Sec. K-1. 19-A MRSA §2202, sub-§13 is enacted to read:
13. Premium from noncustodial parents. The Department of Human Services, Division of Support Enforcement and Recovery shall collect a premium from noncustodial parents whose children are MaineCare members and who have legally been determined to be responsible for medical care contributions for these children.
Sec. K-2. 22 MRSA §14, as amended by PL 1999, c. 731, Pt. TT, §§1 to 6, is further amended to read:
§14. Action against parties liable for medical care rendered to assistance recipients; assignment of claims
1. Recovery procedures. When benefits are provided or will be provided to a beneficiary member under the Medicaid MaineCare program administered by the department pursuant to the United States Social Security Act, Title XIX or under the elderly low-cost drug program under section 254, including any prescription drug programs administered under the auspices of MaineCare, referred to collectively in this section as MaineCare, for the medical costs of injury, disease, disability or similar occurrence for which a 3rd party is, or may be, liable, the commissioner may recover from that party the reasonable value cost of the benefits provided. This right of recovery is separate and independent from any rights or causes of action belonging to a beneficiary member under the Medicaid MaineCare program or under the elderly low-cost drug program under section 254. For Medicaid MaineCare recipients who participated in the Medicaid MaineCare managed care program, "reasonable value cost" means the total value of coverable medical services provided measured by the amount that Medicaid MaineCare would have paid to providers directly for such services, were it not for the managed care system. The Medicaid MaineCare program and the elderly low-cost drug program under section 254 are is the payors payor of last resort and shall provide medical coverage only when there are no other available resources. The Attorney General, or counsel appointed by the Attorney General, may, to enforce this right, institute and prosecute legal proceedings directly against the 3rd party in the appropriate court in the name of the commissioner.
In addition to the right of recovery set forth in this subsection, the commissioner must also be subrogated, to the extent of any benefits provided under the Medicaid MaineCare program or under the elderly low-cost drug program under section 254, to any cause of action or claim that a beneficiary member has against a 3rd party who is or may be liable for medical costs incurred by or on behalf of the beneficiary member. The Attorney General, or counsel appointed by the Attorney General, to enforce this right may institute and prosecute legal proceedings in the name of the injured person, beneficiary member, guardian, personal representative, estate or survivor. If necessary to enforce the commissioner's right of recovery, the Attorney General, or counsel appointed by the Attorney General, may institute legal proceedings against any beneficiary member, including the agent, representative or attorney of that member, who has received a settlement or award from a 3rd party.
The commissioner's right to recover the reasonable value cost of benefits provided constitutes a statutory lien on the proceeds of an award or settlement from a 3rd party if recovery for Medicaid MaineCare costs was or could have been included in the recipient's claim for damages from the 3rd party. The commissioner is entitled to recover the amount cost of the benefits actually paid out or, with regard to Medicaid recipients who participated in the managed care program when the commissioner has determined that collection will be cost-effective, the reasonable value of benefits provided to the extent that there are proceeds available for such recovery after the deduction of reasonable attorney's fees and litigation costs from the gross award or settlement. In determining whether collection will be cost-effective, the commissioner shall consider all factors that diminish potential recovery by the department, including but not limited to questions of liability and comparative negligence or other legal defenses, exigencies of trial that reduce a settlement or award in order to resolve the recipient's claim and limits on the amount of applicable insurance coverage that reduce the claim to the amount recoverable by the recipient. The department's statutory lien may not be reduced to reflect an assessment of a pro rata share of the recipient's attorney's fees or litigation costs. The commissioner may, at the commissioner's discretion, compromise, or otherwise settle and execute a release of, any claim or waive any claim, in whole or in part, if the commissioner determines the collection will not be cost-effective or that the best possible outcome requires compromise, release or settlement.
2-A. Assignment of rights of recovery. The receipt of benefits under the Medicaid MaineCare program administered by the department pursuant to the United States Social Security Act, Title XIX or under the elderly low-cost drug program under section 254 constitutes an assignment by the recipient or any legally liable relative to the department of the right to recover from 3rd parties for the medical cost of injury, disease, disability or similar occurrence for which the recipient receives medical benefits. The department's assigned right to recover is limited to the amount of medical benefits received by the recipient and does not operate as a waiver by the recipient of any other right of recovery against a 3rd party that a recipient may have.
The recipient is also deemed to have appointed the commissioner as the recipient's attorney in fact to perform the specific act of submitting claims to insurance carriers or endorsing over to the department any and all drafts, checks, money orders or any other negotiable instruments connected with the payment of 3rd-party medical claims.
2-B. Direct reimbursement to health care provider. When an insured is eligible under the Medicaid MaineCare program administered by the Department of Human Services pursuant to the United States Social Security Act, Title XIX or under the elderly low-cost drug program under section 254 for the medical costs of injury, disease, disability or similar occurrence for which an insurer is liable, and the insured's claim is payable to a health care provider as provided or permitted by the terms of a health insurance policy or pursuant to an assignment of rights by an insured, the insurer shall directly reimburse the health care provider to the extent that the claim is honored.
2-C. Direct reimbursement to department. When an insured is eligible under the Medicaid MaineCare program administered by the Department of Human Services pursuant to the United States Social Security Act, Title XIX or under the elderly low-cost drug program under section 254 for the medical costs of injury, disease, disability or similar occurrence for which an insurer is liable, and the claim is not payable to a health care provider under the terms of the health insurance policy, the insurer shall directly reimburse the Department of Human Services, upon request, for any medical services paid by the department on behalf of a recipient under Medicaid or the elderly low-cost drug program under section 254 the MaineCare program to the extent that those medical services are payable under the terms of the health insurance policy. If the insurer knows or has information upon which to reasonably conclude that the insured is a recipient of MaineCare services, the insurer shall advise the department in writing as to the existence of the claim prior to any other payment.
2-D. Notification of claim. A recipient under Medicaid or the elderly low-cost drug program under section 254 the MaineCare program, or any attorney representing a recipient under Medicaid or the elderly low-cost drug program under section 254 the MaineCare program, who makes a claim to recover the medical cost of injury, disease, disability or similar occurrence for which the party received medical benefits under the Medicaid MaineCare program pursuant to the United States Social Security Act, Title XIX or the elderly low-cost drug program under section 254 shall advise the department in writing with information as required by the department of the existence of the claim.
2-E. Notification of pleading. In any action to recover the medical cost of injury, disease, disability or similar occurrence for which the party received medical benefits under the Medicaid MaineCare program or the elderly low-cost drug program under section 254, the party bringing the action shall notify the department of that action at least 10 days prior to filing the pleadings. Department records indicating medical benefits paid by the department on behalf of the recipient are prima facie evidence of the medical expenses incurred by the recipient for the related medical services.
2-F. Disbursement. Except as otherwise provided in this subsection, a disbursement of any award, judgment or settlement may not be made to a recipient without the recipient or the recipient's attorney first paying to the department the amount of the statutory lien from the award, judgment or settlement or obtaining from the department a release of any obligation owed to it for medical benefits provided to the recipient. If a dispute arises between the recipient and the commissioner as to the settlement of any claim that the commissioner may have under this section, the 3rd party or the recipient's attorney shall withhold from disbursement to the recipient an amount equal to the commissioner's claim. Either party may apply to the Superior Court or the District Court in which an action based upon the recipient's claim could have been commenced for an order to determine a reasonable amount in satisfaction of the statutory lien, consistent with federal law, considering whether an independent action by the commissioner would have been cost-effective. If either party applies under this subsection to the court for an order to determine a reasonable amount, the court may not order payment in satisfaction of such a lien for an amount less than 75% of the recovery, net of reasonable attorney's fees and litigation costs, unless that amount exceeds the amount of the lien.
2-H. Honoring of assignments. The following provisions apply to claims for payment submitted by the department or a health care provider.
A. Whenever a participating health care provider or the department submits claims to an insurer, as defined in Title 24-A, section 4, or to a health maintenance organization on behalf of a recipient under Medicaid or the elderly low-cost drug program under section 254 the MaineCare program for whom an assignment of rights has been received, or whose rights have been assigned by the operation of law, the insurer or health maintenance organization doing business in the State must respond within 60 days of receipt of a claim by forwarding payment or issuing a notice of denial directly to the submitter of the claim.
B. Whenever a nonparticipating health care provider or the department on behalf of a nonparticipating provider submits claims to an insurer, as defined in Title 24-A, section 4, or a health maintenance organization that operates through a series of participation agreements on behalf of a recipient under Medicaid or the elderly low-cost drug program under section 254 the MaineCare program for whom an assignment of rights has been received or whose rights have been assigned by the operation of law, the insurer or health maintenance organization doing business in the State must respond within 60 days of receipt of a claim by forwarding payment, issuing a notice of denial or issuing a copy of the explanation of benefits directly to the submitter of the claim.
2-I. Claims against estates of MaineCare recipients. Claims against the estates of Medicaid MaineCare recipients are governed by this subsection.
A. The department has a claim against the estate of a Medicaid MaineCare recipient when, after the death of the recipient:
(1) Property or other assets are discovered that existed and were owned by the recipient during the period when Medicaid MaineCare benefits were paid for the recipient and disclosure of the property or assets at the time benefits were being paid would have rendered the recipient ineligible to receive the benefits;
(2) It is determined that the recipient was 55 years of age or older when that person received Medicaid MaineCare assistance; or
(3) It is determined that the recipient has received or is entitled to receive benefits under a long-term care insurance policy in connection with which assets or resources are disregarded and medical assistance was paid on behalf of the recipient for nursing facility or other long-term care services.
B. The amount of Medicaid MaineCare benefits paid and recoverable under this subsection is a claim against the estate of the deceased recipient.
(1) As to assets of the recipient included in the probated estate, this claim may be enforced pursuant to Title 18-A, Article III 3, Part 8.
(2) As to assets of the recipient not included in the probated estate, this claim may be enforced by filing a claim in any court of competent jurisdiction.
C. A claim may not be made under paragraph A, subparagraph (2) or (3) until:
(1) The recipient has no surviving spouse; and
(2) The recipient has no surviving child who is under age 21 or who is blind or permanently and totally disabled as defined in 42 United States Code, Section 1382c.
D. Paragraph A, subparagraphs (2) and (3) apply only to a recipient who died on or after October 1, 1993 for Medicaid MaineCare payments made on or after October 1, 1993.
E. A claim under paragraph A, subparagraph (2) must be waived if enforcement of the claim would create an undue hardship under criteria developed by the department.
F. As used in this subsection, unless the context otherwise indicates, the term "estate" means:
(1) All real and personal property and other assets included in the recipient's estate, as defined in Title 18-A, section 1-201; and
(2) Any other real and personal property and other assets in which the recipient had any legal interest at the time of death, to the extent of that interest, including assets conveyed to a survivor, heir or assign of the deceased recipient through tenancy in common, survivorship, life estate, living trust, joint tenancy in personal property or other arrangement.
3. Definitions. For purposes of this section, "3rd party" or "liable party" or "potentially liable party" means any entity, including, but not limited to, an insurance carrier that may be liable under a contract to provide health, automobile, workers' compensation or other insurance coverage that is or may be liable to pay all or part of the medical cost of injury, disease, disability or similar occurrence of an applicant or recipient of benefits under Medicaid or the elderly low-cost drug program under section 254 the MaineCare program. For purposes of this section and sections 18 and 19, an "insurance carrier" includes health insurers, group health plans as defined in 29 United States Code, Section 1167(1), service benefit plans and health maintenance organizations.
"Liable party," "potentially liable party" or "3rd party" also includes the trustee or trustees of any mortuary trust established by the recipient or on the recipient's behalf in which there is money remaining after the actual costs of the funeral and burial have been paid in accordance with the terms of the trust and in which there is no provision that the excess be paid to the decedent's estate. "Liable party," "potentially liable party" or "3rd party" may also include the recipient of benefits under Medicaid or the elderly low-cost drug program under section 254 the MaineCare program.
Sec. K-3. 22 MRSA §16-A is enacted to read:
§16-A. Mandatory insurance data matches
1. Persons receiving MaineCare benefits. Upon request by the department in order to identify persons who have been employed in the State or who have been employers in the State or who received monetary benefits of any kind from a state agency, all state agencies shall provide to the department information about persons who have been receiving, are currently receiving or are legally responsible for some or all of the medical expenses of an individual who is receiving MaineCare benefits. The information must be transmitted promptly in response to the department's request and must be provided in a manner that allows the department's electronic identification of former or current MaineCare members who had or have income during any period of MaineCare coverage.
2. Persons with health insurance coverage. Upon request by the department, a nonprofit hospital or medical service organization authorized under Title 24 or an insurer authorized under Title 24-A shall provide to the department a list of persons who have health insurance coverage with the organization or insurer. The information must be transmitted promptly in response to the department's request and must be provided in a manner that allows the department's electronic identification of former or current MaineCare members who had or have health insurance coverage during any period of MaineCare coverage.
Sec. K-4. 22 MRSA §1815, as amended by PL 1991, c. 752, §2, is further amended to read:
Each application for a license to operate a hospital, convalescent home or nursing home must be accompanied by a nonrefundable fee of $10 for each bed contained within the facility. Hospitals shall pay $100 for each bed contained within the facility. Nursing and convalescent homes shall pay $45 for each bed contained with the facility. Each application for a license to operate an ambulatory surgical facility must be accompanied by the fee established by the department. The department shall establish the fee for an ambulatory surgical facility, not to exceed $500, on the basis of a sliding scale representing size, number of employees and scope of operations. All licenses issued must be renewed annually upon payment of a like fee. The State's share of all fees received by the department under this chapter must be deposited in the General Fund. A license granted may not be assignable or transferable. State hospitals are not required to pay licensing fees.
Sec. K-5. 22 MRSA §3173-C, sub-§1, as amended by PL 1993, c. 6, Pt. C, §5, is further amended to read:
1. Authorization required. The department may not require any Medicaid recipient MaineCare member to make any payment toward the cost of a Medicaid MaineCare service unless that payment is specifically authorized by this section, except that any copayment or premium expressly approved by the federal Secretary of the Department of Health and Human Services as part of a waiver must be implemented.
Sec. K-6. 22 MRSA §3173-C, sub-§2, as amended by PL 1993, c. 6, Pt. C, §6, is further amended to read:
2. Prescription drug services. Except as provided in subsections 3 and 4, a payment of $2 $2.50 for generic drugs and $3 for brand-name drugs each drug is to be collected from the Medicaid recipient MaineCare member for each drug prescription that is an approved Medicaid MaineCare service. For the purposes of this section, a brand-name drug is defined as a single-source drug, a cross-licensed drug or an innovator drug for which a lower-cost generic equivalent is available. Copayments must be capped at $25 per month per member. If a recipient member is prescribed a drug in a quantity specifically intended by the provider or pharmacist, for the recipient's health and welfare, to last less than one month, only one payment for that drug for that month is required.
Sec. K-7. 22 MRSA §3173-C, sub-§7, ¶¶P and Q, as enacted by PL 1993, c. 410, Pt. I, §9, are amended to read:
P. Substance abuse services, $2; and
Q. Hospital inpatient services, $3 per patient day.;
Sec. K-8. 22 MRSA §3173-C, sub-§7, ¶¶R and S are enacted to read:
R. Federally qualified health center services, $3 per patient day; and
S. Rural health center services, $3 per patient day.
Sec. K-9. 22 MRSA §3173-F is enacted to read:
§3173-F. Charging or increasing premiums
1. Premiums. The department may apply to the federal Centers for Medicare and Medicaid Services for a waiver or amend a pending or current waiver under the Medicaid program authorizing the department to impose cost sharing on some or all persons eligible for MaineCare under the Katie Beckett option authorized by the federal Tax Equity and Fiscal Responsibility Act of 1982. Premiums must be implemented on a sliding scale.
2. Rules. The department shall adopt rules providing for sanctions when complete, timely payment of premiums has not been made and providing grace periods applicable to such late or incomplete payments and allowing waiver of premiums for good cause. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
3. Copayments. The department may request, as part of the waiver request under subsection 1, permission to charge members copayments above those allowed in current federal regulation and statute.
Sec. K-10. 22 MRSA §3174-T, sub-§5, ¶A, as amended by PL 1999, c. 731, Pt. PP, §2, is repealed and the following enacted in its place:
A. Premiums must be paid at the beginning of each month for coverage for that month. Premium payments must be between 1% and 2% of family income. Premiums must be imposed in a manner that places less burden on those with lower incomes than on those with higher incomes.
Sec. K-11. 22 MRSA §3174-V, as enacted by PL 1999, c. 401, Pt. T, §1, is amended to read:
§3174-V. Federally qualified health center reimbursements
Beginning in fiscal year 1999-00 2003-04, the reimbursement requirements listed in subsections 1 and 2 apply to payments for certain federally qualified health centers as defined in 42 United States Code, Section 1395x, subsection(aa)(1993).
1. Services furnished by center. The department shall reimburse a federally qualified health center no less than 100% of reasonable costs, reduced by the total copayments for which members are responsible, for services furnished by the center within the scope of service approved by the federal Health Resources and Services Administration or the commissioner if that center:
A. Is receiving a grant under Section 330 of the federal Public Health Services Act; or
B. Is receiving funding under contract with the recipient of a grant under Section 330 of the federal Public Health Services Act, is identified as a subrecipient in the Section 330 grantee's approved scope of work and meets the requirements to receive a grant under Section 330 of that Act.
2. Contracted services. When a federally qualified health center otherwise meeting the requirements of subsection 1 contracts with a managed care plan for the provision of Medicaid services, the department shall reimburse that center the difference between the payment received by the center from the managed care plan and 100% of the reasonable cost, reduced by the total copayments for which members are responsible, incurred in providing the services within the scope of service approved by the federal Health Resources and Services Administration or the commissioner. Any such managed care contract must provide payments for the services of a center that are not less than the level and amount of payment that the managed care plan would make for services provided by an entity not defined as a federally qualified health center.
Sec. K-12. 22 MRSA §3174-AA is enacted to read:
The department shall require MaineCare members to purchase maintenance drugs by mail order when substantial cost efficiencies can be obtained by doing so.
Sec. K-13. 22 MRSA §3521, last ¶, as enacted by PL 1999, c. 790, Pt. B, §3, is amended to read:
The department shall, after hearing, in a manner consistent with the Maine Administrative Procedure Act, adopt rules governing eligibility, application procedures, services covered and reimbursement procedures, including member responsibility for a $10 copayment for prescriptions; a $10 copayment for an office visit to a physician, optometrist or optician; and a $50 copayment for a hospital procedure or an ambulatory surgical center procedure. The authority to adopt rules granted by this paragraph is deemed to be the same authority granted by former section 3501-B.
Sec. K-14. 22 MRSA §3790, sub-§1, as enacted by PL 1997, c. 530, Pt. B, §1, is amended to read:
1. Established. The department shall establish a student financial aid program based on need for up to 2000 participants known as the Parents as Scholars Program, referred to in this section as the "program," to aid needy students who have dependent children and who are matriculating in postsecondary undergraduate 2-year and 4-year degree-granting education programs. Enrollees in the program must be provided with a package of student aid that includes aid for living expenses equivalent to that provided pursuant to chapter 1053-B, medical assistance pursuant to chapter 855 and services equivalent to those provided pursuant to chapter 1054-A. A family that ceases to receive aid under this chapter as a result of increased child support or increased hours of, or increased income from, employment is eligible to receive transitional support services in accordance with section 3762, subsection 8. The program must be supported with funds other than federal block grant funds provided under the United States Social Security Act, Title IV-A, except that federal funds may be used in accordance with federal law if their use does not result in the imposition of conditions of participation or program requirements other than those established by this chapter.
Sec. K-15. Review cost sharing requirements. The department shall review the cost sharing requirements in the MaineCare program in consultation with the Medicaid Advisory Committee and, by February 15, 2005, submit a report including proposed legislation to the Joint Standing Committee on Health and Human Services for restructuring cost-sharing in the MaineCare program in a manner that places the least burden on those with the lowest incomes. The legislation must include a monthly aggregate cap that may vary by household income for each MaineCare household on which these costs are imposed.
Sec. K-16. Pursuit of federal funding for disproportionate share shortfall for institutions for mental disease and periodic reports. The Commissioner of Human Services and the Commissioner of Behavioral and Developmental Services shall work with the State's 2 freestanding, nonprofit psychiatric hospitals and the Maine Congressional Delegation to advocate for the elimination of the current federal cap on disproportionate share funds that are available for institutions for mental disease, or for other federal reforms, that would ensure adequate federal funding for the population served by those hospitals. The commissioners shall report their progress in writing to the joint standing committee of the Legislature having jurisdiction over appropriations and financial affairs and the joint standing committee of the Legislature having jurisdiction over health and human services matters no later than April 15, 2003 and quarterly thereafter over the state fiscal years ending June 30, 2004 and June 30, 2005. The initial report must quantify the impact of reforms to MaineCare reimbursement and other program changes and savings projected to address the federal funding shortfall over the biennium. Subsequent quarterly reports must provide appropriate updates on funding and federal advocacy.
Sec. K-17. Suspension of inflation and return on equity payments to nursing facilities. Notwithstanding any other provisions of law, the Department of Human Services may not include in its reimbursement of nursing facilities under the MaineCare program any amounts designed to provide for inflation adjustments or a return on equity capital for state fiscal years 2003-04 and 2004-05.
Sec. K-18. Merger. The Department of Human Services and the Department of Behavioral and Developmental Services shall merge into a single department to perform the duties of both departments. The departments shall commence merger activities immediately. The departments shall cooperate with any other entities of State Government and community providers involved in accomplishing this merger. The merger must:
1. Streamline services to clients;
2. Provide central points of contact for clients needing multiple services;
3. Coordinate use of contracts for service;
4. Maximize funding sources;
5. Minimize administrative overhead;
6. Eliminate duplication of services and administrative activities; and
7. Otherwise create efficiencies and cost-savings in the provision of services.
The departments shall participate in producing a plan to implement the merger, which must be submitted along with any necessary implementing legislation to the Second Regular Session of the 121st Legislature by January 1, 2004.
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