facility level of care established by the Department.
(F) Suspension. Services may be suspended for up to thirty (30) days while the consumer is hospitalized or using institutional care. If such circumstances extend beyond thirty (30) days, the consumer’s eligibility in the program will be terminated.
(G) Services under this Section may be suspended, reduced, denied or terminated by the Department, the Assessing Services Agency, or the Home Care Coordinating Agency, as appropriate, for the following reasons:
(1) The consumer does not meet eligibility requirements;
(2) The consumer declines services;
(3) The
consumer is eligible to receive long-term care services under MaineCare
including any MaineCare Special Benefits, except as otherwise provided in this
section for MaineCare Private Duty Nursing/Personal Care Services.;
(4) The consumer is eligible and chooses to receive services under the Consumer Directed Home Based Care Program enacted by 26 MRSA Section 1412-G;
(5) Based on the consumer’s most recent MED assessment, the plan of care is reduced to match the consumer’s needs as identified in the reassessment and subject to the limitations of the program ;
(6) The health or safety of individuals providing services is endangered;
(7) Services have been suspended for more than thirty (30) days;
(8) Consumer refuses personal care or nursing services;
(9) Consumer has failed to make his/her calculated monthly co-payment within thirty (30) days of receipt of the co-pay bill ;
(10) When the consumer or designated representative gives fraudulent information to Department of Human Services, the Assessing Services Agency or Home Care Coordinating Agency;
(11) The consumer is eligible to receive home health services for some or all of the services authorized under this section from Medicare or another third party payer; or
(12) There are insufficient funds to continue to pay for services for all current consumers which results in a change affecting some or all consumers.
Notice of intent to reduce ,deny, or terminate services under this section will be done in accordance with Section 40.01 of this policy manual.
63.04 COVERED SERVICES
Covered services are available for consumers meeting the eligibility requirements set forth in Section 63.02. All covered services require prior authorization by the Department, or its Assessing Services Agency, consistent with these rules, and are subject to the limits in Section 63.03. The Authorized Plan of Care shall be based upon the consumer’s assessment outcome scores recorded on the Department’s Medical Eligibility Determination (MED) form, according to it’s definitions, and the timeframes therein and the Task Time Allowances defined in the appendix to this section.
Services provided must be required for meeting the identified needs of the consumer, based upon the outcome scores on the MED form, and as authorized in the plan of care. Coverage will be denied if the services provided are not consistent with the consumer’s authorized plan of care. The Department may also recoup payment from the Home Care Coordinating Agency for inappropriate services provision, as determined through post payment review. The Assessing Services Agency has the authority to determine the plan of care, which shall specify all services to be provided, including the number of hours for each covered service.
The Assessing Services Agency will use Task Time Allowances set forth in the appendix to this section to determine the time needed to complete authorized ADL and IADL tasks for the plan of care not to exceed the program limits specified elsewhere in this section.
Covered Services are:
(A) Care Coordination is a system for implementing, locating, coordinating, reviewing,and monitoring of services identified and authorized by the Assessing Services Agency during the eligibility determination process and documented on the care plan summary portion of the MED form. Care Coordination tasks performed by the Home Care Coordinating Agency staff which are required for overall program administration, management, distribution of funds and reporting include, but are not limited to:
(1) Ensuring the implementation, monitoring and modification of a consumer plan of care within the Assessing Services Agency authorized plan of care;
(2) Advocating on behalf of the consumer for access to appropriate community resources;
(3) Implementing the Assessing Services Agency authorized care plan and coordinating of service providers who are responsible for delivery of services pursuant to the consumer’s authorized plan of care and identified needs;
(4) Maintaining contacts, on behalf of the consumer, with family members, designated representative, guardian, providers of services or supports and the Assessing Services Agency to ensure the continuity of care and coordination of services;
(5) Monitoring the services and support; and evaluating the effectiveness of the plan with the consumer or the designated representative, guardian and providers of services or support;
(6) Calculating the consumer’s co-payment based on the estimated copayment determined by the Assessing Services Agency and receipt and review of the documented dependent allowances and disability related expenses. Consumers receiving services under this section may be selected for verification of income and assets;
(7) Notifying the Assessing Services Agency of the due date of the annual financial reassessment.
(8) Coordinating and requesting of required and unscheduled reassessments including the provision of an up to date status report of the consumer and their situation.
(9) Preparing the consumer for the reassessment process.
(10) Beginning discharge planning on the first day of services. A discharge plan will enable the consumer to transition to other services, as appropriate;
(11) In the event a consumer experiences an unexpected need, the Home Care Coordinating Agency has the authority to adjust the frequency of services under the authorized care plan, in order to meet the needs, as long as the total authorized care plan hours for the eligibility period are not exceeded
(12) In the event a consumer experiences an emergency or acute episode as defined in Section 63.01(C), the Home Care Coordinating Agency has the authority to adjust the authorized plan of care up to 15% of the monthly authorized amount not to exceed the applicable cap. Services resulting from an acute or emergency incident may not continue beyond fourteen (14) days and the Home Care Coordinating Agency must request a reassessment on the date the increase is implemented;
(13) Issuing a “notice of intent to reduce, deny or terminate HBC services” as defined and applicable in Section 63.03.
(14) Other administrative tasks include, but are not limited to:
(a) Processing assessment packets;
(b) Maintaining consumer records;
(c) Tracking and reporting services;
(d) Preparing the Home Care Coordinating Agency budget and processing of claims to the Department;
(e) Contracting with service providers and requiring compliance by any and all sub-contractors with policy requirements; and conducting required utilization review activities.
(f) Reimbursing subcontracted home care providers; and
(g) Preparing information as required by the Department.
(B) Care Monitoring. Care monitoring are those services provided by a licensed social services or health professional (contracted with or employed by the Home Care Coordinating Agency), to assist the Home Care Coordinating Agency to identify the medical, social, educational, and other needs of an eligible consumer, and facilitate access to needed services. Care monitoring may be provided only to eligible consumers who are receiving or awaiting other authorized HBC services. Care monitoring is provided according to the plan of care authorized by the Assessing Services Agency and implemented by the Home Care Coordinating Agency. The care monitor will complete the following activities and report findings to the Home Care Coordinating Agency based on the task specific authorization:
(1) monitor services delivered;
(2) evaluate the effectiveness of the implementation of the authorized plan of care;
(3) advocate on behalf of the consumer;
(4) counsel the consumer or responsible party about the plan of care authorized by the Assessing Services Agency ;
(5) evaluate the consumer’s health status and services needs;
(6) identify gaps in service or care needs;
(7) document and submit to the Home Care Coordinating Agency progress notes that include the outcome of the face-to-face care monitoring; and
(8) make recommendations for any authorized care plan modifications or need for referrals to community resources.
(C) Health Assessments. This service shall include a health assessment as defined in Section 63.01(P), as well as any other nursing services that are required/authorized in the plan of care. Health assessments may be required periodically for Levels II, III, IV of care as defined in Section 63.02(B)(2)(3) and (4). The frequency of periodic assessments may be reduced if recommended by the RN conducting the health assessment and determined appropriate following review with the HCCA and MDT members.
(D) Diagnostic Services. Diagnostic services necessary and not covered by a third party payor, to enhance the authorized plan of care, including independent living evaluation. Exclude venipuncture services.
(E) Homemaking Services. Homemaking services means services to assist a consumer with his or her general housework, meal preparation, grocery shopping, laundry, and incidental personal hygiene and dressing. When authorizing a plan of care that includes homemaker services the Assessing Services Agency will use the task time allowances specified in the appendix attached to this section not to exceed program caps. If the consumer is receiving care at Level I, IADL tasks may constitute up to, but shall not exceed, 10 hours per month of authorized services.
(F) Personal Assistance Services. Personal assistance services to aid consumers with ADLs and IADLs.
(1) Personal assistance ADL services include bed mobility, transfer, locomotion, eating, toilet use, bathing and personal hygiene, dressing, and health maintenance activities. When authorizing a plan of care that includes personal care assistance services the Assessing Services Agency will use the task time allowances specified in the appendix attached to this section not to exceed limits specified elsewhere in this Section.
(2) Personal Assistance IADL services include meal preparation, grocery shopping, routine housework and laundry, which are directly related to the consumer’s plan of care.
i. These tasks must be performed in conjunction with direct care to the consumer.
ii. These IADL tasks would otherwise be normally performed by the consumer if he or she were physically or cognitively able to do so, and it must be established by the Assessing Services Agency that there is no family member or other person available and willing to assist with these tasks.
iii. If the consumer is receiving care at Level I, IADL tasks may constitute up to, but shall not exceed, 10 hours per month of authorized personal care services. If the consumer’s plan of care authorizes IADL tasks, time for IADL tasks may not exceed two-thirds of the total weekly time authorized for all personal care services.
iv. If the consumer is receiving care at Level II, III or IV, at least one-third of the total weekly time authorized for personal care services must be for covered ADL assistance under this section, which may be provided in the consumer’s residence or at an adult day services program.
(3) All personal care assistance services may be used for ADLs if necessary.
(4) No individual providing this service may be reimbursed for more than 40 hours of care per week for an individual consumer.
(5) When authorizing a consumer’s plan of care, personal assistance care services must be authorized in accordance with the Task Time Allowances not to exceed programs caps or limits specified elsewhere in this section (see appendix to this section) If these times are not sufficient when considered in the light of a consumer’s extraordinary circumstances as identified by the authorized agent, the authorized agent may make an appropriate adjustment except when the maximum limit for IADL hours applies. Task time allowances will consider the possibility for concurrent performances of activities and tasks listed. Services listed in the Task Time Allowances that are not covered services under this section may not be authorized.
(6) The “one Hour” PCA visit is a one –hour visit to deliver personal care services and health maintenance activities to a member, no more then once per day. This service may be authorized up to seven days per week. If a person requires more then one hour of personal care service on a given day, then the PCA services must be billed using the half-hour units.
(G) Handyman/Chore Service. Chore services to assist a consumer with occasional heavy-duty cleaning ,raising and lowering of combination screen/storm windows, repairs and similar minor tasks to eliminate safety hazards in the environment.
(H) Home Health Services. Home health services to assist a consumer with health and medical and ADL needs as identified on the MED form and authorized by the Assessing Services Agency. These include nursing; home health aide and certified nursing assistant services; physical, occupational, and speech therapy; and medical social services, when no other method of third party payment is available. Home Health services may only be purchased from licensed agencies and shall be reimbursed at an hourly rate. When authorizing personal care services provided by a HHA or CNA, the Assessing Services Agency must use the task time allowances set forth in the appendix attached to this section to authorize the time covered to complete authorized ADL and IADL tasks for the plan of care not to exceed the program caps or limits specified elsewhere in this section.
(I) Respite. Services provided to individuals, furnished on a short term basis because of the absence of or need for relief of the caregiver. This service may be provided at home, in a licensed Adult Day Program, or in an institutional setting. An institution is:
(1) An assisted housing program licensed in accordance with 22 M.R.S.A. §7851(3);
(2) A nursing facility or unit, licensed in accordance with 22 M.R.S.A. §1811-1824;
(3) An acute care or rehabilitation facility, licensed in accordance with 22 M.R.S.A. §1811-1824; or
(4) A facility for the treatment or management of people who have mental retardation or mental illness.
The annual cost of respite services may not exceed an annual cap as established by the Bureau of Elder and Adult Services and is included in the individual’s annual care plan cost limit. A consumer receiving MaineCare Private Duty Nursing/Personal Care Services may receive respite services to the extent that budgeted resources permit and to the extent that there is no waiting list under Section 63.
(J) Transportation. Personal Care Assistants, Certified nursing assistants, home health aides and homemakers may escort or transport a consumer only to carry out the plan of care. Any individual providing transportation must hold a valid State of Maine driver's license for the type of vehicle being operated. All providers of transportation services shall maintain adequate liability insurance coverage for the type of vehicle being operated. Escort services may be provided only when a consumer is unable to be transported alone, there are no other resources (family or friends) available for assistance, and the transportation agency can document that the agency is unable to meet the request for service. Reimbursement shall only be made for mileage in excess of ten (10) miles per single trip on a one-way trip for transportation provided by personal care assistants, homemakers, or other ho