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Acute Care Services
Long-Term Care Services


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Benefits by State: Maine (October 2008) Notes
 
 
 
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Acute Care Services

Is the Benefit Covered? Copayment Requirement Prior Approval Requirement Coverage Limitations Reimbursement Methodology Populations Covered


Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes Fee for service CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes $.50-$3/day at Mental Health Clinic, depending on payment, up to $20/month Specified procedures and services Fee for service CN & MN
Federally Qualified Health Center Services
Yes Prospective cost based rate/visit CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes $3/day up to $30/month All Medicare benefits/days must be exhausted before Medicaid is billed Cost based payment per discharge with limits CN & MN
Outpatient Hospital Services
Yes $.50-$3/day, depending on payment, up to $30/month Cost based payment with limits CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes $.50-$2/day, depending on payment, up to $20/month Substance abuse services limited to 30 weeks Fee for service or negotiated rate CN & MN
Rural Health Clinic Services
Yes $.50-$3/day, depending on payment, up to $30/month Specified procedures and services Prospective cost based rate/visit CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes Specified procedures and services Fee for service at 75% of physician fee CN & MN
Chiropractor Services
Yes $.50-$2/day, depending on payment, up to $20/month Limited to acute conditions, rehabilitation potential required Fee for service CN & MN
Dental Services
Yes Specified procedures Limited to trauma care, diagnostic procedures for acute conditions, and emergency treatment for relief of pain and infection Fee for service CN & MN
Medical and Remedial Care - Other Practitioners
Medical/Surgical Services of a Dentist
Yes Specified services Fee for service CN & MN
Nurse Midwife Services
Yes Specified procedures and services Fee for service CN & MN
Nurse Practitioner Services
Yes Specified procedures and services Fee for service CN & MN
Optometrist Services
Yes $.50-$2/day, depending on payment, up to $20/month Specified services Limited to dispensing and fitting eyeglasses and 1 routine eye exam/2 years, 1 routine eye exam/year for ICF/MR residents Fee for service CN & MN
Physician Services
Yes $.50-$2/day, depending on payment, up to $20/month Specified procedures and services Specified procedures and services Fee for service CN & MN
Podiatrist Services
Yes $.50-$2/day, depending on payment, up to $20/month Specified procedures and services Routine foot care covered only for specified systemic conditions Fee for service CN & MN
Psychologist Services
Yes $.50-$2/day, depending on payment, up to $20/month 16 one-hour visits/year for individual or group counseling Fee for service CN & MN
Prescription Drugs
Prescription Drugs
Yes $3/Rx, up to $30/month, no copayment required for mail order Rxs Non-preferred drugs 4 brand Rxs/month for residents in supervised settings AWP-15% for brand Rx , AWP-13% for generic Rx, AWP-17% for direct supply drugs, plus $3.35 dispensing fee for each in urban areas and 55-65 cents higher in rural areas; AWP-60% for generic Rx and AWP-20% for brand Rx through mail order pharmacy, plus $1.00 dispensing fee for each CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
Yes $.50-$2/day, depending on payment, up to $20/month Limited to acute conditions or where assistance with ADLs is demonstrated, rehabilitation potential required Fee for service CN & MN
Physical Therapy Services
Yes $.50-$2/day, depending on payment, up to $20/month Limited to acute conditions or where assistance with ADLs is demonstrated, rehabilitation potential required Fee for service CN & MN
Services for Speech, Hearing and Language Disorders
Yes $.50-$2/day for speech pathology services, depending on payment, up to $20/month Decline in oral communication or ability to chew or swallow must be demonstrated, rehabilitation potential required Fee for service CN & MN
Products and Devices
Dentures
Yes Yes 1 full upper and/or lower denture or 1 partial denture/5 years Fee for service CN and MN
Eyeglasses
Yes $.50-$3/day, depending on payment, up to $30/month Specified items and services 1 pair eyeglasses/lifetime, minimum diopter correction required, contact lenses not covered Products provided by state's volume purchase contractor, dispensing provider paid fee for service CN & MN
Hearing Aids
Yes Yes Limited to residents in state-licensed nursing facilities Cost based payment with limits CN & MN
Medical Equipment and Supplies
Yes $.50-$3/day, depending on payment, up to $30/month (not applicable to oxygen and related equip) Specified services Varying limits depending on item Fee for service CN & MN
Prosthetic and Orthotic Devices
Yes $.50-$3/day, depending on payment, up to $30/month Specified items costing more than $500 1 pair orthotic shoes and 1 pair shoe inserts/year Fee for service CN & MN
Transportation Services
Ambulance Services
Yes $.50-$3/day, depending on payment, up to $30/month Fee for service CN & MN
Non-Emergency Medical Transportation Services
Yes Transportation of nursing facility residents See service-specific FN CN & MN
Other Services
Diagnostic, Screening and Preventive Services
Yes Screening services limited to sexually transmitted diseases, diagnostic and preventive services Fee for service CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women
Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes $.50-$1/day, depending on payment up to $10/month for each service type Specified procedures Fee for service CN & MN
Targeted Case Management
Yes Coverage limitations vary by setting and provider Negotiated rate CN & MN


Long-Term Care Services

Community Based Care
Home and Community Based Services Waiver
Yes Services for the following populations: 2, 4 & 8 - See service-specific FN Dependent upon the services provided CN & MN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes $.50-$3/day, depending on payment, up to $30/month Yes Fee for service using Medicare cost ceilings CN & MN
Hospice Care
Yes Two 90-day periods and additional 60-day periods as necessary Prospective per diem or hourly rates based on Medicare methodology CN & MN
Personal Care Services
Yes $.50-$3/day, depending on payment, up to $50/month Yes 2-4 hours/week based on specified LOC criteria, assistance with IADLs dependent on need Fee for service using hourly rates with annual payment ceiling based on LOC CN & MN
Private Duty Nursing Services
Yes $.50-$3/day, depending on payment, up to $50/month Yes Beneficiaries must meet specified level of care criteria Fee for service with annual payment ceiling based on LOC CN & MN
Program of All-Inclusive Care for the Elderly
No
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes 10 hosp leave days/year, 36 therapeutic leave days/year Cost based payment using percentage of charge CN & MN
Inpatient Psychiatric Services, under age 21
Yes Admission Cost based payment using percentage of charge CN & MN
Intermediate Care Facility Services for the Mentally Retarded
Yes 25 hosp leave days/year, 52 therapeutic leave days/year Prospective cost based per diem with limits CN & MN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes 10 hosp leave days/year, 36 therapeutic leave days/year Prospective per diem based on cost, up to Medicare limits CN & MN
Religious Non-Medical Health Care Institution and Practitioner Services
No


Notes: MaineCare is the name of the healthcare program in this State that provides coverage for residents living below the federal poverty level (FPL) as well as others with low-income. The Medicaid program is a part of MaineCare as is the State’s SCHIP, called CubCare, for which some of its members with higher family income are required to make nominal monthly premiums. Maine has also added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997 in a program called Workers with Disabilities. These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits, if their income is at or below 250 percent of the FPL. Beneficiaries in this group with income above 150 percent of the FPL pay an income-based monthly premium. MaineCare beneficiaries may voluntarily enroll in DirigoChoice, a managed care entity, if they work for an eligible business. The State has an approved Section 1115 HIFA Waiver from CMS under which it extended Medicaid eligibility to childless adults with income at or below 125 percent of the FPL. This population receives a limited benefit package under a plan called MaineCare Basic, which places limits on services, such as the number of hospital services per year. The information provided in the tables does not reflect this limited benefit package.
 
 
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