Current through 2024-38, September 18, 2024
1.07-1
Definitions Relative to this Section
A. Insurer is:
1. Any commercial insurance company offering
health or casualty insurance to individuals or groups, including both
experience-rated insurance contracts and indemnity contracts;
2. Any profit or nonprofit prepaid plan
offering either medical services or full or partial payment for the diagnosis
or treatment of any injury, disease, or disability; or
3. Any organization administering health or
casualty insurance plans for professional associations, unions, fraternal
groups, employer-employee benefit plans, and any similar organization offering
these payments or services, including self-insured and self-funded
plans.
B. Third Party is
any individual, entity, benefit or program, excluding MaineCare, that is or may
be liable to pay all or part of the medical cost of injury, disease, or
disability of an applicant or member as described in Section 1.07-3.
C. EPSDT are services provided to MaineCare
members under the age of 21 and described in Chapter II, Section 94, Early and
Periodic Screening, Diagnosis and Treatment Services, of the MBM.
1.07-2
Premiums for
Enrollment under Group Health Plans
As a result of the Omnibus Budget Reconciliation
Act of 1990 (OBRA 90, Section 4402), covered services include
MaineCare payment of group health plan premiums when a member's enrollment
under a group health plan is cost-effective. MaineCare considers a premium
payment cost-effective when the costs of a member's MaineCare services are
likely to be greater than the cost of paying the premium for a member to
receive care under the group health plan. The Division of Third Party Liability
of MaineCare Services determines cost-effectiveness and follows guidelines
approved by the Centers for Medicare and Medicaid Services.
1.07-3
Provider/Department/Member
Responsibility Regarding Third Party Liability
A. State and federal rules and regulations
determine the Department's liability for payment of claims submitted to
MaineCare for services provided to individuals enrolled in a health maintenance
organization or managed care plan or those who have other available third party
resources.
B. MaineCare is the
payer of last resort. The only exception is for services involving Indian
Health Services (IHS) claims. IHS is the payer of last resort for Native
Americans enrolled in MaineCare.
C.
If a claim has been denied by a member's third party payer for services deemed
as not medically necessary, the provider must appeal the decision of the third
party payer before billing MaineCare EXCEPT AS PROVIDED BELOW. If the appeal
results are unfavorable, the provider must submit the original denial, the
appeal results and a completed claim form to MaineCare for evaluation.
Providers do not have to appeal the decision of a
Medicare denial of reimbursement if:
(1) the denial is based on Local Coverage
Determinations (LCDs) or National Coverage Determinations (NCDs); or
(2) the service was provided by a Licensed
Marriage and Family Therapist (LMFTs), Licensed Professional Counselor (LCPCs)
or Licensed Master Social Workers Clinical Conditional (LMSW-CC) and the Member
has an established relationship with the provider and another provider is not
available.
D. The
Department recognizes extenuating circumstances where services covered by third
party payers:
1. May not be geographically
accessible;
2. Members are not
given the opportunity to directly choose a provider that participates in the
member's primary insurance. This may occur, for example, when the provider is
involved in the member's care to interpret test or radiological results or to
administer anesthesia; or 3. Good cause has been established pursuant to
42
C.F.R. §
433.147.
The Department will reimburse for services for which the
member would otherwise be eligible in instances where these extenuating
circumstances exist. The Department shall have total discretion to adopt
standards for the above circumstances for members covered by third party
insurers.
A member may request an extenuating circumstance
exception in writing to the Director of MaineCare Services, Department of
Health and Human Services, 11 State House Station, Augusta, Maine 04333-0011.
If the member's request for extenuating circumstances is denied, the Department
shall provide written notice to the member of the member's right to an
administrative hearing
E. The provider must establish whether the
member has third party resources available for payment of the rendered service.
Third party resources may include, but not be limited to, private or group
insurance benefits, participation in a health maintenance organization (HMO),
Workers' Compensation, Medicare or other potentially liable insurers and
responsible parties. For all questions involving the determination of coverage
by a third party insurer, providers may contact MaineCare Services, the
Division of Third Party Liability, directly to verify health insurance
information.
F. The provider must
take all necessary and reasonable measures within the provider's ability to
receive payment from such resources prior to billing MaineCare. Payment by the
primary HMO to non-participating providers does not obligate MaineCare to pay
as a secondary payer. This applies even if the primary HMO authorizes the
service. If the provider will not be eligible to receive MaineCare
reimbursement as a result of failing to participate in the member's plan, the
member must be notified in writing that he or she will be billed. This must be
done prior to providing the service and documented in the member's record. The
following exceptions apply:
1. When a claim
is for EPSDT; and
2. When the
third party liability has not yet been established
(litigation).
G. In cases
where third party payment responsibility is questionable or unavailable,
providers are responsible for billing the Department for covered services
within the one (1) year time frame described in Section
1.10 of this
Chapter.
H. The Department will
take reasonable measures to ascertain any legal liability of third parties for
medical care and services rendered to members, the need for which arises out of
injury, disease or disability. With the exception of those services described
in this sub-section, MaineCare is not liable for payment of services when
denied or paid at a rate reduced by a liable third party payer, including
Medicare, because the services were not authorized, or a non-participating
provider provided services that were coverable under the plan.
I. The Department is not responsible for
payment of services inappropriately obtained (including self-referrals which
result in reduced payments) by a member enrolled with any liable third party
payer including Medicare or for making additional payments to providers that
offer discounts to (or that agree to accept reduced payments from) third party
payers.
J. The Department is not
liable for payment of services provided to MaineCare members enrolled with a
liable third party payer, including Medicare, when services have not been
authorized prior to provision and/or approved by the member's primary care
physician when required.
K. The
Department is responsible for payment of a copayment, deductible or coinsurance
required by a third party payer when services have been appropriately obtained
under MaineCare. Such payments shall be limited to the maximum amount
designated by the Department for covered services, in accordance with Section
1.07-7(B) and (C).
L. The
Department shall also be responsible for payment of covered services provided
outside an eligible individual's liable third party payer including Medicare,
in situations where providers available to the individual under the plan were
geographically unavailable (i.e., out-of-state policyholder).
M. The member must do whatever his or her
primary health plan requires to assure that the plan provides maximum coverage
for services. This includes, but is not limited to, seeing a geographically
accessible participating provider, seeking referrals from his or her primary
care provider where indicated, utilizing network providers, obtaining prior
authorization when required, or other actions as appropriate. If the member
fails to do what is necessary to maximize benefits from these primary payers,
MaineCare will not reimburse the provider for the service and the member will
be responsible for payment.
1.07-4
Implementing Maine State Income
Tax Refund Offset
The Department will seek reimbursement from a third party
when the party's liability is established after assistance is granted and in
any other case in which the liability of a third party existed but was not
treated as a resource.
Submission to the Maine State Tax Assessor for state
income tax refund offset may be utilized to recover money from an individual or
entity that is due the Department.
A.
Established Debt1. When
implementing a Maine State Income Tax Refund Offset, the Department will notify
the individual or entity of the alleged debt and his or her right to an
administrative hearing.
2. If the
individual or entity fails to request a hearing within sixty (60) calendar days
of the date of the receipt of the notice alleging the debt, the individual or
entity is deemed to have forfeited the right to an administrative hearing and
waived any objection he or she may have to this debt, and the Department will
implement a Maine State Income Tax Refund Offset. The debt shall be deemed paid
only to the extent of the amount received by the Department.
B.
Administrative
Hearing
If an administrative hearing is requested within sixty
(60) calendar days of the date of the receipt of the notice alleging the debt,
a hearing shall be held pursuant to the Maine Administrative Hearings
Regulations. In determining if a debt is established, the hearing shall be
limited to the issue of whether the money is due the Department. If a hearing
was held and the alleged debt owed to the Department was affirmed by the
hearing decision, the Department will implement a Maine State Income Tax Refund
Offset. The offset shall be applied, and the debt shall be deemed paid, only to
the extent of the amount received by the Department.
C.
Notification of State Tax
Assessor
The Department shall notify the State Tax Assessor
annually of all individuals or entities who owe a debt to the Department that
is greater than twenty-five dollars ($25.00).
D.
Changes to the Notification
The Department shall notify the State Tax Assessor of
any decrease in or elimination of past due debt which has been submitted for
effective collection by State Income Tax Refund Offset.
E.
Administrative Hearing-Tax
Offset
Pursuant to
36 M.R.S.
§5276-A(2), before a
tax offset may be made, the State Tax Assessor will provide notice to the
debtor of the intended tax offset and of the debtor's right to request that
hearing.
Upon such timely request, an administrative hearing
shall be held pursuant to
5 M.R.S. §8001,
et. seq. and the Maine Administrative Hearings Regulations.
These hearings shall be limited to the issues of whether the debt is
collectable and whether any post collection events have affected the
debt.
F.
Finalization
of Offset
If the debtor fails to make a timely request for a
hearing or a hearing is held before the Department and a collectable debt is
determined to be due the Department, the offset is final except as determined
by further appeal. The Department must release to the taxpayer any offset
refund amount determined after a hearing not to be a debt due to the agency
within ninety (90) calendar days of such determination or as otherwise provided
by the creditor agency in a promulgated rule.
1.07-5
Medicare
Medicare, authorized by Title XVIII of the
Social Security Act, provides health insurance for most
individuals age sixty-five (65) and over, and for others who meet specified
disability requirements. Medicare benefits include hospital insurance and
related care (Part A) and supplemental medical insurance (Part B).
MaineCarecomplements and supplements the Medicare Program, subject to Section
1.07-5(C). Each person eligible for Medicare (Part A and/or Part B) is issued a
red, white and blue Social Security Health Insurance Card showing the
beneficiary claim number, Medicare coverage and effective date.
In order to receive MaineCare reimbursement, providers
must accept assignment (unless specifically noted in other Chapters of this
Manual) of Medicare for services to MaineCare members for whom
coinsurance/insurance and deductible may be payable. All providers delivering
services reimbursable by Medicare must participate in Medicare in order to
receive MaineCare reimbursement.
Providers must indicate acceptance of this assignment by
checking the appropriate box on the Medicare invoice. Coinsurance and
deductible charges for Medicare covered services are to be made to the
Department only after adjudication of the claim by the Medicare Intermediary or
carrier.
In determining the Department's liability for the
Medicare deductible and coinsurance the following shall hold:
A.
Hospitals, Nursing
Facilities, (except as provided below for hospitals and nursing facilities for
QMB only), Federally qualified health centers, rural health centers,
physicians, psychologists, Advanced Practice Registered Nurses, ambulance
providers, mental health clinics, ambulatory care clinics, QMB providers,
podiatrists, and optometrists may bill MaineCare for Medicare coinsurance and
deductible. The total payment from both Medicare and MaineCare cannot exceed
the lowest rate that Medicare determines to be the allowed amount.
B.
Indian Health Centers
Indian Health Centers providing services under ambulatory
care clinics are eligible for the all inclusive rate published in the most
recent federal register.
C. For all other providers, for claims
received on or after March 1, 2000, (except for psychologists, for whom the
effective date is April 1, 2001, and podiatrists for whom the effective date is
September 21, 2001, and optometrists for whom the effective date is July 1,
2002) the total payment to the provider from both Medicare and MaineCare cannot
exceed the lower of the Medicare approved amount or the maximum allowance
established by the Department for services provided, in cases where assignment
is required. In cases where assignment is not required (as described in Chapter
II, Section 60, "Medical Supplies and Durable Medical Equipment", of the
MaineCare Benefits Manual), payment will not exceed the
maximum allowance established by the Department for the services
provided.
D. If CMS approves,
effective January 1, 2014, for hospitals and nursing facility providers, for
Qualified Medicare Beneficiary without other Medicaid (QMB Only), MaineCare
will limit cost sharing payments to the amount necessary to provide a total
payment equal to the amount MaineCare would pay for these services under the
State plan.
E.
Impermissible
Balance Billing of QMBs: Providers are strictly prohibited, under
42 USC §
1396a(n)(3), from seeking to
collect any amount from a QMB for Medicare deductibles or coinsurance, even if
the MaineCare payment is less than the total amount of the Medicare deductible
and coinsurance. Providers are, however, allowed to collect from the QMB Member
any MaineCare copayment for the service.
1.07-6
Assignment: Medicare Part B and
Companion Plan I Payments
MaineCare is not liable for payment of any charges for
services provided to dually eligible (MaineCare/Medicare) members that exceed
the approved amount by Medicare Part A, Part B unless specifically noted in
other Chapters and for Companion Plan I collectively. MaineCare's liability is
limited to the lowest amounts listed in Section 1.07-7(C).
1.07-7
Procedures
A. All providers must:
1. Take all necessary and reasonable measures
within the provider's ability to receive payment from any third party resource
(accept assignment, enrollment, participation), also available to their
eligible patients, before billing MaineCare with the exception of those
services described in Section 1.07-3;
2. Identify third party resources and total
third party payments on the MaineCare claim;
3. Wait ninety (90) calendar days from the
date of service for a MaineCare member or policyholder to cooperate with
respect to third party resources. If after ninety (90) calendar days the member
or policyholder has failed to cooperate, MaineCare may then be billed,
according to appropriate billing instructions available from the Department.
MaineCare does not reimburse providers that
inappropriately provide services to MaineCare members enrolled in a health
maintenance organization or managed care plan who do not participate in the HMO
or managed care plan, or where services must be authorized prior to provision
by the member's primary care provider.
Cooperative policyholder(s) and/or members
include:
a. Those who provide
necessary third party insurance information to providers when requested to do
so;
b. Those for whom providers are
able to obtain necessary signatures required to process third party claims; and
c. Those who have been reimbursed
by a third party, and have then reimbursed the provider for the services for
which they received the reimbursement. The Department will not reimburse in any
situation where the member or policyholder received third party payment because
the provider did not accept assignment and/or was not
enrolled.
4. Show
evidence of third party resource responses (explanation of benefits, including
explanation of the basis for denials, and related information) prior to billing
MaineCare for covered services. Claims that include such evidence may only be
billed to the Department as instructed, according to the appropriate billing
instructions.
5. Bill MaineCare
without having received payment or denial notice from the third party in cases
where insurance is provided by an absent parent of a member. Providers must
first bill the third party. If no answer is received within one hundred (100)
calendar days of the date of service, providers may then bill MaineCare.
Providers must certify they have billed the insurer and
have not received a response. Certification must be submitted on the provider's
office letterhead. For proper certification wording and the Department's
follow-up plans, please see the following:
Proper Certification Wording:
I certify that I have submitted the attached claim
to _______________________ (health insurance company name).
I have waited one hundred (100) calendar days. I
have received no response.
I understand the Department will audit provider
compliance with these certification requirements.
________________________________
(Signature)
________________________________
(Date)
6. Ensure that any time a MaineCare bill
(copy) or an itemized hospital bill is given to a MaineCare member, attorney or
insurance company, the following must be stated on the copy: "MaineCare Member
Benefits Assigned to the State of Maine by Law."
B.
Payments to Hospitals
MaineCare payment for hospital services is based upon
rules established by the Department of Health and Human Services that are in
effect for dates of service, less payment obligated or made by any third party.
When a third party payment is available, MaineCare will pay only the difference
between the amount of the third party payment and the MaineCare allowed
amount.
C.
Individual
Providers Balance Billing After Third Party Payment
When billing MaineCare after receiving a third party
payment, individual providers must follow these procedures:
1.
Fee-for-Service Claims
a. Charges must equal the allowed amount as
agreed to with the particular insurance carrier as determined from the
Explanation of Benefits (EOB).
b.
The third party amount must equal the actual third party payment plus any
withheld amount as indicated on the insurance company's EOB.
2.
Capitated Services
Charges must equal the copay amount when balance billing
for capitated services. Capitated services should be billed with the charges
equal to the copay amount. Capitated services are services covered under the
monthly capitation payment agreement between a managed care plan and the
member's provider.
