MaineCare Eligibility

Overview

In addition to the clinical data feeds received from HIE-participating organizations, HealthInfoNet also receives a daily member eligibility file from the Office of MaineCare Services (MaineCare) that identifies MaineCare (Medicaid) members so that reporting can be stratified to meet precise workflow needs.

Eligible Members & Eligible Encounters

On each reporting dashboard, there are two filter options to help users identify their attributed patients who are covered by MaineCare (Medicaid) insurance.

Filter

Description

MaineCare Eligible Member

The indication of whether a user’s attributed patients are active, eligible MaineCare (Medicaid) members at the time of reporting per MaineCare’s daily member eligibility file.

Valid values include Yes (i.e., patients that are active, eligible MaineCare members) and No (i.e., patients that are not active, eligible MaineCare members).

Additional Note: Should a patient’s MaineCare eligibility status vary over the course of the 365-day encounter lookback period, only those patients who are active, eligible members at the time of reporting will be reported using this filter option.

MaineCare Eligible Encounter

For non-utilization reporting dashboards:

The indication of whether a user’s attributed patients have had a MaineCare- (Medicaid-) eligible encounter in the last 365 days, regardless of whether the patients are currently active, eligible Medicaid members per MaineCare’s daily member eligibility file.

Valid values include Yes (i.e., patients that had a MaineCare-eligible encounter) and No (i.e., patients that did not have a MaineCare-eligible encounter).

For utilization reporting dashboards:

The indication of whether encounters had by a user’s attributed patients in the last 365 days were rendered at the time when the patients were active, eligible MaineCare (Medicaid) members per MaineCare’s daily member eligibility file.

Valid values include Yes (i.e., MaineCare-eligible encounter) and No (i.e., non-MaineCare eligible encounter).

Additional Notes:

Should a patient’s MaineCare eligibility status vary over the course of the 365-day encounter lookback period, only those encounter records with admission dates coinciding with their active eligibility status will be reported using this filter option.
Should a patient’s MaineCare eligibility status retroactively change over the course of the 365-day encounter lookback period, per updates in MaineCare’s daily member eligibility file, reporting will refresh accordingly to add/remove encounter records with admission dates coinciding with their revised active eligibility status.

For MaineCare staff users, the only attributed patients that are available for reporting purposes are those who have had a MaineCare (Medicaid-) eligible encounter in the last year: MaineCare Eligible Encounter = Y. Reporting can then be further stratified to identify only those attributed patients who are active, eligible MaineCare (Medicaid) members at the time of reporting per MaineCare’s daily member eligibility file: MaineCare Eligible Member = All, Y, or N. This view of attributed patients is aligned with prior reporting provided to the Office of MaineCare Services through the MaineCare Analytics Platform (MAP).

Since both the MaineCare Eligible Member and MaineCare Eligible Encounter filter options exist on each reporting dashboard, the table below translates how to use the filters together and/or independently.

MaineCare Eligible Member	MaineCare Eligible Encounter	Outcome
All	All	Shows information for a user’s attributed patients regardless of Medicaid eligibility criteria.
All	Yes	Shows information for only a user’s attributed patients who had a Medicaid-eligible encounter in the last 365 days, regardless of whether the patients are currently active, eligible Medicaid members per MaineCare’s daily member eligibility file.
All	No	Shows information for only a user’s attributed patients who did not have a Medicaid-eligible encounter in the last 365 days, regardless of whether the patients are currently active, eligible Medicaid members per MaineCare’s daily member eligibility file.
Yes	All	Shows information for only a user’s attributed patients who are active, eligible MaineCare (Medicaid) members at the time of reporting per MaineCare’s daily member eligibility file.
Yes	Yes	Shows information for only a user’s attributed patients who are active, eligible MaineCare (Medicaid) members at the time of reporting per MaineCare’s daily member eligibility file and who had a Medicaid-eligible encounter in the last 365 days.
Yes	No	Shows information for only a user’s attributed patients who are active, eligible MaineCare (Medicaid) members at the time of reporting per MaineCare’s daily member eligibility file and who did not have a Medicaid-eligible encounter in the last 365 days.
No	All	Shows information for only a user’s attributed patients who are not active, eligible MaineCare (Medicaid) members at the time of reporting per MaineCare’s daily member eligibility file.
No	Yes	Shows information for only a user’s attributed patients who are not active, eligible MaineCare (Medicaid) members at the time of reporting per MaineCare’s daily member eligibility file but who had a Medicaid-eligible encounter in the last 365 days.
No	No	Shows information for only a user’s attributed patients who are not active, eligible MaineCare (Medicaid) members at the time of reporting per MaineCare’s daily member eligibility file and who did not have a Medicaid-eligible encounter in the last 365 days.