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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.04 - MEMBER PARTICIPATION

Current through 2024-29, July 17, 2024
The Office for Family Independence defines a member as a
						person determined to be financially eligible in accordance with the eligibility
						standards published in the
MaineCare Eligibility
						Manual
.
The
MaineCare Eligibility Manual
is
						published and maintained by the Office for Family Independence. Detailed
						information regarding financial eligibility standards can be obtained by
						contacting the Regional Offices of the Department of Health and Human Services.
						If there are any conflicts or inconsistencies between financial eligibility
						guidelines described in this Manual and the
MaineCare Eligibility
						Manual
, the
MaineCare Eligibility Manual
governs.
Members are also subject to eligibility requirements to
						determine need for specific services as detailed in other Chapters and Sections
						of this Manual. The Department may reassess a member's medical eligibility at
						any time. Pursuant to
						42 C.F.R. §
												435.916, if the Department has information
						about anticipated changes in a member's circumstances, the Department must
						re-determine eligibility at the appropriate time based on those changes.
The Department issues an identification card to all
						members. Providers must verify an individual's eligibility for MaineCare prior
						to providing services. Eligibility may be verified by point of service systems
						and web-based systems available to providers. MaineCare eligibility
						verification can also be checked by calling the Department's Interactive Voice
						Response System. Providers that do not have access to a touch-tone telephone
						may contact Provider Services as described in Section
						1.13. Verification of
						financial eligibility does not assure reimbursement if any requirements for
						medical eligibility and prior authorization have not been met. The Department
						reserves the right to change the frequency of card issuance; to provide
						separate cards for members restricted to seeing certain providers (See Chapter
						IV of the MBM); and to change the card format and content.
1.04-1
Additional Eligibility
					 Considerations
A.
Retroactive
					 Eligibility for Services
The following retroactive reimbursement procedure does
						not apply to situations where a person has knowingly misrepresented his or her
						status to a provider as a MaineCare applicant or member.
In some cases, MaineCare eligibility may be determined
						retroactively. If covered services were provided during a period of retroactive
						eligibility and if the member made any payment toward those
						retroactively-covered services, the provider, if requested to do so by the
						member within nine (9) months of the date of the original written notification
						of MaineCare eligibility, must reimburse the member the full amount paid by the
						member within fourteen (14) days of being notified by the member. Failure to
						reimburse the member will result in sanctions as defined in Section
						1.20. The provider may
						then bill MaineCare for those same services. If covered services were provided
						during a period of retroactive eligibility and the member has not made payments
						towards those covered services, the provider has one (1) year from the date the
						eligibility was granted to file a claim correctly with the Department.
B.
Individuals Residing in
					 Public Institutions
For inmates involuntarily confined in a public
						institution, state or federal prison, jail, detention facility or other penal
						facility, who are MaineCare members, MaineCare will pay only for covered
						inpatient medical institution services provided to the inmate while an
						inpatient in a hospital, nursing home, ICF/IID Intermediate Care Facility for
						Individuals with Intellectual Disability or juvenile psychiatric facility.
						MaineCare will not pay for any other services.
MaineCare will pay for all MaineCare coverable services
						for individuals admitted to and residing in an Institution for Mental Diseases
						(IMD) for over thirty (30) days, if the individual is under twenty-one (21)
						years of age or over sixty-five (65) years of age. MaineCare will not cover the
						cost of services for individuals who are age twenty-one (21) and over and under
						sixty-five (65) years of age while residing in an IMD.
C.
Undocumented Non-Citizens
MaineCare coverage for emergency services for
						undocumented non-citizens extends only to those services necessary to stabilize
						the emergency condition. MaineCare does not cover any further treatment or
						rehabilitation resulting from the emergency even though such treatment may be
						necessary.
Please refer to Chapter I, Section 1.02-4(D) of this
						Manual for the complete definition of emergency services for undocumented
						non-citizens.
D.
Other Categories
The Office for Family Independence may establish other
						categories in accordance with the
MaineCare Eligibility
						Manual
. These special categories define or limit the particular
						services a person may be eligible to receive. For example, in the category of
						"Qualified Medical Beneficiary (QMB) eligible only," MaineCare covers only the
						Medicare coinsurance and deductible. If Medicare does not allow the service,
						the member is responsible.