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 IV › Sec2 144-101-IV-1 - Restriction Plans › Subsection 144-101-IV-1.03 - DEFINITIONS

Current through 2024-29, July 17, 2024
For purposes of this Section, the following definitions
						shall apply:
1.03-1
Authorized
					 Agent
is the organization authorized by the Department of Health and
					 Human Services (DHHS) to perform specified functions pursuant to a signed
					 contract or other approved signed agreement.
1.03-2
Educational Opportunities
means the opportunities provided by DHHS or its Authorized Agent to discuss the
					 member's pattern of health care utilization, in which discussion the member
					 receives information on how to obtain or use appropriate health care services
					 or receives a referral to an appropriate agency to obtain services for the
					 identified utilization problem.
1.03-3
Health Care Provider
is
					 an individual or entity that furnishes health care services or benefits to
					 persons for which payment is reimbursable through the MaineCare
					 Program.
1.03-4
Health Care
					 Services
are all services covered under the Maine Medical Assistance
					 Program. These services include, but are not limited to, primary care provider,
					 pharmacy and hospital services.
1.03-5
Lock-In
is a federally
					 authorized program specified in the Code of Federal Regulations (
					 42 CFR §
												431.54(e) ) that provides
					 that a MaineCare member who has utilized MaineCare services at a frequency or
					 amount that is not medically necessary may be restricted to designated health
					 care providers that are enrolled as MaineCare providers. Lock-In will only be
					 deemed necessary once the Member Review Team has determined that the member has
					 exhausted all Educational Opportunities. The Team may enroll a member in a
					 Lock-In corresponding to the type of Over-Utilization by the member. A member
					 may be enrolled in more than one type of Lock-In. A Lock-In is a basis of
					 denial for a claim for payment of services outside the terms of the Lock-In.
					 Lock-In restrictions do not apply to emergency services, that is, stabilization
					 of an emergency medical condition as defined in Section 1.02-4.B. &C. of
					 Chapter I of the MaineCare Benefits Manual. There are four types of Lock-in:
A.
Full Restriction (Lock-In type
					 1)
- This Lock-In type requires a member to be restricted to the core
					 providers of a Primary Care Physician, a Hospital, a Pharmacy and may include
					 restrictions within additional provider types. Full restriction will occur when
					 clinical review has identified Over-Utilization in any two of the core provider
					 types.
B.
Partial Lock-In
					 (Lock-In type 2)
- This Lock-In type restricts the member to a provider
					 in one or multiple types of health care providers when clinical review has
					 identified Over-Utilization in one or more types of health care providers but
					 the standard of a Full restriction is not met.
C.
Prescriber Lock
-
In
					 (Lock-In type 3)
- This Lock-In type restricts the member to one or more
					 specific Prescribers for prescriptions when clinical review has indentified
					 Over-Utilization in one or more types of prescriptions. The Member Review Team
					 may designate multiplePrescribers for the member for differing types of
					 prescriptions.
D.
Pharmaceutical Restriction (Lock-In type 4)
- This Lock-In type
					 restricts the member from being able to obtain one or more specific drug
					 categories (classes) when clinical review has identified Over-Utilization in
					 one or more drug categories.