MaineCare Benefits Manual, Proposed Rules

Concise Summary:This proposed rule repeals and replaces the existing Chapters II and III of Section 13, Targeted Case Management Services and Allowances for Targeted Case Management Services, in accordance with the federal mandate. The proposed rule complies with the mandate of the federal Medicaid regulation amendment (see 72 Fed. Reg. 68,077 (Dec. 4, 2007) (Interim final rule, to be codified at 42 C.F.R. Parts 431, 440 and 441) which institutes major changes including restrictive definitions of covered TCM services, and major changes to provider reimbursement and billing. The proposed rule defines TCM covered services; clarifies that MaineCare will not cover duplicative services; and sets forth the eligibility process, and the federal requirement of transitioning to one comprehensive case manager. Chapter III establishes new billing procedure codes based on HIPAA compliant HCPCS coding. Chapter III also implements a change in reimbursement to the Provider/Case Management Agency through the requirement of billing in fifteen (15) minute increments, and also requires comprehensive documentation of services by providers. The Department will comply with all federal noticing requirements to both recipients and providers. The Department is currently working with CMS on a State Plan amendment which will comply with the federal TCM regulation.

Deadline for Comments: Comments must be received by midnight, May 3, 2008.

Concise Summary: The Department of Health and Human Services is proposing changes to Maine Care Benefits Manual, Chapter II, Section 95, Podiatric Services. The proposed rule requires that all podiatric services be prior authorized by the Department or its Authorized Agent. This rulemaking additionally limits coverage of podiatric services to only those members who meet specified medical criteria. The proposed rule eliminates coverage of routine podiatric care and eliminates coverage of bunion surgery. The Department proposes several other structural, administrative and grammatical changes within this rulemaking to make the rule consistent with language in other areas of the MaineCare Benefits Manual (MBM). These changes are required to meet the directive of the Maine State Legislature to cut $232,500 from the general fund per state fiscal year from podiatry services. This proposed rule does not have any adverse impact on small business other than the reductions in covered services as described above.

Deadline for Comments: Comments must be received by midnight, June 9, 2008.

Concise Summary:This rule making proposes to eliminate the language and requirements for Independent Living Assessments as these are no longer done. In addition, changes are proposed to reduce the number of face to face care management visits as well as loosen requirements for home modifications rules. Finally, other minor changes are proposed to make the language consistent with the language in the 1915(c) Federal waiver. Proposed changes will be adopted contingent upon approval by CMS.

Deadline for Comments: Comments must be received by midnight, June 22, 2008.

Concise Summary: The Office of MaineCare Services is proposing changes to the MaineCare Benefits Manual, Chapters II and III, Section 90, Physician Services. The Department proposes an increase to the MaineCare reimbursement rate for physician services from fifty-three percent (53%) to sixty-one and seven tenths percent (61.7%) as of July 1, 2008. In addition to these changes, the Department is proposing to add application of fluoride topical varnish by physicians for members under the age of twenty-one (21) who are at high risk for caries.

Deadline for Comments: Comments must be received by midnight, June 29, 2008.

Concise Summary: The Department of Health and Human Services is proposing changes to Chapter VI, Primary Care Case Management (PCCM). The changes increase the primary care case management fee to $3.50 per member per month. The rule proposes an expansion to PCCM eligibility to include those members with Supplemental Security Income (SSI) who are not eligible for Medicare. The Department added language to sub-section 1.08-2 (o) stating that participating physicians must oversee and manage a care plan for patients who have chronic conditions including but not limited to: Chronic Obstructive Pulmonary Disease (COPD), Asthma, Cardiovascular Disease (CVD), depression and/or diabetes. Some MaineCare members will be exempted from participation, including but not limited to those who are hospitalized (inpatient) on the date they are enrolled, those Native American or Alaskan members who by federal authority may voluntarily opt out of the program, and certain foster children. The Department also proposes that PCCM providers no longer be required to manage audiology, speech and hearing services. The Department has additionally updated language consistent with Chapter I that clarifies care for undocumented aliens. The Department proposes several other structural, administrative and grammatical changes and updates to make the rule consistent with language in other areas of the MaineCare Benefits Manual (MBM). This proposed rule does not have any adverse impact on small business.

Deadline for Comments: Comments must be received by midnight, June 29, 2008.

Concise Summary: The proposed changes require hospitals to report NDC drug utilization to the Department for physician administered drugs, often referred to as "j code" drugs. Hospitals designated as "340 B hospitals" will be exempt from this requirement. The US Centers for Medicare and Medicaid Services (CMS) has required that state Medicaid programs have in place a mechanism for collecting National Drug Codes (NDC Codes) on all physician-administered drugs. The purpose of this requirement is to allow states to continue to collect negotiated rebates from drug manufacturers for drugs paid for by Medicaid programs. The proposed rule will require hospitals to submit quarterly utilization reports of the Medicaid Top 20 Physician-Administered Multiple Source Drugs ("j code" drugs), listed at: http://www.cms.hhs.gov/DeficitReductionAct/Downloads/Top20PhysicianAdministered.pdf.

Deadline for Comments: Comments must be received by midnight August 1, 2008

Concise Summary: The proposed rule consolidates Outpatient Services under one Section of the MaineCare Benefits Manual, ensuring better coordination of services. Emergency Services, which used to be covered as a stand alone service, has been incorporated into Outpatient services. Comprehensive Assessment, which was incorporated into Outpatient Services, is being covered and coded for reimbursement as a stand alone service. This rulemaking also adds proration language for partial months of Children’s Assertive Community Treatment (ACT) in Chapter II. Crisis Services have been renamed and redefined to better reflect current services being provided. Child and Family Behavioral Health Treatment and Community Based Treatment for Children Without Permanency have been merged into one service and renamed Children’s Home and Community Support Services for better coordination. Collateral contacts have also been added as a stand alone service for children who receive Children’s Home and Community Support Services. Independent providers not employed by a Mental Health Agency will be able to provide within the scope of their licensure and be reimbursed for services provided to MaineCare members. Additionally, the Chapter III of this new Section will contain HIPAA compliant coding. Other than providers of these specific services, this rule is not expected to fiscally impact or create new recording burdens for other small businesses and is not expected to yield new costs for municipal or county governments.

Deadline for Comments: Comments must be received by midnight August 21, 2008