MaineCare Benefits Manual - Emergency Rules

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: June 11, 2009

CONCISE SUMMARY:These emergency rules establish increased rates of reimbursement for speech and hearing agencies to comply with FY 2010 budget requirements.

Effective Date: July 1, 2009

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.

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.

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.

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.

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.

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.

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.

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.

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: August 1, 2009

CONCISE SUMMARY: The Emergency rule specifies a correction in the rate for Day Treatment.

Effective Date: July 1, 2009

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: August 1, 2009

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: August 31, 2009

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: September 8, 2009

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: September 23, 2009

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: October 5, 2009

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.