An Act To Ensure Compliance with Federal Medicaid Requirements LR 2641(02)
Maine Legislature, Session 121, LD 1695
Committee Amendment CA_A_S433 (Senate)
Amends: 22 MRSA §13, 22 MRSA §42

COMMITTEE AMENDMENT "A to S.P. 627, L.D. 1695, Bill, "An 
Act To Ensure Compliance with Federal Medicaid Requirements" 
Amend the bill by striking out everything after the enacting 
clause and before the summary and inserting in its place the 
following: 
'Sec. I. 22 MRSA §13, sub-§6, as enacted by PL 2003, c. 419, 
§1, is amended to read: 
6. 
Limi tation on actions to recover overpayments. 
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 
e~ and 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. 
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 pursuant to federal regulation and state 
rule. 
Page I-LR2641(2) 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT ft.' to S,p, 627, L,D, 1695 
C. 
For the purposes of this subsection, "overpayment" does 
not include an overestimate made as part of a prospective 
interim 
payment, 
a 
3rd-party 
liability 
recovery, 
a 
departmental administrative error or receivership fees or 
debt. 
In addition, 
this 
subsection does 
not apply to 
routine adjustments of $2,500 or less that result from 
claims editing or processing. 
Sec. 2. 22 MRSA §42, sub-§7, l(H, as enacted by PL 2003, c. 
419, §2, is amended to read: 
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 existing and available records of goods or services are 
defective, the department may impose 1:he a fee or sanction 
9~, 
including 
total 
recoupment. 
Total 
recoupment 
for 
defective records is warranted only when the provider has 
failed to demonstrate by a preponderance of the evidence 
that 
the 
disputed 
goods 
or 
services 
were 
medically 
necessary, 
MaineCare-covered goods 
or 
services 
and 
were 
actually provided to eligible MaineCare members.' 
SUMMARY 
This amendment replaces the bill. 
The amendment retains the 
provision 
of 
the 
bill 
defining 
"overpayment" 
and 
adds 
an 
exclusion for certain routine adjustments of $2,500 or less. 
The 
amendment retains the provision on administrative appeals of 
informal reviews. 
The amendment clarifies the use of existing 
and available records, limits the application of total recoupment 
and limits proof that services or goods were actually provided to 
situations in which the provider has proven by a preponderance of 
the evidence that the goods or services were medically necessary, 
MaineCare-covered goods or services. 
The amendment corrects an 
error in current law that pertains to the Department of Human 
Services' 
terminating or 
suspending 
the 
participation of 
a 
provider in the MaineCare program. 
FISCAL \"OTE REQLlRED 
(See attached) 
COMMITTEE AMENDMENT 
Approved: 03/09104 ;tP'aC!. 
Office of Fiscal and Program Review 
LD 1695 
An Act To Ensure Compliance with Federal Medicaid Requirements 
LR 2641(02) 
Fiscal Note for Bill as Amended by Committee Amendment ,~, 
Committee: Health and Human Services 
~ 
Fiscal Note Required: Yes 
Fiscal Note 
Minor cost increase - General Fund 
Minor savings - General Fund 
LR2641(2) - Fiscal Note - Page 1 of 1