MaineCare Benefits Manual - Proposed Rules

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: 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: 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: 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 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.

Deadline for Comments: Comments must be received by midnight January 9, 2010

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.

Deadline for Comments: Comments must be received by midnight January 8, 2010

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.

Deadline for Comments: Comments must be received by midnight January 1, 2010

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.

Deadline for Comments: Comments must be received by midnight January 29, 2010

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.   

Deadline for Comments: Comments must be received by midnight January 29, 2010

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.

Deadline for Comments: Comments must be received by midnight January 31, 2010

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.

Deadline for Comments: Comments must be received by midnight January 31, 2010

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.

Deadline for Comments: Comments must be received by midnight February 4, 2010

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.

Deadline for Comments: Comments must be received by midnight February 13, 2010

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.

Deadline for Comments: Comments must be received by midnight February 12, 2010

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.

Deadline for Comments: Comments must be received by midnight February 13, 2010

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).

Deadline for Comments: Comments must be received by midnight February 28, 2010

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.

Deadline for Comments: Comments must be received by midnight February 28, 2010

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.

Deadline for Comments: Comments must be received by midnight February 27, 2010

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.

Deadline for Comments: midnight February 27, 2010

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.

Deadline for Comments: midnight March 1, 2010