An Act To Create a Program To Implement Choice of Health Plans in the MaineCare Program and Amend the MaineCare Program
Maine Legislature, Session 123, LD 1820
Committee: Health and Human Services
Sponsors: WESTON, TARDY, HASTINGS, MILLS, RAYE, SMITH, SNOWE-MELLO, TURNER, LEWIN, WALKER
Amends: 22 MRSA §18, 22 MRSA §3173-C, 22 MRSA §3174-L

Legislative Document 
No. 1820 
S.P.650 
April 4, 2007 
An Act To Create a Program To Implement Choice of Health Plans 
in the MaineCare Program and Amend the MaineCare Program 
Reference to the Committee on Health and Human Services suggested and ordered printed. 
Presented by Senator WESTON of Waldo. 
JOY J. O'BRIEN 
Secretary of the Senate 
Cosponsored by Representative TARDY of Newport and Senators: HASTINGS of Oxford, 
MILLS of Somerset, RAYE of Washington, SMITH of Piscataquis, SNOWE-MELLO of 
Androscoggin, TURNER of Cumberland, Representatives: LEWIN of Eliot, WALKER of 
Lincolnville. 
Printed on recycled paper 
Be it enacted by the People of the State of Maine as follows: 
PART A 
Sec. A-I. 22 MRSA §18, sub-§l, as enacted by PL 1997, c. 795, §5, is amended 
to read: 
1. Program. The Private Health Insurance Premium Program is operated by the 
Bureau of Medical Services within the department and implements the provisions of 42 
United States Code, Section 1396a(a)(25)(G) and 1396e. The program is mandatory for 
persons for whom the department has determined that the program is cost-effective under 
subsection 2. 
Sec. A-2. 22 MRSA §18, sub-§6 is enacted to read: 
6. Condition of enrollment. Cooperation of the individual with the department to 
determine eligibility for the Private Health Insurance Premium Program and cost-
effectiveness under subsection 2 is a condition of enrollment in MaineCare. 
The 
department shall require the cooperation of the individual at the time of application or 
within 3 months of the date of application and at the time of review and renewal of 
enrollment. 
Sec. A-3. 22 MRSA §3173-C, as amended by PL 2003, c. 451, Pt. H, § 1 and as 
affected by §3, is further amended to read: 
§3173-C. Copayments and premiums 
1. 
Authorization required. The department may not require any MaineCare 
member to make any payment toward the cost of a MaineCare service unless that 
payment is specifically authorized by this section, except that any copayment or premium 
expressly approved by the federal Secretary of the Department of Health and Human 
Services as part of a waiver must be implemented. 
2. 
Prescription drug services. 
Except as provided in subsections 3 and 4, a 
payment of $2.50 for each drug is to be collected from the MaineCare member for each 
drug prescription that is an approved MaineCare service. Copayments must be capped at 
$25 per month per member. If a member is prescribed a drug in a quantity specifically 
intended by the provider or pharmacist, for the recipient's health and welfare, to last less 
than one month, only one payment for that drug for that month is required. 
3. 
Exemptions. No copayment may be imposed with respect to the following 
servIces: 
A. 
Family planning services; 
B. 
Services furnished to individuals under 21 years of age; 
C. 
Services furnished to any individual who is an inpatient in a hospital, nursing 
facility or other institution, if that individual is required, as a condition of receiving 
Page I - 123LR1l40(Ol)-1 
services in that institution, to spend for costs of care alI but a minimal amount of 
income required for personal needs; 
D. 
Services furnished to pregnant women, and services furnished during the post-
partum phase of maternity care to the extent permitted by federal law; 
E. 
Emergency services, as defined by the department; 
F. 
Services furnished to an individual by a Health Maintenance Organization, as 
defined in the United States Social Security Act, Section 1903(m), in which fie the 
individual is enrolIed; and 
G. 
Any other service or services required to be exempt under the provisions of the 
United States Social Security Act, Title XIX and successors to it. 
II 
4. Persons in state custody. Any copayment imposed on a Medicaid recipient in the 
custody of the State is to be collected from the state agency having custody of the 
recipient. 
7. 
Capayments. 
Notwithstanding any other provision of law, the following 
co payments per service per day are imposed and reimbursements are reduced, or both, to 
the following levels: 
A. 
Outpatient hospital services, $3; 
B. 
Home health services, $3; 
C. 
Durable medical equipment services, $3; 
D. 
Private duty nursing and personal care services, $5 per month; 
E. 
Ambulance services, $3; 
F. 
Physical therapy se"'lices, $2; 
C. 
Occupational thefap,' sen'ices, $2; 
U. 
Speech therap,' sen'ices, $2; 
I. 
Podiatl)' services, $2; 
J. 
Ps,'chologist services, $2; 
K. Chiropractic sen'ices, $2; 
L. 
Laboratol)' and x ray services, $1; 
M. Optical services, $2; 
N. 
Optometric services, $3; 
O. 
Mental health clinic sen'ices, $2; 
P. 
Substance abuse sen'ices, $2; 
Q. 
Hospital inpatient sen'ices, $3 per patient day; 
R. 
federally qualified health center sen'ices, $3 per patient day, effecti'/e lui" I, 
2004; and 
8. 
R\:lfal health center services, $3 per patient day. 
The department ma;' adopt rules to adjust the copa;'ments set forth in this subsection. 
The rnles ma;' adjust amounts to ensure that copa;'ments are deemed nominal in amount 
and may include monthly limits or exclusions per service category. The need to maintain 
provider participation in the Medicaid program to the extent required by 42 United States 
Code, Section 1392(a)(30)(A) or an)' successor provision of lavi must be considered in 
any reduction in reimbursement to providers or imposition of copayments. 
8. Copayments. Notwithstanding any other provision of law, copayments to be paid 
by members are subject to the provisions of this subsection. In accordance with this 
subsection a provider may charge a copayment to a member and, if the member does not 
pay the copayment, the provider may refuse to provide the service or item for which the 
copayment was charged. 
A. Copayments may not be charged to the following populations or for the following 
servIces: 
(1) Children under 6 year of age whose family incomes are below 133% of the 
nonfarm income official poverty line; 
(2) Children 6 years of age or older and under 19 years of age whose family 
incomes are below 100% of the nonfarm income official poverty line; 
(3) Pregnant women and women who are within 60 days of having delivered a 
child; 
(4) Recipients offederal supplemental security income benefits; 
(5) Women being treated for breast or cervical cancer; 
(6) Children in foster care and adoption assistance programs under chapter 1071; 
(7) Members who reside in licensed residential facilities run by or contracted for 
by the State in which the residents are subject to a personal needs allowance 
under rules adopted by the department; and 
(8) 
Copayments may not be charged for pregnancy-related services, family 
planning services, hospice or preventive services for children under 18 years of 
age. 
B. Except as otherwise provided in this paragraph, copayments must be charged by 
providers of services and items, and reimbursements are reduced as follows. 
(1) For members whose income is below 100% of the nonfarm income official 
poverty line, copayments are limited to nominal amounts as determined by rule 
adopted by the department and may not be required in order for the member to 
receive the service or item. 
(2) For members whose income is between 100% and 150% of the nonfarm 
income official poverty line, except as otherwise provided in this subparagraph, 
copayments are set at 10% ofthe cost of the service or item. 
(3) For members whose income is above 150% of the nonfarm income official 
poverty line, except as otherwise provided in this subparagraph, copayments are 
set at 20% of the cost of the service or item. 
C. For all members, copayments and premiums are limited to an aggregate limit of 
5% of family income over a 3-month period. 
9. Premiums. Premiums for health coverage are subject to the provisions of this 
subsection. 
A. Premiums may not be charged to the following populations and for the following 
services: 
(1) Children under 6 years of age whose family incomes are below 133% of the 
nonfarm income official poverty line; 
(2) Children 6 years of age or older and under 19 years of age whose family 
incomes area below 100% of the nonfarm income official poverty line; 
(3) Pregnant women and women who are within 60 days of having delivered a 
child; 
(4) Recipients offederal supplemental security income benefits; 
(5) Women being treated for breast or cervical cancer; 
8 
(6) Children in foster care and adoption assistance programs under chapter 1071; 
(7) Members who reside in licensed residential facilities run by or contracted for 
by the State in which the residents are subject to a personal needs allowance 
under rules adopted by the department; and 
(8) All members whose family income is below 150% of the nonfarm income 
official poverty line. 
B. Except as provided in paragraph A, for all members whose family income is at or 
above 150% of the nonfarm income official poverty line, premiums are set at 3% of 
family income. 
C. For all members, copayments and premiums are limited to an aggregate limit of 
5% of family income over a 3-month period. 
D. The department shall suspend coverage for a member who is more than 60 days in 
arrears in the payment of premiums required by this subsection. 
Sec. A-4. Rulemaking. The Department of Health and Human Services shall 
adopt rules to implement this Part. 
Rules adopted pursuant to this Part are routine 
technical rules as defined by the Maine Revised Statutes, Title 5, chapter 375, subchapter 
2-A and take effect October 1,2007. 
Sec. A-S. Effective date. This Part takes effect October 1,2007, except that prior 
to that date the Department of Health and Human Services is authorized to commence 
rulemaking as provided in section 4 in order for those rules to take effect October 1, 
2007. 
, 
PARTB 
Sec. B-1. 22 MRSA §3174-LL is enacted to read: 
§3174-LL. MaineCare Choice program 
There is established within the MaineCare program the MaineCare Choice program 
to provjde members a choice of customized benefit plans from health carriers beginning 
days after approval of a waiver for the program by the federal Department of Health 
and Human Services, Centers for Medicare and Medicaid Services. 
1. Definitions. As used in this section, unless the context otherwise indicates, the 
following terms have the following meanings. 
A. "Carrier" has the same meaning as in Title 24-A, section 4301-A, subsection 3 
with the additional requirement that the carrier must be approved by the department 
to offer a customized plan for members who choose to enroll in the plan or who are 
enrolled by the department and do not disenroll in order to obtain employer-based 
health coverage using the procedures for disenrollment established by the department 
under rules adopted for enrollment and disenrollment. 
B. 
"Customized plan" or "plan" means a package of medically necessary health 
benefits and enhanced health benefits, offered by a health carrier, that has been 
approved by the department as meeting the benchmark standards established in the 
federal Deficit Reduction Act of2005. 
C. "Members" means members of the MaineCare program under this chapter who 
are adults without minor children or who are adults and children without a disability. 
D. "Participating drug outlet" has the same meaning as "drug outlet" in Title 32, 
section 13702, subsection 10 with the additional requirement that the drug outlet has 
chosen to voluntarily participate in the program. 
E. "Program" means the MaineCare Choice program established under this section. 
2. Coverage. The program shall offer health coverage to members through a choice 
of customized plans. A carrier shall include in a plan coverage for medically necessary 
health benefits and may include enhanced benefits designed to promote the involvement 
of the member in personal health decisions, behaviors and care and treatment, as 
determined by rules of the department for the plan. Enhanced health benefits may be 
1 
used by the carrier to provide incentives to improve health status up to the amount of 
$125 per member per year in credit dollars that may be used at participating drug outlets. 
3. Department responsibilities. The department has the following responsibilities 
with regard to the program. 
A. The department shall pay premiums to the carriers who offer plans under the 
program. Premiums must be calculated by the department using formulas that reflect 
the level of need of the member and that require risk to be borne by the carrier. 
B. If a member disenrolls from a plan or is disenrolled by the department in order to 
obtain coverage in employer-sponsored health coverage, the department shall provide 
for payment of premiums, deductibles, coinsurance and cost-sharing obligations for 
the member using the Private Health Insurance Premium Program under section 18. 
C. 
The department shal1 provide reinsurance for plans providing coverage for 
members that live in rural areas. 
D. The department shal1 provide informational materials for members eligible for 
enrol1ment in the program and counseling on a group and an individual basis to assist 
members and applicants with the choice of a plan. Individual counseling must be 
available statewide, including at the home of members for whom traveling to an 
office would be a hardship, and must be specific to the member. Counseling may be 
provided by department staff or through contracted services. 
Counselors who 
II 
provide individual counseling must have access to the member's MaineCare health 
record in order to assist the member in choosing a plan that is appropriate to the 
member's health care needs. 
E. 
The department shall adopt rules to implement this section. 
Rules adopted 
pursuant to this paragraph are routine technical rules as defined in Title 5, chapter 
375, subchapter 2-A. 
Sec. B-2. Submission required. By January 1, 2008 the Department of Health 
and Human Services shall submit to the federal Department of Health and Human 
Services, Centers for Medicare and Medicaid Services a completed application for a 
waiver for the MaineCare Choice program as established in the Maine Revised Statutes, 
Title 22, section 3 I 74-LL. 
PART C 
Sec. C-l. 22 MRS A §3174-MM is enacted to read: 
§3174-MM. Enhanced benefits plan 
The department shall establish an enhanced benefits plan, referred to in this section as 
"the plan," to provide incentives for members enrol1ed in the plan to participate in 
wellness activities. 
1. Plan components. The plan must include the following components: 
A. 
A schedule of qualifying activities that earn a member enhanced benefits, 
including but not limited to compliance with preventive health care, health screenings 
I 
and physical examinations, participation in wellness activities and adherence to 
prescribed regimens of care for the prevention, management, care and treatment of 
chronic diseases and conditions; 
B. An enrollment process that establishes the member's enhanced benefits account 
after the member has enrolled and completed qualifying activities under paragraph A; 
C. A system for recording when an enrol1ed member earns and spends enhanced 
benefits, which must include an efficient method by which the member may use 
enhanced benefits. 
The system must limit use to qualified health-related 
expenditures, which may include the purchase of health coverage but may not include 
payment in cash to the enrol1ed member. The system must provide for return to the 
department of unused funds when an enrolled member's account has been dormant 
for 3 years; and 
D. 
Oversight by the enhanced benefits plan oversight committee as provided in 
subsection 2. 
2. Oversi2ht. The commissioner shall appoint a volunteer enhanced benefits plan 
oversight committee to guide in the development and oversee the implementation of the 
plan. The oversight committee shall advise the department regarding the designation of 
activities that will be used to qualify a member for enhanced benefits, determination of 
the process for enrollment and the system for earning and recording enhanced benefits. 
Sec. C-2. 
Application for waiver; implementation. 
The Department of 
Health and Human Services shall apply to the federal Department of Health and Human 
Services, Centers for Medicare and Medicaid Services for a waiver to establish and 
implement the enhanced benefits plan under the MaineCare program. Implementation of 
the enhanced benefits plan must begin within 120 days of receipt of approval by the 
department. 
SUMMARY 
This bill amends the MaineCare program consistent with the federal Deficit 
Reduction Act of2005. 
The bill expands the operation of the private health insurance premium program, 
changes the structure of copayment requirements, adds premiums for certain members 
and establishes the MaineCare Choice program and the enhanced benefits program.