MaineCare Benefits Manual - Proposed Rules

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.

Deadline for Comments: Comments must be received by midnight August 21, 2009

Concise Summary: The Office of MaineCare Services is proposing changes to the MaineCare Benefits Manual, Chapter II, Section 4, Ambulatory Surgical Center Services. The Department proposes updating the policy to reflect CMS changes. The Department proposes several other structural and grammatical changes within this rulemaking.

Deadline for Comments: Comments must be received by midnight July 24, 2009

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. Further the Department proposes requiring providers to document services provided, including the type of visit, diagnoses and procedures on the CMS 1500 form.

Deadline for Comments: Comments must be received by midnight July 27, 2009

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.

Deadline for Comments: Comments must be received by midnight August 15, 2009

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.

Deadline for Comments: Comments must be received by midnight August 22, 2009

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.

Deadline for Comments: Comments must be received by midnight October 8, 2009

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.

Deadline for Comments: Comments must be received by midnight October 23, 2009

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.

Deadline for Comments: Comments must be received by midnight November 6,2009

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.

Deadline for Comments: Comments must be received by midnight November 6,2009

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.

Deadline for Comments: Comments must be received by midnight November 29, 2009

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.

Deadline for Comments: Comments must be received by midnight November 27, 2009

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.

Deadline for Comments: Comments must be received by midnight November 26, 2009

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.

Deadline for Comments: Comments must be received by midnight December 3, 2009

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.

Deadline for Comments: Comments must be received by midnight November 26, 2009

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.

Deadline for Comments: Comments must be received by midnight December 17, 2009

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.

Deadline for Comments: Comments must be received by midnight December 3, 2009

Concise Summary: These proposed rules seek to achieve a number of goals:

• establish HIPAA compliant coding for the delivery of services with implementation of MaineCare’s new claims system, MIHMS;
• fulfill the Legislature’s directive, as expressed in PL 2007, ch. 71, which allows for speech therapy benefits for members who, without a maintenance level of speech therapy services, may reasonably suffer a significant decline in their ability to communicate orally, safely swallow or masticate;
• establish 2010 agency rate increases as directed in Maine’s FY 2011 budget;
• correct a unit error in code SHC 25;
• other, minor grammatical changes within this rulemaking.

Deadline for Comments: Comments must be received by midnight December 15, 2009

Concise Summary: The Department intends to transition to a new claims system, MIHMS. 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. These rules incorporate other grammatical corrections including the removal of references to the HCFA 1500 form and removal of two provider sub-specialties which no longer have enrolled providers, as these providers previously transitioned to other specialties.

Additionally, these proposed rules seek to permanently adopt Chapter II and III, Section 3 emergency rules currently in place which allow ambulatory care clinics, school, and Home Health Agencies to administer seasonal and H1N1 flu vaccinations with MaineCare reimbursement.

Deadline for Comments: Comments must be received by midnight December 4, 2009