(cont.) APPENDIX I All incontinence supplies provided to MaineCare members must meet or exceed the quality standards detailed in the table below as pursuant to standards set by the International Organization Standard (ISO). Providers are expected to retain any documentation supporting product quality in the event that the State requests it. Standard Performance Maximum Performance Standard Performance Maximum Performance Disposable Underwear/ Disposable Underwear\ Parameter Disposable Briefs Disposable Briefs Pull-on Pull-on Light/ Moderate Heavy/Maximum Light/ Moderate Heavy/Maximum Youth, Youth, Adult Adult Youth, Adult Youth, Adult Adult size sizes Adult size sizes Adult size sizes Adult size sizes size medium, extra size medium, extra size medium, extra size medium, extra small large large small large large small large large small large large At At ISO Total At At least At least At least At least At least At least At At least At least least least Absorbent 900 1000 1600 1300 1800 700 900 1000 1200 1400 2100 1100 Capacity grams grams grams grams grams grams grams grams grams grams grams grams 60.12 APPENDIX I (cont.) T. Manual Wheelchairs Manual Wheelchairs (including Standard wheelchairs) are covered if: a. Criteria 1, 2, 3, 4, 5and 6 (below) are met; and b. Criterion 7 or 8 is met. 1. The member has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:
APPENDIX I (cont.) All incontinence supplies provided to MaineCare members must meet or exceed the quality standards detailed in the table below as pursuant to standards set by the International Organization Standard (ISO). Providers are expected to retain any documentation supporting product quality in the event that the State requests it. Parameter Standard Performance Maximum Performance Standard Performance Maximum Performance Disposable Briefs Disposable Briefs Disposable Underwear/ Pull-on Disposable Underwear\ Pull-on Light/ Moderate Heavy/Maximum Light/ Moderate Heavy/Maximum Youth, Adult size small size medium, large sizes extra large Youth, Adult size small Adult size medium, large Adult sizes extra large Youth, Adult size small size medium, large Adult sizes extra large Youth, Adult size small size medium, large Adult sizes extra large ISO Total Absorbent Capacity At 900 grams At least 1000 grams At least 1600 grams At least 1300 grams At least 1800 grams At least 2100 grams At least 700 grams At least 900 grams At least 1100 grams At 1000 grams At least 1200 grams At least 1400 grams 60.12 APPENDIX I (cont.) T. Manual Wheelchairs Manual Wheelchairs (including Standard wheelchairs) are covered if: a. Criteria 1, 2, 3, 4, 5and 6 (below) are met; and b. Criterion 7 or 8 is met. 1. The member has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:
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