An Act To Amend MaineCare Benefits as Allowed by the Federal Deficit Reduction Act of 2005 March 6, 2007
Maine Legislature, Session 123, LD 1120
Committee: Health and Human Services
Sponsors: MILLS

Legislative Document 
No. H20 
S.P.372 
An Act To Amend MaineCare Benefits as Allowed by the Federal 
Deficit Reduction Act of 2005 
March 6, 2007 
Reference to the Committee on Health and Human Services suggested and ordered printed. 
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Presented by Senator MILLS of Somerset. 
Printed on recycled paper 
JOY J. O'BRIEN 
Secretary of the Senate 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1. 22 MRS A §3173-C, as amended by PL 2003, c. 20, Pt. K, §§5 to 8 and c. 
451, Pt. H, § 1 and affected by §3, is further amended to read: 
§3173-C. Copayments and premiums 
1. 
Authorization required. The department may not require any MaineCare 
member, referred to in this section as "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 
services in that institution, to spend for costs of care all 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 Except as applied to nonemergency use of emergency services, 
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 lie the 
individual is enrolled; 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. 
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. 
CepRyments. 
Notwithstanding any other provision of la'N, the follo'Ning 
copayments per service per day are imf"osed and reimbursements are reduced, or both, to 
the follo\'l'ing levels: 
Page I -123LRI408(OI)-t 
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 services, $2; 
C. 
Occupational therapy services, $2; 
H. 
Speech therapy services, $2; 
I. Podiatry services, $2; 
J. 
Ps~'chologist services, $2; 
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K. Chiropractic sept' ices, $2; 
L. 
Laboratory and x ra~' services, $1 ; 
M. 
Optical services, $2; 
N. 
Optometric services, $3; 
O. 
Mental health clinic services, $2; 
P. 
Substance abuse services, $2; 
Q. 
Hospital inpatient services, $3 per patient day; 
R. 
Federally qualified health center services, $3 per patient day, effective July 1, 
2004; and 
S. 
Rural health center services, $3 per patient day. 
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The department may adopt rules to adjust the copayments set forth in this subsection. 
The rules ma~' adjust amounts to ensure that copayments 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 b)' 42 United States 
Code, Section 1392(a)(30)(J\) or an)' successor provision of la'"" 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 co payment, the provider may refuse to provide the service or item for which the 
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copayment was charged. 
A. Copayments may not be charged to the following populations: 
(I) Children who have not attained 6 years of age whose family incomes are 
below 133% of the nonfarm income official poverty line; 
(2) Children 6 years of age and 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; 
and 
(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. 
B. Copayments may not be charged for pregnancy-related services, family planning 
services, hospice care or preventive services for children who have not attained 18 
years of age. 
C. 
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. 
D. 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 between 100% and 150% of the nonfarm 
income official poverty line, except as otherwise provided in this subparagraph, 
copayments are set at 10% of the cost of the service or item. For nonemergency 
use of emergency services, copayments are set at twice the amount otherwise 
applicable to the emergency service. The hospital must first screen the member 
for the purposes of determining the member's health condition prior to requiring 
payment of the nonemergency use copayment. The hospital must inform the 
member of the increased copayment applicable to the member's non emergency 
use of emergency services and must provide information about nonemergency 
providers who could provide appropriate health care services to the member. 
(2) 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. 
For non emergency use of 
emergency services, copayments are set by rule adopted by the department. The 
hospital must first screen the member for the purposes of determining the 
member's health condition prior to requiring payment of the nonemergency use 
copayment. The hospital must inform the member of the increased copayment 
applicable to the member's nonemergency use of emergency services and must 
provide information about non emergency providers who could provide 
appropriate health care services to the member. 
E. Copayments for prescription and over-the-counter drugs that are subject to the 
formulary standards of section 3174-M, subsection I-A are subject to the provisions 
of this subsection. 
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(1) For all members, copayments for preferred drugs are limited to the amounts 
determined by rule adopted by the department. 
(2) For members whose family income is below 150% of the nonfarm income 
official poverty line, copayments for drugs are limited to nominal amounts. 
(3) For members whose family income is at or above 150% of the nonfarm 
income official poverty line, copayments for drugs are set at 20% of the cost of 
non preferred drugs and 10% of the cost of preferred drugs. 
(4) For all members, copayments at the higher rate applicable to nonpreferred 
drugs must be waived when the prescribing health care practitioner determines 
that the preferred drug is less effective for the member or will have an adverse 
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health impact on the member and informs the department of that determination. 
F. 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: 
(1) Children who have not attained 6 years of age whose family incomes are 
below 133% of the nonfarm income official poverty line; 
(2) Children 6 years of age and 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 of federal 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) All members whose family income is below 150% of the nonfarm income 
official poverty line. 
B. For all members whose family income is at or above 150% of the nonfarm income 
official poverty line, premiums are set at amounts to be determined by the department 
by rule. 
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. 
10. 
Nonemergency use of emergency services. 
As used in this section, 
"nonemergency use of emergency services" means use of emergency services in a 
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hospital for care or treatment other than for an emergency medical condition, as defined 
in the federal Balanced Budget Act of 1997, Public Law 105-33, III Stat. 251. 
11. Rulemaking. The department shall adopt rules to implement this section. Rules 
adopted pursuant to this subsection are routine technical rules as defined in Title 5, 
chapter 375, subchapter 2-A. 
Sec. 2. Rulemaking. By January 1, 2008, the Department of Health and Human 
Services shall adopt rules to implement this Act. 
Sec. 3. Effective date. This Act takes effect October 1, 2007. 
SUMMARY 
This bill imposes cost sharing in the form of premiums and copayments for services, 
items and prescription drugs in the MaineCare program consistent with the provisions of 
the federal Deficit Reduction Act of2005.