An Act to Clarify MaineCare Program Requirements Regarding Certain High-risk Health Care Providers
Maine Legislature, Session 131, LD 0432
Committee: Health and Human Services
Sponsors: MADIGAN
Amends: 22 MRSA §5307

Legislative Document
No. 432
H.P. 265
House of Representatives, February 2, 2023
An Act to Clarify MaineCare Program Requirements Regarding 
Certain High-risk Health Care Providers
Submitted by the Department of Health and Human Services pursuant to Joint Rule 204.
Reference to the Committee on Health and Human Services suggested and ordered printed.
ROBERT B. HUNT
Clerk
Presented by Representative MADIGAN of Waterville.
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  22 MRSA §5307, sub-§1, as enacted by PL 2021, c. 400, §1, is repealed 
and the following enacted in its place:
1.  Definitions.  As used in this section, unless the context otherwise indicates, the 
following terms have the following meanings.
A.  "Final adverse action" has the same meaning as in 42 Code of Federal Regulations, 
Section 424.502 (2008) in effect on November 19, 2008.
B.  "High-risk provider" means a provider the department has determined is high risk 
in accordance with subsection 2-A.
C.  "Person with ownership interest" means a person who has at least a 5% direct or 
indirect ownership interest in a high-risk provider or a provider in a high-risk provider 
category.
D.  "Provider" has the same meaning as "provider" or "supplier" in 42 Code of Federal 
Regulations, Section 400.202 (1983) in effect on January 1, 2022.
E.  "Provider in a high-risk provider category" has the same meaning as "high 
categorical risk: Provider and supplier categories" in 42 Code of Federal Regulations, 
Section 424.518(c)(1) (2020) in effect on December 28, 2020.
F.  "State Police" means the Department of Public Safety, Bureau of State Police.
Sec. 2.  22 MRSA §5307, sub-§2, as enacted by PL 2021, c. 400, §1, is amended to 
read:
2.  Background check.  The department shall request a background check for a 
MaineCare provider applicants applicant who are is a high-risk providers or provider, a 
provider in a high-risk provider categories as those terms are defined by department rule 
category or a person with ownership interest.  The applicant subject to the background 
check is responsible for the fees associated with the background check.  The background 
check must include criminal history record information obtained from the Maine Criminal 
Justice Information System and the Federal Bureau of Investigation.
A.  The criminal history record information obtained from the Maine Criminal Justice 
Information System must include a record of public criminal history record information 
as defined in Title 16, section 703, subsection 8.
B.  The criminal history record information obtained from the Federal Bureau of 
Investigation must include other state and national criminal history record information.
C.  A provider applicant shall submit to having fingerprints taken.  The State Police, 
upon payment by the provider applicant, shall take or cause to be taken the applicant's 
fingerprints and shall forward the fingerprints to the State Bureau of Identification so 
that bureau can conduct state and national criminal history record checks.  Except for 
the portion of the payment, if any, that constitutes the processing fee charged by the 
Federal Bureau of Investigation, all money received by the State Police for purposes 
of this paragraph must be paid over to the Treasurer of State.  The money must be 
applied to the expenses of administration incurred by the Department of Public Safety.
D.  The subject of a Federal Bureau of Investigation criminal history record check may 
obtain a copy of the criminal history record check by following the procedures outlined 
in 28 Code of Federal Regulations, Sections 16.32 and 16.33.  The subject of a state 
criminal history record check may inspect and review the criminal history record 
information pursuant to Title 16, section 709.
E.  State and national criminal history record information of a provider applicant must 
be used by the department for the purpose of screening that provider applicant.
F.  Information obtained pursuant to this subsection is confidential.  The results of 
background checks received by the department are for official use only and may not be 
disseminated to any other person or entity.  
G.  An individual whose enrollment as a MaineCare provider has expired and who has 
not applied for renewal may request in writing that the State Bureau of Identification 
remove the individual's fingerprints from the bureau's fingerprint file.  In response to a 
written request, the bureau shall remove the individual's fingerprints from the 
fingerprint file and provide written confirmation of that removal.  
Sec. 3.  22 MRSA §5307, sub-§2-A is enacted to read:
2-A.  High-risk provider adjustments by the department.  The department shall 
adjust the categorical risk for a provider to high if any of the following conditions exist:
A.  Within the previous 10-year period:
(1) The MaineCare program has imposed a payment suspension on the provider 
based on credible allegations of fraud, waste or abuse;
(2) The United States Department of Health and Human Services, Office of 
Inspector General or another state's Medicaid program has excluded the provider 
from Medicaid;
(3) A Medicare contractor revoked the provider's billing privileges and the provider 
is attempting to:
(a) Enroll as a new provider; or
(b) Establish billing privileges for a new service location; or
(4)  The provider was subject to a final adverse action;
B.  Within the previous 6-month period, the United States Department of Health and 
Human Services, Centers for Medicare and Medicaid Services lifted a temporary 
moratorium for a particular provider type that prevented the provider from enrolling as 
a MaineCare provider and that provider is now a MaineCare provider applicant;
C.  The United States Department of Health and Human Services, Office of Inspector 
General excluded the provider from Medicare; or
D. The provider:
(1)  Owes $1,000 or more to the department as a result of a Medicaid overpayment 
that is not currently under appeal or in a payment plan;
(2)  Has been terminated or is otherwise precluded from billing Medicaid; or
(3)  Has been excluded from any federal health care program.
SUMMARY
This bill clarifies the MaineCare program requirements with regard to certain high-risk 
providers.  It also requires a person with a certain level of ownership interest in a high-risk 
provider to submit to a fingerprint-based criminal history record background check.