Maine ME
ME Medicaid (MaineCare): FFS-only with PCCM (Primary Care Case Management) for assigned members. No comprehensive risk-based MCO program. PA goes through Office of MaineCare Services (OMS) via MIHMS. Behavioral Health Homes (BHHs) provide care coordination. Pharmacy is state-administered. NOT a WISeR pilot state. Cub Care = ME's CHIP brand.
ME Medicaid (MaineCare): FFS-only with PCCM (Primary Care Case Management) for assigned members. No comprehensive risk-based MCO program. PA goes through Office of MaineCare Services (OMS) via MIHMS. Behavioral Health Homes (BHHs) provide care coordination. Pharmacy is state-administered. NOT a WISeR pilot state. Cub Care = ME's CHIP brand.
Who administers prior authorization in Maine
Structural facts on file
MaineCare is FFS-only (no comprehensive risk MCO; PCCM only). PA criteria are NOT in a portal — they live as binding RULE TEXT inside the MaineCare Benefits Manual (MBM = Code of Maine Rules 10-144 Ch. 101), published by the Secretary of State as per-section .docx files at maine.gov/sos/cec/rules/10/ch101.htm. Three chapters: Ch. I = General Administrative Policies & Procedures (Sec. 1 contains the canonical, cross-service PRIOR AUTHORIZATION provisions, 32 PA references), Ch. II = Covered Services (each service section, e.g. Sec. 60 DME, embeds its own 'PRIOR AUTHORIZATION REQUIREMENTS' subsection), Ch. III = Allowances/fee schedules. Authority = DHHS Office of MaineCare Services (OMS); claims via MIHMS; provider/fiscal-agent help desk is now Gainwell Technologies. UM contractor (Kepro/Acentra) performs reviews but the BINDING criteria are the MBM rule text. Pharmacy PA is fully state-administered via the PDL at mainecarepdl.org (Optum/Change Healthcare-hosted): PDL workbook, per-drug PA forms, DUR. NO managed-care delegation, NO per-MCO PA. Operational shape = FFS rule-manual state, pharmacy carved to state PDL vendor.
Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.
Last award: 2008-05-01. Next due: ?. Contracts extended through: None.
status=partial
## 1. How ME requires PA Maine's Medicaid program, MaineCare, operates under a FFS-only model with no comprehensive-risk MCO. Prior Authorization (PA) requirements are embedded within the MaineCare Benefits Manual (MBM), published by the Secretary of State as per-section files. The MBM serves as the binding rule text for PA criteria. For specific services, detailed PA/medical-necessity criteria appear in respective MBM sections: - **Pharmacy**: co-payments waived; medical necessity required (PDL applies — minimum two-week trial for most drugs, step-therapy, documentation of dose titration and adverse-effect management; non-preferred drugs require failure/intolerance to preferred drugs). - **Power Wheelchairs (PWCs)**: medical necessity documented by a physician; step-therapy may be required. - **Home Health Services**: requires a face-to-face encounter within the eligibility period, with frequency/duration documented in the plan of care. - **Occupational Therapy Services**: covered for medically necessary treatment following acute hospital stays, post-surgical procedures, or terminal illness; documentation must include rehabilitation potential and pain-management plans. ## 2. How ME publishes and reports PA MaineCare's PA criteria are published within the MaineCare Benefits Manual (MBM), available on the Secretary of State's website (`maine.gov/sos/cec/rules/10`). The MBM is structured into chapters and sections, with each service/drug category carrying its own PA requirements. The state does not have a fully centralized PA portal; criteria are embedded within MBM documents, which are updated periodically without real-time online PA-status access. Effective dates vary by section. ## 3. ME's CMS-0057-F and PA-reform compliance posture MaineCare's CMS-0057-F compliance is not explicitly detailed in the source documents. Relevant structure includes a behavioral-health (BH) carve-out to a state ASO (Administrative Services Organization) and two 1115 waivers (one for individuals with HIV/AIDS and one for an SUD Care Initiative), which may carry waiver-specific PA requirements. Maine is **not** a WISeR state. (WISeR = the federal "Wasteful and Inappropriate Service Reduction" Medicare prior-authorization model, which applies only to AZ, NJ, OH, OK, TX, and WA — not Maine.) No WISeR participation should be inferred for ME. ## 4. How ME runs its own program MaineCare operates under a FFS-only model with specific carve-outs and waivers: - **Behavioral Health (BH) Carve-out**: Behavioral health services are managed by a state ASO, which handles PA for these services. - **1115 Waivers**: Two active 1115 waivers provide specialized care (HIV/AIDS; SUD Care Initiative), with their own PA processes. The fiscal-agent history shows transitions from ACS-Inc to Conduent/Gainwell, which does not change the core PA criteria in the MBM. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Embedded PA Criteria**: PA requirements are embedded within the MaineCare Benefits Manual rather than a centralized portal. - **Behavioral Health Carve-out**: BH services have an ASO-managed PA process, separate from the main FFS program. - **1115 Waivers**: Two 1115 waivers with specialized care and potentially unique PA requirements. ### Missing/Uncertain: - **Centralized Portal**: No fully centralized PA portal; real-time PA status/outcome access is limited. - **Foster Care MCO Program**: None mentioned (consistent with the FFS-only model). - **Gold Card Law**: Specific provisions unspecified in the source documents. These gaps highlight where further research or clarification from state agencies would help.