1.02-1
General
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.
1.02-2
Departmental
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.
1.02-4
General 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.
1.02-5
Department/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 (3rd) 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.
