C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.02

Current through 2024-46, November 13, 2024

Subsection 144-101-I-1.02 - MAINECARE ADMINISTRATION

1.02-1General

The Maine Department of Health and Human Services (the Department) is responsible for administering MaineCare in compliance with federal and state statutes, and for administrative policies.

A.Federal Authority

Federal authority for Medicare, Medicaid, and CHIP rests with the Secretary of the Federal Department of Health and Human Services. Primary responsibility within the Department of Health and Human Services in turn rests with the Centers for Medicare and Medicaid Services (CMS).

B.State Authority

Authority for the Department of Health and Human Services to accept and administer any funds which may be available from private, local, state, or federal sources for the provision of the services set forth in this Manual is established by 22 M.R.S., §§10, 12 and 3173. The regulations themselves are issued pursuant to authority granted to the Department of Health and Human Services by 22 M.R.S. §§42(1), and 3173.

1.02-2Departmental

The Commissioner of the Department of Health and Human Services has delegated authority for administering the MaineCare Programs as follows:

A. The Department of Health and Human Services, Office for Family Independence, determines eligibility for MaineCare.

B. The Department of Health and Human Services, Program Integrity Unit and Division of Audit, monitors the MaineCare Program for fraud, abuse, and inefficient use of funds, and also administers sanctions, recovers overpayments and applies penalties.

C. The Office of MaineCare Services performs numerous functions related to the delivery of MaineCare services, including, but not limited to, the following:

1. Clinical and quality management including,

a. Prior authorization;

b. Classification Review/Case Mix;

c. Pharmacy management;

d. Provider resource/development;

e. Care management; and

f. Quality assurance;

2. MaineCare operations, including provider and member services, claims research and adjustment, and claims processing;

3. Policy development and revision, including development and revision of MaineCare rules regarding the amount, duration and scope of services and the management of the Medicaid State Plan and related federal waivers;

4. Identifying and collecting reimbursement from legally liable parties for medical expenditures paid by the Department, including estate recovery, casualty recovery, drug rebates, and private health insurance premiums;

5. Customer Service, including provider and member services and claims research and adjustments.

Some functions of MaineCare Services may be provided by agents under contract to the Department.

1.02-3 Agency Rulemaking

In the event that any requirement of this Chapter I is inconsistent with the requirements of any other Chapter of the MBM, the requirements of this Chapter I shall control.

The Department publishes Notices of Agency Rulemaking in the major newspapers to cover the entire State. Copies of proposed rules regarding MaineCare benefits are made available upon request prior to the adoption of any rule, by contacting MaineCare Services, Division of Policy.

Copies of all rules, including proposed, emergency and final rules are also available on the MaineCare Services web site at no cost. The website address is: http://www.maine.gov/dhhs/oms/rules/index.shtml. All rules are promulgated in accordance with the provisions outlined in the Maine Administrative Procedure Act (APA) and all other applicable statutes and executive orders. Interested parties may also subscribe with MaineCare Services to receive electronic notices of proposed rulemaking. Printed copies are available for a fee. Members, other state agencies, providers of the particular administrative units, contractors with the administrative unit, public or private non-profit organizations, and agencies or groups representing constituent populations who may be impacted by the printed materials being requested, and selected legislative offices may receive one (1) MaineCare Benefits Manual at no charge upon request. A fee will be charged for additional requests for policies. A sixty-five dollar ($65.00) fee will be charged for additional requests for the entire MaineCare Benefits Manual.

The Department must give notice of proposed rulemaking to the following interested parties before a hearing or before the deadline for comments, if no hearing is scheduled:

A. Any person specified in the statute authorizing the rulemaking;

B. Any person who, within the past year, has filed a written request with the Agency for notice of rulemaking. The Department may charge a fee reasonably related to the cost of this service; and

C. Any trade, industry, professional interest group or regional publication that the Department deems effective in reaching affected persons.

1.02-4General Definitions

A.Authorized Entity means an organization, entity or individual authorized by the Department to perform specified functions pursuant to a signed contract or other approved signed agreement.

B."Covered Health Care Provider" means a health care provider, as defined in 45 C.F.R. § 160.103, specifically, a provider of medical or health services and any other person or organization that furnishes, bills, or is paid for health care in the normal course of business.

C.Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:

1. Serious jeopardy to the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child);

2. Serious impairment to bodily functions; or

3. Serious dysfunction of any bodily organ or part.

D.Emergency Medical Condition for Undocumented Non-Citizens means a medical condition (including emergency labor and delivery) characterized by sudden onset, and manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

1. Serious jeopardy to the member's health;

2. Serious impairment to bodily functions; or

3. Serious dysfunction of any bodily organ or part.

MaineCare will not cover any services after stabilization of the emergency condition for undocumented non-citizens. Examples of services that are not considered an emergency medical condition include, but are not limited to: dialysis, organ transplants, school based services, personal care services, waiver services, nursing facility services and hospice services.

E.Medical Necessity or Medically Necessary services are those reasonably necessary medical and remedial services that are:

1. Provided in an appropriate setting;

2. Recognized as standard medical care, based on national standards for best practices and safe, effective, quality care;

3. Required for the diagnosis, prevention and/or treatment of illness, disability, infirmity or impairment and which are necessary to improve, restore or maintain health and well-being;

4. MaineCare covered services (subject to age, eligibility, and coverage restrictions as specified in other Sections of this Manual as well as Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) requirements as detailed in Chapter II, Section 94 of this Manual);

5. Performed by enrolled providers within their scope of licensure and/or certification; and 6. Provided within the regulations of this Manual.

F.Member means any person enrolled in the MaineCare program.

G.National Provider Identifier (NPI) is a unique, 10 digit, intelligence free, identification number issued by CMS to covered health care providers. Intelligence free means that the numbers do not carry other information about healthcare providers such as the state in which they live or their medical specialty.

H.Provider means any individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents of any partnership, group association, corporation, institution, or entity that is enrolled in the MaineCare program as one of the following:

1.Rendering Provider (also known as a Servicing Provider) is defined as an individual MaineCare provider who performs services for eligible MaineCare members through a Group or Facility/Agency/Organization (FAO). A rendering provider does not bill MaineCare directly. The billing provider submits claims and receives payment on behalf of the rendering provider.

2.Billing Provider means the MaineCare provider submitting claims and receiving MaineCare payment for services. Billing providers perform these functions on behalf of the rendering provider.

3.Non-Billing, Ordering, Prescribing and Referring (NOPR) Provider - A physician or non-physician practitioner who is eligible to enroll in MaineCare, qualified to order, prescribe and/or refer services or supplies for MaineCare-eligible members, and has an NPI, but may not submit claims for payment for services provided to Medicaid Members. In order for MaineCare to reimburse for orders, prescriptions and/or referral of services or supplies resulting from the order of an NOPR Provider, the NOPR Provider must be enrolled in MaineCare as a MaineCare NOPR Provider.

1.02-5Department/Provider Notices and Information Dissemination

A. Unless otherwise specified by statute or regulation the Department may provide notices or disseminate information to the provider by any of the following methods:

1. In person by a person authorized by MaineCare Services who signs a proof of service.

2. Regular U.S. mail, with proper postage, to the address on file with the Provider Enrollment Unit.

3. Certified mail, return receipt, to the last known address.

4. Facsimile to the number on file with the Provider Enrollment Unit.

5. Electronic mail to the e-mail address on file with the Provider Enrollment Unit.

B. When sent to the "pay-to" addresses on file with the Provider Enrollment Unit, notices and/or information will be presumed to have been received by the provider:

1. By facsimiles and e-mails, the same day they were sent.

2. By regular U.S. mail, the third (3^rd) day after the notice or information was deposited in the mail.

3. By certified mail, return receipt, the date the mail receipt is signed by the provider, its agent, or employees.

C. Except as required by other sections of the MBM, notices or information provided to the Department may be sent to the Director, MaineCare Services, Department of Health and Human Services, 11 State House Station, Augusta, Maine, 04333-0011.

D. Notices or information dissemination must be provided within the timeframes outlined in the MBM and the provider agreement.

C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.02