Highlight on Maine: Maine Tightens TANF Benefits with Drug Test Enforcement

By Lisa A. Weder

In a push to make Maine’s residents more self-sufficient, Governor Paul R. LePage (R-Me.) says it’s time to enforce a drug testing law on convicted drug felons who receive or apply for welfare benefits. On Wednesday, August 6, 2014, the former businessman turned governor announced that the Maine Department of Health and Human Services (Maine HHS) will carry out its plans to drug test those felons who receive Temporary Assistance for Needy Families (TANF) benefits.

TANF benefits are funded under Part A of Title IV of the Social Security Act (SSA), as amended by sec. 5507 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), which awards states grant funding to provide health services and education and job training to low-income individuals. TANF benefits are designed to:

  • Assist needy families in ways that children can be cared for in their own homes;
  • Promote job preparation, work, and marriage to foster independence in needy parents;
  • Prevent and reduce out-of-wedlock pregnancies; and
  • Encourage the formation and maintenance of two-parent families.

Welfare reform was a large part of Maine’s 2012-2013 budget, which implemented a new five-year limit on welfare benefits. The governor’s reasoning for instituting the drug-testing policy revolves around spending tax dollars wisely. “Maine people expect their tax dollars to be spent supporting our most vulnerable citizens—children, the elderly and the disabled,” said LePage. “We must ensure that our tax dollars do not enable the continuation of a drug addiction.” The thought is that someone using drugs will misspend TANF assistance funding and put their family’s needs on the back burner. The governor asserts that being drug-free enables welfare beneficiaries to move away from poverty and toward financial independence.

Maine HHS has implemented its drug-testing procedures and program with best practices, privacy, fairness, and accountability in mind, according to Maine HHS Commissioner, Mary Mayhew. When a person applies for TANF benefits, the individual must indicate whether he or she has a prior drug-related felony conviction. If that is the case, the state will schedule a drug test and notify the person 24 hours prior to the actual test. A person testing positive the first time can take the test one more time. According to Maine’s state website, a first offense results in the termination of adult benefits, and a second offense may result in the family’s loss of benefits. The tests are funded by the state.

To avoid termination of welfare benefits, an afflicted individual may enroll in an HHS-approved substance abuse program. Persons failing to disclose that they are convicted drug felons violate the program rules and face immediate termination of TANF benefits.

Maine’s new rule was originally introduced in 2011, but becomes effective October 1, 2014. Some question why the governor is enforcing the policy now in light of the fact that Maine is ranked 47th in terms of job creation. Portland, Maine’s local news channel, WCSH6, interviewed Democratic political analyst Ethan Strimling who said that “ … in terms of getting people off welfare, it’s not going to do us much good.” The policy will be published in August 2014 and will be subject to a public hearing and final approval by the Attorney General’s office.

The question yet to be answered is whether Maine’s drug testing policy will help or hinder families receiving TANF benefits.

Refuse to Buy Subsidized Coverage? No Charity Care for You.

Some hospitals are toying with the idea of scaling back their charity programs in response to worries that providing free or discounted care to patients with low incomes and no insurance may dissuade them from purchasing government-subsidized health insurance through the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) Health Insurance Exchanges, according to a report by Kaiser Health News (KHN).

Charity Care Policies

While the ACA requires that hospitals make their written charity care policies widely available, it does not impose any specific requirements as to eligibility for such programs.

According to the charity care policy posted online by Southern New Hampshire Medical Center, “[A]pplicants who refuse to purchase federally-mandated health insurance when they are eligible to do so will not be awarded charity care.” The policy also cuts off charity care for those who choose not to apply for the state’s Medicaid expansion program.

Alternatives to Limiting Charity Care

While some hospitals are enacting restrictions like this one, others are choosing simply to require patients to make a contribution toward the services received, such as $100 for emergency care.

“Patients will continue to receive needed medical care regardless of their ability to make payment at the time of service,” Kim Kitson, spokeswoman for Barnes Jewish Hospital in St. Louis told KHN. The hospital provides discounts for patients with incomes up to three times the federal poverty level.

Considerations for Hospitals

In evaluating possible changes to their charity policies, hospital executives must also weigh whether patients are unwilling to pay or if they could not afford purchasing coverage even with a government subsidy. Ultimately, though, KHN reports that hospitals have a strong interest in having more insured patients, especially since the ACA cuts government payments to providers for uncompensated care.

Todd Nelson of the Healthcare Financial Management Association told KHN, “Hospitals have always encouraged patients to apply for coverage they are entitled to receive, whether commercial insurance through employer or through programs like Medicaid.”

‘Terminal Illness’ Definition Stays Alive

In an advance release of its final rule on the 2015 payment rate and wage index for hospices, CMS opted not to adopt changes to the definitions of “terminal illness” and “related conditions” in the context of the Medicare hospice benefit.

As reported last week, the final rule, which is scheduled to be published in the Federal Register on Aug. 22, CMS adopts the payment and wage index adjustments that were disclosed in the May 8 proposed rule and analyzes hospice payment reform.

The proposed rule also invited public comments on the broader definitions of “terminal illness” and “related conditions” it set forth to be adopted in possible future rulemaking.

Organizations Weigh In

Several organizations chimed in with their thoughts and suggestions. For example:

  • In its comment letter to CMS, the Society for Post-Acute Care and Long-Term Medicine (AMDA) expressed its concern about the terminal illness definition’s focus on disease, stressing that “Abnormal and advancing physical, emotional, social and/or intellectual processes” is the same as “disease.” According to AMDA, removing “abnormal” from the phrase would ensure that frailty, a result of the aging process that is linked to depression and mortality, is included in the definition.
  • The National Association for Home Care & Hospice (NAHC) wrote a letter to CMS questioning whether the new definitions are needed. NACH also took issue with the proposed rule’s definition of related conditions as those that “interact or potentially interact with terminal illness; and/or which are contributory to the symptom burden of the terminally ill individual.” The association noted that this might imply hospices are responsible for all of a patient’s conditions.
  • In its letter to CMS, the Visiting Nurse Associations of America (VNAA) noted that the broader definitions in the proposed rule are unnecessary and perhaps too complex. The organization urged CMS to instead retain the existing Social Security Act definitions of the terms and to “convene a panel of interdisciplinary clinical experts, including hospice clinicians practicing in the field, to develop a consensus definition” the terms.
  • Leading Age, an association of not-for-profit organizations, submitted comments on the proposed “related conditions” definition. Specifically, the association asked CMS to clarify that longstanding and/or preexisting conditions are excluded from the definition. It also suggested excluding “comorbidies that do not have a direct causal connection to the illness that contributed to the prognosis that the individual has a life expectancy of six months or less.”

Future Changes Possible

Despite the concerns raised by these and other organizations, CMS has not incorporated any changes to the definitions in the final rule. The agency acknowledged receiving “a significant number of comments representing diverse stakeholder groups” but noted that it will consider them later, for “possible future rulemaking.”

AHA Looks Through Congress Towards CMS, Urges Transparency

The American Hospital Association (AHA) wrote a letter encouraging members of the Senate to increase access to health care data while maintaining patient privacy and the security of patient information. The letter seeks to uncover the currently unavailable wealth of CMS data, which AHA says can be used to improve upon the quality and value of health care. Through measures that are targeted at CMS, AHA believes data sets can be made into accessible, practical, and efficient tools for research and progress.


The letter focuses on Medicare claims data that CMS, at present, makes only partially available. AHA recommends that CMS be required to make data from across the continuum of care accessible, so that opportunities for improvement in the quality of care can be identified for the whole continuum of care. To effectuate that goal, AHA says that the Part B Carrier and the Part B Durable Medical Equipment limited data set (LDS), the standard analytic files (SAF), and the Part D prescription drug data should be made accessible to interested parties and researchers. Part of the AHA recommendation is to have CMS streamline current practices. For example, AHA suggests that the access to research identifiable files (RIFs) be simplified from the current system, which requires a review board approval for each project, to a system where researchers are granted a “one-time clearance” from the review board for a specified period of time.


The AHA also expresses in the letter its support for initiatives to improve price and quality transparency among providers. For example, the letter indicates AHA’s support for the Health Care Price Transparency Promotion Act (H.R. 1326), which would impose a requirement on states to have or establish laws requiring hospitals to disclose price data for certain services.As part of its involvement in a Healthcare Financial Management Association (HFMA) report, which the AHA attached to its letter, the AHA identified that health plans are best situated to pass along pricing data to insured patients. In keeping with that understanding, the letter recommends to congress that health plans should be the primary source of pricing information for insured patients. AHA also recommends that CMS publish additional quality data while maintaining awareness about the comparative usefulness and relevance of the data it provides.


In a separate section, the AHA sets out several cautionary statements regarding the need for prudence as data access grows. The letter emphasizes that “caution must be exercised to ensure privacy and security is maintained.” The AHA letter includes a reminder to congress that de-identified data can be reconnected to individuals with relative ease. In light of the ease of extrapolating protected information from health care data, the letter urges congress to exercise a heightened level of caution when considering making information available to entities that are not considered covered entities under the Health Insurance Portability and Accountability Act (HIPAA) (P.L. 104-191).