Emergency Rulemaking Archives

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MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services WORD  PDF   
Concise Summary: This emergency rulemaking, effective July 1, 2013, seeks to implement provisions in the 2014-15 budget law (P.L. 2013, ch. 368 LD 1509). Specifically, this rulemaking will: a) increase the reimbursement rate per psychiatric discharge for members under 18 years of age from hospitals in the Lewiston-Auburn area to $9,128.31; and b) reduce the outpatient Ambulatory Payment Classification (APC) rate for Acute Care Non-Critical Hospitals and Rehabilitation Hospitals from 93% to 83.7% of the adjusted Medicare APC rate for outpatient services; if multiple procedures are performed, the Department will pay 83.7% -- rather than 93% -- of Medicare’s single bundled APC rate; calculations for outlier payments will follow Medicare rules and also be paid at 83.7% -- rather than 93% -- of the Medicare payment. The rulemaking also corrects two clerical errors: (1) page 15, the proper heading should be “Section 45.04 Acute Care Critical Access Hospitals;” and (2) on pages 11 and 18, removes “un” from “unadjusted” so the proper word is “adjusted.” The Department is seeking approval from the Centers for Medicare and Medicaid Services for a state plan amendment for this change.
Effective Date: July 1, 2013
 
MaineCare Benefits Manual, Chapter 101, Chapter III, Section 65, Behavioral Health Services WORD  PDF   
Concise Summary: This emergency rule will adopt a legislative initiative of P.L. 2013, Ch. 368 § WWWW-1 (L.D. 1509, 'An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2013, June 30, 2014 and June 30, 2015'). The amended rule restores the reimbursement rates for licensed clinical professional counselors (LCPCs) and licensed marriage and family therapists (LMFTs) to levels in place prior to March 1, 2013 for MaineCare Benefits Manual, Chapters III, Section 65, Behavioral Health Services beginning July 1, 2013. This change in rates requires a State Plan Amendment to be approved by the Centers for Medicare and Medicaid Services (CMS). The Department will request approval of a State Plan Amendment.
Effective Date: July 1, 2013
 
MaineCare Benefits Manual, Chapter II, Section 97, Private Non-Medical Institution Services WORD  PDF   
Concise Summary: This emergency rule eliminates Private Non-Medical Institution Services (PNMI), Appendix D (Child Care Facilities), Model 3 (Intensive Mental Health Services for Infants and/or Toddlers). The reimbursement rate is being eliminated in a separate emergency rulemaking for Chapter III, Section 97. Although eligible infants and toddlers will no longer be able to access PNMI Appendix D, Model 3 intensive mental health services, they will be eligible for medically necessary behavioral health services through Section 65, Behavioral Health Services.
Effective Date: June 26, 2013
 
MaineCare Benefits Manual, Chapter III, Section 97, Private Non-Medical Institution Services WORD  PDF   
Concise Summary: This emergency rule eliminates the reimbursement rate for PNMI Appendix D (Child Care Facilities), Model 3 (Intensive Mental Health Services for Infants and/or Toddlers), because that service is being eliminated in a separate emergency rulemaking for Chapter II, Section 97. Although eligible infants and toddlers will no longer be able to access PNMI Appendix D, Model 3 intensive mental health services, they will be eligible for medically necessary behavioral health services through Section 65, Behavioral Health Services.
Effective Date: June 26, 2013
 
MaineCare Benefits Manual, Chapter II, Section 45, Hospital Services WORD  PDF   
Concise Summary: This emergency rulemaking seeks to implement 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: March 25, 2013
 
Chapter 101, MaineCare Benefits Manual (MBM), Chapter I, Section 1, General Administrative Policies and Procedures. WORD  PDF   
Concise Summary: The 125th Maine Legislature, Second Regular Session, enacted 22 MRSA § 1714-D to conform to the requirements of the Patient Protection and Affordable Care Act of 2010 (PPACA) regarding the suspension of payments, in whole or in part, to providers who are subject to credible allegations of fraud. This emergency rule gives the Department authority to suspend payments to MaineCare providers who are the subject of a credible allegation of fraud. Changes to Chapter I, Section 1, are made to §§1.18 (G) and (H) and 1.19-6, and include a newly created §1.20-3. The Legislature authorized the Department to adopt emergency rules to implement Title 22, MRSA §1714-D without the necessity of demonstrating that immediate adoption is necessary to avoid a threat to public health or safety or the general welfare, if notice is given through a MaineCare provider listserv notification and five (5) days or more are allowed for comment prior to adoption of the rule. The Department gave notice of the emergency rulemaking to interested parties and providers through a MaineCare provider listserv notification. Public comments regarding the emergency rule were accepted from December 7 through December 12, 2012.
Effective Date: March 26, 2013
 
MaineCare Benefits Manual, Chapter II, Section 67, Nursing Facility Services WORD  PDF   
Concise Summary: This emergency rulemaking seeks to implement 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.
Effective Date: March 25, 2013
 
MaineCare Benefits Manual, Chapter III, Section 65, Behavioral Health Services WORD  PDF   
Concise Summary: This emergency rule implements a budget savings initiative of L.D. 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. The amended rule reduces reimbursement rates for Licensed Clinical Professional Counselors (LCPC) and Licensed Marriage and Family Therapists (LFMT) by 5%. This change in rates requires a State Plan Amendment to be approved by the Centers for Medicare and Medicaid Services (CMS); the Department will request approval of a State Plan Amendment retroactive to the effective date of this rule.
Effective Date: March 5, 2013
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services Word    
Concise Summary: See page 3 of Emergency Rule document for Concise Summary.
Effective Date: June 27, 2012
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services PDF   
Concise Summary: This emergency rulemaking updates 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 is decreasing 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 is also being 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 is also making 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.
Effective Date: April 24, 2012
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services WORD  PDF   
Concise Summary: This emergency rule is being adopted pursuant to Public Law, Chapter 477, LD 1816, the Maine State Supplemental Budget passed by the 125th Maine State Legislature and signed into law by Governor Paul R. LePage on February 26, 2012, which directed the Department to reduce the current limitations on brand name drugs to allow a member to receive a total of two (2) brand name drugs per month when a generic equivalent is available. In addition, the Department is making additional changes to this rule as identified in the Department’s Administrative Savings proposals. These initiatives are part of a range of adjustments that the Department is making through the adopted 2012 Supplemental Budget, to include: a discontinuation of reimbursement for nutritional products through retail pharmacies and reduction of reimbursement for brand-name medications provided at a retail pharmacy from the current methodology of Average Wholesale Price (AWP) minus (-) fifteen percent (15%) to AWP minus (-) sixteen percent (16%). This rulemaking includes other changes that will achieve savings, or support the Department in achieving savings, but are not directly included in the DHHS Supplemental Budget. This rulemaking adds criteria for early refills for mail order prescriptions in excess of a ninety percent (90%) threshold, which is expected to achieve cost savings. The Department will also add Wholesale Acquisition Cost reimbursement methodology for generic, brand name and specialty medications as a reimbursement methodology. Finally, the Department is adding a provision that a provider may be limited to billing based on the Federal Upper Limit (FUL) unless the Department meets FUL in the aggregate, which is automatically calculated at the point of sale. The Department requires pharmacy providers to bill at the lowest of the reimbursement methodologies listed in the rule, therefore, the inclusion of WAC as a reimbursement methodology and the addition of language allowing providers to bill based on FUL, unless the Department meets FUL in the aggregate, is expected to result in cost savings. Finally, this rulemaking will include a change that was previously enacted through an emergency rulemaking, effective February 1, 2012, that increased the dispensing fee for mail-order pharmacies from one-dollar ($1.00) to two-dollars and fifty cents ($2.50). This change is included in this rulemaking in order to avoid two separate emergency rules existing for the same section of policy at one time. The effective date for this change will begin again upon enactment of this emergency rule.
Effective Date: April 1, 2012
 
MaineCare Benefits Manual, Section 95, Chapter II, Podiatric Services WORD  PDF   
Concise Summary: This emergency rule is being adopted pursuant to Public Law 2011, Chapter 477, LD 1816, 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, which directs the Department to reduce reimbursement of MaineCare Podiatric Services by ten percent (10%). This change is not expected to have an adverse effect on the administrative burdens of small businesses.
Effective Date: April 1, 2012
 
MaineCare Benefits Manual, Section 75, Chapter II, Vision Services WORD  PDF   
Concise Summary: The Department is adopting the following changes for Chapter 101, MaineCare Benefits Manual, Section 75, Chapter II, Vision Services, pursuant to Public Law 2011, Chapter 477, the Maine State Supplemental Budget enacted by the 125th Maine State Legislature and signed into law by Governor Paul R. LePage on February 23, 2012. This emergency rule is being adopted in accordance with Part M of the Supplemental Budget, requiring that, effective April 1, 2012, MaineCare Services reimburse for only 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. Plaquinil) will continue to be covered as medically indicated. The enactment of this emergency rule is estimated to save $23,708 for State Fiscal Year (SFY) 2012 and $126,442 for SFY 2013, respectively.
Effective Date: April 1, 2012
 
MaineCare Benefits Manual, Section 15, Chapter II, Chiropractic Services WORD  PDF   
Concise Summary: : The Department is adopting changes to Chapter 101, MaineCare Benefits Manual, Section 15, Chapter II, Chiropractic Services pursuant to Public Law 2011, Chapter 477, the Maine State Supplemental Budget enacted by the 125th Maine State Legislature and signed into law by Governor Paul R. LePage on February 23, 2012. This emergency rule is being adopted in accordance with Part M, requiring that effective April 1, 2012, MaineCare Services reimburse Section 15, Chiropractic Services only up to a strict limit of twelve (12) visits per rolling calendar year for adult members. The adoption of this emergency rule is estimated to save $29,072 for State Fiscal Year (SFY) 2012 and $157,805 for SFY 2013, respectively
Effective Date: April 1, 2012
 
MaineCare Benefits Manual, Chapter III, Section 68, Occupational Therapy Services WORD  PDF   
Concise Summary: This emergency rule is being adopted pursuant to Public Law 2011, Chapter 477, LD 1816, 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. Part M-1 requires the Department to reduce MaineCare reimbursement of Occupational Therapy Services by ten percent (10%). Part EE-1 authorizes the Department to promulgate this rule by emergency rulemaking.
Effective Date: April 1, 2012
 
Chapter 101, MaineCare Benefits Manual, Section 85, Chapter III, Physical Therapy Services WORD  PDF   
Concise Summary: This emergency rule is being adopted pursuant to Public Law 2011, Chapter 477, LD 1816, 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. Part EE-1 authorizes the Department to promulgate this rule by emergency rulemaking. Part M-1 requires the Department to reduce MaineCare reimbursement of Physical Therapy Services by ten percent (10%) effective April 1, 2012.
Effective Date: April 1, 2012
 
MaineCare Benefits Manual, Section 80, Chapter II, Pharmacy Services Word   
Concise Summary: The emergency rule will increase the dispensing fee paid to mail order pharmacies to $2.50 (two dollars and fifty cents). This emergency rulemaking is necessary in order to support administrative savings initiatives included in the 2012 Supplemental Budget.
 
MaineCare Benefits Manual, Chapters II & III, Section 29, Support Benefits for Adults with Intellectual Disabilities or Autistic Disorders WORD  PDF   
Concise Summary: Pursuant to 5 M.R.S.A. § 8054, the Department has determined that immediate adoption of these rules is necessary to avoid an immediate threat to public health, safety or general welfare. The Department’s findings with regard to the existence of an emergency are as follows: Section 29 services are governed by a Centers for Medicare and Medicaid (CMS) Medicaid waiver. CMS approved amendments to the waiver, and a waiver renewal with an effective date of January 1, 2011. The Department was unable to adopt Section 29 rules with the required amendments on January 1, 2011. The Department now needs to adopt these rules immediately on July 1, 2011, in order to comply with the CMS approved waiver, and the Department will also seek CMS approval to change the effective date of the approved waiver from January 1, 2011 to July 1, 2011. The following changes are made in these emergency rules 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 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 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 & III of this Section of the MaineCare Benefits Manual to Support Benefits for Adults with Intellectual Disabilities or Autistic Disorders, to match the name of the waiver, as approved by CMS. (Substituting the term “intellectual disability” for “mental retardation” also comports with P.L. 2009, ch. 571). Eligibility for Section 29 services now includes the diagnoses of Asperger’s Syndrome, Pervasive Developmental Disorder (not otherwise specified), Autistic Disorder, Rett's Disorder and Childhood Disintegrative Disorder, as approved by CMS in the waiver amendment. The Department corrected a typographical error in Chapter II. Limits on Respite Services were 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 and the Department did not make the corresponding change in Chapter II. Lastly, in Chapter III, procedure codes that are obsolete have been deleted.
Effective Date: July 1, 2011
 
MaineCare Benefits Manual, Chapter III, Section 32, Allowances for Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders WORD  PDF   
Concise Summary: The emergency adopted rule creates a new Section of the MaineCare Benefits Manual that will be known as Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders. These services are provided to members through a Home and Community Based Waiver program approved by the Centers for Medicare and Medicaid Services (CMS). Chapter III establishes billing procedure codes based on HIPAA compliant CPT coding. 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. This emergency rule is a companion to an emergency rule that establishes the rules for delivering these services in Maine Care Benefits Manual Ch. II, Section 32. This rule will be provisionally adopted pending approval by the Legislature.
Effective Date: July 1, 2011
 
MaineCare Benefits Manual, Chapter II, Section 32, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders WORD  PDF   
Concise Summary: The Emergency Adopted rule creates a new Section of the MaineCare Benefits Manual that will be known as 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. 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. This emergency rule is a companion to an emergency major substantive rule that establishes rates for services in MaineCare Benefits Manual Ch. III, Section 32.
Effective Date: July 1, 2011
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services WORD  PDF   
Concise Summary: Effective July 1, 2011, the Department will reimburse acute care, non-critical access hospitals for inpatient services using a Diagnostic Related Group (DRG) billing methodology similar to that used by Medicare. The DRG methodology includes a statewide direct care rate, as well as hospital specific estimated capital and medical education rates. The latter two components of the per-discharge payment will be cost settled. This DRG system precludes payment for certain hospital acquired conditions. Statewide rates were calculated without using data from rehabilitation hospitals. In order to assure cost neutrality of the conversion, rates for psychiatric distinct units are being lowered. Settlement methodology for years paid prior to implementation of DRG payment methodology was clarified to ensure consideration of all claims based payments. Additionally, the supplemental pools for both critical and non-critical access hospitals are being adjusted to reflect the conversion of one hospital to critical access status. The distribution methodology for the supplemental pool for non-critical access hospitals will be changed to reflect the elimination of hospital specific discharge rates as part of the conversion to DRG methodology. The Department is seeking CMS approval of the state plan for this change.
Effective Date: July 1, 2011
 
MaineCare Benefits Manual, Chapter I, Section 1.10-2, Time Limits for Submission of Claims. WORD   
Concise Summary: Under this emergency rule claims for services provided before September 1, 2010 must be filed by January 31, 2011. This emergency rule only affects Chapter I, Sections 1.04 and 1.10-2 of the MaineCare Benefits Manual. Under existing rules, providers have one year from date of service to submit claims for payment. This change shortens that period for services provided prior to September 1, 2010. This emergency rule establishes a January 31, 2011 deadline for submitting claims for services provided before September 1, 2010. The Maine Claims Management System (MECMS) is being decommissioned and will stop accepting claims by January 31, 2011. Providers must submit claims for services provided before September 1, 2010 by January 31, 2011 or they will be unable to recover payment for them. (Claims for services on or after September 1st are being processed by the Maine Integrated Health Management Solutions (MIHMS) system.) Accommodations are made in the rule for claims involving coordination of benefits and retroactive eligibility. Adjustments will continue to be accepted for 120 days from the date of the remittance statement. This emergency rule is being adopted to provide certainty to MaineCare providers regarding the deadline for filing claims so that they can avoid financial uncertainty or loss in order to ensure providers’ ability to provide critical services to MaineCare members.
Effective Date: November 16, 2010
 
MaineCare Benefits Manual, Chapter II, Section 97, Private Non-Medical Institutions and Chapter III, Section 97 Private Non-Medical Institutions, Appendix B Principles of Reimbursement for Substance Abuse Treatment Facilities WORD   
Concise Summary: This is emergency rulemaking. The Legislature ordered various reductions in expenditures in the MaineCare program to counteract predicted deficits and balance the budget. P.L. 2009 c. 571. The reduction in reimbursements for substance abuse treatment facilities was selected by the Legislature after careful consideration, and it will be implemented in a fair and equitable manner. In effecting this legislative mandate, the Department is acting under its emergency rule-making authority, 5 M.R.S.A. § 8054. Emergency action is necessary to avoid the disruption of vital health care services to a substantial number of Maine citizens. The amendments to Chapter III, § 97 change the method of reimbursing substance abuse treatment facilities from an interim rate/cost-settlement basis to fixed per diem rates depending on the type of service. The new fixed rates are set forth in the regulation, and appropriate, HIPAA compliant billing codes are provided. Chapter II, § 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. These rules are not expected to have an adverse impact on small businesses, municipalities or counties.
Effective Date: November 15, 2010
 
MaineCare Benefits Manual, Chapter III, Section 96, Private Duty Nursing and Personal Care Services WORD   
Concise Summary: The rates for some Private Duty Nursing and Personal Care Services are incorrect. There is presently a financial cap on services for certain Private Duty Nursing and Personal Care Services. Members utilizing the services where the rate is presently too high may reach their cap before they would have if these rates are not corrected. In situations where the rate is too low providers are not being properly reimbursed. Therefore, the Department must further amend this rule to correct rates listed for “RN Services” (T1002), “Personal Support Services (FPSO)” (S5125) and “Medication Administration” (T1502). The unit of the services in this section was amended on June 27, 2010 to indicate that (unless indicated otherwise) the listed services are to be billed per 15 minutes, as opposed to the 30 minute unit as was previously the case. The amended rates for “RN Services”, “Personal Support Services (FPSO)” and “Medication Administration” were not listed accurately in the June 27, 2010 rule change. In addition, the language in this rule has been revised to better align with the language used in the nationally recognized HCPCS coding manual.
Effective Date: October 28, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 40, Home Health Services WORD   
Concise Summary: In order to assure Home Health providers are being paid at the correct rate of reimbursement for the “Administration of oral, intramuscular and/or subcutaneous medication by health care agency/professional, per visit” (0551/T1502), the Department is amending Chapter III, Section 40 to reflect a corrected rate of $84.95 per visit. This emergency rule also amends Chapter II to include language specifying that providers will be reimbursed for a set rate regardless of the length of the visit”. This is a change to a major substantive rule and it will not be permanently adopted until it has been approved by the Legislature
Effective Date: October 18, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 43, Hospice Services WORD   
Concise Summary: The emergency rule adopts the codes necessary when billing the Maine Integrated Health Management Solution (MIHMS) therefore allowing providers to bill correctly in the new system. The Revenue/HCPC combinations to be included are 0651/T2042 Routine Home Care (per diem), 0652/T2043 Continuous Home Care (hourly), 0655/T2044 Inpatient Respite Care (per diem), 0656/T2045 General Inpatient Care (per diem), 0657/appropriate CPT code per Section 90, Physician Services. In addition, the emergency rule permits 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: October 6, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 21, Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder. WORD   
Concise Summary: The emergency major substantive rule adopts new rates for Shared Living Providers pursuant to PL 2009, Ch 571, §§ A-25, A-26, and CCCC-3.
Effective Date: October 1, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter III Principles of Reimbursement, Section 97, Private Non-Medical Institution Services, Appendix D: Child Care Facilities WORD   
Concise Summary: This is emergency rulemaking. 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 and the Department’s emergency rulemaking authority 5 MRSA §8054 this emergency rule specifies rate reductions for services under Section 97 Private Non-Medical Institution Services, Appendix D: Child Care Facilities. Additionally the emergency rule eliminates one accounting requirement for providers that is no longer necessary, thereby reducing the administrative burden for providers. These rules are not expected to have an adverse impact on small businesses, municipalities or counties.
Effective Date: October 1, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapters II and III, Section 40, Home Health Services WORD   
Concise Summary: This is emergency rulemaking. These are changes to major substantive rules and they will not be permanently adopted until they have been approved by the Legislature. The Department is adopting through emergency rule-making, amendments to MaineCare Benefits Manual, Section 40, Chapters II and III, Home Health Services. In order to meet Center for Medicare and Medicaid Services requirements for HIPAA-compliant codes, the Department is adopting the Maine Integrated Health Management System (MIHMS) which is expected to become operational in the near future. Chapter II of the emergency rule-making directs providers to the new website addresses for CMS definitions related to billing and for the new billing instructions and billing codes for services and non routine medical supplies that will be utilized by MIHMS. The amendment adds a new definition for “non routine medical supplies”, directs providers how to access the list of non routine medical supplies which can be reimbursed under Section 40 and creates a process for adding to this list. It redefines the unit of service, making it consistent with the services associated with the new HIPAA compliant codes. Chapter III of this emergency rule provides the new HIPAA-compliant codes and the associated units of service that must be used by Home Health Services providers to bill for services when MIHMS is implemented.
Effective Date: September 1, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 31, Federally Qualified Health Center Services WORD   
Concise Summary: The following emergency rule is for MaineCare Benefits Manual, Chapters II and III, Section 31, Federally Qualified Health Clinics. This emergency rule is necessary to correct billing instructions and Chapter III coding requirements to ensure FQHC providers can bill for covered services for MaineCare members upon implementation of MIHMS. Failure to adopt these changes may result in providers being unable to bill and receive reimbursement for services rendered. This may result in members not receiving access to necessary care, thus causing a potential threat to health and safety. Furthermore, the Department is delaying the requirement for providers to report all encounter data on the UB 04 form until October 1, 2010. This will allow providers sufficient time to make necessary software and billing changes to meet the Department’s reporting requirements.
Effective Date: September 1, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 103, Rural Health Clinic Services WORD   
Concise Summary: The following emergency rule is for MaineCare Benefits Manual, Chapters II and III, Section 103, Rural Health Clinic Services. This emergency rule is necessary to correct billing instructions and Chapter III coding requirements to ensure RHC providers can bill for covered services for MaineCare members upon implementation of MIHMS. Failure to adopt these changes may result in providers being unable to bill and receive reimbursement for services rendered. This may result in members not receiving access to necessary care, thus causing a potential threat to health and safety. Furthermore, the Department is delaying the requirement for providers to report all encounter data on the UB 04 form until October 1, 2010. This will allow providers sufficient time to make necessary software and billing changes to meet the Department’s reporting requirements.
Effective Date: September 1, 2010
 
Emergency Rule: MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Mental Retardation or Autistic Disorder Word   
Concise Summary: This emergency Major Substantive rule provisionally adopts new rates of payment for services provided under this program. The rates are based on reductions mandated by the Legislature in the supplemental budget. Specifically, the rates of reimbursement for day habilitation and work support services are reduced by 2%; the rates for services provided in a residential setting are reduced by 1%; and all other rates are reduced by 10%. In addition, a modified rate for use in calculating the Agency Home Supports per diem is established for hours in excess of 168 per week. The billing codes are modified to comply with the requirements of the new Maine Integrated Health Management System (MIHMS), anticipated to come into use starting September 1, 2010 or later dependent upon implementation of the new system. Finally, the name of this section is changed to Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorders.
Effective Date: 2010-07-01
 
Chapter III, Section 29, Community Support Benefits for Members with Mental Retardation or Autistic Disorder word   
Concise Summary: The Department is adopting emergency reductions in rates paid for services to members in the Community Supports program, MBM, § 29. This action must be taken on an emergency basis in order to preserve services to members within the state’s current fiscal constraints. In addition, the Department adopts minor changes in the billing codes to be employed with the adoption of the Maine Integrated Health Management System, anticipated to occur in August.
Effective Date: July 1, 2010
 
MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities Word   
Concise Summary: The Department adopts amendments to MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement, on an emergency basis in order to comply with the State Supplemental Budget initiative to balance the State budget. The following is included in this emergency rule-making: applying an additional inflation of 12.37% to the routine cost component for SFY 11; calculating 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; removing reimbursement Principle 101, Staff Enhancement Payments (SEP), from the rules.
Effective Date: July 1, 2010
 
MaineCare Benefits Manual, Chapter III,Section 45, Hospital Services Word   
Concise Summary: This emergency rule changes the definition of “discharge.” P.L. 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 3 days following an inpatient admission for the same diagnosis.” This emergency rulemaking makes that change; the Department will reimburse for only 1 discharge, if a patient is readmitted to the same hospital within 72 hours for the same diagnosis. 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: July 1, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 28, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations word   
Concise Summary: This Emergency Rule makes the following changes: Chapter II: The Department is adding 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 has determined that the immediate adoption of this emergency rule is necessary to avoid a threat to public health, safety or general welfare, because these children are currently receiving Section 27 (Early Intervention) services, and will continue t have a need for medically necessary services after Section 27 is repealed effective September 1, 2010, or when MIMHS is implemented.. Federal Medicaid law, 42 USC 1396d(r)(5)(commonly known as “EPSDT”) requires state Medicaid agencies to provide to Medicaid recipients under 21 years of age “necessary health care, diagnostic services, treatment, and other measures described in section 1905(a) of the [Social Security] Act to correct or ameliorate defects and physical and mental illnesses and condition s discovered by the screening services…” This emergency rule complies with EPSDT. Additionally, schools, as defined in the regulation, have been added as a new provider of Section 28 services. The emergency rule states that for the time period July 1, 2010 through October 31, 2010, prior authorization is not required for any Section 28 services. The Department has determined that an immediate threat to public health, safety or general welfare arises because the Department needs additional time to refine its prior authorization process, and in the meantime needs to provide the services in a reasonable prompt manner to the member. Chapter III: The emergency rule adopts a 2% rate reduction for all covered services. P.L. 2009, ch. 571 PART A, Sec. A-25 required the Department to reduce funding based on a 10% reduction to the rates paid to providers under Section 28. However, P.L. 2009, ch. 571 PART RRRR, Sec. RRRR-1 authorized the Department to use funds provided in this Part to adjust MaineCare rates, otherwise subject to a 10% reduction, to actuarially based rates, as deemed necessary and applicable by the Department. The Department has determined that it is necessary and applicable to use the additional funding so that the Section 28 rates were reduced by 2%, not 10%.
Effective Date: July 01, 2010
 
MaineCare Benefits Manual, Section 113, Chapter III, Allowances for Transportation Services Word   
Concise Summary: This emergency rule adopts the cost savings measures reflected in the Maine June 2010 Supplemental Budget, resulting in a 6.5% decrease in all Allowances for Transportation Services reimbursement rates to become effective August 1, 2010. Of note, rate standardization was already in process for many months to prepare for the implementation of Maine Integrated Health Management Solution (MIHMS), the CMS certified billing system, therefore The Department determined that rate standardization was necessary to occur in this rulemaking prior to the 6.5% budgeted rate decrease.
Effective Date: August 1, 2010
 
MaineCare Benefits Manual, Chapter III, Section 68, Occupational Therapy Services word   
Concise Summary: This emergency rule specifies rate reductions effective 07/01/10 pursuant to the supplemental budget (PL 2009, Ch. 571, Sec. A-25). The rule specifies a reduction in rates of 10% for all Occupational Therapy Services and corrects a unit error for evaluation and re-evaluation services from a previously adopted rule, a correction that is required if budget savings are to be met.
Effective Date: July 1, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 65, Behavioral Health Services word   
Concise Summary: The emergency rule adopts the rates as directed in the supplemental budget approved by the Maine State Legislature, LD 1671, Part OOO, §000-1. Part A-25, Part RRRR, Sec. RRRR-1, resulting in a 2% (two percent) reduction in Children’s Home and Community Based Treatment and collateral contacts and a 10% (ten percent) reduction in Family Psychoeducation Treatment Program Services, Neurobehavioral Status exam, Psychological testing, and Opioid Treatment. Additionally, the emergency rule adopts specific eligibility requirements for services beyond seventy two (72) quarter hour units of service in a service year for Mental Health Outpatient Services.
Effective Date: July 1, 2010
 
Adopted Emergency Rule: MaineCare Benefits Manual, Chapter 101, Chapter III, Section 23, Developmental and Behavioral Clinic Services word   
Concise Summary: The Department is adopting an emergency rule for MaineCare Benefits Manual, Chapter 101, Chapter III, Section 23, Developmental and Behavioral Clinic Services pursuant to PL 2009, CH 571, Part A and Part OOO, § 000-1 (June 2010 State of Maine Supplemental Budget). The reductions in reimbursement set forth in these rules were selected after consideration by the Legislature. The Department is required to reduce the fees set forth in this policy by 10%, effective 07/01/2010. Therefore a 10% reduction to services has been applied to rates in this policy.
Effective Date: 2010-07-01
 
MaineCare Benefits Manual, Chapter III, Section 17, Community Support Services word   
Concise Summary: The emergency rules specify new rates effective 7/1/10 pursuant to the supplemental budget, PL2009, Ch.571, Part A §25 and Part OOO§ 000-1. The rule specifies a reduction in rates of 3 % for Community Integration and 4% for all other services in Section 17, Community Support Services.
Effective Date: 2010-07-01
 
MaineCare Benefits Manual, Chapter III, Section 50, Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded Word   
Concise Summary: This emergency rule does away with 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 persons with mental retardation. Instead, the rule refers providers to the reimbursement methods and rate for Community Support Services set forth in 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 rulemaking will not be finally adopted until approved by the Legislature.
Effective Date: 2010-04-01
 
Chapter 101, Ch II, Section 90, Physicians Services Word   
Concise Summary: Pursuant to PL 2009, chapter 213, effective March 1, 2010, the Department is increasing the MaineCare reimbursement rate for non-hospital based physician services from 56.94% to 70% effective 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. This emergency rule will remain in effect for 90 days while the Department promulgates rules to permanently adopt this rate change. No adverse impact on small businesses is anticipated from adoption of this rule.
Effective Date: 2010-03-01
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services Word   
Concise Summary: The Department has determined that the immediate adoption of these rules is necessary to avoid an immediate threat to public health, safety, or general welfare. The threat to public health is due to the expected escalation of H1N1 (swine flu) this fall. Accordingly, MaineCare is immediately adding reimbursement for administration of seasonal flu shots (H1N1) and other allowed vaccines under 32 MRSA § 13831 for licensed Maine pharmacists retroactive to October 1, 2009. Furthermore, retroactive to November 1, 2009, MaineCare pharmacies who compound the drug Tamiflu for MaineCare children and othe MaineCare members where there is a medical need and where 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. This emergency rulemaking will allow the Department to immediately work with pharmacists so that they can be reimbursed for the administration of these vaccines. These rules will remain in effect for 90 days while the Department permanently adopts these changes in a proposed rulemaking. A public hearing will be held as part of that separate rulemaking.
Effective Date: 2009-11-18
 
Chapter II, Section 60, Medical Supplies and Durable Medical Equipment Word  PDF   
Concise Summary: The Department has determined that the immediate adoption of these rules is necessary to assure that initiatives directed by the Maine State Legislature are immediately implemented to achieve required savings in the budget law, in accordance with PL 2009, ch. 213. The Legislature authorized the Department to do emergency rulemaking in conjunction with budget initiatives without the necessity of demonstrating that immediate adoption is necessary to avoid a threat to public health, safety or general welfare (P.L. 2009, ch. 213, Part RRRR). Effective October 5, 2009 the Department is changing 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 providers 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, apenea 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: 2009-10-05
 
MaineCare Benefits Manual Chapters II and III, Section 3, Ambulatory Care Clinics Word  PDF   
Concise Summary: The Department has determined that the immediate adoption of these rules is necessary to avoid an immediate threat to public health, safety, or general welfare. The threat to public health is due to the expected escalation of 2009 Influenza A (H1N1) this fall. The Department needs to act immediately to assure that as many citizens as possible are protected against H1N1 and seasonal flu. This public health emergency has been a topic discussed by the World Health Organization, the United States Department of Health and Human Services Secretary Kathleen Sebelius, and Maine Governor John E. Baldacci. On June 13, 2009, HHS Secretary Sebelius issued a public health emergency proclamation under the Public Readiness and Emergency Preparedness Act (42 U.S.C. §247-d-6d). On September 1, 2009, Governor Baldacci issued an Emergency Proclamation, requiring the DHHS Maine Center for Disease Control to coordinate with the Maine Emergency Management Agency to identify those qualified health care providers determined necessary to participate in planned vaccinations for seasonal and H1N1 flu. This emergency rule is intended to increase participation of providers who may administer such vaccines, by providing financial reimbursement for administration of the vaccines for MaineCare eligible members, in hopes of increasing the numbers of MaineCare members who are vaccinated against both seasonal and H1N1 flu, and making such vaccinations available as soon as possible. Accordingly, MaineCare is immediately adding reimbursement for administration of H1N1 and seasonal flu shots in flu clinics provided by Maine’s ambulatory care clinics. Ambulatory Care Clinic providers, schools, and Home Health Agencies will be reimbursed $5 per vaccination for administration of these flu vaccines to MaineCare members. It is crucial that as many individual as possible immediately receive seasonal flu vaccines, since those who contract seasonal flu are at greater risk for either contracting or experiencing complications for H1N1 flu. It is even more critically important that high risk populations, such as pregnant women, children and young adults up to age 24, persons with diabetes, compromised immunosuppressive systems, and asthma, many of which are covered by MaineCare, have access to these vaccinations. This emergency rulemaking will allow ambulatory care clinics to vaccinate MaineCare members in hopes of reducing the impact of both H1N1 and seasonal flu in Maine this fall. These rules will remain in effect for 90 days while the Department permanently adopts these changes in a proposed rulemaking. The emergency 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: 2009-09-13
 
MaineCare Benefits Manual Chapter III, Section 3, Ambulatory Care Clinics Word  PDF   
Concise Summary: The Department has determined that the immediate adoption of these rules is necessary to avoid an immediate threat to public health, safety, or general welfare. The threat to public health is due to the expected escalation of H1N1 (swine flu) this fall. The Department needs to act immediately as Maine’s children return to school to assure that as many citizens are possible are protected against both H1N1 and seasonal flu. Accordingly, MaineCare is immediately adding reimbursement for administration of H1N1 and seasonal flu shots in Maine’s ambulatory care clinics. MaineCare will reimburse $5 per vaccination for administration of these flu vaccines, which will be supplied at no cost to school-based ambulatory care clinics by the Maine CDC. This emergency rulemaking will allow the Department to immediately work with school departments to appropriately enroll them as ambulatory care clinic providers so that they can be reimbursed for the administration of these state supplied vaccines. This emergency rulemaking will allow school based ambulatory care clinics to be reimbursed to vaccinate Maine’s children as they return to school, in hopes of reducing the impact of H1N1 and seasonal flu in Maine this fall. These rules will remain in effect for 90 days while the Department permanently adopts these changes in a proposed rulemaking. A public hearing will be held as part of that separate rulemaking.
Effective Date: 2009-09-08
 
MaineCare Benefits Manual Chapters II & III, Section 13, Allowances for Targeted Case Management Services Word  PDF   
Concise Summary: The Department has determined that the immediate adoption of these rules is necessary to comply with legislative requirements for budgeted savings in accordance with P.L. 2009, ch. 213, Part CC..Additionally, the Maine Legislature authorized the Department to do emergency rulemaking in connection with budget initiatives, without the necessity of demonstrating that immediate adoption is necessary to avoid a threat to public health, safety or general welfare. P.L. 2009, ch. 213, Part RRRR. The Department adopted emergency targeted case management rules with an effective date of August 1, 2009. After that date, the Department realized that the emergency rules excluded coverage for individuals receiving protective services, and that these individuals had a critical need of the TCM services. Accordingly, the Department determined that it needed to adopt this emergency rule to get services to this critical group of individuals. This emergency rule contains the following changes to the August 1, 2009 emergency rule: (1) Includes coverage to individuals who receive protective services; (2) changes billing for some TCM services from 15 minute increments to monthly billing; and (3) 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 anticipates achieving a cost savings in the General Fund of $ 4,138,665 per State fiscal year 2010/2011. The Department expects an annual decrease in annual aggregate (state and federal) expenditures of $11,744,223.00 per State fiscal year 2010/2011. Pursuant to 5 M.R.S.A. § 8054, the Department has determined that immediate adoption of this provision is necessary to avoid an immediate threat to public health, safety or general welfare because of the economic crisis facing the State of Maine. The U.S. economy is in a deep recession. Maine faces a deficit of approximately $780 million for the 2010-2011 biennium. The Department determined that changes to Targeted Case Management Services were necessary, along with the legislatively mandated budgeted savings, to assure that the financial crisis did not deepen. These rules will remain in effect for 90 days while the Department proposes the rules through the regular Administrative Procedures Act (APA) process to permanently adopt the rules. A public hearing will be held as part of that process. 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: 2009-08-31
 
MaineCare Benefits Manual, Chapter III, Section 97, and Appendix D and E, Private Non-Medical Institutions Word  PDF   
Concise Summary: The Department has determined that the immediate adoption of these rules is necessary to assure targeted budget savings are met. In this rulemaking, the Department is adding language detailing eligibility criteria and requiring prior authorization for children’s PNMI 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. In this Section, the Department is also defining models of PNMI services for which standard rates are being set in a separate rulemaking pertaining to reimbursement of PNMI services in Chapter III, Section 97. These rules will remain in effect for 90 days while the Department permanently adopts these changes in a proposed rulemaking. A public hearing will be held as part of that separate rulemaking. This rule has no impact on small businesses, counties or municipalities, other than those providers with twenty or fewer employees. These rule changes are expected to result in total savings of $8,538,368. The changes for children’s PNMI services will result in cost savings per State Fiscal year of $6,838,368, $2,091,857 from general funds, $4,404,593 from federal funds and $341,819 from other special revenue. The changes for adult PNMI services are expected to result in an additional $1.7 million savings per State Fiscal year, $1,615,000 from general funds and $85,000 from other special revenue.
Effective Date: 2009-08-01
 
MaineCare Benefits Manual, Chapter II, Section 97, Private Non-Medical Institutions Word  PDF   
Concise Summary: The Department has determined that the immediate adoption of these rules is necessary to assure targeted budget savings are met. In this rulemaking, the Department is adding language detailing eligibility criteria and requiring prior authorization for children’s PNMI 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. In this Section, the Department is also defining models of PNMI services for which standard rates are being set in a separate rulemaking pertaining to reimbursement of PNMI services in Chapter III, Section 97. These rules will remain in effect for 90 days while the Department permanently adopts these changes in a proposed rulemaking. A public hearing will be held as part of that separate rulemaking. This rule has no impact on small businesses, counties or municipalities, other than those providers with twenty or fewer employees. This rule making expects to yield a net cost savings of $6.5 million per State Fiscal Year for children’s PNMI initiatives, and an additional $1.6 million in adult behavioral health PNMI services.
Effective Date: 2009-08-01
 
MaineCare Benefits Manual, Chapters II & III, Section 13, Targeted Case Management Services Word  PDF   
Concise Summary: The Department is repealing and replacing Targeted Case Management rules in this Emergency rulemaking. Services in the former rule will no longer be available upon implementation of these rules. Target groups have been consolidated and redefined. Several target groups are being deleted, including Pregnant and Postpartum women, Adults with Diabetes and Asthma and Members who are receiving Healthy Futures Services. The Department is adding language detailing eligibility criteria for Children and Adults to include 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. Children’s targeted case management services require prior authorization, . 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 rulemaking contains changes to the TCM service and delivery required by federal Medicaid regulation. 42 C.F.R. § § 440.169 and 441.18. For example, this rule clarifies that MaineCare will not cover multiple case management services; and sets forth the eligibility process, and the requirement of transitioning to one comprehensive case manager for children and adult members. Chapter III establishes 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 fifteen (15) minute increments. Record-keeping requirements for TCM providers have been added to the rule. On June 1, 2009, the Department mailed a notice to TCM recipients notifying them of changes to the TCM service. On June 31, 2009, the Department published a Notice of Change in Medicaid Reimbursement Methodology to notify TCM providers of rate changes. The Department anticipates achieving a cost savings in the General Fund of $ 4,138,665 per State fiscal year 2010/2011. The Department expects an annual decrease in annual aggregate (state and federal) expenditures of $11,744,223.00 per State fiscal year 2010/2011. 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: 2009-08-01
 
MaineCare Benefits Manual, Section 46, Psychiatric Hospital Services, Chapter II Word  PDF   
Concise Summary: These emergency rules establish admission eligibility and continuing eligibility criteria for psychiatric hospitals. 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.
Effective Date: 2009-07-01
 
MaineCare Benefits Manual, Section 45, Hospital Services, Chapter II - Emergency Rule Word  PDF   
Concise Summary: These emergency 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.
Effective Date: 2009-07-01
 
10-144, CH 101, MaineCare Benefits Manual, Chapters II & III, Section 17, Community Support Services Word  PDF   
Concise Summary: These emergency rules specify a new level of service called Community Rehabilitation Services to provide community support to qualifying individuals with an assessed need for that level of service. The rules replace the Global Assessment Functioning (GAF) scale with the Level of Care Utilization System (LOCUS) as a component of eligibility criteria for Community Support Services. The rules specify the services and delivery requirements for ACT clients. The rules provide HIPAA-compliant billing codes for use in the Maine Integrated Health Management Solution (MIMHS) system when it is implemented. The rules also include some formatting and other technical changes to improve clarity.
Effective Date: 2009-07-01
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services Word  PDF   
Concise Summary: The Department has determined that the immediate adoption of these rules is necessary to assure that initiatives directed by the Maine State Legislature are immediately implemented to achieve required hospital expenditure savings in the budget law, per PL 2009, ch. 213, part CC. The Legislature authorized the Department to do emergency rulemaking on or before December 31, 2009, for provisions over which the Department has subject matter jurisdiction, without the necessity of demonstrating that immediate adoption is necessary to avoid a threat to public health, safety or general welfare (P.L. 2009, ch. 213, Part RRRR). Effective July 1, 2009 the Department will reduce hospital reimbursement. For acute care non-critical access hospitals, inpatient discharge rates (except for those from psychiatric units) will be reduced 6.7% and reimbursement for outpatient services will decrease to 83.8% of costs. For critical access hospitals and hospitals reclassified to a wage area outside Maine, reimbursement for inpatient and outpatient services will be reduced to 109% of costs. For all acute care hospitals, including critical access, hospital based physician reimbursement will be 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. If approved by CMS, the Department caps the PIP payment so that the total payment to all hospitals is not less than 80%. In addition, these rules eliminate the COLA adjustment for SFY's 2010 and 2011 for acute care non-critical access hospitals for inpatient discharge rate and for psychiatric unit discharge rates. The Department estimates that this reimbursement reduction will result in a decrease of $25,554,918 in annual aggregate (state and federal Medicaid funds) expenditures for settled hospital expenditures. This emergency 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: 2009-07-01
 
Chapter 101, MaineCare Benefits Manual, Chapters II and III, Section 96, Private Duty Nursing and Personal Care Services Word  PDF   
Concise Summary: The Department adopts emergency rules for Chapters II and III of Section 96, Private Duty Nursing and Personal Care Services. Specifically, this emergency rule includes two new definitions in the rule. In addition, a new level of eligibility, level IX, is added for MaineCare members who require medication administration and assistance with ADLs or IADLs. Two new provider codes are added to Chapter III to permit reimbursement for these services.
Effective Date: 2009-07-01
 
MaineCare Benefits Manual, Chapter III, Section 17, Community Support Services Word  PDF   
Concise Summary: The Emergency rule specifies a correction in the rate for Day Treatment.
Effective Date: 2009--07-01
 
MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities Word  PDF   
Concise Summary: These emergency rules amend methodology language throughout Section 80 used to properly establish the prospective per diem rates beginning July 1, 2009 for providers. These rules repeal and replace the emergency rules that are currently in place as of June 11, 2009. These changes include revisions to dates and methodology used to trend forward or inflate direct care and routine costs, updates to the percent of the median used in the July 1, 2009 rebasing calculation, and clarifies the direct care add-on and hold harmless principles. In addition, the Department is repealing the emergency rule for Ch. III, Sec. 67, which was adopted on June 11, 2009, and which adopted a modified methodology for the one time supplemental payment to eligible nursing facilities. The Department is including the CMS approved methodology of the one time supplemental payment as part of this emergency rule, for the purpose of simplifying this complex rule. Finally, this rule making includes a new principle that identifies the methodology used to establish rates for remote island facilities. These emergency rules remain in effect up to ninety (90) days.
Effective Date: 2009-07-01
 
MaineCare Benefits Manual, Chapter III, Section 21, Home and Community Benefits for Members with Mental Retardation or Autistic Disorder Word  PDF   
Concise Summary: The emergency adoption of this major substantive rule specifies new rates that are effective July 1, 2009. The change in rates is mandated by the Legislature. The budget initiative requires that rates by reduced by six (6) %; however, the budget initiative specifies that the reduction is from the rates that were effective in December 2008.
Effective Date: 2009-07-01
 
MaineCare Benefits Manual, Section 109, Chapter III, Speech and Hearing Services Word  PDF   
Concise Summary: These emergency rules establish increased rates of reimbursement for speech and hearing agencies to comply with FY 2010 budget requirements.
Effective Date: 2009-07-01
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities Word  PDF   
Concise Summary: In this emergency rule making, the Department is implementing changes in the one-time payment methodology. Since March 15, 2009, the Centers for Medicare and Medicaid Services (CMS) has informed the Department that its state plan must be modified to clarify the one time supplemental payment. Specifically, the dates of service on which the payment will be based will begin January 1, 2009 instead of July 1, 2008. In addition, the Department was required to add more specific language that describes the methodology that will be used for the calculation of the one-time payment. These emergency rules will be in effect for ninety (90) days.
Effective Date: 2009-06-11