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 X › Sec2 144-101-X-4 - Limited Family Planning Benefit › Subsection 144-101-X-4.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
Unless otherwise indicated, the following terms have the
						following meanings:
4.02-1
Benefit
is the Limited Family Planning Services.
4.02-2
Enrollee
is an individual
					 who has applied for and been determined eligible to receive services under this
					 Chapter.
4.02-3
Family
					 Planning Related Services
refers to medical diagnosis and treatment
					 services, including reproductive health services, provided as part of or as
					 follow up to a family planning visit.
4.02-4
Family Planning Services
refers to services relating to the individuals' desire to prevent or delay
					 pregnancy, or regulate the number and spacing of children.
4.02-5
Federal Poverty Levels (FPL)
are the income levels established annually by the U.S. Department of
					 Health and Human Services and can be found on the Internet at:
					 http://aspe.os.dhhs.gov/poverty/index.shtml;an individual also can received a
					 copy of the current FPL amounts by contracting his/her local DHHS office, or by
					 writing to:
Office for Family Independence
11 State House Station
19 Union Street
Augusta, ME 04333
4.02-6
MaineCare Eligibility
					 Manual
is the Office for Family Independence procedures that
					 establish application and eligibility determination policies for MaineCare
					 assistance. This manual can be found under the 10-144
Code of MaineCare
					 Regulations
, Chapter 332 at:
http://www.maine.gov/sos/cec/rules/10/ch332.htm
.
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-4.03 - ELIGIBILITY

Current through 2024-29, July 17, 2024
Individuals must meet the eligibility criteria as set
						forth below:
A. Be an individual who
					 is not pregnant; and
B. Be an
					 individual whose income is at or below 209% (two hundred and nine percent) of
					 the FPL; and
C. Meet any additional
					 criteria for the Benefit required under the
MaineCare Eligibility
					 Manual
.
It is the responsibility of the provider to verify an
						Enrollee's eligibility for the Limited Family Planning Benefit, as described in
MaineCare Benefits Manual
, Chapter I, prior to providing
						services.
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-4.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
A covered service is a service for which payment to a
						provider is permitted under this section of the
MaineCare Benefits
						Manual
. The services covered under this policy are listed
						below:
A. Office visits for family
					 planning.
B. FDA-approved oral
					 contraceptives, devices, and supplies.
C. Over-the-counter contraceptives, including
					 condoms, spermicides, and sponges, if prescribed.
D. Patient family planning education and
					 counseling.
E. Follow-up visits for
					 complications associated with contraceptive methods.
F. Breast and pelvic exams and cancer
					 screening.
G. Pap smears,
					 colposcopies, biopsies, and cryotherapies for cervical dysplasia.
H. Treatment of genital tract and genital
					 skin infections and disorders.
I.
					 Diagnosis and treatment of Sexually Transmitted Infections (STIs).
J. Testing, prevention education, counseling
					 and referral for Human Immunodeficiency Virus (HIV).
K. Limited pharmacy services, consisting of
					 birth control supplies and medications, vaccines, and supplies to prevent and
					 treat STIs and other reproductive health infections.
L. Limited laboratory services, consisting of
					 testing for STIs, HIV, anemia, sickle cell disease, cervical and testicular
					 cancer screening, and pap smears.
M. Anesthesia services when medically
					 necessary for a procedure that is covered under the Limited Family Planning
					 Benefit.
N. Sterilization if a
					 properly completed sterilization consent form in accordance with the
					 requirements of 42 C.F.R. 441, Subpart F, is attached to the billing
					 claim.
O. Provision of immunization
					 services for STIs, including but not limited to, Hepatitis B where medically
					 indicated.
P. Treatment of major
					 complications related to family planning services and family planning-related
					 services (e.g., treatment of perforated uterus due to IUD insertion; severe
					 menstrual bleeding by Depo-Provera injection, requiring dilation and curettage;
					 or treatment of surgical; or anesthesia-related complications during a
					 sterilization procedure).
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-4.05 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
MaineCare will not reimburse for services provided that
						are non-covered services under this benefit. Non-covered services
						include:
A. Infertility
					 treatment.
B. Abortion services and
					 abortion-related services.
C.
					 Artificial Insemination.
D.
In vitro
fertilization.
E. Fertility drugs.
F. Treatment for HIV (These services are
					 covered under the Maine HIV/AIDS Waiver).
G. Hysterectomies.
H. Transportation.
I. Services unrelated to family
					 planning.
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-4.06 - PROFESSIONAL AND OTHER QUALIFIED STAFF

Current through 2024-29, July 17, 2024
The following professional staff who are fully,
						provisionally, or conditionally licensed, or recognized to practice by the
						state in which services are provided, are qualified professional staff for
						purposes of this rule subject to the limitations below. All qualified
						professional staff must be MaineCare enrolled providers in order to be
						reimbursed for services provided under this policy.
A.
Physicians
.
B.
Physician assistant
may
					 provide family planning, medical, and counseling services when he or she has
					 obtained full or temporary licensure from the Board of Licensure in Medicine or
					 Osteopathy, which must be renewed bi-annually in accordance with Board rules.
					 Such services may be performed only when delegated by a physician in accordance
					 with the rules and regulations governing physician assistants.
C. A
family planning nurse
					 practitioner
or
certified nurse-midwife
may provide family
					 planning, medical, and counseling services when he or she is a graduate of a
					 certified nurse practitioner program or its equivalent, and when he or she
					 holds a current nurse practitioner or nurse-midwife license to practice in the
					 state in which services are provided.
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-4.07 - ENROLLEE'S RECORDS

Current through 2024-29, July 17, 2024
There shall be a specific record for each Enrollee which
						shall include, but not necessarily be limited to:
A. The Enrollee's name, address, and birth
					 date;
B. The Enrollee's medical and
					 social history, including immunization records, as appropriate;
C. A description of the findings from the
					 physical examination;
D. Long and
					 short range medical goals, as appropriate;
E. A description of any tests ordered and
					 performed and their results;
F. A
					 description of treatment, counseling, or follow-up care provided and the dates
					 scheduled for revisits;
G. Notation
					 of any medications and/or supplies dispensed or prescribed;
H. Recommendations for and referral to other
					 sources of care;
I. The dates on
					 which all services were provided; and
J. Written progress notes, which shall
					 identify the services provided.
Other qualified staff (woman's specialists, educators,
						etc.) may sign record entries relative to history-taking, updates, instruction,
						and pregnancy testing and results.
Entries are required for each date of service billed and
						must include the name, title, and signature of the service
						provider.
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-4.08 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
MaineCare reimbursement shall be made only for those
						family planning counseling, instruction and medical services which are provided
						directly to the member.
A. The
					 maximum amount of payment for services rendered shall be the lowest of the
					 following:
1. The provider's usual and
					 customary charge.
2. Payment for
					 services listed in the Limited Family Planning Benefit table (attached hereto
					 as Appendix A) at the rate established by MaineCare as listed on the
					 Department's rate-setting website:
					 https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx.
3. The lowest amount allowed by Medicare Part
					 B when such service is covered.
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-4.09 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Billing codes that "prevent or delay pregnancy or
						otherwise control family size" now require an FP modifier in MIHMS.
All Limited Family Planning Benefit claim forms require a
						family planning diagnosis code, with the exceptions of pharmacy and laboratory
						claims, from the approved diagnosis codes listed on the attached Appendix A.
						Claims without an approved family planning diagnosis code will be
						denied.
Family Planning Service providers shall bill for services
						under this Section in accordance with the billing requirements of the
						Department of Health and Human Services, including use of the CMS 1500 claim
						form. For instructions and to download a CMS 1500 sample claim form, see the
						OMS "Billing Instructions" web page, available at:
						https://mainecare.maine.gov/Billing%20Instructions.
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-4.10 - LIMITATIONS

Current through 2024-29, July 17, 2024
Services provided under this policy cannot be billed
						under core visits by Federally Qualified Health Clinics, Rural Health Clinics,
						or Indian Health Centers. Billing must comply with the Limited Family Planning
						Benefit billing instructions.
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-4.11 - COST-SHARING

Current through 2024-29, July 17, 2024
There are no co-payments for services received under the
						Limited Family Planning Benefit policy.
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-4.12 - APPEAL RIGHTS

Current through 2024-29, July 17, 2024
The Enrollee has appeal rights as described in Chapter 1
						of the
MaineCare Benefits Manual
.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter I - DEFINITIONS

Current through 2024-29, July 17, 2024
Unless otherwise indicated, the following terms shall have
				  the following meanings:
1. "AFDC"
				means the Aid to Families With Dependent Children Program.
2. "Benefits" means services as set forth in
				the Maine Health Program Rules, Chapter III, Benefits.
3. "Bureau" means the Bureau of Medical
				Services.
4. "Department" means the
				Department of Human Services.
5.
				"Eligibility Specialist" means a Department of Human Services, Bureau of Income
				Maintenance worker responsible for determining eligibility.
6. "Employer supported plan" means a group
				insurance plan in which the employer makes a contribution on behalf of
				employees and/or their dependents.
7. "Federal poverty guidelines" means the
				federal poverty levels established as required by the United States Omnibus
				Budget Reconciliation Act of 1981, Public Law 97-35, Sections 652 and 673(2),
				as periodically updated.
8.
				"Medicaid" means the program administered by the Department that provides
				medical assistance to eligible individuals as set forth in Title XIX.
9. "Premium" means a fee which is required to
				be paid in order to receive "transition" benefits or the amount the Department
				contributes toward the recipient's employer-supported health insurance plan, as
				the context indicates.
10. "Primary
				Care Case Management" is a system wherein primary care providers enter into a
				written agreement with the Department to deliver or arrange for delivery of a
				specific set of health care services for a panel of participants.
11. "Program. means Maine Health Program.
				This includes the "basic" Program for recipients whose income is at or below
				100% of the federal poverty guidelines and the "transition" Program for
				recipients whose income is more than 100% but less than or equal to 150% of the
				federal poverty guidelines.
12.
				"Recipient" means an individual enrolled in the Program.
13. "SSI" means Supplemental Security
				Income.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter II - PROGRAM PARTICIPATION › Section 144-103-II-2.1 - Applicants

Current through 2024-29, July 17, 2024
The Maine Health Program is closed to new
					 applicants.
Maine Health Program and certain Medicaid recipients whose
					 eligibility is under review are not considered new applicants. This includes
					 the following:
- A Maine Health Program recipient who then participates in
					 Medicaid for a period of time and who is determined again eligible for the
					 Program. Eligibility from the Maine Health Program to Medicaid and back to the
					 Maine Health Program must be continuous with no break in coverage;
- A Maine Health Program recipient in the "basic" Program
					 who is determined eligible for the "transition" Program;
- Maine Health Program recipient in the "transition"
					 Program who is determined eligible for the "basic" Program; or
- Maine Health Program recipient terminated from the
					 transition, Program due to failure to pay a premium who is subsequently
					 reinstated.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter III - BENEFITS › Section 144-103-III-3.2 - Limitations On Substance Abuse And Inpatient Psychiatric Services

Current through 2024-29, July 17, 2024
1. Inpatient Psychiatric
Payment is limited to three (3) days per episode with up to
					 twenty-one (21) additional days per episode.
2. Substance Abuse
Detoxification services - payment is limited to three (3)
					 days per episode with a maximum of three (3) episodes per year and up to two
					 (2) additional days per episode.
Rehabilitation services - payment is limited to three (3)
					 days for a maximum of one episode per year and additional days, up to a maximum
					 total of seventeen (17) days which includes any detoxification days immediately
					 before the rehabilitation days.
A year is defined as twelve (123 months beginning with the
					 date the recipient receives the first service. Hospital utilization review (UR)
					 committees will be responsible for determining medical necessity for additional
					 days beyond the three (3) day limit.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter III - BENEFITS › Section 144-103-III-3.3 - Medicare Part A and B

Current through 2024-29, July 17, 2024
The Medicare Part A and B deductible and co-insurance and
					 the Part B premium are covered services.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter III - BENEFITS › Section 144-103-III-3.4 - Non-Covered Services

Current through 2024-29, July 17, 2024
The following services are not covered by the
					 Program.
1. Long Term Care Services
ICF-MR Services (MMAM, Chapter II Section 50 )
Home and Community Based Waiver Services for the Elderly,
					 (MMAM, Chapter II, Section 19 )
Home and Community Based Waiver Services for
Persons with Mental Retardation (MMAM, Chapter II, Section
					 21 )
Home and Community Based Waiver Services for the Physically
					 Disabled (MMAM, Chapter II, Section 22 )
Home and Community Based Waiver Services for Adults With
					 Disabilities (MMAM, Chapter II, Section 18 )
Private Duty Nursing and Personal Care Services (MMAM,
					 Chapter II, Section 67 )
Nursing Facility Services (MMAM, Chapter II, Section 67
					 )
2. Targeted Case
				  Management Services (MMAM, Chapter II Section 13 )
3. Pregnancy Related Services
Pregnancy related services means the benefits provided to
					 pregnant women under the Medicaid Program.
4. Broken Appointments
5. Day Health Services (MMAM, Chapter II,
				  Section 26 )
6. Developmental and
				  Behavioral Evaluation Clinic Services (MMAM, Chapter II, Section 23 )
7. Early Intervention Services (MMAM, Chapter
				  II, Section 27 )
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter IV - EMPLOYER SUPPORTED GENERAL PLANS › Section 144-103-IV-4.1 - General

Current through 2024-29, July 17, 2024
As a condition of eligibility, Program recipients must
					 participate in available employer supported health plans if the Department
					 determines that it is cost effective for it to pay the cost of the plans on
					 behalf of the recipients. If the Department determines that it is not cost
					 effective to contribute toward the cost of the plans, the Department shall not
					 be obligated to contribute toward the cost of the plans.
Enrollment in the plan is a condition of Program
					 eligibility except for an individual who is unable to enroll on his/her own
					 behalf. For example, if a spouse is unable to enroll freely on his/her own
					 behalf, the failure to enroll does not affect the spouse's eligibility for
					 Program benefits.
A recipient who is participating in an employer supported
					 plan must remain enrolled in the plan until the Department completes its cost
					 effectiveness determination. The Department will begin paying premiums as soon
					 as arrangements can be made to do so. The Department will pay the recipient's
					 premium until it completes its cost effectiveness determination at which time
					 it will notify the recipient, in writing, of its determination to continue or
					 discontinue payment.
A recipient who is not participating in an available
					 employer supported plan will be required to enroll if the Department determines
					 it is cost effective to contribute toward the cost of the plan of behalf of the
					 recipient. Recipients must provide the Department with proof of enrollment no
					 later than thirty (30) days from the date of the cost effectiveness
					 determination. Recipients who are unable to enroll in an employer supported
					 plan must notify the Department no later than thirty (30) days from the date of
					 behalf effectiveness determination notice as to their reason for not enrolling.
					 Recipients will have the opportunity to claim good cause (e.g. enrollment
					 period not open) for not enrolling. Good cause will be established by the
					 Bureau of Medical Services' Third Party Liability Unit.
The recipient is responsible for reporting any changes in
					 employer supported health plan benefits or premiums to the Department as soon
					 as they are known.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter IV - EMPLOYER SUPPORTED GENERAL PLANS › Section 144-103-IV-4.2 - Cost Effectiveness Determination

Current through 2024-29, July 17, 2024
As a condition of eligibility, recipients must cooperate
					 with the Department in providing the information necessary for the Department
					 to determine cost effectiveness.
The Department's criteria for determining cost
					 effectiveness include, but are not limited to, the following:
- administrative feasibility,
- comparison of benefits,
- review of deductible and co-pay requirements, and
- amount of employer contribution.
The Department may pay either the insurer or the employer
					 on behalf of the Program recipient. The Department will make payments on a
					 monthly basis. Payments will be made prospectively only.
In the event the Department is unable to pay the insurer or
					 employer, the Department may reimburse the recipient. Recipients may be
					 required to submit documentation that they paid the premium, e.g., pay stubs,
					 to the Department monthly. Payment will be made retroactively except, if good
					 cause exists, the Department shall provide a one time advance payment at the
					 time a recipient is required to enroll in an employer plan. Good cause will be
					 established by the Bureau of Medical Services Third Party Liability
					 Unit.
The Department will discontinue paying premiums when a
					 recipient is no longer eligible to participate in the Program except the
					 Department may continue premium payments for a one month grace period once the
					 recipient ceases to be eligible for the Program.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter IV - EMPLOYER SUPPORTED GENERAL PLANS › Section 144-103-IV-4.3 - Review

Current through 2024-29, July 17, 2024
The Department shall review the cost effectiveness of
					 continuing to pay premiums for recipients when eligibility is redetermined and
					 will notify recipients in writing of its decision to continue or discontinue
					 paying premiums prior to the beginning of the new eligibility period.
The Department will also evaluate continuing payment of
					 premiums during the eligibility period if additional information becomes more
					 available that indicates the recipient's circumstances or employer supported
					 health plan has changed. The Department will notify recipients, in writing, of
					 its decision to discontinue paying premiums.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter IV - EMPLOYER SUPPORTED GENERAL PLANS › Section 144-103-IV-4.4 - Wraparound

Current through 2024-29, July 17, 2024
Recipients enrolled in available employer supported health
					 plans that do not provide all of the Program benefits or the same level of
					 Program benefits shall be provided with a medical card that entitles them to
					 receive Program benefits that are not covered by their employer supported
					 plan.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter IV - EMPLOYER SUPPORTED GENERAL PLANS › Section 144-103-IV-4.5 - Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

Current through 2024-29, July 17, 2024
COBRA provides that certain qualified beneficiaries who
					 would otherwise lose their group health coverage due to termination of
					 employment or long term disability may elect to continue coverage under the
					 same group plan for up to 36 months. COBRA allows the employee to buy the same
					 coverage by paying monthly premiums equal to 102% of the original group
					 insurance premium. The two percent is allowed for administrative expenses.
					 COBRA applies to all private companies and state and local governments with at
					 least 20 employees.
If a recipient for whom the Department is paying a premium
					 terminated his/her employment and COBRA coverage is available, the Department
					 will determine if it is cost effective to contribute to the COBRA
					 premium.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter V - PREMIUMS › Section 144-103-V-5.1 - Overview

Current through 2024-29, July 17, 2024
Recipients in the "transition" Program are required to pay
					 a premium as a condition of eligibility.
When two (2) members of a household are required to pay a
					 premium, the household may opt to not pay a premium for one of those
					 individuals. Coverage will be closed or denied for that individual electing not
					 to pay a premium.
The Department will provide 12 day advance written
					 notification to recipients informing them of the monthly premium amount.
					 Recipients must sign, date and return the notice form by the end of the month
					 in which the 12 day notice period ends, agreeing to pay the premium to the
					 Department. If the signed and dated form is not returned, coverage will be
					 denied or closed.
Example: A recipient in the basic. Program is determined
					 eligible for the "transition" Program on August 5th effective for September.
					 The individual is provided with the 12 day written notice that s/he is required
					 to pay a premium effective for the month of September.
The signed and dated notice must be returned to the
					 Department by August 30th. The September payment is due September
					 1st.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter V - PREMIUMS › Section 144-103-V-5.2 - Changes In Circumstances That Affect Payment Of Premiums

Current through 2024-29, July 17, 2024
Recipients are required to report changes in circumstances
					 that may affect payment of a premium. If changes in circumstances that would
					 have resulted in payment of a premium are not reported timely, past due
					 premiums must be paid in order for coverage to continue or be reinstated.
Example: The income of a recipient increases from <100%
					 of the poverty guidelines to 135% of the guideline. The increase is received on
					 August 25th but the information is not reported to the Department. The
					 Department learns of the increase in income and notifies the individual of fee
					 requirements with a 12 day notice ending October 18th. The recipient is
					 eligible for "transition" Program coverage in November only if s/he pays a
					 premium for October that would have been required if the change hand been
					 reported timely. Since the change was not reported timely, the first month in
					 which the premium is due is determined by allowing for the 12 day notice from
					 the date the change occurred (increased income was received).
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter V - PREMIUMS › Section 144-103-V-5.3 - Payment

Current through 2024-29, July 17, 2024
Payment is due on the first day of each month for which
					 coverage is being granted. A grace period to the end of the month is allowed
					 for late payment. If payment is not received on or before the premium due date,
					 the recipient will be notified that i$ the premium is not received by the end
					 of the grace period, eligibility will end the last day of the month unless good
					 cause is established. Good cause can be established by the Eligibility
					 Specialist.
Example: A recipient is determined eligible for the
					 "transition" Program for the month of June. The June premium payment is due
					 June 1st. The grace period ends June 30th. If payment is not received by June
					 30th, the recipient is terminated for nonpayment of the premium effective June
					 30th.
The premium must be paid by check or money order payable to
					 the Treasurer, State of Maine and sent or delivered to the Medical Assistance
					 Unit at the Department's Regional Office which covers the area in which the
					 recipient lives. Cash will not be accepted.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter V - PREMIUMS › Section 144-103-V-5.4 - Reinstatement After Non-Payment

Current through 2024-29, July 17, 2024
When a recipient has been terminated due to failure to pay
					 a premium, s/he will not be eligible for reinstatement for one month from the
					 termination date. Reinstatement(6) is possible for any remaining months of
					 eligibility. The recipient must apply and must pay any premiums due for past
					 coverage and the first reinstatement month premium prior to being reinstated.
					 Coverage is not provided for bills incurred during periods of
					 non-enrollment.
Example: A recipient receives coverage for June but fails
					 to pay the June premium prior to June 30th and is terminated from the Program
					 effective June 30th. In October, the recipient wants to be reinstated. Since
					 the individual received coverage for June the premium for June is required
					 before current coverage can be granted. Also the individual must pay the
					 October premium prior to reinstatement. Upon payment of the June, and October
					 premiums, the individual is enrolled for October. Coverage for medical bills
					 incurred in July, August and September is not provided.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter V - PREMIUMS › Section 144-103-V-5.5 - Premium Schedule

Current through 2024-29, July 17, 2024
The premium schedule is based on the federal poverty
					 guidelines and will be revised annually to reflect adjustments in the federal
					 poverty guidelines. Premium contributions are based on the countable income
					 amount calculated to determine eligibility and the number of household members
					 to be enrolled.
MONTHLY PREMIUM CONTRIBUTION PER RECIPIENT
Family
Size 101-125% 126-150%
First Individual $10.30 $16.80
Each Added
individual $ 3.45 $ 5.65
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter VI - GENERAL ADMINISTRATIVE POLICIES › Section 144-103-VI-6.1 - Maine Medical Assistance Manual

Current through 2024-29, July 17, 2024
The following Maine Medical Assistance Manual (MMAM)
					 provisions apply to Maine Health Program recipients.
1. Provider Participation (MMAM Chapter I,
				  Section 1.03 )
2. Recipient
				  Eligibility (MMAM Chapter I, Section 1.04, except 1.04-1)
3. Supplementation By Recipients (MMAM
				  Chapter I, Section 1.05 )
4 Services Covered And Non-covered (MMAM Chapter I, Section
					 1.06, except 1.06-2-C)
5. Third Party
				  Liability (MMAM Chapter I, Section 1.07, except 1.07-23
6. Submittal of Claims (MMAM Chapter I,
				  Section 1.08 )
7. Payment Process
				  (MMAM Chapter I, Section 1.09 )
8.
				  Claims Adjustments (MMAM Chapter I, Section 1.10 )
9. Inquiry Process (MMAM Chapter I, Section
				  1.11 )
10. Audits (MMAM Chapter I,
				  Section 1.123
11. Utilization
				  Review (MMAM Chapter I, Section 1.133
12. Surveillance (MMAM Chapter I, Section
				  1.14 )
13. Prior Authorization
				  (MMAM Chapter I, Section 1.15 )
14.
				  Provision of Necessary Transportation to Medical Services (MMAM Chapter I,
				  Section 1.16 )
15. Sanctions
				  Against Providers (MMAM Chapter I Section 1.17 )
16. Provider Fraud/Abuse (MMAM Chapter I,
				  Section 1.18, except 1.18-2)
17.
				  Provider Appeals (MMAM Chapter I, Section 1.19 )
18. Recipient Appeals (MMAM Chapter I,
				  Section 1.20 )
19. Enrollee
				  Restriction Program (MMAM Chapter IV, Section 1 )
20 Primary Care Case Management (MMAM Chapter VI Section 1
					 )
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 103 - MAINE HEALTH PROGRAM RULES › Chapter VI - GENERAL ADMINISTRATIVE POLICIES › Section 144-103-VI-6.2 - Maine Medicaid Eligibility Manual

Current through 2024-29, July 17, 2024
The following Maine Medicaid Eligibility Manual provisions
					 apply to Maine Health Program recipients.
1. Referrals to Child and Adult Protective
				  Units (Maine Medicaid Eligibility Manual, Section 1131 )
2. Referrals to the Fraud Investigation Unit
				  (Maine Medicaid Eligibility Manual, Section 1132 )
3. Confidentiality (Maine Medicaid
				  Eligibility Manual, Section 1140 )
4. Record Retention (Maine Medicaid
				  Eligibility Manual, Section 1150 )
5. Replacement of Medical Identification
				  Cards (Maine Medicaid Eligibility Manual, Section 1170 )
6. Fair Hearings (Maine Medicaid Eligibility
				  Manual, Sections 1180 and 1181 )
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-2 - Maine Drugs for the Elderly Benefit › Subsection 144-104-2.01 - AUTHORITY

Current through 2024-29, July 17, 2024
The Maine Drugs for the Elderly Benefit, also referred to
					 as the Maine Low Cost Drugs for the Elderly or Disabled (DEL) Benefit, is
					 authorized by, and these regulations are issued under, the authority of
					  22 M.R.S.A.
					 §254-D(7). The
					 Commissioner of the Department of Health and Human Services has delegated the
					 responsibility for administration of the Benefit to the Office of MaineCare
					 Services.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-2 - Maine Drugs for the Elderly Benefit › Subsection 144-104-2.03 - ELIGIBILITY

Current through 2024-29, July 17, 2024
An individual is eligible to receive services as set forth
					 in this Section if he or she meets the eligibility requirements established in
					 10-144 C.M.R. Chapter 333. Some participants may have restrictions on the type
					 and amount of benefits they are eligible to receive under this
					 Section.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-2 - Maine Drugs for the Elderly Benefit › Subsection 144-104-2.04 - PARTICIPATION IN MEDICARE PART D

Current through 2024-29, July 17, 2024
Participants must exhaust other pharmacy benefits
					 including Medicare Part D and MaineCare before using DEL benefits under this
					 Section.
2.04-1 Authorized
				  Representative
The Department may act as an authorized representative for
					 or appoint a designee to act as an authorized representative for participants
					 who are dually eligible for DEL and Medicare Part D.
As an authorized representative, the Department may:
a. deem eligible and enroll and reenroll
				  participants in a Medicare Part D plan;
b. apply for Medicare Part D benefits and
				  subsidies on behalf of participants;
c. establish rules by which participants may
				  opt out of participation in Medicare Part D; and
d. at its discretion, file exceptions and
				  appeals pertaining to Medicare Part D eligibility or benefits on behalf of
				  participants.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-2 - Maine Drugs for the Elderly Benefit › Subsection 144-104-2.05 - REQUIREMENTS FOR PHARMACY PARTICIPATION IN DEL

Current through 2024-29, July 17, 2024
A pharmacy that wishes to submit claims for payment under
					 the Drugs for the Elderly Benefit must:
1. Comply with all provider and
				  administrative process requirements set forth in Chapter 104, Section 1;
				  and
2. Be enrolled as a MaineCare
				  pharmacy provider.
The Department may issue a request for proposals from
					 labelers or manufacturers and issue a contract for the provision of generic
					 drugs. Participating providers may be required by the Department to obtain a
					 generic drug from labelers or manufacturers with which the Department
					 contracts. The Department will notify providers and give instructions for
					 compliance with this provision.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-2 - Maine Drugs for the Elderly Benefit › Subsection 144-104-2.06 - BENEFITS

Current through 2024-29, July 17, 2024
Only those drugs of manufacturers that have both a valid
					 rebate agreement with the federal government pursuant to
					 42 U.S.C. §
											1396r-8 and a DEL Rebate Agreement are
					 covered in the DEL Benefit. A prescription drug of a manufacturer that does not
					 enter into an agreement pursuant to this paragraph is reimbursable only if the
					 Department determines the prescription drug is essential. The Department, at
					 its sole discretion, will determine that a drug is essential based on medical
					 necessity. In addition, drugs may be subject to prior authorization and the
					 step order as set forth in this Section. The Department may refuse coverage for
					 a drug when the prescriber cannot demonstrate medical necessity.
2.06-1
Basic Benefit
A. Covered Drugs
1. Prescription Drugs
The Basic benefit covers brand-name and generic drugs when
					 administered for the following conditions and illnesses: heart disease,
					 diabetes, high blood pressure, arthritis, chronic lung disease (including
					 emphysema and asthma), anticoagulation, hyperlipidemia (high cholesterol),
					 incontinence, thyroid disease, osteoporosis (bone density loss), Parkinson's
					 disease, glaucoma, and multiple sclerosis/ amyotrophic lateral sclerosis (Lou
					 Gehrig's Disease).
2.
				  Over-The-Counter Drugs
Some over-the-counter drugs are covered in the DEL Benefit
					 when the Department determines that they are both cost-effective and that they
					 have a National Drug
Code (NDC) number. These drugs will be approved only when
					 the prescriber can demonstrate, with appropriate medical justification, that
					 the use of these drugs is medically necessary. The Department may exclude from
					 coverage drugs that are equivalent to drugs that are available
					 over-the-counter.
3.
				  Benefits for Medicare Part D Eligible Beneficiaries. The Department will
				  continue to cover Medicare Part D Excluded Drugs for eligible participants so
				  long as those drugs are covered for other DEL participants. The Department will
				  post a complete list of these drugs on its designated website. The Department
				  will also continue DEL coverage for premiums, deductibles, co-payments, and
				  coverage gaps (donut hole) in Medicare Part D coverage, as defined in Chapter
				  104, Section 4, to the extent that funds are available.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-2 - Maine Drugs for the Elderly Benefit › Subsection 144-104-2.07 - DISPENSING PRACTICES

Current through 2024-29, July 17, 2024
Retail pharmacy providers may dispense up to a 34-day
					 supply of brand name drugs and up to a 90-day supply of generic drugs.
Mail order pharmacies may only dispense up to 90-day
					 supplies of generic or brand-name drugs. When refilling a prescription through
					 mail order, refills may be provided only at a participant's request; mail order
					 pharmacies may not automatically refill prescriptions for participants.
Providers dispensing prescriptions via telepharmacy must
					 obtain approval from the Department. Providers must assure that participant
					 counseling is available at the remote site from the dispensing provider or the
					 provider delivering the prescription, and that only qualified staff, as defined
					 by the Maine State Board of Pharmacy, deliver prescriptions.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-2 - Maine Drugs for the Elderly Benefit › Subsection 144-104-2.08 - FINANCIAL PARTICIPATION (CO-PAYMENT)

Current through 2024-29, July 17, 2024
When the DEL Benefit level requires a co-payment, the
					 Department requires each DEL participant to pay the co-payment for drugs, as
					 set forth above. There are no exceptions. If the participant refuses to pay the
					 co-payment, the pharmacy will deny the service.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-2 - Maine Drugs for the Elderly Benefit › Subsection 144-104-2.09 - ELIGIBILITY CARD

Current through 2024-29, July 17, 2024
The Department of Health and Human Services issues an
					 eligibility card to each eligible participant enrolled in the DEL Benefit. A
					 participant must present the eligibility card to the participating pharmacy
					 upon request.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-2 - Maine Drugs for the Elderly Benefit › Subsection 144-104-2.10 - AMOUNT AND DURATION OF BENEFITS

Current through 2024-29, July 17, 2024
The Department may stop reimbursing for covered drugs if,
					 in any fiscal year, all the funds appropriated for DEL have been expended. When
					 necessary, the Department will provide participants and participating
					 pharmacies with prior notice of the date upon which reimbursement will
					 cease.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-2 - Maine Drugs for the Elderly Benefit › Subsection 144-104-2.11 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
The Department will reimburse participating pharmacies only
					 for drugs that are covered drugs as set forth above.
The DEL Benefit is the payor of last resort. If the
					 participant has another prescription drug coverage plan, that plan must be
					 billed first.
A. The Department may
				  establish the Maine Maximum Allowable Cost (MMAC) for covered drugs,
				  considering the following factors:
1. Multiple
				  manufacturers;
2. Broad wholesale
				  price span;
3. Availability of
				  drugs to retailers at the selected cost;
4. High volume of utilization; and
5. Bioequivalence or
				  interchangability.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-2 - Maine Drugs for the Elderly Benefit › Subsection 144-104-2.12 - PHARMACY RURAL DISPENSING FEE ADJUSTMENT

Current through 2024-29, July 17, 2024
The Department will pay a supplemental dispensing fee for
					 prescriptions provided to members residing in rural areas in an attempt to
					 assure continuing access to prescription services for these members. The rural
					 dispensing fee will range from 55¢ to 65¢ per prescription dispensed
					 to rural members, and will change on a quarterly basis to reflect the prior
					 quarter's number of prescriptions filled. The Department will distribute the
					 rural dispensing fee adjustment retrospectively on a quarterly basis. The
					 Department will calculate the quarterly adjustment for each pharmacy by taking
					 that quarter's total allotment and dividing the total allotment for the quarter
					 by the number of prescriptions filled for rural members in the quarter. The
					 Department will then group these by pharmacy and distribute in the quarter
					 following. Pharmacies will be notified on a quarterly basis on the Department's
					 designated website the amount of the adjustment for the quarter.
Rural members will be defined using a standard and
					 federally recognized definition of rural using Metropolitan Statistical Area
					 (MSA) designations. The Department will determine MSA/Non-MSA designation based
					 on the zip code of the member's residence.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-2 - Maine Drugs for the Elderly Benefit › Subsection 144-104-2.13 - APPEALS

Current through 2024-29, July 17, 2024
Each participant has the right to an administrative hearing
					 to appeal any decision by the Department that adversely affects that
					 participant's benefit. These appeal rights are set forth in Chapter 104,
					 Section 1.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-2 - Maine Drugs for the Elderly Benefit › Subsection 144-104-2.14 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Participating pharmacies must bill in accordance with the
					 Department's billing instructions set forth in the pharmacy's MaineCare
					 agreement.