An Act To Clarify Medicaid Managed Care Ombudsman Services
Maine Legislature, Session 127, LD 1498
Committee: Health and Human Services
Sponsors: VACHON, VOLK, BATTLE, COREY, FOLEY, GERRISH, GINZLER, HEAD, HYMANSON, MAKER, MALABY, ORDWAY, PICCHIOTTI, PICKETT, TUELL, CYRWAY, DAVIS, VALENTINO
Amends: 22 MRSA §3174-X

Legislative Document 
No. 1498 
H.P. 1021 
House of Representatives, December 23, 2015 
An Act To Clarify Medicaid Managed Care Ombudsman Services 
Approved for introduction by a majority of the Legislative Council pursuant to Joint Rule 
203. 
Received by the Clerk of the House on December 21, 2015.  Referred to the Committee on 
Health and Human Services pursuant to Joint Rule 308.2 and ordered printed pursuant to Joint 
Rule 401. 
ROBERT B. HUNT 
Clerk 
Presented by Representative VACHON of Scarborough. 
Cosponsored by Senator VOLK of Cumberland and 
Representatives: BATTLE of South Portland, COREY of Windham, FOLEY of Wells, 
GERRISH of Lebanon, GINZLER of Bridgton, HEAD of Bethel, HYMANSON of York, 
MAKER of Calais, MALABY of Hancock, McCLELLAN of Raymond, McELWEE of 
Caribou, ORDWAY of Standish, PICCHIOTTI of Fairfield, PICKETT of Dixfield, TUELL of 
East Machias, Senators: CYRWAY of Kennebec, DAVIS of Piscataquis, VALENTINO of 
York. 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1.  22 MRSA §3174-X, as enacted by PL 1999, c. 681, §1, is repealed and the 
following enacted in its place: 
§3174-X.  Contracted ombudsman services 
1.  Definitions.  As used in this section, unless the context otherwise indicates, the 
following terms have the following meanings. 
A.  "Children's health insurance program" means the state children's health insurance 
program under Title XXI of the Social Security Act. 
B.  "Eligible member" means a person who is eligible to participate as a member or 
beneficiary of the MaineCare program or the children's health insurance program. 
C.  "Medicaid managed care" means all Medicaid and children's health insurance 
program programs and services that are determined by the United States Department 
of Health and Human Services to be managed care programs. Such managed care 
programs include but are not limited to primary care case management and health 
homes or other patient-centered medical homes that include MaineCare or children's 
health insurance program members, including behavioral health homes. 
D.  "Ombudsman" means the director of the program and persons employed or 
volunteering to perform the work of the program. 
E.  "Outreach and education" includes, but is not limited to, work site and 
community-based training and workshops; outreach at events such as town fairs, 
expositions and health fairs; development of mailings about coverage options, open 
enrollment periods and other important updates; information hotline response, 
including providing information and referrals to members and eligible members who 
call; and screening for eligibility for coverage programs, including programs other 
than Medicaid programs. 
F.  "Program" means the ombudsman program established under this section. 
2.  Program established.  The ombudsman program is established as an independent 
program to provide ombudsman services to the Medicaid managed care population 
regarding Medicaid services provided by the department and the department's office for 
family independence and office of MaineCare services.  The program shall consider and 
promote the best interests of the Medicaid and children's health insurance program 
populations, answer inquiries and investigate, advise and work toward resolution of 
complaints of infringement of the rights of a member or eligible member.  The program 
shall include outreach and education to eligible members and those who serve eligible 
members, including health care providers, social service providers and health insurance 
navigators and other enrollment professionals.  The program shall function through the 
staff of the program, subcontractors and any volunteers recruited and trained to assist in 
the duties of the program. 
3.  Contracted services; political activity prohibited.  The program shall operate by 
contract with a nonprofit organization that is best able to provide services on a statewide 
basis.  The ombudsman may not be actively involved in state-level political party 
activities or publicly endorse, solicit funds for or make contributions to political parties 
on the state level or candidates for statewide elective office.  The ombudsman may not be 
a candidate for or hold any statewide elective or appointive public office. 
4.  Program services.  The first priority in the work of the program and the contract 
for ombudsman services under subsection 3 must be case-specific advocacy and 
enrollment services.  In performing services under this section, the program, as it 
determines to be appropriate, may create and maintain records and case-specific reports. 
The program may: 
A.  Provide information to the public about the services of the program through a 
comprehensive outreach program.  The program shall provide information through a 
toll-free telephone number or numbers; 
B.  Answer inquiries, investigate and work toward resolution of complaints regarding 
the performance and services of the department and participate in conferences, 
meetings and studies that may improve the performance of the department; 
C.  Provide services to members and eligible members to assist them in protecting 
their rights; 
D.  Inform members and eligible members of the means of obtaining services from 
the department; 
E.  Provide information and referral services; 
F.  Analyze and provide opinions and recommendations to agencies, the Governor 
and the Legislature on state programs, rules, policies and laws; 
G.  Determine what types of complaints and inquiries will be accepted for action by 
the program and adopt policies and procedures regarding communication with 
members and eligible members making inquiries or complaints and the department; 
H.  Apply for and use grants, gifts and funds for the purpose of performing the duties 
of the program; and 
I.  Collect and analyze records and data relevant to the duties and activities of the 
program and make reports as required by law or as the department considers 
appropriate. 
5.  Information for members and eligible members; eligibility.  The program, in 
consultation with appropriate interested parties, shall provide information about eligibility 
requirements and procedures for enrolling in MaineCare to members and eligible 
members, including their dependents.  The providing of the information under this 
subsection does not constitute representation of members and eligible members. Members 
and eligible members may seek and receive information regardless of whether they are 
represented by legal counsel.  The information must be provided free of charge to 
members and eligible members. 
This subsection does not create new rights or obligations concerning the provision of 
legal advice or representation of members and eligible members. 
6.  Confidentiality of records.  Information held by or records or case-specific 
reports maintained by the program are confidential. Disclosure may be made only if the 
ombudsman determines such disclosure is lawful and in the best interest of the member or 
eligible member. 
7.  Liability.  Any person who in good faith submits a complaint or inquiry to the 
program pursuant to this section is immune from any civil or criminal liability arising 
from that complaint or inquiry.  For the purpose of any civil or criminal proceedings, 
there is a rebuttable presumption that any person acting pursuant to this section did so in 
good faith.  The ombudsman and employees and volunteers of the program are employees 
of the State for the purposes of the Maine Tort Claims Act. 
8.  Information.  Information about the services of the program must be given to all 
members and eligible members who receive or are eligible to receive services from the 
department and from persons and entities contracting with the department for the 
provision of Medicaid services. 
9.  Report.  The program shall report to the department according to the requirements 
of the program contract under subsection 3. 
10.  Funding.  The department shall contract for ombudsman services under this 
section as long as nonstate funding is available for use as the state seed money for such a 
contract and General Fund money is not required. 
SUMMARY 
Current law requires the Department of Health and Human Services to contract for 
ombudsman services for the Medicaid managed care population as long as nonstate 
funding is available.  This bill retains that provision and establishes the ombudsman 
program in statute, describes the Medicaid managed care population and specifies the 
duties of the ombudsman program, which include providing services and outreach for 
members and eligible members of the Medicaid program and the state children's health 
insurance program under Title XXI of the Social Security Act.