Certified Seed Forms for Mainecare


TO: Superintendent of Schools, Business Managers, CDS Regional Boards of Directors, CDS Regional Site Directors
FROM: Angela Faherty, Ph.D., Acting Commissioner
DATE: July 9, 2010
RE: Certified Seed Forms for Mainecare

On a yearly basis, CDS regional sites and school administrative units need to complete certified seed forms for the Department of Health and Human Services Mainecare program. The Department of Health and Human Services is implementing a new data system as of September 1, 2010. Because of the new data system, this year each unit will need to complete two forms, one covering July 1, 2010 to August 31, 2010, and a second form covering September 1, 2010 to June 30, 2011.

Form #1 Contained in This Letter
The Department of Health and Human Services is requiring that both the Superintendent of schools and a representative of the Department of Education sign the form covering July 1, 2010 to August 31, 2010. Each Superintendent must print out and complete the form that is contained in this letter, sign the form and send it to Jaci Holmes, State House Station 23, Augusta, Maine 04333-0023.

Form #2 Covering September 1, 2010 to June 30, 2011
The second form can be accessed at: http://www.maine.gov/education/medicaid/index.html

The following instructions for completing this form were developed by Mainecare, are replicated here and are contained on the second Certified Public Expenditures Agreement form.  

This  form only applies to providers enrolled in MIHMS under the following provider types:
87 – Public School
88 – Special Purpose Private School
89 – Intermediate Education Unit
90 – Government Agency

I.) You will need to complete a separate form for each NPI number and/or service location ID that you have enrolled in MIHMS.
When  it asks for the service location ID for any applicable locations of the Provider, these numbers should have been provided to you in the welcome letter upon enrollment in MIHMS.

II.) The Certified Seed Amount is the amount of your special education budget that pertains to services provided to Mainecare eligible clients/students.
Attention Schools!
A simple calculation for this would be to subtract out any personnel or building related costs from your special education budget, then take that number and multiply it by the percentage of students you know to be Mainecare eligible to get your final seed number.

III.) Have an authorized official, i.e. superintendent, director, certify the funds by providing their name, title, signature and the date.

IV.) Finally, fax the form to the number provided.”

The Departments of Education and Health and Human Services will be providing a joint conference call to provide guidance on how to complete the second form on   July 16, 2010 from   9 to 10 AM.

Call in number: 1-888-560-3504 (Corrected Number)
Passcode: 179040

Please fax the second form directly to Mainecare at 1-877-314-8776.

If you have questions, please call Jaci Holmes, Federal State Legislative Liaison at 624-6669.

Form for July 1, 2010-August 31, 2010
Department of Health and Human Services
Financial Services
11 State House Station
Augusta, Maine  04333-0011
Tel: (207) 287-3161; Fax: (207) 287-1862

TTY: 1-800-606-0215



for Targeted Case Management, Day Treatment, Ambulatory Care Clinic, and School Based Rehabilitative Service Providers

I certify that                                                                                                                                          has Public funds in the amount of  $                                 to provide services to MaineCare eligible clients for the period
July 1, 2010 through August 31, 2010.  These public funds will be used solely to provide services under (select one)

    Section 13 of the MaineCare Benefits Manual – Targeted Case Management Services
    Section 41 of the MaineCare Benefits Manual – Day Treatment Services
    Section 104 of the MaineCare Benefits Manual – School Based Rehabilitative Services
    Section 3 of the MaineCare Benefits Manual – Ambulatory Care Clinics

and are not used as matching public funds to receive federal financial participation in any other Service area.
Public Funds Provided by:                                                                                           
Print Name & Title of Individual Signing Below:                                              
Signature:                                                                                 Date:                                     
I certify that when                                                                                                                                             has billed MaineCare in the amount of $                                                , (amount entered on this line is equal to the amount entered above divided by 0.2514) further MaineCare billing from this provider shall cease until such time that additional public funds are available and certified.

Print Name & Title of Individual Signing Below:                                                                      

Provider ID:  

Signature:                                                                                  Date:                                                

Mail/Fax Forms to Attention: Natalie Bragan
Or Email Forms to: natalie.bragan@maine.gov

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