Sec. TT-1. 22 MRSA §14, sub-§1, as amended by PL 1999, c. 668, §94, is further amended to read:
1. Recovery procedures. When benefits are provided or will be provided to a beneficiary under the Medicaid 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 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 of the benefits provided. This right of recovery is separate and independent from any rights or causes of action belonging to a beneficiary under the Medicaid program or under the elderly low-cost drug program under section 254. For Medicaid recipients who participated in the Medicaid managed care program, "reasonable value" means the total value of coverable medical services provided measured by the amount that Medicaid would have paid to providers directly for such services, were it not for the managed care system. The Medicaid program is and the elderly low-cost drug program under section 254 are the payor payors of last resort and should 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 program or under the elderly low-cost drug program under section 254, to any cause of action or claim that a beneficiary has against a 3rd party who is or may be liable for medical costs incurred by or on behalf of the beneficiary. 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, 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 who has received a settlement or award from a 3rd party.
The commissioner's right to recover the reasonable value of benefits provided constitutes a statutory lien on the proceeds of an award or settlement from a 3rd party if recovery for Medicaid 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 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 compromise, or 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.
Sec. TT-2. 22 MRSA §14, sub-§2-A, as amended by PL 1999, c. 668, §95, is further amended to read:
2-A. Assignment of rights of recovery. The receipt of benefits under the Medicaid 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.
Sec. TT-3. 22 MRSA §14, sub-§§2-B and 2-C, as amended by PL 1999, c. 668, §96, are further amended to read:
2-B. Direct reimbursement to health care provider. When an insured is eligible under the Medicaid 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 or 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 of Human Services. When an insured is eligible under the Medicaid 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 recipient or the elderly low-cost drug program under section 254 to the extent that those medical services are payable under the terms of the health insurance policy.
Sec. TT-4. 22 MRSA §14, sub-§§2-D and 2-E, as amended by PL 1999, c. 668, §97, are further amended to read:
2-D. Notification of claim. A recipient under Medicaid recipient or the elderly low-cost drug program under section 254, or any attorney representing a recipient under Medicaid recipient or the elderly low-cost drug program under section 254, 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 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 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.
Sec. TT-5. 22 MRSA §14, sub-§2-H, ¶¶A and B, as amended by PL 1999, c. 668, §98, are further amended to read:
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 recipient or the elderly low-cost drug program under section 254 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 recipient or the elderly low-cost drug program under section 254 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.
Sec. TT-6. 22 MRSA §14, sub-§3, as amended by PL 1999, c. 668, §99, is further amended to read:
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 benefits or the elderly low-cost drug program under section 254. 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 the benefits under Medicaid benefits or the elderly low-cost drug program under section 254.
Sec. TT-7. 22 MRSA §254, sub-§4-A, as amended by PL 1999, c. 401, Pt. KKK, §1 and affected by §10 and c. 531, Pt. F, §2, is further amended to read:
4-A. Payment for drugs provided. The commissioner may establish the amount of payment to be made by recipients toward the cost of prescription or nonprescription drugs, medication and medical supplies furnished under this program provided that, for persons at or below 185% of the federal poverty line, the total cost for any covered purchase of a prescription or nonprescription drug or medication provided under the basic component of the program or the total cost of any covered purchase of a generic prescription drug or medication under the supplemental component of the program does not exceed 20% of the price allowed for that prescription under program rules or $2, whichever is greater. For the supplemental component of the program, the total cost paid by the program for any covered purchase of a prescription drug or medication may not exceed $2. For the supplemental component of the program except as otherwise provided in this subsection, the total cost paid by the individual for any covered purchase of a prescription drug or medication may not exceed the cost of the program for that drug or medication minus the $2 paid by the program. The commissioner shall establish annual limits on the costs incurred by eligible household members for covered prescriptions or nonprescription drugs or medications, after which the program must pay 80% of the cost of all prescriptions or nonprescription drugs or medications covered by the supplemental component of the program. The limits must be set by the commissioner by rule as necessary to operate the program within the program budget;
Sec. TT-8. 22 MRSA §254, sub-§10, as amended by PL 1999, c. 551, §1, is further amended to read:
10. Eligible individuals. To be eligible for the program, an individual must be:
A. At least 62 years of age; or
B. Nineteen years of age or older and determined to be disabled by the standards of the federal social security program; and
Sec. TT-9. 22 MRSA §254, sub-§11, as enacted by PL 1999, c. 551, §2, is amended to read:
11. Retention of eligibility. A person who was eligible for the program at any time from August 1, 1998 to July 31, 1999 and who does not meet the requirements of subsection 10 retains eligibility for the program until February 28, 2001 if that person is a member of a household of an eligible person.; and
Sec. TT-10. 22 MRSA §254, sub-§12 is enacted to read:
12. Funds not to lapse. Funds appropriated from the General Fund to carry out the purpose of this section may not lapse but must carry from year to year.
Sec. TT-11. PL 1999, c. 401, Pt. KKK, §9 is repealed.
Sec. TT-12. Allocation. The following funds are allocated from Other Special Revenue funds to carry out the purposes of this Part.
2000-01
HUMAN SERVICES, DEPARTMENT OF
Low-cost Drugs to Maine's Elderly
All Other $10,000,000
Provides for the allocation of funds from the Fund for a Healthy Maine to expand the supplemental program to cover 80% of the cost of generic drugs not covered in the basic program and to institute a catastrophic component whereby the department would establish an annual limit on the total costs to be paid by eligible persons in the program.
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