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131st MAINE LEGISLATURE
FIRST REGULAR SESSION-2023
Legislative Document No. 84S.P. 51 In Senate, January 4, 2023
An Act to Strengthen Third-party Liability Requirements for the
MaineCare Program
Submitted by the Department of Health and Human Services pursuant to Joint Rule 204.
Reference to the Committee on Health and Human Services suggested and ordered printed.
DAREK M. GRANT
Secretary of the Senate
Presented by Senator BALDACCI of Penobscot. Page 1 - 131LR0166(01)
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2 as amended by PL 2007, c. 240, Pt. JJJ, §§2 and
3 3 and c. 448, §8 and affected by §14, is further amended to read:
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5 payment submitted by the department or a health care provider.
6 A. Whenever the department submits claims to a health insurer, as included in 42
7 United States Code, Section 1396a(a)(25)(I), including self-insured plans, group health
8 plans as defined in the federal Employee Retirement Income Security Act of 1974,
9 Section 607(1), service benefit plans, managed care organizations, pharmacy benefit
10 managers or other parties that are, by statute, contract or agreement, legally responsible
11 for payment of a claim for a health care item or service, on behalf of a current or former
12 recipient under the MaineCare program for whom an assignment of rights has been
13 received, or whose rights have been assigned by the operation of law, the health insurer
14 doing business in the State or providing coverage to a resident of this State must
15 respond to the department within 60 days and:
16 (1) Provide information, with respect to individuals who are eligible for or are
17 provided medical assistance under the MaineCare program, upon the request of the
18 State, to determine during what period the individual or the individual's spouse or
19 dependents may be or may have been covered by a health insurer and the nature of
20 the coverage that is or was provided by the health insurer, including the name,
21 address and identifying number of the plan, in a manner prescribed by the United
22 States Secretary of Health and Human Services;
23 (2) Accept the State's right of recovery and the assignment to the State of any right
24 of an individual or other entity to payment from the party for an item or service for
25 which payment has been made under the state plan and, in the case of a responsible
26 3rd party that requires prior authorization for an item or service furnished to an
27 individual eligible to receive medical assistance under the MaineCare program,
28 accept authorization provided by the State that the item or service is covered under
29 the MaineCare program for that individual, as if the authorization were the prior
30 authorization made by the 3rd party for the item or service;
31 (3) Respond to any inquiry by the State regarding a claim for payment for any
32 health care item or service that is submitted not later than 3 years after the date of
33 the provision of such health care item or service; and
34 (4) Agree not to deny a claim submitted by the State solely on the basis of the date
35 of submission of the claim, the type or format of the claim form or, a failure to
36 present proper documentation at the point-of-sale that is the basis of the claim or,
37 in the case of a responsible 3rd party, a failure to obtain a prior authorization for
38 the item or service for which the claim is being submitted, if:
39 (a) The claim is submitted by the State within the 3-year period beginning on
40 the date on which the item or service was furnished; and
41 (b) Any action by the State to enforce its rights with respect to such claim is
42 commenced within 6 years of the State's submission of such claim. Page 2 - 131LR0166(01)
1 C. A payment made as part of an assignment by a 3rd party to the MaineCare program
2 or a contractor acting on behalf of the MaineCare program is considered final 2 years
3 after the date of the payment and when final the payment is not subject to adjustment.
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5 This bill adds 3rd-party liability requirement provisions for MaineCare claims for
6 payment and adds a provision to apply MaineCare assignment provisions to out-of-state
7 carriers who provide coverage to residents of this State. The bill also provides that
8 payments made under assignment to the MaineCare program by a 3rd party are final after
9 2 years.
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