§ 22 §14 — Action against parties liable for medical care rendered to assistance recipients; assignment of claims

1.
Recovery procedures.
When benefits are provided or will be provided to a member under the MaineCare program administered by the department pursuant to the United States Social Security Act, Title XIX, including any prescription drug programs administered under the auspices of MaineCare, referred to collectively in this section as MaineCare, 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 cost of the benefits provided. This right of recovery is separate and independent from any rights or causes of action belonging to a member under the MaineCare program. For MaineCare recipients who participated in the MaineCare managed care program, "cost" means the total value of coverable medical services provided measured by the amount that MaineCare would have paid to providers directly for such services, were it not for the managed care system. The MaineCare program is the payor of last resort and 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.
2.
Condition for eligibility.
2-A.
Assignment of rights of recovery.
The receipt of benefits under the MaineCare program 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.
2-B.
Direct reimbursement to health care provider.
When an insured is eligible under the MaineCare program for the medical costs 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.
When an insured is eligible under the MaineCare program 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 insurance policy, the insurer shall directly reimburse the Department of Health and Human Services for any medical services paid by the department on behalf of a recipient under the MaineCare program to the extent that those medical services are payable under the terms of the insurance policy. If the insurer knows or has information upon which to reasonably conclude that the insured is a recipient of MaineCare services, the insurer shall advise the department in writing as to the existence of the claim prior to any other payment.
2-D.
Notification of claim.
A recipient under the MaineCare program, or any agent, representative or attorney representing a recipient under the MaineCare program, 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 MaineCare program shall notify the department in writing prior to settlement negotiations and provide information required by the department of the existence of the claim. If the notice is not given and the department's ability to recover for benefits paid is compromised, the department may institute legal proceedings against a recipient, including the agent, representative or attorney of that recipient, who has received a settlement or award from a 3rd party. The department may accept a letter of MaineCare claim protection in lieu of this section.
2-E.
Notification of pleading.
In an action to recover the medical cost of injury, disease, disability or similar occurrence for which the party received medical benefits under the MaineCare program, the party bringing the action shall notify the department of that action at least 10 days prior to filing the pleadings. The notification must provide timely opportunity for the department, at its discretion, to intervene in all actions as an interested party. If adequate opportunity to intervene is not given and the department’s ability to recover for benefits paid is compromised, the department may institute legal proceedings against a recipient, including the agent, representative or attorney of that recipient, who has received a settlement or award from a 3rd party. The department may accept a letter of MaineCare claim protection in lieu of intervention. 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.
2-F.
Disbursement.
Except as otherwise provided in this subsection, a disbursement of any award, judgment or settlement may not be made to a recipient without the recipient or the recipient's attorney first paying to the department that amount of the award, judgment or settlement that constitutes reimbursement for medical payments made or obtaining from the department a release of any obligation owed to it for medical benefits provided to the recipient. If a dispute arises between the recipient and the commissioner as to the settlement of any claim that the commissioner may have under this section, the 3rd party or the recipient's attorney shall withhold from disbursement to the recipient an amount equal to the commissioner's claim. Either party may apply to the Superior Court or the District Court in which an action based upon the recipient's claim could have been commenced for an order to determine a reasonable amount in satisfaction of the statutory lien, consistent with federal law.
2-G.
Claims against estates of certain Medicaid recipients.
2-H.
Honoring of assignments.
The following provisions apply to claims for payment submitted by the department or a health care provider.
2-I.
Claims against estates of MaineCare recipients.
Claims against the estates of MaineCare recipients are governed by this subsection.
2-J.
Authority to contract for attorney services.
The department is authorized to pursue rights under this section, including 3rd-party reimbursement of MaineCare costs in workers' compensation claims cases, through contracted attorney services. The department may adopt rules as necessary to implement this subsection. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A.
3.
Definitions.
For purposes of this section, "3rd party" or "liable party" or "potentially liable party" means any entity, including, but not limited to, any health insurer as included in 42 United States Code, Section 1396a(a)(25)(I) and any other parties that are, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, 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 the MaineCare program. For purposes of this section and sections 18 and 19, an "insurance carrier" includes, but is not limited to, health insurers, group health plans as defined in 29 United States Code, Section 1167(1), service benefit plans and health maintenance organizations, as well as any other entity included in 42 United States Code, Section 1396a(a)(25)(I).

Legislative History

PL 1979, c. 145 (NEW). PL 1979, c. 610, §§1,2 (AMD). PL 1981, c. 24, §§1,2 (AMD). PL 1981, c. 698, §92 (AMD). PL 1987, c. 203 (AMD). PL 1987, c. 621 (AMD). PL 1989, c. 397, §2 (AMD). PL 1989, c. 778, §§1-3 (AMD). PL 1991, c. 9, §§N1-6 (AMD). PL 1991, c. 815, §1 (AMD). PL 1993, c. 410, §§I2,3 (AMD). PL 1993, c. 707, §I1 (AMD). PL 1995, c. 462, §§D2,3 (AMD). PL 1997, c. 395, §E1 (AMD). PL 1997, c. 795, §§1-4 (AMD). PL 1999, c. 483, §§1,2 (AMD). PL 1999, c. 668, §§94-99 (AMD). PL 1999, c. 731, §§TT1-6 (AMD). PL 2003, c. 20, §K2 (AMD). PL 2003, c. 689, §B6 (REV). PL 2005, c. 12, §DDD9 (AMD). PL 2005, c. 12, §DDD17 (AFF). PL 2007, c. 240, Pt. JJJ, §§1-4 (AMD). PL 2007, c. 311, §1 (AMD). PL 2007, c. 381, §§1-4 (AMD). PL 2007, c. 423, §1 (AMD). PL 2007, c. 448, §§7-9 (AMD). PL 2007, c. 448, §14 (AFF). PL 2009, c. 150, §3 (AMD). PL 2017, c. 402, Pt. C, §§41, 42 (AMD). PL 2017, c. 402, Pt. F, §1 (AFF). PL 2019, c. 348, §2 (AMD). PL 2019, c. 417, Pt. B, §14 (AFF). PL 2023, c. 162, §1 (AMD).