C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.04
The Office for Family Independence defines a member as a person determined to be financially eligible in accordance with the eligibility standards published in the MaineCare Eligibility Manual.
The MaineCare Eligibility Manual is published and maintained by the Office for Family Independence. Detailed information regarding financial eligibility standards can be obtained by contacting the Regional Offices of the Department of Health and Human Services. If there are any conflicts or inconsistencies between financial eligibility guidelines described in this Manual and the MaineCare Eligibility Manual, the MaineCare Eligibility Manual governs.
Members are also subject to eligibility requirements to determine need for specific services as detailed in other Chapters and Sections of this Manual. The Department may reassess a member's medical eligibility at any time. Pursuant to 42 C.F.R. § 435.916, if the Department has information about anticipated changes in a member's circumstances, the Department must re-determine eligibility at the appropriate time based on those changes.
The Department issues an identification card to all members. Providers must verify an individual's eligibility for MaineCare prior to providing services. Eligibility may be verified by point of service systems and web-based systems available to providers. MaineCare eligibility verification can also be checked by calling the Department's Interactive Voice Response System. Providers that do not have access to a touch-tone telephone may contact Provider Services as described in Section 1.13. Verification of financial eligibility does not assure reimbursement if any requirements for medical eligibility and prior authorization have not been met. The Department reserves the right to change the frequency of card issuance; to provide separate cards for members restricted to seeing certain providers (See Chapter IV of the MBM); and to change the card format and content.
The following retroactive reimbursement procedure does not apply to situations where a person has knowingly misrepresented his or her status to a provider as a MaineCare applicant or member.
In some cases, MaineCare eligibility may be determined retroactively. If covered services were provided during a period of retroactive eligibility and if the member made any payment toward those retroactively-covered services, the provider, if requested to do so by the member within nine (9) months of the date of the original written notification of MaineCare eligibility, must reimburse the member the full amount paid by the member within fourteen (14) days of being notified by the member. Failure to reimburse the member will result in sanctions as defined in Section 1.20. The provider may then bill MaineCare for those same services. If covered services were provided during a period of retroactive eligibility and the member has not made payments towards those covered services, the provider has one (1) year from the date the eligibility was granted to file a claim correctly with the Department.
For inmates involuntarily confined in a public institution, state or federal prison, jail, detention facility or other penal facility, who are MaineCare members, MaineCare will pay only for covered inpatient medical institution services provided to the inmate while an inpatient in a hospital, nursing home, ICF/IID Intermediate Care Facility for Individuals with Intellectual Disability or juvenile psychiatric facility. MaineCare will not pay for any other services.
MaineCare will pay for all MaineCare coverable services for individuals admitted to and residing in an Institution for Mental Diseases (IMD) for over thirty (30) days, if the individual is under twenty-one (21) years of age or over sixty-five (65) years of age. MaineCare will not cover the cost of services for individuals who are age twenty-one (21) and over and under sixty-five (65) years of age while residing in an IMD.
MaineCare coverage for emergency services for undocumented non-citizens extends only to those services necessary to stabilize the emergency condition. MaineCare does not cover any further treatment or rehabilitation resulting from the emergency even though such treatment may be necessary.
Please refer to Chapter I, Section 1.02-4(D) of this Manual for the complete definition of emergency services for undocumented non-citizens.
The Office for Family Independence may establish other categories in accordance with the MaineCare Eligibility Manual. These special categories define or limit the particular services a person may be eligible to receive. For example, in the category of "Qualified Medical Beneficiary (QMB) eligible only," MaineCare covers only the Medicare coinsurance and deductible. If Medicare does not allow the service, the member is responsible.
C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.04