reglab/statecodes huggingface dataset:
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VI › Section 144-101-VI-01 - Primary Care Case Management (replaced by Section 03 on June 21, 2022) › Subsection 144-101-VI-01.10 - INFORMAL CONFERENCES/ADMINISTRATIVE HEARINGS

Current through 2024-29, July 17, 2024
1.10-1
Members
A. General Members who have a grievance may
					 request either an informal conference and/or an administrative hearing. A
					 member does not have to file a complaint before filing a grievance.
B. Informal Conferences Members may request
					 an informal conference with the OMS. Requests may be made verbally or in
					 writing by contacting MaineCare Member Services. The request must be made
					 within ten (10) calendar days of the date of the notice of adverse findings.
The OMS will schedule an informal conference within ten
						(10) calendar days of receipt of the request and will give written notice prior
						to the informal conference to the following parties:
The member requesting the conference;
													The staff responsible for the decision affecting
						  the member, if appropriate; and
													The member's designated representative, if
						  known.
The Director of OMS or a designee who was not involved in
						the decision under review will conduct the conference and allow all
						participants to offer relevant information. A record of the conference will be
						made, including the identity of the participants, a summary of the information
						presented, and copies of all written material presented or submitted.
The Director of OMS or his/her designee will issue a
						written decision of the matter within ten (10) calendar days of the date of the
						conference. The decision will include a brief statement of the reasons for the
						decision and an explanation of the member's right to request an administrative
						hearing if s/he is dissatisfied with the decision. The OMS will mail a copy of
						the decision to each party entitled to receive notice.
C. Administrative Hearings All members may
					 request an administrative hearing in accordance with provisions of Chapter I of
					 this Manual.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VI › Section 144-101-VI-02 - MaineCare DirigoChoice Initiative

Current through 2024-29, July 17, 2024
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VI › Section 144-101-VI-03 - Primary Care Plus › Subsection 144-101-VI-0301 - INTRODUCTION

Current through 2024-29, July 17, 2024
Primary Care Plus (PCPlus) is a model that gives Primary
						Care Providers (PCPs) greater flexibility and incentives to effectively meet
						MaineCare members' health care needs by transitioning away from a volume-based
						(fee-for-service) payment system with little connection to value, toward an
						approach that provides Population-Based Payments (PBPs) tied to cost- and
						quality-related outcomes. Participation in PCPlus is voluntary for PCPs. For
						PCPs that elect to participate, the Maine Department of Health and Human
						Services (Department) shall share quality and utilization data, offer a
						value-based payment model, and provide technical assistance to help practices
						transform care delivery and achieve performance outcomes.
Member participation in this model is voluntary, is based
						on members' selection of a PCP, and has no bearing on MaineCare members'
						freedom of choice to access services from any qualified MaineCare provider.
						Section 1905(t)(1) of the Social Security Act (
						42
						U.S.C. §
												1396d(t)(1) )
						provides the federal statutory authority for PCPlus.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VI › Section 144-101-VI-03 - Primary Care Plus › Subsection 144-101-VI-0303 - PROVIDER REQUIREMENTS

Current through 2024-29, July 17, 2024
Each PCP shall:
A. Be approved by the Department through the
					 PCPlus application process. The application process will open, at a minimum,
					 annually, and providers must receive initial approval and subsequently
					 recertify annually;
B. Be a
					 provider or provider group (i.e. solo or group practice) that delivers primary
					 care services, limited to the following:
1. A
					 physician (including residents), nurse practitioner, certified nurse midwife,
					 or physician assistant with a primary specialty designation of pediatrics,
					 general practice, family practice/medicine, geriatrics, internal medicine,
					 obstetrics, gynecology, or other specialties approved by the Department, where
					 Primary Care Services account for fifty percent (50%) of the service location's
					 collective billing;
2. A rural
					 health clinic (as defined in MBM, Section 103 );
3. A federally qualified health center (as
					 defined in MBM, Section 31 ); or
4.
					 A tribal health clinic (as defined in MBM, Section 9 ); and
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VI › Section 144-101-VI-03 - Primary Care Plus › Subsection 144-101-VI-0304 - COVERED SERVICES

Current through 2024-29, July 17, 2024
The Department reimburses PCPlus PCPs for locating,
						coordinating, and monitoring health care services to provide Members with
						high-quality and cost-effective care.
This includes locating MaineCare providers who can
						provide timely access to patient centered, culturally and linguistically
						appropriate, medically necessary MaineCare covered services. This also includes
						supporting whole-person coordination and transitions of care; completing timely
						prior authorizations; providing referrals and clinician orders; tracking and
						following up on referrals; and closing care gaps.
PCPs shall document all covered services provided to
						Members in their EHR. PCPs shall:
A.
Care Plans
. Partner with Members and other care team members to
					 create care plans that support members' needs. Use shared-decision aids and
					 consider Members' health literacy levels in assessment and care planning.
					 Include both clinician and patient action plans in the care plan as clinically
					 appropriate;
B.
Care
					 Coordination
. Engage in coordination with any external care coordinator,
					 case manager, discharge planners, or care team of the Member, as determined
					 appropriate by the needs of the Member, in accordance with all applicable state
					 and federal privacy laws and best practices to support the Member's care goals.
					 This may include but is not limited to coordinating covered services with
					 providers of: Section 13, Targeted Case Management; Section 17, Community
					 Support Services; Section 91, Health Home Services Community Care Teams;
					 Section 92, Behavioral Health Homes; and Section 93, Opioid Health Homes. When
					 coordinating and partnering with other providers, PCPs shall not duplicate
					 efforts;
C.
Assessments.
Connect Members to clinically appropriate assessments
					 including, but not limited to, Medical Eligibility Determination (MED)
					 assessments for long-term care needs;
D.
Care Transition Services
.
					 Provide care transition services between healthcare providers and settings to
					 ensure continuity of care and reduce emergency department (ED) use, morbidity,
					 mortality, inpatient admissions, readmissions, and lengths of stay.
Pediatric-to-adult health care transition services shall
						include but are not limited to the following:
1. Preparing a current medical summary and
					 plan of care;
2. Identifying an
					 adult primary care provider;
3.
					 Scheduling and ensuring that initial and follow-up appointments with the adult
					 primary care provider are kept; and
4. Facilitating linkages to other adult care
					 providers (e.g., reproductive, behavioral, medical specialties);
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VI › Section 144-101-VI-03 - Primary Care Plus › Subsection 144-101-VI-0305 - MEMBER ATTRIBUTION

Current through 2024-29, July 17, 2024
A. Attribution is
					 the process of assigning members to a PCP panel. MaineCare members will be
					 attributed to a PCP if all the following criteria are met:
1. The member is eligible for all MaineCare
					 state plan services; and
2. The
					 member has received at least one eligible Primary Care Service from a PCP
					 during the Attribution Assessment Period or has contacted MaineCare Member
					 Services to request assignment to a PCP.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VI › Section 144-101-VI-03 - Primary Care Plus › Subsection 144-101-VI-0306 - REPORTING REQUIREMENTS

Current through 2024-29, July 17, 2024
In addition to the documentation and reporting
						requirements of MBM, Chapter I, Section
						1, and other reports that may be
						required by the Department, PCPs shall report as follows.
3.06-1
Application and Annual
					 Certification
Each PCP shall submit documentation required by the
						Department and comply with other information-sharing requirements from the
						Department, initially and then annually, through a recertification process to
						determine their appropriate Tier (3.03).
PCPs shall maintain documentation of all requirements
						described in Section 3.03 and make the documents available upon request for
						review by the Department. If a PCP fails to fulfill requirements for the
						approved Tier level for more than thirty (30) continuous days, the PCP shall
						notify the Department in writing. The Department may (a) require an action plan
						from the PCP to address satisfaction of the requirement(s) and/or (b) adjust a
						PCP's Tier to ensure Tier assignment is consistent with maintenance of stated
						requirements. The Department may adjust the PCP's Tier if the PCP fails to
						comply with this rule. The Department shall provide notice to the PCP thirty
						(30) business days in advance of any Tier change.
3.06-2
Attribution
PCPs shall provide any required practice and/or rendering
						provider information requested by the Department in order for the Department to
						accurately perform PCPlus attribution.
3.06-3
Performance Assessment
PCPs are eligible for payment based on outcomes of
						specified quality measures as set forth in Section 3.08-2. Data sources for
						measures may include, but are not limited to, claims, clinical data, and
						information submitted by the PCP. PCPs shall submit all data necessary to
						compile and report on PCPlus performance measures.
Providers who fail to submit performance, application
						and/or annual recertification-related data and/or reports may be terminated
						from the PCPlus program.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VI › Section 144-101-VI-03 - Primary Care Plus › Subsection 144-101-VI-0307 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
3.07-1
Beneficiary Protections
Providers may not engage in any marketing and/or other
						activities intended to result or resulting in the selective recruitment and
						enrollment of individuals with more favorable health status. Section
						1905(t)(3)(D) of the Social Security Act prohibits discrimination based on
						health status, marketing activities included.
3.07-2
Termination
The Department may terminate a provider from the PCPlus
						program based on failure to meet program requirements or any other basis
						provided in Ch. I, Sec. 1.20-1 of the MBM. Termination from the PCPlus program
						will be in accordance with the provisions of Ch. I, Sec. 1.19-1. PCPs may
						terminate their participation from PCPlus without cause with thirty (30) days'
						notice by sending written notification to
						PCP-Network-Services.DHHS@maine.gov.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VI › Section 144-101-VI-03 - Primary Care Plus › Subsection 144-101-VI-0308 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
3.08-1
Population-Based Payment
Population-Based Payments (PBPs) are monthly payments
						that the Department shall calculate quarterly for each participating PCP. The
						Department calculates the PBP by adding the Tier PMPM Rate and the Population
						Group and Risk Category PMPM Rate and multiplying the sum by the PCP's total
						number of attributed Members. Both PMPM rates are determined annually.
A. Tier PMPM Rate This PMPM rate is
					 determined by the provider's Tier, and the Department adjusts this PMPM rate by
					 the Performance-Based Adjustment (PBA) when calculating the PBP, per Section
					 3.08-2. Each Tier described in Section 3.03 has a PMPM rate:
Tier One: $2.10
Tier Two: $6.30
Tier Three: $6.90
B. Population Group and Risk Category PMPM
					 Rate Annually, the Department will assign Members to a population group based
					 on their eligibility category in the most recent month of the PBA Assessment
					 Period and a risk category based on the most recent Risk Score. The population
					 groups are children, adults, aged/blind/disabled, and dual-eligible. The risk
					 categories are "generally well" and "complex." Each combination of population
					 group and risk category has a PMPM rate (see Figure 1). The Department
					 calculates the overall PMPM rate by multiplying the number of Members the PCP
					 has in each combination of population group and risk category by the assigned
					 PMPM rate. The Department then adds the totals from each combination and
					 divides by the PCP's number of Members.
Providers may request a reassessment of their Population
						Group and Risk Category PMPM if there is a significant change within the
						practice, such as a relocation or inclusion of a new population.
Figure 1. Population group and risk
								  category PMPM rates
Population
								  Group
Risk Category
Generally Well
								  PMPM
Complex PMPM
Children
$1.65
$4.95
Adults
$1.15
$3.00
Aged, Blind, Disabled
$2.25
$6.60
Duals
$2.50
$8.75
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VII › Section 144-101-VII-5 - Estate Recovery › Subsection 144-101-VII-5.01 - STATUTORY AUTHORITY

Current through 2024-29, July 17, 2024
The following statutory authorities govern the
						definitions and rules defined under this Section of the
MaineCare
						Benefits Manual
:
22
						M.R.S. §§14(2-I),
						42,
						3173
22 M.R.S.
						§3174-GG
42 U.S.C. §
												1396a(a) (18)
42
						U.S.C. §
												1396p(b)
Centers for Medicare and Medicaid Services (CMS,)
						Medicaid State Plan Amendment (Maine), TN-21-0013 (approved December 16,
						2021)
P.L. 2021, ch. 398
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VII › Section 144-101-VII-5 - Estate Recovery › Subsection 144-101-VII-5.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
5.02-1
Assets
means property,
					 real or personal, tangible or intangible, or any interest therein, and anything
					 that may be the subject of ownership. It includes assets conveyed to a
					 survivor, heir or assignee of the deceased Member through a tenancy in common,
					 survivorship, life estate, living trust, joint tenancy in personal property or
					 other similar arrangement.
5.02-2
Department
is the Department of Health and Human Services.
5.02-3
Dependent
is:
A. A surviving spouse; or
B. A surviving child who is under age
					 twenty-one (21); or
C. A surviving
					 adult child who is blind or permanently and totally disabled.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VII › Section 144-101-VII-5 - Estate Recovery › Subsection 144-101-VII-5.03 - ELIGIBILITY

Current through 2024-29, July 17, 2024
Following the death of a Member, the Department shall
						assert a claim against the estate of that Member or the Member's beneficiary
						for MaineCare benefits that the Member received when:
A. The Member owned undisclosed property or
					 other assets during the period when MaineCare benefits were paid for the Member
					 and disclosure of the property or assets at the time benefits were being paid
					 would have rendered the Member ineligible to receive the benefits; or
B. The Member was fifty-five (55)
					 years of age or older when the Member received MaineCare benefits; or
C. The Member received or was
					 entitled to receive benefits for nursing facility services, long-term care
					 services, or other institutional care services under a long-term-care insurance
					 policy and MaineCare paid for those services on behalf of the Member. This
					 paragraph shall not apply in the case of an individual who was entitled to
					 receive benefits under an insurance policy meeting the requirement of the
					 Long-term Care Insurance Partnership Program described in Section 5.02-10 to
					 the extent that payments are made under that policy.
Effective November 24, 2021, the Department's claim is
						limited to the amount paid by MaineCare for all nursing facility services, home
						and community-based services, and related hospital and prescription drug
						services paid on behalf of the Member.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VII › Section 144-101-VII-5 - Estate Recovery › Subsection 144-101-VII-5.04 - RECOVERY PROCEDURE

Current through 2024-29, July 17, 2024
Assets subject to recovery pursuant to this section will
						be identified primarily through the MaineCare eligibility process. This method
						is not intended to be exclusive and assets may be identified through any legal
						means.
5.04-1
Processing Claims
					 against Assets
When it is determined that a MaineCare Member's estate is
						subject to recovery, the Department may file:
A. A claim in Probate Court against all
					 assets included in the deceased Member's estate. The process for filing such a
					 claim is governed by existing provisions of the Probate Code regarding
					 creditors' claims. See 18-C M.R.S. Article 3, Part 8.
B. A claim in any court of competent
					 jurisdiction against real and personal property and other assets in which the
					 Member had any legal interest at death to the extent of that interest.
C. A claim in any court of
					 competent jurisdiction or any other legal means to recover the cost of medical
					 services provided during a period of inaccurate eligibility. A notice of intent
					 to recover shall be provided prior to filing suit.
D. If asserted against the estate, a claim
					 may not be enforced until:
1. The Member has
					 no surviving spouse; and
2. The
					 Member has no surviving child who is under age twenty-one (21); or
3. The Member has no surviving child who is
					 blind or permanently and totally disabled. For the purposes of this section, a
					 surviving child must be blind or determined to be disabled at the time the
					 Department seeks recovery.
The time the Department seeks recovery means the earlier
						of (1) the date of the Department's notice of claim to the legally authorized
						representative of the estate or known family members or heirs; or (2) the date
						on which the Department files a claim in Probate Court.*
*
The Department shall submit to CMS and
						anticipates approval for a State Plan Amendment related to these
						provisions.
E. The Department shall provide heirs,
					 assignees or transferees of a deceased Member an opportunity to pay a claim
					 under this subsection through a voluntary payment arrangement that is
					 acceptable to the Department. The payment arrangement may consist of a payment
					 plan, promissory note, or other payment mechanism.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VII › Section 144-101-VII-5 - Estate Recovery › Subsection 144-101-VII-5.05 - NOTICE

Current through 2024-29, July 17, 2024
A. Reasonable efforts to give notice of
					 Estate Recovery requirements to Members will be made at the time of application
					 for MaineCare.
B. Reasonable
					 efforts to give notice will be provided pursuant to the relevant provisions of
					 the Probate Code or to the legally authorized representative of the Member's
					 estate when recovery is being sought. If there is no legally authorized
					 representative, the State shall make reasonable efforts to notify known family
					 Members or heirs. If no one comes forward on the Member's behalf to settle the
					 estate, the State may seek appointment as personal representative as a creditor
					 pursuant to the Probate Code. Notice shall include the action the State intends
					 to take, the basis for the action, the amount sought to be recovered and a copy
					 of these rules.
C. Lack of notice
					 pursuant to this section does not bar application of Estate Recovery.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VII › Section 144-101-VII-5 - Estate Recovery › Subsection 144-101-VII-5.06 - TIME OF CLAIM

Current through 2024-29, July 17, 2024
A claim will not be enforced until the deceased Member
						has no surviving dependent.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VII › Section 144-101-VII-5 - Estate Recovery › Subsection 144-101-VII-5.08 - WAIVERS

Current through 2024-29, July 17, 2024
A.
UNDUE HARDSHIP WAIVER
An applicant may request a waiver of a claim under§
												5.03(B)
						if enforcement of the claim would cause an undue hardship for the
						applicant.
Eligibility criteria for an undue hardship
						waiver:
The applicant must demonstrate they have a beneficial interest
						in the estate and that the applicant is dependent upon the assets of the
						estate, as defined below.
1.
Dependence upon Estate Assets:
The applicant must demonstrate
					 their financial circumstances require them to rely upon the assets of the
					 estate by meeting one of the following criteria:
a. The estate assets or property received by
					 survival or distribution are part of a business, including a working farm,
i. upon which the applicant was dependent for
					 applicant's livelihood during the decedent's lifetime, and
ii. the recovery of which by the Department
					 would deprive the applicant of their sole means of livelihood,
or
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VII › Section 144-101-VII-5 - Estate Recovery › Subsection 144-101-VII-5.09 - ESTATE RECOVERY EXEMPTION WITH QUALIFIED LTC INSURANCE PARTNERSHIP POLICY

Current through 2024-29, July 17, 2024
If a Member covered under a long-term care insurance
						policy received benefits for which assets or resources were disregarded through
						the MaineCare Eligibility process as outlined in the MaineCare Eligibility
						Manual, Part 14, Section 4.1, the Department will not seek adjustment or
						recovery from the Member's estate for the amount of assets or resources
						disregarded. The amount of disregard for estate recovery is equal to the total
						amount of the insurance benefits paid to or on behalf of the individual.
A. Before applying an exemption for a
					 qualified long term care insurance policy described under this subsection, the
					 Department must determine that the policy is a qualifying long term care
					 insurance policy. The Department will verify the policy by reviewing the list
					 of qualified policies posted on the Maine Bureau of Insurance website at
http://www.maine.gov/pfr/insurance/
.
B. The Member needs to ensure that any long
					 term care insurance policy, for which an exemption is sought, qualifies for an
					 exemption under the criteria adopted by the Bureau of Insurance. This can be
					 done by contacting an eligibility specialist in the Department's Office for
					 Family Independence (OFI).
C.
					 Within 60 days of notice of the Department's claim, the amount of benefits paid
					 to the Member or on the Member's behalf must be confirmed by the Department.
					 This time period may be extended if reasonable efforts have been made to obtain
					 the confirmation information. If the amount is not confirmed, the Department
					 will use the amount disregarded when eligibility was first determined as the
					 value of the exemption unless a different amount is proven before recovery
					 occurs. Evidence of the amounts paid may be submitted in the form of statements
					 from the insurer or other reliable claims payment information. The Department
					 may request additional information relevant to the exemption prior to final
					 recovery.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VII › Section 144-101-VII-5 - Estate Recovery › Subsection 144-101-VII-5.10 - CLAIM REDUCTION

Current through 2024-29, July 17, 2024
A. When the
					 collection of the Department's claim would otherwise deplete the estate fully,
					 the Department, at its discretion may reduce its claim in order to permit whole
					 or partial reimbursement of an heir or devisee for use of personal resources to
					 protect against damage or loss of value to the Member's vacant* real property
					 occurring during the Member's last two years that the Member was
					 institutionalized if the Member executed a Department approved Intent to Return
					 Home form and delivered that signed form to the eligibility office.
For claims of real property upkeep and preservation
						following the Member's death, any expenses beyond two years following the death
						will not be allowed unless the estate provides a plan for payment of the claim
						that is approved by the Department.
B. The heir or devisee must request such
					 reduction in writing, and the request must be supported by proof of payments
					 made and the reasonableness of such payments.
All reasonable requests for a claim reduction will be
						considered on an individual basis. The procedure for making a request is as
						follows:
1. A request for claim
					 reduction must be made within six (6) months from the Member's death or within
					 thirty (30) days from the notice of the Department's claim, whichever is
					 later.
2. The request must contain
					 a written statement of the circumstances constituting the claim reduction and
					 all supporting documentation.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter VII › Section 144-101-VII-5 - Estate Recovery › Subsection 144-101-VII-5.11 - AGENCY REVIEW

Current through 2024-29, July 17, 2024
A decision pursuant to this section is final unless
						within thirty (30) days of the date of the decision, the person making the
						request sends a written request for agency review to:
Estate Recovery
Office of MaineCare Services
Department of Health and Human Services
11 State House Station
Augusta, Maine 04333-0011
The agency review shall be conducted through the
						Department's Office of Administrative Hearings.
If the person making the request is dissatisfied with the
						final decisions of the Office of Administrative Hearings, he/she may appeal
						this final agency decision to the Superior Court.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-1 - Benefit for People Living with HIV/AIDS › Subsection 144-101-X-1.01 - SUMMARY

Current through 2024-29, July 17, 2024
This section establishes procedures for implementing the
						Benefit for People Living with HIV/AIDS (Benefit), a waiver granted by the
						federal Centers for Medicare and Medicaid Services. Under the waiver, MaineCare
						provides a targeted set of services for some individuals diagnosed with
						HIV/AIDS who are not eligible for full MaineCare benefits. The benefit is a
						disease management program with defined treatment protocols. Candidates for the
						benefit must agree to be monitored and participate in medical treatment.
The goal of the waiver is to improve the health status of
						individuals diagnosed with HIV/AIDS in Maine by improving access to continuous
						health care services, arresting progression of HIV/AIDS status by providing
						early and optimal care coupled with high quality and cost efficiency, and
						expanding coverage to additional low-income individuals diagnosed with HIV with
						the savings generated from diseaseprevention and the delayed onset of AIDS.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-1 - Benefit for People Living with HIV/AIDS › Subsection 144-101-X-1.02 - AUTHORITY

Current through 2024-29, July 17, 2024
The authority for this Section is
						22 M.R.S.
						Section3, the authority stated in Chapter I
						of the
MaineCare Benefits Manual
, and the Special Terms and
						Conditions contained in 11-W-00128/1, Maine Medicaid Section 1115 Health Care
						Reform Demonstration for Individuals with HIV/AIDS, a waiver granted by the
						federal Centers for Medicare and Medicaid Services under Title XIX, §
						1115(a) of the
Social Security Act
.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-1 - Benefit for People Living with HIV/AIDS › Subsection 144-101-X-1.03 - DEFINITIONS

Current through 2024-29, July 17, 2024
Unless otherwise indicated, the following terms have the
						following meanings:
1.03-1
Benefit
is the waiver program, Benefit for People Living with
					 HIV/AlDS.
1.03-2
Enrollee
is an individual who has applied for and been determined
					 eligible to receive services under this Chapter.
1.03-3
Federal Poverty Levels
					 (FPL)
are the income levels established annually by the
U.S.
					 Omnibus Reconciliation Act of 1981
, Public Law 97-35, §§ 652
					 and 673 (s). Current FPL amounts issued annually by the U.S. Department of
					 Health and Human Services can be found on the Internet at:
http://aspe.hhs.gov/poverty-guidelines
.
1.03-4
MaineCare Eligibility
					 Manual
is the manual of rules of the Office for Family
					 Independence that establishes application and eligibility determination
					 policies for MaineCare coverage.
See 10-144 C.M.R.Ch.
					 332.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-1 - Benefit for People Living with HIV/AIDS › Subsection 144-101-X-1.04 - ELIGIBILITY

Current through 2024-29, July 17, 2024
To be eligible as an enrollee, an individual must:
1.04-1 Test positive for HIV (with or without
					 AIDS diagnosis);
1.04-2 Have
					 individual income at or below 250 percent of the FPL;
1.04-3 Sign a consent form indicating s/he
					 understands and agrees to the requirements for receiving this benefit, which
					 are included in this Chapter and in the
MaineCare Eligibility
					 Manual
; and
1.04-4 Meet
					 any additional eligibility criteria for the benefit required under the
MaineCare Eligibility Manual
.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-1 - Benefit for People Living with HIV/AIDS › Subsection 144-101-X-1.07 - COST SHARING

Current through 2024-29, July 17, 2024
1.07-1
Co-payments
A. Demonstration
					 enrollees are required to pay a co-pay for physician services, pharmaceuticals,
					 and some other services. Required co-payments for the respective services are
					 as follows:
Services
Co-payment
Prescription Drugs
$10.00 (for 30 day supply)
Physician Visits
$10.00
Outpatient Hospital Services
$3.00
Ambulance Services
$3.00
Physical Therapy Services
$2.00
Occupational Therapy Services
$2.00
Psychologist Services
$2.00
Laboratory Services
$1.00
Mental Health Clinic Services
$2.00
Substance Abuse Services
$2.00
Hospital Inpatient Services
$3.00 per patient day
Federally Qualified Health Center Services
$3.00 per patient day
Rural Health Center Services
$3.00 per patient day
B. If this chapter conflicts with co-payment
					 policies addressed in other chapters of the MBM, this chapter
					 governs.
C. Co-payment dispute
					 policies are in Chapter I of the MBM.
D. No co-payment may be imposed on enrollees
					 with respect to the following services and populations:
1. Family planning;
2. Individuals under 21 years of
					 age;
3. An individual who is an
					 inpatient in a hospital, nursing facility, or other institution, and is
					 required to spend all their income for costs of care, with the exception of a
					 minimal amount for personal needs;
4. Pregnant women and services furnished
					 during the post-partum phase of maternity care to the extent permitted by
					 federal law;
5. Emergency services,
					 as defined by the Department;
6.
					 Services furnished to an individual by a Health Maintenance Organization, as
					 defined in Section 1903(m) of the
Social Security Act
, in
					 which he/she is enrolled; and
7.
					 Any other service or services required to be exempt under the provisions of the
Social Security Act
, Title XIX and successors to
					 it.
E. Additional
					 assistance may be available from the Maine CDC, Division of Infectious Disease,
					 with co-payments and premiums through the AIDS Drug Assistance Program
					 (ADAP).
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-1 - Benefit for People Living with HIV/AIDS › Subsection 144-101-X-1.08 - WAITING LIST

Current through 2024-29, July 17, 2024
1.08-1 Enrollment
					 for this benefit for enrollees is capped based on expenditures approved by the
					 federal Centers for Medicare and Medicaid Services. If the cap is reached, the
					 Maine Center for Disease Control may terminate enrollment and implement and
					 maintain a waiting list. Applicants who are financially and medically eligible
					 for the benefit are placed on the waiting list according to the date the
					 application is received by the Office for Family Independence. Individuals are
					 notified in writing that they have been placed on the waiting list.
As openings for this benefit occur, the Office for
						Family Independence provides written notice to individuals on the waiting list,
						starting with the individual who is first on the waiting list. The
MaineCare Eligibility Manual
may require financial eligibility
						to be updated before the benefit can begin.
1.08-2 The Maine Center for Disease Control
					 will remove names from the waiting list if an individual:
A. loses financial eligibility;
B. is found eligible for MaineCare full
					 benefits;
C. is no longer a Maine
					 resident;
D. requests that his/her
					 name be removed from the waiting list; or
E. deceases.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-1 - Benefit for People Living with HIV/AIDS › Subsection 144-101-X-1.09 - DISENROLLMENT

Current through 2024-29, July 17, 2024
1.09-1 An enrollee can be disenrolled from
					 the benefit for any of the following reasons:
A. Failure to meet the eligibility
					 requirements of the
MaineCare Eligibility Manual
;
B. Refusal to sign the Informed Consent
					 form;
C. Refusal to discuss care
					 management with the benefit's nurse coordinator;
"Refusal" occurs when for at least a six-month (6)
						period and after at least two (2) contact attempts by the nurse coordinator,
						the enrollee does not respond, or the enrollee explicitly refuses to
						communicate with the nurse coordinator;
D. Noncompliance with the treatment
					 recommendations/plan;
"Noncompliance" occurs when for at least a six-month (6)
						period, an enrollee has refused to follow treatment recommendations or to
						comply with a recommended care plan developed by the provider primarily
						responsible for managing the enrollee's HIV/AIDS disease. Non-compliance
						assumes that the enrollee had adequate time to complete the treatment
						recommendations, or had the care plan explained to him or her, and had the
						opportunity to seek an alternative opinion. Non-compliance must be substantive
						and relates only to complying with a medication regimen, office visits, or
						laboratory monitoring.
E. A
					 dated, signed written disenrollment request from the enrollee is received by
					 the Department.
All disenrollments for non-compliance will be reviewed
						and approved by the Department's Medical Director, the MaineCare Director, or a
						MaineCare designee.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Section 144-101-X-2 - Non-categorical Adults - Repealed

Current through 2024-29, July 17, 2024
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-3 - Katie Beckett Benefit › Subsection 144-101-X-3.01 - SUMMARY

Current through 2024-29, July 17, 2024
This section describes basic provisions of the Katie
						Beckett benefit that reimburses services for certain children who meet Social
						Security criteria for disability, but are otherwise not eligible for MaineCare
						services. This rule supplements other sections of the MaineCare Eligibility and
						MaineCare Benefits Manuals.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-3 - Katie Beckett Benefit › Subsection 144-101-X-3.02 - AUTHORITY

Current through 2024-29, July 17, 2024
The authority for this Section is: Section 5090 of the
						MaineCare Eligibility Manual (10-144 Code of Me. Regs. Ch. 332); Title XIX,
						§§ 1902(e)(3)(B)(iii) and 1916 of the Social Security Act (
						42 U.S.C. §§
												1396a(e)(3)(B) and
						1396o
						); Attachment 4.18-F Pages 1-7 of the Maine State Plan under Title XIX of the
						Social Security Act; and
						 22 M.R.S.A.
						§§3173,
						3173-F.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-3 - Katie Beckett Benefit › Subsection 144-101-X-3.03 - DEFINITIONS

Current through 2024-29, July 17, 2024
Unless otherwise indicated, the terms in this section
						have the following meanings:
1.
Benefit
is the Katie Beckett MaineCare coverage and
					 services.
2.
Department
is the Maine Department of Health and Human Services.
3.
Federal Poverty Levels (FPL)
are the income levels established annually by the United States Omnibus
					 Reconciliation Act of 1981, Public Law 97-35, Sections 652 and 673(2). Current
					 FPL amounts are issued annually by the U.S. Department of Health and Human
					 Services and can be requested from a local Department office or found on the
					 Internet at: http://aspe.os.dhhs.gov/poverty/index.shtml [File Link Not
					 Available].
4.
MaineCare
					 Eligibility Manual
is the Department's Office of Integrated Access and
					 Support procedures that govern application and eligibility determination
					 policies for MaineCare coverage.
See 10-144 Code of Me. Regs. Ch.
					 332
5.
Member
is an individual determined eligible for services under this Section.
6.
Social Security
					 Administration
is the federal agency that governs federal Medicaid
					 policy and determines federal disability requirements for eligibility under the
					 Katie Beckett benefit.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-3 - Katie Beckett Benefit › Subsection 144-101-X-3.04 - ELIGIBILITY

Current through 2024-29, July 17, 2024
To qualify for the MaineCare Katie Beckett benefit, a
						child must apply through the Office of Integrated Access and Support. The child
						must:
1. Be age 18 and under (up to
					 age 19);
2. Not be eligible for
					 MaineCare under any other category;
3. Meet Social Security Administration
					 criteria for disability as determined by the Department or its Agent.
See Title XVI of the Social Security Act,
					 42 U.S.C. §§
													1382, et seq., and 20 Code of Fed. Regs.
					 §416.924(a).
4.
					 Reside in the community; (not in a medical institution as defined in the
					 MaineCare Eligibility Manual);
5.
					 Need in-patient care provided by a hospital, nursing facility, psychiatric
					 hospital, or an Intermediate Care Facility for Persons with Mental Retardation
					 (ICF-MR) but not reside in one of these facilities;
6. Have an initial face-to-face medical
					 assessment completed by the Department or its agent to determine if the child
					 meets medical eligibility and if so, the type of facility the child would
					 qualify under; and
7. Meet
					 financial and any other additional eligibility criteria for Katie Beckett
					 coverage as required by the MaineCare Eligibility Manual.
See 10-144
					 Code of Me. Regs. Ch. 332, §5090.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-3 - Katie Beckett Benefit › Subsection 144-101-X-3.05 - MEDICAL REVIEWS

Current through 2024-29, July 17, 2024
1.
Annual
					 Review
Each year based on the month the Member is enrolled, a
						Member must be recertified as medically and financially eligible. The Member or
						his or her personal representative must submit:
A. A medical assessment which includes
					 written information from the Member's provider verifying the Member's medical
					 condition and medically ordered treatments.
B. A written statement of the household's
					 annual income;
C. A written
					 statement of the Member's annual income; and
D. Any additional requirements of the
					 MaineCare Eligibility Manual, including submission of additional medical
					 information to meet Social Security Administration disability rules.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-3 - Katie Beckett Benefit › Subsection 144-101-X-3.06 - PREMIUMS

Current through 2024-29, July 17, 2024
Katie Beckett Members whose household income is greater
						than 150% of the Federal Poverty Level must pay monthly premiums. The amount of
						premium is based on the total household income and number of individuals in the
						household, and whether the Member has other health care coverage. Premium
						amounts, exemptions, and other premium requirements are in the MaineCare
						Eligibility Manual.
See 10-144 Code of Me. Regs. Ch. 332, § 5090.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-3 - Katie Beckett Benefit › Subsection 144-101-X-3.07 - APPEAL RIGHTS

Current through 2024-29, July 17, 2024
A Member has appeal rights as described in Chapter I,
						Section 1.22 of MaineCare Benefits Manual.
See 10-144 Code of Me. Regs.
						Ch. 101 (I), Sec. 1.22.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-4 - Limited Family Planning Benefit › Subsection 144-101-X-4.01 - SUMMARY

Current through 2024-29, July 17, 2024
This section establishes procedures for implementing the
						Limited Family Planning Benefit. Under the Limited Family Planning Benefit,
						MaineCare provides a targeted set of family planning services and supplies and
						family planning-related services to eligible individuals who are not otherwise
						eligible for full MaineCare benefits. No other MaineCare services, except those
						listed in this policy, are covered. Services performed by providers must be
						within the scope of practice of his or her professional licensure as defined by
						state law.
The goal is to improve the health of individuals and
						families in Maine by improving access to family planning services and
						decreasing the overall costs of healthcare by helping prevent or delay
						pregnancies and to improve overall reproductive health of
						Enrollees.