Subsection 144-101-I-1.09 - COPAYMENT A copayment will be charged to each MaineCare member each time certain MaineCare services are provided if stipulated in the Chapter and Section of this Manual covering those services. If a section does not specify that copays be charged, no MaineCare copayment is collected from MaineCare members for services provided under that section. If a copayment is required, the exact amount of the copayment shall be as specified in the MBM that covers the specific service provided.
1.09-1Copayment AmountThis section supplements the copayment information included in all sections of Chapter II of the MBM, except in those sections where additional provisions are specifically noted.
A. The member shall be responsible for copayments up to the limit per month specified in the section of Chapter II covering the particular service, whether the copayment has been paid or not. The limit may vary, depending upon the service type. After the monthly cap has been reached, the member shall not be required to make additional copayments and the provider shall receive full MaineCare reimbursement for covered services.B. No provider may deny services to a member for failure to pay a copayment. Providers must rely upon the member's representation that he or she does not have the money available to pay the copayment. A member's inability to pay a copayment does not relieve him/her of liability for a copayment.C. Providers are responsible for documenting the amount of copayments charged to each member regardless of whether the member has made payment.1.09-2Copayment ExemptionsNo copayment may be imposed with respect to the following services:
A. Family planning services and supplies;B. Services furnished to members under twenty-one (21) years of age;C. Services furnished to any individual who is an inpatient in a hospital, skilled nursing facility, nursing facility, ICF/IID, or other medical institution, or a resident of a private non-medical institution, if that individual is determined by the Department to be responsible, as a condition of receiving services in that institution, to have an "assessment" or a "cost of care." Cost of care is defined in the MaineCare Eligibility Manual and is not waived or affected by any of these exemptions;D. Services and drugs furnished to pregnant women, including services and drugs provided during the three (3) months following the end of a pregnancy;E. Services received under the Limited Family Planning Benefit;F. Members in State custody;G. Services provided in Indian Health Service Centers and services for Native American members who are eligible to receive services funded by Contract Health Services. H. Members under State guardianship;I. Members receiving Hospice Services;J. Emergency services as defined in Chapter I, Section 1.02.4(B) of this Manual;K. Tobacco cessation services and products;L. Members whose monthly copayment sum has totaled five percent (5%) of their monthly income;M. Any additional exceptions listed in specific sections of Chapter II of this Manual. Providers are responsible for verifying copayment responsibility by calling Provider Services or other means made available by the Department.
For billing instructions for copayment exemptions, see the specific section in Chapter II of the MBM under which services are provided.
1.09-3Copayment DisputesProviders must notify members of their right to dispute copayments. If a member believes that he or she is exempt from a copayment, disputes the amount of the copayment, or has been denied a service for failure to make a copayment, he or she may contact the Department for assistance in resolving that dispute. Complaints should be directed to the Director, MaineCare Services, 11 State House Station, Augusta, Maine 04333-0011.
C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.09