Proposed Rulemaking Archives

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MaineCare Benefits Manual, Ch. III Section 65, Behavioral Health Services WORD  PDF   
Concise Summary: This proposed rule seeks to permanently adopt the emergency rule that 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, Ch. III Section 65, Behavioral Health Services beginning July 1, 2013. The Legislature mandated the reimbursement rates be restored to LCPCs and LMFTs in P.L. 2013 ch. 368 §WWWW-1 and authorized the Department to do emergency rule-making. 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.
Comment Deadline: August 22, 2013 Posted: July 29, 2013
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services WORD  PDF   
Concise Summary: This proposed rulemaking seeks to permanently adopt changes already made on an emergency basis, implementation of a budget savings initiative of P.L. 2013, ch. 368, (LD 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). 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 Access 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.
Comment Deadline: August 29, 2013 Posted: July 25, 2013
 
MaineCare Benefits Manual, Chapter II, Section 45, Hospital Services word  pdf   
Concise Summary: This proposed rulemaking seeks to permanently adopt changes already made on an emergency basis, implementation of 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.
Comment Deadline: June 13, 2013 Posted: May 14, 2013
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services word  pdf   
Concise Summary: This proposed rulemaking seeks to permanently adopt changes already made on an emergency basis, implementation of 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 rule allows reimbursement for a distinct substance abuse unit discharge rate for acute care non-critical access hospitals who meet the standard. The rate is $4,898 per stay. The Department is seeking CMS approval of the state plan for this change.
Comment Deadline: June 13, 2013 Posted: May 14, 2013
 
, MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures. word  pdf   
Concise Summary: This rule change is proposed to permanently adopt the provisions within an emergency rule which will expire on June 24, 2013. The federal Patient Protection and Affordable Care Act of 2010 (PPACA) requires the suspension of payments to providers who are the subject of a credible allegation of fraud. This proposed rule defines the term “credible allegations of fraud” and provides for exceptions and appeal procedures consistent with the requirements of the PPACA. As authorized by the State Legislature, this rule provides for a person to request expedited relief from a suspension of payments.
Comment Deadline: June 13, 2013 Posted: May 14, 2013
 
MaineCare Benefits Manual, Section 19, Chapters II & III, Home and Community Benefits for the Elderly and for Adults with Disabilities word  pdf   
Concise Summary: The Department is proposing changes to this rule to provide services for members using Home and Community Benefits for the Elderly and for Adults with Disabilities (Section 19) concurrently with the operation of a 1915(b) Non-Emergency Transportation Waiver. These proposed changes to Section 19 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. Members who receive services under this policy will be provided Non-Emergency Transportation under Section 113 of the MaineCare Benefits Manual. The Department will contract with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of Non-Emergency Transportation services for eligible MaineCare members. The Broker(s) will be responsible for establishing a network of Non-Emergency Transportation drivers to deliver Non-Emergency Transportation services to eligible members who live in their assigned region. The proposed rule also makes technical changes to language and names when usage has changed or has been deemed inappropriate by the Maine Legislature. Specifically, the changes: a. Replace references to “mental retardation” with references to “intellectual disability”, as required by P.L. 2012, Ch. 542, §B(5), An Act To Implement the Recommendations of the Department of Health and Human Services and the Maine Developmental Disabilities Council Regarding Respectful Language; b. Replace references to “Office of Integrated Access and Support” with references to “Office of Family Independence,”; c. Replace references to “Office of Adults with Cognitive and Physical Disabilities Services” with references to “Office of Aging and Disability Services”; and, d. Remove “if CMS approves” language, as CMS approved the changes, effective 9/1/10.
Comment Deadline: June 13, 2013 Posted: May 14, 2013
 
MaineCare Benefits Manual, Chapter 101, Chapter III, Section 32, Allowances for Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders word  pdf   
Concise Summary: This rule is to permit MaineCare members to access transportation services along with their 1915(c) Home and Community Benefits. The Department is proposing changes to this rule to provide services for members with Intellectual Disabilities and Autistic Disorders concurrently with the operation of a 1915(b) Non-Emergency Transportation Waiver. These proposed changes to Section 32 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. Members who receive services under this policy will be provided Non-Emergency Transportation under Section 113 of the MaineCare Benefits Manual. The Department will contract with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of Non-Emergency Transportation services for eligible MaineCare members. The Broker(s) will be responsible for establishing a network of Non-Emergency Transportation drivers to deliver Non-Emergency Transportation services to eligible members who live in their assigned region.
Comment Deadline: June 13, 2013 Posted: May 13, 2013
 
MaineCare Benefits Manual, Section 29, Chapter III, Allowances for Support Services for Adults with Intellectual Disabilities or Autistic Disorder WORD  PDF   
Concise Summary: The Department of Health and Human Services (DHHS) is proposing to amend Chapter III, Section 29 of the MaineCare Benefits Manual, by removing the procedure code for Transportation Services. This change is necessary to comply with the concurrent operation of a new 1915(b) Non-Emergency Transportation Waiver. These proposed changes to Section 29 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. Going forward, members who receive services under the Section 29 waiver will be provided non-emergency transportation through Section 113 of the MaineCare Benefits Manual. Under risk-based contractual agreements, the Department will contract with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of non-emergency transportation services for eligible MaineCare members. The Broker(s) will be responsible for establishing a network of non-emergency transportation drivers to deliver non-emergency transportation services to eligible members who live in their assigned region.
Comment Deadline: June 13, 2013 Posted: May 13, 2013
 
MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder WORD  PDF   
Concise Summary: This letter gives notice of a proposed rule: MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder. The Department of Health and Human Services (DHHS) is proposing two substantive changes to Chapter III, Section 21 of the MaineCare Benefits Manual. First, the Department is proposing to remove the procedure code for Transportation Services, in order to comply with the concurrent operation of a new 1915(b) Non-Emergency Transportation Waiver. These proposed changes to Section 21 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. Going forward, members who receive services under the Section 21 waiver will be provided non-emergency transportation through Section 113 of the MaineCare Benefits Manual. Under risk-based contractual agreements, the Department will contract with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of non-emergency transportation services for eligible MaineCare members. The Broker(s) will be responsible for establishing a network of non-emergency transportation drivers to deliver non-emergency transportation services to eligible members who live in their assigned region. Second, the Department is proposing to add a HCPCS procedure code for Behavioral Consultation, G9007 HI. The proposed reimbursement rate for Behavioral Consultation is $14.85 per fifteen minute unit. The Centers for Medicare and Medicaid Services have approved the addition of Board Certified Behavior Analyst to provide Behavioral Consultation. Lastly, the Department is also proposing to update several internet addresses that appear through Chapter III, Section 21. Rules and related rulemaking documents may be reviewed at, or printed from, the MaineCare Services website at http://www.maine.gov/dhhs/oms/rules/index.shtml or for a fee, interested parties may request a paper copy of rules by calling (207) 287-9368. For those who are deaf or hard of hearing and have a TTY machine, the TTY number is 711. A concise summary of the proposed rule is provided in the Notice of Agency Rule-making Proposal, which can be found at http://www.maine.gov/sos/cec/rules/notices.html. This notice also provides information regarding the rule-making process. Please address all comments to the agency contact person identified in the Notice of Agency Rule-making Proposal
Comment Deadline: June 13, 2013 Posted: May 13, 2013
 
MaineCare Benefits Manual, Section 21, Chapter II, Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorders word  pdf   
Concise Summary: The Department is proposing a number of unrelated changes to this rule. The Department is proposing changes to the rule to comply with the concurrent operation of a 1915 (b) Non-Emergency Transportation Waiver. These proposed changes to Section 21 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. The proposed change to Section 21 includes referencing the regional, risk-based, pre-paid ambulatory health plan (PAHP) Brokerages operating under a 1915(b) waiver approved by the Centers for Medicare and Medicaid Services (CMS). Under risk-based contractual agreements, the Department will contract with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of Non-Emergency Transportation (NET) services for eligible MaineCare members. The Broker(s) will be responsible for establishing a network of NET drivers to deliver NET transportation services to eligible members who live in their assigned region. The Department is also proposing other technical changes. 1. The website for The Maine College of Direct Support is being updated to a current link and can be accessed on the internet at: http://www.maine.gov/dhhs/oads/disability/ds/cds/index.shtml 2. The Department is proposing to add language clarifying that the assessment referral form may be the BMS 99 form currently in use or some other form approved by the Department. This change is in anticipation of a move to a new functional assessment tool, the Supports Intensity Scale (SIS). 3. Requirements for Direct Support Professionals are being added, requiring DSPs to complete four specific modules prior to being left alone with a member. 4. The Department is proposing to delete Appendix IV and replace it with a more simple statement of the combined limits on Work Support and Community Support in the main text of the rule.
Comment Deadline: June 13, 2013 Posted: May 13, 2013
 
MaineCare Benefits Manual, Chapters II, Section 113, Non-emergency NET Transportation Services WORD  PDF   
Concise Summary: On June 6, 2012, the Centers for Medicare and Medicaid (CMS) approved a 1915(b) waiver to provide Medicaid non-emergency medical transportation using a regional risk-based prepaid ambulatory health plan (PAHPS). The waiver ends on June 30, 2013, and the Department is engaged in discussions with CMS to extend the transportation waiver. The CMS approval provided that two provisions of Title XIX of the Social Security Act are waived: (1) Section 1902(a)(4)(single source provider); and (2) Section 1902(a)(23)(Freedom of Choice). MaineCare members eligible to receive non-emergency transportation services under this waiver include members who receive home and community-based services (HCBS) waiver programs. In developing its waiver application, from late 2010 through 2012, the Department had conducted several meetings regarding MaineCare transportation with stakeholders in various forums. The Department met with the Maine Transportation Association multiple times, presented information to the MaineCare Advisory Committee at monthly meetings throughout the process, consulted with the Federally Recognized Tribes, as well as conducting multiple stakeholder meetings pertaining to the RFP. These meetings included meeting with advocacy groups such as Speak Up for Us, with the local transportation companies and also internal stakeholders in the Maine Department of Transportation. The Department issued an RFP for this transportation waiver services, and is concluding contracts with several entities, who are known as “Brokers”, and who will provide MaineCare transportation services regionally, throughout the state. The Department will reimburse the Brokers on a per member/per month fee. The Brokers will be responsible for establishing a network of Drivers to deliver the transportation services to MaineCare members who live in their assigned region. This rule proposes to repeal in its entirety the current Section 113 (Transportation Services), ch. II and III, and replaces it with the proposed rule.
Comment Deadline: June 14, 2013 Posted: May 10, 2013
 
MaineCare Benefits Manual, Chapter II, Section 67, Nursing Facility Services      
Concise Summary: This rulemaking seeks to permanently implement changes made on an emergency basis, a budget savings initiative of LD 250, An Act To Make Supplemental Appropriations and Allocations for the Expenditures of State Government and To Change Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Year Ending June 30, 2013. If CMS approves, payment of bed holds for a semi-private room for a short-term hospitalization of the member shall be granted up to four (4) days’ (midnights) absence through June 30, 2013, as long as the member is expected to return to the nursing facility. Effective July 1, 2013, payment for these bed holds shall be granted up to four (4) days’ (midnights) absence during the twelve (12) month state fiscal year (July 1 through June 30) and every state fiscal year thereafter. The Department will also, if CMS approves, reduce reimbursement for a leave of absence from thirty-six days in a twelve-month period to no more than one (1) day in leave of absence from March 25, 2013 through June 30, 2013; and, effective July 1, 2013, one (1) day of leave of absence during the twelve (12) month state fiscal year (July 1 through June 30) and every state fiscal year thereafter. This proposed rule also incorporates additional changes to those made on an emergency basis by removing references to “transportation agency” and replacing it with a new Non-Emergency Transportation (NET) Broker, in order to comply with the new transportation broker program the Department is proposing in Section 113.
Comment Deadline: June 13, 2013 Posted: May 7, 2013
 
MaineCare Benefits Manual, Chapter III, Section 65, Behavioral Health Services WORD  PDF   
Concise Summary: This proposed rule seeks to permanently adopt a 5% reduction to reimbursement rates for Licensed Clinical Professional Counselors (LCPC) and Licensed Marriage and Family Therapists (LMFT), as directed by the Maine State Legislature in P.L. 2013, Ch. 1, § A-23 (“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 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 March 5, 2013
Comment Deadline: May 9, 2013 Posted: April 5, 2013
 
MaineCare Benefits Manual, Chapter II, Section 65, Behavioral Health Services WORD  PDF   
Concise Summary: This proposed rule seeks to permanently adopt the emergency rule in accordance with P.L. 2011, ch. 657, (L.D. 1746), Part A, S, § S-1 (125th Legis.) effective January 1, 2013 that limits MaineCare reimbursement for methadone for the treatment of addiction to opioids to a maximum of twenty four (24) months per lifetime, except as permitted with prior authorization beyond twenty-four (24) months. Only treatment after January 1, 2013 will count toward the limit.
Comment Deadline: April 26, 2013 Posted: March 27, 2013
 
MaineCare Benefits Manual, Chapter II, Section 85, Physical Therapy Services Word  PDF   
Concise Summary: This proposed rule will increase the limits for Physical Therapy Services to allow for up to five (5) treatment visits and one (1) evaluation within twelve (12) months, when provided pursuant to a pain management care plan.
Comment Deadline: Midnight March 21, 2013 Posted: February 20, 2013
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services. Word  PDF   
Concise Summary: This proposed rule will impose limits on opioid medications used for the treatment of pain, pursuant to PL 2011, ch. 657, Part O, the Department of Health and Human Services 3rd Supplemental Budget. The rule includes definitions of acute and non-acute pain, establishes certain exclusions as described in the legislation, mandates the use of a pain management care plan when a member requires the use of opioid medications for the treatment of pain beyond the prescribed limits, and identifies therapeutic treatment options that must be utilized for members who are prescribed opioid medications to treat non-acute pain.
Comment Deadline: Midnight March 21, 2013 Posted: February 20, 2013
 
MaineCare Benefits Manual, Chapters II & III, Section 91, Health Home Services Word  PDF   
Concise Summary: This proposed rulemaking seeks to permanently adopt Health Home Services which were put into place via emergency rule, effective January 1, 2013. This is a new MaineCare regulation which establishes “Health Homes” for MaineCare beneficiaries who suffer from certain chronic health conditions (including a mental health condition [excluding Serious and Persistent Mental Illness and Serious Emotional disturbance]; a substance use disorder; tobacco use; diabetes; heart disease; overweight or obese as evidenced by a Body Mass Index over 25; Chronic Obstructive Pulmonary Disease; hypertension; hyperlipidemia; developmental and intellectual disorders; circulatory congenital abnormalities; asthma; acquired brain injury; and seizure disorders). Congress enacted the Affordable Care Act which, in part, authorized States to offer Medicaid Health Home Services as a way to improve health care through coordinated care and at a reduced cost. For the first two years that a state offers Medicaid Health Home Services, the federal matching rate equals 90%. Under Maine’s Health Home program, members eligible for Health Home services will be assigned to a “Health Home Practice”(HHP, which is a primary care practice that has completed an application and been approved by MaineCare as an HHP). The HHP is responsible for providing acute and preventive care, managing chronic illnesses, coordinating specialty care and referrals to social, community, and long-term care supports, providing comprehensive care management, and providing access to 24/7 coverage. The HHP is required to work with a Community Care Team (CCT is a multi-disciplinary, community-based, practice-integrated care management team that has completed an application and been approved by MaineCare as a CCT) to identify members with the most intense health care needs and to provide more intense Health Home services for such members. The number of members receiving CCT services at any point in time is capped at 5% of each HHP’s members.
Comment Deadline: Midnight, Thursday March 7, 2013 Posted: February 5, 2013
 
MaineCare Benefits Manual, Chapter VI, Section 1, Primary Care Case Management Word  PDF   
Concise Summary: The Patient Centered Medical Home (PCMH) program is being replaced by the Health Home Initiative described in the new/proposed MaineCare Benefits Manual, Chapters II & III, Section 91 (“Health Home Services”) that is concurrently going through the rulemaking process.
Comment Deadline: Midnight, Thursday March 7, 2013 Posted: February 5, 2013
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services   PDF   
Concise Summary: This proposed rulemaking seeks to permanently adopt changes already made on an emergency basis that implemented the use of the Ambulatory Payment Classification (APC) system-based reimbursement for almost all outpatient services, including lab and radiology, for private, Non-Critical Access and rehabilitation hospitals, effective July 1. Maine is adopting Medicare methodology and will pay 93% of the Medicare rate. These hospitals will no longer receive any Prospective Interim Payments (PIP). Reflecting these changes, the general description of the types of hospitals in Maine and the related reimbursement methodologies will change. Critical Access Hospitals would be exempted from the requirements to count readmissions within 72 hours as part of the initial discharge. The DHHS will be seeking CMS approval of the State Plan for these changes. PLEASE NOTE THAT DEADLINE FOR RECEIVING COMMENTS IS SEPTEMBER 14, 2012
Comment Deadline: September 14, 2012 Posted: August 16, 2012
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services   PDF   
Concise Summary: This rule is being proposed, in part, to reduce reimbursement for retail pharmacy providers pursuant to administrative savings initiative associated with the 2012 Department of Health and Human Services (DHHS) Supplemental Budget. The reimbursement methodology will be of Average Wholesale Price (AWP) minus sixteen percent (16%). Additionally, the proposed rule will, consistent with previous emergency rules, increase the dispensing fee paid to mail order pharmacies from one dollar ($1.00) per prescription to two dollars and fifty cents ($2.50). The Department is proposing a portion of this rule in accordance with Part BB-1 of the 2012 Supplemental Budget requiring that MaineCare Services impose a mandatory substitution for a brand-name drug of a generic and therapeutically equivalent drug as required by the Maine Revised Statutes, Title 32, section 13781, with certain exceptions. The criteria regarding prescription medications utilized for managing weight or enhancing nutrient intake will be revised. The proposed rule will add language to further clarify the documentation that may be requested by the Department when processing prior authorization requests for opioids or narcotic prescription medications. Additionally, the proposed rule will add criteria for early refills for mail order prescriptions in excess of a ninety percent (90%) threshold. Wholesale Acquisition Cost (WAC) will be added as a reimbursement methodology for generic, brand-name and specialty prescription medications. The proposed rule will add language to indicate that a provider may bill for generic drugs based on the Federal Upper Limit (FUL) if it is the lowest form of reimbursement of those methodologies listed in the rule, unless the Department meets FUL in the aggregate, which is automatically calculated at the point of service. The proposed rule will add language to include the coverage of 340B prescription medications, the process for reimbursement of 340B medications and the enrollment instructions for those providers eligible to enroll in the 340B drug program. In addition, the fee for compound medications that are stock supply and those that are solutions or lotions involving no weighing has been eliminated. This change provides clarity for providers. The CMS 1500 claim form has been revised and now allows for more than one National Drug Code (NDC) to be included on an individual claim; the Department proposes adding language to require that the NDC for each active and inactive ingredient and the corresponding quantity used for each ingredient be included on the claim form. Finally, the proposed rule will remove section 80.09-2, Returned Reusable Drugs for Retail Pharmacy Providers. This program was previously tied to a budget initiative However, since the implementation of the Medicare Prescription Drug Benefit (Medicare Part D), there is no longer any savings associated with this program. PLEASE NOTE THAT DEADLINE FOR RECEIVING COMMENTS IS SEPTEMBER 14, 2012
Comment Deadline: September 14, 2012 Posted: August 16, 2012
 
MaineCare Benefits Manual, Chapter II, Section 4, Ambulatory Surgical Center Services Word   PDF   
Concise Summary: The Department of Health and Human Services is proposing to repeal Chapter 101, MaineCare Benefits Manual, Chapter II, Section 4, Ambulatory Surgical Center Services, in accordance with Public Law 2011, c. 657, Part A, the Maine State Supplemental Budget. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Comment Deadline: August 9, 2012 Posted: July 3, 2012
 
MaineCare Benefits Manual, Chapters II and III, Section 150, STD Screening Clinic Services Word  PDF   
Concise Summary: The Department of Health and Human Services is proposing to repeal Chapter 101, MaineCare Benefits Manual, Chapters II and III, Section 150, STD Screening Clinic Services, in accordance with Public Law 2011, c. 657, Part A, the Maine State Supplemental Budget. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Comment Deadline: August 9, 2012 Posted: July 3, 2012
 
MaineCare Benefits Manual, Chapter III, Section 21 Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder WORD  PDF   
Concise Summary: The rule proposes to adopt a 5% decrease in rates for Agency Home Support per diem as directed by P.L.2011, Chapter 477, § M-1.
Comment Deadline: August 3, 2012 Posted: June 28, 2012
 
MaineCare Benefits Manual, Chapter 101, Section 21, Chapter II, Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorders Word   PDF    
Concise Summary: The Department is proposing to remove language from 21.02-7 Employment Setting, as required by Resolve Chapter 49, LD 28, passed by the 125th Legislature that states that “Members with disabilities should constitute no more than 50% of the business’s workforce at any given worksite or location.” The Department is proposing to add language to clarify that a Licensed Clinical Social Worker (LCSW) or Licensed Clinical Professional Counselor (LCPC) can provide psychological or behavioral consultation. Additionally, if approved by CMS, the Department is proposing to add a Board Certified Behavior Analyst (BCBA) as a qualified provider who can provide psychological or behavioral consultation. Limits are being proposed to be added; no one member Agency Home Support placements will be approved after this rule has been adopted. Also, Home Support ¼ hour- T2017 is not to exceed three hundred and thirty six (336) quarter hour units or eighty four (84) hours a week. And, lastly for limits, authorizations for services to be provided out-of-state will not exceed sixty (60) days of service within a given fiscal year, and not exceed sixty (60) days within any six (6) month period. Language that had previously been in provider contracts or riders is also being proposed to be added to the policy. Technical language changes are also being proposed.
Comment Deadline: August 26, 2012 Posted: June 26, 2012
 
MaineCare Benefits Manual, Chapters II & III, Section 65, Behavioral Health Services WORD  PDF   
Concise Summary: This rule is being proposed, in part, to comply with 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 26, 2012. Parts of this rule are being proposed in accordance with Part M of said Budget requiring that MaineCare Services reduce reimbursement of Opioid Treatment (Methadone) from $72.00 per week to $60.00. This change is currently in effect through an emergency rule, effective April 1, 2012. Additionally, this proposed rule includes changes from the general administrative savings portion of the Maine State Supplemental Budget. These proposed changes include the revision of several HCPC codes to CPT codes, which will allow Medicare crossover claims to be processed automatically, reducing the administrative burden for providers and the Department, thereby generating budgetary savings. It also includes language that will require a Mental Health Agency to employ or contract with an MD or DO to be the agencies’ Medical Director in order to be recognized by MaineCare as an agency and be reimbursed and paid at the higher agency rate. Those providers who do not employ a Medical Director and are currently enrolled and reimbursed at the higher agency rate will need to re-enroll as an Independent Practitioner and will be reimbursed at the lower Independent Practitioner rate. Finally, this proposed rule also includes several changes that are not related to the Supplemental Budget, but are necessary to provide clarity to providers, remove outdated information and to achieve compliance with national correct coding standards.
Comment Deadline: June 14, 2012 Posted: May 11, 2012
 
MaineCare Benefits Manual, Chapter III, Section 68, Occupational Therapy Services WORD  PDF   
Concise Summary: This rule is proposed pursuant to Public Law 2011 ch. 477 sec. M-1, 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. This rule is being proposed in accordance with Part M of said Budget requiring that MaineCare Services reduce reimbursement of Occupational Therapy Services by ten percent (10%) effective April 1, 2012.
Comment Deadline: June 14, 2012 Posted: May 11, 2012
 
MaineCare Benefits Manual, Chapter III, Section 85, Physical Therapy Services WORD  PDF   
Concise Summary: This rule is proposed pursuant to Public Law 2011 ch. 477 sec. M-1, 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. This rule is being proposed in accordance with Part M of said Budget requiring that MaineCare Services reduce reimbursement of Physical Therapy Services by ten percent (10%) effective April 1, 2012.
Comment Deadline: June 14, 2012 Posted: May 11, 2012
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services WORD  PDF   
Concise Summary: This rulemaking seeks to permanently adopt changes already made on an emergency basis. The rule 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. This proposed rulemaking, beyond seeking to permanently adopt changes already made on an emergency basis, will also seek to end reimbursement for certain Provider Preventable Conditions (PPC), as defined by Medicare and federally required by the Patient Protection and Affordable Care Act. The DHHS will be seeking CMS approval of the State Plan for these changes.
Comment Deadline: June 10, 2012 Posted: May 4, 2012
 
MaineCare Benefits Manual, Chapter III, Section 32, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders Word   PDF    
Concise Summary: The Department went to emergency rulemaking on July 1, 2011 to establish Chapter III, Section 32, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders that details procedure codes and rates of reimbursement for covered services as described in Chapter II, Section 32. During the initial rulemaking, the Department receiving compelling comments and determined Chapter III required changes in order to address the comments. The proposed rule lapsed and the Department is reopening the rule in order to make changes as a result of comment received during the comment period. The per diem rate for Home Support Family is $142.03 a day and the Department is proposing to increase it to $265.83 a day. The Department is proposing to add an increased level of support fee structure to allow children to better be supported to live in the natural home, raising the rate to $502.79 per diem. Also, the Department proposes to increase the rate for behavioral consultation from $13.75 to $21.00 per quarter hour.
Comment Deadline: March 8, 2012 Posted: May 1, 2012
 
MaineCare Benefits Manual, Chapter II, Section 32, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders Word   PDF   
Concise Summary: The Department established Chapter II, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders in July of 2011. The Department decided to reopen Chapter II in response to comments to the initial proposed rule. The Department is proposing to add an Appendix I to Chapter II that would provide for an increased level of home support where certain criteria of need are met. The Department proposes to add definitions in Section 32.02 for the terms “Behavioral Interventions,” “Restraint” and “Seclusion.” The Department is proposing to add clarifying language to Section 32.03 regarding eligibility and priority. Additionally, the Department proposes to add language specifying the individual cost limits for waiver services, as set forth in the waiver application approved by the Centers for Medicare and Medicaid. Other technical changes and formatting are being proposed.
Comment Deadline: March 8, 2012 Posted: May 1, 2012
 
MaineCare Benefits Manual, Section 75, Chapter II, Vision Services Word   PDF    
Concise Summary: The Department of Health and Human Services (DHHS) is proposing to adopt permanently previously adopted emergency changes to Chapter 101, MaineCare Benefits Manual, Section 75, Chapter II, Vision Services, to comply with Public Law 2011, Chapter 477, Maine State Supplemental Budget. This change limits MaineCare Services reimbursement to one (1) routine eye exam every three (3) rolling calendar years for members ages twenty-one (21) and over. Routine eye exams indicated as the standard of care for specific medical diagnoses (ex. diabetes) or for high-risk medication use (ex. Plaquenil) will continue to be covered as medically indicated.
Comment Deadline: June 1, 2012 Posted: April 24, 2012
 
MaineCare Benefits Manual, Section 95, Chapter II, Podiatric Services Word  PDF    
Concise Summary: This rule is being proposed to permanently adopt the requirement of Public Law 2011, Chapter 477, the Maine State Supplemental Budget, Part M-1 requiring that MaineCare Services reduce reimbursement of Podiatric Services by ten percent (10%). As there is no Chapter III billing chapter for Section 95, Podiatric Services, this rulemaking also necessarily updates the policy with the DHHS Rate Setting website address where providers may access their current reimbursement rates. The Department is also updating other website links in the policy to align with current Departmental procedures.
Comment Deadline: June 3, 2012 Posted: April 24, 2012
 
Section 15, Chapter II, Chiropractic Services Word  PDF   
Concise Summary: The Department of Health and Human Services (DHHS) is proposing to adopt permanently previously adopted emergency changes to Chapter 101, MaineCare Benefits Manual, Section 15, Chapter II, Chiropractic Services, pursuant to Public Law 2011, Chapter 477, the Maine Supplemental Budget. The change limits reimbursement for Section 15, Chiropractic Services to twelve (12) visits per rolling calendar year for adult members. The Department is also clarifying Section 15.04, Specific Eligibility for Care, to align with the definition of rehabilitation potential earlier in the Section.
Comment Deadline: May 31, 2012 Posted: April 24, 2012
 
MaineCare Benefits Manual, Chapter III, Section 32, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders Word     
Concise Summary: The Department went to emergency rulemaking on July 1, 2011 to establish Chapter III, Section 32, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders that details procedure codes and rates of reimbursement for covered services as described in Chapter II, Section 32. During the initial rulemaking, the Department receiving compelling comments and determined Chapter III required changes in order to address the comments. The proposed rule lapsed and the Department is reopening the rule in order to make changes as a result of comment received during the comment period. The per diem rate for Home Support Family is $142.03 a day and the Department is proposing to increase it to $265.83 a day. The Department is proposing to add an increased level of support fee structure to allow children to better be supported to live in the natural home, raising the rate to $502.79 per diem. Also, the Department proposes to increase the rate for behavioral consultation from $13.75 to $21.00 per quarter hour.
Comment Deadline: March 8, 2012 Posted: February 9, 2012
 
Chapter 101, Section 32, Chapter II, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders Word     
Concise Summary: The Department established Chapter II, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders in July of 2011. The Department decided to reopen Chapter II in response to comments to the initial proposed rule. The Department is proposing to add an Appendix I to Chapter II that would provide for an increased level of home support where certain criteria of need are met. The Department proposes to add definitions in Section 32.02 for the terms “Behavioral Interventions,” “Restraint” and “Seclusion.” The Department is proposing to add clarifying language to Section 32.03 regarding eligibility and priority. Additionally, the Department proposes to add language specifying the individual cost limits for waiver services, as set forth in the waiver application approved by the Centers for Medicare and Medicaid. Other technical changes and formatting are being proposed.
Comment Deadline: March 8, 2012 Posted: February 8, 2012
 
MaineCare Benefits Manual, Chapter III, Section 50, Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded (ICF-MR) Services WORD  PDF   
Concise Summary: The Legislature amended 36 MRSA 2872, by increasing the tax on ICF-MRs from 5.5% to 6%, effective October 1, 2011. P.L. 2011, ch. 411. This rule proposes to change ICF MR reimbursement to allow reimbursement of the 6% tax, subject to CMS approval. This rule has a retroactive application with an effective date of October 1, 2011, which is authorized under 22 MRSA Sec. 42(8) because this rule amendment will benefit providers, by increasing their reimbursement.
Comment Deadline: January 19, 2012 Posted: December 7, 2011
 
MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities WORD  PDF   
Concise Summary: This proposed rulemaking, if CMS approves, will raise the Cost of Living Adjustment (COLA) for Nursing Facilities to 2% beginning on October 1, 2011. This is prompted by changes to P.L. 2011, ch. 411. The retroactive application of this rule is permitted under 22 MRSA 42(8).
Comment Deadline: December 16, 2011 Posted: November 15, 2011
 
MaineCare Benefits Manual, Chapter II, Section 9, Indian Health Service WORD  PDF   
Concise Summary: The proposed rule would consolidate and update all rules pertaining to reimbursement of Indian Health Service (IHS) clinic services to one new section of MaineCare Benefits Manual (MBM) policy in order to better serve the public and meet federal requirements by making requirements clearer. Some services provided by IHS providers are subject to different federal guidelines. Separation of these rules will clarify specific rules for IHS providers. The Department will also add guidelines for co-payment exemptions and tribal consultation, to be in compliance with new federal guidelines. Currently IHS services are included in MBM Section 3, Ambulatory Care Clinics. Section 3, Ambulatory Care Clinics will be amended at the same time as this rule-making to delete those portions that will now be part of Section 9, Indian Health Services.
Comment Deadline: December 1, 2011 Posted: October 7, 2011
 
MaineCare Benefits Manual, Chapters II & III, Section 3, Ambulatory Care Clinic Services WORD  PDF   
Concise Summary: The proposed rule would consolidate and update all rules pertaining to reimbursement of Indian Health Service (IHS) clinic services to one new section of MaineCare Benefits Manual (MBM) policy in order to better serve the public and meet federal requirements by making requirements clearer. Some services provided by IHS providers are subject to different federal guidelines. Separation of these rules will clarify specific rules for IHS providers. The Department will also add guidelines for co-payment exemptions and tribal consultation, to be in compliance with new federal guidelines. Currently IHS services are included in MBM Section 3, Ambulatory Care Clinics. Section 3, Ambulatory Care Clinics will be amended at the same time as this rule-making to delete those portions that will now be part of Section 9, Indian Health Services.
Comment Deadline: December 1, 2011 Posted: October 7, 2011
 
MaineCare Benefits Manual, Chapter I, Section 2, State Medicaid Health Information Technology WORD  PDF   
Concise Summary: The proposed rule implements federal regulations under which MaineCare will manage and administer the Electronic Health Records(EHR)Incentive Program for qualifying Medicaid providers. The Department will pursue initiatives that encourage the adoption of certified EHR technology and promote quality health care outcomes and data sharing. Under the American Recovery and Reinvestment Act significant monetary incentive payments are offered to Eligible Professionals and Eligible Hospitals for implementing EHR that meet certain standards. The proposed rule establishes the program by which qualified providers may apply for and receive significant incentive payments for the adoption, implementation or upgrading EHR technology, or demonstration of meaningful use of EHR. Members should benefit from improved health outcomes, increased patient safety, care coordination, increased efficiency and lower health care costs through the adoption and meaningful use of EHR technology. The proposed rule will create a new section to MaineCare Benefits Manual, Chapter I: Section 2, State Medicaid Health Information Technology.
Comment Deadline: September 16, 2011 Posted: August 12, 2011
 
MaineCare Benefits Manual, Chapters II and III, Section 13, Targeted Case Management Services WORD  PDF   
Concise Summary: This rulemaking proposes elimination of two target groups currently being reimbursed under Chapter 13, Targeted Case Management (TCM); “Case Management Services for Children Involved with Protective Services”, and “Case Management Services for Adults Involved with Protective Services”. Additionally the rulemaking proposes additional medical eligibility criteria for the target group “Members Experiencing Homelessness”. Chapter II is also changed to; delete obsolete language concerning the 2009 transition to one Comprehensive Case Manager, clarify supervision of comprehensive case managers, eliminate some professional staff categories, clarify qualifications for social workers and add a requirement for documentation that members have had choice of providers. Chapter III is changed to align the standard units of service and maximum allowance for two categories of TCM services with the other TCM categories.
Comment Deadline: September 1, 2011 Posted: August 2, 2011
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services WORD  PDF   
Concise Summary: This rule seeks to permanently adopt certain provisions of the emergency rule that took effect July 1, 2011. Those changes include reimbursing 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. In compliance with CFR 447.26, this DRG system precludes payment for certain hospital acquired conditions. 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. This proposed rule makes additional changes not included in the emergency rule. Rehabilitation hospitals will be reimbursed under a fixed rate per discharge methodology instead of using a DRG-based methodology. There is now a separate section of rule for these hospitals. For clarification, supplemental pool payment methodology for non-critical access hospitals has been moved to its own section since it applies to three different categories: acute care non-critical access hospitals, rehabilitation hospitals and hospitals reclassified to a wage area outside Maine. Language was added to DSH policy that allows DSH payments exceeding an individual hospital’s cap to be used for other hospitals to the extent allowable. Methodology for estimated payments made to state owned hospitals was clarified. Additionally, the cap on outpatient prospective interim payments to acute care non-critical access hospitals and rehabilitation hospitals has been changed to 70%.
Comment Deadline: September 2, 2011 Posted: July 26, 2011
 
MaineCare Benefits Manual, Section 32, Chapter III, Allowances for Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders-Major Substantive Rule WORD  PDF   
Concise Summary: The Department is creating 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 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 major substantive rule is a companion to a routine technical rule proposing to establish the rules for delivering these services in MaineCare Benefits Manual Ch. II, Section 32. These rules were adopted on an emergency basis effective July 1, 2011.
Comment Deadline: August 25, 2011 Posted: July 25, 2011
 
MaineCare Benefits Manual, Section 32, Chapter II, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders WORD  PDF   
Concise Summary: The Department is creating 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 will be provided to children through 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 routine technical rule is a companion to a major substantive rule proposing to establish rates for services in MaineCare Benefits Manual Ch. III, Section 32. These rules were adopted on an emergency basis effective July 1, 2011.
Comment Deadline: August 25, 2011 Posted: July 25, 2011
 
MaineCare Benefits Manual, Chapters II & III, Section 109, Speech and Hearing Services WORD  PDF   
Concise Summary: The Department of Health and Human Services is proposing this rule to remove any differing requirements for school based providers, and require them to meet all other requirements of comparable community based providers. In addition, the Department will clarify that medical necessity for these services requires appropriate documentation, and that provision of services must be documented. Each member’s written progress note must now contain the start and stop time of the service provided to the MaineCare member. Additionally, the proposed Chapter III contains multiple corrected units of service to HIPAA compliant coding in preparation for MIHMS certification, adds billing modifiers, and removes one redundant billing code S9152 Speech therapy, re-evaluation. The Department proposes necessary rate adjustments to remain cost neutral with the corrected units of service. Procedure codes 92526, 92550, 92565, 92568, 92610, V5364, V5364 TF are added in this proposed rule and will be reimbursed retroactively to 09/01/2010. This proposed rule also clarifies how some of the HIPAA compliant billing codes are state-level defined and applied and adds three new billing modifiers.
Comment Deadline: August 18, 2011 Posted: July 14, 2011
 
MaineCare Benefits Manual, Chapters II & III, Section 85, Physical Therapy Services WORD  PDF   
Concise Summary: This proposed rule will remove any differing requirements for school based providers, and require them to meet all other requirements of comparable community based providers. In addition the Department clarifies that pursuant to 42 CFR 440.110, MaineCare physical therapy services must be prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice under Maine law and must be provided by or under the direction of a qualified licensed physical therapist. Medical necessity for and the provision of these services to MaineCare members requires appropriate documentation. Each member’s written progress note must contain the start and stop time of the service. In Chapter III of this Section, billing modifiers TL and TM will be required for all services that are delivered under a Maine Department of Education Individualized Family Service Plan (IFSP) or an Individualized Education Plan (IEP), respectively.
Comment Deadline: August 18, 2011 Posted: July 14, 2011
 
MaineCare Benefits Manual, Chapters II & III, Section 68, Occupational Therapy Services WORD  PDF   
Concise Summary: This proposed rule will remove any differing requirements for school based providers, and require them to meet all other requirements of comparable community based providers. In addition the Department clarifies that pursuant to 42 CFR 440.110, MaineCare occupational therapy services must be prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice under Maine law and must be provided by or under the direction of a qualified licensed occupational therapist. Medical necessity for and the provision of these services to MaineCare members requires appropriate documentation. Each member’s written progress note must contain the start and stop time of the service. The Department is correcting that adult members are responsible for copayments up to $20 per month for Occupational Services. In Chapter III of this Section, billing modifiers TL and TM will be required for all services that are delivered under a Maine Department of Education Individualized Family Service Plan (IFSP) or an Individualized Education Plan (IEP), respectively.
Comment Deadline: August 18, 2011 Posted: July 14, 2011
 
Chapters II & III, Section 29, Community Support Benefits for Members with Mental Retardation and Autistic Disorders WORD  PDF   
Concise Summary: The Department is proposing this rule to permanently adopt an emergency rule that was adopted effective July 1, 2011. Section 29 services are governed by a Centers for Medicare and Medicaid (CMS) Medicaid waiver. CMS approved amendments to the waiver, and renewed the waiver 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; hence the emergency rules were adopted effective July 1, 2011. The Department is seeking approval from CMS to change the effective date of the approved waiver from January 1, 2011 to July 1, 2011. The following changes are proposed in order to comply with the CMS approval of the waiver amendment and extension: Annual hourly limits for Community Support services are reduced from 1,300 to 1,125 hours. Annual hourly limits for Work Support services are increased from 300 to 600 hours. The combined annual hourly limit for when members use both Community Support and Work Support services is reduced to 1,125 from 1,300 hours. The Department is adding Appendix III to Chapter II, which is composed of charts, to show how hours for the two services can be combined. The Department is changing the name of both Chapters II and III of this Section, to Support Services for Adults with Intellectual Disabilities or Autistic Disorders, to match the name of the waiver, as approved by CMS. (Substituting the terms “intellectual disability” for “mental retardation” also comports with P.L. 2009, ch. 571). Eligibility for Section 29 services will include the diagnoses of Asperger’s Syndrome, Pervasive Developmental Disorder (not otherwise specified), Autistic Disorder, Rett’s Disorder and Childhood Disintegrative Disorder. The Department corrected a typographical error in Chapter II: Limits on Respite Services was added to indicate that the Respite per diem rate is $90.00. The reduction from $100.00 to $90.00 was made in 2010 for Chapter III and the Department did not make the corresponding change to Chapter II. Lastly, in Chapter III, procedure codes that are obsolete have been deleted.
Comment Deadline: August 5, 2011 Posted: June 29, 2011
 
MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies WORD  PDF   
Concise Summary: The proposed rule amends language to indicate that a provider may bill for up to a 72 day supply of incontinence supplies. The websites listed in this rule have been updated. In addition, several prior authorization criteria have been removed and providers are now directed to visit the MIHMS provider portal for information regarding prior authorizations and to locate criteria utilized by the Department. The reimbursement methodology has been revised for miscellaneous Medical Supplies and Durable Medical Equipment. A new requirement has been added to indicate that a face-to-face encounter is required during the 6 months preceding the physician’s written order for durable medical equipment. This is a mandatory provision of the Patient Protection and Affordable Care Act, PL 111-148 § 6407.
Comment Deadline: June 30, 2011 Posted: May 27, 2011
 
MaineCare Benefits Manual, 10-144 C.M.R. Ch 101, Chapter II, Section 109, Speech and Hearing Services WORD  PDF   
Concise Summary: The Department of Health and Human Services proposes this routine technical rule to clarify that unlicensed Speech and Language Clinicians holding a Certificate 293, as defined by the Maine Department of Education regulations Chapter 115 Part II, 2.6, are not qualified providers of MaineCare services. This rule change assures compliance with 42 CFR § 440.110, the federal regulation that requires that speech language pathologists delivering medically necessary services in all settings, including schools, meet state licensure requirements or have completed educational and work requirements equivalent to that which earns a certificate from the American Speech and Hearing Association.
Comment Deadline: May 15, 2011 Posted: April 7, 2011
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 30, Allowances for Family Planning Agency Service WORD  PDF   
Concise Summary: MaineCare Services is filing this proposed rule to correct coding and reimbursement rates for Allowances for Family Planning Services and to provide billing instructions for the Department’s new MMIS system (MIHMS). Additionally, a “FP” billing modifier will now be required for all services performed exclusively to prevent or delay pregnancy or otherwise control family size. This modifier assures the State can properly track expenditures eligible for 90% Federal matching funds. MaineCare rates of reimbursement in Chapter III of this rule will align with the reimbursement rates paid to other providers who perform these services, including Section 90, Physicians Services. The rule provides some codes that apply retroactively. The reimbursement rates are current on the effective date of the rule. Subsequent to the effective date, the rates in effect and other information will be posted and available at: www.maine.gov/dhhs/audit/rate-setting/index.shtml.
Comment Deadline: March 10, 2011 Posted: February 9, 2011
 
MaineCare Benefits Manual, Chapter II, Section 45, Hospital WORD  PDF   
Concise Summary: The Department proposes to limit the quarterly reporting of outpatient claims for single source drugs and the top 20 physician-administered multiple source drugs as listed on a CMS website to the following hospitals: Acute Care Critical Access Hospitals, Private Psychiatric Hospitals and Hospitals Reclassified to a Wage Area Outside Maine by the Medicare Geographic Classification Review Board Prior to October 1, 2008.
Comment Deadline: March 14, 2011 Posted: February 7, 2011
 
MaineCare Benefits Manual, Chapter III, Section 85, Physical Therapy Services WORD  PDF   
Concise Summary: The Department of Health and Human Services is proposing this rule to correct some units of service in the Chapter III of this Section, to be compliant with units mandated by the Centers of Medicare and Medicaid Services (CMS). Consequently, the Department is proposing rate adjustments, based on utilization, that remain cost neutral with the new units of service.
Comment Deadline: March 10, 2011 Posted: February 7, 2011
 
Ch 101, Chapter III, Section 68, Occupational Therapy Services WORD  PDF   
Concise Summary: The Department of Health and Human Services is proposing this rule to correct some units of service in the Chapter III of this Section, to be compliant with units mandated by the Centers of Medicare and Medicaid Services (CMS). Additionally, the Department is proposing cost neutral rate adjustments
Comment Deadline: March 10, 2011 Posted: February 7, 2011
 
MaineCare Benefits Manual, 10-144 C.M.R. Ch 101, Chapter II, Section 75, Vision Services--COMMENT DEADLINE EXTENDED WORD  WORD   
Concise Summary: Pursuant to Executive Order No. 09 FY 11/12 (January 10, 2011), the comment deadline for this rulemaking is extended for 90 days. The Department is proposing the following changes to the rule: (1) that prosthetics be provided only by ophthalmologist or optometrist, since opticians are not licensed to provide this service; (2) that prior authorization be deleted for tint, photochromatic or ultraviolet lenses, however, the Department is adding medical necessity requirements for these lenses into the rule; (3) that the Department’s authorized agent be utilized for certain services; (4) that there is no one-year warranty for normal wear and tear for articles purchased under the Vision Care Volume Purchase Contract; (5) deleting the provision that allows providers to determine a need for repair/replacement of glasses/lenses; and (6) proposing that the Contractor be responsible for furnishing postage-paid mailers to providers for returning defective items to the Contractor and, if used, the Contractor assumes financial responsibility.
Comment Deadline: April 30, 2011 Posted: February 4, 2011
 
MaineCare Benefits Manual, Chapter III, Section 28, Rehabilitative and WORD  PDF   
Concise Summary: The proposed rule provides a corrected rate for Specialized Services in Section 28, Rehabilitation and Community Support Services for Children with Cognitive Impairments and Functional Limitations. The corrected rates are for services provided 1:1 (H2021 HK), groups with two patients served (H2021 HQ HK UN), groups with three patients served (H2021 HQ HK UP) and groups with four patients served (H2021 HQ HK UQ). There was an error in calculating the rates that are in place for Specialized Services, this proposed rule will correct that error. The Department intends to adopt this retroactively to September 1, 2010.
Comment Deadline: March 11, 2011 Posted: February 3, 2011
 
Chapter 101, MaineCare Benefits Manual, Section 65, Chapter III, Behavioral Health Services WORD  PDF   
Concise Summary: The Department is proposing to add a code modifier “HA” to Children’s Assertive Community Treatment Services (ACT) to distinguish this treatment, for billing purposes, from Adult ACT found in Section 17, Community Support Services. The Department proposes to adopt the corrected rate retroactively to July 1, 2010. Additionally, collateral contact rates were reduced in error by 10% effective July 01, 2010 and instead should have been reduced by 2%. The Department proposes to adopt the corrected rates retroactively to July 01, 2010. Lastly, group ratio procedure codes are being added to Children’s Behavioral Health Day Treatment to allow for more accurate reimbursement. These new codes do not change the reimbursement rates for these services. The Department proposes to adopt this change retroactively to September 01, 2010.
Comment Deadline: March 11, 2011 Posted: January 20, 2011
 
SPECIAL NOTICE      
Concise Summary: NOTICES OF MAINECARE PROPOSED RULES THAT WERE POSTED ON THIS WEBSITE, BUT HAD NOT YET BEEN PUBLISHED IN THE NEWSPAPER, HAVE BEEN REMOVED PENDING FURTHER REVIEW.------------- LISTED BELOW ARE THE PROPOSED RULES WHICH HAVE BEEN REMOVED:----------------------------------- MAINECARE BENEFITS MANUAL, --- CHAPTERS II AND III, SECTION 40, HOME HEALTH SERVICES ----- CHAPTER III, SECTION 50, PRINCIPLES OF REIMBURSEMENT FOR INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED ---- CHAPTER III, SECTION 65, BEHAVIORAL HEALTH SERVICES
No comment deadline Posted: January 12, 2011
 
MaineCare Benefits Manual, Chapter III, Section 50, Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded WORD  PDF   
Concise Summary: This rule is reproposed to reschedule a public hearing cancelled due to the closure of all State offices on December 27, 2010 and to allow time for public comment on the proposed rule. This proposed 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 MaineCare Benefits Manual (MBM), Chapters II and III, Section 21. The amendment is made necessary by the repeal of MBM, Section 24, Day Habilitation Services. The amendment will also allow the billing code for this service to conform to federally required codes and the implementation of the Department’s new claims processing system. Since this rule is a Major Substantive rule, it will not be finally adopted until approved by the Legislature. This change was adopted on an emergency basis effective April 1, 2010.
Comment Deadline: March 14, 2011 Posted: January 6, 2011
 
MaineCare Benefits Manual, Chapters II and III, Section 40, Home Health Services WORD  PDF   
Concise Summary: The Department proposes these rules to begin the process of permanently adopting emergency rules that were effective September 1, 2010 and October 18, 2010, and to make additional changes to Chapters II and III Section 40, Home Health Services. These changes require major substantive rules and they will not be permanently adopted until they have been approved by the Legislature. The Department proposes to provisionally adopt amendments in Chapter II to clarify the service authorization procedures for approval of care plans, changing the process from a “prior authorization” process to an “authorization process”. “Authorized agent” and “unit of service” are redefined. The time frame for obtaining authorization is clarified and the language “Classification Period” is corrected to “eligibility period” consistent with authorization procedural language. The process is amended to be applicable to all members receiving services under Section 40, except for members receiving psychotropic medication services under 40.02-5B. The amendment also clarifies that documentation of rehabilitation potential for certain services applies to all members receiving those services. The amendment adds a 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. The Department adds requirements related to a face-to-face encounter between the Member and the physician or designated provider who is certifying the medical necessity for Home Health Services. Finally in Chapter III the Department adopts new HIPAA- compliant codes and the units of service associated with them. These codes are necessary in order to meet Center for Medicaid Services (CMS) requirements for a certified health claims system. These rules are not expected to have an adverse impact on small businesses, municipalities or counties.
Comment Deadline: March 14, 2011 Posted: January 6, 2011
 
MaineCare Benefits Manual, Chapter II Section 97, Private Non-Medical Institution Services, Chapter III Section 97, Private Non-Medical Institution Services Appendix B: Principles of Reimbursement for Substance Abuse Treatment Services WORD  PDF   
Concise Summary: The amendments to Chapter III, Section 97 change the method of reimbursing PNMI substance abuse treatment facilities from an interim rate/cost-settlement basis to fixed per diem rates depending on the type of service. The new standardized rates are set forth in the regulation, and appropriate, HIPAA compliant billing codes are provided. Chapter II, Section 97 is amended to coordinate with changes to Chapter III regarding the method of reimbursement for these services. Minor revisions are made to the names of some services. The changes are necessary to meet budget reduction targets. The Legislature ordered various reductions in expenditures in the MaineCare program to counteract predicted deficits and balance the budget. P.L. 2009, ch. §571. The reduction in reimbursements for PNMI substance abuse treatment facilities was selected by the Legislature after careful consideration, and it will be implemented in a fair and equitable manner. It is anticipated that the proposed changes will result in savings of $264,744 in State fiscal year 2011. These changes were adopted my emergency rule effective November 15, 2010
Comment Deadline: February 5, 2011 Posted: January 5, 2011
 
MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures ( 2ND PUBLICATION) WORD  PDF   
Concise Summary: The Department is proposing numerous changes to the MaineCare Benefits Manual (MBM), Chapter 101, Chapter 1, Section 1, General Administrative Policies and Procedures to assure that provider requirements align with the Department’s new claims system and to up-date other aspects of the rule. The methods of claims submission reflect various updates in moving from MECMS to MIHMS. Chapter I retains the one (1) year deadlines from dates of services for the correct filing of claims, but adds the proviso that if the service was provided before September 1, 2010, then the claim must be filed within one (1) year or before January 31, 2011, whichever is sooner. Various other changes are made, including requiring that provider license renewals must be received within 30 days prior to the date of expiration or change, and that providers must update ownership information on an annual basis. The Department also proposes to add a new exemption for copayments, to add information regarding filing and managing claims in MIHMS, to recognize nurse licensure to include current, unencumbered compact licenses from another compact state, and to strengthen the Department’s ability to collect overpayments and, pursuant to federal law, to eliminate payments to entities outside the United States. Various grammatical and structural changes are also made to the rule. A hearing was held on January 5, 2011on this proposed rule, however, the agency found it necessary to re-publish the rule and schedule another hearing.
Comment Deadline: February 4, 2011 Posted: January 5, 2011
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 65, Behavioral Health Services WORD  PDF   
Concise Summary: The Department is proposing to add a code modifier “HA” to Children’s Assertive Community Treatment Services (ACT) to distinguish this treatment, for billing purposes, from Adult ACT found in Section 17, Community Support Services. The Department proposes to adopt the corrected rate retroactively to July 1, 2010. Additionally, collateral contact rates were reduced in error by 10% effective July 01, 2010 and instead should have been reduced by 2%. The Department proposes to adopt the corrected rates retroactively to July 01, 2010. Lastly, group ratio procedure codes are being added to Children’s Behavioral Health Day Treatment to allow for more accurate reimbursement. These new codes do not change the reimbursement rates for these services. The Department proposes to adopt this change retroactively to September 01, 2010.
Comment Deadline: February 10, 2011 Posted: January 4, 2011
 
MaineCare Benefits Manual, Chapter III, Principles of Reimbursement, Section 97, Private Non-Medical Institution Services, Appendix D, Child Care Facilities--EXTEND COMMENT PERIOD WORD  PDF   
Concise Summary: Pursuant to Executive Order No. 09 FY 11/12 (January 10, 2011), the comment deadline for this rulemaking is extended for 90 days. The Department proposed these rules to begin the process of permanently adopting emergency rules that were effective October 1, 2010. The rule specifies a reduction in reimbursement rates for PNMI Child Care Facilities for State Fiscal Year 2011. In order to meet the necessary budget reduction for Fiscal Year 2011 the Department is reducing reimbursement rates for Treatment Foster Care Services by 3.2% (not to be passed to parents) and reduces reimbursement rates to all other Appendix D facilities to achieve an aggregate savings of 3.56% for those services. These rules are major substantive and they will not be permanently adopted until they have been approved by the Legislature.
Comment Deadline: April 20, 2011 Posted: December 17, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures WORD  PDF   
Concise Summary: The Department is proposing numerous changes to the MaineCare Benefits Manual (MBM), Chapter 101, Chapter 1, Section 1, General Administrative Policies and Procedures to assure that provider requirements align with the Department’s new claims system and to up-date other aspects of the rule. The methods of claims submission reflect various updates in moving from MECMS to MIHMS. Chapter I retains the one (1) year deadlines from dates of services for the correct filing of claims, but adds the proviso that if the service was provided before September 1, 2010, then the claim must be filed within one (1) year or before January 31, 2011, whichever is sooner. Various other changes are made, including requiring that provider license renewals must be received within 30 days prior to the date of expiration or change, and that providers must update ownership information on an annual basis. The Department also proposes to add a new exemption for copayments, to add information regarding filing and managing claims in MIHMS, to recognize nurse licensure to include current, unencumbered compact licenses from another compact state, and to strengthen the Department’s ability to collect overpayments and, pursuant to federal law, to eliminate payments to entities outside the United States. Various grammatical and structural changes are also made to the rule.
Comment Deadline: January 18, 2011 Posted: December 16, 2010
 
MaineCare Benefits Manual, Chapter III, Section 50, Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded Word     
Concise Summary: This proposed 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 MaineCare Benefits Manual (MBM), Chapters II and III, Section 21. The amendment is made necessary by the repeal of MBM, Section 24, Day Habilitation Services. The amendment will also allow the billing code for this service to conform to federally required codes and the implementation of the Department’s new claims processing system. Since this rule is a Major Substantive rule, it will not be finally adopted until approved by the Legislature. This change was adopted on an emergency basis effective April 1, 2010.
Comment Deadline: 2011-01-18 Posted: December 7, 2010
 
MaineCare Benefits Manual, Ch 101, Chapters II & III, Section 43, Hospice Services WORD     
Concise Summary: This rule proposes to permanently adopt previously filed emergency rules reflecting the codes necessary when billing the Maine Integrated Health Management Solution (MIHMS), therefore, allowing providers to bill correctly in the new system. In addition, this rule further proposes to permanently adopt the previously filed emergency rule permitting terminally ill MaineCare members under the age of 21 to receive hospice services without requiring them to forgo other treatments covered by MaineCare. This implements Section 2302 of the Affordable Care Act (Pub. L. No. 111-148 as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. No. 111-152)).
Comment Deadline: December 09, 2010 Posted: November 15, 2010
 
MaineCare Benefits Manual, Chapter III, Section 96, Private Duty Nursing and Personal Care Services WORD     
Concise Summary: The proposed rule permanently adopt corrected rates for Private Duty Nursing And Personal Care Service Providers that were put into effect via emergency rule effective 10/28/10. The Department is also making technical changes to reflect language that ensures compliance with the State’s new fiscal agent, MIHMS.
Comment Deadline: December 16, 2010 Posted: November 9, 2010
 
MaineCare Benefits Manual, Chapter III, Section 21, Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder WORD     
Concise Summary: The proposed rule will permanently adopt a major substantive emergency rule that took effect 10/1/10. The emergency rule established new rates. The Department is proposing to permanently adopt new rates for Shared Living Providers pursuant to PL 2009, Ch 571 §§ A-25, A-26, and CCCC-3 that were put into effect via emergency rule effective 10/1/10. The Department is also making technical changes to the rule to remove procedure codes that were effective for MECMS, the payment system that was effective prior to 9/1/10.
Comment Deadline: November 25, 2010 Posted: November 1, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 103, Rural Health Clinic Services Word      
Concise Summary: The following proposed rule is for MaineCare Benefits Manual, Chapters II and III, Section 103, Rural Health Clinic Services (RHC). The proposed rule amends billing instructions and Chapter III coding requirements to ensure RHC providers can bill for covered services for MaineCare members upon implementation of MIHMS. Furthermore, the Department is delaying the requirement for providers to report all encounter data on the UB 04 form until October 1, 2010. The proposed changes will allow providers sufficient time to make necessary software and billing changes to meet the Department’s reporting requirements.
Comment Deadline: 2010-10-15 Posted: September 9, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 31, Federally Qualified Health Center Services Word     
Concise Summary: The proposed rule amends billing instructions and Chapter III coding requirements to ensure FQHC providers can bill for covered services for MaineCare members upon implementation of MIHMS. 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.
Comment Deadline: 2010-10-15 Posted: September 9, 2010
 
NOTICE - 2 MaineCare Benefits Manual, Chapter III, Section 30, Allowances for Family Planning Agency Services---BILLING CODE REQUIREMENTS BILLING CODE REQUIREMENTS     
Concise Summary: ATTACHED ARE THE BILLING CODE REQUIREMENTS MENTIONED IN NOTICE 1 OF THE RULEMAKING PROPOSAL FOR THIS RULE
No comment deadline Posted: September 2, 2010
 
NOTICE 1 - MaineCare Benefits Manual, Chapter III, Section 30, Allowances for Family Planning Agency Services word     
Concise Summary: ----IMPORTANT NOTICE----- FOR BILLING CODE REQUIREMENTS SEE NOTICE 2 FOR THIS RULE The intent of this rulemaking was to repropose Ch III, Section 30, Allowances for Family Planning for another public hearing. Due to comments submitted during the two public comment periods, MaineCare Services has discovered coding errors for some of the billing codes and will be filing an Emergency Rule anticipated effective date of October 1st, 2010, the previous effective date of this reproposed rule. In the meantime, MaineCare has asked that providers hold their claims that include the incorrect codes which may be found in the document attached below. Public Comments will continue to be accepted until the comment deadline of 09/12/2010. =========================================================== PREVIOUS NOTICE: Effective January 1, 2010, CMS no longer recognizes American Medical Association (AMA) Current Procedural Terminology (CPT) consultation codes 99241-99245 for inpatient facility and office/outpatient settings previously used in the Section. To align with Medicare standards, the proposed changes will remove these consultation codes and introduce preventative medicine counseling (separate procedure) billing codes appropriate to the services which are being performed. This rule is being re-proposed solely to schedule another public hearing since the Department wants to assure that all Family Planning Agencies are aware of the proposed rule changes which are significant with Maine Integrated Health Management System (MIHMS) implementation. There are no additional changes to this proposed rule.
Comment Deadline: 2010-09-12 Posted: September 2, 2010
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services Word     
Concise Summary: This proposed rule seeks to adopt a new definition of “discharge” in order to reduce funding to hospitals when a MaineCare patient is subsequently readmitted to the hospital within 72 hours following an inpatient admission for the same diagnosis. Additionally, this rule proposes to make changes, effective November 1, 2010, to allow hospitals reclassified to a wage area outside Maine by the Medicare Geographic Classification Review Board to become eligible for supplemental pool payments under the Acute Care Non-Critical Access Hospitals provision of this rule. This rule will save $200,000 General Fund dollars per fiscal year. 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.
Comment Deadline: 2010-09-10 Posted: August 5, 2010
 
MaineCare Benefits Manual, 10-144 C.M.R. Ch 101, Chapter III, Section 113, Allowances for Transportation Services word     
Concise Summary: This proposed rule will adopt emergency rules reflecting the cost savings measures of the Maine June 2010 Supplemental Budget, resulting in a 6.5% decrease in all Allowances for Transportation Services reimbursement rates to be 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.
Comment Deadline: 2010-09-06 Posted: July 28, 2010
 
Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities word     
Concise Summary: The Department proposes changes to the above named section of policy. These changes begin permanent adoption of the budget-related emergency rules that are effective July 1, 2010 as well as include additional clarification to the rules related to Maine Integrated Health Management System (MIHMS). Specifically, changes related to budget initiatives include: 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 and removing reimbursement Principle 101, Staff Enhancement Payments (SEP), from the rules. In addition, the Department also proposes changes to §41.2.3(D), by eliminating the language describing Sanction principles prior to MIHMS implementation. Similarly, the Department proposes eliminating language under §80.3.4 describing the calculation of the direct care component prior to MIHMS implementation. Finally, the Department proposes clarification under Principle 81 that describes the rate determination schedule.
Comment Deadline: 2010-08-07 Posted: July 8, 2010
 
MaineCare Benefits Manual, Chapter III, Section 29, Community Support Benefits for Members with Mental Retardation or Autistic Disorder word     
Concise Summary: The Department is proposing changes to Chapter III, Section 29, Community Support Benefits for Members with Mental Retardation or Autistic Disorder. These changes were adopted as an Emergency Rule on July 1, 2010. Specifically, this rule proposes a reduction in reimbursement rates by 2% for day habilitation and work support services; all other services are reduced by 10%. These proposed rules comply with State statute regarding budget initiatives designed to balance the State budget. In addition, the Department is adopting minor changes in the billing codes to be employed with the adoption of the Maine Integrated Health Management system, anticipated to occur in August.
Comment Deadline: 2010-08-14 Posted: July 8, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 21, Home and Community Benefits for Adults with Mental Retardation or Autistic Disorder word     
Concise Summary: The Department proposes changes to Chapter III, Section 21, Home and Community Benefits for Adults with Mental Retardation or Autistic Disorder. Specifically, this proposed rule reduces the reimbursement rates by 2% for day habilitation and work support services and reduces rates for services delivered in a residential setting by 1%; all other services are reduced by 10%. In addition, the Department proposes modifications to certain codes in order to make policy align with the new claims system structure. 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. This proposed rule also changes the title of this Chapter to Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorder. This proposed rule-making is necessary in order to begin permanent adoption of the emergency rule in effect as of July 1, 2010. These are major substantive rules that must be approved by the legislature before they are finally adopted. These amendments were previously adopted as an emergency rule on July 1, 2010
Comment Deadline: 2010-08-14 Posted: July 7, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 28, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations word     
Concise Summary: The proposed rule permanently adopts new rates that were adopted via emergency rule effective 7/1/10. Chapter II: The Department added 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. Additionally, schools, as defined in the regulation, have been added as a new provider of Section 28 services. Chapter III: The proposed rule will permanently adopt 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 determined that it is necessary and applicable to use the additional funding so that the Section 28 rates were reduced by 2%, not 10%. The proposed rule also adds new group ratios for 2:1 (two members to one staff) and 3:1 (three members to one staff) service delivery. The proposed rule provides that during a start up period of July 1, 2010 through October 31, 2010, prior authorization is not required for any Section 28 services.
Comment Deadline: 2010-08-14 Posted: July 7, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 65, Behavioral Health Services word     
Concise Summary: PLEASE NOTE: PUBLIC HEARING POSTPONED TO 8-16-10 This rule making will permanently adopt emergency rules that were put into effect 7/1/2010 pursuant to the supplemental budget, LD 1671, Part OOO, § OOO-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 proposed 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
Comment Deadline: 2010-08-26 Posted: July 7, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 68, Occupational Therapy Services word     
Concise Summary: This rule is being proposed pursuant to the supplemental budget, which specifies a reduction in rates of 10% for Occupational Therapy Services. The rule also includes a unit correction for evaluation and re-evaluation services.
Comment Deadline: 2010-08-13 Posted: July 7, 2010
 
MaineCare Benefits Manual Chapter III, Section 23, Developmental and Behavioral Evaluation Clinic Services Word     
Concise Summary: The Department is proposing changes to Chapter III. Chapter III proposes a 10% reduction in rates due to PL2009, Ch. 571, Part A § 26 which will permanently adopt emergency rules in place on July 1, 2010. Other routine technical changes have been made in this rulemaking.
Comment Deadline: 2010-08-06 Posted: June 29, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 17, Community Support Services Word     
Concise Summary: The proposed rule permanently adopts emergency rule that were effective 7/1/10 pursuant to the supplemental budget PL2009, Ch.571, Part A §25 and Part OOO§ 000-1. The reduction in rates is 3% for Community Integration and a 4% decrease in rates for all other services under Section 17, Community Support Services. This was necessary to comply with the supplemental budget.
Comment Deadline: 2010-08-05 Posted: June 29, 2010
 
Proposed Rule: MaineCare Benefits Manual, Chapter 101, Chapter VIII, Section 2, Health Insurance Purchase Option Word     
Concise Summary: The Department of Health and Human Services, MaineCare Services, is proposing to delete sections of the MaineCare Benefits Manual, Chapter VIII, Section 2. Specifically, sections defining the eligibility portion of this policy; 2.03, 2.04, 2.05, 2.07, 2.08, 2.09 and 2.10 are being deleted. Concurrent to this rulemaking, the Office of Integrated Access and Support is proposing to administer the eligibility portion of this program and publish the information in their own MaineCare Eligibility Manual. MaineCare Services will continue to include language in the MaineCare Benefits Manual defining the benefits available through the Health Insurance Purchase Option program. This will not impact or decrease benefits presently provided to MaineCare members. This rule will have no adverse impact on small business.
Comment Deadline: 2010-07-30 Posted: June 29, 2010
 
MaineCare Benefits Manual Chapter III, Section 23, Developmental and Behavioral Evaluation Clinic Services word     
Concise Summary: The Department is proposing changes to Chapter III. Chapter III proposes a 10% reduction in rates due to PL2009, Ch. 571, Part A § 26 which will permanently adopt emergency rules in place on July 1, 2010. Other routine technical changes have been made in this rulemaking.
Comment Deadline: 2010-08-06 Posted: June 24, 2010
 
MaineCare Benefits Manual, Chapter III Section19, Home and Community Benefits for the Elderly and Adults with Disabilities Word     
Concise Summary: In Chapter III, the Department is proposing the elimination of local codes and replacing them with HIPPA-compliant service codes. The proposed amendment consolidates the billing codes for services to the two different populations served by the program, Adults with Disabilities and the Elderly. In some instances, new rates and billing increments for services are proposed. In addition, the proposed rule has changed the description of services. These changes correspond to the realignment of services in the proposed MBM, Chapter II, Section 19, which will be adopted upon MIHMS implementation. This rule will become effective with the implementation of the Maine Integrated Health Management System (MIHMS) anticipated in August. Some of the proposed changes to this chapter are subject to approval of the federal Medicaid authority, the Centers for Medicaid and Medicare Services.
Comment Deadline: 2010-07-16 Posted: June 11, 2010
 
Chapter III-Section 85, Physical Therapy Services word     
Concise Summary: The Office of MaineCare Services is proposing changes to the MaineCare Benefits Manual, Chapter III, Section 85, Physical Therapy Services. These changes seek to correct a unit error in a previous adopted rule, specifically: • Code 97001, Physical Therapy Evaluation, was tied to a 15 minute unit, but should instead be billed per evaluation • Code 97002, Physical Therapy Re-evaluation, was tied to a 15 minute unit, but should instead be billed per re-evaluation
Comment Deadline: 2010-07-08 Posted: June 3, 2010
 
Chapters II and III Section 13, Targeted Case Management Services Word     
Concise Summary: In this rulemaking, the Department proposes changes to Chapter II and III Section 13, Targeted Case Management Services. The Changes in Chapter II Section 13 will eliminate a target group “Members With Long Term Care Needs” from the eligibility under the Rule. These Members can receive comparables services under several other sections of MaineCare policy, including Home and Community Based Waivers. In addition in Chapter II Section 13, the Department clarifies that Members receiving care coordination under the waiver “Benefits for People Living with HIV” may not additionally get Targeted Case Management under Section 13. In Chapter III Section 13 the Department proposes to change the Unit of Service for billing for several target groups and recalculate the Maximum Allowances accordingly.
Comment Deadline: 2010-07-05 Posted: May 27, 2010
 
MaineCare Benefits Manual, Chapters II, Section 85, Physical Therapy Services Word     
Concise Summary: The Office of MaineCare Services is proposing changes to the MaineCare Benefits Manual, Chapter II, Section 85, Physical Therapy Services. This proposed rule seeks to achieve a number of goals to facilitate the delivery of physical therapy services in school settings, specifically: • allow services to be ordered by a practitioner of the healing arts, • remove the maximum limit of two (2) visits per year for sensory integration for members under age twenty-one (21), • establish schools as an eligible provider, and • remove the requirement that a physician or primary care provider sign a member’s plan of care every three (3) months for members under age twenty-one (21).
Comment Deadline: 2010-07-01 Posted: May 24, 2010
 
MaineCare Benefits Manual, Chapter II, Section 109, Speech and Hearing Services Word     
Concise Summary: These proposed rules seek to achieve a number of goals to facilitate the delivery of Speech and Hearing services in school settings, specifically: 1. allow services to be ordered by a practitioner of the healing arts, 2. establish schools as an approved setting for the delivery of services, 3. authorize speech and language clinicians holding a Certificate 293 to deliver services, and 4. other minor, technical corrections.
Comment Deadline: 2010-07-01 Posted: May 24, 2010
 
MaineCare Benefits Manual, Chapter II, Section 68, Occupational Therapy Services Word     
Concise Summary: The Office of MaineCare Services is proposing changes to the MaineCare Benefits Manual, Chapter II, Section 68, Occupational Therapy Services. This proposed rule seeks to achieve a number of goals to facilitate the delivery of occupational therapy services in school settings, specifically: • allow services to be ordered by a practitioner of the healing arts, • remove the maximum limit of two (2) visits per year for sensory integration for members under age twenty-one (21), • establish schools as an eligible provider, and • remove the requirement that a physician or primary care provider sign a member’s plan of care every three (3) months for members under age twenty-one (21).
Comment Deadline: 2010-07-01 Posted: May 24, 2010
 
MaineCare Benefits Manual, Chapter II, Section 101, Medical Imaging Services Word     
Concise Summary: The Department of MaineCare Services is proposing changes to MaineCare Benefits Manual, Chapter II, Section 101, Medical Imaging Services. Contingent upon Maine Integrated Health Management System (MIHMS) implementation, the proposed rule modifies reimbursement methodology to pay at seventy percent (70%) of the lowest level in the 2009 Medicare fee schedule for Maine area “99” for all services under this policy and will include adjustments for place of service and modifiers. This change in methodology will not result in a reduction in payment for medical imaging services. The Department also made other structural, administrative, grammatical and clarifying changes within this rulemaking.
Comment Deadline: 2010-06-18 Posted: May 13, 2010
 
MaineCare Benefits Manual, Chapter II, Section 21 Home and Community Benefits for Adults with Mental Retardation or Autistic Disorder Word     
Concise Summary: The Department proposes replacing the term “mental retardation” with “intellectual disabilities” where appropriate, to conform to more modern terminology. This is consistent with the newest revision to the Diagnostic and Statistical Manual and the Department’s focus on respectful language. Also, the Department proposes to rename the initial classification process to “Determination of Eligibility.” Provisions regarding owned-operated businesses in the employment setting are clarified. Furthermore, the Department proposes to reduce the maximum allowance for community support service hours and work support service hours. The Department also proposes clarification language around work support services provided by a Direct Support Professional (DSP) to one member at a time. The Department establishes two additional grounds for involuntary termination of services to a member. Qualifications for DSPs and Employment Specialists are amended in this proposed rule-making. The proposed rules specify the use of the appeals process for members outlined in Chapter I of the MaineCare Benefits Manual. Finally, the rule includes a new Appendix IV, which outlines the various combinations of community support and work support hours available. The proposed changes conform the regulation to amendments contained in the waiver renewal application recently submitted to CMS.
Comment Deadline: 2010-06-17 Posted: May 13, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 5, Ambulance Services Word     
Concise Summary: The Department of Health and Human Services proposes language in Chapter II to lift prior authorization requirements for all four air ambulance transportation services when performed within state borders. Out of state air ambulance services continue to require prior authorization following the guidelines set forth in Section 1.14-2 of the Maine Care Benefits Manual. Reflecting the 2010-2011 Supplemental Budget (P.L. 2009, c. 571, Part A, Section 26) allowance, Chapter III contains proposed rate changes to 70% of Medicare-allowed rates. These proposed set-rate fees are in response to the CMS requirements 42 CFR 414.601 et seq., as well as serve to replace the supplemental payments used in previous rulemakings under this Section. Other non-substantive changes were made to correct format and grammar.
Comment Deadline: 2010-06-06 Posted: April 27, 2010
 
MaineCare Benefits Manual, Chapter III, Section 7, Free-Standing Dialysis Services Word     
Concise Summary: The Department of Health and Human Services, MaineCare Services, is proposing changes to Chapter VIII, Section 7, Free-Standing Dialysis Services. Specifically, the Department proposes to require that providers bill using HCPCS codes along with Revenue codes when billing for Free-Standing Dialysis Services. This will be effective upon implementation of the new claims system, MIHMS, with a 30 day notice to providers. This is necessary in order to be consistent with Medicare guidelines, satisfy correct coding, and to remain HIPPA compliant.
Comment Deadline: 2010-05-28 Posted: April 12, 2010
 
MaineCare Benefits Manual, Chapter III, Section 50, Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded Word     
Concise Summary: The Maine Department of Health and Human Services, Office of MaineCare Services, proposes changes to MaineCare Benefits Manual, Chapter III, Section 50, Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded. This proposed 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. Since this rule is a Major Substantive rule, it will not be finally adopted until approved by the Legislature.
Comment Deadline: 2010-05-14 Posted: April 8, 2010
 
Chapter II, Section 95, Podiatric Services Word     
Concise Summary: The Department of Health and Human Services Office of MaineCare Services is proposing changes to the MaineCare Benefits Manual, Chapter II, Section 95, Podiatric Services The proposed rule change requires, for some services, providers to access prior authorization criteria that are industry recognized criteria utilized by a national company under contract, in addition to prior authorization criteria set forth in the rule itself. Providers can access these prior authorization criteria by accessing the OMS website at: http://www.maine.gov/dhhs/oms/provider_index.html, which will have a link to the PA portal. In cases where the portal requires that certain prior authorization criteria be met, and the member fails to meet those criteria, such services will not be covered or allowed under the MaineCare program.
Comment Deadline: 2010-06-03 Posted: April 8, 2010
 
MaineCare Benefits Manual, Chapter II, Section 35, Hearing Aids and Services Word      
Concise Summary: The Department of MaineCare Services is proposing changes to MaineCare Benefits Manual, Chapter II, Section 35, Hearing Aids and Services. The proposed rule change requires, for some services, providers to access prior authorization criteria that are industry recognized criteria utilized by a national company under contract, in addition to prior authorization criteria set forth in the rule itself. Providers can access these prior authorization criteria by accessing the OMS website at: http://www.maine.gov/dhhs/oms/provider_index.html which will have a link to the PA portal. In cases where the portal requires that certain prior authorization criteria be met, and the member fails to meet those criteria, such services will not be covered or allowed under the MaineCare program. Also in this rulemaking, the Department will require documented evidence that a hearing test has occurred within preceding 6 months. Finally, in Section 35.07 B, the Department is now requiring a trial period of 30 days, after which the Audiologists or Hearing Aid Dealer and Fitter must provide written confirmation that the device meets the member’s need and should be purchased.
Comment Deadline: 2010-06-03 Posted: April 8, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 25, Dental Services Word      
Concise Summary: In Chapter II of Section 25, Dental Services, the proposed rule change requires, for Temporomandibular Joint Treatment (TMJ), that providers access prior authorization criteria that are industry recognized criteria utilized by a national company under contract, in addition to prior authorization criteria set forth in the rule itself. Providers can access these prior authorization criteria by accessing the OMS website at: http://www.maine.gov/dhhs/oms/provider_index.html which will have a link to the PA portal. In cases where the portal requires that certain criteria be met, and the member fails to meet those criteria, such services will not be covered or allowed under the MaineCare program. In Chapter III of Section 25, the Department is clarifying that PA is not required for D4341, if a member has a diagnosis code 101. To the extent that payment for D4341 has been denied is a member has a diagnosis of 101, the Department will approve reimbursement retroactively.
Comment Deadline: 2010-06-03 Posted: April 8, 2010
 
MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment Word      
Concise Summary: The Department of MaineCare Services is proposing changes to MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment. The Department proposes, to require, for some services, providers to access prior authorization criteria that is industry recognized criteria utilized by a national company under contract. Providers can access prior authorization criteria by accessing the OMS website at: http://www.maine.gov/dhhs/oms/provider_index.html which will include a link to the PA portal. In cases where the portal requires that certain criteria be met, and the provider fails to meet those criteria, such services will not be covered or allowed under the MaineCare program. Also, in this rulemaking, the Department proposes the addition of coverage for Microprocessor Controlled Knee Protheses when certain criteria are met. Providers can access the criteria at the above web portal. Furthermore, the Department is now requiring all repairs to DME equipment with total cost that exceed 60% of replacement, require prior authorization. Finally, the Department is clarifying current incontinence limitations in this rule, in addition to making re-formatting changes in this rulemaking.
Comment Deadline: 2010-06-03 Posted: April 8, 2010
 
Maine State Services Manual, 10-144, Chapter 101, Ch II, Section 90, Physicians Services Word     
Concise Summary: The Department is making changes to MaineCare Benefits Manual, Chapter 101, Section 90, Physician’s Services Ch II. The changes increase the MaineCare reimbursement rate for 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. Providers can visit the Office of MaineCare’s website for the current fee schedule. The fee schedule can be found at http://portalxw.bisoex.state.me.us/oms/proc/pub_proc.asp?cf=mm.
Comment Deadline: 2010-04-15 Posted: March 16, 2010
 
Repeal of MaineCare Benefits Manual, Chapters II & III, Section 41, Day Treatment and Proposal of MaineCare Benefits Manual, Chapters II & III, Section 65, Behavioral Health Services Word     
Concise Summary: Chapters II & III, Section 41, Day Treatment of the MaineCare Benefits Manual is being repealed and the service Day Treatment is being moved to Chapters II & III, Section 65, Behavioral Health Services. The service as described in Section 65 must be medically necessary and provided by qualified staff. HIPAA compliant coding will be utilized. Behavioral Health Professionals and Licensed Clinical Staff will be allowed to provide Children’s Behavioral Health Day Treatment Service in a school setting; reimbursement will be based on level of credential. The maximum number of hours reimbursed will be reduced from eight (8) to six (6) per day. In addition, Section 65 imposes additional eligibility requirements for Children’s Behavioral Health Day Treatment. Behavioral Health Day Treatment may be provided by Schools and by mental health agencies who provide programs in private special purpose schools. Additionally, Schools will be allowed to provide the following services, as long as they have enrolled to provide them and the qualified staff: 65.06-3, Outpatient Services, 65.06-4 Family Psychoeducational Treatment, 65.06-7 Neurobehavioral Status Exam and Psychological Testing, 65.06-9 Children’s Home and Community Based Treatment, 65.06-10 Collateral Contacts Children’s Home and Community Based Treatment, and 65.06-13 Children’s Behavioral Health Day Treatment. There are routine technical changes in order to prepare for the implementation of MIMHS. HIPAA compliant coding for Children’s ACT services is being proposed. The requirement for a hospital to have a Mental Health License is being removed. The limit for members in a Differential Substance Abuse Treatment (DSAT) substance abuse group is being changed. Other routine technical changes to Section 65, Behavioral Health Services have also been proposed.
Comment Deadline: 2010-04-12 Posted: March 4, 2010
 
Chapter II, Section 4, Ambulatory Surgical Centers Word     
Concise Summary: The Department of Health and Human Services, MaineCare Services, proposes changes to Chapter II, Section 4.04, Section 4.05 and Section 4.07 in order to update and clarify policy language. In Section 4.04-A, the Department is adding language to state that payment for implanted presbyopia-correcting intraocular lens and astigmatism correcting intraocular lens will be paid at the rate of a conventional intraocular lens. In section 4.04-B, the Department is eliminating website information that is stated in 4.04-Covered Services and adding language that states that ASC covered services may be billed in addition to the surgical procedure. In Section 4.05, Non-Covered Services, the Department is deleting the 3rd and 4th paragraph “Payment for” Presbyopia-Correcting Intraocular Lens, etc, as this is clarified in Section 4.04-A. In section 4.07-2 the Department is proposing to change the language to clarify that when there are multiple procedures in the same operative session MIHMS will pay for one procedure, which has the highest payment amount.
Comment Deadline: 2010-04-14 Posted: March 4, 2010
 
Chapter VI, Section 3, MaineNET, Chapter 101, MaineCare Benefits Manual Word     
Concise Summary: The Department of Health and Human Services, MaineCare Services, is proposing to repeal Chapter VI, Section 3, MaineNET. MaineNET is a voluntary MaineCare program that was originally implemented around 2000 to improve health outcomes and manage program costs by providing clinical and administrative coordination of primary, acute, behavioral and long-term care services for elders and adult with disabilities who are MaineCare recipients. Due to no enrollment, this program has not been operational since approximately 2001.
Comment Deadline: 2010-04-12 Posted: February 23, 2010
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services Word     
Concise Summary: This serves as Notice of MaineCare Reimbursement Methodology Change. Estimate of any expected increase or decrease in annual aggregate expenditures: these changes will result in an estimated total reimbursement reduction to hospitals in the amount of $1,605,082 in SFY 10 and $14,055,559 in SFY 11. This change in methodology brings MaineCare hospital reimbursement more in line with the many states which utilize the Medicare DRG reimbursement system and the Medicare APC system, and it also reduces the total MaineCare obligation to the hospitals. The rule proposes to change the reimbursement methodology for acute care non critical access hospitals as follows: Inpatient discharges would be reimbursed on a Medicare DRG-based system, and would include a direct care DRG rate, as well as estimated capital and medical education costs. This reimbursement would be subject to interim and final settlements. Outpatient services would be reimbursed based on a percentage of Medicare Ambulatory Payment Classification (APC) rates, which would include lab and radiology costs. APC would be reimbursed based on submitted claims and would not be subject to settlement. Hospital-based physician costs would be paid based on submitted claims and subject to settlement. Acute care non-critical access hospitals will continue to be reimbursed under the PIP methodology for services provided until the first day of the hospital’s first fiscal year after MIHMS goes live, at which time the proposed DRG and APC methodologies would go into effect. There will be no PIP reimbursement for services provided on or after that date. In addition, effective July 1, 2010, the rule proposes to: reduce the inpatient portion of the PIP rate for acute care non-critical access hospitals by 4%; reduce the inpatient DRG rate by 4%; and reduce the distinct psychiatric unit discharge rate by $500 per hospital. Effective April 1, 2010, the rule proposes to reduce reimbursement to acute care critical access hospitals to 101% of allowable inpatient and outpatient costs. These proposed changes are subject to CMS approval. Hospitals will receive at least a 30 day notice of “go live” date for MIHMS.
Comment Deadline: 2010-03-01 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 96, Private Duty Nursing and Personal Care Services Word     
Concise Summary: The Department is proposing changes to the above named sections of the MaineCare Benefits Manual. Specifically, proposed changes to Chapter II include adding two services: care coordination and skills training. These services were formerly billed under Section 13, Targeted Case Management, as part of a per member per month fee. In addition, the proposed rules remove the term “Personal Care Assistant (PCA)” from rule and replace with “Personal Support Specialist (PSS)”. The Department also proposes to remove the definition of and reference to the Home Care Coordination Agency (HCCA), as the functions of the HCCA are no longer needed. Instead, the Service Coordination Agency will be providing the care coordination and skills training services. Proposed changes also include the addition of a “limits” section, which outlines the allowed maximum number of billable hours for each service. The Department also proposes to extend suspension of services from 30 days to 60 days. Changes are also proposed to PSS training requirements, allowing for job shadowing and on-the-job training to count toward the required number of training hours. In Chapter III, the Department proposes to eliminate all local codes and replace with HIPAA-compliant service codes needed to bill for all services covered under Chapter II.
Comment Deadline: 2010-02-27 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 19, Home and Community Benefits for the Elderly and Adults with Disabilities Word     
Concise Summary: The Department is proposing changes to the above named sections of the MaineCare Benefits Manual. Specifically, the Department proposes changes to the arrangement and billing of case management services. These changes include unbundling the three main services that formulate the current case management service. These services are skills training, financial management services, and care coordination. Historically, these services have been bundled together and paid with a per member, per month rate. In addition, all references to the term Home Care Coordination Agency (HCCA) are deleted because the functions of the HCCA are no longer necessary. Also, the proposed language consistently refers to “personal support specialist (PSS)” throughout the rules. Several definitions are also added to rule, including: Care Coordination, Financial Management Services, Service Coordination Agency, Skills Training, Supports Brokerage, and Waiver Services Provider. Proposed changes also include adding a limits section, which outlines the allowed maximum number of billable hours for care coordination and skills training. Additionally, these rules propose that the Office of Elder Services maintain member wait lists and that the Division of Finance under DHHS collect any cost of care that has been determined by MaineCare eligibility from the member. Both functions are currently performed by the HCCA. Finally, chapter II changes include structural reorganization as well as elimination of any redundancy found throughout the rules. In Chapter III, the Department is proposing the elimination of local codes and replacing with HIPPA-compliant service codes. In some instances, new rates and billing increments for services are proposed. All changes proposed in these rules support implementation of the Maine Integrated Health Management System (MIHMS) in March. Some of the changes proposed in this rule-making will require amendment of the waiver document filed with the Federal Centers for Medicare and Medicaid Services (CMS), and these amendments will require CMS approval before they are effective.
Comment Deadline: 2010-02-27 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 22, Home and Community Benefits for Adults with Physical Disabilities Word     
Concise Summary: The Department proposes changes to the above named Section of policy. Specifically, these proposed changes impact Section 22.05, Covered Services, by separately identifying the services that make up the current case management service. These services are skills training, financial management services, and supports brokerage. In addition, all references to “provider” are replaced with “Service Coordination Agency”. Proposed changes also include clarification under Section 22.06, Limits, which outlines the allowed maximum number of billable hours for each service. Additionally, these rules propose that the Office of Adults with Cognitive and Physical Disabilities maintain member wait lists and that the Department collect the cost of care from the member. Both functions are currently performed by the provider agency. Finally, chapter II changes include structural reorganization as well as elimination of any redundancy found throughout the rules. In Chapter III, the Department is proposing to add three HIPAA-compliant service codes needed to bill for skills training, financial management services and supports brokerage. The Department is also proposing to allow providers to bill for installation of the Personal Emergency Response System (PERS), which is consistent with other Home and Community Based waiver programs. Additionally, the Department proposes that the attendant care rate increase from $2.61 to $2.72 per fifteen minutes.
Comment Deadline: 2010-02-28 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 12, Consumer Directed Attendant Services Word     
Concise Summary: The Department is proposing changes to the above named sections of the MaineCare Benefits Manual. Specifically, proposed changes to Chapter II include adding two services: care coordination and skills training. These services were formerly billed under Section 13, Targeted Case Management, as part of a per member per month fee. In addition, all references to “provider” are replaced with “Service Coordination Agency”. Proposed changes also include the addition of a “limits” section, which outlines the allowed maximum number of billable hours for each service. Finally, chapter II changes include structural reorganization as well as elimination of any redundancy found throughout the rules. In Chapter III, the Department is proposing to add the two HIPAA-compliant service codes needed to bill for care coordination and skills training. A new rate is also proposed for attendant care services. All changes proposed in these rules support implementation of the Maine Integrated Health Management System (MIHMS).
Comment Deadline: 2010-02-28 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 67, Nursing Facility Services and Principles of Reimbursement for Nursing Facilities Word     
Concise Summary: The Department proposes the following changes to Chapter II, Section 67, Nursing Facility Services: adds language describing the practice of continued stay in a NF when a resident is no longer medically eligible for NF services and is awaiting placement for a residential care setting; adds a service for residents who have been receiving services under Section 24, Day Habilitation Services, which are being repealed; complies with State statute that allows residents to receive maintenance-level therapy when it has been determined the services are medically necessary in order to avoid a significant deterioration in ability to communicate orally, safely swallow or masticate; expands eligibility for specialized services for members with MR or “other related condition”; and changes terminology that is compliant with the new claims system. Furthermore, the Department proposes changes to Chapter III, Principles of Reimbursement for Nursing Facilities, by changing the methodology establishing the direct care cost components and consequently the prospective per diem rates for facilities. Additionally, methodology is added under principal 70 to support facilities billing for community support services, formerly billed under Section 24. The Department also proposes language that is now in state statute regarding depreciation recapture. Finally, proposed changes also include adding the OBRA Assessment definition as well as deleting the DRI definition.
Comment Deadline: 2010-02-13 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 27, Early Intervention Services Word     
Concise Summary: The Department proposes to repeal MaineCare Benefits Manual, Chapters II & III, Section 27, Early Intervention Services. The services covered under this section can be provided by qualified providers under other sections of the MaineCare Benefits Manual, e/g, Psychological testing, Section 65, Behavioral Health Services, Occupational Therapy, Section 68, Speech Therapy, Section 109 and Physical Therapy, Section 85.
Comment Deadline: 2010-02-12 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 104, School Based Rehabilitative Services Word     
Concise Summary: The Department is proposing toRepeal MaineCare Benefits Manual, Chapters II & III, Section 104 School Based Rehabilitative Services. The services covered under this Section can be provided by qualified providers under other sections of the MaineCare Benefits Manual, Section 65, Behavioral Health Services, Occupational Therapy, Section 68, Speech Therapy, Section 109 and Physical Therapy, Section 85.
Comment Deadline: 2010-02-13 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services Word     
Concise Summary: The Department is proposing changes to MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services. MaineCare is proposing to retroactively increase reimbursement for administration of seasonal flu vaccines (H1N1) and other immunizations allowed under 32 MRSA § 13831 for licensed Maine pharmacists effective October 1, 2009. MaineCare will reimburse $5 per vaccination for administration of these vaccines. Furthermore, retroactive to November 1, 2009, MaineCare pharmacies who compound the drug Tamiflu for MaineCare children and other 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.
Comment Deadline: 2010-02-04 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter II, Section 46, Psychiatric Hospital Services Word     
Concise Summary: These proposed rules seek to add admission eligibility and continuing eligibility criteria for psychiatric hospital detoxification services and developmental disorders unit services. The Department needs to ensure that MaineCare services are delivered only to individuals who are eligible for those services. These changes will assure the efficient operation of the MaineCare program. Further, the administrative burden of utilization review will be lessened if the admission and continuing eligibility criteria are clear from the beginning.
Comment Deadline: 2010-01-31 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter II, Section 45, Hospital Services Word     
Concise Summary: These proposed rules seek to add admission eligibility and continuing eligibility criteria for hospital detoxification services. The Department needs to ensure that MaineCare services are delivered only to individuals who are eligible for those services. These changes will assure the efficient operation of the MaineCare program. Further, the administrative burden of utilization review will be lessened if the admission and continuing eligibility criteria are clear from the beginning. These proposed rules also seek to remove specifics in billing instructions and reporting of rebatable drugs in favor of listing those specifics on the DHHS website. These changes would consolidate those instructions to one location.
Comment Deadline: 2010-01-31 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 31, Federally Qualified Health Center Services Word      
Concise Summary: The Proposed rule adds a new provision under “reimbursement” which sets forth the Department’s legal obligations for individuals who are eligible for Medicare, some of whom are also eligible for Medicaid (QMB only, QMB plus and non QMBs). This section complies with federal regulations on Medicare cost sharing. Also, the Department intends to transition to a new information system, MIHMS in 2010, with 30 days notice to providers. Upon implementation of MIHMS, the Department proposes to delete the current local billing codes in Chapter III, Table 1, and replace them with the codes in Chapter III, Table 2 to become compliant with Federal HIPAA regulations. Further the Department proposes requiring providers to bill services, including documenting the type of visit, diagnoses and procedures on the UB04 claim form, which will replace the CMS 1500 form.
Comment Deadline: 2010-01-29 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter III, Section 26, Day Health Services Word     
Concise Summary: The Department is proposing to remove the modifiers TF and TG attached to the S5100 code for Day Care Services. These modifiers are no longer necessary to distinguish the three levels of care upon MIHMS implementation. Providers will only need to bill the S5100 to receive reimbursement for members at any level of care.
Comment Deadline: 2010-01-29 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II & III Section 29, Community Support Benefits for Members with Mental Retardation and Autistic Disorder Word      
Concise Summary: The proposed rule amends § 29 of Chapters II and III of the MaineCare Benefits Manual by eliminating the Behavioral Add-on rate enhancement for providers of Community Support, Employment Specialist and Work Support Services. Additionally, the rates for Community Support, Employment Support Specialist and Work Support Services are being reduced by eight cents ($0.08) per unit to conform with the current rates for these services under § 21, Chapter III, Home and Community Benefits for Members with Mental Retardation of Autistic Disorder.
Comment Deadline: 2010-01-01 Posted: February 5, 2010
 
MaineCare Benefits ManualChapters II & III, Section 23, Developmental and Behavioral Evaluation Clinic Services Word      
Concise Summary: The Department is proposing changes to both Chapters II and III. Chapter II will contain new service descriptions for the Child Abuse Evaluation and the Developmental and Behavioral Evaluation. Chapter III will contain HIPAA compliant codes with new hourly rates. Other routine technical changes are being made to the rule.
Comment Deadline: 2010-01-08 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter II, Section 94, Prevention, Health Promotion, and Optional Treatment Services Word      
Concise Summary: The Department of Health and Human Services is proposing changes to this section to update terminology and make technical corrections to prepare for the Maine Integrated Health Management Solution (MIHMS). Additionally, the rule is being renamed.
Comment Deadline: 2010-01-09 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter III, Private Non-Medical Institution (PNMI) Services, and Appendix D and E Word      
Concise Summary: In this major substantive rulemaking, the Department is proposing to provisionally adopt the August 1, 2009 Emergency Substantive PNMI, Ch. III Rule, currently in effect as well as propose other additional clarifications. The Department proposes to amend Appendix D (Child Care PNMI Facilities) by deleting the cost settlement requirement. Instead, the Department is proposing to adopt a standardized capitated rate for five (5) levels of child services based on a child’s diagnosis and level of acuity. These rates were established by analyzing data from claims and time studies and unbundling service components to establish an Upper Payment Limit. The Department has added new billing codes for children’s services. The capitated rate includes reimbursement for all PNMI services required by a child for his/her category of level of care including all staffing required both by Maine licensing guidelines, and as identified in the child’s individual service plan, The Legislature mandated the 5 levels of child services in its budget initiative enacted into law ( P.L. 2009, ch. 213, Part CC). The Department proposes to amend Appendix E (Community Residences for Persons with Mental Illness) by deleting “scattered site” PNMI services. The Department anticipates that those services will still be provided to members in their apartments, but instead will be reimbursed through Community Support Services under Section 17 of the MaineCare Benefits Manual. Other proposed changes in Chapter III update billing codes for the Department’s new claims system for all other PNMI services, and clarify in Chapter III where language pertaining to auditing cost reports no longer applies to Appendix D PNMI services.
Comment Deadline: 2009-11-07 Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures Word     
Concise Summary: The Department is proposing to make the following changes to the above named rule: define billing and rendering (servicing) provider; set forth additional requirements for emergency services; clarify that providers must supply requested information to the Department, and that there is a continuing duty to update provider information; clarify the types of financial information that may be requested; set forth additional requirements for termination procedures; simplify provider requirements related to e-signatures and facsimiles obtained for member files; add a section on provider debt establishing that provider debt attaches to any person with an ownership interest in the provider, or against any officer or director of the provider; adds the coverage of a new eligibility group (presumptive eligibility for pregnant women); requires that providers of managed care services must have a referral from the member’s PCP; adds additional requirements for the PA process; deletes PA requirements for alcohol treatment services reimbursed by the Indian Health Service; defines behavioral health emergencies for PA purposes; provides that national standards may be used as criteria for defining “medically necessary”; sets forth procedures following a provider suspension. The Department expects that these changes will be budget neutral. These proposed changes should not adversely impact those facilities with staff of 20 or fewer employees. In addition, this proposed rule-making is not expected to create any new compliance burdens for counties or municipalities.
Comment Deadline: 2009-11-15 Posted: October 28, 2009
 
MaineCare Benefits Manual, Chapter IV, Restriction Plans Word  PDF   
Concise Summary: The rule was proposed in July 2009, and due to compelling comments, the rule has been clarified. The proposed rule restructures the restriction plans from two to four plans to improve the health care of MaineCare members and to integrate Member Lock-In plans with the new MaineCare claims system, Maine Integrated Health Management System (MIHMS). Lock-In type 1 requires a member to be restricted to the core providers of a Primary Care Physician, a Hospital, a Pharmacy and any other applicable health care professional. Lock-In type 2 restricts the member to one or multiple types of health care providers. Lock-In type 3 restricts the member to one or multiple specific prescriber(s) for their prescriptions. Lock-In type 4 restricts the member from being able to obtain a specific drug category (class). Additionally, the rule is renamed.
Comment Deadline: 2009-11-26 Posted: October 28, 2009
 
MaineCare Benefits Manual, Chapters II & III, Section 24, Day Habilitation Services, and Chapters II & III, Section 28 Rehabilitation and Community Support Services for Childrenwith Cognitive Impairments and Functional Limitations Word  PDF   
Concise Summary: The Department is proposing a new MaineCare section, Section 28, which will provide current Section 24 services, as well as additional services, to an expanded children’s eligibility group. The Department is repealing Section 24 because it is deleting this service for adults. The Department anticipates that most adults who now receive Section 24 services will be provided this service under some institutional providers. The Department will provide advance written notice to members to inform them of this reduction and change in service.
Comment Deadline: 2009-11-27 Posted: October 28, 2009
 
MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment Word  PDF   
Concise Summary: The Department is proposing changes to MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment to achieve required savings in the budget law, in accordance with PL 2009, ch. 213. The Department is proposing changes to its reimbursement methodology so that it will reimburse for DME/Medical Supplies as follows: (1) For DME/medical supplies that are not “miscellaneous DME/medical supplies” or made available through an exclusive contract with the Department, providers will be reimbursed at the lower of: the Medicare rate, the provider’s Usual and Customary Charge or a MaineCare fee schedule published on the Department’s website. (2) For DME/medical supplies, which contains the phrase “miscellaneous,” “accessories,” "not otherwise specified" or "not otherwise classified" in its description, MaineCare will reimburse at either the Manufacturers’ Suggested Retail Price (MSRP) minus twenty percent (20%) or in cases where there is no listed MSRP, providers will be paid their Usual and Customary Charges minus thirty percent (30%). (3) Where the Department has entered into a contract with a supplier, the Department will reimburse based on the price 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.
Comment Deadline: 2009-12-03 Posted: October 27, 2009
 
MaineCare Benefits Manual, Chapters II & III, Section 102, Rehabilitative Services Word  PDF   
Concise Summary: This letter gives notice of a proposed rule: MaineCare Benefits Manual, II & III, Section 102, Rehabilitative Services. The proposed Chapter II renames services to clarify and reorganize services for better applicability and to allow for flexible patient centered care. Additionally, Chapter III has been recoded in a manner consistent with HIPAA compliant coding. Services have been realigned from a level system to a concurrent provision system. Members currently have three levels of service that may only be accessed non concurrently up to 22 hours a week, the rule redesign allows a member to receive one of four services concurrently up to 18 hours a week, allowing for a more effective and efficient service delivery. The new services are Clinical Assessment and Reassessment, which was formerly Clinical Evaluation. Level I Intensive Rehabilitative Services is being replaced by Intensive Integrated Neurorehabilitation. Group services will no longer be reimbursed. Level II Post Acute Rehabilitative Services is being replaced by Neurobehavioral Rehabilitation, with one-on-one (1:1), group and family services. And lastly, Level III Day Health Rehabilitative Services are being replaced by Self Care/Home Management and Community/Work reintegration, with group services. Other routine and Technical changes have been made to the proposed rule.
Comment Deadline: 2009-11-26 Posted: October 22, 2009
 
Chapters II and III Section 85, Physical Therapy Services Word  PDF   
Concise Summary: The Office of MaineCare Services is proposing changes to the MaineCare Benefits Manual, Chapters II and III, Section 85, Physical Therapy Services. These changes seek to:
  • change the definition of “maintenance therapy” to allow medically necessary occupational therapy services if the services prevent a member from suffering a significant decline in function that would result in an extended length of stay or placement in an institutional hospital setting;
  • replace local billing codes with HIPAA compliant code; adjust rates in a budget neutral fashion to match new billing codes;
  • remove “Collateral Contacts” as a billable service upon MIHMS go live; and
  • propose other structural, administrative and grammatical changes.
Comment Deadline: 2009-11-06 Posted: September 29, 2009
 
Chapters II and III Section 68, Occupational Therapy Services Word  PDF   
Concise Summary: The Office of MaineCare Services is proposing changes to the MaineCare Benefits Manual, Chapters II and III, Section 68, Occupational Therapy Services. These changes seek to:
  • change the definition of “maintenance therapy” to allow medically necessary occupational therapy services if the services prevent a member from suffering a significant decline in function that would result in an extended length of stay or placement in an institutional hospital setting;
  • replace local billing codes with HIPAA compliant code; adjust rates in a budget neutral fashion to match new billing codes;
  • remove “Collateral Contacts” as a billable service upon MIHMS go live; and
  • propose other structural, administrative and grammatical changes.
Comment Deadline: 2009-11-06 Posted: September 29, 2009
 
MaineCare Benefits Manual, Chapters II & III, Section 30, Family Planning Agency Services and Allowances for Family Planning Agency Services Word  PDF   
Concise Summary: The Department has proposed changes to this section to update the policy language, unbundle services, replace local codes with HIPAA compliant codes and standardize rates. Also contained within this rulemaking is the elimination of coverage for infertility treatment, elimination of coverage for cervical caps, and expansion of coverage to include blood testing and counseling related to HIV and Hepatitis. These changes will become effective upon implementation of MIHMS Providers will be notified at least thirty (30) days prior to the effective date.
Comment Deadline: 2009-12-17 Posted: September 26, 2009
 
Chapters II and III, Section 13 Targeted Case Management Services Word  PDF   
Concise Summary: These rules propose to permanently adopt changes set forth in the August 31, 2009 emergency rule which replaced the August 1, 2009 emergency rules regarding targeted case management. This rulemaking proposes to make permanent the following emergency changes: Target groups are consolidated and redefined. Several target groups are deleted, including Pregnant and Postpartum women, Adults with Diabetes and Asthma and Members who are receiving Healthy Futures Services. There is new language detailing eligibility criteria for Children and Adults 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. This rule adds prior authorization for children’s targeted case management services. This rule also reduces funding for children’s targeted case management by limiting services to two (2) months for children with scores between fifty (50) and seventy (70) on the Child and Adolescent Functional Assessment Scale. The assessment tool score may not be the sole criterion for determining medical necessity, needs and/or eligibility. This rule also proposes that MaineCare will not cover multiple TCM services; and sets forth the eligibility process, and the requirement of transitioning to one comprehensive case manager for children and adult members. Chapter III proposes new billing procedure codes based on HIPAA compliant HCPCS coding. Chapter III also implements a change in reimbursement to some Providers/Case Management Agencies through the requirement of billing in 15 minute increments, while other TCM services require monthly or weekly billing. Record keeping requirements, per the federal Medicaid requirement, have been proposed in this rule. This rule also provides TCM coverage for individuals receiving protective services, and changed 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.
Comment Deadline: 2009-10-23 Posted: September 15, 2009
 
Chapters II and III, Section 25, Dental Services Word  PDF   
Concise Summary: The Department of Health and Human Services is proposing changes to the MaineCare Benefits Manual, Chapters II and III, Section 25, Dental Services. The Department proposes amending the language in sub-section 25.03-2 (G) for Tobacco Cessation Counseling to be consistent with the language in Chapter III, Section 90, Physician’s Services. The Department is also proposing the addition of language to sub-section 25.04-1 For Adult Dental Care Requirements. The language will clarify criteria for imminent tooth loss, pursuant to 22 M.R.S.A § 3174-F. Furthermore, the Department is proposing the removal of Appendix III-Supplemental Payment to General Dentists. Instead the Department is increasing the reimbursement for selected dental codes in Chapter III of this Policy.
Comment Deadline: 2009-10-08 Posted: August 28, 2009
 
Chapter II, Section 97, Private Non-Medical Institution Service Word  PDF   
Concise Summary: These proposed rules will permanently adopt emergency rules already in effect for prior authorization of behavioral health PNMI services. The rules also propose additional prior authorization criteria for other PNMI services, and the Department is adding language detailing medical eligibility criteria. 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 children’s PNMI services for which standard rates are being set in a separate rulemaking pertaining to reimbursement of PNMI services in Chapter III, Section 97. The Maine State Legislature has directed the Department to achieve $6.8 million savings per State fiscal year in this rulemaking for children’s services. Another $ 1.7 million of savings is expected through the scattered site housing changes.
Comment Deadline: 2009-10-04 Posted: August 26, 2009
 
Chapter VII, Section 5 Estate Recovery Word  PDF   
Concise Summary: The Department of Health and Human Services is proposing changes to the MaineCare Benefits Manual, Chapter VII, Section 5, Estate Recovery. This proposed rule makes four specific changes to the Estate Recovery program. The rule adds an exemption reflecting the value of benefits paid under a qualified long term care insurance policy. Amounts exempted from recovery due to qualified LTC insurance policies are expected to be significantly offset by overall MaineCare savings resulting due to more long term care services being paid through private insurance. This rule also limits the availability of the Care Given Exemption to persons whose incomes are less than or equal to 200 percent of the federal poverty level, as mandated by the federal Centers for Medicare and Medicaid Services. Under the new “care given exemption” language, the Department has far less authority to waive recovery from certain estate assets than it could under the pre-existing rules. The proposed rule also includes two policy changes mandated by the Legislature, barring estate recovery from members’ joint tenancy interests in real property and striking language relating to delayed recovery from the estates of certain survivors. The Department also made other structural, administrative, grammatical and clarifying within this rulemaking.
Comment Deadline: 2009-09-07 Posted: July 29, 2009
 
MaineCare Benefits Manual, Chapter VI, Primary Care Case Management (PCCM) Word  PDF   
Concise Summary: The Department of Health and Human Services is proposing changes to Chapter VI, Primary Care Case Management (PCCM) to add a new level of services, Patient Center Medical Home. Patient Centered Medical Home services will assure effective, efficient and accessible health care services for eligible MaineCare members. Provider requirements are included in the proposed rule. Providers who are approved to deliver this service will receive $3.50 per member per month to deliver patient centered medical home services. This management fee is in addition to the $3.50 they have received for providing PCCM services for a total of $7.00 per member per month. Providers will be required to deliver additional integration of patient services, and participate in on-going educational and evaluation activities. The Department also added language to clarify what groups may not be required to participate in PCCM or PCMH services to be in compliance with federal guidelines and updated sections that have been revised or consolidated in the MaineCare Benefits Manual. The rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. The rulemaking has no adverse impact on small business.
Comment Deadline: 2009-09-13 Posted: July 28, 2009
 
MaineCare Benefits Manual, Chapters II and III, Section 67, Nursing Facility Services Word  PDF   
Concise Summary: The Department is proposing to permanently adopt emergency rules that became effective July 1, 2009. Specific proposed changes include: revisions of dates and methodology used to trend forward or inflate direct care and routine costs, updating the percent of the median used in the July 1, 2009 rebasing calculation, and clarifying the direct care add-on and hold harmless principles. In addition, the Department is proposing the one-time payment methodology, which is already approved by CMS. Furthermore, this proposal includes a new principle that identifies the methodology used to establish rates for remote island facilities. Other minor and technical changes are considered in this rule making.
Comment Deadline: 2009-09-06 Posted: July 23, 2009
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services Word  PDF   
Concise Summary: The Department is proposing to permanently adopt emergency rules currently in place that reduce hospital reimbursement. As mandated by the Legislature, in P.L. 2009, ch. 213, Part CC, effective July 1, 2009 the Department reduced hospital reimbursement. For acute care non-critical access hospitals, inpatient discharge rates (except for those from psychiatric units) were reduced 6.7% and reimbursement for outpatient services was decreased to 83.8% of costs. For critical access hospitals and hospitals reclassified to a wage area outside Maine, reimbursement for inpatient and outpatient services was reduced to 109% of costs. For all acute care hospitals, including critical access, hospital based physician reimbursement was decreased from 100% to 93.3% of allowable costs for inpatient non-emergency physicians, to 93.4% of costs for inpatient emergency physicians and to 83.8% of costs for outpatient non-emergency physicians. In addition, these emergency rules eliminated the COLA adjustment for SFY’s 2010 and 2011 for non critical access acute care hospitals for inpatient discharge rate and for psychiatric unit discharge rates. Th e Department capped the PIP payment so that the total payment to all hospitals is not less than 80%. All of the above mentioned changes are contingent upon approval from CMS.
Comment Deadline: 2009-08-31 Posted: July 22, 2009
 
MaineCare Benefits Manual, Chapter III, Section 22, Home and Community Benefits for Adults with Physical Disabilities Word  PDF   
Concise Summary: The Department proposes to adjust the rates for personal care attendant services under this section. Specifically, the proposal increases the rate from $2.57 to $2.61 per fifteen minutes. This is being proposed because the rate that was adopted in March 2009 did not adjust for the total amount of state funds allocated for the program. In order to claim full Federal match for this program, this rate needs to be adjusted an additional four cents. In addition, this rate is now consistent with the personal care attendant rates reimbursed under Section 12 of the MaineCare Benefits Manual.
Comment Deadline: 2009-08-27 Posted: July 21, 2009
 
MaineCare Benefits Manual, Chapter II, Section 46, Psychiatric Hospital Services Word  PDF   
Concise Summary: These proposed rules seek to permanently adopt 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. The Department is also removing Katie Beckett eligibility criteria from this section and consolidating it into Chapter 10, Section 3. There are no changes in Katie Beckett eligibility in this rulemaking. Consolidating the Katie Beckett eligibility into one section will achieve administrative simplification by making the criteria easier to find.
Comment Deadline: 2009-08-21 Posted: July 14, 2009
 
MaineCare Benefits Manual, Chapter II Section 45 Hospital Services Word  PDF   
Concise Summary: These proposed rules seek to permanently adopt 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. The Department is removing Katie Beckett eligibility criteria from this section and consolidating it into Chapter 10, Section 3. There are no changes in Katie Beckett eligibility in this rulemaking. Consolidating the Katie Beckett eligibility into one section will achieve administrative simplification by making the criteria easier to find. This rulemaking also proposes to require hospitals to report all rebatable physician administered drugs by National Drug Code effective January 1, 2010 in order to meet FY 2010 budget savings.
Comment Deadline: 2009-08-21 Posted: July 14, 2009
 
MaineCare Benefits Manual, Chapter III Section 109 Speech and Hearing Services Word  PDF   
Concise Summary: These proposed rules seek to permanently adopt emergency rules currently in effect that increased rates for speech and hearing agencies as directed in Maine’s FY 2010 budget.
Comment Deadline: 2009-08-22 Posted: July 14, 2009
 
MaineCare Benefits Manual, Chapters II and III, Section 40, Home Health Services Word  PDF   
Concise Summary: The Department proposes changes to the above named section of policy. Specifically, in Chapter II, the Department is proposing to change §40.05-E, Medical Supplies, which will eliminate routine supplies as a separately coverable service. The costs associated with these supplies will be included in the service rates listed in Chapter III. Furthermore, this section also clarifies language for non-routine supplies to state that these supplies are not billable under section 40 and must be billed under section 60. In addition, the Department is simultaneously proposing Chapter III and proposes new HIPAA compliant codes for the reimbursable services under this section. These coding changes are required in order to comply with Federal statute. All changes must be approved by the legislature as these are major substantive rules and are planned to go in effect upon implementation of MIHMS.
Comment Deadline: 2009-08-15 Posted: July 7, 2009
 
MaineCare Benefits Manual, Chapters II & III, Section 17, Community Support Services Word  PDF   
Concise Summary: These proposed 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.
Comment Deadline: 2009-08-07 Posted: July 2, 2009
 
MaineCare Benefits Manual, Chapter III, Section 15, Chiropractic Services Word  PDF   
Concise Summary: The Office of MaineCare Services is proposing changes to the MaineCare Benefits Manual, Chapter III, Section 15, Chiropractic Services. The Department proposes to change the pricing modifier requirement for global services to require the use of modifiers with the implementation of the new claims system.
Comment Deadline: 2009-07-07 Posted: July 1, 2009
 
MaineCare Benefits Manual, Chapters II & III Section 7, Free-Standing Dialysis Services Word  PDF   
Concise Summary: The proposed rule is a new section of the MaineCare Benefits Manual. Currently, providers of dialysis services are billing MaineCare under Section 90, Physician Services. The Physician Services rule does not contain any policy pertaining to dialysis services. This new rule is a stand-alone policy for dialysis providers with its own definitions; covered services, including renal dialysis, prescribed drugs, and training for home dialysis; eligibility requirements; reimbursement; limitations; and billing instructions. This rule is not expected to have any adverse impact on small business.
Comment Deadline: 2009-08-24 Posted: June 30, 2009
 
MaineCare Benefits Manual, Chapter IV Restriction Plans Word  PDF   
Concise Summary: The proposed rule restructures the restriction plans from two to four plans to improve the health care of MaineCare members and to integrate Member Lock-In plans with the new MaineCare claims system, Maine Integrated Health Management System (MIHMS). Lock-In type 1 requires a member to be restricted to a designated Primary Care Physician, a Hospital, a Prescriber, a Pharmacy and any other applicable health care professional. Lock-In type 2 restricts the member to one or multiple types of health care providers. Lock-In type 3 restricts the member to one or multiple specific prescriber(s) for their prescriptions. Lock-In type 4 restricts the member from being able to obtain a specific drug category (class). Additionally, the rule is renamed.
Comment Deadline: 2009-08-10 Posted: June 30, 2009
 
MaineCare Benefits Manual, Chapters II and III, Section 150, STD Screening Clinic Services Word  PDF   
Concise Summary: The proposed changes to this section increase the reimbursement rate to providers, add information on clinical record keeping, and update the policy language. The local code is replaced by a HIPAA compliant code.
Comment Deadline: 2009-08-21 Posted: June 30, 2009
 
MaineCare Benefits Manual, Chapters II and III, Section 23, Developmental and Behavioral Evaluation Clinic Services Word  PDF   
Concise Summary: The Department proposes to repeal MaineCare Benefits Manual, Chapter II and III, Section 23, Developmental and Behavioral Evaluation Clinic Services. The evaluation and assessment services covered in this section can be provided under other sections of the MaineCare Benefits Manual governing specific services, e.g., psychological testing, occupational therapy assessments, speech and language evaluations, etc. In addition, the current billing codes employed under § 23 do not comply with federally mandated coding requirements. Providers will be directed to use standardized HIPAA compliant codes for the specific services they provide.
Comment Deadline: 2009-06-08 Posted: June 30, 2009
 
MaineCare Benefits Manual, Chapters II & III, Section 62, Genetic Testing and Clinical Genetic Services Word  PDF   
Concise Summary: The Department gives notice of a proposed repeal of a rule: MaineCare Benefits Manual, Chapters II & III, Section 62, Genetic Testing and Clinical Genetic Services. The Department is repealing this section of the MaineCare Benefits Manual to simplify the billing for this service and to repeal outdated clinical provisions currently in Section 62, Genetic Testing and Clinical Genetic Services. Currently the majority of genetic services are being billed under Sections 90 and 55 of the MaineCare Benefits Manual. Providers who were currently billing under Section 62 will now bill under Sections 90, Physicians Services and 55, Laboratory Services, as appropriate. No services are being reduced as a result of this rulemaking.
Comment Deadline: 2009-08-08 Posted: June 30, 2009
 
MaineCare Benefits Manual, Chapter III, Section 21, Home and Community Benefits for Members with Mental Retardation or Autistic Disorder. Word  PDF   
Concise Summary: The proposed major substantive rule provisionally adopts amendments to certain rates paid to providers of home and community based services. The new rates were adopted on and emergency basis, effective July 1, 2009, pursuant to the budget act. The change in rates is mandated by the Legislature. The budget initiative requires that rates be reduced by 6%; however, the budget initiative specifies that the reduction is from rates effective in December 2008. In addition, changes to billing codes are proposed to comply with federal coding requirements. The coding changes will take effect when the Department's new claims processing system becomes operational, expected to occur in February, 2010. Providers will receive 30 days notice of the effective date of the coding changes.
Comment Deadline: 2009-08-09 Posted: June 30, 2009
 
MaineCare Benefits Manual, Chapters II & III, Section 103, Rural Health Center Services Word  PDF   
Concise Summary: The Department intends to transition to a new information system, MIHMS in 2010, with 30 days notice to providers. Upon implementation of MIHMS, the Department proposes to delete the current local billing codes in Chapter III, Table 1, and replace them with the codes in Chapter III, Table 2, to become compliant with Federal HIPAA regulations. Furthermore, the Department proposes requiring providers to bill services, including documenting the type of visit, diagnoses and procedures on the UB04 claim form, which will replace the CMS 1500 form.
Comment Deadline: 2009-07-27 Posted: June 30, 2009
 
MaineCare Benefits Manual, Chapter III, Section 29, Community Benefits for Members with Mental Retardation and Autistic Disorder. Word  PDF   
Concise Summary: The proposed rule merely adds a modifier to the procedure code for transportation services. It will become effective at the time the Department's new claims payment system becomes operational, expected to occur in February 2010.
Comment Deadline: 2009-08-14 Posted: June 29, 2009
 
MaineCare Benefits Manual, Chapters II and III, Section 96, Private Duty Nursing and Personal Care Services Word  PDF   
Concise Summary: The Department proposes changes to Chapters II and III of Section 96, Private Duty Nursing and Personal Care Services in order to begin permanent adoption of the emergency rule that takes effect July 1, 2009. Specifically, this proposed rule includes adding two definitions to the rule. This rule making also proposes a new level of eligibility, level IX, for those MaineCare eligible members who require medication administration services and assistance with ADLs or IADLs. As a result of these new criteria, Chapter III is also being proposed to include two new codes that will provide the ability for qualified providers to bill for such services. In addition to these changes, the Department proposes to update the names of the Departmental Offices that are mentioned in the rule. Other minor technical and grammatical changes are also proposed.
Comment Deadline: 2009-08-16 Posted: June 29, 2009
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services Word  PDF   
Concise Summary: The Department of Health and Human Services is proposing changes to Chapter II, Section 80, Pharmacy Services. The proposed rule edits the definition of the Maine Maximum Allowable Cost as a result of savings initiatives. The changes will allow Maine to MAC cost of items such as diabetic supplies and Specialty drugs. This rule also removes language in 80.05-3 (b), which states that reimbursement for B-12 for documented pernicious anemia or megaloblastic anemia drugs will be made only for the conditions described and only when the prescriber has written the diagnosis on the prescription. The Department will no longer cover these medications unless prior authorization is awarded. Finally, the Department is adding section 80.04-3, Academic Detailing Committee to comply with 22 M.R.S.A § 2685. The Committee members will be appointed by the Department and will provide evidence based education, outreach, improve quality measures and encourage better communication between the Department and health care professionals to reduce health complications and unnecessary cost associated with inappropriate drug prescribing. The Department also made other structural, administrative, grammatical and clarifying changes within this rulemaking.
Comment Deadline: 2009-07-30 Posted: June 23, 2009
 
MaineCare Benefits Manual, Chapters II & III, Section 90, Physician’s Services Word     
Concise Summary: In Chapter II of this rulemaking, the Department proposes, to require, for some services, providers to access prior authorization criteria that is industry recognized criteria utilized by a national company under contract. Providers can access criteria by utilizing the following portal: http://www.maine.gov/dhhs/oms/provider_index.html. In cases where the portal requires that certain criteria be met, and the provider fails to meet those criteria, such services will not be covered or allowed under the MaineCare program. The proposed rule also changes the reimbursement methodology by reimbursing providers at 70% of the Medicare fee schedule effective March 1, 2010 consistent with the March 1, 2010 Emergency rulemaking and another rulemaking proposed on March 17, 2010. Upon implementation of the MIHMS system, MaineCare will require providers to utilizing Medicare’s fee schedule based on place of service and modifiers. Finally, the Department has changed transplant criteria to require members to be free of alcohol and drug use for 6 months prior to transplant. In Chapter III of this rulemaking, upon implementation of Maine’s Integrated Health Management System (MIHMS), the Department will repeal Chapter III, Section 90, since all necessary methodology and billing information can be found at either Chapter II or on the Department’s website.
Comment Deadline: 2010-06-03 Posted:
 

 

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