Subsection 144-101-II-7.05 - LIMITATIONSMaineCare reimburses free-standing dialysis services as composite or non-composite services, patterned after the Medicare Policy Benefits Manual, Chapter 11: http://www.cms.hhs.gov/manuals/Downloads/bp102c11.pdf and any successor documents. This reference details drugs and laboratory tests considered composite and non-composite and the expected frequency for each dialysis method. MaineCare will only reimburse home-based dialysis by the composite methodology.
The following limitations apply for all services under this Section:
1. Composite reimbursement covers all routine personnel, drugs, laboratory tests, supplies and services associated with routine dialysis. 2. Non-composite or non-routine dialysis items or services as defined by Medicare include selected drugs, laboratory tests, blood and supplies that may be billed according to requirements in other sections of MaineCare policy, but on the same bill as the services included in the composite package. 3. Frequency of services must be consistent with the Medicare Policy Benefits Manual, Chapter 11 - Section 30.1.4. Other drugs- MaineCare covers certain other drugs, such as epoetin alfa, outside of the composite rate when documented as medically necessary in relation to dialysis. 5. Medicare Part D- MaineCare will not cover drugs covered by Medicare Part D for those members who are eligible for Medicare Part D. The Department may automatically enroll such eligible MaineCare members without creditable coverage into Medicare Part D, and act as an authorized agent on their behalf. The Department will reimburse Medicare Part D Excluded Drugs for members dually eligible for Medicare Part D when those drugs are otherwise covered by MaineCare. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-7, subsec. 144-101-II-7.05