аЯрЁБс>ўџ ]_ўџџџ\џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅС@ №П§%bjbjУ.У. 08ЁDЁDП=џџџџџџˆІІІІІІІКККК8ђ,К I.>:xŽŽŽŽŽŽ>@@@*j z( ŠH$7JR‰LЖЎHІŽŽŽŽŽЎHІІŽŽУH   Ž"ІŽІŽ> Ž>  ІІ Ž2 рmѓЏ|zЪКА" *йH0 I ?Mв"?M ККІІІІ?MІ  ŽŽ ŽŽŽŽŽЎHЎHє14-191 DEPARTMENT OF BEHAVIORAL AND DEVELOPMENTAL SERVICES Chapter 40: REQUIREMENTS FOR FUNDING SERVICES SUMMARY: This rule establishes requirements regarding the utilization of other funding sources for services before State General Funds may be utilized. I. STATEMENT OF INTENT It is the intent of this rule to ensure that financial resources are used efficiently and effectively to provide services to the greatest number of people possible. In this regard the Department intends to maximize the use of available non-General Fund financial resources. This rule applies to all persons who apply for services funded or licensed by the Department or from the Department directly and to providers who seek Departmental funds. Individuals must take all reasonable steps to obtain financial support for which they may be eligible. This includes applying for the benefits and providing the other benefit sources with necessary information to determine eligibility for the benefits. Other benefits for which the individual must apply include but are not necessarily limited to Social Security, Medicaid (including Katie Beckett waiver), Medicare and private insurance, as applicable. II. DEFINITIONS “Commissioner” means the Commissioner of the Department of Behavioral and Developmental Services or designee. “Hearings Unit” means the State Administrative Hearings Office chosen by DBDS to provide hearing officers to preside at appeals hearings on Level III grievances and to make Recommendations to the Commissioner for Final Agency Action. “Other Benefit Sources” may include but are not necessarily limited to Social Security, Medicaid, Medicare, private insurance, Child Development Services (Title IV). “Persons” include adult recipients of services or their guardians if one has been appointed, and parents, guardians or custodians of children who are recipients of services. “Program Director” is the person designated as the manager of Mental Health Services, the manager of Mental Retardation Services, the manager of Children’s Services or the Director of the Office of Substance Abuse, as applicable. “Services” includes any behavioral health or developmental service provided by the Department under authority of statute or rule, or by a provider under contract or agreement with the Department for which a cost is realized or a fee is charged. III. DEMONSTRATION OF APPLICATION FOR ALTERNATE FUNDING A. Upon First Referral/Request for Services Persons who seek or are referred for services as defined above must demonstrate eligibility or application for other benefit sources. Persons who are eligible for or entitled to other benefits must utilize those benefits. Information documenting eligibility, or information necessary to determine eligibility for other benefits sources must be furnished to providers of services by the person referred for or requesting BDS services within a reasonable period of time following the initial referral or request for services. Providers of services shall assist persons requesting services in demonstrating eligibility or application for other benefit sources. Persons who must meet a deductible or spend down, or make premium payments to be eligible, must comply with those requirements. Grant funds may be used to the extent necessary to provide services while persons are spending down or paying a deductible. B. During the Provision of Services Persons whose eligibility or entitlement for other benefits changes during the course of service provision must take all reasonable steps to obtain benefits to which they are entitled or eligible. Persons who refuse to make application for other benefits for which they may be eligible or entitled, will be considered ineligible for services financed by General Fund resources unless there is a clinically-based justification for the refusal. IV. APPEALS A. Informal review Providers and persons who have been denied payment for services may request a review by the Program Director overseeing the service. The request must be made in writing to the Program Director and must arrive within ten (10) working days of the denial of payment. The request for review shall state the reasons for the request and shall be accompanied by any supporting documentation. Supporting documentation must include that described at III.A. above After receiving the request for review, the Program Director shall promptly review the request, the material submitted in support of the request and any other material available to the Program Director and relevant to the decision. Within thirty (30) working days of the receipt of the request, the Program Director shall respond to the provider and person in writing, stating the determination of the review and the reason(s) for the determination. B. Administrative Hearing; Recommended Decision The provider or person who receives an adverse determination of an informal review may request an administrative hearing by submitting a written request therefore to the Commissioner no later than thirty (30) calendar days following the date of the Program Director’s decision. The issues in the administrative hearing and in any appeals therefrom shall be limited to the issues raised by the provider or person in writing in the informal review. A provider or person who fails to submit a request for informal review shall be deemed to have waived the right to an administrative hearing and to any further review of the decision. The Commissioner shall forward the request for administrative hearing to an independent hearing officer or independent hearings unit within seven (7) calendar days of receipt. At least twenty (20) calendar days before the administrative hearing, the hearing officer or hearings unit shall notify the provider or person of the date, time and place of the hearing and the name of the hearing officer. The hearing shall be held in conformity with the fb88 Administrative Procedure Act, 5 MRSA symbol 232 \f "Math C" \s 149051 et seq. The provider or person may be represented by legal counsel at the hearing and may request the issuance of subpoenas to compel other persons to appear at the hearing to testify on relevant issues. An electronic recording or verbatim transcript must be made of any administrative hearing pursuant to this section. Unless otherwise agreed by the parties, the hearing officer must issue, and file with the Commissioner, a written recommended decision with findings of fact within ten (10) calendar days of the close of the hearing. C. Final Decision of Commissioner Any recommended decision of a hearing officer is subject to further review by the Commissioner, who must issue a final decision adopting, modifying, or rejecting the hearing officer’s recommended decision. The Commissioner must issue the final decision no later than thirty (30) calendar days from the date of receipt of the recommended decision. Parties may submit written memoranda to the Commissioner within ten (10) calendar days of the date of the recommended decision. The recommended decision of a hearing officer shall be deemed adopted by the Commissioner if no final decision is issued within thirty (30) calendar days from the date of receipt of the recommended decision. The Commissioner’s decision constitutes final agency action for purposes of judicial review under the fb88 Administrative Procedure Act. STATUTORY AUTHORITY: 34B MRSA symbol 232 \f "Math C" \s 14symbol 232 \f "Math C" \s 14 1231-33, 1409, 5003(2)(c), 5436, 6202 EFFECTIVE DATE: July 6, 2002 14-191 Chapter 40 page page 4 Proofed 9/11/02 -.ЛМUKФХOLNsљњ013уŽ|}™š› Ір с Л!р!$Ž$%;%<%X%Y%Z%[%їэїуїзїузЩзїзЩзЩэїзЗзЗ З ˜З„Ззvзvзvїiїi˜ijh‚aЧB*Uphh‚aЧB*OJQJ^Jph&h‚aЧ6B*CJOJQJ^JaJphjh‚aЧU,jh‚aЧB*CJOJQJU^JaJph#h‚aЧB*CJOJQJ^JaJphh‚aЧ5B*CJaJphh‚aЧB*CJaJphh‚aЧ7B*phh‚aЧ5B*phh‚aЧB*ph)<=klm     3 4 І Ї Ј И Й ( ) МѓѓѓпѓѓпѓѓѓѓЫѓЫѓѓѓѓЫѓЫѓЫ Ца p@ „а„0§^„а`„0§ Ца p@ &dPЦџ  Ца p@ П%ќ%ўўМНlmTUKLM…†ГД”•ХЦNѓпѓпѓЫѓѓѓѓѓѓЗѓЗЋ— Ца p@ „ „`њ^„ `„`њ Ца p@  Ца p@ „ „`њ^„ `„`њ Ца p@ „а„0§^„а`„0§ Ца p@ „а„0§^„а`„0§  Ца p@ NOMNst123?@TUѓпгЧѓГЧЧЄЄЄЄЧ$$ Ца p@ „ „`њ^„ `„`њ$$ Ца p@  Ца p@ „ „`њ^„ `„`њ  Ца p@   Ца p@  Ца p@ „ „`њ^„ `„`њ Ца p@ туŽр с Л!М!п!р!$Ž$%%ыпгУГгГгЃгггЃгЃ Ца p@ &dPЦџ Ца p@ „`њ`„`њ Ца p@ „`њ`„`њ Ца p@ „^„ Ца p@   Ца p@  Ца p@ „ „`њ^„ `„`њ%%% %Ё%Б%П%Р%С%Т%ч%ш%щ%ъ%ђ%њ%ћ%ќ%§%ѓѓѓѓууоообЯЪЪЪЪЯЯу$a$ $&dPЦџa$$a$ Ца p@ „^„  Ца p@ 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