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A Joint Project of the Maine
Association of Interdependent Neighborhoods |
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Volume 9 No. 2 |
August 2005 |
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MAIN
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A Joint Project of the Maine
Association of Interdependent Neighborhoods |
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Volume 9 No. 2 |
August 2005 |
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MEJP Files Court Cases
to Improve Access to MaineCare BenefitsPrescription Drug Prior Authorization Hearing Delays
Morse v. Commissioner, Maine Department of Health and Human Services (DHHS)
Long delays in MaineCare prescription drug prior authorization appeals should now be over, thanks to a recent settlement of a lawsuit brought in federal court by Jack Comart, MEJP Litigation Director. MEJP’s client, Ms. Morse, had waited over 10 months for a fair hearing. She was appealing a MaineCare decision denying her the prescription drug which her doctor had prescribed for her. MEJP sued DHHS, arguing that, under federal law, MaineCare hearing decisions must be made within 90 days of when the person appeals. The Department settled the case, agreeing to a number of changes in the appeals process to assure that hearings are completed within the 90-day limit. DHHS will be providing quarterly reports to MEJP so we can monitor compliance with the Court Order.
MaineCare Eligibility Requirements for Women with Breast or Cervical Cancer
Gilbert v. Commission, Maine Department of Health and Human Services (DHHS)
MEJP has filed suit to challenge problems with Maine’s Breast and Cervical Health Program (MBCHP). MEJP’s client was diagnosed with breast cancer. She is 38. She was denied MaineCare by MBCHP, a program of the Maine Bureau of Health at DHHS, because they said that they do not provide breast or cervical cancer screening services or MaineCare to women under age 40.
MEJP’s lawsuit seeks to force MBCHP to adopt rules, provide due process rights to applicants and to make sure that eligible women are able to get MaineCare, even if they don’t qualify for MBCHP’s screening program. The suit also seeks to make sure that when a woman with breast or cervical cancer goes to the local MaineCare office, or fills out a MaineCare application, that she is screened for MaineCare eligibility based on her cancer diagnosis.
The MBCHP Screening Program provides breast and cervical cancer screening for women who:
are age 40 through 64 (or over 64, if not enrolled in Medicare Part B);
have income up to 250% of the federal poverty guidelines; and
do not have adequate health insurance.
If a woman meets these standards and goes to an approved screener then the program will pay for the screening services.
MBCHP contracts with 128 primary care approved screener sites around the state to offer annual breast and pelvic exams, mammograms and Pap tests, as well as follow-up tests to diagnose cancer. If the woman is diagnosed with breast or cervical cancer, then MBCHP automatically enrolls her in MaineCare.
The screening program is funded largely by federal funds from the Centers for Disease Control. The state also contributes funds to this program. The program has operated without any duly promulgated rules and MBCHP does not have an appeals process, if applicants are denied services.
MaineCare Coverage for Women Diagnosed with Breast or Cervical Cancer
Women who are diagnosed with breast or cervical cancer are eligible for MaineCare if:
they have been diagnosed with breast or cervical cancer by one of the 128 primary care sites that contracts with MBCHP; and
they don’t have adequate health insurance; and
they are under age 65
There are no income or asset limits for women in this eligibility group.
The problem is that if a woman under age 40 or over 250% of poverty goes to MBCHP, she is told she is not eligible for services. She is not told that, even though she is ineligible for MBCHP screening, that she might be eligible for the MaineCare program. Likewise, if someone diagnosed with breast or cervical cancer contacts a DHHS MaineCare office directly, instead of through MBCHP, the current MaineCare system does not let the woman know that MBCHP exists or even that she may be eligible for MaineCare because of the diagnosis!
More information about MBCHP or call DHHS at 1-800-350-5180 (TTY: 1-207-287-8015).If you have been diagnosed with breast or cervical cancer and have questions about your
eligibility for MaineCare, call Crystal Bond at MEJP, 1-866-626-7059, ext. 205.
