reglab/statecodes huggingface dataset:
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 144-104-3 - Maine Rx Plus Benefit › Subsection 144-104-3.01 - AUTHORITY

Current through 2024-29, July 17, 2024
The Maine Rx Plus Benefit is authorized by, and these
					 regulations are issued under, the authority of
					  22 MRSA
					 §2681(14). 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 144-104-3 - Maine Rx Plus Benefit › Subsection 144-104-3.04 - ENROLLMENT CARD

Current through 2024-29, July 17, 2024
The Department or its authorized agent will issue an
					 eligibility card to each participant enrolled in the Maine Rx Plus Benefit. The
					 Department will issue permanent cards by mail.
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 144-104-3 - Maine Rx Plus Benefit › Subsection 144-104-3.05 - 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, Maine State Services Manual, Administrative Policies and
					 Procedures.
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 144-104-3 - Maine Rx Plus Benefit › Subsection 144-104-3.06 - PHARMACY PARTICIPATION

Current through 2024-29, July 17, 2024
A. Only
				  participating pharmacies may submit claims for payment under the Maine Rx Plus
				  Benefit. To become a participating pharmacy a pharmacy must meet all of the
				  following criteria:
1. Comply with all
				  provider and administrative process requirements set forth in Chapter 104,
				  Section 1;
2. Be enrolled as a
				  MaineCare pharmacy provider; and
3.
				  Execute a Maine Rx Plus Provider Agreement with the Department.
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 144-104-3 - Maine Rx Plus Benefit › Subsection 144-104-3.07 - DISPENSING PRACTICES

Current through 2024-29, July 17, 2024
Dispensing practices must be in accordance with the best
					 medical, pharmaceutical and economical practice.
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.
The Department may issue a request for proposals from
					 labelers or manufacturers and issue a contract for the provision of generic
					 drugs. Participant 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 144-104-3 - Maine Rx Plus Benefit › Subsection 144-104-3.08 - TERMINATION OF PHARMACY PARTICIPATION

Current through 2024-29, July 17, 2024
A participating pharmacy may terminate participation in
					 the Maine Rx Plus Benefit at any time by following the termination provisions
					 set forth in the Maine Rx Plus Provider Agreement.
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 144-104-3 - Maine Rx Plus Benefit › Subsection 144-104-3.10 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
A. Eligible Claims
Maine Rx Plus provides benefits for discounted drugs only
					 when participants do not have coverage under a comparable or superior
					 prescription drug plan. Participating pharmacies must always determine the
					 existence of and seek reimbursement from an individual's comparable or superior
					 prescription drug benefit prior to submitting claims to the Maine Rx Plus
					 Benefit.
B. Amount of
				  Reimbursement for Retail Pharmacies
For each eligible prescription filled, the participating
					 retail pharmacy will be reimbursed a $3.35 dispensing fee plus the lowest of
					 the following:
1. Federal Upper Limits
				  (FUL) as defined in Chapter II, Section 80, Pharmacy Services, of the MaineCare
				  Benefits Manual (MBM); or
2. Maine
				  Maximum Allowable Cost (MMAC) as defined in Chapter II, Section 80, Pharmacy
				  Services, of the MBM; or
3. Average
				  Wholesale Price minus 13%; or
4.
				  The participating pharmacy's Usual and Customary (U & C) Price;
				  or
5. The State Upper Limit (250%
				  of Average Manufacturer's Cost for multi-source generic drugs) plus a $2.35
				  professional fee.
The Department will not pay any costs for payments for
					 which the participant is responsible.
The Department will also reimburse the participating
					 pharmacy in the amount of any applicable secondary discount, which the pharmacy
					 will pass along in full as an additional discount to the Maine Rx Plus
					 participant.
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 144-104-3 - Maine Rx Plus Benefit › Subsection 144-104-3.11 - 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 144-104-3 - Maine Rx Plus Benefit › Subsection 144-104-3.12 - RECORDS FOR AUDIT PURPOSES

Current through 2024-29, July 17, 2024
The participating pharmacy must agree to submit to an
					 audit. The Department of Health and Human Services or its designated agent will
					 conduct the audit using records and transactions involving the dispensing of
					 any and all prescription drugs under the Maine Rx Plus Benefit. The
					 participating pharmacy must also agree to furnish for review all materials and
					 information regarding payment, including actual prescriptions, invoices for
					 drug purchases, other appropriate documents, and any additional information
					 that may be required by those authorized to determine compliance with this
					 policy.
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 144-104-3 - Maine Rx Plus Benefit › Subsection 144-104-3.13 - FRAUD OR ABUSE

Current through 2024-29, July 17, 2024
A. The State of
				  Maine administers the Maine Rx Plus Benefit and participating pharmacies and
				  participants are subject to Maine statutes pertaining to fraud.
B. All provisions relating to fraud and abuse
				  and related sanctions outlined in Chapter 104, Section 1 of the Maine State
				  Services Manual are applicable.
C.
				  Fraud includes, but is not limited to an eligible participant allowing,
				  assisting or conspiring with an ineligible individual to obtain drugs under
				  this Benefit.
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 144-104-3 - Maine Rx Plus Benefit › Subsection 144-104-3.14 - CONFIDENTIALITY

Current through 2024-29, July 17, 2024
The Department follows/subscribes to all State or Federal
					 law, rules or regulations related to confidentiality, as further detailed 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 144-104-4 - Maine Part D Wrap Benefits › Subsection 144-104-4.01 - AUTHORITY

Current through 2024-29, July 17, 2024
This benefit is authorized by, and these regulations are
					 issued under, the authority of
					  22 M.R.S.A.
					 §254-D. The Commissioner of the
					 Department of Health and Human Services has delegated the responsibility for
					 administration of the benefit to the Office of Maine Care
					 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 144-104-4 - Maine Part D Wrap Benefits › Subsection 144-104-4.03 - 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, and adheres to the additional requirements outlined
					 below. Some participants may have restrictions on the type and amount of
					 benefits they are eligible to receive under this Section.
The Department will enter enrolled participants into its
					 electronic database. Entry into the Department's electronic database may occur
					 in one of three ways:
1.
				  Auto-enrollment whereby the Department automatically enrolls the participant
				  into an approved PDP and enters the participant into the Department's database;
				  or
2. Self-enrollment by the
				  participant into an approved PDP. Participants who self enroll must communicate
				  their enrollment to the Department, at which time the Department will confirm
				  the information and enter the participant into its database. Providers should
				  inform participants to call the Department's toll free help line at
				  1-866-796-2463 to report self-enrollment; or
3. If the Centers for Medicare and Medicaid
				  Services (CMS) enrolls Medicare Savings Program (MSP) participants into an
				  approved PDP.
DEL and Part-D eligible Maine Care members can receive wrap
					 benefits through any CMS approved PDP.
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 144-104-4 - Maine Part D Wrap Benefits › Subsection 144-104-4.04 - PARTICIPATION IN MEDICARE PART D WRAP BENEFITS

Current through 2024-29, July 17, 2024
Participants must exhaust other pharmacy benefits
					 including Medicare Part D and Maine Care before using benefits under this
					 Section.
4.04-1
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 eligible for 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 enrollees;
c. establish rules by which enrollees 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
				  enrollees.
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 144-104-4 - Maine Part D Wrap Benefits › Subsection 144-104-4.05 - BENEFITS

Current through 2024-29, July 17, 2024
As detailed in Chapter 104, Section 2, the DEL benefit is
					 limited to 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. The Maine
					 Part D Wrap Benefit additionally allows coverage of drugs of manufacturers that
					 may not have both a valid DEL and federal rebate agreement. Drugs may be
					 subject to prior authorization and the step order as set forth in Chapter 104,
					 Section 2. The Department may refuse coverage for a drug when the prescriber
					 cannot demonstrate medical necessity.
4.05-1
Covered Benefits
See the chart in Appendix A for a summary of Covered
					 Benefits under this Section.
4.05-2
Prior Authorization (PA)
The Department may require prior authorization for certain
					 drugs in this benefit, and follows guidelines as set forth in Chapter 104,
					 Section 2.
4.05-3
Preferred Drug List
In order to facilitate appropriate utilization, the
					 Department utilizes the Preferred Drug List as detailed in Chapter 104, Section
					 2.
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 144-104-4 - Maine Part D Wrap Benefits › Subsection 144-104-4.06 - 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.
Drugs must be dispensed according to guidelines detailed
					 in Chapter 104, Section 2.
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 144-104-4 - Maine Part D Wrap Benefits › Subsection 144-104-4.07 - FINANCIAL PARTICIPATION (CO-PAYMENT)

Current through 2024-29, July 17, 2024
The Department requires each participant to pay a
					 co-payment for drugs, as set forth in the chart in Appendix A. 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 144-104-4 - Maine Part D Wrap Benefits › Subsection 144-104-4.08 - ELIGIBILITY LETTER

Current through 2024-29, July 17, 2024
The Department of Health and Human Services issues an
					 eligibility card to each eligible participant enrolled in this 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 144-104-4 - Maine Part D Wrap Benefits › Subsection 144-104-4.09 - 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 this benefit have been
					 expended. 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 144-104-4 - Maine Part D Wrap Benefits › Subsection 144-104-4.10 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
The Department will reimburse participating pharmacies only
					 for drugs that are covered drugs as set forth in Maine Care Benefits Manual,
					 Chapter 101, Chapter II, Section 80, Pharmacy Services, or in Maine State
					 Services Manual, Chapter 104, Section 2, Drugs for the Elderly Benefit. This
					 benefit is the payor of last resort. If the participant has another
					 prescription drug coverage plan, that plan must be billed
					 first.
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 144-104-4 - Maine Part D Wrap Benefits › Subsection 144-104-4.11 - 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 144-104-4 - Maine Part D Wrap Benefits › Subsection 144-104-4.12 - 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 Maine Care
					 agreement.
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 144-104-4 - Maine Part D Wrap Benefits › Appendix 144-104-A - MAINE PART D WRAP BENEFITS COVERAGE CHART

Current through 2024-29, July 17, 2024
Eligibility Group
Co-Payment
Premiums
Deductible
Gap
Part D
Excluded Drugs*
Dual Eligibles Residing in Nursing Facilities
N/A
N/A
N/A
N/A
Covered as reimbursed under Maine Care Benefits
							 Manual, Chapter II, Section 80 P harmacy Services
Dual Eligibles residing in Assisted Living and Level
							 I, II, III and IV PNMI Eligibles (as reimbursed under Maine Care Benefits
							 Manual, Chapter III, Appendices C and F, Section 97, Private Non-Medical
							 Institution Services), or who are co-pay exempt under Chapter 1, Section 1.09-2
							 of the Maine Care Benefits Manual.
100% of all co-payments
N/A
N/A
N/A
Covered as reimbursed under Maine Care Benefits
							 Manual, Chapter II, Section 80 P harmacy Services
All other Dual Eligibles
50% of the cost of Brand Name drugs with a cap of $10
							 per prescription, and 100% of the cost of generics up to $2.50.
N/A
N/A
N/A
Covered as reimbursed under Maine Care Benefits
							 Manual, Chapter II, Section 80 P harmacy Services
Medicare Savings Program DEL Eligibles (QMB, SLMB, QI)
50% of the cost of Brand Name drugs with a cap of $10
							 per prescription, and up to $2.50 per generic.
N/A
N/A
N/A
Covered as paid under Chapter 104, Section 2, DEL
							 Policy
DEL members eligible for Medicare Part D
Not covered
100% of Part D Premiums
50% of the Part D deductible
Members will have co-pay of 20% plus $2.
Covered as paid under Chapter 104 DEL Policy
*Please see the following website for a
							 list of covered Part D excluded drugs:
www.Maine Carepdl.org
(under "General
							 Pharmacy Info")
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 144-104-5 - Health Insurance Purchase Options › Subsection 144-104-5.01 - INTRODUCTION

Current through 2024-29, July 17, 2024
The Health Insurance Purchase Option (HIPO) is available to
					 children under the age of 19 who lose their MaineCare or CubCare eligibility
					 because the family income at the time of reapplication exceeds the income
					 limits for those programs in effect at the time of the review. The amount of
					 the monthly premium is determined annually by the Office of MaineCare
					 Services.The Office of Integrated Access and Support bills and collects the
					 monthly premiums from clients who agree to participate in this
					 option.
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 144-104-5 - Health Insurance Purchase Options › Subsection 144-104-5.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
Unless otherwise indicated, the following terms shall have
					 the following meanings:
5.02-1
Office of MaineCare Services (OMS)
and the
Office of
				  Integrated Access and Support (OIAS)
within the Department of Health and
				  Human Services are responsible for establishing rules regarding the Health
				  Insurance Purchase Option.
5.02-2
COBRA
is the Consolidated Omnibus Budget Reconciliation Act of
				  1986 that provides for continuation of group health coverage for certain
				  individuals whose coverage would otherwise be terminated.
5.02-3
Covered Services
are
				  services set forth in Chapter II of the MaineCare Benefits Manual.
5.02-4
Cub Care
provides medical
				  assistance to eligible individuals as established by Title XXI of the Social
				  Security Act; Public Law 1997, Chapter 777; and was amended at P.L 1999,
				  Chapter 401, Part QQ.
5.02-5
Department
is the Maine Department of Health and Human
				  Services.
5.02-6
Health
				  Insurance Purchase Option (HIPO
) allows MaineCare and Cub Care enrollees
				  who lose eligibility due to changes in income to purchase coverage.
5.02-7
MaineCare Benefits Manual
is the MaineCare Services manual that establishes policies regarding covered
				  services and service delivery systems.
5.02-8
Medicaid (MaineCare)
provides medical assistance to eligible individuals as established by Title XIX
				  of the Social Security Act.
5.02-9
Premium
is a fee which is required to be paid in order to be
				  eligible for the Health Insurance Purchase Option.
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 144-104-5 - Health Insurance Purchase Options › Subsection 144-104-5.03 - BENEFIT DELIVERY SYSTEM

Current through 2024-29, July 17, 2024
HIPO uses the same benefit delivery system and the same
					 rules for enrollment in either fee-for-service or managed care as Medicaid and
					 Cub Care.
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 144-104-5 - Health Insurance Purchase Options › Subsection 144-104-5.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
The services described in Chapter II of the MaineCare
					 Benefits Manual are HIPO covered services when provided in accordance with the
					 policies set forth in Chapter II.Any new MaineCare service(s) automatically
					 shall be incorporated as a HIPO covered service on the date the MaineCare
					 policy becomes effective.
Co-payments and deductibles may not be charged for covered
					 services provided under HIPO.
Payment may be made by the Department only for HIPO
					 covered services provided to individuals who are eligible for those services on
					 the date the services are actually provided.
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 144-104-5 - Health Insurance Purchase Options › Subsection 144-104-5.05 - DETERMINATION OF PREMIUM AMOUNT

Current through 2024-29, July 17, 2024
MaineCare Services is responsible for computing the
					 premium for the purchase of coverage under the Health Insurance Purchase
					 Option.The amount of the premium will be determined annually.The premium will
					 be the total of:
A. The MaineCare and
				  Cub Care enrollee per month cost for services, based on the average annual cost
				  for the two fiscal years prior to the year for which MaineCare Services is
				  calculating the premium; and
B. Two
				  percent of the per child per month administrative costs for the MaineCare and
				  Cub Care programs.
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 144-104-6 - Independent Practice Dental Hygienist Services › Subsection 144-104-6.01 - INTRODUCTION

Current through 2024-29, July 17, 2024
This rule implements a state-funded program to provide
					 reimbursement of Independent Practice Dental Hygienists (IPDHs) and to
					 Federally Qualified Health Centers (FQHCs) employing IPDHs for certain services
					 provided to MaineCare Members for the period October 1, 2012 through September
					 30, 2013.
The Department establishes this program only for this
					 retroactive time period for the following reason: in 2012 the Maine Legislature
					 enacted a law [P.L. 2011, ch. 457, as codified in 22 MRSA 3174-RR]) requiring
					 the Department, by October 1, 2012, to reimburse IPDHs and FQHCs employing
					 IPDHs under the MaineCare program for certain services provided to eligible
					 MaineCare Members.
The Department is required to get approval from the Centers
					 for Medicare and Medicaid (CMS) for this new type of MaineCare provider.
As of the effective date of this rule, the Department has
					 not yet gotten CMS approval, and the earliest effective date of CMS approval
					 would be October 1, 2013.
Accordingly, the purpose of this rule is to allow IPDHs and
					 FQHCs who employed IPDHs to receive state reimbursement under this section for
					 services they provided to eligible MaineCare members for the period of time
					 October 1, 2012 through September 30, 2013.
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 144-104-6 - Independent Practice Dental Hygienist Services › Subsection 144-104-6.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
6.02-1
Federally Qualified Health
				  Center (FQHC):
A facility or program that is federally qualified and may
				  also be known as a community health center, migrant health center, or
				  health-care program for the homeless. A center is "federally qualified" if it:
A. is receiving a grant under Section 330 of
				  the Federal Public Health Service (PHS) Act;
B. is receiving funding from such a grant
				  under a contract with the recipient of a grant and meets the requirements to
				  receive a grant under Section 330 of the PHS Act;
C. is determined by the Secretary of the
				  Department of Health and Human Services, to meet the requirements for receiving
				  such a grant (look-alike), based on the recommendation of the Health Resources
				  and Services Administration (HRSA) within the Public Health Service;
D. was treated by the Secretary (of Health
				  and Human Services), for purposes of Medicare Part B, as a comprehensive
				  federally funded health center as of January 1, 1990; or
E. is an outpatient health program or
				  facility operated by a tribe or tribal organization under the Indian
				  Self-Determination Act or by an urban Indian organization receiving funds under
				  Title V of the Indian Health Care Improvement Act.
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 144-104-6 - Independent Practice Dental Hygienist Services › Subsection 144-104-6.03 - PROVIDER PARTICIPATION

Current through 2024-29, July 17, 2024
This section reimburses two providers for services provided
					 during the period October 1, 2012 through September 30, 2013:
A. IPDHs; and
B. FQHCs who employed IPDHs to provide IPDH
				  services.
To be reimbursed under this section:
A. IPDHs and FQHCs must be enrolled as
				  MaineCare providers at the time the claim is submitted;
B. FQHCs must have been enrolled as a
				  MaineCare provider, on the date the IPDH service was provided, during the time
				  period October 1, 2012 through September 30, 2013.
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 144-104-6 - Independent Practice Dental Hygienist Services › Subsection 144-104-6.04 - MEMBER ELIGIBILITY

Current through 2024-29, July 17, 2024
The individual had to have been an enrolled MaineCare
					 Member, on the date the IPDH service was provided, during the time period
					 October 1, 2012 to September 30, 2013, in order to be eligible for these
					 services.
Some individual Members may have restrictions on the type
					 and amount of services they are eligible to receive.
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 144-104-6 - Independent Practice Dental Hygienist Services › Subsection 144-104-6.05 - COVERED SERVICES

Current through 2024-29, July 17, 2024
6.05-1
General.
The Department will reimburse
					 IPDHs, and FQHCs who employed IPDHs providing such services, for the following
					 services, if provided to eligible Members, and if services were provided during
					 the period October 1, 2012 through September 30, 2013:
A. Prophylaxis performed on a Member who was
				  21 years of age or younger;
B.
				  Topical application of fluoride performed on a Member who was 21 years of age
				  or younger;
C. Provision of oral
				  hygiene instructions;
D. The
				  application of sealants;
E.
				  Temporary fillings, pursuant to Guidelines below; and
F. Processing and exposing Radiographs
				  (X-rays) as permitted under the Pilot Project for Independent Practice Dental
				  Hygienists to Process and Expose Radiographs (X-rays) in Underserved Areas of
				  Maine, pursuant to Guidelines below.
6.05-2
Guidelines For Temporary Fillings (protective
					 restoration)
The IPDH must have been in compliance with the Maine Board
					 of Dental Examiner's regulation governing hygienist placement of temporary
					 fillings (02-313 CMR 2, Appendix 1, Appendix 1, Figures 1 & 2, available at
www.mainedental.org
).
Nothing in these rules shall be construed as placing
					 liability for the temporary filling on the dentist performing the follow-up
					 visit.
6.05-3
Guidelines For Radiographs (x-rays)
The IPDH must have been in compliance with the Maine Board
					 of Dental Examiners' regulation, (02-313 CMR 16, Rules to Implement a 2-Year
					 Pilot Project for Independent Practice Dental Hygienists to Process Dental
					 Radiographs in Underserved Areas of the State, available at
www.mainedental.org
), which
					 govern the Pilot Project authorized by the Maine State Legislature in Resolve
					 2011, Ch. 67 (LD 230)(Resolve, To Establish a Pilot Project for Independent
					 Practice Dental Hygienists to Process Radiographs in Underserved Areas of the
					 State), as amended by Resolve 2012, Ch. 153 (LD 1891)(Resolve, to Amend the
					 Pilot Project for Independent Practice Dental Hygienists to Process Radiographs
					 in Underserved Areas of the State).
The Department will reimburse only IPDHs for their service
					 of exposing and processing X-rays. The Department will not reimburse any
					 dentist (even if the dentist was a MaineCare dentist), who had entered into a
					 written agreement with the IPDH that provided that the dentist would be
					 available to interpret all dental radiographs within 21 days from the date the
					 radiograph is taken, for reading or interpreting the X-rays that were exposed
					 and processed by the IPDH.
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 144-104-6 - Independent Practice Dental Hygienist Services › Subsection 144-104-6.06 - NON COVERED SERVICES

Current through 2024-29, July 17, 2024
IPDHs will not receive reimbursement under this regulation
					 for services which they provided in private dental offices, or if they
					 practiced under the Public Health Supervision Status ( as defined in the Maine
					 Board of Dental Examiners regulations, 02 313 CMR 2).
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 144-104-6 - Independent Practice Dental Hygienist Services › Subsection 144-104-6.08 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Notwithstanding section 1.07-2 of the Maine State Services
					 Manual, the Department will reimburse for claims under this section for dates
					 of services retroactive to October 1, 2012 and for services rendered no later
					 than September 30, 2013, provided that the claim is submitted no later than
					 December 31, 2014.
Billing must be done in accordance with the American Dental
					 Association's "CDT 2014 Dental Procedure Codes" publication, the MBM Chapters
					 II & III, Section 25, and the Department's current billing instructions.
					 Billing instructions are available upon request or at:
https://mainecare.maine.gov/Billing%20Instructions/Forms/Publication.aspx
.
Billing for IPDH services provided in an FQHC should follow
					 the billing instructions in Chapter 101, MaineCare Benefits Manual, Chapters II
					 & III, Section 31, "Federally Qualified Health Center 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 144-104-7 - Abortion Services for Maine Care Members › Subsection 144-104-7.01 - INTRODUCTION

Current through 2024-29, July 17, 2024
This rule implements state-funded Abortion services for
					 MaineCare members. The Department of Health and Human Services (the
					 "Department") establishes this policy pursuant to P.L. 2019, ch. 274, as
					 codified in
					 22 M.R.S.
					 §3196 (Coverage for non-Medicaid
					 services to MaineCare members). The Abortion services covered under this rule
					 are not federally approved Medicaid services and must be funded solely by state
					 funds. The Commissioner of the Department has delegated the responsibility for
					 administration of these services to the Office of MaineCare Services. All
					 applicable federal and state laws governing Abortions, including, but not
					 limited to,
Maine Revised Statutes
Title 22 Chapter 263-B
					 (Abortions), are incorporated herein.
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 144-104-7 - Abortion Services for Maine Care Members › Subsection 144-104-7.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
7.02-1
Abortion:
The intentional
				  interruption of a pregnancy by the allocation of external agents, whether
				  chemical or physical, or the ingestion of chemical agents with an intention
				  other than to produce a live birth or to remove a dead fetus, regardless of the
				  length of gestation.
7.02-2
Health Care Professional:
A physician or physician assistant
				  licensed under 32 M.R.S. §§ 2561-2600, or 32 M.R.S. §§
				  3263-3300 -F or a person licensed under
				  32 M.R.S.
				  §§2101 -
				  2261 to
				  practice as an advanced practice registered nurse.
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 144-104-7 - Abortion Services for Maine Care Members › Subsection 144-104-7.03 - MEMBER ELIGIBILITY

Current through 2024-29, July 17, 2024
The individual must be eligible for MaineCare services as
					 determined by the Office for Family Independence (OFI) using the established
					 policies and procedures in the
MaineCare Eligibility
					 Manual
.
Some members may have restrictions on the type and amount
					 of services they are eligible to receive.
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 144-104-7 - Abortion Services for Maine Care Members › Subsection 144-104-7.04 - PROVIDER REQUIREMENTS

Current through 2024-29, July 17, 2024
A. Health Care
				  Professionals must be enrolled as MaineCare providers to be reimbursed for
				  Abortion services under this policy.
B. Professionals providing Abortion services
				  must be Health Care Professionals as defined in
				  22 M.R.S.
				  §1596.
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 144-104-7 - Abortion Services for Maine Care Members › Subsection 144-104-7.05 - COVERED SERVICES

Current through 2024-29, July 17, 2024
The Department shall provide coverage to MaineCare members
					 for Abortion services that are not covered or reimbursed by Medicaid, including
					 medical services and supplies incidental or preliminary to an Abortion, when
					 performed by a Health Care Professional in a licensed general hospital or
					 outpatient setting.
A. Health Care
				  Professional/surgical charges for performing the Abortion. These charges
				  include the usual, uncomplicated pre- and post-operative care and visits
				  related to performing the Abortion.
B. Hospital or clinic charges associated with
				  the Abortion. This includes the facility fee for use of the operating room;
				  supplies and drugs necessary to perform the Abortion; and charges associated
				  with routine, uncomplicated pre- and post-operative visits by the
				  patient.
C. Medication
				  Abortions.
D. Health Care
				  Professional charges for administering the anesthesia necessary to induce or
				  perform an Abortion.
E. Drug
				  charges for medication usually provided to or prescribed for the patient who
				  undergoes an uncomplicated Abortion. This includes routinely provided oral
				  analgesics and antibiotics to prevent septic complication of Abortion, and
				  Rho-GAM.
F. Charges for
				  histo-pathological laboratory tests performed routinely.
G. Charges for other laboratory tests
				  performed prior to performing the Abortion to determine the anesthetic/surgical
				  risk of the patient (e.g., CBC, electrolytes, blood typing).
H. Ultra sounds related to the
				  Abortion.
I. One follow-up
				  visit/exam occurring within 30 days from the date of the Abortion.
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 144-104-7 - Abortion Services for Maine Care Members › Subsection 144-104-7.06 - PROVIDER REIMBURSEMENT

Current through 2024-29, July 17, 2024
Reimbursement using solely state funding will be available
					 for Abortion services as described in this benefit based on the provider's
					 current applicable MaineCare rate for abortion services that are covered by
					 MaineCare. Providers agree to accept this rate as payment in full and will not
					 hold members responsible for any payment over the rate.
The Department shall be the payor of last resort. The
					 Department will not reimburse for any services which otherwise would be
					 reimbursed by Medicaid, Medicare, private insurance, or other
					 payor(s).
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 144-104-7 - Abortion Services for Maine Care Members › Subsection 144-104-7.07 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Health Care Professionals must bill in accordance with the
					 Department's billing instructions.
https://mainecare.maine.gov/Default.aspx
.
These are not MaineCare claims and shall not be reimbursed
					 through MaineCare funding. Providers must retain documentation in support of
					 the separate reimbursements received for state-funded abortions and
					 state-funded abortion-related services.
The Department will review claims and may perform audits
					 or post payments review of claims to determine whether providers have properly
					 submitted claims and properly received state-funded reimbursement for
					 services.
Sanctions may be imposed by the Department against a
					 provider as set forth in the
Maine State Services Manual
,
					 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 144-104-7 - Abortion Services for Maine Care Members › Subsection 144-104-7.08 - TIME LIMITS FOR SUBMISSION OF CLAIMS

Current through 2024-29, July 17, 2024
The following time limits apply unless waived under special
					 circumstances by the Department. Providers have one (1) year from the date
					 services are provided to file a claim correctly with the Department, regardless
					 of when eligibility is verified.
Since it is the responsibility of providers to verify
					 eligibility, members may not be billed for covered services that have been
					 denied by the Department for exceeding this time limit for claims submission
					 because the provider did not verify eligibility.
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 144-104-7 - Abortion Services for Maine Care Members › Subsection 144-104-7.09 - APPEALS

Current through 2024-29, July 17, 2024
Providers' and participants' appeal rights are set forth in
					 the
Maine State Services Manual
, 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 144-104-8 - Abortion Services for Maine Care Members › Subsection 144-104-8.01 - PURPOSE

Current through 2024-29, July 17, 2024
This rule implements 5 MRSA c. 167, which directs the
					 Department of Health and Human Services ("the Department") to develop a program
					 to allow for the wholesale importation of prescription drugs from Canada (the
					 "program"), and to submit a proposal to the federal Secretary of Health and
					 Human Services to approve the program. At the time that the law was enacted,
					 there was no defined pathway for application to the federal government for
					 approval of such a program. On July 31st 2019, the
					 federal government released its Safe Importation Action Plan, which newly
					 described its intent to promulgate rules governing prescription drug
					 importation demonstration projects by states, wholesalers, and pharmacists.
					 These federal rules will be based on
					 21 U.S.C. §
											384, the same federal law that c. 167
					 requires the program to comply with. As of April
					 28th, 2020, a final rule has not been promulgated by
					 the federal government.
This rule creates a process to inform the design of the
					 program and provides that the Department will submit an application to the
					 federal government no later than May 1, 2020, and, if the federal rule is not
					 finalized prior to May 1st, 2020, that the
					 Department shall submit a subsequent or revised application as soon as
					 practicable after finalization of the federal rule.
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 144-104-8 - Abortion Services for Maine Care Members › Subsection 144-104-8.02 - PROCESS FOR DEVELOPING PROGRAM DESIGN

Current through 2024-29, July 17, 2024
In preparation for an application to the federal
					 government, the Department will consult with appropriate federal, other State
					 of Maine agencies, other state officials, and interested parties. It will
					 undertake a process to ensure the development of a program design that is
					 effective, efficient, and practicable, meets state and federal requirements,
					 and achieves the intent of the law. The program elements to be discussed
					 include, but are not limited to:
A.
Infrastructure for the importation of the drugs
. This includes
				  (but is not limited to):
a. Determining the
				  entities involved in the program domestically and internationally, and the
				  licensing and oversight of them, including the creation of a new licensing
				  pathway, if needed;
b. Evaluating
				  the costs of establishment and ongoing administration of the program, and what
				  fee structure would be necessary to support it;
c. Assessing the willingness of existing
				  actors to participate in the program; and
d. Ensuring the safety of imported
				  drugs.
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 144-104-8 - Abortion Services for Maine Care Members › Subsection 144-104-8.03 - APPLICATION TO THE UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES FOR APPROVAL AND CERTIFICATION

Current through 2024-29, July 17, 2024
Following the conclusion of the stakeholder input process
					 and no later than May 1st, 2020, the Department
					 shall submit an application to the U.S. Department of Health and Human Services
					 to establish a state importation program. If the final federal rule is not
					 released before May 1, 2020, the department shall submit a subsequent or
					 revised application to establish a state importation program as soon as is
					 practicable after the release of the final federal rule. Should the Department
					 determine that further rulemaking is necessary to implement the requirements of
					 the program design, additional rules will be proposed.