2012 DHHS Supplemental Budget Notice

March 16, 2012

Effective April 1, 2012, there will be changes to MaineCare services and reimbursement. These changes are required as part of the Department of Health and Human Services’ Supplemental Budget, which was signed by Governor LePage on February 26, 2012. PUBLIC Law, Chapter 477, LD 1816, 125th Maine State Legislature. The changes are outlined below.

Many of the changes listed below will be implemented through an emergency rulemaking. These rules will be effective April 1, 2012. You can find copies of the emergency rules after April 1, 2012 by going to the link posted below and clicking on emergency: .

The emergency rule will not be available until March 31, 2012.

MCBM, Section 2, Adult Family Care Services

There will be a 10% rate reduction for Adult Family Care services.

MCBM, Section 15, Chiropractic Services

MaineCare Services will reimburse up to a strict limit of twelve (12) visits per rolling year for members who are twenty-one (21) and over.

MCBM, Section 60, Durable Medical Equipment (DME)

Eliminate Sales Tax: The Department will discontinue reimbursing for sales tax for DME supplies. Providers should no longer use the S9999 billing code.

MCBM, Section 65, Behavioral Health Services

Transition Clinical Services in Section 65: Behavioral Health Agencies that do not employ a medical director must enroll as a group of providers, and get reimbursed at the rate as listed in the Emergency Rule.

The emergency adopted rules specify that only a provider who furnishes “Clinic Services,” as defined at 42 C.F.R. 440.90, by or under the direction of a physician may qualify as a Mental Health Agency. Some providers that were treated as Mental Health Agencies under the prior rules will not meet this definition. Such providers must reenroll as Behavioral Health Clinician Groups, and will be reimbursed at the Independent Practitioner rate.

Transition Section 65 to CPT codes: The Department will require that the codes Mental Health Agencies and Independent Practitioners use for Outpatient and Medication Management Services transition from the current H codes to the appropriate 9000 series codes. This will align with how providers bill and receive payment from Medicare, and will allow Medicare crossover claims to be processed automatically, reducing the administrative burden for providers and the Department.

Methadone: Opioid treatment rates will be reduced from $72.00 per week to $60.00 per week.

MCBM, Section 68, Occupational Therapy

There will be a 10% rate reduction for Occupational Therapy services.

MCBM, Section 75, Vision Services

Adults on MaineCare will be eligible for one (1) routine eye exam once every three (3) years. Previously, MaineCare had paid for one (1) routine exam every two (2) years.

Members in Intermediate Care Facilities for the Mentally Retarded (ICF-MRs) will continue to be eligible for one (1) routine eye exam per year.

MaineCare will still pay for exams by ophthalmologists when medically necessary, for example, to care for specific medical diagnoses (e.g. diabetes) or for high-risk medication use (e.g. Plaquinil).

These changes apply only to members who are age 21 and over.

MCBM, Section 80, Pharmacy Services

Two brand limit: MaineCare Services will pay for only two (2) brand-name prescriptions each month, however, MaineCare members can get more than two brand name drugs each month if there is no therapeutically equivalent generic available or they have a Prior Authorization to do so.

This new limit has exclusions. Some examples of when the two-brand limit does not apply include: - children under the age of twenty-one, - pregnant women, - brand-name drugs required by federal law, - brand-name drugs for the treatment of cancer, HIV or AIDS, - brand-name antipsychotic drugs, - brand-name drugs that the Department has determined to be more cost-effective than a generic.

Smoking cessation: There will be new yearly limits for MaineCare members. These limits have not been determined. This information will be provided by the Department as soon as possible. This change only affects MaineCare members who are 21 and over.

Discontinue reimbursement for nutritional products at retail pharmacies: MaineCare will no longer pay for nutritional supplements, such as baby formula or Ensure, at retail pharmacies.

MaineCare will still pay for nutritional supplements if purchased at medical supply dealers, when deemed medically necessary.

These products may be covered for members who have a chronic illness or trauma and cannot eat orally, but Prior Authorization is required.

A complete list of these supplies can be found on the MaineCare website.

Pharmacy Reimbursement: Reimbursement will be reduced for brand-name medications provided at a retail pharmacy from the current methodology of Average Wholesale Price (AWP) minus (-) 15% to AWP minus (-) 16%.

MCBM, Section 85, Physical Therapy Services

There will be a 10% rate reduction for Physical Therapy services.

MCBM, Section 95, Podiatry Services

There will be a 10% rate reduction for Podiatric services. The new rates can be found on the DHHS Rate Setting website.


Hospital Assessment: For state fiscal year 12-13, an assessment is imposed against each hospital in the State. The assessment is equal to 0.39% of net operating revenue as identified on the hospital’s most recent audited financial statement for the hospital’s fiscal year that ended during calendar year 2008.

Mandate EFT Payments: MaineCare providers will be required to receive payment for services by Electronic Funds Transfer, as outlined in Chapter 1 of the MCBM.

MIHMS Provider inquiries can be directed to 1-866-690-5585.