An Act To Improve Complaint Resolution and Hearing Procedures in the Department of Human Services Further amend the bill by striking out everything after the title and before the summary and inserting in its place the following: , Be it enacted by the People of the State of Maine as follows: Sec. 1. 22 MRSA §13, sub-§6 is enacted to read: 6. Limitation on actions to recover over.papents. The department may impose a sanction or withhold payment from a MaineCare provider in order to recover or impose penalties for an overpayment for services rendered or goods delivered under the MaineCare program as provided in this subsection. A. The department may impose a sanction or withhold payment when the department has obtained an order from Superior Court allowing interim sanctions upon showing a substantial likelihood that overpayment or fraud has occurred or that substantial harm to the department will result from further delay or when the department has taken final agency action and the provider has waived or exhausted its right to judicial review. Page l-LR1441(2) COMMITTEE AMENDMENT
Maine Legislature, Session 121, LD 1356
Committee Amendment CA_A_S233 (Senate)
Amends: 22 MRSA §13, 22 MRSA §42, 22 MRSA §48, 22 MRSA §1714-A

COMMITTEE AMENDMENT" A" to S.P. 444, L.D. 1356, Bill, "An 
Act To Provide Fair Hearing Procedures in the Department of Human 
Services" 
Amend the bill by striking out the title and substituting 
the following: 
'An Act To Improve Complaint Resolution and Hearing Procedures in 
the Department of Human Services' 
Further amend the bill by striking out everything after the 
title and before the summary and inserting in its place the 
following: 
, Be it enacted by the People of the State of Maine as follows: 
Sec. 1. 22 MRSA §13, sub-§6 is enacted to read: 
6. 
Limitation on actions to recover over.papents. 
The 
department may 
impose 
a 
sanction or withhold payment 
from 
a 
MaineCare provider in order to recover or impose penalties for an 
overpayment for services rendered or goods delivered under the 
MaineCare program as provided in this subsection. 
A. 
The department may impose a sanction or withhold payment 
when the department has obtained an order from Superior 
Court allowing interim sanctions upon showing a substantial 
likelihood that overpayment or fraud has occurred or that 
substantial harm to the department will result from further 
delay or when the department has taken final agency action 
and the provider has waived or exhausted its right to 
judicial review. 
Page l-LR1441(2) 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT .. A 
.. to S.P. 444, L.D. 1356 
B. 
Notwithstanding 
paragraph 
A, 
the 
department 
may 
terminate or suspend the participation of a provider in the 
MaineCare 
program 
in lieu 
of 
recoupment 
pending 
final 
determination regarding an overpayment as long as 30 days' 
notice is given. 
Sec. 2. 22 MRSA §42, sub-§7, as enacted by PL 2001, c. 666, 
Pt. C, §l, is amended to read: 
7. 
Appeal process. 
The department shall amend the rules 
governing 
appeals 
of 
informal 
review 
decisions 
of 
Meaieaia 
MaineCare payment and cost report audit and review issues filed 
by MaineCare providers e~-~~~-~~~~~~-£e£~~ee£-~-ffieaiea* 
aBa-£emea~a~-~4~~~~~-~&~~~~~~~a-seFviees of goods and 
services or initiated by the department and any other informal 
review decisions that seek to 
impose 
repayment. 
recovery or 
recoupment obligations or sanctions or fines on providers as 
provided in this subsection. 
A. 
The department shall give to the provider involved in an 
informal 
review 
decision written 
notice 
of 
the 
appeal 
process and the time period for filing a notice of appeal. 
gT--~~~~~-saa**-~~~~-~it~-a-~~~~-peFseBs 
wae-~~-£~--empleyee&-~--~ae-~~~&~-~~--iBaepeBaeB~T 
iffipaF~ia*-aeaFiB~-e~~ieeF-seFvieesT 
C. 
Compensation under 
~ae ~ contract into which the 
department enters for hearing officer services may reflect 
the number of appeals on which recommendations are made by 
the hearing officer and may not reflect the substance of the 
recommendations made by the hearing officer. 
D. 
The hearing officer shall conduct a hearing de novo on 
issues raised in the notice of appeal filed by the provider 
and shall in a timely manner render a written recommendation 
based on the record and in accordance with applicable state 
and federal law, rule and regulation. 
The hearing officer 
shall provide a copy of the recommendation to the department 
and to the provider along with notice of the opportunity to 
submit written comments to the commissioner. 
E. 
The 
recommendation of 
the hearing officer must 
be 
forwarded to the commissioner for a final decision, based on 
the record, which must include any written comment submitted 
in a timely manner by the provider and the department. The 
commissioner may adopt, adopt with modification or reject 
the recommendation of the hearing officer. The commissioner 
shall issue a final decision in writing, which must include 
the reasons for any departure from the recommendation of the 
COMMITTEE AMENDMENT 
~-" 
COMMITTEE AMENDMENT "A" to S.P. 444, L.D. 1356 
hearing officer 
and 
notice 
of 
the 
process 
for 
appeal 
pursuant to Title 5, chapter 375, subchapter VIII. 
If the 
commissioner deviates from a prior decision cited in the 
course of a proceeding, the final decision must include an 
explanation of the reason that the prior decision was not 
followed. 
F. 
By July L 
2004 the department shall make available on 
its publicly accessible site on the Internet the decisions 
in all MaineCare provider appeals beginning January 1, 2004, 
including the recommendations of the hearing officer and the 
decision of the commissioner. 
(1) 
The site must include a search feature allowing 
users 
to obtain information on specific 
issues 
of 
interest. 
(2) 
The site must protect information that is personal 
or confidential. 
G. 
In lieu of the 
appeal 
procedure provided 
in this 
subsection, 
the 
parties 
may 
choose 
arbitration 
by 
a 
qualified arbitrator or panel of arbitrators as provided in 
this paragraph. 
By January 1, 2004, the department shall 
adopt rules to implement this paragraph that are consistent 
with federal law and regulation. 
Rules adopted pursuant to 
this paragraph are routine technical rules as defined in 
Title 5, chapter 375, subchapter 2-A. 
(1) 
The arbitrator or panel of arbitrators must be 
selected and compensated as agreed by the parties. 
(2) 
Arbitration under this paragraph is available only 
when the amount in controversy is $10,000 or less and 
the 
subject 
matter 
in 
controversy is 
assessments, 
recovery 
or 
recoupment 
orders, 
sanctions 
or 
administrative fines. 
(3) 
A 
provider 
choosing 
arbitration 
under 
this 
paragraph may waive any right of appeal. 
H. 
In 
an administrative 
appeal 
of 
an 
informal 
review 
decision under this subsection, the department bears the 
burden 
of 
proving 
a 
violation 
of 
law 
or 
rule 
by 
a 
preponderance of the evidence. 
If the department proves 
that 
records 
of 
goods 
or 
services 
are 
defective, 
the 
department may impose the sanction of total recoupment only 
when 
the 
provider 
has 
failed 
to 
demonstrate 
by 
a 
preponderance of the evidence that the disputed goods or 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT .. A 
.. to S.P. 444, L.D. 1356 
services 
were 
actually 
provided 
to 
eligible 
MaineCare 
members. 
The department shall provide funding for contractual services 
under this subsection from within existing resources. 
Sec.3. 22 MRSA §48 is enacted to read: 
§48. 
Provider relations 
Department 
personnel 
assigned 
to 
MaineCare 
provider 
relations shall assist MaineCare providers in addressing and 
resolving 
in' a 
cost-effective 
and 
expeditious 
manner 
any 
disagreements between the department and providers or groups of 
providers. 
Provider 
relations 
personnel 
shall 
recei ve 
and 
investigate complaints and concerns from providers regarding the 
MaineCare 
program 
and 
the 
MaineCare 
reimbursement 
prior 
to 
informal review or administrative hearing. 
In performing their 
duties under this subsection, the provider relations personnel 
must have 
access to 
the Director of the 
Bureau of Medical 
Services. 
The department shall implement the provisions of this 
section within existing resources. 
Sec. 4. 22 MRSA §1714-A, sub-§2, as amended by PL 2001, c. 
596, Pt. B, §4 and affected by §25, is further amended to read: 
2. 
Establishment of debt. 
A debt is established by the 
department when it notifies a provider of debt that the provider 
owes the department pursuant to a 
~i:aa~--l'e€efi€-i.,l-ia~4e:a decision 
and order that constitutes final 
agency action. 
A debt is 
collectible by the department 31 days after exhaustion of all 
administrative appeals and any jUdicial review available under 
Title 5, chapter 375. 
Sec. 5. 22 MRSA §1714-A, sub-§5, as enacted by PL 1991, c. 
568, §4, is amended to read: 
5. 
Department 
may 
offset. 
The 
department 
may 
offset 
against current reimbursement owed to a provider or any entity 
related by ownership or control to that provider any debt it is 
owed by that provider after the debt becomes collectible. 
The 
department shall adopt rules that implement this subsection and 
define the ownership or control relationships that are subject to 
an offset under this subsection. 
Rules adopted pursuant to this 
subsection are routine technical rules as defined in Title 5, 
chapter 375, subchapter 2-A. 
Sec. 6. 
Complaint resolution and informal hearing process 
recommendations. 
By January 5, 
2004, the Department of Human 
Services 
and 
the 
Department of 
Behavioral 
and 
Developmental 
COMMITTEE AMENDMENT 
",. -\. 
COMMITTEE AMENDMENT 'A" to S.P. 444, L.D. 1356 
Services, in conjunction with their duties with regard to merger 
of the 2 departments under Public Law 2003, chapter 20, Part K, 
section 18, shall report to the Joint Standing Committee on 
Heal th 
and 
Human 
Services 
recommendations 
to 
improve 
the 
MaineCare complaint resolution and informal hearing process that 
ensure 
that 
MaineCare 
providers 
receive 
fair 
and 
impartial 
complaint resolution procedures and informal hearings.' 
SUMMARY 
This amendment replaces the bill. 
It removes the emergency 
provisions, reimbursement of the service provider for attorney's 
and 
consultant's 
fees, 
the 
MaineCare 
provider 
ombudsman, 
retroactivity provisions and the requirement of a showing of no 
harm to the public before imposition of sanctions or withholding 
of payments. 
It provides limitations on the authority of the 
Department of Human Services to recover overpayments, amends the 
informal appeal process, allows arbitration and restricts the 
sanction of total recoupment. 
It requires MaineCare provider 
relations personnel to assist MaineCare providers in addressing 
and resolving disagreements and corrects outdated language. 
It 
requires 
rulemaking 
to 
define 
the 
ownership 
and 
control 
relationships that apply in MaineCare offset situations. 
It 
requires a report from the Department of Human Services and the 
Department 
of 
Behavioral 
and 
Developmental 
Services 
on 
recommendations regarding complaint resolution and the hearing 
process. 
FISCAL :\OTE REQUIRED. 
(See attached) 
COMMITTEE AMENDMENT 
Fiscal Detail and Notes 
Approved: 05/20103 frac. 
Office of Fiscal and Program Review 
LD 1356 
An Act to Improve Complaint Resolution and Hearing Procedures in the 
Department of Human Services 
LR 1441(02) 
Fiscal Note for Bill as Amended by Committee Amendment ,A" S-}. 3> 
Committee: Health and Human Services 
Fiscal Note Required: Yes 
Fiscal Note 
Minor cost increase - General .Fund 
Any additional costs to the Department of Human Services and the Department of Behavioral and Developmental 
Services can be absorbed by the departments utilizing existing resources. 
LR1441f?)  Fi""",1 Nntl"  P""p 1 r.f"1