Subsection 144-101-I-1.07 - THIRD PARTY LIABILITY1.07-1Definitions Relative to this SectionA. 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; or3. 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. 1.07-2Premiums 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.
1.07-3Provider/Department/Member Responsibility Regarding Third Party LiabilityA. 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.1.07-4Implementing Maine State Income Tax Refund OffsetThe 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.
1.07-5Medicare 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 CentersIndian 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.1.07-6Assignment: Medicare Part B and Companion Plan I PaymentsMaineCare 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).
1.07-7ProceduresA. 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 Claimsa. 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.
C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.07