Adopted Rulemaking Archives

MaineCare Benefits Manual, Chapter II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorders word  pdf 
Concise Summary: The Department adopted changes to the rule to comply with the concurrent operation of a 1915 (b) Non-Emergency Transportation Waiver. The change to Section 21 includes referencing the regional, risk-based, Pre-Paid Ambulatory Health Plan (PAHP) Brokerages operating under a 1915(b) waiver approved by the Centers for Medicare and Medicaid Services (CMS). Under risk-based contractual agreements, the Department will contract with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of Non-Emergency Transportation (NET) services for eligible MaineCare members. The Broker(s) will be responsible for establishing a network of NET drivers to deliver NET transportation services to eligible members who live in their assigned region. These changes to Section 21 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. The Department is also adopting other changes. 1. The website for The Maine College of Direct Support has been updated and can be accessed on the internet at: http://www.maine.gov/dhhs/oads/disability/ds/cds/index.shtml 2. The Department added language clarifying that the assessment referral form may be the BMS 99 form currently in use or some other form approved by the Department. This change is in anticipation of a move to a new functional assessment tool, the Supports Intensity Scale (SIS). 3. Requirements for Direct Support Professionals were added, requiring DSPs to complete four specific modules prior to being left alone with a member. 4. The Department deleted Appendix IV and replaced it with a more simple statement of the combined limits on Work Support and Community Support in the main text of the rule. A change to the final rule was also made based on comments, allowing staff six months to obtain the Direct Support Professional, consistent with Section 29. The final rule now reads “All new staff or subcontractors shall have six (6) months (1040 hours, one thousand and forty) of actual employment from date of hire, or two (2) calendar years, whichever is less, to obtain DSP certification or demonstrate proficiency through DHHS’s approved Assessment of Prior Learning.”
Effective Date: August 3, 2013
View Comments: word  Posted: August 8, 2013
 
CHAPTER III, SEC 29, SUPPORT SERVICES FOR ADULTS WITH INTELLECTUAL DISABILITIES AND AUTISTIC DISORDER word  pdf 
Concise Summary: This provisionally adopted rule proposes to provide that Section 29 MaineCare members access transportation for their Section 29 services through Section 113 Non-Emergency Transportation Services. On October 2, 2012, CMS approved an amendment to the Section 29 Waiver to waive the Section 1902(a) (32) freedom of choice provision, to limit the Section 29 Member’s choice of provider of transportation services, in order that this waiver will be consistent with the requirements of the Section 113 Waiver. The April 23, 2013, Centers for Medicare & Medicaid Services (CMS) approval of the Maine Non-Emergency Medical Transportation Waiver (MaineCare Benefits Manual, Section 113) expressly required that this Maine 1915(c) home- and community-based services (HCBS) Waiver use the Section 113 Waiver for all transportation needs for its members. This rule has been provisionally adopted and submitted to the Maine State Legislature for final approval. The Department will adopt an emergency major substantive rule so that this change can be effective upon implementation of the Section 113 Non-Emergency Transportation (NET) program, as required by CMS. This rule change is not anticipated to have any adverse impact on small businesses or impose any additional costs on municipalities or counties.
Effective Date: To be determined; provisional adoption
View Comments: word  Posted: August 8, 2013
 
CHAPTER III, SECTION 32,ALLOWANCES FOR WAIVER SERVICES OR CHILDREN WITH INTELLECTUALDISABIITIES OR PERVASIVE DEVELOPMENTAL DISORDERS word  pdf 
Concise Summary: This provisionally adopted rule proposes to have Section 32 MaineCare members’ access transportation for their Section 32 services through the same Section 113 Transportation Broker who provides them transportation for all of their other MaineCare medical needs and appointments. The April 23, 2013 Centers for Medicare & Medicaid Services (CMS) approval of the Maine Non-Emergency Transportation waiver (MaineCare Benefits Manual, Section 113) expressly required that all of the Maine 1915(c) home and community based services (HCBS) waivers use the Section 113 waiver for all transportation needs for its Members. On October 2, 2012 CMS approved an amendment to Section 32 waiver to waiver the Section 1902(a) (32) freedom of choice provision, to limit the Section 32 Member’s choice of provider of transportation services, in order that this waiver will be consistent with the requirements of the Section 113 waiver. The Department will adopt an emergency major substantive rule so that this change can be effective upon implementation of the Section 113 Non-Emergency Transportation (NET) program, as required by CMS. This rule has been provisionally adopted and submitted to the Maine State Legislature for final approval. A. Statutory Authority: 22 M.R.S.A. 42, 3173 B. Effective date: To be determined, provisional adoption
Effective Date: To be determined, provisional adoption
View Comments: word  Posted: August 8, 2013
 
MaineCare Benefits Manual, Chapter 101, Section 19, Chapters II & III, Home and Community Benefits for the Elderly and for Adults with Disabilities word  pdf 
Concise Summary: The Department adopted changes to this rule to provide services for members using Home and Community Benefits for the Elderly and for Adults with Disabilities (Section 19) concurrently with the operation of a 1915(b) Non-Emergency Transportation Waiver. These changes to Section 19 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. Members who receive services under this policy will be provided Non-Emergency Transportation under Section 113 of the MaineCare Benefits Manual. The Department will contract with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of Non-Emergency Transportation services for eligible MaineCare members. The Broker(s) will be responsible for establishing a network of Non-Emergency Transportation drivers to deliver Non-Emergency Transportation services to eligible members who live in their assigned region. The final rule also made technical changes to language and names when usage has changed or has been deemed inappropriate by the Maine Legislature. Specifically, the changes: d. Replace references to “mental retardation” with references to “intellectual disability,” as required by P.L. 2012, Ch. 542, B(5), An Act To Implement the Recommendations of the Department of Health and Human Services and the Maine Developmental Disabilities Council Regarding Respectful Language; e. Replace references to “Office of Integrated Access and Support” with references to “Office for Family Independence”; f. Replace references to “Office of Elder Services” with references to “Office of Aging and Disability Services”; and, d. Remove “if CMS approves” language from certain provisions, as CMS approved the changes to the relevant provisions effective 9/1/10.
Effective Date: August 3, 2013
View Comments: word  Posted: August 8, 2013
 
MaineCare Benefits Manual, Ch II, Section 29, Support Services for Adults with Intellectual Disabilities and Autistic Disorder WORD  PDF 
Concise Summary: A public hearing was held on June 3, 2012. There were no attendees. The comment deadline was June 13, 2013. The Department is adopting changes to the rule to comply with the concurrent operation of a 1915 (b) Non-Emergency Transportation Waiver. The change to Section 29 includes referencing the regional, risk-based, pre-paid ambulatory health plan (PAHP) Brokerages operating under a 1915(b) waiver approved by the Centers for Medicare and Medicaid Services (CMS). Under risk-based contractual agreements, the Department will contract with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of Non-Emergency Transportation (NET) services for eligible MaineCare members. The Broker(s) will be responsible for establishing a network of NET drivers to deliver NET transportation services to eligible members who live in their assigned region. These transportation-related changes to Section 29 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. The Department is also adopting a number of other changes. 1. The Department added language clarifying that, for purposes of initial and continuing eligibility, the annual cost of a member’s services under the Section 29 waiver may not exceed fifty percent (50%) of the statewide average annual cost of care for an individual in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), as determined by the Department. The rule clarifies that reimbursement for Employment Specialist Services is limited to ten hours per month. Neither of these limits are new; each were included in the waiver application approved by CMS, but had not previously been identified in the Section 29 policy. 2. The website for The Maine College of Direct Support was updated and can be accessed on the internet at: http://www.maine.gov/dhhs/oads/disability/ds/cds/index.shtml 3. The adopted rule made technical changes to language and names when usage had changed or had been deemed inappropriate by the Maine Legislature. Specifically, the changes: a. Replaced references to “mental retardation” with references to “intellectual disability” as required by P.L. 2012, ch. 542, B(5), An Act To Implement the Recommendations of the Department of Health and Human Services and the Maine Developmental Disabilities Council Regarding Respectful Language; b. Replaced references to “Office of Integrated Access and Support” with references to “Office for Family Independence”; c. Replaced references to “Office of Adults with Cognitive and Physical Disabilities Services” with references to “Office of Aging and Disability Services”; d. Clarified the definitions of Correspondent, Case manager, Intellectual Disability and Autism. This change was to align this policy with services provided under Section 21 of the MaineCare Benefits Manual; and, e. Removed language making certain provisions contingent on approval by CMS, as CMS has now granted approval. 4. The Department added language clarifying that the assessment referral form may be the BMS 99 form currently in use or some other form approved by the Department. This change is in anticipation of a move to a new functional assessment tool, the Supports Intensity Scale (SIS). 5. Requirements for Direct Support Professionals were added, requiring DSPs to complete four specific modules prior to being left alone with a member. 6. The Department adopted language requiring providers to put in place an informed consent policy and comply with the Department’s regulations governing reportable events. These are not new requirements, but had previously been included directly in the contracts between the Department and individual providers. 7. The Department adopted various clarifications to the planning process. 8. The Department deleted Appendix III and replaced it with a more simple statement of the combined limits on Work Support and Community Support in the main text of the rule.
Effective Date: August 3, 2013
View Comments: WORD  Posted: August 8, 2013
 
MaineCare Benefits Manual, Chapter II, Section113, Non-Emergency Transportation (NET) Services WORD  PDF 
Concise Summary: The Department is permanently adopting this final rule, Chapter 101, MaineCare Benefits Manual (MBM), Chapter II, Section 113, which will implement MaineCare’s Non-Emergency Transportation (NET) Service system, in order to achieve compliance with the Centers for Medicare and Medicaid Services (CMS) waiver. Upon adoption, this rule will repeal the current Section 113, chapters II and III, and replace it with the adopted rule. The rule previously included language which limited the age of unescorted youth to 16 years old. However, after further review, the Department and the Attorney General’s Office agreed to restore the original language to the final rule in order to address concerns about limiting access to services for members. Therefore, the Department now changes Section 113.04 (F) regarding Escort and Attendant Services to state the following: The Broker must allow, without charge to the Escort or Member, one (1) Escort to accompany a Member or group of Members who are residents of a nursing home, blind, deaf, have an intellectual disability, are less than 12 years of age, or as otherwise determined by MaineCare staff require an Escort to a covered service. The Broker is not responsible for arranging or compensating an Escort for services rendered except, upon request, for the cost of public transportation. The Broker must send tokens, vouchers or passes to Members and escorts, when necessary to enable the escort to travel with the Member. On April 23, 2013, CMS approved a one year extension of Maine's 1915(b) waiver to provide NET services using regional, risk-based, Pre-Paid Ambulatory Health Plan (PAHP) Brokerages in alignment with Maine’s eight (8) transit regions. The Department received responses to an RFP for the transportation waiver and is in the process of executing risk-based contracts with the transportation Brokers, who will coordinate MaineCare transportation services for eligible members regionally, throughout the state. The Brokers are responsible for establishing a network of transporters to deliver NET services to eligible members who live in their assigned region. The Department will reimburse the Brokers on a per Member/per month fee basis. MaineCare members eligible to receive NET services under this waiver include members who receive Home and Community-Based Waiver Services. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents
Effective Date: August 3, 2013
View Comments: WORD  Posted: August 2, 2013
 
MaineCare Benefits Manual, Ch 1, Sec 1, 1.18 (G) and (H) Program Integrity; 1.19-6, Suspension or Withholding of Payments Pending a Final Determination; 1.20-3, Suspension of Payments Upon Credible Allegation of Fraud WORD  PDF 
Concise Summary: This rulemaking implements certain requirements of the Patient Protection and Affordable Care Act (PPACA), P.L. 111-148, and pursuant to 22 M.R.S.A. 1714-E. The rule requires the suspension of payments to providers who are the subject of a credible allegation of fraud. This rule defines the term “credible allegations of fraud,” provides for exceptions and appeal procedures, including the right for a person to request expedited relief from a suspension of payments, consistent with the requirements of the PPACA and 22 M.R.S.A. 1714-E
Effective Date: June 30, 2013
View Comments: word  Posted: July 5, 2013
 
MaineCare Benefits Manual, Chapter II, Section 45, Hospital Services WORD  PDF 
Concise Summary: This adopted rulemaking implements a budget savings initiative of LD 250, An Act To Make Supplemental Appropriations and Allocations for the Expenditures of State Government and To Change Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Year Ending June 30, 2013. This change reduces reimbursement for leave of absence days awaiting nursing facility placement from thirty-six days in the State’s fiscal year (July 1 through June 30) to one, and for the period March 1, 2013 through July 1, 2013. Hospitals will be reimbursed for only one day of leave of absence for days awaiting nursing facility placement. The Department is seeking approval from the federal Centers for Medicare and Medicaid Services for a state plan amendment for this change.
Effective Date: June 23, 2013
View Comments: WORD  Posted: June 28, 2013
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services WORD  PDF 
Concise Summary: This rulemaking implements a budget initiative of LD 250, An Act To Make Supplemental Appropriations and Allocations for the Expenditures of State Government and To Change Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Year Ending June 30, 2013. This rule allows reimbursement for a distinct substance abuse unit discharge rate for acute care non-critical access hospitals who meet the standard. The rate is $4,898 per stay. The Department is seeking CMS approval of the state plan for this change.
Effective Date: June 23, 2013
View Comments: WORD  Posted: June 28, 2013
 
MaineCare Benefits Manual, Chapter II, Section 67, Nursing Facility Services WORD  PDF 
Concise Summary: This adopted rulemaking implements a budget savings initiative of LD 250, An Act To Make Supplemental Appropriations and Allocations for the Expenditures of State Government and To Change Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Year Ending June 30, 2013. If CMS approves, payment of bed holds for a semi-private room for a short-term hospitalization of the member shall be granted up to four (4) days (midnights) absence through June 30, 2013, as long as the member is expected to return to the nursing facility. Effective July 1, 2013, payment for these bed holds shall be granted up to four (4) days (midnights) absence during the twelve (12) month state fiscal year (July 1 through June 30) and every state fiscal year thereafter. The Department will also, if CMS approves, reduce reimbursement for a leave of absence from thirty-six days in a twelve-month period to no more than one (1) day in leave of absence from March 25, 2013 through June 30, 2013; and, effective July 1, 2013, one (1) day of leave of absence during the twelve (12) month state fiscal year (July 1 through June 30) and every state fiscal year thereafter. This rule permanently adopts changes already made on an emergency basis. This rule also removes references to “transportation agency” and replaces it with a new Non-Emergency Transportation (NET) Broker, in order to comply with the new transportation broker program the Department is proposing in Section 113. The effective date for this was changed in this adopted version of the rule.
Effective Date: June 23, 2013
View Comments: WORD  Posted: June 28, 2013
 
MaineCare Benefits Manual, Ch-II & III-Section 20-Home and Community Based Services for Adults with Other Related Conditions. WORD  PDF 
Concise Summary: The Department of Health and Human Services (DHHS) is adopting this rule to provide services to members with other related conditions. The Department has created a new section of the MaineCare Benefits Manual outlining the covered services, program requirements, and reimbursement rates for a home- and community-based program for adults with “Related Conditions.” A “Related Condition” (defined in full at 42 C.F.R. 435.1010) is a condition that causes impairment of general intellectual functioning or adaptive behavior similar to the impairment characteristic of an intellectual disability. This new MaineCare service, provided to eligible members through a Home and Community Based Waiver program approved by the Centers for Medicare and Medicaid Services, will provide supports necessary to assist individuals with a Related Condition to live in the community rather than in institutional settings. Chapter II of Section 20 (titled “Home and Community Based Services for Adults with Other Related Conditions Services”) details the program requirements and services offered under the waiver. Those services include: Assistive Technology, Care Coordination, Communication Aids, Community Support, Consultation and Assessment, Employment Specialist Services, Home Accessibility Adaptations, Home Support, Non-Medical Transportation Services, Non-Traditional Communication Assessment, Non-Traditional Communication Consultation, Occupational Therapy (Maintenance) Service, Personal Care, Physical Therapy (Maintenance) Service, Specialized Medical Equipment, Speech Therapy (Maintenance) Service, and Work Support. Chapter III of Section 20 (titled “Allowances for Home and Community Based Services for Adults with Other Related Conditions”) established billing procedure codes (based on HIPAA compliant CPT coding) and reimbursement rates for the waiver services. Changes were made to the final rule based on comments and the need for technical changes. Language changes referring to Money Follows the Person/Homeward Bound were made based on comments. The prohibition of Adult Day Health Services concurrently with this waiver has been removed based on comments. The Department has added exception language to allow members in two different Home and Community Based Waivers to live together. The Department removed the exemption of a child protective check. The prohibition on out-of-state providers has been removed from the final rule based on comments. Additionally, technical corrections were also made. Throughout the rule, DHHS was substituted for Department for consistency in the rule. Multiple grammatical corrections were made throughout the rule. 20.04-1 and -2 have been reordered so that Procedure for Developing the Care Plan is now section 20.04-1 and Content of the Care Plan is now section 20.04-2. 20.03-2.G.-The Department added language in this section to state: “Can have his or her health and welfare needs assured in the community setting, as stated in 20.08-2(E) (1) and (2).” 20.03-4.A. -The Department added language in this section to state: “And the Department” 20.03-4. -The Department added language in this section to state: “The list will be prioritized as specified above such that when there is a funded opening, an individual will be selected from priority one first and then immediately from priority two if there are not any completed and approved applicants from priority one.”
Effective Date: July 1, 2013
View Comments: WORD  Posted: June 27, 2013
 
MAINECARE BENEFITS MANUAL, CH II, SEC 21, HOME AND COMMUNITY BENEFITS FOR MEMBERS WITH INTELLECTUAL DISABILITIES OR AUTISTIC DISORDER Word  PDF 
Concise Summary: The adopted rule complies with Resolve 2011, ch. 49 to remove language from Section 21.02-7 Employment setting requiring that “Members with disabilities should constitute no more than 50% of the business’s workforce at any given worksite or location.” The Department adopted language clarifying that a Licensed Clinical Social Worker (LCSW) or Licensed Clinical Professional Counselor (LCPC) can provide behavioral consultation. Moreover, the Department has expanded the list of qualified providers who can provide behavioral consultation to include Board Certified Behavior Analysts (BCBAs). This waiver amendment has been approved by the Centers for Medicare and Medicaid Services. The Department adopted several limits on Section 21 services, including that one-member Agency Home Support placements will no longer be approved after 12/1/12; the Home Support hour- T2017 is limited to three hundred and thirty six (336) quarter hour units or eighty four (84) hours a week; and authorizations for services to be provided out-of-state are limited to (60) days of service within a given fiscal year and sixty (60) days within any six (6) month period. This rule change incorporates into the rule a previously existing restriction that the annual costs not exceed 200% of the statewide average annual cost of care for an individual in an Intermediate Care Facility for persons with Intellectual Disabilities (ICF/ID). Lastly, contracted language has been added to the policy to reflect provider’s contracts and riders, and various technical language changes were also adopted. These changes are not expected to have any adverse impact on small businesses or impose any additional costs on municipalities or counties.
Effective Date: December 24, 2012
  Posted: December 24, 2012
 
MaineCare Benefits Manual Chapters II & III, Section 65, Behavioral Health Services PDF  Word 
Concise Summary: CONCISE SUMMARY: This rule is being adopted, in part, to comply with Public Law 2011, Chapter 477, (the Maine State Supplemental Budget) passed by the 125th Maine State Legislature and signed into law by Governor Paul R. LePage on February 23, 2012, section M-1 of which required that MaineCare Services reduce reimbursement of Opioid Treatment (Methadone) from $72.00 per week to $60.00. This change is currently in effect through an emergency rule, effective June 29, 2012. Finally, this adopted rule also includes several changes that are not related to the Supplemental Budget, but are necessary to provide clarity to providers, remove outdated information and to achieve compliance with national correct coding standards.
Effective Date: October 31, 2012
View Comments: Comments  Posted: October 31, 2012
 
Provisional Adoption, Chapter III, Section 21, Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder Word: Provisional Adopted Rule  Word: Summary of Comments 
Concise Summary:
  Posted: October 15, 2012
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services PDF   
Concise Summary: This rule will adopt a variety of changes, many of which were initially implemented on an emergency basis throughout the course of three separate emergency rulemakings. The Department is adopting this rule in part to comply with P.L. 2011, Chapter 377, Section BB-1, requiring that MaineCare Services impose a mandatory substitution for a brand-name drug of a generic and therapeutically equivalent drug as required by the Maine Revised Statutes, Title 32, section 13781, with certain exceptions. This provision was previously implemented by emergency rule. The Department had also promulgated a related emergency rule, effective 4/1/12, that further limited the number of brand-name drugs members may receive per month without Prior Authorization. However, after further legal analysis, the Department concluded that the budgetary requirement to substitute generic drugs appears to preclude a specified limit on brand-name medications. This adopted rule also changes language that was included in an emergency rule previously adopted, effective 4/1/12 that listed medical food as a non-covered service. This exclusion was originally included to comply with an administrative initiative in the 2012 Supplemental Budget. However, after implementation, the Department discovered that members were having difficulties accessing nutritional products through a Durable Medical Equipment dealer, and promulgated an emergency rule on 6/27/12 to restore reimbursement. This rule will more permanently restore reimbursement, permitting members to continue to obtain nutritional products through a pharmacy. This rule also finally adopts a change that was an initiative included in the Department’s Administrative Savings proposal which reduced reimbursement for brand-name drugs to Average Wholesale Price minus (-) sixteen percent. This change was included in all previous emergency rules and proposed rulemaking. This rule also implements changes that were not included in any of the three emergency rules previously adopted. There include: - Revisions clarifying the role of the Department’s representation in the Drug Utilization Review (DUR). - Revisions clarifying the criteria regarding prescription medications utilized for managing weight or enhancing nutrient intake. - Additional language clarifying the documentation that may be requested by the Department when processing Prior Authorization requests for opioids or narcotic prescription medications. - Added criteria for early refills for mail order prescriptions in excess of a ninety percent (90%) threshold, which is expected to reduce waste of prescription medications. - The addition of Wholesale Acquisition Cost (WAC) as a reimbursement methodology for generic, brand-name and specialty prescription medications. - Added language indicating that a provider may bill based on the Federal Upper Limit (FUL) if it is the lowest form of reimbursement of those methodologies listed in the rule, unless the Department meets FUL in the aggregate, which is automatically calculated at the point of service. This change is necessary to comply with 42 CFR 447.512 – 447.516. - Added language governing the coverage of 340B prescription medications, the process for reimbursement of 340B medications and the enrollment instructions for those providers eligible to enroll in the 340B drug program. - Elimination of the fee for compound medications that are stock supply and those that are solutions or lotions involving no weighing, in order to provide clarity for providers. - Added language to request that, for compounded drugs the NDC for each active and inactive ingredient and the corresponding quantity used for each ingredient be included on the claim form. - Removal of section 80.09-2, Returned Reusable Drugs for Retail, Pharmacy Providers. This program was previously tied to a budget initiative. However, since the implementation of the Medicare Prescription Drug Benefit (Medicare Part D), there is no longer any savings associated with this program. Removal of the reimbursement methodology of the Federal Upper Limit (FUL) for brand name drugs. After discussion with the Centers for Medicare and Medicaid Services (CMS), it was determined that FUL is not an allowable reimbursement methodology for brand-name drugs.
Effective Date: October 1, 2012
  Posted: October 3, 2012
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services   PDF 
Concise Summary: This rulemaking permanently adopts changes already made on an emergency basis that implemented the use of the Ambulatory Payment Classification (APC) system-based reimbursement for almost all outpatient services, including lab and radiology, for private, Non-Critical Access and rehabilitation hospitals, effective July 1. Maine is adopting Medicare methodology and will pay 93% of the Medicare rate. These hospitals will no longer receive any Prospective Interim Payments (PIP). Reflecting these changes, the general description of the types of hospitals in Maine and the related reimbursement methodologies has changed. Critical Access Hospitals are exempted from the requirements to count readmissions within 72 hours as part of the initial discharge. As noted in the rule, some of the changes are contingent on CMS approval, which the Department will seek through a request for a state plan amendment.
Effective Date: September 28, 2012
  Posted: October 3, 2012
 
MaineCare Benefits Manual, Chapters II & III, Section 150, STD Screening Clinic Services PDF   Word 
Concise Summary: CONCISE SUMMARY: The Department of Health and Human Services (DHHS) is adopting the repeal of Chapter 101, MaineCare Benefits Manual, Chapters II and III, Section 150, STD Screening Clinic Services, in accordance with Public Law 2011, c. 657, Part A, the Maine State Supplemental Budget. The repeal of this rule will not impose any implementation or compliance costs upon municipalities or counties or have any adverse impact on small businesses.
Effective Date: August 30, 2012
View Comments: Word  Posted: August 29, 2012
 
MaineCare Benefits Manual, Chapter III, Section 68, Occupational Therapy Services Word   PDF  
Concise Summary: This rulemaking is being done pursuant to the provisions of Public Law 2011, Chapter 477, Part M-1, the Maine State Supplemental Budget which was passed by the 125th Maine State Legislature and signed into law by Governor Paul R. LePage on February 23, 2012. This law required that, effective April 1, 2012, MaineCare Services reduce reimbursement of Occupational Therapy Services by ten percent (10%). This rule will permanently adopt the emergency rule that was effective April 1, 2012.
Effective Date: June 29, 2012
View Comments: Word   Posted: June 26, 2012
 
MaineCare Benefits Manual, Chapter III, Section 85, Physical Therapy Services Word   PDF  
Concise Summary: This rulemaking is being adopted pursuant to the provisions of Public Law 2011, Chapter 477, Part M-1, the Maine State Supplemental Budget which was passed by the 125th Maine State Legislature and signed into law by Governor Paul R. LePage on February 23, 2012. This law required that, effective April 1, 2012, MaineCare Services reduce reimbursement of Physical Therapy Services by ten percent (10%). This rule will permanently adopt the emergency rule that was effective April 1, 2012.
Effective Date: June 29, 2012
View Comments: Word   Posted: June 26, 2012
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services Word   PDF  
Concise Summary: This rule permanently adopts changes already made on an emergency basis, updating the supplemental pool amount and method for distributing that pool to Non-Critical Access and other hospitals to better align with Diagnosis Related Group reimbursement. Effective April 24, 2012, the Department decreased the supplemental pool for Non-Critical Access, Rehabilitation Hospitals and Hospitals Reclassified to a Wage Area Outside Maine from $51,847,218 to $51,642,035. The distribution methodology for that pool was amended from a system based solely on the relative share of MaineCare discharges to one that also uses the relative share of MaineCare days. The Department also instituted caps on Prospective Interim Payments (PIP) consistent across the system so that the total payment to all hospitals receiving a PIP is not less than 70% of the calculated amount of the total PIP for the current year. This rulemaking, beyond permanently adopting changes already made on an emergency basis, also ends reimbursement for certain Provider Preventable Conditions (PPC), as defined by Medicare and federally required by the Patient Protection and Affordable Care Act. The DHHS will be seeking CMS approval of the State Plan for these changes.
Effective Date: June 28, 2012
View Comments: Word   Posted: June 26, 2012
 
MaineCare Benefits Manual, Section 75, Chapter II, Vision Services Word   PDF  
Concise Summary: The Department of Health and Human Services (DHHS) is permanently adopting the April 1, 2012, emergency changes to Chapter 101, MaineCare Benefits Manual, Section 75, Chapter II, Vision Services, to comply with Public Law 2011, Chapter 477, the Maine State Supplemental Budget. This change limits MaineCare Services reimbursement to one (1) routine eye exam every three (3) rolling calendar years for members ages twenty-one (21) and over. Routine eye exams indicated as the standard of care for specific medical diagnoses (ex. diabetes) or for high-risk medication use (ex. Plaquenil) will continue to be covered as medically indicated.
Effective Date: June 26, 2012
View Comments: Word   Posted: June 26, 2012
 
MaineCare Benefits Manual, Section 95, Chapter II, Podiatric Services Word   PDF 
Concise Summary: This rule permanently adopts the requirement of Public Law 2011, Chapter 477, the Maine State Supplemental Budget, Part M-1 requiring that MaineCare Services reduce reimbursement of Podiatric Services by ten percent (10%). As there is no Chapter III billing chapter for Section 95, Podiatric Services, this rulemaking also necessarily updates the policy with the DHHS Rate Setting website address where providers may access their current reimbursement rates. The Department is also updating other website links in the policy to align with current Departmental procedures.
Effective Date: June 26, 2012
View Comments: Word  Posted: June 26, 2012
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section32, Allowances for Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders WORD  PDF 
Concise Summary: This is a major substantive rule and will be final thirty days after it is filed. The Legislature approved the rule for final adoption in 2011-Resolve chapter 160, Regarding Legislative Review of Portions of Chapter 101, MaineCare Benefits Manual, Chapter III, Section 32, Allowances for Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders, a major substantive rule of the Department of Health and Human Services. The final adopted rule establishes a section of the MaineCare Benefits Manual that is known as Allowances for Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders. These services are provided to children under a Home and Community Based Waiver program approved by the Centers for Medicare and Medicaid Services (CMS). Services in Chapter II include Home Support, Home Accessibility Adaptations, Transportation, Consultation, Communication Aids and Respite Care. Chapter III establishes the rates for services. Services will be provided to children with Intellectual Disabilities or Pervasive Developmental Disorders to support them to live in the community rather than in institutional settings. This change is not expected to have an adverse economic impact on small businesses or municipalities and counties.
Effective Date: June 20, 2012
View Comments: WORD  Posted: May 24, 2012
 
Chapter 101, MaineCare Benefits Manual, Chapter II, Section 32, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders WORD  PDF 
Concise Summary: The adopted rule establishes a new section 32.10 in Chapter II that provides for an increased level of home support where certain criteria of need are met. The Department added definitions in Section 32.02 for the terms “Behavioral Interventions,” “Restraint” and “Seclusion.” The Department added clarifying language to Section 32.03 regarding eligibility and priority and reordered some of the wording. Additionally, the Department added language specifying the individual cost limits for waiver services, as set forth in the waiver application approved by the Centers for Medicare and Medicaid Services. Other technical changes and formatting were also done. This change is not expected to have an adverse economic impact on small businesses or municipalities and counties
Effective Date: June 20, 2012
View Comments: WORD  Posted: May 24, 2012
 
MaineCare Benefits Manual, Chapters II & III, Section 85, Physical Therapy Services WORD  PDF 
Concise Summary: This adopted rule will remove any differing requirements for school-based providers of MaineCare physical therapy services, and require them to meet all other requirements of comparable community-based providers of such services. In addition the Department clarifies that pursuant to 42 CFR 440.110, MaineCare physical therapy services must be prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice under Maine law and must be provided by or under the direction of a qualified licensed physical therapist. Medical necessity for and the provision of these services to MaineCare members requires appropriate documentation. Each member’s written progress note must contain the start and stop time of the service. In Chapter III of this Section, billing modifiers TL and TM will be required for all services that are delivered under a Maine Department of Education Individualized Family Service Plan (IFSP) or an Individualized Education Plan (IEP), respectively
Effective Date: December 1, 2011
View Comments: WORD  Posted: November 16, 2011
 
MaineCare Benefits Manual, Chapters II & III, Section 109, Speech and Hearing Services WORD  PDF 
Concise Summary: : The Department of Health and Human Services is adopting this rule to remove any differing requirements for school-based providers of MaineCare speech and hearing services, and require them to meet all other requirements of comparable community-based providers of such services. In addition, the Department will clarify that medical necessity for these services requires appropriate documentation, and that provision of services must be documented. Each member’s written progress note must now contain the start and stop time of the service provided to the MaineCare member. Additionally, in this adopted rule the Department corrects multiple units of service in the Chapter III to move to HIPAA compliant coding in preparation for MIHMS federal certification, adds billing modifiers, and removes one redundant billing code. The Department’s Rate Setting unit carefully analyzed utilization to establish cost neutral reimbursement rates. These rates will be reevaluated in six months to assure members have access to these important services. To address public rate concerns in this final rule, the Department will allow providers to use the modifier 22 to gain additional reimbursement for Increased Procedural Services on all non-Evaluation and Management billing codes of this Section. Appending the modifier 22 will allow for manual claim review by the Department’s clinical staff or its authorized agent. If clinical documentation attached to the modifier 22 claim supports that substantial additional work was required, the provider will then receive an additional twenty percent (20%) reimbursement for that service to the MaineCare member. The following procedure codes 92526, 92550, 92565, 92568, 92610, V5364, V5364 TF, which were reimbursable historically, are added to MIHMS in this adopted rule and will be covered retroactively to 09/01/2010. Procedure codes 92585 and 96110 will be reimbursed by the Department going forward, as of the effective date of this rulemaking. In response to public comment, Ear Mold/Inserts (V5264) will have an increased reimbursement rate to 70% of the Medicare rate as of the effective date of this rulemaking. This adopted Chapter III also clarifies how some of the HIPAA compliant billing codes of this Section are state-level defined. (For example: Speech group therapy is defined as two to four MaineCare members with one clinician with appropriate documentation made for each individual in his/her medical record). Three (3) billing modifiers have been added to this Section for Departmental tracking purposes, as follows: TL will be required for services performed under an Individualized Family Service Plan (IFSP), TM will be required for all services delivered under an Individualized Education Plan (IEP) with the MaineCare addendum, and 52 (Reduced Services) will be required when a service is reduced or applied to one ear and not both. The Department made several technical corrections in the final rule, including changes in definition clarifications, grammar, punctuation and consistency of the format.
Effective Date: December 1, 2011
View Comments: WORD  Posted: November 16, 2011
 
MaineCare Benefits Manual, Chapters II & III, Section 68, Occupational Therapy Services WORD  PDF 
Concise Summary: This adopted rule removes any differing requirements for school-based providers of MaineCare occupational therapy services and requires them to meet all other requirements of comparable community-based providers of such services. In addition, the Department clarifies that pursuant to 42 CFR 440.110, MaineCare occupational therapy services must be prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice under Maine law and must be provided by or under the direction of a qualified licensed occupational therapist. Medical necessity for and the provision of these services to MaineCare members requires appropriate documentation. Each member’s written progress note (also referred to as treatment or session note) must contain the start and stop time of the service. In this final rule the Department corrects that adult members are responsible for copayments up to $20 per month for Occupational Services. In Chapter III of this Section, billing modifiers TL and TM will be required for all services that are delivered under an Individualized Family Service Plan (IFSP) or an Individualized Education Plan (IEP) with the MaineCare Addendum for medical necessity, respectively.
Effective Date: December 1, 2011
View Comments: WORD  Posted: November 15, 2011
 
MaineCare Benefits Manual, Chapter II, Section 32, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders WORD  PDF 
Concise Summary: The adopted rule establishes a new section of the MaineCare Benefits Manual that is known as Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders. These services are provided to children under a Home and Community Based Waiver program approved by the Centers for Medicare and Medicaid Services (CMS). Services in Chapter II include Home Support, Home Accessibility Adaptations, Transportation, Consultation, Communication Aids and Respite Care. Services will be provided to children with Intellectual Disabilities or Pervasive Developmental Disorders to support them to live in the community rather than in institutional settings. This change is not expected to have an adverse effect on the administrative burdens of small businesses.
Effective Date: November 1, 2011
View Comments: WORD  Posted: October 27, 2011
 
MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment WORD  PDF 
Concise Summary: The adopted rules add language indicating that providers may bill for up to a 72-day supply of incontinence supplies, which allows for increased ease of access for members residing in rural areas. The websites listed in the proposed rule were updated. Additionally, several prior authorization criteria were removed and providers were directed to the MIHMS provider portal for information regarding prior authorizations and criteria utilized by the Department. The Department received several comments suggesting that the inclusion of a secured website and proprietary medical criteria that members or their representatives are not able to access violates the Maine Administrative Procedures Act, Federal due process laws, as well as 42 CFR 431.18 (Availability of agency program manuals) and a 1998 “Dear State Medicaid Director” letter from the Centers for Medicare and Medicaid Services. In order to address the commenters’ concerns, the Department has removed the proposed change of citation to this website and return those sections of the rule to their original state. Thus, the original MaineCare Services website and State developed medical criteria remain part of the adopted rule. The Department is working with its Medical Director to analyze criteria and to determine which prior authorizations can be removed and this will be addressed in a future rulemaking. The reimbursement methodology for miscellaneous Durable Medical Equipment and Medical Supplies has been revised to indicate that if a piece of Durable Medical Equipment or Medical Supplies has a nationally recognized code then that code must be used. If there is no code available a miscellaneous code must be used and a prior authorization must be submitted. Finally, a new requirement has been added to indicate that a face-to-face encounter by a physician, physician assistant, nurse practitioner or a clinical nurse specialist is required during the 6 months preceding the physician’s written order for Durable Medical Equipment. This federal law, the Patient Protection and Affordable Care Act (PL 111-148 6407), is effective January 1, 2011.
Effective Date: October 24, 2011
View Comments: WORD  Posted: October 20, 2011
 
MaineCare Benefits Manual, Chapters II & III, Section 29, Support Services for Adults with Intellectual Disabilities or Autistic Disorders WORD  PDF 
Concise Summary: This rule permanently adopts an emergency rule that became effective on July 1, 2011. The following changes were made in order to comply with the CMS approval of the waiver amendment and extension: Annual hourly limits for Community Support services were reduced from 1,300 to 1,125 hours. Annual hourly limits for Work Support services were increased from 300 to 600 hours. The combined annual hourly limit for when members use both Community Support and Work Support services was reduced to 1,125 from 1,300 hours. The Department has added Appendix III to Chapter II, which is composed of charts, to show how hours for the two services can be combined. The Department changed the name of both Chapters II and III of this Section, to Support Services for Adults with Intellectual Disabilities or Autistic Disorders, to match the name of the waiver, as approved by CMS. Substituting the terms “intellectual disability” for “mental retardation” also comports with P.L. 2009, ch. 571. Eligibility for Section 29 services includes the diagnoses of Asperger’s Syndrome, Pervasive Developmental Disorder (not otherwise specified), Autistic Disorder, Rett’s Disorder and Childhood Disintegrative Disorder. The Department corrected a typographical error in Chapter II: Limits on Respite Services was added to indicate that the Respite per diem rate is $90.00. The reduction from $100.00 to $90.00 was made in 2010 for Chapter III, but the Department did not make the corresponding change to Chapter II. Lastly, in Chapter III, procedure codes that are obsolete have been deleted. A public hearing was held on July 26, 2011. The comment deadline was August 5, 2011. This change is not expected to have an adverse impact on small businesses, or on counties or municipalities.
Effective Date: October 4, 2011
View Comments: WORD  Posted: September 30, 2011
 
MaineCare Benefits Manual, Chapter I, Section 2,State Medicaid Health Information Technology Program. WORD  PDF 
Concise Summary: This rule establishes policies for the Medicaid Health Information Technology (HIT) electronic health record (EHR) incentive payment program for Medicaid professionals and hospitals overseen by MaineCare Services (OMS). In order to be eligible, a professional or hospital must: 1) be of a certain type of professional or hospital and meet Medicaid or needy individual patient thresholds established for that type of professional or hospital as shown in Sections 1.04 and 1.05 of the rule; 2) adopt, implement or upgrade certified electronic health records before being approved for the first payment; and 3) meaningfully use the EHR before being approved for subsequent payments. The benefits to the participants are significant. An EP can receive a first year incentive payment of $21,250 for the initial adoption, implementation or upgrade of certified EHR technology. Upon establishing meaningful use of EHR technology, EPs will receive $8,500 in each of the next five payment years. The total amount of the EHR incentive payments for EPs over the six year payment period is $63,700. Based on a number of factors, Eligible Hospitals (EHs) receive $2,000,000 plus additional payments based on EHR incentives over a three (3) year period. Upon adopting, implementing or upgrading and establishing meaningful use of certified EHR technology, Eligible Hospitals receive 50% of the total incentive payment amount in the first year, 40% in the second year and 10% in the final third year. MaineCare will manage, administer and oversee the EHR Incentive Program for Medicaid providers as well as pursue initiatives that encourage the adoption of certified EHR technology and promote quality health care outcomes and data sharing. Members should benefit from improved health outcomes, increased patient safety, care coordination, increased efficiency and lower health care costs through meaningful use of EHR technology.
Effective Date: October 4, 2011
View Comments: WORD  Posted: September 30, 2011
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services WORD  PDF 
Concise Summary: The adopted rule moves acute care non-critical access hospitals to Diagnosis-Related Group (DRG) reimbursement methodology effective 7/1/2011 as reflected in the recent state budget, P.L. 2011, ch. 380. The supplemental pools for both critical and non-critical access hospitals are adjusted to reflect the conversion of one hospital to critical access status. The distribution methodology for the supplemental pool for non-critical access hospitals was changed to reflect the elimination of hospital specific discharge rates as part of the conversion to DRG methodology. Rehabilitation hospitals will be reimbursed under a fixed rate, per-discharge methodology instead of using a DRG-based methodology effective October 1, 2011. Language was added to DSH policy that allows Disproportionate Share Hospital (DSH) payments exceeding an individual hospital’s cap to be used for other hospitals to the extent allowable. Methodology for estimated payments made to state owned hospitals was clarified. The minimum level on outpatient prospective interim payments to acute care non-critical access hospitals and rehabilitation hospitals has been changed to 70%. There is now a separate section of rule for these hospitals. Rates for distinct psychiatric units were raised to previous levels effective October 1, 2011. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: September 28, 2011
View Comments: WORD  Posted: September 29, 2011
 
MaineCare Benefits Manual, Chapters II and III, Section 40, Home Health Services. WORD  PDF 
Concise Summary: This is permanent adoption of emergency rules that were effective September 1, 2010 and October 18, 2010 with additional changes resulting from the rulemaking process. These are changes to Major Substantive Rules and they were reviewed and approved by the Legislature in Resolve 2011, Chapter 100. The rule is changed to add requirements related to a face-to-face encounter between the Member and the physician or other designated provider who is certifying the medical necessity for home health service. Chapter II is changed to direct providers to the new website addresses for Center for Medicare and Medicaid Services definitions related to billing and for new billing instructions and billing codes for services and non routine medical supplies. The amendments to the rule add a new definition for “non routine medical supplies”, direct providers how to access the list of non routine medical supplies which can be reimbursed under Section 40 and create a process for adding to this list. The rule changes redefine the unit of service, making it consistent with the services associated with the new required HIPAA compliant codes. Chapter III is changed to provide the new HIPAA-compliant codes and the associated units of service that must be used by Home Health Services providers to bill for services.
Effective Date: September 1, 2011
View Comments: WORD  Posted: August 8, 2011
 
MaineCare Benefits Manual, Chapter II, Section 75, Vision Services WORD  PDF 
Concise Summary: The Department is adopting the following rule changes: (1) that prosthetics be provided only by ophthalmologist or optometrist, since opticians are not licensed to provide this service; (2) that prior authorization be deleted for tint, photochromatic or ultraviolet lenses; however, the Department is proposing to insert the medically necessary requirements for these lenses into the rule; (3) that the Department’s authorized agent be utilized for certain services; (4) that there is no one year warranty for normal wear and tear for articles purchased under the Vision Care Volume Purchase Contract (Contractor); (5) deleting the provision that allows providers to determine a need for repair/replacement of glasses/lenses; and (6) proposing that the Contractor be responsible for furnishing postage-paid mailers to providers for use in returning defective items to the Contractor. When providers use these mailers, the Contractor is solely responsible for the cost of items lost in transit; otherwise the provider assumes the financial responsibility. These rule changes do not have any adverse economic impact on municipal or county governments or small businesses.
Effective Date: August 25, 2011
View Comments: WORD  Posted: August 5, 2011
 
MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder WORD  PDF 
Concise Summary: The Department is adopting a major substantive final rule, Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder. This final rule was approved by the legislature in Resolve Chapter 78. This rule will be effective 30 days after the final filing with the Secretary of State. The rule is being adopted pursuant to Resolve 2011, chapter 78. The Department also made technical changes to the rule to remove procedure codes that were effective for MECMS, the payment system that was effective prior to September 1, 2010.
Effective Date: September 1, 2011
View Comments: WORD  Posted: August 3, 2011
 
MaineCare Benefits Manual, Chapter III, Section 50, Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded WORD  PDF 
Concise Summary: This rule permanently adopts a provisionally adopted major substantive rule which eliminates costs for Community Support Services (formerly called Day Habilitation Services) as part of the cost basis of the per diem rate for Intermediate Care Facilities for the Mentally Retarded. Instead, the rule refers providers to the reimbursement methods and rate for Community Support Services set forth in MaineCare Benefits Manual (MBM), Chapters II and III, Section 21. The amendment is made necessary by the repeal of MBM, Section 24, Day Habilitation Services. The amendment will also allow the billing code for this service to conform to federally required codes and the implementation of the Department’s new claims processing system. This change was adopted on an emergency basis effective April 1, 2010. The Legislature authorized the adoption of this rule on June 21, 2011. This rule change does not have any adverse economic impact on municipal or county governments or small businesses.
Effective Date: September 2, 2011
View Comments: WORD  Posted: August 3, 2011
 
MaineCare Benefits Manual, Ch III Section 97 Principles of Reimbursement for Private Non-Medical Institution Services, Appendix D: Child Care Facilities. WORD  PDF 
Concise Summary: This is permanent adoption of emergency rules that were effective October 1, 2010. The Department of Administrative and Financial Services quantified the General Fund fiscal problem as a potential shortfall of almost $400 million in the Governor’s initial proposed supplemental budget on December 18, 2009. The final supplemental budget enacted by the Legislature reflects a slight upturn in revenues and authorizes General Fund appropriations for the current biennium of approximately $5.53 billion. The Legislature has ordered various cuts in the MaineCare program in order to balance the budget, per PL 2009, c. 571. The reduction in reimbursement set forth in this rule was selected after careful consideration and it will be implemented in a fair and equitable manner. The Department was required to reduce fees paid to certain providers. Pursuant to the supplemental budget, PL 2009, ch. 571, Part A, A-26 this rule specifies rate reductions for services under Section 97 Private Non-Medical Institution Services, Appendix D: Child Care Facilities. Additionally the rule eliminates one accounting requirement for providers that is no longer necessary, thereby reducing the administrative burden for providers. Effective July 1, 2011 the final rule additionally adjusts the rates to continue the savings for the following fiscal year. This is major substantive rulemaking and this adopted rule was reviewed and authorized by the legislature in Resolve of 2011, Chapter 98
Effective Date: September 1, 2011
View Comments: WORD  Posted: July 28, 2011
 
MaineCare Benefits Manual, Chapter II, Section 109, Speech and Hearing Services WORD  PDF 
Concise Summary: The Department of Health and Human Services is adopting this routine technical rule to clarify that unlicensed Speech and Language Clinicians holding a Certificate 293, as defined by the Maine Department of Education regulations Chapter 115 Part II, 2.6, are not qualified providers of MaineCare services. This rule change assures compliance with 42 CFR 440.110. This rule change requires that speech language pathologists delivering medically necessary services in all settings, including schools, meet state licensure requirements.
Effective Date: July 1, 2011
View Comments: WORD  Posted: June 29, 2011
 
MaineCare Benefits Manual, Chapter III, Section 28, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations WORD  PDF 
Concise Summary: The adopted rule provides a corrected rate for Specialized Services in Section 28, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations. The corrected rates are for services provided 1:1 (H2021 HK), groups with two patients served (H2021 HQ HK UN), groups with three patients served (H2021 HQ HK UP) and groups with four patients served (H2021 HQ HK UQ). There was an error in calculating the rates that are in place for Specialized Services; this adopted rule will correct that error. The Department adopts this rule change retroactive to September 1, 2010. This rule change will not have any adverse economic impact on counties, municipalities or small businesses.
Effective Date: June 11, 2011
View Comments: WORD  Posted: June 21, 2011
 
MaineCare Benefits Manual, Chapter II, Section 45, Hospital Services, Reporting Requirements WORD  PDF 
Concise Summary: The adopted rule will limit the quarterly reporting of outpatient claims for single source drugs and the top 20 physician-administered multiple source drugs as listed on a CMS website to the following hospitals: Acute Care Critical Access Hospitals, Private Psychiatric Hospitals and Hospitals Reclassified to a Wage Area Outside Maine by the Medicare Geographic Classification Review Board prior to October 1, 2008. Drugs purchased through Section 340B of the Public Health Act are exempt from this requirement.
Effective Date: June 15, 2011
View Comments: WORD  Posted: June 15, 2011
 
MaineCare Benefits Manual, Chapter III, Section 30, Allowances for Family Planning Agency Services WORD  PDF 
Concise Summary: The Department of Health and Human Services is adopting this rule to correct some units of service in the Chapter III of this Section to become HIPAA compliant as mandated by the Centers of Medicare and Medicaid Services (CMS) and, in preparation for the federal certification of Maine Integrated Health Management System (MIHMS). Based on an analysis of provider utilization, the Department has completed rate adjustments that remain cost neutral in the aggregate with the corrected HIPAA compliant codes and units of service. As of the effective date of this rule, Family Planning agencies will be reimbursed at the same fee for service rates as other providers of these services, including Section 90, Physicians Services. The Department will reevaluate these rates at least annually. Corrected lesion billing codes will be covered retroactively to September 1, 2010, to allow providers to bill these services accurately. Additionally, a “FP” billing modifier will now be required for all services performed exclusively to prevent or delay pregnancy or otherwise control family size. This modifier assures the State can properly track expenditures eligible for 90% Federal matching funds.
Effective Date: July 1, 2011
View Comments: WORD  Posted: June 15, 2011
 
MaineCare Benefits Manual, Chapter III, Section 85, Physical Therapy Services WORD  PDF 
Concise Summary: The Department of Health and Human Services is adopting this rule to correct some units of service in the Chapter III of Section 85 to become HIPAA compliant as mandated by the Centers of Medicare and Medicaid Services (CMS) and, in preparation for the federal certification of Maine Integrated Health Management Solution (MIHMS). Based on an analysis of provider utilization, the Department has completed rate adjustments that remain cost neutral with the corrected HIPAA compliant codes and units of service. Also, these changes result in all primary payers utilizing the same billing codes and units of service, assuring that MaineCare is indeed the payer of last resort.
Effective Date: July 1, 2011
View Comments: WORD  Posted: June 9, 2011
 
Chapter 101, MaineCare Benefits Manual, Chapter III Section 68, Occupational Therapy Services WORD  PDF 
Concise Summary: The Department of Health and Human Services is adopting this rule to correct some units of service in the Chapter III of Section 68 to become HIPAA compliant as mandated by the Centers of Medicare and Medicaid Services (CMS) and, in preparation for the federal certification of Maine Integrated Health Management System (MIHMS). Based on an analysis of provider utilization, the Department has completed rate adjustments that remain cost neutral with the corrected HIPAA compliant codes and units of service. Also, these changes result in all primary payers utilizing the same billing codes and units of service, assuring that MaineCare is indeed the payer of last resort.
Effective Date: July 1, 2011
View Comments: WORD  Posted: June 9, 2011
 
SPECIAL NOTICE-Reimbursement Policy Clarification and Overpayment Adjustments, MaineCare Benefits Manual, Chapter 101, Chapters II & III, Section 7, Free Standing Dialysis Services PDF   
Concise Summary: This letter is to provide policy and reimbursement clarification for Free Standing Dialysis Services and address overpayment adjustment options. It has come to our attention that there have been some reimbursement discrepancies with Free Standing Dialysis Services in the MIHMS claims system.
Effective Date: N/A
  Posted: June 8, 2011
 
MaineCare Benefits Manual, Chapter III, Section 65, Behavioral Health Services WORD  PDF 
Concise Summary: The adopted rules permanently adopt a modifier for Children’s’ Assertive Community Treatment (ACT)-HA for billing purposes to distinguish this service from Section 17 Community Support Services, Adult Assertive Community Treatment (ACT). The adopted rules also permanently adopt corrected rates for Collateral Services for Children’s Home and Community Based Treatment. The rate increase will be retroactive to July 1, 2010. Lastly, the adopted rules permanently adopt group ratio procedure codes for Children’s Behavioral Health Day Treatment. The new modifier and group ratio codes will be effective June 7, 2011. Lastly, the adopted rules permanently adopt group ratio procedure codes for Children’s Behavioral Health Day Treatment. The new modifier and group ratio codes will be effective June 7, 2011. Finally an HA modifier is added to three crisis services (H2011, H0018, S9482) as a technical correction, effective June 7, 2011.
Effective Date: June 7, 2011
View Comments: WORD  Posted: June 3, 2011
 
NOTICE OF REDUCTION: Community Support Services For Adults with Intellectual Disabilities or Autistic Disorder WORD   
Concise Summary: This is a Notice of Reduction in Hours of MaineCare’s Community Support Services For Adults with Intellectual Disabilities or Autistic Disorder. The adopted rule is expected to be effective July 1 and will be posted on this site shortly after it has been adopted.
Effective Date: July 1, 2011
  Posted: June 1, 2011
 
MaineCare Benefits Manual, Chapter II & III, Section 97, Private Non-Medical Institution Services, Appendix B: Principles of Reimbursement for Substance Abuse Treatment Services WORD  WORD 
Concise Summary: The amendments to Chapter III, Section 97 change the method of reimbursing PNMI substance abuse treatment facilities from an interim rate/cost-settlement basis to fixed per diem rates depending on the type of service. The new standardized rates are set forth in the regulation, and appropriate, HIPAA compliant billing codes are provided. Chapter II, Section 97 is amended to coordinate with changes to Chapter III regarding the method of reimbursement for these services. Minor revisions are made to the names of some services. The changes are necessary to meet budget reduction targets. The Legislature ordered various reductions in expenditures in the MaineCare program to counteract predicted deficits and balance the budget. P.L. 2009, ch. 571. The reduction in reimbursements for PNMI substance abuse treatment facilities was selected by the Legislature after careful consideration, and it will be implemented in a fair and equitable manner. It is anticipated that the proposed changes will result in savings of $264,744 in State fiscal year 2011. These changes were first adopted by emergency rule effective November 15, 2010.
Effective Date: February 13, 2011
View Comments: WORD  Posted: February 16, 2011
 
MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures. WORD  PDF 
Concise Summary: The Department is adopting numerous changes to the MaineCare Benefits Manual (MBM), Chapter 101, Chapter 1, Section 1, General Administrative Policies and Procedures to assure that provider requirements align with the Department’s new claims system and to up-date other aspects of the rule. The methods of claims submission reflect various updates in moving from the Maine Claims Management System (MECMS) to the Maine Integrated Health Management Solution (MIHMS) claims system. Chapter I retains the one (1) year deadlines from dates of services for the correct filing of claims, but adds the proviso that if the service was provided before September 1, 2010, then the claim must be filed within one (1) year or by January 31, 2011, whichever is sooner. Various other changes are made, including requiring that provider license renewals must be received within 30 days prior to the date of expiration or change, that providers must update ownership information on an annual basis and that out-of-state providers treating MaineCare members on an emergency basis must contact the Department within 24 hours. The Department also adopts federally required changes to copayments, including an exemption from copayments for Native Americans (42 C.F.R. 447.57) and a limit on total copayments to 5% of income (42 C.F.R. 447.78). The Department adds information regarding filing and managing claims in MIHMS, recognizes nurse licensure to include current, unencumbered compact licenses from another compact state, strengthens the Department’s ability to collect overpayments determined by providers (P.L. 111-148, 6506) eliminates obsolete billing codes and pursuant to federal law, eliminates payments to entities outside the United States (P.L. 111-148, 6505). Various grammatical and structural changes are also made to the rule.
Effective Date: February 13, 2011
View Comments: COMMENTS  Posted: February 10, 2011
 
MaineCare Benefits Manual, Chapter III, Section 21, Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder - PROVISIONAL ADOPTION WORD  PDF 
Concise Summary: THIS RULE IS A MAJOR SUBSTANTIVE RULE AND HAS BEEN PROVISIONALLY ADOPTED. THIS RULE MUST HAVE THE APPROVAL OF THE LEGISLATURE BEFORE IT CAN BE ADOPTED AS A FINAL RULE. THIS RULE WAS ADOPTED AS AN EMERGENCY AND WAS EFFECTIVE OCTOBER 1, 2010. THE EMERGENCY RULE WILL REMAIN IN EFFECT UNTIL THE FINAL RULE IS APPROVED AND ADOPTED. ANOTHER NOTICE WILL BE PUBLISHED WHEN THE FINAL RULE IS ADOPTED AND THAT NOTICE WILL INDICATE THE EFFECTIVE DATE. The Department is provisionally adopting rates for Shared Living Providers pursuant to PL 2009, Ch 571 A-25, A-26, and CCCC-3 that were effective 10/1/10 via emergency rule. The Department also made technical changes to the rule to remove procedure codes that were effective for MECMS, the payment system that was effective prior to 9/1/10.
Effective Date: AFTER LEGISLATIVE APPROVAL
View Comments: PDF  Posted: January 7, 2011
 
MaineCare Benefits Manual, Chapter III, Section 96, Private Duty Nursing and Personal Care Services WORD  PDF 
Concise Summary: The Department adopts this final rule with the following changes: the 15 minute rate for RN services is $10.58, (an increase to the proposed rate of $9.25), due to comments received during rulemaking. Some providers and recipients were concerned that the proposed rate of $9.25 for RN services was too low and therefore some providers would refuse to provide services at this rate. The Department believes that this higher rate can be achieved while maintaining cost neutrality. The rule also makes changes to the titles of some services, in order to comply with the National Correct Coding Initiative (NCCI).
Effective Date: January 9, 2011
View Comments: WORD  Posted: January 6, 2011
 
MaineCare Benefits Manual, Chapters II & III, Section 43, Hospice Services WORD  PDF 
Concise Summary: These rules permanently adopt previously filed emergency rules reflecting the codes necessary when billing through Maine Integrated Health Management Solution (MIHMS), therefore, allowing providers to bill correctly in the new system. In addition, these rules permanently adopt the previously filed emergency rule permitting terminally ill MaineCare members under the age of 21 to receive hospice services without requiring them to forgo other treatments covered by MaineCare. This implements Section 2302 of the Affordable Care Act (Pub. L. No. 111-148 as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. No. 111-152)).
Effective Date: January 4, 2011
View Comments: WORD  Posted: January 6, 2011
 
MaineCare Benefits Manual, Chapters II & III, Section 31, Federally Qualified Health Center Services Word   
Concise Summary: The adopted rules amended billing instructions and Chapter III coding requirements to ensure that FQHC providers could bill for covered services for MaineCare members upon implementation of MIHMS. Also, the rule amended Chapter II, Section 31.06-1 to recognize the licensure of advanced practice and registered nurses who hold a current, unencumbered compact license from another compact state they claim as their legal residence. The rule allowed providers sufficient time to make necessary software changes and billing changes to meet the Department’s reporting requirements.
Effective Date: 2010-11-29
View Comments: Word  Posted: December 7, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section # 103, Rural Health Clinic Services Word   
Concise Summary: The adopted rules amend billing instructions and Chapter III coding requirements to ensure that FQHC providers are able to bill for covered services for MaineCare members upon implementation of MIHMS. The rule also requires providers to report all encounter data on the UB 04 form. Also, the rule recognizes licensure of advanced practice and registered nurses who hold a current, unencumbered compact license from another compact state they claim as their legal residence.
Effective Date: 2010-11-29
View Comments: Word  Posted: December 7, 2010
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services WORD   
Concise Summary: This adopted rule changes the definition of “discharge”. Public Law 2009, ch. 571, Part A, Sec. A-26 directs the Department to reduce funding to hospitals by “limiting reimbursement to hospitals when a MaineCare patient is subsequently readmitted to the hospital within three days following an inpatient admission for the same diagnosis”. This rulemaking makes that change. The Department will reimburse for only one discharge if a patient is readmitted to the same hospital within 72 hours for the same diagnosis. Additionally, this adopted rule makes changes, effective November 1, 2010, to allow hospitals reclassified to a wage area outside Maine by the Medicare Geographic Classification Review Board to become eligible for supplemental pool payments under the Acute Care Non-Critical Access Hospitals provision of this rule. This rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. This rulemaking has no adverse impact on small businesses employing twenty or fewer employees.
Effective Date: September 28, 2010
View Comments: WORD  Posted: November 9, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 29, Community Support Benefits for Members with Mental Retardation or Autistic Disorder WORD   
Concise Summary: The Department is adopting changes to Ch. III Section 29, Community Support Benefits for Members with Mental Retardation or Autistic Disorder. These changes have been in place as an Emergency Rule since July 1, 2010. Specifically, this rule enacts a reduction in reimbursement rates by 2% for day habilitation and work support services; all other services are reduced by 10%. This complies with Legislative budget initiatives designed to balance the State budget. In addition, the Department is adopting minor changes in the billing codes to be employed with the adoption of the Maine Integrated Health Management Solution. This change is not expected to have an adverse effect on the administrative burdens of small businesses.
Effective Date: September 28, 2010
View Comments: WORD  Posted: October 15, 2010
 
Me State Services Manual, Ch 104, Sec 5, Health Insurance Purchase Option & REPEAL OF CH VIII, SEC. 2 WORD   
Concise Summary: The Department of Health and Human Services, MaineCare Services, is deleting a section of the MaineCare Benefits Manual, Chapter VIII, Section 2, and creating a new section of the Maine State Services Manual. Concurrent to this rulemaking, the Office of Integrated Access and Support is adding the eligibility portion of this program and publishing the information in a manual maintained by that Office. The benefits of this State administered program have not changed.
Effective Date: September 15, 2010
View Comments: WORD  Posted: October 14, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities WORD   
Concise Summary: The Department permanently adopts amendments to Chapter 101, MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities, in order to comply with the State Supplemental Budget initiative to balance the State budget and to address changes related to the implementation of the Maine Integrated Health Information Management System (MIHMS). The following are changes in the rule: application of an additional inflation of 12.37% to the routine cost component for SFY 11; calculation of the upper limit on the base year cost per day based on the median multiplied by 88.73 % for direct care and routine cost components; clarification of the rate determination schedule under Principle 81 and removal of reimbursement Principle 101, Staff Enhancement Payments (SEP), from the rules. This rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. This rulemaking has no adverse impact on small businesses employing twenty or fewer employees.
Effective Date: September 29, 2010
View Comments: WORD  Posted: October 13, 2010
 
Ch. 101, MaineCare Benefits Manual, Chapter III, Section 68, Occupational Therapy Services WORD   
Concise Summary: This final rule is adopted pursuant to the supplemental budget, P.L. 2009, ch. 571, Sec. A-25 (pp. 70 & 72), which specifies a reduction in rates of 10 % for Occupational Therapy Services. The rule also includes a unit correction for evaluation and re-evaluation services to be consistent with national coding standards. This final rule permanently adopts the emergency rule that went into effect on July 1, 2010.
Effective Date: September 28, 2010
View Comments: WORD  Posted: September 28, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 28, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations WORD   
Concise Summary: The adopted rule specifies a new category of children who are eligible for Section 28 services: those children between the ages of birth and five years who have been diagnosed with a specific congenital or acquired condition, with a written assessment by a physician that they will meet the functional impairment criteria if services and supports are not provided to these children. The Department also added schools, as defined in the regulation, as a new provider of Section 28 services. Additionally, the final rule clarifies that all staff working in the capacity of a BHP must obtain BHP certification by July 1, 2011. The final rule permanently adopts a 2% rate reduction that took effect 7/1/10 for all covered services. Other routine technical changes were also made to the final rule. This rule change is not expected to have an adverse effect on municipalities or counties in the delivery of medically necessary services. An economic impact statement regarding businesses of 20 or fewer employees is on file with the Department.
Effective Date: September 28, 2010
View Comments: WORD  Posted: September 27, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 23, Developmental and Behavioral Evaluation Clinic Services WORD   
Concise Summary: The final rule permanently adopts emergency rules that took effect 7/1/10, the rule adopted a 10% decrease in rates for Developmental and Behavioral Evaluation Clinic Services. This change is not expected to have an adverse effect on the administrative burden of small businesses.
Effective Date: September 28, 2010
View Comments: WORD  Posted: September 27, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 65, Behavioral Health Services WORD   
Concise Summary: The adopted rules specify rate reductions that took effect via emergency rule, 7/1/10. The adopted rules also specify criteria for members who need services beyond 72 quarter hour units for Outpatient Services. Both of these actions were pursuant to PL 2009, ch 571. Additionally, as a technical correction, the final rule details the provisional approval of BHP’s for Children’s Behavioral Health Day Treatment. This process is identical to the provisional approval process for Children’s Home and Community Based Treatment. This change is not expected to have an adverse effect on the administrative burdens of small businesses.
Effective Date: September 28, 2010
View Comments: WORD  Posted: September 27, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 17, Community Support Services WORD   
Concise Summary: The final rules permanently adopt emergency rules that took effect 7/1/10. The rule adopted a 3% decrease in rates for Community Integration and a 4% decrease in all other services. The Department has an economic impact statement on file. Contact the person below for more information on the economic impact. This rule change will not have any impact on municipalities and counties.
Effective Date: September 28, 2010
View Comments: WORD  Posted: September 24, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 113, Allowances for Transportation Services WORD   
Concise Summary: This final rule permanently adopts the cost savings measures mandated by Maine’s June 2010 Supplemental Budget resulting in a 6.5% decrease to all Allowances for Transportation Services reimbursement rates. These were in effect by emergency rule on August 1, 2010. Rate standardization had already been in progress for many months to prepare for the implementation of Maine Integrated Health Management Solution (MIHMS), the CMS certified billing system; therefore the Department completed rate standardization prior to addressing the 6.5% budgeted rate decrease.
Effective Date: September 28, 2010
View Comments: WORD  Posted: September 23, 2010
 
Chapters II and III, Section 13, Targeted Case Management Services WORD   
Concise Summary: The Department adopted changes to Chapter II and III, Section 13, Targeted Case Management Services. The changes eliminate the target group “Members With Long Term Care Needs” from the eligibility portion of the rule, as those members can receive comparable Case Management Services under several Home and Community Based Waivers. The Department also converted some billing units to weekly billing for the following target groups: “Children Involved with Protective Services (State Agencies),” and “Adults Involved with Protective Services.” The Department combined “Targeted Case Management Services For Adults with Developmental Disabilities (Provided by State Employees)” and “Targeted Case Management Services For Adults With Developmental Disabilities,” and the service will be billed in a weekly service unit as “Targeted Case Management Services For Adults with Developmental Disabilities.” The Department also changed the unit of service for billing Targeted Case Management Services for Adults With HIV to 15 minutes increments. The Department withdrew one proposed change in Section 13 that would have eliminated Section 13 TCM services for members who receive care coordination under the HIV waiver. Upon further analysis and receipt of compelling comments, the Department determined that the care coordination under the HIV waiver is not comparable to TCM provided under Section 13, and will continue to make this crucial services available to eligible members under Section 13. All of these changes are implemented with the Department’s new claims system.
Effective Date: September 1, 2010
View Comments: WORD  Posted: September 1, 2010
 
Chapter 101 MaineCare Benefits Manual, Chapter II, Section 109, Speech and Hearing Services WORD   
Concise Summary: This adopted rule achieves a number of goals to facilitate the delivery of Speech and Hearing services in school settings, specifically: 1. allow services to be ordered by a practitioner of the healing arts, 2. establish schools as an approved setting for the delivery of services, 3. authorize speech and language clinicians holding a Certificate 293 to deliver services, and 4. other minor, technical corrections.
Effective Date: September 1, 2010
View Comments: WORD  Posted: September 1, 2010
 
MaineCare Benefits Manual, Chapter II, Section 85, Physical Therapy Services WORD   
Concise Summary: This adopted rule achieves a number of goals to facilitate the delivery of physical therapy services in school settings, specifically: • allow services to be ordered by a practitioner of the healing arts, • remove the maximum limit of two (2) visits per year for sensory integration for members under age twenty-one (21), • establish schools as an eligible provider, and • remove the requirement that a physician or primary care provider sign a member’s plan of care every three (3) months for members under age twenty-one (21).
Effective Date: September 1, 2010
View Comments: WORD  Posted: September 1, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 90, Physician Services WORD   
Concise Summary: The final rule change incorporates new prior authorization language in Chapter II of this policy. The new language will allow the Department to use evidence based medical criteria based on nationally accepted criteria when determining medical necessity for certain services. Adopting these criteria will ensure that medical services are delivered to members in an appropriate way consistent with national standards of care. Services requiring prior authorization and their criteria can be found at: http://www.maine.gov/dhhs/oms/provider_index.html. In cases where the criteria are not met, the Provider/Member may submit additional supporting evidence such as medical documentation, to demonstrate that the requested service is medically necessary. The Department has amended the Transplant criteria, which can be found in Appendix A of this policy. The Department’s new criteria will require members to be free of alcohol and drug use for 6 months prior to transplants. This change was made to be consistent with industry wide standards of care. The Department is modifying Section 90.09-2 MaineCare Reimbursement to allow for MaineCare to reimburse and make adjustments according to Medicare place of service rates and modifiers. Furthermore, upon implementation of Maine’s Integrated Health Management System (MIHMS), the Department will repeal Chapter III, Section 90 of this policy as this Section has become unnecessary. No services are being reduced because of this change. The Department also made other structural, administrative, grammatical and clarifying changes within this rulemaking. This rule change is not anticipated to have any adverse impact on small business or create any new compliance burdens for municipalities and counties.
Effective Date: August 9, 2010
View Comments: WORD  Posted: August 19, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 25, Dental Services WORD   
Concise Summary: In Chapter II of Section 25, Dental Services, the final rule change requires, for Temporomandibular Joint Treatment (TMJ), that providers access prior authorization criteria that are industry recognized criteria utilized by a national company under contract, in addition to prior authorization criteria set forth in the rule itself. Providers can access these prior authorization criteria by accessing the OMS website at: http://www.maine.gov/dhhs/oms/provider_index.html, which will have a link to the PA portal. In cases where the criteria are not met, the Provider/Member may submit additional supporting evidence such as medical documentation, to demonstrate that the requested service is medically necessary. In Chapter III of Section 25, the Department is clarifying that PA is not required for code D4341, if a member has a diagnosis code 101- acute necrotizing ulcerative gingivitis (ANUG). To the extent that payment for code D4341 has been denied and the member has a diagnosis of 101-acute necrotizing ulcerative gingivitis (ANUG), the Department may approve reimbursement retroactively. The Department also made other structural, administrative, grammatical and clarifying changes within this rulemaking. This rule change is not anticipated to have any adverse impact on small business or create any new compliance burdens for municipalities and counties.
Effective Date: August 9, 2010
View Comments: Word  Posted: August 19, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 5, Ambulance Services word   
Concise Summary: This rulemaking is adopting language in Chapter II to lift prior authorization requirements for all four air ambulance transportation services when performed within state borders. Out of state air ambulance services continue to require prior authorization following the guidelines set forth in Section 1.14-2 of the Maine Care Benefits Manual. Reflecting the 2010-2011 Supplemental Budget (P.L. 2009, c. 571, Part A, Section 26) allowance, Chapter III rates change to 70% of Medicare-allowed rates. These set-rate fees are in response to the CMS requirements of 42 CFR 414.601 et seq., as well as serve to replace the supplemental payments used in previous rulemakings under this Section. These rules will become effective on August 1, 2010, prior to the implementation of Maine Integrated Health Management Solution (MIHMS).
Effective Date: August 1, 2010
View Comments: word  Posted: July 23, 2010
 
MaineCare Benefits Manual, Chapter III, Section 7, Free Standing Dialysis Services word   
Concise Summary: This final rule requires that providers bill using HCPCS codes along with Revenue codes when billing for Free-Standing Dialysis Services. This will be effective upon implementation of the new claims system, MIHMS, with a 30 day notice to providers. This is necessary in order to be consistent with Medicare guidelines, satisfy correct coding, and to remain HIPAA compliant.
Effective Date: July 26, 2010
View Comments: word  Posted: July 23, 2010
 
MaineCare Benefits Manual, Chapter II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorder Word   
Concise Summary: The Department adopts the term “intellectual disabilities” where appropriate, to conform to more modern terminology. This is consistent with the newest revision to the Diagnostic and Statistical Manual and the Department’s focus on respectful language. Also in this adopted rule, the Department renames the initial classification process to “Determination of Eligibility.” Provisions regarding owned-operated businesses in the employment setting are clarified. Furthermore, the Department adopts rules that reduce the maximum allowance for community support service hours and work support service hours. The Department also clarifies language around work support services provided by a Direct Support Professional (DSP) to one member at a time. Additionally, the Department establishes two additional grounds for involuntary termination of services to a member in this rule-making. Qualifications for DSPs and Employment Specialists are amended in this final rule-making. These adopted rules also specify the use of the appeals process for members outlined in Chapter I of the MaineCare Benefits Manual. Finally, the adopted rule includes a new Appendix IV, which outlines the various combinations of community support and work support hours available.
Effective Date: July 1, 2010
View Comments: Word  Posted: July 8, 2010
 
Chapter 101, Chapters II & III, Section 65, Behavioral Health Services and repeal of Chapters II & III, Section 41, Day Treatment Services word   
Concise Summary: The adopted rule repeals Chapters II & III, Section 41, Day Treatment Services and incorporates Children’s Behavioral Health Day Treatment Services in to Chapters II & III, Section 65, Behavioral Health Services. The rule adoption was necessary to utilize HIPAA compliant codes and assure medically necessary services were being delivered by qualified staff. Schools were also added as a qualified provider. Other routine technical changes to the rule were also made
Effective Date: July 1, 2010
View Comments: Word  Posted: July 8, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 22, Home and Community Benefits for the Physically Disabled word   
Concise Summary: The changes adopted in this rulemaking involve expanding covered services to include those services that are bundled under the current case management service. These services are skills training, financial management services, and supports brokerage and will now be billed separately. The Department also adopts language that outlines the allowed maximum number of billable hours for each service. Also adopted in this final rule is language surrounding waiting list and cost of care practices. In Chapter III, the Department adopts three HIPAA-compliant service codes needed to bill for skills training, financial management services and supports brokerage. The Department also adopts an installation code for the Personal Emergency Response System (PERS), which is consistent with other Home and Community Based waiver programs. Finally, the Department adopts a new attendant care rate. All adopted changes will be implemented upon MIHMS go-live. Providers should follow current rules and protocols until that time. Providers will be notified at least thirty (30) days in advance of MIHMS implementation.
Effective Date: MIHMS implementation
View Comments: word  Posted: July 8, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 19, Home and Community Benefits for the Elderly and Adults with Disabilities word   
Concise Summary: The Department is adopting these final changes to Chapter II, Section 19: Services that were previously included under Comprehensive Care Management services have been broken out and clarified as Skills Training Services, Financial Management Services, and Care Coordination Services. The Home Care Coordination Agency (HCCA) has been deleted, and replaced with Service Coordination Agencies (SCA), which will coordinate services. However, the SCA providing care coordination services to a member may not be a provider of direct care services. A Limits provision limits the number of allowable hours for Skills Training Services and Care Coordination/Supports Brokerage Training Services. Additionally, this adopted rule requires the Office of Elder Services to maintain Member waiting lists, and it requires the Department to collect the Cost of Care from the Member. The adopted rule also adds a new type of provider: the Care Coordinator. This rule also allows Section 19 services to be suspended for up to 60 days without a Member losing eligibility for Section 19 services
Effective Date: MIHMS implementation
View Comments: word  Posted: July 7, 2010
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services Word   
Concise Summary: These adopted rules establish Medicare DRG and APC billing methodology for hospitals. Inpatient discharges will be reimbursed on a Medicare DRG-based system, and include a direct care DRG rate, as well as estimated capital and medical education costs. This reimbursement will be subject to interim and final settlements. Billing for outpatient discharges will also be required to begin capturing the data required to transition to paying outpatient claims with APC methodology. This final rule also makes a technical correction in the supplemental pool amount the Department allocates. These proposed changes are subject to CMS approval. Hospitals will receive at least a 30 day notice of “go live” date for MIHMS.
Effective Date: 2010-06-28
View Comments: word  Posted: June 29, 2010
 
Final Rule: MaineCare Benefits Manual, Chapters II & III, Section 96, Private Duty Nursing and Personal Care Services Word   
Concise Summary: The Department is adopting these changes to Chapter II: Care coordination and skills training services are covered under this Section. These services must be approved by Centers for Medicare and Medicaid Services (CMS) before they become effective. The Home Care Coordination Agency (HCCA) has been deleted, and replaced with Service Coordination Agencies (SCA), which will coordinate services. However, the SCA providing care coordination services to a member may not be a provider of direct care services. A limits provision limits the number of allowable hours for Skills Training Services and Care Coordination/Supports Brokerage Training Services. These rules also extend the ability to suspend services from 30 days to 60 days without a Member losing eligibility under this Section. Personal Support Specialist (PSS) training requirements are modified to allow job shadowing and on-the-job training to count toward the required number of training hours for PSSs. The Department also adopts the following changes to Chapter III: HIPAA-compliant service codes are included in Chapter III. The final rule clarifies billing by including the addition of two codes: T1019, Personal Support Services (PSS), and S5125TF, PCA Supervisit. These codes are necessary in order for Personal Support Agencies to bill for these services. In addition, the Department removed the 0589 revenue code from the S5125 HCPCs code as originally proposed. The revenue code is not required in order to bill for these particular PSS services.
Effective Date: IMPLEMENTATION OF MIHMS
View Comments: word  Posted: June 23, 2010
 
MaineCare Benefits Manual, Chapter 101, Ch II, Section 90, Physician’s Services Word   
Concise Summary: The Department gives notice of a final rulemaking: MaineCare Benefits Manual, Chapter 101, Section 90, Physician’s Services Ch II. This rulemaking formally adopts an Emergency rule effective March 1, 2010. The Department has increased the MaineCare reimbursement rate for non-hospital based physician services from 56.94% to 70% retroactive to March 1, 2010. This increase will not include reimbursement for procedures performed by radiologists, radiation oncologists, and pathologists, who currently receive a higher rate of reimbursement. No procedure codes are decreased as a result of this rulemaking. Furthermore, this increase does not apply to other sections of policy within the MaineCare Benefits Manual, Chapter 101. Providers can visit the Office of MaineCare’s website for the current fee schedule. The fee schedule can be found at http://portalxw.bisoex.state.me.us/oms/proc/pub_proc.asp?cf=mm.
Effective Date: 2010-06-01
View Comments: Word  Posted: May 27, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 12, Consumer Directed Attendant Services. Word   
Concise Summary: The Department adopts these rules in order to comply with the new Maine Integrated Health Management System (MIHMS) that requires fee for service reimbursement methodology and HIPAA-compliant codes. The Department expands covered services under this Section to include care coordination and skills training. This is a result of eliminating long-term care targeted case management as a covered service from Section 13, Targeted Case Management Services. These services have formerly been billed as a per member/per month fee. Additionally, the Department adopts limits for billable hours for each service. Chapter III contains three HIPAA-compliant codes for billing care coordination, skills training, and attendant care services. The Department made the following changes to the final rule as a result of public comment to these rules or comments to other sections: elimination of the requirement for an assessment at 6 months, clarification of conflict of interest language in the Service Coordination Agency definition, clarification that initial skills training must occur within 30 days of receipt of the MED assessment. The Department also finds that, as of the date of adoption of this rule, MIHMS has not yet been implemented. This finding requires an adjustment in the effective date, as set forth below.
Effective Date: MIHMS IMPLEMENTATION
View Comments: Word  Posted: May 24, 2010
 
MaineCare Benefits Manual, Chapter 101, Chapter II, Section 4, Ambulatory Surgical Center Services Word   
Concise Summary: The adopted rule clarifies and updates language. Section 4.04-A states that payment for implanted presbyopia-correcting intraocular lens and astigmatism-correcting intraocular lens will be at the rate of payment for a conventional intraocular lens. In section 4.04-B, the Department is eliminating website information that is stated in 4.04 Covered Services. It is also adding language that states that ASC covered services may be billed in addition to the surgical procedure. In section 4.05 Non-Covered Services, the Department is deleting the 3rd and 4th paragraph “Payment for” Presbyopia-Correcting Intraocular Lens, etc., as this is clarified in Section 4.04-A. In section 4.07-2 the Department is changing the language to clarify that when there are multiple procedures in the same operative session, MIHMS will pay only for the procedure that has the highest payment amount.
Effective Date: 2010-06-01
View Comments: Word  Posted: May 20, 2010
 
MaineCare Benefits Manual, Chapter II, Section 45, Hospital Services Word   
Concise Summary: These adopted rules add admission eligibility and continuing eligibility criteria for hospital detoxification services. These rules also remove specific billing instructions and reporting of rebatable drugs in favor of listing those specifics on the DHHS website. These changes consolidate those instructions to one location. These changes will assure the efficient operation of the MaineCare program. Further, the administrative burden of utilization review will be lessened if the admission and continuing eligibility criteria are clear from the beginning. This rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. This rulemaking has no adverse impact on small businesses employing twenty or fewer employees.
Effective Date: 2010-05-22
View Comments: Word  Posted: May 7, 2010
 
MaineCare Benefits Manual, Chapter(s) II & III, Section 31, Federally Qualified Health Center Services Word   
Concise Summary: The adopted rules add a new provision under “reimbursement” which sets forth the Department’s legal obligations for individuals who are eligible for Medicare, some of whom are also eligible for Medicaid (QMB only, QMB plus and non QMBs). This section complies with federal regulations on Medicare cost sharing. Also, the Department intends to transition to a new information system, MIHMS in 2010, with 30 days notice to providers. Upon implementation of MIHMS, the Department will delete the current local billing codes in Chapter III, Table 1, and replace them with the codes in Chapter III, Table 2 to become compliant with Federal HIPAA regulations. Further, the Department will require providers to bill services, including documenting the type of visit, diagnoses and procedures on the UB04 claims form, which will replace the CMS 12500 form. This adopted rule should not adversely impact those facilities with staff of 20 or fewer employees. In addition, this proposed rule-making is not expected to create any new compliance burdens for counties or municipalities.
Effective Date: 2010-05-01
View Comments: Word  Posted: May 3, 2010
 
Ch III Section 21 Home and Community Benefits for Members with Mental Retardation or Autistic Disorder Word   
Concise Summary: The final adopted rules specify rates. Additionally, the final rules specify changes to billing codes necessary to comply with federal coding requirements. The coding changes will take effect when the Department’s new claims processing system (MIMHS) becomes operational, which is expected to occur in August, 2010. Providers will receive 30 days notice of the effective date of the coding changes.
Effective Date: 2010-06-01
  Posted: April 27, 2010
 
MaineCare Benefits Manual, Section 94, Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) [formally known as Prevention, Health Promotion, and Optional Treatment Services] Word   
Concise Summary: The adopted rule updates terminology, clarifies certain sections, and makes technical corrections to prepare for the Maine Integrated Health Management Solution (MIHMS). Additionally, the rule is being renamed. This rule is not expected to have an adverse impact on municipalities, counties, or small businesses.
Effective Date: 2010-05-01
View Comments: Word  Posted: April 23, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 67, Nursing Facility Services and Principles of Reimbursement for Nursing Facilities Word   
Concise Summary: The Department is adopting Chapters II and III, Section 67, Nursing Facility Services and Principles of Reimbursement for Nursing Facilities. Specifically, the Department adopts language describing the practice of continued stay in a NF when a resident is no longer medically eligible for NF services and is awaiting placement for a residential care setting. The amended rules also expand eligibility for specialized services for members with MR or “other related condition”. Furthermore, the amended rules allow residents to receive maintenance-level speech therapy when it has been determined the services are medically necessary in order to avoid a significant deterioration in ability to communicate orally, safely swallow or masticate. The Department adopts changes to Chapter III, Principles of Reimbursement for Nursing Facilities, by changing the methodology establishing the direct care cost components and consequently the prospective per diem rates for facilities. Additionally, methodology is adopted under principal 70 to support facilities billing for community support services. The Department also adopts language regarding depreciation recapture. These changes do not impose negative fiscal impact on small businesses with twenty (20) or fewer employees or create any new compliance burdens for municipalities and counties.
Effective Date: 2010-04-01
View Comments: WORD  Posted: April 23, 2010
 
MaineCare Benefits Manual, Chapter III, Section 97, Private Non-Medical Institutions, and Chapter III, Appendices D and E Word   
Concise Summary: In this major substantive rulemaking, the Department is finally adopting the August 1, 2009 Emergency Substantive PNMI, Ch. III Rule, currently in effect as well as other additional clarifications. These rules were provisionally adopted by the Department and have now been finally approved by the Maine State Legislature in Resolve 2009, chapter 166. The Department amends Appendix D (Child Care PNMI Facilities) by deleting the cost settlement requirement. Instead, the Department adopted a standardized capitated rate for five (5) levels of child services based on a child’s diagnosis and level of acuity. These rates were established by analyzing data from claims and time studies and unbundling service components to establish an Upper Payment Limit. The Department added new billing codes for children’s services. The capitated rate includes reimbursement for all PNMI services required by a child for his/her category of level of care including all staffing required both by Maine licensing guidelines, and as identified in the child’s individual service plan. The Legislature mandated the 5 levels of child services in its budget initiative enacted into law (P.L. 2009, ch. 213, Part CC). The Department amended Appendix E (Community Residences for Persons with Mental Illness) by deleting “scattered site” PNMI services. Other changes in Chapter III update billing codes for the Department’s new claims system for all other PNMI services, and clarify in Chapter III where language pertaining to auditing cost reports no longer applies to Appendix D PNMI services.
Effective Date: 2010-05-15
View Comments: Word   Posted: April 15, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 104, School Based Rehabilitative Services Word   
Concise Summary: The adopted rules repeal Section 104, School Based Rehabilitation Services. Because this rule change is a repeal, there is no cost of implementation or compliance imposed by this rule on municipalities, counties or small businesses.
Effective Date: 2010-03-10
View Comments: Word  Posted: March 11, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 27, Early Intervention Word   
Concise Summary: The adopted rules repeal Section 27, Early Intervention Services. Because this rule change is a repeal, there is no cost of implementation or compliance imposed by this rule on municipalities, counties or small businesses.
Effective Date: 2010-03-10
View Comments: Word  Posted: March 11, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 23, Developmental and Behavioral Evaluation Clinic Service Word   
Concise Summary: The adopted rules specify new service descriptions accompanied by HIPPA compliant coding with new hourly rates.
Effective Date: 2010-04-01
View Comments: Word  Posted: March 10, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 85, Physical Therapy Services Word   
Concise Summary: These adopted rules: 1. change the definition of “maintenance therapy” to allow medically necessary physical therapy services if the services prevent a member from suffering a significant decline in function that would result in an extended length of stay or placement in an institutional hospital setting; 2. replace local billing codes with HIPAA compliant code; 3. adjust rates in a budget neutral fashion to match new billing codes; 4. remove “Collateral Contacts” as a billable service upon MIHMS go live; and 5. adopt other structural, administrative and grammatical changes.
Effective Date: 2010-03-10
View Comments: Word  Posted: March 9, 2010
 
Chapters II & III, Section 68, Occupational Therapy Services Word    
Concise Summary: These adopted rules: 1. change the definition of “maintenance therapy” to allow medically necessary occupational therapy services if the services prevent a member from suffering a significant decline in function that would result in an extended length of stay or placement in an institutional hospital setting; 2. replace local billing codes with HIPAA compliant code; 3. adjust rates in a budget neutral fashion to match new billing codes; 4. remove “Collateral Contacts” as a billable service upon MIHMS go live; and 5. adopt other structural, administrative and grammatical changes.
Effective Date: 2010-03-10
View Comments: Word  Posted: March 5, 2010
 
Chapters II & III, Section 28, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations Final rule  Member notice  
Concise Summary: The adopted rules establish a new service: Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations.
Effective Date: 2010-04-01
View Comments: Public comments   Posted: March 4, 2010
 
MaineCare Benefits Manual, Chapter II & III, Section 109, Speech and Hearing Services Word   
Concise Summary: These final rules achieve a number of goals: 1. Establishes HIPAA compliant coding for the delivery of services with implementation of MaineCare’s new claims system, MIHMS; 2. Establishes increased agency rates for services effective July 1, 2010 to comply with FY 2010 budget requirements; and 3. Fulfills the Legislature’s directive, as expressed in PL 2007, ch. 71, which allows for speech therapy benefits for members who, without a maintenance level of speech therapy services, may reasonably suffer a significant decline in their ability to communicate orally, safely swallow or masticate. This change is expected to decrease extended stays or placements in institutional settings. This rulemaking has no adverse impact on small businesses employing fewer than twenty employees.
Effective Date: 2010-03-01
View Comments: Word  Posted: March 2, 2010
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services Word   
Concise Summary: The Department is adopting changes to MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services. The adopted rules are necessary to avoid a threat to public health, safety, or general welfare. The threat to public health is due to the expected escalation of H1N1 (swine flu) this year. MaineCare is adopting the increase in reimbursement for administration of seasonal flu vaccines (H1N1) and other immunizations allowed under 32 MRSA 13831 for licensed Maine pharmacists. MaineCare will reimburse $5 per vaccination for administration of these vaccines. Furthermore, MaineCare pharmacies who compound the drug Tamiflu for MaineCare children and other MaineCare members where there is a medical need and when the pharmacy is unable to provide Tamiflu Suspension will receive a $10.00 compounding fee. This is so that MaineCare children are not denied access to a medically necessary antiviral during this flu season.
Effective Date: 2010-02-16
View Comments: Word  Posted: February 23, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 102, Rehabilitative Services Word   
Concise Summary: The adopted rules specify renamed and defined services to clarify and reorganize services for better applicability and to allow for flexible patient centered care in Chapter II. Additionally, Chapter III has been recoded in a manner consistent with HIPAA compliant coding. Services have been realigned from a level system to a concurrent provision system. The final rule redesign allows a member to receive one of four services concurrently up to 18 hours a week, allowing for a more effective and efficient service delivery. The new services are Clinical Assessment and Reassessment, which was formerly Clinical Evaluation. Level I Intensive Rehabilitative Services was replaced by Intensive Integrated Neurorehabilitation. Group services will no longer be reimbursed. Level II Post Acute Rehabilitative Services was replaced by Neurobehavioral Rehabilitation, with one-on-one (1:1), group and family services. And lastly, Level III Day Health Rehabilitative Services were replaced by Self Care/Home Management and Community/Work reintegration, with group services. Other routine and technical changes have been made to the proposed rule.
Effective Date: 2010-04-01
View Comments: Word  Posted: February 23, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 29, Community Support Benefits for Members with Mental Retardation and Autistic Disorder Word   
Concise Summary: The adopted rules eliminate the Behavioral Add-on rate enhancement for providers of Community Support, Employment Specialist and Work Support Services. Additionally, the rates for Community Support, Employment Support Specialist and Work Support Services were reduced by eight cents ($0.08) per unit. This change is to conform with the current rates for these services under 21, Chapter III, Home and Community Benefits for Members with Mental Retardation of Autistic Disorder.
Effective Date: 2010-03-01
View Comments: Word  Posted: February 18, 2010
 
MaineCare Benefits Manual, Chapter IV, Restriction Plans Word   
Concise Summary: The adopted rules restructure the restriction plans from two to four plans to improve the health care of MaineCare members and to integrate Member Lock-In plans with the new MaineCare claims system, Maine Integrated Health Management System (MIHMS). Lock-In type 1 requires a member to be restricted to a designated Primary Care Physician, a Hospital, a Prescriber, a Pharmacy and any other applicable health care professional. Lock-In type 2 restricts the member to one or multiple types of health care providers. Lock-In type 3 restricts the member to one or multiple specific prescriber(s) for their prescriptions. Lock-In type 4 restricts the member from being able to obtain a specific drug category (class). Additionally, the rule was renamed and technical corrections were done.
Effective Date: 2010-03-01
View Comments: Word  Posted: February 18, 2010
 
MaineCare Benefits Manual, Chapter III, Section 26, Day Health Services Word   
Concise Summary: The Department adopts changes Chapter III of Section 26, Day Health Services. Specifically, the TF and TG modifiers attached to the S5100 code for Day Care Services are removed. These modifiers are no longer necessary to distinguish the three levels of care upon MIHMS implementation. As a result, providers will only need to bill the S5100 to receive reimbursement for members at any level of care. These changes do not impose any cost municipalities or counties and do not impose any administrative burden on small businesses with twenty (20) or fewer employees. Although these rules are effective on March 1, 2010, these rules will not be implemented until MIHMS. Until MIHMS implementation, providers should continue to bill MECMS with the current three codes. Providers will be notified at least 30-days in advance of implementing the new claims system.
Effective Date: 2010-03-01
View Comments: Word  Posted: February 11, 2010
 
MaineCare Benefits Manual, Chapter VII, Section 5, Estate Recovery Word   
Concise Summary: This rulemaking is being adopted to ensure that the Estate Recovery rules fully comply with the terms of Maine’s State Medicaid Plan, as approved by the federal Centers for Medicare and Medicaid Services (CMS), and to incorporate programmatic changes mandated by the Legislature. The Department is adopting language that will implement an Estate Recovery Exemption with Qualified Long Term Care policies. These changes will allow the Department to disregard the amount of benefits covered by a qualified long term care policy. The amount of the disregard will be equal to the amount of the insurance benefits made to or on behalf of the decedent. Furthermore, the adopted rules remove language under Section 5.07, Care Given Exemption, and replace it with Section 5.08,Hardship Waiver Based on Care Given Exemption. This adopted change allows the Department to consider a care given exemption from estate recovery for a person requesting the waiver if their income is less than two hundred percent (200%) of federal poverty and if health maintenance activities and personal care services were performed for the member during part or all of the two (2) years immediately prior to the member’s death. All care given exemptions will not exceed the value of any MaineCare benefits paid on behalf of the member.
Effective Date: 2010-01-01
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 13, Targeted Case Management Services Word   
Concise Summary: This rulemaking adopts the following changes for Targeted Case Management Services: Target groups are consolidated and redefined. Several target groups are deleted, including Pregnant and Postpartum women, Adults with Diabetes and Asthma and Members who are receiving Healthy Futures Services. There is new language detailing eligibility criteria for Children and Adults applicable to Case Management Services for Children with Developmental Disabilities and Behavioral Health Disorders as well as Case Management Services for Adults with Developmental Disabilities, Behavioral Health Disorders, Substance Abuse Disorders, HIV, Long Term Care Needs and Members Experiencing Homelessness. This rule adds a prior authorization requirement for children’s targeted case management services. This rule also reduces funding for children’s targeted case management by limiting services to two (2) months for children with scores between fifty (50) and seventy (70) on the Child and Adolescent Functional Assessment Scale. The assessment tool score may not be the sole criterion for determining medical necessity, needs and/or eligibility. This rule also clarifies that MaineCare will not cover multiple TCM services; and it sets forth the eligibility process, and the requirement of transitioning to one comprehensive case manager for children and adult members. Chapter III adds new billing procedure codes based on HIPAA-compliant HCPCS coding. Chapter III also implements a change in reimbursement to some Providers/Case Management Agencies through the requirement of billing in 15- minute increments, while other TCM services require monthly or weekly billing. Record-keeping requirements, per the federal Medicaid requirement, have been adopted in this rule. This rule also provides TCM coverage for individuals receiving protective services, and this rule changes eligibility for homeless individuals so that these individuals are not required to have resided in a homeless shelter either currently or in the past 90 days. The Department made some minor corrections and edits in the final rule as a result of comments, which are summarized in the Department’s Response to Comments.
Effective Date: 2009-11-30
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 150 STD Screening Clinic Services Word   
Concise Summary: The adopted rules of Chapter II of Section 150 slightly increase provider reimbursement rate, add information on clinical record keeping, as well as update policy language to include the two additional provider-types of Certified Nurse Practitioners and Certified Nurse Midwives to align with other sections of MaineCare policy. Meanwhile, Chapter III Section 150 establishes a new billing procedure code based on HIPAA compliant CPT coding. Coding changes will take effect when the Department’s new claims processing systems (MIHMS) becomes operational, expected to occur in March 2010. Providers will be notified at least thirty (30) days prior to the effective date.
Effective Date: 2009-12-23
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter II & III, Section 3, Ambulatory Care Clinic Services Word   
Concise Summary: These final rules achieve a number of goals: - permanently adopt emergency rules currently in place which allow for the administration of H1N1 and seasonal flu vaccines by Ambulatory Care Clinic providers, schools and Home Health Agencies; - adopt new, HIPAA compliant billing codes to take effect when MaineCare’s new claims system, MIHMS, goes live; - remove reference to 2 sub-specialties that no longer have enrolled providers; - and other, minor grammatical changes. This rulemaking has no adverse impact on small businesses employing fewer than twenty employees.
Effective Date: 2009-12-21
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 25, Dental Services Word   
Concise Summary: The Department of Health and Human Services is adopting changes to the MaineCare Benefits Manual, Chapters II and III, Section 25, Dental Services. The Department amended language in sub-section 25.03-2 (G) for Tobacco Cessation Counseling to be consistent with the language in Chapter III, Section 90, Physician’s Services. The Department is also adopting new language in sub-section 25.04-1 For Adult Dental Care Requirements. The language clarifies criteria for imminent tooth loss. Furthermore, the Department is removing Appendix III-Supplemental Payment to General Dentists. Instead, the Department is increasing the reimbursement for selected dental codes in Chapter III of this Policy. The rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. The rulemaking has no adverse impact on small business, as all providers impacted by these rules employ more than twenty employees.
Effective Date: 2010-01-01
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures Word   
Concise Summary: The Department adopts changes to the MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures. These rules define billing and rendering (servicing) provider; set forth additional requirements for emergency services; clarify that providers must supply requested information to the Department, and that there is a continuing duty to update provider information; clarify the types of financial information that may be requested; set forth additional requirements for termination procedures; simplify provider requirements related to e-signatures and facsimiles obtained for member files; add the coverage of a new eligibility group (presumptive eligibility for pregnant women); require that providers of managed care services must have a referral from the member’s PCP; outline the requirements for the PA process; delete PA requirements for alcohol treatment services reimbursed by the Indian Health Service; provide that national standards may be used as criteria for defining “medically necessary”; and set forth procedures following a provider suspension. As a result of public comment, the following four changes were made to the final rule; removal of Section 1.03-7, Provider Debt; replacing “and” with “or” under Section 1.06-4 to clarify that coverage of services for medically necessary treatment under presumptive eligibility is for the pregnant woman or the fetus; clarifying under Section 1.06-5(C) that certain services do not require a referral as outlined under Chapter VI, Primary Care Case Management; adding language under Section 1.14-2(B)(1) to allow for an extension of the one-day requirement for out of state providers who cannot verify MaineCare membership; and deleting language under Section 1.14-2(C)(2) that outlined requirements for behavioral health emergency services for children. The adopted changes do not create any additional compliance burdens or adversely impact counties or municipalities, or businesses with twenty (20) or fewer employees.
Effective Date: 2010-01-11
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment Word   
Concise Summary: The Department is adopting changes to its reimbursement methodology so that it will reimburse for DME/Medical Supplies as follows: (1) For DME/medical supplies that are not “miscellaneous DME/medical supplies” or made available through an exclusive contract with the Department, providers will be reimbursed at the lower of: the Medicare rate, the provider’s usual and customary charge or a MaineCare fee schedule published on the Department’s website. (2) For DME/medical supplies, which contains the phrase “miscellaneous,” “accessories,” "not otherwise specified" or "not otherwise classified" in its description, MaineCare will reimburse at either the Manufacturers’ Suggested Retail Price (MSRP) minus twenty percent (20%) or in cases where there is no listed MSRP, providers will be paid their Usual and Customary Charges minus thirty percent (30%). (3) Where the Department has entered into a contract with a supplier, the Department will reimburse based on the priced contained in the contract. In addition, the Department (1) will no longer provide coverage for non-sterile wipes for all MaineCare members; (2) is placing limits on pressure mattress pads, commodes, walkers, pneumonic compressor devices, apnea monitors, etc., (3) is defining criteria for reclining wheelchairs; (4) is clarifying standards for phototherapy for the treatment of seasonal affective disorder; and (5) is reducing the amount of allowable incontinence supplies.
Effective Date: 2010-01-04
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 30, Family Planning Agency Services and Allowances for Family Planning Agency Services Word   
Concise Summary: The adopted rules will update the policy language, unbundle services, replace local codes with HIPAA compliant codes and standardize rates. Also contained within this rulemaking is the elimination of coverage for infertility treatment, elimination of coverage for cervical caps, and expansion of coverage to include blood testing and counseling related to HIV and Hepatitis. These changes will become effective upon implementation of MIHMS. Providers will be notified at least thirty (30) days prior to the effective date.
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter III, Section 15, Chiropractic Services Word  PDF 
Concise Summary: These final rules allow for HIPAA compliant billing of chiropractic services under MaineCare’s new claims system, MIHMS. This rulemaking has no adverse impact on small businesses employing fewer than twenty employees.
Effective Date: 2009-11-23
View Comments: Word  Posted: November 17, 2009
 
MaineCare Benefits Manual, Chapter II, Section 4, Ambulatory Surgical Centers Word  PDF 
Concise Summary: These final rules update the definition of Ambulatory Surgical Center, per CMS Conditions for Care; update the conditions of care; clarify non-covered services; add documentation for assessments and informed consents; and make minor grammatical changes. This rulemaking has no adverse impact on small businesses employing fewer than twenty employees.
Effective Date: 2009-11-18
View Comments: Word  Posted: November 13, 2009
 
Chapter 275-Reporting Requirements for Pharmaceutical Manufacturers and Labelers; Office of the Attorney General, 26-239, Chapter 111, Reporting Requirements for Pharmaceutical Manufacturers and Labelers. Word  PDF 
Concise Summary: This letter gives notice of a final rule: Department of Health and Human Services, 10-144, Chapter 275-Reporting Requirements for Pharmaceutical Manufacturers and labelers; Office of the Attorney General, 26-239, Chapter 111, Reporting Requirements for Pharmaceutical Manufacturers and Labelers. This final rulemaking clarifies Maine requirements for clinical trial registration and results reporting, compatible with current and anticipated Federal reporting requirements and with the capabilities of the publicly funded website, www.ClinicalTrials.gov. The rule modifies the scope of the trials required to be registered and reported. It includes requirements to report on observational studies and clarifies the requirements of reporting post hoc analysis of trial results. This rulemaking provides contact information and clarifies the application of penalty for violations. This rule change does not require reposting of previously posted trials. Other minor technical, grammatical and structural changes are included within this rulemaking. This rule change is not anticipated to have any adverse impact on small business.
Effective Date: 2009-11-02
View Comments: Word  Posted: November 2, 2009
 
MaineCare Benefits Manual, Chapter II, Section 97, Private Non-Medical Institutions Word  PDF 
Concise Summary: This rule will adopt an expiring emergency rule which added language detailing eligibility criteria, requiring prior authorization for children’s and adult’s behavioral health PNMI services, and defining models of children’s PNMI services for which standard rates are being set in separate major substantive rulemaking this month pursuant to Chapter III of Section 97. In addition, this rule will adopt additional definitions subsequently proposed which will facilitate eligibility and prior authorization determinations, including additional criteria for some services. These changes are necessary to assure that PNMI services are medically necessary and that more cost effective community based services are used to the fullest extent possible. The Department expects to achieve significant cost savings as a result of these changes as directed by the Legislature, while still providing services deemed medically necessary. The rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. The rulemaking has no adverse impact on small business, as all providers impacted by these rules employ more than twenty employees.
Effective Date: 2009-10-30
View Comments: Word  Posted: October 30, 2009
 
Chapters III, Section 22, Home and Community Benefits for the Physically Disabled Word  PDF 
Concise Summary: The Department adopts Chapter III, Section 22, Home and Community Benefits for the Physically Disabled for purposes of increasing the attendant care services rate. This rate increase results from funds that were formerly reimbursed with all State dollars and will now receive Federal match. This rate change is retroactive to July 1, 2009.
Effective Date: 2009-11-01
View Comments: Word  Posted: October 27, 2009
 
MaineCare Benefits Manual, Chapter VI, Primary Care Case Management Word  PDF 
Concise Summary: The Department of Health and Human Services is adopting changes to Chapter VI, Primary Care Case Management (PCCM) to add a new level of services, Patient Center Medical Home. Patient Centered Medical Home services will assure effective, efficient and accessible health care services for eligible MaineCare members. Provider requirements are included in the adopted rule. Providers who are approved to deliver this service will receive $3.50 per member per month to deliver patient centered medical home services. This management fee is in addition to the $3.50 they receive for providing PCCM services for a total of $7.00 per member per month. Providers will be required to deliver additional integration of patient services, and participate in on-going educational and evaluation activities. The Department also added language to clarify what groups may not be required to participate in PCCM or PCMH services to be in compliance with federal guidelines and updated sections that have been revised or consolidated in the MaineCare Benefits Manual. The rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. The rulemaking has no adverse impact on small business.
Effective Date: 2009-11-01
View Comments: Word  Posted: October 25, 2009
 
MaineCare Benefits Manual, Chapters II & III, Section 62, Genetic Testing and Clinical Genetic Services Word  PDF 
Concise Summary: The Department gives notice of a final repeal of a rule: MaineCare Benefits Manual, Chapters II & III, Section 62, Genetic Testing and Clinical Genetic Services. The Department is repealing this section of the MaineCare Benefits Manual to simplify the billing for this service and to repeal outdated clinical provisions currently in Section 62, Genetic Testing and Clinical Genetic Services. Currently the majority of genetic services are being billed under Sections 90 and 55 of the MaineCare Benefits Manual. Providers who were currently billing under Section 62 will now bill under Sections 90, Physicians Services and 55, Laboratory Services, as appropriate. No services are being reduced as a result of this rulemaking.
Effective Date: 2009-10-01
View Comments: Word  Posted: October 1, 2009
 
Chapters II & III, Section 7, Free-Standing Dialysis Services Word  PDF 
Concise Summary: The adopted rule is a new Section of MaineCare Benefits Manual. Currently, providers of dialysis services are billing MaineCare under Section 90, Physician Services. The Physician Services rule does not contain any policy pertaining to dialysis services. This new rule is a stand-alone policy for dialysis providers with its own definitions; covered services, including renal dialysis, prescribed drugs, and training for home dialysis; eligibility requirements; reimbursement; limitations; and billing instructions.
Effective Date: 2009-10-01
View Comments: Word  Posted: October 1, 2009
 
MaineCare Benefits Manual, Chapter III, Section 29, Community Support Benefits for Members with Mental Retardation and Autistic Disorder Word  PDF 
Concise Summary: The adopted rules specify modifiers that providers will use when the new payment system, MIMHS is implemented. Providers will receive a notice thirty days in advance of the code implementation. 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.
Effective Date: 2009-11-01
View Comments: Word  Posted: September 28, 2009
 
MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facility Services Word  PDF 
Concise Summary: These rules adopt methodology for the case mix index, the direct care cost component, and the routine cost component in order for the nursing facilities to be properly reimbursed. As a result of public comment, two changes were made to the methodology used to calculate upper limits for the direct care and routine cost components. Specifically, the peer group upper limit for the direct care and routine cost components are now based on the median base year cost per day multiplied by 89.185% as opposed to the 87.122% in the proposed rule. This change will be made retroactive to July 1, 2009. In addition, the Department is adopting a new reimbursement methodology for remote island nursing facilities. These rules are necessary to ensure continued MaineCare funding for nursing facility services provided to the medically fragile residents of Maine.
Effective Date: 2009-09-28
View Comments: Word  Posted: September 28, 2009
 
Chapters II & III, Section 17, Community Support Services Word  PDF 
Concise Summary: The final rules permanently adopt emergency rules were in effect 7/1/09. A new service was established called Community Rehabilitation Services that took the place of Section 97, Private Non Medical Institution rules, scattered site PNMIs for persons with severe and persistent mental illness. This service is billed on a per diem basis using a HIPAA compliant code to comply with certification requirements for the new payment system, Maine Integrated Health Management System (MIMHS). Additionally, the final rule removed the Global Assessment of Functioning Score (GAF) and replaced it with Level of Care Utilization System (LOCUS) used to determine eligibility for Section 17 services. This was part of a budget initiative estimated to save $ 1,683,730.00 SFY 10 and $ 1,910,941.00 SFY11 in the general fund. The enhanced FMAP may alter the actual final savings. The final rule also defined requirements for Assertive Community Treatment (ACT), including a HIPAA compliant per diem code (H0040) that will be effective when the new MaineCare claims payments system, Maine Integrated Health Management System (MIMHS) begins processing claims. Providers will be notified thirty (30) days in advance of the change. The code for Intensive Case Management (ICM) was changed to a HIPAA compliant code (H0023) that is currently being used in Section 65, Behavioral Health Services ( but being phased out) that will be effective when the new MaineCare claims payments system, Maine Integrated Health Management System (MIMHS) begins processing claims. Providers will be notified thirty (30) days in advance of the change. Other routine technical changes in response to comments were also made in the final rule. 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.
Effective Date: 2009-10-01
View Comments: Word  Posted: September 25, 2009
 
MaineCare Benefits Manual, Section 46, Psychiatric Hospital Services, Chapter II Word  PDF 
Concise Summary: These final rules establish admission eligibility and continuing eligibility criteria for psychiatric hospitals within psychiatric hospitals. These changes assure the efficient operation of the MaineCare program by ensuring that only individuals who are eligible receive the service. Further, the administrative burden of utilization review is lessened when the admission and continuing eligibility criteria are clear from the beginning.
Effective Date: 2009-09-28
View Comments: Word  Posted: September 22, 2009
 
Section 109, Speech and Hearing Services, Chapter III Word  PDF 
Concise Summary: These adopted rules permanently adopt emergency rules currently in place which increase reimbursement rates for speech and hearing agencies as directed in the FY 2010 budget.
Effective Date: 2009-09-28
View Comments: Word  Posted: September 22, 2009
 
Section 45, Hospital Services, Chapter III Word  PDF 
Concise Summary: The Department is permanently adopting emergency rules currently in place that reduce hospital reimbursement. As mandated by the Legislature, in P.L. 2009, ch. 213, Part CC, effective July 1, 2009 the Department reduced hospital reimbursement. For acute care non-critical access hospitals, inpatient discharge rates (except for those from psychiatric units) were reduced 6.7% and reimbursement for outpatient services was decreased to 83.8% of costs. For critical access hospitals and hospitals reclassified to a wage area outside Maine, reimbursement for inpatient and outpatient services was reduced to 109% of costs. For all acute care hospitals, including critical access, hospital based physician reimbursement was decreased from 100% to 93.3% of allowable costs for inpatient non-emergency physicians, to 93.4% of costs for inpatient emergency physicians and to 83.8% of costs for outpatient non-emergency physicians. In addition, these rules eliminate the COLA adjustment for SFY’s 2010 and 2011 for non critical access acute care hospitals for inpatient discharge rate and for psychiatric unit discharge rates. Th e Department capped the PIP payment so that the total payment to all hospitals is not less than 80%. All of the above mentioned changes are contingent upon approval from CMS.
Effective Date: 2009-09-28
View Comments: Word  Posted: September 22, 2009
 
Section 45, Hospital Services, Chapter II Word  PDF 
Concise Summary: These adopted rules establish admission eligibility and continuing eligibility criteria for hospital psychiatric unit services. These changes will assure the efficient operation of the MaineCare program by ensuring that only individuals who are eligible receive the service. Further, the administrative burden of utilization review will be lessened if the admission and continuing eligibility criteria are clear from the beginning. These rules also require reporting of additional physician administered rebatable drugs.
Effective Date: 2009-09-28
View Comments: Word  Posted: September 22, 2009
 
Ch. 101, MaineCare Benefits Manual, Chapter II and III, Section 96, Private Duty Nursing and Personal Care Services Word  PDF 
Concise Summary: These rules permanently adopt the emergency and proposed rules that establish a new Level IX eligibility level for Section 96 services. These criteria are based on eligible members’ medication administration needs and assistance with ADLs and IADLs. Furthermore, the Department adopts Chapter III, which provides three codes to providers that will be billing for Level IX services. Other minor technical and grammatical changes are also adopted.
Effective Date: 2009-09-28
  Posted: September 22, 2009
 
MaineCare Benefits Manual, Chapter’s II and III, Section 103, Rural Health Services Word  PDF 
Concise Summary: The Department intends to transition to a new information system, MIHMS in 2010, with 30 days notice to providers. Upon implementation of MIHMS, the Department will delete the current local billing codes in Chapter III, Table 1, and replace them with the codes in Chapter III, Table 2, to become compliant with Federal HIPAA regulations. Furthermore, the Department is requiring providers to bill services, including documenting the type of visit, diagnoses and procedures on the UB04 claim form, which will replace the CMS 1500 form.
Effective Date: 2009-09-21
  Posted: September 16, 2009
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services Word  PDF 
Concise Summary: The Department of Health and Human Services is adopting MaineCare Benefits Manual, Ch II, Section 80, Pharmacy Services. The adopted rules edit the definition of the Maine Maximum Allowable Cost as a result of savings initiatives. This rule also removes language in 80.05-3 (b), which allowed reimbursement for B-12 for documented pernicious anemia or megaloblastic anemia drugs for the conditions described and when the prescriber has written the diagnosis on the prescription. Finally, the Department is adding section 80.04-3, Academic Detailing Committee, to comply with 22 M.R.S.A 2685. The Committee will provide evidence based education and outreach, improve quality measures and encourage better communication between the Department and health care professionals to reduce health complications and unnecessary cost associated with inappropriate drug prescribing. The Department also made other structural, administrative, grammatical and clarifying changes within this rulemaking.
Effective Date: 2009-10-01
View Comments: Word  Posted: September 16, 2009
 
Ch. 101, MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment Word  PDF 
Concise Summary: The adopted rules reflect changes to repeal and replace Section 60 in order to clarify the policy and to achieve legislatively mandated cost savings. Proposed changes include new language under Limitations, additional prior authorization requirements, and new language to clarify that items procured under a contract with the Department must be purchased, billed and reimbursed according to the terms of the contract. This Section has been totally replaced due to extensive formatting changes, including a thorough restructuring of the Appendix. Changes made to the Section 60 proposed rule based on the State budget include: increasing the markup of the acquisition cost of DME to 40% from 30%, and DME providers must deduct any prompt payment discounts when determining the acquisition cost of DME. Several additional changes were made to clarify the Section 60 proposed rule due to comments received and legal review, such as; sleep studies for CPAP and Bi-Pap done within the last three (3) years will be accepted; limits for incontinent supplies for members under 21 were removed; and the time to obtain a written prescription for a Power Mobility Device was changed to 45 days. The adopted rule does not impose an economic burden on municipalities or counties. The adopted rules are not expected to increase reporting, record keeping, or other administrative costs or skills necessary for reporting or recording for small businesses.
Effective Date: 2009-07-01
View Comments: Word  Posted: June 24, 2009
 
Chapters II and III, Section 6, Assisted Living Services Word  PDF 
Concise Summary: In this rulemaking, the Department eliminated services provided under MaineCare Benefits Manual, Chapters II and III, Section 6, Assisted Living Services. The Department has determined that it is necessary to repeal these rules because these services were never approved as MaineCare services by CMS. Section 6 Assisted Living Services will no longer be provided under MaineCare as of July 1, 2009. The Members currently receiving Assisted Living services will receive required notification of the discontinuation of these services and will receive an eligibility determination to assess what benefits and services they remain eligible for. Most will be eligible for MaineCare services under Section 96, Private Duty Nursing and Personal Care Services.
Effective Date: 2009-07-01
View Comments: Word  Posted: June 16, 2009
 
MaineCare Benefits Manual, Chapter X, Section 2 (Non-Categorical Adults) Word  PDF 
Concise Summary: The final rule repeals MaineCare Benefits Manual, Chapter X, Section 2, Benefits for Childless Adults, because most of the sub-sections duplicate rules in the MaineCare Eligibility Manual, Section 11000, and promulgates a new Chapter X, Section 2, now called Non-Categorical Adults, listing the covered services for this coverage group. In July 2008, the Department repealed sections 58, 100, and 111, and incorporated those services into Section 65 services. The covered services have not changed but the list of covered services has been revised to reflect the changes made in the consolidated MaineCare Benefits Manual, Chapter II, Section 65, Behavioral Health Services rules, adopted as final rules on October 29, 2008. This rule will not have any adverse impact on the administration of small businesses.
Effective Date: 2009-06-30
View Comments: Word  Posted: June 15, 2009
 
Final Rule: Ch. 101 MaineCare Benefits Manual Chapters II and III Section 45 Hospital Services Word  PDF 
Concise Summary: This adopted rule adjusts hospital reimbursement methodology. Chapter III, Section 45 clarifies and revises reporting requirements and defines the MaineCare Supplemental Data Form, and clarifies that cross-over payments are made to the extent required by CMS. Chapter III also increases the supplemental pool to be distributed among non-critical access hospitals from approximately $36 to $45 million and counts 50% of the psychiatric discharges when distributing the pool; increases the pool for the critical access hospital from $2 to 3.5 million; increases the PIP cap to approximately 81%; creates a separate section for Hospitals Reclassified to a Wage Area Outside Maine by the Medicare Geographic Classification Review Board and limits reimbursement under that section to hospitals reclassified prior to the effective date of the rule; revises sections 45.03, 45.04, 45.05 and 45.06 to separate the calculation of the PIP from the calculation of the Department’s obligation at settlement; establishes base discharge rates for acute care non-critical access hospitals (Franklin Memorial hospital services rate was changed due to a revision made to the base year report); and removes outdated material. Several provisions have a retroactive effective date of 10/1/08. Pursuant to 22 M.R.S.A. 42(8), the Department is authorized to adopt rules with retroactive application when, as here, it is necessary to maximize available revenue sources, and there is no adverse financial impact on any MaineCare provider or member. These rules permanently adopt emergency rules, effective February 21, 2009, that reduce hospital-based physician reimbursement to 46.21% of costs, which is the closest to 70% of the Medicare fee schedule that the Department could fund with the resources used for physician reimbursement, as adjusted by the Supplemental Budget, which reduced reimbursement by $1,947,490 of state dollars. A percentage of costs is being used to calculate 70% of the Medicare fee schedule absent claims—based data. Prospective Interim Payments (PIP) will be lowered in an amount corresponding to the anticipated hospital-based physician payment reimbursement, which are paid separately and not paid as part of PIP. Permanent adoption of this methodology change will be contingent upon approval by the U.S. Center for Medicare and Medicaid Services (CMS). Two proposed changes were withdrawn as a result of comments and legislative action. The provision for hospitals to report professional services on a CMS 1500 form separate from facility fees was withdrawn due to a moratorium enacted by Congress. Also, the reimbursement of non-emergency room hospital-based physicians at 70% of the Medicare fee schedule was withdrawn due to contrary pending legislation in the 1 st session of the 124 th Legislature. Two links were updated in Chapter II, Section 45.11 and Section 45.12. This rulemaking does not adversely impact counties or municipalities, and it does not adversely impact small businesses of twenty (20) or fewer employees because the service affected by the rate reduction is not provided by small businesses.
Effective Date: 2009-05-23
View Comments: Word  Posted: June 5, 2009
 
Final Rule: Ch. 101 MaineCare Benefits Manual Chapter III Section 21 Home and Community Benefits for Members with Mental Retardation or Autistic Disorder Word  PDF 
Concise Summary: This rule permanently adopts major substantive rules approved by the Maine State Legislature and currently in effect by emergency rule.
Effective Date: 2009-06-28
View Comments: Word  Posted: June 5, 2009
 
Chapter III, Section 97, and Appendices B, D, E, and F, Private Non-Medical Institution Services Word  PDF 
Concise Summary: These rules permanently adopt emergency rules already in place that have recently been approved by the Maine State Legislature in LR 1883(03). The rules eliminate bedhold day reimbursement for PNMI services. Specific changes in these rules include that bedhold day codes are eliminated from Chapter III, including BQL, BRL, MRPL, RHL RHL9, RML RML2, RTSL, and PL. Some language regarding occupancy rates was also eliminated from Appendices B, D, E, and F. The Department also replaced some local codes with HIPAA-compliant standard codes that will not be implemented until further notice when the new claims system is operating. Providers will be given prior notice of the change for these billing codes.
Effective Date: 2009-07-02
View Comments: Word  Posted: June 2, 2009
 
Final Rule: Ch. 101, MaineCare Benefits Manual, Chapters II & III, Section 5, Ambulance Services Word  PDF 
Concise Summary: The adopted rules reflect changes to this section to increase Ambulance Services base rates that will include ancillary services. Ancillary Services, which include oxygen, oxygen administration supplies such as disposable oxygen masks, intravenous therapy, EKG, endotracheal intubation, pulse oximetry, telemetry and defibrillation, will no longer be billed separately. RN services will also no longer be billed separately as the base rate for Specialty Care Transport has been increased. A definition of Specialty Care Transport has been added. These changes are being made so only HIPAA compliant codes will be utilized. Other changes to this section were made to update policy language. The proposed rule does not impose an economic burden on small business, municipalities or counties. EFFECTIVE DATE: May 21, 2009
Effective Date: 2009-05-21
View Comments: Word  Posted: April 22, 2009
 
Chapter III, Section 19, Home and Community Benefits for the Elderly and Adults with Disabilities Word  PDF 
Concise Summary: The adopted rules establish different reimbursement rates for comprehensive care management services and mileage reimbursement for health care attendants. Specifically, comprehensive care management rates are reduced from $139.00 to $126.50 as directed by the emergency and supplemental budgets. The comprehensive care management rate reduction produces $62,000 in savings to the General fund for SFY 09. The mileage rates for health care attendants (specifically HHAs, CNAs, PCAs) are increased from $.32 per mile to $.44 per mile. This mileage rate change has a minimal budgetary impact to the General fund.
Effective Date: 2009-03-30
View Comments: Word  Posted: March 29, 2009
 
Chapters II of Section 90- Physician Services, Section 55-Laboratory Services, Section 75-Vision Services, Section 95-Podiatry Services, Section 101-Medical Imaging and Ch III of Section 90 Physician's Services Word  PDF 
Concise Summary: This letter gives notice of a final rule: MaineCare Benefits Manual 10-144, Chapters II of Section 90- Physician Services and Section 55-Laboratory Services, Section 75-Vision Services, Section 95-Podiatry Services, Section 101-Medical Imaging and Ch III of Section 90 Physician's Services. The Department adopts the increase to the MaineCare reimbursement rate for non-hospital based physician services from 53% to 56.94% as of July 1, 2008. Furthermore, the Department is proposing to remove some prior authorization requirements for services including but not limited to hyperbaric oxygen therapy, cochlear implants, circumcision, septoplasty, and skin tag removal. Finally the Department is adopting changes to Chapter II Section 55-Laboratory Services, Section 75-Vision Services, Section 95-Podiatry Services, Section 101-Medical Imaging. The Department has amended the language under the "reimbursement" sections to these areas of policy to clarify that the increase mentioned above does not apply to these services. MaineCare will reimburse the lowest of 53% of 2005 Medicare rates, the provider's usual and customary or the allowed amount of the Medicare Part B carrier for these services. Providers can visit the Office of MaineCare's website for a list of MaineCare covered services and rates. This rule change clarifies what the current rate is; the rate is not being decreased.
Effective Date: 2009-03-29
View Comments: Word  Posted: March 24, 2009
 
Chapter II, Section 21, Home and Community Benefits for members with Mental Retardation or Autistic Disorder Word  PDF 
Concise Summary: The adopted rule eliminates Behavioral Add On. Additionally, the rule creates an added level of support for Home Support Shared Living and Home Support Family Centered Support. Lastly, Intensive Family Centered Support was eliminated as a type of Home Support. This rule is not anticipated to impose on small businesses any additional administrative cost required for compliance.
Effective Date: 2009-03-29
View Comments: Word  Posted: March 13, 2009
 
Chapters II & III, Section 29, Community Support Benefits for members with Mental Retardation and Autistic Disorder Word  PDF 
Concise Summary: The final rule adopts emergency rules that were put in to place on 1/1/09. The final rule reduces reimbursement for Community Support, Employment Specialist Services and Work Support with Medical Add On. The final rule also eliminates Behavioral Add On. This rule is not anticipated to impose on small businesses any additional administrative cost required for compliance.
Effective Date: 2009-03-29
View Comments: Word  Posted: March 13, 2009
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities Word  PDF 
Concise Summary: The Department has permanently adopted rule changes for Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities, in order to comply with budget appropriations for nursing facility reimbursement and State statute for conversion of nursing facility beds and medical director costs. Specifically, the new rate methodology changes the base year from 1998 to 2005 to calculate direct care and routine care costs; the rule clarifies the impact of conversion of nursing facility beds to residential care beds; and the base year cost for medical director is increased from $1,200 to $10,000. The Department also adopts changes that establish a new prospective per diem rate by adding a direct care regional cost component, hold harmless provision, and direct care add-on to the rule. In addition, all providers will receive a one time payment for the time period between July 1, 2008 and December 15, 2008, which equitably distributes a portion of the money appropriated in the budget. Other changes made in this rulemaking include the ability for the Department to waive administrator costs that are included under the management ceiling for smaller nursing facilities of forty (40) or fewer beds. Other minor technical, format and grammatical changes were adopted.
Effective Date: 2009-03-15
View Comments: Word  Posted: March 11, 2009
 
Chapter III, Section 12, Consumer Directed Attendant Services Word  PDF 
Concise Summary: The Department permanently adopts these rules to comply with Federal HIPAA guidelines for coding for attendant care services. Until now, these services have been billed using local codes. After research and testing, the Department has determined that the HIPAA compliant codes can be implemented in the current system. The provider (s) billing under this section will only need to make minor billing changes as a result of this change. There are no adverse impacts on small business or municipalities as a result of this change.
Effective Date: 2009-02-01
View Comments: Word  Posted: February 1, 2009
 
10-144 MaineCare Benefits Manual, Chapter II, Section 2, Adult Family Care Services Word  PDF 
Concise Summary: The adopted rules permanently adopt emergency rules currently in place. This rule increases the limit of reimbursable beds in an Adult Family Care Home from six to eight beds. This rule also adds an additional type of licensure that Adult Family Care Homes may have in order to be reimbursed appropriately when the facility has more than six beds. Previously, Adult Family Care Homes must be licensed as an Assisted Living Program: Level III Residential Care Facility. Those facilities with more than six beds will require licensure as an Assisted Living Program: Level IV Residential Care Facility. This rule is not anticipated to have any negative economic impact on small businesses.
Effective Date: 2008-09-30
View Comments: Word  Posted: September 22, 2008
 
Chapter II and III, Section 35, Hearing Aids and Services Word  PDF 
Concise Summary: The adopted rules reflect the current practice of only allowing members under age 21 to receive this service. Prior Authorization has been eliminated for all but one code. Updated criteria for medical evaluation and testing were added. Audiologists were added as hearing aid dispensers to conform to a change in their scope of practice. Terminology, such as using MaineCare instead of Medicaid and member instead of recipient, is also updated. Chapter III establishes new billing codes based on HIPAA compliant coding.
Effective Date: 2008-12-01
View Comments: Word  Posted: June 11, 2008
 

 

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