Source: http://legislature.maine.gov/statutes/22/title22sec14.html
Timestamp: 2018-02-23 14:36:41
Document Index: 337243316

Matched Legal Cases: ['§14', '§14', '§14', '§13', '§14', '§1', '§1', '§1', '§7', '§14', '§2', '§2', '§6', '§2', '§3', '§4', '§2', '§2', '§8', '§14', '§3', '§2', '§8', '§14', '§2', 'art 8', '§2', '§9', '§17', '§1', '§9', '§17', '§2', '§9', '§17', '§3', '§12', '§17', '§3', '§1', '§4', '§9', '§14', '§1', '§1', '§92', '§2', '§1', '§1', '§1', '§1', '§94', '§1', '§1', '§1', '§1', '§7', '§14', '§3']

Title 22, §14: Action against parties liable for medical care rendered to assistance recipients; assignment of claims
§14 PDF
§14 MS-Word
§13-A
§14. Action against parties liable for medical care rendered to assistance recipients; assignment of claims
[ 2007, c. 381, §1 (AMD) .]
2. Condition for eligibility.
[ 1981, c. 24, §1 (RP) .]
The recipient is also deemed to have appointed the commissioner as the recipient's attorney in fact to perform the specific act of submitting claims, making inquiries, requesting information, verifying other previous, current or potential coverage for the recipient or the recipient's spouse or dependents or endorsing over to the department any and all drafts, checks, money orders or any other negotiable instruments connected with the payment of 3rd-party medical claims to 3rd parties, liable parties or potentially liable 3rd parties. The appointment includes complete access to medical expense records and data, insurance policies and coverage and all other information relating to MaineCare's duty to cost-avoid and seek other coverage or payment response.
[ 2007, c. 240, Pt. JJJ, §1 (AMD); 2007, c. 448, §7 (AMD); 2007, c. 448, §14 (AFF) .]
2-B. Direct reimbursement to health care provider. When an insured is eligible under the MaineCare program for the medical costs of injury, disease, disability or similar occurrence for which an insurer is liable, and the insured's claim is payable to a health care provider as provided or permitted by the terms of a health insurance policy or pursuant to an assignment of rights by an insured, the insurer shall directly reimburse the health care provider to the extent that the claim is honored.
[ 2003, c. 20, Pt. K, §2 (AMD) .]
2-C. Direct reimbursement to department. When an insured is eligible under the MaineCare program for the medical costs of injury, disease, disability or similar occurrence for which an insurer is liable, and the claim is not payable to a health care provider under the terms of the insurance policy, the insurer shall directly reimburse the Department of Health and Human Services for any medical services paid by the department on behalf of a recipient under the MaineCare program to the extent that those medical services are payable under the terms of the insurance policy. If the insurer knows or has information upon which to reasonably conclude that the insured is a recipient of MaineCare services, the insurer shall advise the department in writing as to the existence of the claim prior to any other payment.
[ 2003, c. 20, Pt. K, §2 (AMD); 2003, c. 689, Pt. B, §6 (REV) .]
2-D. Notification of claim. A recipient under the MaineCare program, or any agent, representative or attorney representing a recipient under the MaineCare program, who makes a claim to recover the medical cost of injury, disease, disability or similar occurrence for which the party received medical benefits under the MaineCare program shall notify the department in writing prior to settlement negotiations and provide information required by the department of the existence of the claim. If the notice is not given and the department's ability to recover for benefits paid is compromised, the department may institute legal proceedings against a recipient, including the agent, representative or attorney of that recipient, who has received a settlement or award from a 3rd party. The department may accept a letter of MaineCare claim protection in lieu of this section.
[ 2007, c. 381, §2 (AMD) .]
2-E. Notification of pleading. In an action to recover the medical cost of injury, disease, disability or similar occurrence for which the party received medical benefits under the MaineCare program, the party bringing the action shall notify the department of that action at least 10 days prior to filing the pleadings. The notification must provide timely opportunity for the department, at its discretion, to intervene in all actions as an interested party. If adequate opportunity to intervene is not given and the department’s ability to recover for benefits paid is compromised, the department may institute legal proceedings against a recipient, including the agent, representative or attorney of that recipient, who has received a settlement or award from a 3rd party. The department may accept a letter of MaineCare claim protection in lieu of intervention. Department records indicating medical benefits paid by the department on behalf of the recipient are prima facie evidence of the medical expenses incurred by the recipient for the related medical services.
[ 2007, c. 381, §3 (AMD) .]
2-F. Disbursement. Except as otherwise provided in this subsection, a disbursement of any award, judgment or settlement may not be made to a recipient without the recipient or the recipient's attorney first paying to the department that amount of the award, judgment or settlement that constitutes reimbursement for medical payments made or obtaining from the department a release of any obligation owed to it for medical benefits provided to the recipient. If a dispute arises between the recipient and the commissioner as to the settlement of any claim that the commissioner may have under this section, the 3rd party or the recipient's attorney shall withhold from disbursement to the recipient an amount equal to the commissioner's claim. Either party may apply to the Superior Court or the District Court in which an action based upon the recipient's claim could have been commenced for an order to determine a reasonable amount in satisfaction of the statutory lien, consistent with federal law.
[ 2007, c. 381, §4 (AMD) .]
2-G. Claims against estates of certain Medicaid recipients.
[ 1993, c. 410, Pt. I, §2 (RP) .]
2-H. Honoring of assignments. The following provisions apply to claims for payment submitted by the department or a health care provider.
A. Whenever the department submits claims to a health insurer, as included in 42 United States Code, Section 1396a(a)(25)(I), including self-insured plans, group health plans as defined in the federal Employee Retirement Income Security Act of 1974, Section 607(1), service benefit plans, managed care organizations, pharmacy benefit managers or other parties that are, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, on behalf of a current or former recipient under the MaineCare program for whom an assignment of rights has been received, or whose rights have been assigned by the operation of law, the health insurer doing business in the State must respond to the department within 60 days and:
(b) Any action by the State to enforce its rights with respect to such claim is commenced within 6 years of the State's submission of such claim. [2007, c. 240, Pt. JJJ, §2 (AMD); 2007, c. 448, §8 (AMD); 2007, c. 448, §14 (AFF).]
B. [2007, c. 240, Pt. JJJ, §3 (RP).]
[ 2007, c. 240, Pt. JJJ, §§2, 3 (AMD); 2007, c. 448, §8 (AMD); 2007, c. 448, §14 (AFF) .]
2-I. Claims against estates of MaineCare recipients. Claims against the estates of MaineCare recipients are governed by this subsection.
A. The department has a claim against the estate of a MaineCare recipient when, after the death of the recipient:
(1) Property or other assets are discovered that existed and were owned by the recipient during the period when MaineCare benefits were paid for the recipient and disclosure of the property or assets at the time benefits were being paid would have rendered the recipient ineligible to receive the benefits;
(2) It is determined that the recipient was 55 years of age or older when that person received MaineCare assistance; or
(3) It is determined that the recipient has received or is entitled to receive benefits under a long-term care insurance policy in connection with which assets or resources are disregarded and medical assistance was paid on behalf of the recipient for nursing facility or other long-term care services. [2003, c. 20, Pt. K, §2 (AMD).]
B. The amount of MaineCare benefits paid and recoverable under this subsection is a claim against the estate of the deceased recipient.
(1) As to assets of the recipient included in the probated estate, this claim may be enforced pursuant to Title 18-A, Article 3, Part 8.
(2) As to assets of the recipient not included in the probated estate, this claim may be enforced by filing a claim in any court of competent jurisdiction. [2003, c. 20, Pt. K, §2 (AMD).]
C. Except for a claim collected through a voluntary payment arrangement under paragraph C-2, a claim may not be made under paragraph A, subparagraph (2) or (3) until:
(1) The recipient has no surviving spouse; and
(2) The recipient has no surviving child who is under age 21 or who is blind or permanently and totally disabled as defined in 42 United States Code, Section 1382c. [2005, c. 12, Pt. DDD, §9 (AMD); 2005, c. 12, Pt. DDD, §17 (AFF).]
C-1. [2007, c. 423, §1 (RP).]
C-2. The department shall provide heirs, assignees or transferees of a deceased recipient an opportunity to pay a claim under this subsection through a voluntary payment arrangement that is acceptable to the department. The payment arrangement may consist of a payment plan, promissory note or other payment mechanism. [2005, c. 12, Pt. DDD, §9 (NEW); 2005, c. 12, Pt. DDD, §17 (AFF).]
D. Paragraph A, subparagraphs (2) and (3) apply only to a recipient who died on or after October 1, 1993 for MaineCare payments made on or after October 1, 1993. [2003, c. 20, Pt. K, §2 (AMD).]
E. A claim under paragraph A, subparagraph (2) must be waived if enforcement of the claim would create an undue hardship under criteria developed by the department or if the costs of collection are likely to exceed the amount recovered. A waiver may be granted in full or in part. A waiver may not be granted if the recipient or waiver applicant acted to lose, diminish, divest, encumber or otherwise transfer any value of or title to an asset for the purpose of preventing recovery under this subsection. [2005, c. 12, Pt. DDD, §9 (AMD); 2005, c. 12, Pt. DDD, §17 (AFF).]
(2) Any other real and personal property and other assets in which the recipient had any legal interest at the time of death, to the extent of that interest, including assets conveyed to a survivor, heir or assign of the deceased recipient through tenancy in common, survivorship, life estate, living trust, joint tenancy in personal property or other arrangement but not including joint tenancy in real property. [2009, c. 150, §3 (AMD).]
G. The department may accept, hold, transfer title to and sell real property to collect a claim under this subsection. The department may receive title to real property from a personal representative, special or public administrator, creditor, heir, devisee, assignee or transferee in full or partial satisfaction of a claim under this subsection. [2005, c. 12, Pt. DDD, §12 (NEW); 2005, c. 12, Pt. DDD, §17 (AFF).]
[ 2009, c. 150, §3 (AMD) .]
2-J. Authority to contract for attorney services. The department is authorized to pursue rights under this section, including 3rd-party reimbursement of MaineCare costs in workers' compensation claims cases, through contracted attorney services. The department may adopt rules as necessary to implement this subsection. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
[ 2007, c. 311, §1 (NEW) .]
3. Definitions. For purposes of this section, "3rd party" or "liable party" or "potentially liable party" means any entity, including, but not limited to, any health insurer as included in 42 United States Code, Section 1396a(a)(25)(I) and any other parties that are, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, that may be liable under a contract to provide health, automobile, workers' compensation or other insurance coverage that is or may be liable to pay all or part of the medical cost of injury, disease, disability or similar occurrence of an applicant or recipient of benefits under the MaineCare program. For purposes of this section and sections 18 and 19, an "insurance carrier" includes, but is not limited to, health insurers, group health plans as defined in 29 United States Code, Section 1167(1), service benefit plans and health maintenance organizations, as well as any other entity included in 42 United States Code, Section 1396a(a)(25)(I).
[ 2007, c. 240, Pt. JJJ, §4 (AMD); 2007, c. 448, §9 (AMD); 2007, c. 448, §14 (AFF) .]
1979, c. 145, (NEW). 1979, c. 610, §§1,2 (AMD). 1981, c. 24, §§1,2 (AMD). 1981, c. 698, §92 (AMD). 1987, c. 203, (AMD). 1987, c. 621, (AMD). 1989, c. 397, §2 (AMD). 1989, c. 778, §§1-3 (AMD). 1991, c. 9, §§N1-6 (AMD). 1991, c. 815, §1 (AMD). 1993, c. 410, §§I2,3 (AMD). 1993, c. 707, §I1 (AMD). 1995, c. 462, §§D2,3 (AMD). 1997, c. 395, §E1 (AMD). 1997, c. 795, §§1-4 (AMD). 1999, c. 483, §§1,2 (AMD). 1999, c. 668, §§94-99 (AMD). 1999, c. 731, §§TT1-6 (AMD). 2003, c. 20, §K2 (AMD). 2003, c. 689, §B6 (REV). 2005, c. 12, §DDD9 (AMD). 2005, c. 12, §DDD17 (AFF). 2007, c. 240, Pt. JJJ, §§1-4 (AMD). 2007, c. 311, §1 (AMD). 2007, c. 381, §§1-4 (AMD). 2007, c. 423, §1 (AMD). 2007, c. 448, §§7-9 (AMD). 2007, c. 448, §14 (AFF). 2009, c. 150, §3 (AMD).