Proposed Rulemaking

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MaineCare Benefits Manual, Chapters II and III, Section 107, Psychiatric Residential Treatment Facilities WORD  PDF   
Concise Summary: This rulemaking intends to create a new section of policy describing Psychiatric Residential Treatment Facilities (PRTF). The rule addresses the PRTFs’ covered services, policy and procedures, standards, and reimbursement methodology. This service is intended to address a current gap in Maine’s offering of behavioral health services to youth under the age of 21. The PRTF is being created to specifically address a high need to support Maine’s most vulnerable youth, including: youth in out of state placement, youth stranded in psychiatric hospitalization with no safe discharge option, youth stranded in emergency rooms with no safe placement, and incarcerated youth in need of mental health treatment. PRTFs are federally regulated facilities by the Centers for Medicare and Medicaid Services (CMS) via 42 C.F.R. 441 Subpart D and 42 C.F.R.483 Subpart G. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173 5; M.R.S. § 8054 PUBLIC HEARING: Date and Time: Monday, May 21, 2018 at 9:00 am Location: Augusta Civic Center – Piscataquis/Sagadahoc Rooms 76 Community Drive Augusta, Maine 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before May 14, 2018.
Submit Comments (Opens in new window) - Comment Deadline: May 31, 2018 Posted: May 2, 2018
 
MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures WORD  PDF   
Concise Summary: This proposed rulemaking seeks to remove the following language from Section 1.12-2: “The liability for debts owed to the Department by the Provider is enforceable against the Provider, including any person who has an ownership or control interest in the Provider, and against any officer, director, or member of the Provider who, in that capacity, is responsible for any control or any management of the funds or finances of the provider. Personal liability against an officer, director, or member of the Provider described in this section shall be limited to debts owed to the Department occurring or arising during that person’s employment or affiliation with the Provider or to any debts which become known to such a person and not voluntarily disclosed by that person to the Department. Individuals or entities with an ownership or control interest in the provider include: 1) Those with an ownership interest, meaning those in possession of equity in the capital, the stock, or the profits of the provider. 2) Those with an indirect interest, meaning those with an ownership interest in an entity that has an ownership interest in the provider.” The proposed rulemaking also adds the Department’s duplication table of concurrent services to the Appendix section. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173 ______________________ PUBLIC HEARING: Date and Time: May 7, 2018 9: 30 AM Location: Room 600, Burton Cross Building, 111 Sewall Street, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before April 30, 2018. DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on May 17, 2018. AGENCY CONTACT PERSON: Thomas Leet, Comprehensive Health Planner II Thomas.leet@maine.gov AGENCY NAME: MaineCare Services ADDRESS: 242 State St. 11 State House Station Augusta, Maine 04333-0011 TELEPHONE: 207-624-4068 FAX: (207) 287-1864 TTY: 711 (Deaf or Hard of Hearing)
Submit Comments (Opens in new window) - Comment Deadline: May 17, 2018 Posted: April 17, 2018
 
MaineCare Benefits Manual, Chapter II, Section 60, Title: Medical Supplies and Durable Medical Equipment WORD  PDF   
Concise Summary: The proposed rule provides for the following changes in Chapter II, Section 60, Medical Supplies and Durable Medical Equipment (DME): • Updates the definition of DME to align with 42 C.F.R §440.70 (b)(3)(ii); • Adds a storefront exclusion and reimbursement methodology for manufacturers of specialty modified low protein foods and formulas for the purpose of allowing these manufacturers to bill the Department as the supplier of prescription metabolic foods; • Removes language implying absolute exclusions of DME items as this is no longer allowable per 42 C.F.R §440.70; • Adds repair/replacement language for APAP and CPAP devices greater than or equal to five (5) years old. • Removes the list of items considered MaineCare-covered for members residing within a Nursing Facility (NF) or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) to eliminate confusion of covered and non-covered items for members residing within a NF or ICF-IID; • Further defines limitations for orthopedic shoes and other supportive devices for members twenty-one (21) years of age and older to provide clarity of covered services; • Updates limits and requirements for disposable non-sterile gloves when supplied in conjunction with incontinence supplies to cost-effectively manage this covered service; • Increases the allowance of supplies per dispense to ninety-days (90) for items MaineCare considers to be disposable DME; • Updates reimbursement methodology for Medicare covered DME, to align with the 21st Century Cure Act; • Corrects and/or deletes outdated references and website addresses and, • Edits and minor language updates for clarification purposes. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173; 42 C.F.R §440.70; 42 U.S. C. §1396b PUBLIC HEARING: Date: Monday, January 29, 2018 Time: 9:00 AM Location: Marquardt Building, Room # 118, Door D7 32 Blossom Lane, Augusta Maine 04330   The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before Monday, January 15, 2018.
Submit Comments (Opens in new window) - Comment Deadline: February 8, 2018 Posted: January 9, 2018
 
MaineCare Benefits Manual, Chapters II & III, Section 96, Private Duty Nursing and Personal Care Services. WORD  PDF   
Concise Summary: These proposed rules seek to increase rates of reimbursement and level of care limits for personal care and related services pursuant to Public Law 2017, ch. 284, Part MMMMMMM-1, 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, 2018 and June 30, 2019. P.L. 2017, ch. 284, Part MMMMMMM-1, requires the Department to amend its rules for reimbursement rates for the home-based and community-based personal care services under the provisions of 10-144 C.M.R. ch. 101, MaineCare Benefits Manual, Chapters II & III, Private Duty Nursing and Personal Care Services and referenced in the February 1, 2016 report “Rate Review for Personal Care and Related Services: Final Rate Models” prepared for the Department by Burns & Associates, Inc. Further, Part MMMMMMM-1 directs the Department that the increase in rates of reimbursement must be applied in equal proportion to all home-based and community-based personal care and related services referenced in the Burns & Associates, Inc. report using the funding provided for that purpose in Chapter 284. Chapter 284 provides funding to increase the rates. See Part ZZZZZZ, Section ZZZZZZ-2. In addition, Part MMMMMMM-1 directs the Department to ensure that caps and limitations on home-based and community-based personal care and related services are increased to reflect the increase in reimbursement rates that result from this section. The Legislature did not appropriate additional funding for these rate and level of care increases beyond June 30, 2018, therefore, rates and level of care increases will revert to their current levels (pre-July 1, 2017) on July 1, 2018. This Chapter III propose rule seeks to increase the following rates: G0299 (0551)-RN Services G0299 TD UN (0551)-RN Services–multiple patients (2) G0299 TD UP (0551)-RN Services-multiple patients (3) G0300 TE (0559)-LPN Services G0300 TE UN (0559)-LPN Services–multiple patients (2) G0300 TE UP (0559)-LPN Services–multiple patients (3) T1000 TD-Independent RN T1000 TD UN-Independent RN-multiple patients (2) T1000 TD UP-Independent RN–multiple patients (3) T1004 (0571)-Home Health Aide/Certified Nursing Assistant Services T1004 UN (0571)-Home Health Aide/Certified Nursing Assistant Services-multiple patients (2) T1004 UP (0571)-Home Health Aide/Certified Nursing Assistant Services–multiple patients (3) T1019 (0589)-Personal Support Services T1019-Personal Support Services (PCA Agencies only) T1019 UN-Personal Support Services (PCA Agencies only) multiple patients (2) T1019 UP-Personal Support Services (PCA Agencies only) multiple patients (3) S5125 TF (0589)-PCA Supervisit S5125 TF UN (0589)-PCA Supervisit-multiple patients (2) S5125 TF UP (0589)-PCA Supervisit–multiple patients (3) S5125 TF-PCA Supervisit (PCA Agencies only) S5125 TF UN-PCA Supervist (PCA Agencies only) multiple patients (2) S5125 TF UP-PCA Supervisit (PCA Agencies only) multiple patients (3) This Chapter II proposed rule seeks to increase the following level of care limits: Level I Level II Level III Level IV Level Level VIII Level IX The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services (CMS) for these changes. Pending approval, the increased reimbursement rates and corresponding increases in level of care limits will be effective retroactive to July 1, 2017 through June 30, 2018. The new rates and level of care limits will sunset on June 30, 2018, as the rate increases were funded by single year appropriations. Rates and level of care limits will revert to original values on July 1, 2018. A methodology change notice was posted on the Office of MaineCare Services’ website on September 5, 2017. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: December 22, 2017 Posted: November 22, 2017
 
MaineCare Benefits Manual, Chapter III, Section 12, Allowances for Consumer-Directed Attendant Services WORD  PDF   
Concise Summary: This proposed rule complies with Public Law 2017, ch. 284, Part MMMMMMM-1, 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, 2018 and June 30, 2019. P.L. 2017, ch. 284, Part MMMMMMM-1, requires the Department to amends its rules for reimbursement rates for the home-based and community-based personal care services under the provisions of 10-144 C.M.R. ch. 101, MaineCare Benefits Manual, Chapter III, Section 12, Allowances for Consumer-Directed Attendant Services and referenced in the February 1, 2016 report “Rate Review for Personal Care and Related Services: Final Rate Models” prepared for the Department by Burns & Associates, Inc. Part MMMMMMM-1 directs the Department that the increase in rates of reimbursement must be applied in equal proportion to all home-based and community-based personal care and related services referenced in the Burns & Associates, Inc. report using the funding provided for that purpose in Chapter 284. The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services (CMS) for these changes. Pending CMS approval, the increased reimbursement rates will be effective retroactive to July 1, 2017 through June 30, 2018. The new rates will sunset on June 30, 2018, as the rate increases were funded by single year appropriations. Rates will revert to original values on July 1, 2018. A methodology change notice was posted on the Office of MaineCare Services’ website on September 5, 2017. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: December 23, 2017 Posted: November 22, 2017
 
MaineCare Benefits Manual, Chapter I, Section 4, Telehealth Services WORD  PDF   
Concise Summary: The Department is proposing to add clarifying language to the Telehealth Services policy that would allow FQHCs, RHCs, and IHCs to provide covered services as the providing site and bill under their encounter rate. The Department will also be removing the telemonitoring requirement that members have had two or more hospitalizations or Emergency Department visits in the past year, and replacing it with a documentation requirement pursuant to PL 2017, ch 307. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. § 42, 3173, PL 2017, ch 307 PUBLIC HEARING: Date: December 5, 2017 Time: 9:00 AM Location: Room 300, Burton Cross Building, 111 Sewall Street, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before November 27, 2017.
Submit Comments (Opens in new window) - Comment Deadline: December 16, 2017 Posted: November 15, 2017
 
MaineCare Benefits Manual, Chapters II and III, Section 92, Behavioral Health Home Services WORD  PDF   
Concise Summary: This rulemaking adds in a pay-for-performance provision which puts one percent of total PMPM payments at risk pending provider performance on a chronic disease management quality measure and formally increases the reimbursement rate for Behavioral Health Home Organizations (BHHO) to $394.40 per member per month (PMPM) for both adult and child members effective retroactive to January 1, 2016. It also increases, clarifies, and expands on a number of provider requirements and covered services. In addition, the rulemaking: • Adds a definition of “Child” to 92.01-2. • Removes certain professionals/organizations from the list of professionals eligible to serve as the BHHO clinical team leader and psychiatric consultant that do not meet the qualifications, clarifies the appropriate role of Certified Intentional Peer Support Specialists, and requires that each role is filled by a different individual. • Requires that if a lapse in fulfillment of team member roles extends beyond thirty (30) days, the BHHO must notify the Department and maintain records of its efforts to fill the position. • Removes specific mention of the “Learning Collaborative” and replaces this with “technical assistance opportunities” to account for all possible types of practice support which may be available. • Removes requirement that the BHHO “Leadership Team” must attend the technical assistance opportunities. • Requires the BHHO to have an electronic health record upon entry to the BHH program. • Reduces reporting burden by removing the Health Home Provider Functional Requirements reporting and allowing high performing BHHOs to report on the Core Standards annually. • Replaces the term “mental retardation” with “intellectual disability” in 92.03-2 pursuant to 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. • Requires that the BHHO must work with the member to identify a primary care provider. • Strengthens provider requirements around “Enhanced Access” to ensure members have meaningful access to the BHHO 24/7 and that BHHO providers have 24/7 access to member records. • Changes the rule to reflect the opt-in model and process for certification of services. • Updates the assessment tools and criteria to current editions and practice. • Requires the Child and Adolescent Needs and Strengths (CANS) assessment to be reviewed and updated by the BHH a minimum of every one hundred and eighty (180) days and requires that all relevant CANS domains must be entered into the Department’s Enterprise Information System (EIS) and that this information is included in the development of the plan of care. • Requires providers that offer Section 13, Targeted Case Management, Section 17, Community Support Services, Section 91, Health Home Services, and/or Section 93, Opioid Health Home Services in addition to Section 92 services to be able to demonstrate that members are provided information regarding choice of services for which they are eligible. • Adds the covered service Referral to Community and Social Support Services. • Replaces the one-hour minimum billable activity requirement for BHHOs with a requirement to have a monthly member (or family, guardian, caregiver) encounter. • Clarifies and amends what is the minimum activity required in order to qualify for reimbursement. • Adds a general provision that Department shall have sole discretion to impose termination from the BHH program based on failure to meet program requirements. • Makes additional clarifications and minor updates. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173; P.L.2012, ch.542, §B-5; P.L. 111-148 PUBLIC HEARING: Date: December 5, 2017 Time: 8:00 AM Location: Augusta Armory 179 Western Ave. Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before Tuesday, November 28, 2017.
Submit Comments (Opens in new window) - Comment Deadline: December 16, 2017 Posted: November 15, 2017
 
MaineCare Benefits Manual, Chapter III, Section 19, Home and Community Benefits for the Elderly and for Adults with Disabilities WORD  PDF   
Concise Summary: In P.L. 2017, ch. 284, §§MMMMMMM-2, the Legislature directed DHHS to increase reimbursement rates for home-based and community-based personal care and related services in Section 19, and gave emergency rulemaking authority. This proposed rule will permanently adopt the emergency rule changes. Additionally, some procedure, modifier and revenue codes are being proposed to be changed at the same time for the system to correctly pay and track the new rates. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: December 10, 2017 Posted: November 6, 2017
 
MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF   
Concise Summary: The Department is proposing this rulemaking in accordance with P.L. 2017, ch. 284, Sec. MMMMMMM-2. P.L. 2017, ch. 284 provides funding to increase reimbursement rates for 23 procedure codes in Chapter III, Section 21. The legislation directed the Department to increase the rates for the specific procedure codes in equal proportion to the funding provided for that purpose. In addition to the rate increases required by P.L. 2017, ch. 284, the Department is also increasing the rate for a 24th procedure code to create consistency among similar services within the waiver. These increased rates will be effective retroactive to July 1, 2017. The Legislature did not appropriate additional funding for these rate increases beyond June 30, 2018; therefore, rates will revert to their current levels (pre-July 1, 2017) on July 1, 2018. In creating the rates for the 24 codes, the Department examined utilization of these services, and then calculated rates to ensure parity between Section 21 and Section 29, to lessen administrative complications for providers. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173; P.L. 2017, ch. 284, § MMMMMMM-2 PUBLIC HEARING: Date: November 1, 2017 9:00 A.M. (Note: This was originally scheduled for November 2, but due to scheduling issues with the facility has been changed to November 1.) Location: Augusta Armory 179 Western Ave Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before October 23, 2017.
Submit Comments (Opens in new window) - Comment Deadline: November 12, 2017 Posted: October 13, 2017
 
MaineCare Benefits Manual, Chapter III, Section 29, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF   
Concise Summary: The Department is proposing this rulemaking in accordance with P.L. 2017, ch. 284 (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, 2018 and June 30, 2019), §§§ ZZZZZZZ-9, MMMMMMM-2, which provided funding to increase reimbursement rates for 16 procedure codes in Chapter III, Section 29, and directed the Department – via major substantive rulemaking – to increase the rates for the specific procedure codes in equal proportion to the funding provided. The Department has also increased the rate for a 17th procedure code in order to create consistency among similar services within the waiver. These rates will be effective retroactive to July 1, 2017. Funding for these rate increases was only appropriated for SFY18. The Legislature did not appropriate additional funding for these rates beyond June 30, 2018; therefore, rates increased for SFY18 will revert to their current levels (pre July 1, 2017) on July 1, 2018. In accordance with Part III, Sec. TTTT-1 of the Act, the Department adopted these provisions as emergency major substantive rules effective October 1, 2017. The emergency major substantive rules will be in effect for twelve (12) months, or until the Legislature has completed its review. In creating the rates for the codes shown below, the Department examined utilization of these services, and then calculated rates to ensure parity between Section 29 and Section 21, to lessen administrative complications for providers. In addition, the Department is adding two procedure codes for Shared Living services as the Department is contemporaneously adopting an emergency rule for Chapter II, Section 29 to add this benefit as a covered service for members. These rates are consistent with the rates for the same services under Section 21, and include increased rates for SFY18 that will revert to their current levels (pre July 1, 2017) pursuant to P.L. 2017, ch. 284. This change is not expected to have an adverse effect on the administrative burdens of small businesses. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: November 10, 2017 Posted: October 10, 2017
 
MaineCare Benefits Manual, Chapter II, Section 29, Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF   
Concise Summary: The Department proposes this rule in accordance with P.L. 2017, ch. 284 (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, 2018 and June 30, 2019), which provided funding to increase the annual cap for services provided under Section 29 from $23,771 to $47,500. The Act funded Shared Living services as a new residential Covered Service available to eligible members under Section 29. The Department has increased the annual combined services cap from the $47,500 in the legislation to $52,425, to accommodate the annual cost of the newly added Shared Living service, given the rate increase for this service for SFY18, as implemented in a contemporaneous emergency rule for Chapter III, Section 29. In addition, the Department is adding Shared Living, and removing Work Support from, this cap, which will now include Home Support, Community Support, and Shared Living. The Department has increased the annual cap on Respite services to accommodate the rate increase for this service for SFY18 in Chapter III, Section 29, which the Department is also engaged in concurrent emergency rulemaking. Both of these increases in caps will be retroactive to July 1, 2017, pursuant to the increased rates for services in the legislation, and pursuant to 22 M.R.S. 42(8). This proposed rulemaking enacts changes that were made to Section 29 on an emergency basis effective October 1, 2017, and which are effective for ninety (90) days. The proposed rule implements these changes by adding definitions for Administrative Oversight Agency, Shared Living, and Shared Living Provider, and by adding Shared Living as a Covered Service. The combined services cap has been increased to $52,425, and Shared Living has been added to the services included under the cap. Work Support-Individual and Work Support-Group have been removed from the cap. Removing these services from the cap removes the limit on Work Support, and allows members flexibility to use the capped amount for the other services. The annual limit on Respite has been increased from $1,000 to $1,100. The weekly cap on Home Support-Remote Support has been removed to increase member flexibility. These changes are not expected to have an adverse effect on the administrative burdens of small businesses. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: November 10, 2017 Posted: October 10, 2017
 
MaineCare Benefits Manual, Chapter VII, Section 5, Estate Recovery WORD  PDF   
Concise Summary: This rulemaking will add new timeline language to different sections in the Estate Recovery policy to help the Third Party Liability unit enforce the policy. This rulemaking will also rewrite the Hardship Waiver and Care Given Exemption sections to assure that there are no gaps in the policy allowing personal representatives to avoid liability or responsibility and also increase the effectiveness of the policy. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173 PUBLIC HEARING: Date: October 23, 2017 Time: 9:00 AM Location: Room 400, 111 Sewall Street, Burton M. Cross Building, Augusta ME, 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before October 16, 2017.
Submit Comments (Opens in new window) - Comment Deadline: November 3, 2017 Posted: October 4, 2017
 
MaineCare Benefits Manual, Chapter III, Section 2, Adult Family Care Services WORD  PDF   
Concise Summary: This proposed rulemaking seeks to increase the rates of reimbursement for Adult Family Care Services pursuant to Public Law 2015, ch. 481, Part C, An Act to Provide Funding to the Maine Budget Stabilization Fund and To Make Additional Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and To Change Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2016 and June 30, 2017. P.L. 2015, ch. 481, Part C directs the Department to set the inflation adjustment amount in accordance with the United States Department of Labor, Bureau of Labor Statistics’ Consumer Price Index-Medical Care Service Index for the fiscal year ending June 30, 2018. This proposed rule seeks to implement a three and a half (3.5) percent cost-of-living rate increase for adult family care homes for the fiscal year ending June 30, 2018. Chapter III, Section 2, Adult Family Care Services increases the unadjusted price from $46.79 to $48.43 and the resource-adjusted prices accordingly. In addition, Chapter III, Section 2, Adult Family Care Services increases the resource-adjusted prices accordingly to adult family care homes that satisfy the definition of remote island facilities from $48.43 to $55.69. The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services (CMS) for this change. Pending approval, the three and a half (3.5) percent cost-of-living increase will be effective retroactive to July 1, 2017. A Change in Reimbursement Methodology Notice was posted June 28, 2017 on the Office of MaineCare Services’ website. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42(8), 3173; P.L. 2015, ch. 481, Part C PUBLIC HEARING: Date: September 5, 2017 Time: 1:00 p.m. Location: Room 300, Cross Building, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before August 28, 2017. DEADLINE FOR COMMENTS: Comments must be received by 11:59 p.m. on September 15, 2017. AGENCY CONTACT PERSON: Heidi Bechard, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 242 State Street, 11 State House Station Augusta, Maine 04333-0011 heidi.bechard@maine.gov TELEPHONE: 207-624-4074, FAX: (207) 287-1864 TTY: 711 (Deaf or Hard of Hearing)
Submit Comments (Opens in new window) - Comment Deadline: September 15, 2017 Posted: August 16, 2017
 
MaineCare Benefits Manual, Chapters II & III, Section 45, Hospital Services. WORD  PDF   
Concise Summary: This proposed rule provides for the following changes: • An update to reporting requirements for Acute Care Critical Access Hospitals and Private Psychiatric Hospitals to reflect current reporting requirements; • The addition of separate reimbursement for Long Acting Reversible Contraceptives (LARCs) when the device is inserted during the postpartum inpatient hospital stay; • An expansion of the definition of “Discharge” to include inpatient maintenance chemotherapy as an exception to the fourteen-day (14) readmission protocol; • The requirement for providers to submit mapping documents to aid in payment methodology calculations; • An adjustment requiring payment of 100% in the event of a hospital overpayment; • The addition of the payment window rule requiring hospitals or entities wholly-owned or wholly-operated by a hospital, to bill the technical component of outpatient services provided within a 3-day (or 1-day) window preceding inpatient admission on the inpatient claim; • Establishing a modifier to identify and pay non-excepted items and services of off-campus hospital outpatient provider-based departments (PBDs); • A clarification to the out-of-state hospitals section clarifying that laboratory and imaging outpatient services reimbursement shall not exceed the 100% of Medicare reimbursement rate for the Maine area ’99; • An increase in the amount of funds in the supplemental pool to comply with P.L. 2017, Ch. 284, Sec. ZZZZZZ-9; • A restructuring of the supplemental pool methodology used to allocate hospital supplemental pool payments for Non-Critical Access Hospitals, hospitals classified to a wage area outside of Maine by the Medicare Geographic Classification Review Board, and Rehabilitation hospitals; • Terminology and references updates; and • Minor language editing for clarification purposes. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173; P.L. 2017, Ch. 284, Sec. ZZZZZZ-9 PUBLIC HEARING: Monday, August 28, 2017 at 9:00 a.m. Marquardt Building, Room #118, Door D7 32 Blossom Lane, Augusta, ME The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before Monday, August 21, 2017. DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on September 7, 2017. DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on September 7, 2017. AGENCY CONTACT PERSON: Anne Labonte Perreault, Comprehensive Health Planner II Anne.Labonte-Perreault@maine.gov AGENCY NAME: MaineCare Services ADDRESS: 242 State St. 11 State House Station Augusta, Maine 04333-0011 TELEPHONE: 207-624-4082 FAX: (207) 287-1864 TTY: 711 (Deaf or Hard of Hearing)
Submit Comments (Opens in new window) - Comment Deadline: September 12, 2017 Posted: August 8, 2017
 
MaineCare Benefits Manual, Chapter II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF   
Concise Summary: The proposed rule change will expand the number of members who are eligible as Priority 1 on the waitlist for Chapter II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder. The proposed language addresses waitlist eligibility for members whose primary caregiver has reached the age of 65 or has a terminal illness and is having difficulty providing the necessary supports to the member, where the member has no other responsible or willing caregiver. The proposed rule specifies criteria whereby those members may qualify as Priority 1 based on the member’s medical condition or behavioral need; high risk for institutionalization; history of hospitalizations; and imminent danger to the member or others. A provision is also included specifying that Priority 1 is granted only when the member’s needs cannot be met absent provision of services under this comprehensive waiver program. Therefore, Priority 1 on the Section 21 waitlist would be available only for members who specifically need these services; members whose needs could be met with the less intense services provided under the State Plan or Section 29 would be referred to those services. This provision does not preclude the member waiting at another Priority level on the Section 21 waitlist. This rulemaking is required in order to establish clear criteria for prioritization of members, beyond what currently exists. While the Department may offer funded openings to Priority 2 members in the event Priority 1 is exhausted, the Department wishes to establish clear, codified criteria to guide access, now and in the future. The proposed rule also expands the number of members who are eligible as Priority 2. The proposed language expands eligibility to members whose primary caregiver has reached the age of sixty and is having difficulty providing the necessary supports to the member in the family home. A definition of primary caregiver is also included. This will supersede language in the current rule that applies this criterion only to the member’s parents. The proposed provision expands the Priority 2 provision to members being cared for by extended family members, and whose parents are deceased, missing, or unable to care for the member. The proposed rule requires an annual review of the priority assignments of members, in order to remain on the Section 21 waitlist. SEE http://www.maine.gov/dhhs/oms/rules/provider_rules_policies.html for rules and related
Submit Comments (Opens in new window) - Comment Deadline: August 21, 2017 Posted: July 19, 2017
 
NOTICE OF PUBLIC HEARING CANCELLATION, MaineCare Benefits Manual Ch. II & III, Section 45, Hospital Services      
Concise Summary: NOTICE OF PUBLIC HEARING CANCELLATION The Maine Department of Health and Human Services hereby gives notice that the public hearing on Proposed Rule 2017-P073, Section 45, Hospital Services, currently scheduled for Monday, July 10, 2017 at 9:00 a.m. in Augusta, has been cancelled. The Department will not be proceeding with the Section 45 rulemaking as proposed.
No Comments No comment deadline Posted: June 30, 2017
 
MaineCare Benefits Manual, Chapters II and III, Section 45, Hospital Services WORD  PDF   
Concise Summary: This proposed rule provides for the following changes: • An update to reporting requirements for Acute Care Critical Access Hospitals and Private Psychiatric Hospitals to reflect current reporting requirements; • The addition of separate reimbursement for Long Acting Reversible Contraceptives (LARCs) when the device is inserted during the postpartum inpatient hospital stay; • An expansion of the definition of Discharge to include inpatient maintenance chemotherapy as an exception to the fourteen-day (14) readmission protocol; • The requirement for providers to submit mapping documents to aid in payment methodology calculations; • An adjustment requiring payment of 100% in the event of a hospital overpayment; • The addition of the payment window rule requiring hospitals or entities wholly-owned or wholly-operated by a hospital, to bill the technical component of outpatient services provided within a 3-day (or 1-day) window preceding inpatient admission on the inpatient claim; • Establishing a modifier to identify and pay non-excepted items and services of off-campus hospital outpatient provider-based departments (PBDs); • A clarification to the out-of-state hospitals section clarifying that laboratory and imaging outpatient services reimbursement shall not exceed the 100% of Medicare reimbursement rate for the Maine area ’99; • Terminology and references updates; and • Minor language editing for clarification purposes. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173 PUBLIC HEARING: Monday, July 10, 2017 at 9:00 a.m. Marquardt Building, Room #118 32 Blossom Lane, Augusta, ME The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before Monday, July 3, 2017.
Submit Comments (Opens in new window) - Comment Deadline: July 20, 2017 Posted: June 20, 2017
 
MaineCare Benefits Manual, Ch. II, Sec 80, Pharmacy Services WORD  PDF   
Concise Summary: This rulemaking contains different components, each of which is outlined below: Prescribing Opioids for Pain Management This proposed rulemaking includes the addition and implementation of a new sub-section for prescribing opioids for pain management to align with the Department’s Office of Substance Abuse and Mental Health Services rules governing the Controlled Substances Prescription Monitoring Program and Prescription of Opioid Medications. See 14-118, Chapter 11. This section offers a balanced approach to pain management that includes recommendations for using opioids when appropriate, such as with acute injuries and flare ups, for postoperative pain management, and during painful procedures; and recommending multimodal therapies in general for all chronic pain patients. The rule sets out prescriber requirements, limitations, and exemptions that comply with state and federal laws, and provides guidelines for prior authorizations and medical records requirements. Buprenorphine and Buprenorphine Combination Products for Substance Use Disorder This proposed rulemaking adds a new sub-section to this section providing MaineCare rules and guidelines for office-based prescribing of buprenorphine and buprenorphine-combination medications. The section provides best practices guidelines for Medication Assisted Treatment using buprenorphine and derivatives for members who have been diagnosed with Substance Use Disorder (SUD). Prescriber requirements, member requirements, detailed protocols, limitations on members qualified to receive the drug, rules regarding prior authorization, clearly defined maximum daily dosages, as well as requirements for medical records are defined and follow the model established by the Drug Addiction Treatment Act of 2000 (DATA). CMS Outpatient Drug Rule This proposed rulemaking helps align Maine Medicaid policy with the CMS Covered Outpatient Drug final rule. This rulemaking updates the reimbursement methodology for covered outpatient drugs and also updates the pharmacy dispensing fee from to $3.35 to $11.89 following the New England States Consortium Systems Organization (NESCSO) pharmacy cost of dispensing survey. In adding the new requirements and additions to Section 80, the Department has also incorporated a few minor changes to the rule, including but not limited to: adding to and updating the definitions section and updating formatting and numbering as a result of the changes mentioned above. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: May 18, 2017 Posted: April 18, 2017
 
MaineCare Benefits Manual, Chapters II & III, Section 93, Opioid Health Home Services. WORD  PDF  | Link To Application For Opioid Health Homes
Concise Summary: The proposed rule establishes the MaineCare Opioid Health Home (OHH) Services program for addressing the opioid crisis in Maine. The OHH initiative is an innovative model providing comprehensive, coordinated care focused on serving the MaineCare population. In addition to expanding primary care access to treatment for an individual’s substance abuse dependency, the OHH integrates physical, social, and emotional supports to provide holistic care. The model provides a community-based support system focused on team-based clinical care. The OHH team model involves a range of qualified staff, including a Clinical Team Lead, Medication Assisted Therapy (MAT) prescriber, Nurse Consultant, Licensed Alcohol and Drug Counselor, Certified Clinical Supervisor, and Peer Recovery Coach. It is expected that this newly established OHH program will not only result in more individuals receiving the substance abuse treatment they need, but will also lead to improvements in the quality of care they are receiving. OHH services are optional, and members can choose to receive the services from any OHH. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. LINK TO OPIOID HEALTH HOMES APPLICATION: https://www.surveymonkey.com/r/OHHApplication
Submit Comments (Opens in new window) - Comment Deadline: May 18, 2017 Posted: April 12, 2017
 
Chapter X, Section 1, Benefit for People Living with HIV/AIDS WORD  PDF   
Concise Summary: This rule is being proposed in order to update outdated references identifying Department agencies, MaineCare Benefit Manual policies and services, and outdated internet website addresses. The rule also clarifies and lists specific non-covered services and required co-payments for certain services in a more organized, easier to understand form. The rule changes the entity responsible for maintaining the Benefit waitlist from the Maine CDC to the Office for Family Independence. Additional changes to the rule include more specifically-defined objectives that may lead to disenrollment, simplification of disenrollment protocol, clarification of appeal rights language, and minor grammar and punctuation changes. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173 PUBLIC HEARING: Date: Monday, March 6, 2017 Time: 9:30 a.m. Location: Marquardt Building, Room 118, 32 Blossom Lane, Augusta, ME The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before Thursday, March 2, 2017.
Submit Comments (Opens in new window) - Comment Deadline: March 16, 2017 Posted: February 14, 2017
 
MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures WORD  PDF   
Concise Summary: This rule adds a new provision for the exclusion or termination of certain providers who would be excluded under current state and federal law. The rule also updates the provider reinstatement procedures. The rule proposes to add language describing the requirement for providers to pay an enrollment fee for each provider site. The rule also adds language that the Department may deny future rental of equipment to members who fail to return Department rented equipment. The rule adds language that authorizes the Department to request additional information which demonstrates a provider applicant’s ability to provide high-quality care, services, and supplies and to be financially responsible. The rule also adds language that the liability for debts owed to the Department by providers is also enforceable against people and entities with ownership or controlling interest and specifically defines those individuals and entities. The rule also adds tobacco cessation products and services to the list of copayment exemptions. The rule adds language that authorizes providers to refuse to continue to see members who have repeatedly broken appointments. The rule adds language describing NCCI edits and a statement that MaineCare will reject nonconforming claims. The rule also adds clarifying language around out-of-state providers. The Department proposes to add three new grounds for sanctions to include: • An entity that is an HMO or is providing services under a Medicaid waiver program, and has a substantial contractual relationship with an entity that could be excluded from the Medicaid program; • If a provider has been convicted of a crime while performing services as a health care worker or provider; and • Limitation of services for which the provider is authorized to perform and receive payment. In addition, the rule proposes to clarify the role of the Medicaid Advisory Committee. The rule also removes Private Non-Medical Institutions (PNMIs) from the list of facilities that include interpreter services in their reimbursement calculations and language regarding Section 113 of the MaineCare Benefits Manual. The rule also adds language that the Department will not reimburse for interpreter travel time. The rule includes language adding an exception of LCDs or NCDs denials to provider requirement of third party denial appeal process. The rule also proposes to modify the language describing the Department’s liability for the Medicare deductible and coinsurance by addition of specific language directly related to various facilities and eligibility situations and payment or nonpayment of deductible and coinsurance. The rule proposes to remove language stating that the Department will enroll all providers who meet certain requirements, and replacement with a new provision, which sets forth a list of factors the Department may consider in determining whether to enroll or deny enrollment to a provider applicant. The Department proposes to amend and add definitions to the policy. The rule proposes to make technical, grammar, and punctuation edits as well. Lastly, the Department proposes to make changes to conform with state and federal laws. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173; 5 M.R.S. § 4551 et seq; 22 M.R.S. § 42(8); 42 C.F.R. 1007; P.L. 2014, Ch. 444 (An Act to Reduce Tobacco-related Illness and Lower Health Care Costs in MaineCare) (to be codified at 22 M.R.S. § 3174-WW); 42 U.S.C. § 1320a–7; 42 C.F.R. 431.55(h)(2); 42 C.F.R. 455.416(c)l; Patient Protection and Affordable Care Act, Public Law 111–148; Rosa's Law, Public Law 111-256; L.D. 1596 (Resolve, Directing the Department of Health and Human Services To Amend MaineCare Rules as They Pertain to the Delivery of Covered Services via Telecommunications Technology); 22 M.R.S. § 3173-C, sub-§2, as amended by P.L. 2011, Ch. 458 (An Act Regarding Pharmacy Reimbursement in MaineCare). PUBLIC HEARING: Date: Tuesday, February 28, 2017 Time: 9:30 a.m. Place: Marquardt Building 32 Blossom Lane, 1st floor, Room 118 Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed before February 18, 2017.
Submit Comments (Opens in new window) - Comment Deadline: March 10, 2017 Posted: February 7, 2017
 
MaineCare Benefits Manual, Chapter III, Section 19, Home and Community Benefits for the Elderly and Adults with Disabilities WORD  PDF   
Concise Summary: This rule is being proposed in order to comply with L.D. 886, Resolve, Directing the Department of Health and Human Services To Increase Reimbursement Rates for Home-based and Community-based Services. Chapter II, Section 19 was originally promulgated to provide members with the opportunity to remain in their own homes, avoiding or delaying institutional care. Chapter III is the companion rule to Chapter II and provides billing codes and rates for the services described in Chapter II. In this proposed rulemaking, the Department is adding “person-centered” language, clarifying language for “Budget Authority,” and adding new services to this rule that will provide members with additional opportunities to obtain necessary supports and services within their communities. The Department is concurrently proposing Chapter III, Section 19, adding procedure codes for the newly added services in Chapter II, Section 19. The Department is also proposing to increase rates in Chapter III in accordance with L.D. 886, Resolve, Directing the Department of Health and Human Services To Increase Reimbursement Rates for Home-based and Community-based Services. The Legislature passed L.D. 886 to authorize an increase in rates to reflect 50% of the change in rates noted in the final rates modeled in the February 1, 2016 report, “Rate Review for Personal Care and Related Services: Final Rate Models,” prepared for the Department by Burns & Associates, Inc. The rate increase will be retroactive to July 29, 2016. Providers will need to ensure that they are using the appropriate procedure code, modifier, and revenue code for reimbursement of services. The Department is proposing this rule (1) to add person-centered language due to CMS guidance; (2) to add clarifying language to ensure that the State would not be considered a third party employer for members’ attendants hired through the Participant Directed Option; (3) to add three new services: Home Delivered Meals, Living Well (Chronic Disease Management) and Matter of Balance (Falls Prevention) to enhance members opportunities to access necessary supports and services within their communities, avoiding or delaying the need for institutional level of care and, (4) the Department is concurrently proposing Chapter III, Section 19 adding New Procedure Codes for the newly added services in Chapter II, Section 19 and to comply with L.D. 886. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173 PUBLIC HEARING: Date: December 13, 2016 Time: 9:00 AM Location: 19 Union Street, Augusta Maine, Conference Room 110 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before December 1, 2016.
Submit Comments (Opens in new window) - Comment Deadline: December 23, 2016 Posted: November 23, 2016
 
MaineCare Benefits Manual, Chapter II, Section 19, Home and Community Benefits for the Elderly and Adults with Disabilities WORD  PDF   
Concise Summary: This rule is being proposed in order to comply with L.D. 886, Resolve, Directing the Department of Health and Human Services To Increase Reimbursement Rates for Home-based and Community-based Services. Chapter II, Section 19 was originally promulgated to provide members with the opportunity to remain in their own homes, avoiding or delaying institutional care. Chapter III is the companion rule to Chapter II and provides billing codes and rates for the services described in Chapter II. In this proposed rulemaking, the Department is adding “person-centered” language, clarifying language for “Budget Authority,” and adding new services to this rule that will provide members with additional opportunities to obtain necessary supports and services within their communities. The Department is concurrently proposing Chapter III, Section 19, adding procedure codes for the newly added services in Chapter II, Section 19. The Department is also proposing to increase rates in Chapter III in accordance with L.D. 886, Resolve, Directing the Department of Health and Human Services To Increase Reimbursement Rates for Home-based and Community-based Services. The Legislature passed L.D. 886 to authorize an increase in rates to reflect 50% of the change in rates noted in the final rates modeled in the February 1, 2016 report, “Rate Review for Personal Care and Related Services: Final Rate Models,” prepared for the Department by Burns & Associates, Inc. The rate increase will be retroactive to July 29, 2016. Providers will need to ensure that they are using the appropriate procedure code, modifier, and revenue code for reimbursement of services. The Department is proposing this rule (1) to add person-centered language due to CMS guidance; (2) to add clarifying language to ensure that the State would not be considered a third party employer for members’ attendants hired through the Participant Directed Option; (3) to add three new services: Home Delivered Meals, Living Well (Chronic Disease Management) and Matter of Balance (Falls Prevention) to enhance members opportunities to access necessary supports and services within their communities, avoiding or delaying the need for institutional level of care and, (4) the Department is concurrently proposing Chapter III, Section 19 adding New Procedure Codes for the newly added services in Chapter II, Section 19 and to comply with L.D. 886. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173 PUBLIC HEARING: Date: December 13, 2016 Time: 9:00 AM Location: 19 Union Street, Augusta Maine, Conference Room 110 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before December 1, 2016.
Submit Comments (Opens in new window) - Comment Deadline: December 23, 2016 Posted: November 23, 2016
 
MaineCare Benefits Manual, Chapter III, Section 18 Allowances for Home and Community Based Services for Adults with Brain Injury WORD  PDF   
Concise Summary: The Department is proposing a 1% increase to certain rates in Chapter III, Section 18 in accordance with P.L. 2016, ch. 477 (An Act to Increase Payments to MaineCare Providers That Are Subject to Maine’s Service Provider Tax), which provides additional appropriations to certain MaineCare providers who are subject to the service provider tax and who have experienced a recent increase in the tax from 5% to 6%. The Legislature enacted this law as an emergency measure, effective April 15, 2016, recognizing that providers affected by the tax increase had insufficient reserves to withstand this cost increase and that immediate funding was necessary to enable providers to continue providing MaineCare services. The Department adopted changes to this rule on an emergency basis with the increased rates effective retroactive to April 15, 2016. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173, L.D. 1638 PUBLIC HEARING: Date: December 12, 2016 Time: 11:00 AM Location: 19 Union Street, Conference Room 110, Augusta Maine The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before December 2, 2016.
Submit Comments (Opens in new window) - Comment Deadline: December 22, 2016 Posted: November 23, 2016
 
MaineCare Benefits Manual, Chapter III, Section 97, Private Non-Medical Institution (PNMI) Services WORD  PDF   
Concise Summary: CONCISE SUMMARY: These changes are being done in order to comply with: 1) Public Law 2016, Chapter 477, An Act to Increase Payments to MaineCare Providers That Are Subject to Maine’s Service Provider Tax, Private Non-Medical Institution Services providers have experienced an increase in the tax since January 1, 2016. PNMIs are in need of increased funding to continue providing these services to Maine’s vulnerable citizens, including children, individuals with substance use disorders, and adults with intellectual disabilities and autistic disorder. This proposed rulemaking increases the direct care component rate by an additional one (1) percent to Private Non-Medical Institution Services providers. Pursuant to 22 M.R.S. § 42(8), the increase in reimbursement rates will be effective retroactive to July 1, 2016. 2) Chapter III, Section 97 (the “Main Rule”) and Chapter III, Section 97, Appendix C only, the Department repeals and replaces the March 8, 2016 emergency major substantive rule, which made changes pursuant to Resolves 2015, ch. 45, Resolve, To Require the Department of Health and Human Services to Provide Supplemental Reimbursement to Residential Care Facilities in Remote Island Locations. Those changes are incorporated into this major substantive rulemaking. This proposed major substantive rulemaking follows an emergency adoption filed on October 18, 2016. This major substantive rule will remain in effect for up to one year or earlier if the Legislature approves the provisionally adopted major substantive rule. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42(8), 3173; P. L., ch. 477; P.L. 2015, ch. 267; Resolves 2015, ch. 45 PUBLIC HEARING: Date: November 21, 2016 Time: 1:00 p.m. Location: Cross Building, Room 300, Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before November 14, 2016.
Submit Comments (Opens in new window) - Comment Deadline: December 1, 2016 Posted: November 2, 2016
 
MaineCare Benefits Manual, Chapter III, Section 2, Adult Family Care Services WORD  PDF   
Concise Summary: This proposed rulemaking seeks to increase the rates of reimbursement for Adult Family care Services pursuant to: (1) Public Law 2016, ch. 481, Part C, An Act to Provide Funding to the Maine Budget Stabilization Fund and To Make Additional Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and To Change Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2016 and June 30, 2017. This proposed rule implements a four (4) percent cost-of-living rate increase for adult family care homes for the fiscal year ending June 30, 2017. Chapter III, Section 2, Adult Family Care Services increases the unadjusted price from $44.99 to $46.79 and the resource-adjusted prices accordingly. The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services (CMS) for this change. Pending approval, the four (4) percent cost-of-living increase will be effective retroactive to July 1, 2016. A Change in Reimbursement Methodology Notice was published on June 28, 2016. To comply with future cost-of-living increases set forth in P.L. 2016, ch. 481, the Department will engage in subsequent rulemaking at a later date. (2) Resolves 2015, ch. 45, Resolve, To Require the Department of Health and Human Services to Provide Supplemental Reimbursement to Adult Family Care Homes and Residential Care Facilities in Remote Island Locations. The Department is making changes to this rule pursuant to Resolves 2015, ch. 45, which effectuates a supplemental rate payment of fifteen (15) percent to adult family care homes that satisfy the definition of remote island facilities. The Legislature directed the Department to amend its rule by October 1, 2015, to implement the fifteen percent supplemental payment and authorized the Department to do so via emergency rulemaking without the necessity of demonstrating emergency findings. The Department engaged in emergency rulemaking followed by routine technical rulemaking that added a provision to the rule about the supplemental payment. The Department also indicated in these prior rulemakings that it was seeking CMS approval for this change retroactive to October 1, 2015. However, the Department did not include a case mix chart specific to remote island facilities that identifies the increased rate. Through this rulemaking, the Department has added a case mix chart reflecting an unadjusted price of $51.74 (a fifteen percent increase from $44.99) for the period of October 1, 2015 through June 30, 2016, and an unadjusted price of $53.81 (reflecting the fifteen percent supplemental payment and the four percent cost-of-living increase) for the period beginning July 1, 2016. This proposed routine technical rulemaking follows an emergency adoption of Chapter III, Section 2, Adult Family Care Services on October 4, 2016. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42(8), 3173; P. L. 2016, ch. 481, Part C; and Resolves 2015, ch. 45 PUBLIC HEARING: Date: November 1, 2016 Time: 1:00 p.m. Location: 19 Union Street, Room 110, Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before October 26, 2016.
Submit Comments (Opens in new window) - Comment Deadline: November 14, 2016 Posted: October 12, 2016
 
MaineCare Benefits Manual, Chapters II & III, Section 12, Consumer-Directed Attendant Services and Allowances for Consumer-Directed Attendant Services. WORD  PDF   
Concise Summary: The purpose of these rules is to comply with Public Law 2016, ch. 83, Resolves, Directing the Department of Health and Human Services To Increase Reimbursement Rates for Home-based and Community-based Services, which requires the Department to amend its rules for reimbursement rates for personal care and related services provided under the provisions of 10-144 C.M.R. ch.101, MaineCare Benefits Manual, Chapter III, Section 12, Allowances for Consumer-Directed Attendant Services. Chapter III, Allowances for Consumer-Directed Attendant Services, adds modifiers and reimbursement rates for two person and three person member visits for attendant services. Chapter II, Consumer-Directed Attendant Services informs providers, if a single provider is providing personal care services to more than one member, during a single visit, the two or three person procedure code and modifier shall be billed. This law will go into effect on July 29, 2016, without the governor’s signature. The Department is seeking and anticipates receiving approval from the federal Center for Medicare and Medicaid Services for these changes. Pending approval, the increased reimbursement rates and modifiers will be effective retroactive to July 29, 2016. A methodology change notice was published on July 28, 2016. See HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents. PUBLIC HEARING: Date: Monday, October 17, 2016 Time: 1:00 p.m. Location: 19 Union Street, Room 110, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before 5:00 p.m., on Monday, October 11, 2016.
Submit Comments (Opens in new window) - Comment Deadline: October 27, 2016 Posted: September 28, 2016
 
MaineCare Benefits Manual, Chapter III, Section 29 Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF   
Concise Summary: This waiver renewal proposes rule changes to the Comprehensive Home and Community-Based Services (HCBS) Waiver for Persons with Intellectual Disabilities and Autism Spectrum Disorder. Chapter III, Section 29 is a companion to Chapter II, Section 29, Support Services for Members with Intellectual Disabilities or Autism Spectrum Disorder. Chapter III is a major substantive rule and requires legislative approval prior to final adoption of the rule. Significant Updates and Changes to Chapter III, Section 29 includes; o Renaming of the Section from “Allowances for Support Services for Adults with Intellectual Disabilities or Autistic Disorder” to “Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder.” The Department will adopt via emergency rulemaking an increase to the rates in Chapter III in accordance with L.D. 1638. The legislature passed L.D. 1638, An Act to Increase Payments to MaineCare Providers That Are Subject to Maine’s Service Provider Tax, to authorize an increase in the service provider tax. Chapter III, Section 29 lists the procedure codes, descriptions and reimbursement rates for covered services provided to members under its companion rule, Chapter II, Section 29 Support Services for Adults with Intellectual Disabilities or Autistic Disorder. The increased rates will be effective retroactive to April 15, 2016. The following services will have a 1% increase as a result of LD 1638: o T2017, Home Support-Quarter Hour, from $6.27 to $6.33. o T2017 QC, Home Support-Remote Support-Monitor Only, from $1.62 to $1.63 per quarter hour. o T2017 GT, Home Support-Remote Support-Interactive Support, from $6.27 to $6.33 per quarter hour. o T2021, Community Support (day habilitation) from $5.28 to $5.33 per quarter hour. o T2021 SC, Community Support (day habilitation) with Medical Add On from $6.51 to $6.57 per quarter hour. o Replaced H023 HQ Work Support (supported employment) with the following modifiers below: o H2023 UN Work Support (supported employment-Group 2 members served, up to $3.46 per ¼ hour. o H2023 UP Work Support (supported employment-Group 3 members served, up to $2.30 per ¼ hour. o H2023 UQ Work Support (supported employment-Group 4 members served, up to $1.73 per ¼ hour. o H2023 UR Work Support (supported employment-Group 2 members served, up to $1.38 per ¼ hour. o H2023 US Work Support (supported employment-Group 2 members served, up to $1.15 per ¼ hour. In response to recent changes in HCBS rules, the State is working towards, creating greater emphasis on access to community settings and a more person driven focus in the Person Centered Planning process. No members will be affected through the proposal of this rule. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173, L.D. 1638 PUBLIC HEARING: Date: October 19, 2016 Time: 9:00 AM Location: 19 Union Street, Conference Room 110, Augusta ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed above before October 7, 2016.
Submit Comments (Opens in new window) - Comment Deadline: October 29, 2016 Posted: September 28, 2016
 
MaineCare Benefits Manual, Chapter II, Section 29 Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF   
Concise Summary: This waiver renewal proposes rule changes to the Comprehensive Home and Community-Based Services (HCBS) Waiver for persons with Intellectual Disabilities and Autism Spectrum Disorder. The proposed rule includes language that will bring the Department into compliance with new requirements from the Centers for Medicare and Medicaid Services (CMS) HCBS Settings Rule released on January 16, 2014 (see 42 C.F.R. § 441.301(c)). The Department is seeking and anticipates receiving CMS approval for this section. Chapter II, Section 29 is a routine technical rule and does not require legislative approval prior to final adoption of the rule. Significant Updates and Changes to Chapter III, Section 29 include: • Renaming of the section from “Support Services for Members with Intellectual Disabilities or Autistic Disorder” to “Support Services for Members with Intellectual Disabilities or Autism Spectrum Disorder.” • Throughout Section 21, replacement of the term “Mental Retardation” with “Intellectual Disabilities.” • Updating references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. • Added HCBS Settings Rule language to the Introduction. • In the Definitions section: o Updated definition of Autism Spectrum Disorder. o Addition of Clinical Review Team o Addition of Exploitation o Addition of clarifying language to Medical Add On. o Removal of Mental Retardation. o Addition of clarifying language to On Behalf Of. • Under Personal Plan, the language was updated to ensure that the member is driving the process and that the process is more closely aligned with the 42 CFR § 441.301 and 441.303. Direct references to the CFR were included. • In the Covered Services section: o Under Career Planning, addition of quality oriented language. o Addition of clarifying language to Community Support Services. • In the Limits section: o Removed Assistive Technology and Career Planning from the annual limit of $23,771, for members who receive Home Support (remote or quarter hour). o Under Consultation Services, added information regarding limits. o Definition of annual limits for: Occupational Therapy (Maintenance). o Increased the Home Accessibility Adaptions limit from $5,000.00 in a three year period to $10,000 in a three year period. o Added limits for Out of State Services. • In the Duration of Care Section, added requirements for Provider Termination of a Member’s Services. • In Provider Qualifications and Requirements, added: o Additional qualification for Direct Support Professionals. o Additional qualifications for Employment Specialist. o Clarification of Background Check Criteria. o Clarification of Reportable Events & Behavioral Treatment. • Appendix IV- Added Requirements for Section 29 Providers of Home Support Services, Community Support Services, and Employment Specialist Services. In response to recent changes in HCBS rules, the state is working toward creating greater emphasis on access to community settings and a more person driven focus in the Person Centered Planning process. No members will be affected through the proposal of this rule. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173, L.D. 1638 PUBLIC HEARING: Date: October 19, 2016 Time: 9:00 AM Location: 19 Union Street, Conference Room 110, Augusta ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before October 7, 2016.
Submit Comments (Opens in new window) - Comment Deadline: October 29, 2016 Posted: September 28, 2016
 
MaineCare Benefits Manual, Chapter III, Section 21 Allowances for Home and Community Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF   
Concise Summary: This waiver renewal proposes rule changes to the Comprehensive Home and Community-Based Services (HCBS) Waiver for Persons with Intellectual Disabilities and Autism Spectrum Disorder. Chapter III, Section 21 is a companion to Chapter II, Section 21, Home and Community-Based Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder. Chapter III is a major substantive rule and requires legislative approval prior to final adoption of the rule. Significant Updates and Changes to Chapter III, Section 21 includes; o Renaming of the Section from “Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder” to “Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autism Spectrum Disorder.” o Removal of Calculation of the Per Diem Rate for Agency Home Supports. o Clarification of the Average Billing Method. o Removal of the Range in Appendix IIA and IIB. The Department will adopt via emergency rulemaking an increase to the rates in Chapter III in accordance with L.D. 1638. The legislature passed L.D. 1638 to authorize an increase in the service provider tax. Chapter III, Section 21 lists the procedure codes, descriptions and reimbursement rates for covered services provided to members under its companion rule, Chapter II, Section 21 Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder. The increased rates will be effective retroactive to April 15, 2016. The following services will have a 1% increase as a result of LD 1638: o T2017, Home Support (habilitation, residential, waiver), from $6.27 to $6.33 per quarter hour. o T2017 SC, Home Support (habilitation, residential, waiver)-with Medical Add On from $7.50 to $7.57 per quarter hour. o T2017 QC, Home Support (habilitation, residential, waiver)-Remote Support-Monitor Only, from $1.62 to $1.63 per quarter hour. o T2017 GT, Home Support (habilitation, residential, waiver)-Remote Support-Interactive Support, from $6.27 to $6.33 per quarter hour. o T2016, Agency Home Support (habilitation, residential, waiver), from $22.43 to $22.64 per diem. o T2016 SC, Agency Home Support (habilitation, residential, waiver) with Medical Add On, from $19.53 to $19.72 per diem. o T2016 SC, Agency Home Support (habilitation, residential, waiver), from $27.15 to $27.41 per diem. o S5140, Shared Living (Foster Care, adult)-Shared Living Model-One member served, from $126.19 to $127.39 per diem. o S5140 TG, Shared Living (Foster Care, adult)-Shared Living Model-One member served-increased level of support, from $183.52 to $185.27 per diem. o S5140 UN, Shared Living (Foster Care, adult)-Shared Living Model-Two members served, from $63.10 to $63.71 per diem. o S5140 UN TG, Shared Living (Foster Care, adult)-Shared Living Model-Two members served-Increased level of support, from $120.42 to $121.57 per diem. o T2016 U5, Home Support (habilitation, residential, waiver)-Family Centered Support-One member served, from $104.17 to $105.16 per diem. o T2016 TG U5, Home Support (habilitation, residential, waiver)-Family Centered Support-One member served-Increased level of support, from $216.96 to $219.03 per diem. o T2016 UN U5, Home Support (habilitation, residential, waiver)-Family Centered Support-Two members served, from $85.8 to $86.61 per diem. o T2016 UN TG U5, Home Support (habilitation, residential, waiver)-Family Centered Support-Two members served-Increased level of support, from $196.78 to $198.65 per diem. o T2016 UP U5, Home Support (habilitation, residential, waiver)-Family Centered Support-Three members served, from $73.15 to $73.85 per diem. o T2016 UP TG U5, Home Support (habilitation, residential, waiver)-Family Centered Support-Three members served-Increased level of support, from $178.40 to $180.09 per diem. o T2016 UQ U5, Home Support (habilitation, residential, waiver)-Family Centered Support-Four members served, from $61.99 to $62.58 per diem. o T2016 UQ TG U5, Home Support (habilitation, residential, waiver)-Family Centered Support-Four members served-Increased level of support, from $162.16 to $163.71 per diem. o T2016 UR U5, Home Support (habilitation, residential, waiver)-Family Centered Support-Five or members served, from $55.29 to $55.82 per diem. o T2016 UR TG U5, Home Support (habilitation, residential, waiver)-Family Centered Support-Five or members served-Increased level of support, from $153.42 to $154.88 per diem. o T2021, Community Support (day habilitation) from $5.28 to $5.33 per quarter hour. o T2021 SC, Community Support (day habilitation) with Medical Add On from $6.51 to $6.57 per quarter hour. o Replaced H023 HQ Work Support (supported employment) with the following modifiers below: o H2023 UN Work Support (supported employment)-Group 2 members served, up to $3.46 per ¼ hour. o H2023 UP Work Support (supported employment)-Group 3 members served, up to $2.30 per ¼ hour. o H2023 UQ Work Support (supported employment)-Group 4 members served, up to $1.73 per ¼ hour. o H2023 UR Work Support (supported employment)-Group 2 members served, up to $1.38 per ¼ hour. o H2023 US Work Support (supported employment)-Group 2 members served, up to $1.15 per ¼ hour. Chapter III, Section 21 lists the procedure codes, descriptions and reimbursement rates for covered services provided to members under its companion rule, Chapter II, Section 21 Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder. No members will be affected through this emergency rule. Providers of Section 21 services will be reimbursed at a higher rate for services. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173, L.D. 1638 PUBLIC HEARING: Date: October 19, 2016 Time: 1:00 PM Location: 19 Union Street, Conference Room 110, Augusta ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before October 7, 2016.
Submit Comments (Opens in new window) - Comment Deadline: October 29, 2016 Posted: September 28, 2016
 
MaineCare Benefits Manual, Chapter II, Section 21 Home and Community Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF   
Concise Summary: This waiver renewal proposes rule changes to the Comprehensive Home and Community-Based Services (HCBS) Waiver for persons with Intellectual Disabilities and Autism Spectrum Disorder. The proposed rule includes language that will bring the Department into compliance with new requirements from the Centers for Medicare and Medicaid Services (CMS) Home and Community-Based Services (HCBS) Settings Rule released on January 16, 2014 (see 42 C.F.R. § 441.301(c)). The Department is seeking and anticipates receiving CMS approval for this section. Chapter II, Section 21 is a routine technical rule and does not require legislative approval prior to final adoption of the rule. Significant Updates and Changes to Chapter II, Section 21 include: • Renaming of the section from Home & Community Benefits for Members with Intellectual Disabilities or Autistic Disorder to Home & Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder. • Throughout Section 21, replacement of the term “Mental Retardation” with “Intellectual Disabilities.” • Updating references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. • Added HCBS Settings Rule language to the Introduction. • In the Definitions section: o Addition of clarifying language to Administrative Oversight Agency. o Updated definition for Autism Spectrum Disorder. o Addition of Clinical Review Team. o Addition of clarifying language to Medical Add On. o Removal of Mental Retardation. o Addition of clarifying language to Shared Living Provider. • Under Personal Plan, the language was updated to ensure that the member is driving the process and that the process is more closely aligned with the CFR §441.301 and §441.303. Direct references to the CFR were included. • In the Covered Services section: o Under Career Planning addition of quality oriented language. o Under Communication Aids, removed Facilitated communication and added Augmented communication. o Addition of clarifying language to Community Support Services. • In the Limits section: o Addition of language which disallows duplicative services covered by other sections in the MaineCare Benefits Manual. o Under Consultation Services added information regarding limits. o Definition of annual limits for: Occupational Therapy (Maintenance). • In the Duration of Care Section added requirements for Provider Termination of a Member’s Services. • In Provider Qualifications and Requirements, added: o Additional qualification for Direct Support Professionals. o Provider qualifications necessary to perform an Assistive Technology Assessment. o Residential Settings Owned or Controlled by a Provider. o Shared Living (Foster Care, Adult). o Clarification of Background Check Criteria. o Clarification of Reportable Events & Behavioral Treatment. Appendix V- Added Requirements for Section 21 Providers of Home Support Services, Community Support Services, and Employment Specialist Services. In response to recent changes in HCBS rules, the state is working towards, creating greater emphasis on access to community settings and a more person driven focus in the Person Centered Planning process. No members will be affected through the proposal of this rule. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173, L.D. 1638 PUBLIC HEARING: Date: October 19, 2016 Time: 1:00 PM Location: 19 Union Street, Conference Room 110, Augusta ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed above before October 7, 2016.
Submit Comments (Opens in new window) - Comment Deadline: October 29, 2016 Posted: September 28, 2016
 
MaineCare Benefits Manual, Chapters II and III, Section 20 Home and Community Services for Adults with Other Related Conditions. WORD  PDF   
Concise Summary: The Department is proposing to update Chapters II and III, Section 20, Home and Community Benefits for Adults with Other Related Conditions. Chapters II and III are routine technical rules. The Department has previously adopted, via emergency rulemaking, an increase to the rates in Chapter III in accordance with L.D. 1638, An Act to Increase Payments to MaineCare Providers That Are Subject to Maine’s Service Provider Tax. Those rate increases are also included in this proposed rulemaking. The legislature passed L.D. 1638 to authorize an increase in the service provider tax. The increased rates were effective from April 15, 2016. The proposed rule includes additional language that will help bring the Department into compliance with new requirements from the Centers for Medicare and Medicaid Services (CMS) Home and Community- Based Services (HCBS) Settings Regulation released on January 16, 2014 (see 42 C.F.R. § 441.301(c)). The proposed rule also updates eligibility requirements for members, adds clarifying language for Assistive Technology, and adds Career Planning as a new services. More specifically current proposed changes to Chapter II include; • Minor formatting changes throughout the section. • Added HCBS Settings Rule language, within the introduction. • Changed “Authorized Agent” to “Authorized Entity.” • To General Eligibility Criteria, added: Muscular Dystrophy, Huntington’s, Spina Bifida or other rare developmentally based conditions. Removed from General Eligibility Criteria, “any other condition will be reviewed for eligibility by the Office of MaineCare Services Medical Director.” • Added clarifying language under Care Plan Development, E. Selection of Residential Option and Development of Final Care Plan. • Under Covered Services, included data transmission via internet or cable to Assistive Technology Device and Services. • Under Covered Services, included limits to Assistive Technology Device and Services, and moved the $6,000 per service per year limit from the Limits section. Added clarifying language. • Under Covered Services, added Career Planning as a new service. • Under Covered Services, Home Support Services, added new language stating, a Personal Care Assistant, Personal Support Specialist or Direct Support Professional cannot be reimbursed for more than 40 hours per week of services to any one individual waiver member. • Under Limits, Assistive Technology Services, moved the $6,000 per service per year limit to the Covered Services Section. • Under Provider Qualifications and Requirements, added requirements for Career Planning. • Under Provider Qualifications and Requirements, added “Requirements for Residential Settings Owned or Controlled by a Provider.” This section contains language that is pertinent to the HCBS Settings Rule. • Under Quality Reporting added the requirement that providers must utilize the Enterprise Information System (EIS) for Reportable Events. • Under Quality Reporting, added Care Coordination Reporting, Home Support Reporting and Assistive Technology Reporting. Chapter III, Section 20 Allowances for Home and Community Benefits for Adults with Other Related Conditions is also adding a Procedure Code for Career Planning. T2015 U9, Career Planning (Habilitation, prevocational) at $28.00 per hour. The following rates were increased as a result L.D. 1638 and were adopted in the emergency rulemaking: • T2021 U8, Community Support (Day Habilitation) from $5.28 to $5.33 per quarter hour. • T2016 U8, Home Support (Residential Habilitation) from $285.19 to $287.91 per diem. • T2017 U8, Home Support (Residential Habilitation) from $6.33 to $6.39 per quarter hour. • T2017 U8 QC Home Support (Residential Habilitation)-Remote Support-Monitor Only from $1.62 to $1.63 per quarter hour. • T2017 U8 GT Home Support (Residential Habilitation)-Remote Support-Monitor Only from $6.33 to $6.39 per quarter hour. Chapter II, Section 20 defines the services available to members eligible for services under this rule. It also defines service limits and the provider qualifications necessary to deliver the services to members. It’s companion rule, Chapter III, Section 20 Allowances for Home and Community-Based Benefits for Adults with Other Related Conditions, lists the procedure codes, descriptions and reimbursement rates for covered services identified in Chapter II, Section 20. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173, L.D. 1638 PUBLIC HEARING: Date: October 18, 2016 Time: 9:00 AM Location: 19 Union Street, Conference Room 110, Augusta ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before October 11, 2016.
Submit Comments (Opens in new window) - Comment Deadline: October 28, 2016 Posted: September 28, 2016
 
MaineCare Benefits Manual, Chapters II & III, Section 96, Private Duty Nursing and Personal Care Services WORD  PDF   
Concise Summary: The purpose of this rule is to comply with Public Law 2016, ch. 83, Resolve, Directing the Department of Health and Human Services To Increase the Reimbursement Rates for Home-based and Community-based Services. Public Law 2016, ch. 83, requires the Department to amend its rules for reimbursement rates for personal care and related services provided under 10-144 C.M.R. ch. 101, MaineCare Benefits Manual, Chapters II & III, Section 96, Private Duty Nursing and Personal Care Services. This rulemaking adds modifiers and reimbursement rates for multiple member visits, as outlined in Chapter III, Section 96, Private Duty Nursing and Personal Care Services. This law will go into effect on July 29, 2016, without the governor’s signature. Chapter II updates level of care caps. The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services (CMS) for a State Plan Amendment for these changes. Pending approval, pursuant to 22 M.R.S. § 42(8), the increased reimbursement rates, modifiers, and level of care caps will be effective retroactive to July 29, 2016. The Department published a change in reimbursement methodology, pursuant to 42 C.F.R. §447.205, on July 28, 2016. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173; Public Law 2016, ch. 83, Resolve, Directing the Department of Health and Human Services To Increase Reimbursement Rates for Home-based and Community-based Services PUBLIC HEARING: Date: October 11, 2016 Time: 1:00 p.m. Location: 19 Union Street, Room 110, Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before October 4, 2016.
Submit Comments (Opens in new window) - Comment Deadline: October 21, 2016 Posted: September 21, 2016
 
Chapters II & III, Section 17, Community Support Services WORD  PDF   
Concise Summary: 1. Following various changes to Chapter II, Section 17, Community Support Services adopted by the Department on March 22, 2016, certain members no longer met clinical criteria for Community Support Services. This prompted a legislative review of the Section 17 rule changes, after which the Legislature enacted Resolves 2016, ch. 82 (eff. Apr. 26, 2016). This Resolve requires the Department to extend the authorized service period for certain individuals who no longer meet clinical criteria for Section 17 services after the rule changes adopted on March 22, 2016. For members affected by the March 22nd rule change, the Department shall authorize a 120 day extension for the member’s Section 17 services. Additionally, 90-day extensions may be granted, provided the member is able to reasonably demonstrate to the Department, or Authorized Entity, that he or she has attempted to, and has been unable to, access medically necessary covered services under any other section of the MaineCare Benefits Manual. The Chapter II changes shall be effective retroactive to April 26, 2016. The temporary transition period shall end on June 30, 2017. 2. Separately, the Legislature enacted An Act to Increase Payments to MaineCare Providers that are Subject to Maine’s Service Provider Tax, P.L. 2016, ch. 477 (eff. Apr. 15, 2016). Certain MaineCare providers subject to the service provider tax have experienced an increase in the tax to 6% since January 1, 2016. The Legislature thus provided additional appropriations to certain MaineCare providers, including Section 17 providers, in an effort to offset the increase in the provider tax. The Department is seeking and anticipates CMS approval of the reimbursement changes for Section 17 providers. Pending approval, the Department will reimburse providers under the new increased rates retroactively to July 1, 2016 pursuant to P.L. 2016, ch. 477 (eff. Apr. 15, 2016). 3. Each of the new laws were enacted by the Legislature on an emergency basis. Given that each law provides benefits to the regulated community, and the time-sensitive, limited nature of the extension in eligibility, the Department was authorized to enact these changes to Section 17 on an emergency basis, without the findings required by 5 M.R.S. § 8054(2). These emergency rule changes were filed and were effective for ninety (90) days. The Department is now engaging in proposed routine technical rulemaking to permanently adopt these Section 17 rule changes. 4. Finally, the Department notes that on April 29, 2016, the Legislature overrode the Governor’s veto of LD 1696, Resolve, To Establish a Moratorium on Rate Changes Related to Rule Chapter 101: MaineCare Benefits Manual, Sections 13, 17, 28 and 65 (Resolves 2016, ch. 88). That law imposes a moratorium on rulemaking to change reimbursement rates, including Section 17, until after a rate study has been completed and presented to the Legislature. The Department consulted with the Office of Attorney General and the Office of the Attorney General determined and has advised the Department that Resolves 2016, ch. 88 does not prevent the rule changes because (1) the separate law, P.L. 2016, ch. 477, is more specific in regard to changing reimbursement for providers impacted by the Service Provider Tax increase; and (2) these are reimbursement rate increases, thus providing a benefit to MaineCare providers. 5. This rulemaking proposes to remove Clubhouse services and Specialized Group services as they are now available and covered through Section 65, Behavioral Health Services. This will remove the duplication of service and all references to the service within this rule. 6. This rule proposes adding a definition for the Adult Needs and Strengths Assessment, as well as provider requirements for filling out and reporting the assessment at regular intervals via the Department’s Enterprise Information System. 7. This proposed rule aims to add language giving members the option to request to hold for service if providers are unable to meet the seven (7) day face-to-face requirement of new referrals. Members may elect to hold for service only after an agency has adequately informed the member of their options. 8. The rule also seeks to add language to the Individualized Service Plan in 17.04-1.E requiring a goal on a member’s access to primary care, specialty care, and routine appointments. This also requires the MHRT to document evidence of the visit as described in 17.04-1.N. 9. Lastly, this rule seeks to update language of CMS approval about the inclusion of Certified Peer Support Specialists (CIPSS) as part of the ACT Team defined in 17.04-3.A-5. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 MRSA, §42, §3173; P.L. 2016, ch. 477 (eff. Apr. 15, 2016); Resolves 2016, ch. 82 (eff. Apr. 26, 2016) PUBLIC HEARING: Date: Thursday October 06, 2016 Time: 9am-12pm Location: 19 Union St. Room 110 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before September 30, 2016.
Submit Comments (Opens in new window) - Comment Deadline: October 22, 2016 Posted: September 14, 2016
 
MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facility Services WORD  PDF   
Concise Summary: This proposed rulemaking seeks to increase Nursing Facility Services’ prospective and final prospective rate to 100 percent (100%) of all calculated direct care and routine cost components to ensure adequate funding to Nursing Facility Services effective retroactive to July 1, 2016. The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services for this change. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173 PUBLIC HEARING: Date: September 27, 2016 Time: 1:00 p.m. Location: 19 Union Street, Room 110, Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before September 22, 2016.
Submit Comments (Opens in new window) - Comment Deadline: September 22, 2016 Posted: September 6, 2016
 
MaineCare Benefits Manual, Chapter III, Section 40, Home Health Services WORD  PDF   
Concise Summary: The proposed major substantive rule seeks to implement new procedure codes set forth by the Centers for Medicare and Medicaid Services, effective retroactive to January 1, 2016. The procedure code for services of a skilled nurse (RN) in a home health setting is updated to G0299 from G0154TD. The procedure code for services of a skilled nurse (LPN/LVN) in a home health setting is updated to G0300 from G0154TE. Procedure codes G0154TD and G0154TE are eliminated through this rulemaking. Telemonitoring of a patient in their home is proposed as a new covered service in Chapter II, Section 40, Home Health Services. Procedure code S9110 is added in Chapter III to support the reimbursement of this service. The Telemonitoring Services procedure is effective retroactive to April 16, 2016. This major substantive rule will remain in effect for up to one year or earlier if the Legislature approves the provisionally adopted major substantive rule. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173, 5 M.R.S. § 8072 PUBLIC HEARING: Date: August 16, 2016 Time: 1:00 p.m. Location: 19 Union Street, Room 110, Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before August 9, 2016. DEADLINE FOR COMMENTS: Comments must be received by 11:59 p.m. on August 26, 2016. AGENCY CONTACT PERSON: Heidi Bechard, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 242 State St., SHS#11, Augusta, ME 04333 TELEPHONE: 207-624-4074 FAX: (207) 287-1864 TTY: 711 (Deaf or Hard of Hearing)
Submit Comments (Opens in new window) - Comment Deadline: August 26, 2016 Posted: July 27, 2016
 
MaineCare Benefits Manual, Chapter II, Section 40, Home Health Services WORD  PDF   
Concise Summary: This letter gives notice of a proposed rule change to MaineCare Benefits Manual (MBM), Chapter II, Section 40, Home Health Services. This proposed rulemaking seeks to implement the following: 1. New definitions added: Health Care Provider, Interactive Telehealth Services, Telehealth Services, and Telemonitoring Services. Authorized Agent is changed to Authorized Entity and updated throughout the policy. 2. Eligibility for Care changes: Medical Eligibility Requirements for Interactive Telehealth Services and Medical Eligibility Requirements for Telemonitoring Services. 3. Interactive Telehealth Services and Telemonitoring Services are added to Covered Services. 4. Non-Routine Medical Supplies includes an updated link to billing instructions and list of supplies. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173 PUBLIC HEARING: Date: August 16, 2016 Time: 1:00 p.m. Location: 19 Union Street, Room 110, Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before August 9, 2016. DEADLINE FOR COMMENTS: Comments must be received by 11:59 p.m. on August 26, 2016. AGENCY CONTACT PERSON: Heidi Bechard, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 242 State Street, SHS# 11, Augusta, ME 04333 TELEPHONE: 207-624-4074, FAX: (207) 287-1864 TTY: 711 (Deaf or Hard of Hearing)
Submit Comments (Opens in new window) - Comment Deadline: August 26, 2016 Posted: July 27, 2016
 
MaineCare Benefits Manual, Chapter III, Section 109, Speech & Hearing Services WORD  PDF   
Concise Summary: This rule is being proposed to reduce rates for codes 92587 (Agency Rate) and 92588 (Agency and Independent Rate) to align with current Medicare rates for Speech and Hearing Services. The Department also proposes the addition of code 92586 for clarification of limited services. Finally, the Department proposes minor technical edits. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: July 25, 2016 Time: 9:00 AM Location: Room 110, 19 Union Street, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before July 18, 2016.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by midnight August 4, 2016 Posted: June 29, 2016
 
MaineCare Benefits Manual, Chapters II and III, Section 103, Rural Health Clinic Services WORD  PDF   
Concise Summary: This proposed rule amends the rate setting and rate-adjustment processes for the Prospective Payment System (PPS) used to reimburse Rural Health Clinic Services (RHCs). This rulemaking clarifies and expands the current RHC policy and procedures as follows: • Provides additional guidance in the methodology for adjustments of PPS rates; • Amends the process of rate establishment for newly qualifying RHCs; • Provides specific guidance in what constitutes “a change in scope of services”; and • Expands the reporting requirements to support requests for rate adjustments due to a change in scope of services. The Centers for Medicare and Medicaid Services (“CMS”) has approved a Maine State Plan Amendment related to initial rate-setting and “change in scope of services.” The payment methodology for RHCs conforms to Section 702 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173 PUBLIC HEARING: Date: Tuesday, July 12, 2016 Time: 1:00 p.m. Location: 19 Union St., Room 110 Augusta, ME The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before July 5, 2016.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by 11:59 p.m., July 22, 2016 Posted: June 22, 2016
 
MaineCare Benefits Manual, Chapters II and III, Section 31, Federally Qualified Health Center Services WORD  PDF   
Concise Summary: This proposed rule amends the rate setting and rate-adjustment processes for the prospective payment system (PPS) used to reimburse Federally Qualified Health Centers (FQHCs). This rulemaking clarifies and expands the current FQHC policy and procedures as follows: • Provides additional guidance and consistency in the methodology for adjustments of PPS rates; • Amends the process of rate establishment for newly qualifying FQHCs; • Provides specific guidance in what constitutes “a change in scope of services”; and • Expands the reporting requirements in conjunction with a request for rate adjustment due to a “change in scope of services”. The Centers for Medicare and Medicaid Services (“CMS”) has approved a Maine State Plan Amendment related to initial rate-setting and “change in scope of services.” The payment methodology for FQHCs conforms to Section 702 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173 PUBLIC HEARING: Date: Tuesday, July 12, 2016 Time: 9:30 a.m. Location: 19 Union St., Room 110 Augusta, ME The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before Tuesday, July 5, 2016.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by 11:59 p.m., Friday, July 22, 2016 Posted: June 22, 2016
 
MaineCare Benefits Manual, Chapters II and III, Section 65, Behavioral Health Services WORD  PDF   
Concise Summary: This rule makes the following changes to the Medication-Assisted Treatment section: Requiring Medication-Assisted Treatment Facilities to be open at least six days per week throughout the calendar year, updating the twenty-four month prior authorization forms for members who have hit their lifetime methadone cap, adding an authorization form to be completed by the facility within sixty calendar days of the member’s first visit, adding a definition of Medication-Assisted Treatment to the definitions section, adding a Medical Director section to the policy that outlines the Medical Directors’ required responsibilities, adding a Medical Records section that outlines the minimum required documentation that must accompany Medication-Assisted Treatment services, adding a Counseling section that outlines who can perform counseling to members, and the minimum amount of counseling members should receive during treatment, adding a Medication Administration section that establishes initial dosage limits for methadone and diversion control plan measures, and adding an Individualized Service Plan section that establishes the minimum requirements for a member’s service plan. This rule moves MaineCare’s Clubhouse services, which are currently part of Day Supports Services, from Section 17 to Section 65 of the MaineCare Benefits Manual. This rulemaking will also move the Specialized Group Services from Section 17 to Section 65 of the MaineCare Benefits Manual. This rulemaking will also replace the current per hour day treatment procedure code that Clubhouse providers are billing under with the more appropriate Mental Health clubhouse services per 15 minute procedure code. This rule also updates the reference for diagnostic codes required for billing in Section 65.13, Billing Instructions from ICD-9 to ICD-10 codes, and makes minor technical edits. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173 PUBLIC HEARING: Date: July 11, 2016 Time: 9:00 AM Location: Champlain Conference Room, 45 Commerce Dr., Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before July 4, 2016.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by 11:59 PM on July 21, 2016 Posted: June 20, 2016
 
MaineCare Benefits Manual, Section 55, Chapter II, Laboratory Services WORD  PDF   
Concise Summary: This rule is being proposed in order to limit and align urine drug testing to current industry standards. The Department proposes the following: • Drug testing must be supported by documentation in the medical record. • The frequency and choice of assay used should be based on an assessment of the individual member’s risk potential. • Separate payment for testing of adulterants or specimen validity is not reimbursable. • Confirmation testing is covered only to confirm an unexpected result. • Urine drug testing is limited to two (2) specimens per rolling month. Additional test(s) may be requested with a Prior Authorization. • Substance abuse treatment is to be measured by random testing rather than scheduled testing. • Routine urine drug screening should focus on detecting specific drugs of concern. • A presumptive test may be followed by a definitive test to specifically identify drugs or metabolites. Confirmation tests must be performed by a second method. A presumptive test to confirm a presumptive test is not reimbursable. • Standing orders for presumptive testing must be signed and dated no more than sixty (60) days prior to the date of specimen collection. Standing orders for conformation and/or quantitative testing is prohibited. • The Department clarifies what is considered not medically necessary. The Department also proposes adding language for Prior Authorization to the Definitions. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173 PUBLIC HEARING: Date: June 28, 2016 Time: 9:00 AM Location: Room 110, 19 Union Street, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before June 21, 2016.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by 11:59 PM on July 8, 2016 Posted: June 7, 2016
 
MaineCare Benefits Manual, Chapter X, Section 4, Limited Family Planning Benefit WORD  PDF   
Concise Summary: This rule establishes the Limited Family Planning Benefit. Under the Limited Family Planning Benefit, the Department provides for the delivery of federally approved Medicaid services to qualified individuals when their income is equal to or below 209% of the nonfarm income official poverty line for reproductive health care and family planning services. The goal is to improve the health of individuals and families in Maine by improving access to family planning services and decreasing the overall costs of healthcare by helping to prevent or delay pregnancies and to improve overall reproductive health of enrollees. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173; PL 2015, Chapter 356, An Act to Strengthen the Economic Stability of Qualified Maine Citizens by Expanding Coverage of Reproductive Health Care and Family Services. PUBLIC HEARING: Date: Monday, June 6, 2016 Time: 9:30 a.m. Location: Department of Health & Human Services 19 Union Street, Room 110 Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before May 30, 2016.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by 11:59 p.m., Thursday, June 16, 2016 Posted: May 18, 2016
 
MaineCare Benefits Manual, Chapters II & III, Section 2, Adult Family Care Services WORD  PDF   
Concise Summary: The purpose of this rule is to comply with Resolves 2015, ch. 45 Resolve, To Require the Department of Health and Human Services to Provide Supplemental Reimbursement to Adult Family Care Homes in Remote Island Locations. This law went into effect on July 12, 2015 without the Governor’s signature. This rule seeks to implement a supplemental payment to Adult Family Care Homes located on an island not connected to the mainland by a bridge. The supplement payment to eligible Adult Family Care Homes represents a fifteen (15) percent rate increase from the MaineCare rate as established in Chapter III. The Department is seeking approval from the Centers for Medicare and Medicaid Services (CMS) for a State Plan Amendment. Pursuant to 22 M.R.S.A. §42(8), if CMS approves, the supplemental payment for Adult Family Care Homes that satisfy the definition of “remote island facility” will be effective retroactive to October 1, 2015. A Change in Reimbursement Methodology Notice was published on September 30, 2015. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents. PUBLIC HEARING: Date: May 4, 2016 Time: 1:00 PM Location: 19 Union Street, Room 110, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before 5:00 PM, on, April 27, 2016. AGENCY CONTACT PERSON: Heidi Bechard, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 heidi.bechard@maine.gov TELEPHONE: (207)-624-4074 FAX: (207) 287-1864
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by midnight, May 16, 2016 Posted: April 11, 2016
 
MaineCare Benefits Manual, Chapters II & III, Section 43, Hospice Services WORD  PDF   
Concise Summary: This rule is being proposed to comply with the implementation of hospice payment reforms as set out in the Centers for Medicare & Medicaid Services Rule, 42 CFR § 418.302, 306. The final rule requires that State Medicaid programs make revisions to their methodologies for determining the payment rate for Routine Home Care (RHC) and other services. These changes include a new payment methodology for Routine Home Care (RHC) to implement two rates that will result in 1) a higher base payment for the first sixty (60) days of hospice care and 2) a reduced base rate for days thereafter. A new Service Intensity Add-on (SIA) payment for services provided by a Registered Nurse (RN) or clinical social worker during the last seven (7) days of a member’s life has also been added. This rule proposes a retroactive effective date of January 1, 2016. The rulemaking also updates the policy titles and section numbers listed in § 43.05-4, Coverage Restrictions during Hospice Election, to correlate with the current version of the MaineCare Benefits Manual. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: Tuesday, April 19, 2016 Time: 9:00 a.m. Location: 19 Union St., Room 111A, Augusta, ME The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before April 11, 2016.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by midnight April 29, 2016. Posted: March 25, 2016
 
MaineCare Benefits Manual (MBM), Chapter III, Section 15, Chiropractic Services WORD  PDF   
Concise Summary: This rule is being proposed in order to update current billing practices by removing the basic value language that utilizes the units system and replacing the units with rates. Additionally, chiropractic codes will be updated to align with current 2016 CPT codes. These changes include the elimination of code 72090 with the addition of codes 72081, 72082, 72083, and 72084. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: April 19, 2016 Time: 2:30 PM Location: 242 State Street, Conference Room 1, Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before April 12, 2016.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by midnight April 29, 2016 Posted: March 25, 2016
 
MaineCare Benefits Manual, Chapter III, Section 97, Private Non-Medical Institution Services WORD  PDF   
Concise Summary: This proposed major substantive rule seeks to provide a supplemental payment of fifteen (15) percent, in addition to the facility’s MaineCare rate, to residential care facilities in remote island locations. Eligible facilities are those located on an island not connected to the mainland by a bridge. In addition, this rulemaking seeks to increase Private Non-Medical Institutions’(PNMI) assisted living reimbursement rate to four (4) percent. The Department shall seek approval from the federal Centers for Medicare and Medicaid Services (CMS) for a State Plan Amendment for these changes. If CMS approves, the fifteen (15) percent supplemental payments to eligible remote island facilities will be effective retroactive to October 1, 2015. Appendix C and F PNMIs’ assisted living reimbursement rate increase of four (4) percent will be effective retroactive to July 1, 2015. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents. PUBLIC HEARING: Date: Wednesday, April 6, 2016 Time: 1:00 PM Location: 19 Union Street, Room 110, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before 5:00 PM, on Wednesday, March 30, 2016.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by midnight, Monday, April 18, 2016 Posted: March 14, 2016
 
MaineCare Benefits Manual, Chapter II, Section 90, Physician Services WORD  PDF   
Concise Summary: CONCISE SUMMARY: • The rulemaking allows for unlimited coverage of comprehensive tobacco cessation treatment for all members who wish to cease the use of tobacco. These changes to Section 90 will be effective retroactive to August 1, 2014, for members eighteen (18) years of age or older or who are pregnant, in compliance with LD 386, An Act to Reduce Tobacco-related Illness and Lower Health Care Costs in MaineCare (22 MRSA §3174-WW). • This rulemaking adds coverage for oral evaluation by a medical provider for a child under the age of three (3) who does not have a dental home and/or has not seen a dentist in the past year. This rulemaking also amends language for coverage of topical application of fluoride varnish to align with limits described in MBM, Ch. III, Section 25, Dental Services. • The Department proposes to remove the limits of five (5) services in any consecutive seven (7) day period and eight (8) emergency therapy visits “per emergency” for no more than two (2) hours within a single twenty-four (24) hour period. • This rulemaking removes the requirement that providers delivering psychiatric services within their scope of licensure and state law must be under direct supervision of a board eligible or certified psychiatrist. This rule also renames “Psychiatric Services,” to “Behavioral Health Services.” • This rulemaking amends the anesthesia time unit used for billing anesthesia services to one (1) minute intervals, rather than fifteen (15) minutes, in order to comply with Health Insurance Portability and Accountability Act (HIPPA) Version 5010. • This rulemaking clarifies (i) the limit to the number of patients that the anesthesiologist or operating physicians may supervise as a maximum of four (4) patients concurrently, (ii) the service and billing instructions for medically-directed services for physicians; and, (iii) that post-anesthesia care is a requirement of anesthesiology services. • The time periods indicated in surgical services for post-operative treatment are amended to comply with the Centers for Medicare and Medicaid Services (“CMS”) standard fee schedule for durational global surgical periods. • To align with the Early Periodic Screening, Diagnosis, Treatment Program (EPSDT), providers are no longer required to submit Well Child Visit (“Bright Futures”) forms in order to receive MaineCare reimbursement for services. In addition, language in this rulemaking clarifies that participation in EPSDT is optional and that providers are not required to complete a specific rider to deliver covered preventive health services. • This rulemaking amends provider qualifications for obstetrical services to ensure that any appropriately licensed or certified, qualified professional working within their scope of licensure or certification may deliver obstetrical services to MaineCare members. Requirements around hospital admitting privileges are also amended: in order to deliver obstetrical services, providers must personally, or through a formal arrangement, have active hospital admitting privileges to an approved MaineCare hospital which includes maternity services. • This rulemaking updates the methods by which the Department sets rates in the MaineCare Fee Schedule to include an option to obtain an average from other state Medicaid agencies for relevant codes when the code is not priced by Medicare. • The rulemaking also increases the reimbursement of primary care physicians for certain primary care services. This initiative replaces expiring funds provided through the federal Patient Protection and Affordable Care Act (ACA), P.L. 111-148. CMS has approved a Maine State Plan Amendment for this program, effective January 1, 2015. Public Law 2015, Chapter 267 (702 – L.D. 109), Part A approved continued funding of this program, and the Section 90 policy will be updated to reflect the full initiative (an effective date of January 1, 2015). Eligible providers are those practicing with a specialty designation of Family Medicine, Internal Medicine, or Pediatric Medicine or with a subspecialty within these three primary care categories that is recognized by the American Board of Medical Specialties, the American Board of Physician Specialties, or the American Osteopathic Association. Eligibility for the increase is limited to qualified physicians and Advanced Practice Registered Nurses and Physician Assistants practicing under their direct supervision. Hospital-based physicians and physicians providing services as part of a Federally Qualified Health Center or Rural Health Clinic remain ineligible. • This rulemaking moves specific entries under “Covered Services” that describe procedural information, including “Insurance Coverage - Insurance Benefit,” to Section 90.09-2, Reimbursement. • This rulemaking clarifies Section 90.09-3, Reimbursement Rate for Drugs Administered By Other Than Oral Methods, without any change in coverage, reimbursement or procedures. • This rulemaking deletes the separate Computerized Axial Tomography Scan subsection under covered services and includes the same information in 90.04-6, Medical Imaging Services. • This rulemaking states that audiologists, physical therapists, and occupational therapists must follow the expectations and limitations in their applicable sections of policy when rendering services in a physician’s practice. • For consistency with Section 1.03-2, which provides that MaineCare will not provide payment to any entity outside the United States, and as required by Section 6505 of the Patient Protection and Affordable Care Act, P.L. 111-148 (March 23, 2010), the following language has been removed from the policy: “or province” from multiple locations. • This rulemaking also includes other minor and technical changes, such as updating website links, updating language to be consistent with other MaineCare materials, spelling out acronyms, updating names of government agencies, and updating titles of MBM sections. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S.A. §§ 42, 3173; 22 M.R.S. § 3174-WW; Public Law 2015, Chapter 267, Part A; Patient Protection and Affordable Care Act, P.L. 111-148, Section 6505 PUBLIC HEARING: Date: March 7, 2016 Time: 9:00 AM Location: Conference Room 110, Department of Health and Human Services, 19 Union Street, Augusta, Maine 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before 5:00 PM, on Monday, February 29, 2016.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by midnight Thursday, March 17, 2016. Posted: February 12, 2016
 
MaineCare Benefits Manual, Chapter II, Section 4, Ambulatory Surgical Center Services WORD  PDF   
Concise Summary: The Department proposes to align MBM, Section 4, Ambulatory Surgical Center (ASC) Services with the current ASC reimbursement methodology as defined by the outpatient prospective payment system (OPPS) by the Centers for Medicare and Medicaid Services (CMS). The Department also proposes to reimburse physicians or other qualified providers at the facility rate listed in the MaineCare Fee for services delivered in ASCs. CMS-defined all-inclusive rates include prosthetic devices that are considered integral to covered surgical services; MaineCare will no longer reimburse ASCs separately for prosthetic devices that are outside of the all-inclusive rate for covered surgical procedures. Members may procure medically necessary prosthetics through a durable medical equipment provider, physician, or other appropriately licensed provider in accordance with the applicable section of the MBM. Language is also added to Section 4.04 (B), Ancillary Services, to reflect that certain radiology services are eligible for separate payment under the OPPS. Section 4.05, Non-Covered Services, is amended to clarify that per CMS determination, surgeries performed in ASCs are not expected to result in extensive blood loss; when there is a need for blood products, MaineCare considers this a facility service and no separate charge is permitted. Language is also added to describe in more detail which services and supplies are non-covered and where else these services may be covered in the MBM. This rulemaking also adds a general description of which surgical procedures are approved for delivery in an ASC, deletes components of the all-inclusive rate that were listed twice, more closely aligns reimbursement language with the CMS approved State Plan Amendment, removes the disclaimer that the section is dependent upon approval from CMS because approval has been granted, updates the MaineCare provider website URL, and makes minor formatting edits. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: February 19, 2016 Posted: January 19, 2016
 
Repeal of Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 68, Occupational Therapy Services and Proposal of Chapters II & III, Section 85, Physical & Occupational Therapy Services WORD  PDF   
Concise Summary: These changes are being proposed to limit access to, and clarify, services. In particular, the proposed changes combine Sections 85 (Physical Therapy Services) and 68 (Occupational Therapy Services) to cover services that are designed to return members to a normal or previous best level of function, maximize a new best level of function, maintain level of function, or maximize individual independence. In Chapter II, the Department proposes to limit services by allowing adults one (1) evaluation and five (5) treatments per profession, per calendar year, without a prior authorization. Additional services can be requested with a prior authorization. MaineCare members who are under the age of twenty-one (21) shall receive all medically necessary services without prior authorization. Additionally, the Department proposes new reimbursement requirements for splinting supplies. Finally, the Department proposes minor technical edits. The Department proposes to add splinting codes in Chapter III and remove the current link to the codes in Chapter II. Additionally, the Department proposes to update code 92605 from “per service” to “60 minutes” and add code 92618 to cover additional units. Finally, the Department proposes minor coding edits. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: January 12, 2016 Time: 1:00 PM Location: Room 110, 19 Union Street, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before January 5, 2016.
Submit Comments (Opens in new window) - Comment Deadline: January 22, 2016 Posted: December 17, 2015
 
MaineCare Benefits Manual, Chapter III, Section 12, Allowances for Consumer Directed Attendant Services WORD  PDF   
Concise Summary: The purpose of this rule is to comply with Resolve 2015, ch. 50 and L.D. 1350, which requires the Department to increase the reimbursement rate for Attendant Care Services provided under the provisions of 10-144 C.M.R. ch.101, MaineCare Benefits Manual, Chapter II, Section 12. The Department shall seek approval from the federal Centers for Medicare and Medicaid Services (CMS) for a State Plan Amendment for this change. Pursuant to 22 M.R.S.A. §42(8), if CMS approves, the increased reimbursement rates will be effective retroactive to October 1, 2015. The Department published notice of change in reimbursement methodology, pursuant to 42 C.F.R. §447.205, on September 30, 2015. In addition to the rate increase, the Department proposes to remove from Sec. 12, Ch. III references to Levels I, II, and III for Attendant Care Services (procedure codes S5125, S5125 TF and S5125 TG), since a single procedure codes (S5125 U2) is used for all three levels of service. The three Levels of Care are based on the hours of need, as determined by the assessment process, and they remain referenced in Sec. 12, Ch. II. Finally, pursuant to 5 M.R.S.A. §8052(6), the Department proposes to remove the references to the Maine Integrated Health Management Systems (MIHMS), which was implemented on September 1, 2010. Procedure codes H2014, G9001, and G9002 have been utilized since that time. See HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents. PUBLIC HEARING: Date: Wednesday, January 6, 2016 Time: 1:00 PM Location: 19 Union Street, Room 110, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before 5:00 PM, on Monday, December 28, 2015.
Submit Comments (Opens in new window) - Comment Deadline: January 16, 2016 Posted: December 11, 2015
 
MaineCare Benefits Manual, Chapter III, Section 67, Nursing Facility Services WORD  PDF   
Concise Summary: This letter gives notice of a proposed rule change to the MaineCare Benefits Manual (MBM), Chapter III, Section 67, Nursing Facility (NF) Services. This proposed rule change seeks to implement the following: 1. Increase the final prospective rate from 95.12 percent to 97.44 percent. 2. Include the cost of continuing education for direct care staff as a direct care cost component rather than a routine cost component. These changes are being done in order to comply with Public Law 2015, Chapter 267, Part A and L.D. 87, An Act To Implement the Recommendations of the Commission to Continue the Study of Long-term Care Facilities. If the Centers for Medicare and Medicaid Services (CMS) approves, the final prospective rate increase will be effective retroactive to July 1, 2015. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: Tuesday, December 15, 2015 Time: 1:00 PM Location: 19 Union Street, Room 110, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before December 7, 2015.
Submit Comments (Opens in new window) - Comment Deadline: December 28, 2015 Posted: November 18, 2015
 
MaineCare Benefits Manual, Chapter I, Section 4, Telehealth Services WORD  PDF   
Concise Summary: Current MaineCare policy in Chapter 1, Section 1.06-2, allows a limited group of providers to provide services remotely to patients through the use of telehealth, which is defined as “the use of electronic communication by a health care provider to deliver clinical services at a distance for the purpose of diagnosis, disease monitoring, or treatment.” Under the current telehealth rule, for each instance where telehealth is used, a provider is required to submit documentation showing that a physical, social or geographic limitation exists that prevents the provider from delivering a MaineCare covered service to a particular member in a face-to-face encounter, or to otherwise justify the use of telehealth as more appropriate, and to get the Department’s prior authorization before using telehealth services. MaineCare staff and MaineCare providers have found the current telehealth policy to be too restrictive. Providers have found it difficult to obtain approval for telehealth in some cases, and staff has found it challenging to implement a consistent system of review. In response to these challenges, the Legislature passed LD 1596 in 2014. This LD directed the Department to “convene a working group to review the MaineCare rules regarding the definition of telehealth and the technologies used for provider patient interaction involving MaineCare patients” and to make according changes to MaineCare policy. MaineCare staff convened a workgroup consisting of providers, industry stakeholders, advocates, and lawmakers. The group met several times over late spring and summer 2014, and a draft policy was written based on the feedback provided by the group and upon extensive research conducted by MaineCare staff. The drafted policy combined stakeholder recommendations with industry best practices. A working draft of the policy was submitted to the stakeholder group for comments in fall 2014, and the comments were compiled in written form and responded to by MaineCare staff. The proposed new telehealth policy is written as a standalone policy, as opposed to a subsection of Chapter I, Section 1, as it was previously. The new rule will be effective upon the repeal of the current telehealth rule (Ch. I Sec. 1.06-2). The major components of the new telehealth rule are as follows: 1. Removes the prior approval process for use of telehealth; 2. Allows telehealth for all medically necessary services that can be delivered remotely at comparable quality; 3. Provides for an “originating site fee” to be paid to the site housing the patient, while the remote, or provider site, bills for the services rendered; 4. Provides for visual/audio, or, if video/audio is not available, the provision of telephonic services; 5. Requires providers to use secure, HIPAA compliant equipment; and; 6. Requires member choice, written informed consent, and member education. In addition to Interactive Telehealth Services, the policy also provides for a new service known as “Telemonitoring.” Telemonitoring provides electronic communication between a member and healthcare provider whereby health-related data is collected, such as pulse and blood pressure readings that assist healthcare providers in monitoring and assessing the member’s medical conditions. Telemonitoring takes place in the home environment. Home Health agencies deliver Telemonitoring Services. In order to be eligible, a member must have had two or more hospitalizations or emergency department visits related to their diagnosis in the past calendar year, or have continuously received telemonitoring services during the past calendar year and have a continuing need for such services, as documented by an annual note from a licensed healthcare provider. SEE http://www.maine.gov/dhhs/oms/rules/provider_rules_policies.html for rules and related rulemaking documents. THIS RULE WILL NOT HAVE A FISCAL IMPACT ON MUNICIPALITIES. STATUTORY AUTHORITY: 22 M.R.S.A. §§ 42, 3173; LD 1596, Ch. 105, Resolve, Directing the Department of Health and Human Services To Amend MaineCare Rules as They Pertain to the Delivery of Covered Services via Telecommunications Technology PUBLIC HEARING: Date and Time: December 7, 2015 10 AM Location: Room 300, Burton Cross Building,111 Sewall Street, Augusta, Maine 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before November 30, 2015.
Submit Comments (Opens in new window) - Comment Deadline: December 17, 2015 Posted: November 13, 2015
 
MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedure WORD  PDF   
Concise Summary: The Department of Health and Human Services (DHHS) is proposing to remove the Telehealth section from Chapter 101, MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures concurrent with the implementation of Chapter 101, MaineCare Benefits Manual, Chapter I, Section 4, Telehealth Services. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: December 7, 2015 Time: 9:00 AM Location: Room 300, Burton Cross Building, 111 Sewall Street, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before November 30, 2015.
Submit Comments (Opens in new window) - Comment Deadline: December 17, 2015 Posted: November 13, 2015
 
MaineCare Benefits Manual, Chapters II and III, Section 19, Home and Community Benefits for the Elderly and for Adults with Disabilities WORD  PDF   
Concise Summary: In conjunction with the development of the state’s biannual budget, the Department of Health and Human Services (the Department) proposes to increase the reimbursement rate for providers of Attendant Care Services and Personal Care Services in the MaineCare Benefits Manual, Chapter III Section 19, Home and Community Benefits for the Elderly and for Adults with Disabilities. The Department also proposes to increase, the monthly limits for members’ Section 19 services from $4,200/month to $4,603/month. The Maine State Legislature approved these increases when it enacted the budget, Public Law 2015, Chapter 267 (702 – L.D. 109) (Sec. A-32). On June 30, 2015, the Legislature voted to override the Governor’s veto of the budget, which became effective on July 1, 2015. Section 19 services are governed by a Section 1915(c) waiver approved by the Centers for Medicare and Medicaid Services (CMS). Pursuant to PART UU Sec. UU-1 of the budget, the Legislature provided that the Department may effectuate these changes without the need to demonstrate emergency findings in support of emergency rulemaking. As such, on October 13, 2015, the Department filed these emergency rule changes for Section 19 Chapters II and III, effective retroactive to July 1, 2015. To prevent lapse of the emergency rule changes, which are effective for ninety (90) days, the Department is now proposing these changes pursuant to 5 M.R.S.A. §8052. Specifically, in Chapter III, Section 19, the Department proposes to increase: (1) Attendant Care Services (Personal Care Services, Participant Directed Option), billing code S5125, from $2.93 per quarter hour to $3.21 per quarter hour; (2) Personal Care Services (Agency PSS), billing code T1019, from $3.75 per quarter hour to $4.10 per quarter hour and (3) Increase the rate for Adult Day Health Services (S5100), from $2.34 to $3.14 per quarter hour, retroactive to 11/1/2014. The increase in Adult Day Health Services would assure consistency with the rates for the same service in the state funded rule, Section 61, Adult Day Health Services and Section 26, Day Health Services, of the MaineCare Benefits Manual. Costs for Adult Day Health will no longer be counted towards the monthly program cap. In addition, because the Department is proposing to increase reimbursement for services in Chapter III of Section 19, it also seeks to increase the monthly program cap for MaineCare members, so that they are not adversely affected by the reimbursement changes. As such, these proposed rule changes in Chapter II Section 19 increase the limitation in Sec. 19.06(A) from $4,200 per member per month to $4,603 per member per month. Given that the budget was effective on July 1, 2015, the Department proposes to make these changes retroactive to July 1, 2015. The Department has authority for the retroactive effective date under 22 M.R.S.A. §42(8), because these changes increase reimbursement for providers, ensuring that members have access to medically necessary covered services, and otherwise have no adverse impact on either MaineCare providers or members. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: December 10, 2015 Posted: November 6, 2015
 
MaineCare Benefits Manual, Chapters II & III, Section 17, Community Support Services WORD  PDF  | COMMENTS
Concise Summary: This letter gives notice of a proposed rule change to MaineCare Benefits Manual (MBM), Chapters II & III, Section 17, Community Support Services. This proposed rule change seeks to implement the following: 1. New Definitions include Clinician, LOCUS Certified Assessor and Natural Supports. Authorized Agent has been changed to Authorized Entity. Class Member has been removed from the list of Definitions. 2. Eligibility Criteria has been updated to include DSM 5 qualifying diagnoses and to reflect eligible acuity to access benefits. Community Integration Services providers must verify that a member meets specific Eligibility Requirements under 17.02-3 within thirty (30) days of the start date of services. 3. Timeliness and Duration of Care includes a requirement that Community Integration Services providers must conduct an initial face-to-face intake or assessment visit within seven (7) calendar days of referral. 4. Covered Services includes various updates throughout 17.04, including the removal of Intensive Case Management. 5. Limitations, Concurrent Provision of Services has been updated to reflect the removal of Intensive Case Management and identifies Section 92, Behavioral Health Home, and Section 13, Targeted Case Management as services that may not be provided concurrently with Community Integration Services. 6. Professional and Qualified Staff includes “under the direct supervision of a psychiatrist” for registered nurses and physician assistants. Forty hour approved course language has been added to CRMA for the administration and supervision of medication. 7. Chapter III reflects the removal of Intensive Case Management Services, procedure code H0023 and obsolete procedure code CBB10, for Assertive Community Treatment, which expired on 8/31/10 prior to the implementation of the Maine Integrated Health Management System (MIHMS). See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents
Submit Comments (Opens in new window) - Comment Deadline: December 11, 2015 Posted: November 6, 2015
 
MaineCare Benefits Manual, Chapters II and III, Section 96, Private Duty Nursing and Personal Care Services WORD  PDF   
Concise Summary: This rulemaking increases reimbursement rates for Personal Support Services (PSS) provided under 10-144, Chapter 101, MaineCare Benefits Manual, Chapters II and III, Section 96, Private Duty Nursing and Personal Care Services. This rulemaking follows the enactment of the State’s biennial budget, which among other MaineCare rate increases, increased the rates for PSS, effective July 1, 2015. P.L. 2015, ch. 267, Part A, Sec. A-32. To avoid a reduction in services available to members as a result of the increase in PSS reimbursement rates, this rule proposal includes a proportional increase in the monthly cost caps for each affected member’s levels of care. The Department is proposing to adopt the Section 96 rate increases on a retroactive basis pursuant to 22 M.R.S.A. § 42(8). Pending this routine rulemaking process, the Department has also adopted an emergency rule in order to implement the rate increases. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: November 23, 2015 Time: 1:00PM Location: Room 600, Cross Office Building, 111 Sewall Street, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before 5:00 PM, on Monday, November 16, 2015.
Submit Comments (Opens in new window) - Comment Deadline: December 3, 2015 Posted: October 28, 2015
 
MaineCare Benefits Manual, Chapters II and III, Section 96, Private Duty Nursing and Personal Care Services WORD  PDF   
Concise Summary: This rulemaking increases reimbursement rates for Personal Support Services (PSS) provided under 10-144, Chapter 101, MaineCare Benefits Manual, Chapters II and III, Section 96, Private Duty Nursing and Personal Care Services. This rulemaking follows the enactment of the State’s biennial budget, which among other MaineCare rate increases, increased the rates for PSS, effective July 1, 2015. P.L. 2015, ch. 267, Part A, Sec. A-32. To avoid a reduction in services available to members as a result of the increase in PSS reimbursement rates, this rule proposal includes a proportional increase in the monthly cost caps for each affected member’s levels of care. The Department is proposing to adopt the Section 96 rate increases on a retroactive basis pursuant to 22 M.R.S.A. § 42(8). Pending this routine rulemaking process, the Department has also adopted an emergency rule in order to implement the rate increases. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: November 23, 2015 Time: 1:00PM Location: Room 600, Cross Office Building, 111 Sewall Street, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before 5:00 PM, on Monday, November 16, 2015.
Submit Comments (Opens in new window) - Comment Deadline: December 3, 2015 Posted: October 28, 2015
 
MaineCare Benefits Manual, Chapter III, Section 2, Adult Family Care Services WORD  PDF   
Concise Summary: This proposed rule increases by 4% the reimbursement rates for Adult Family Care Services at residential care facilities provided under MaineCare Benefits Manual, Chapter III, Section 2. This rule proposal follows the enactment of the State’s biennial budget, which among other rate increases, increased the rates for Section 2 services, effective July 1, 2015. P.L. 2015, ch. 267, 702 – L.D. 1019, Part A, Sec. A-32, and Part UUUU, Sec. UUUU-1. The Department is proposing to adopt the Section 2 rate increases on a retroactive basis pursuant to 22 M.R.S.A. § 42(8). Pending this routine rulemaking process, the Department has also adopted an emergency rule in order to implement the rate increases. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: November 26, 2015 Posted: October 22, 2015
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services WORD  PDF   
Concise Summary: In compliance with the State’s biennial budget, this rulemaking reduces reimbursement for non-emergent use of the Emergency Department (“ED”). This reimbursement reduction applies to in-state Acute Care Non-Critical Access Hospitals only. The rule change reduces reimbursement of nonemergency use of the ED to the rate of a comparable visit delivered in a private physician office for a non-facility based provider. Non-emergent use of the ED will be identified by the primary diagnosis, as indicated by the ICD-10 codes listed in MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services, Appendix B. The Department published a notice of change in reimbursement methodology for hospital services, pursuant to 42 C.F.R. §447.205, on September 14, 2015. On October 1, 2015, pursuant to 5 M.R.S.A. § 8054, and the authority provided in the biennial budget (P.L. 2015, ch. 267, Part UU), the Department implemented these changes on an emergency basis. The Department shall submit its requested changes for the State Plan Amendment to the Centers for Medicare and Medicaid Services on or before December 31, 2015, with a requested effective date of October 1, 2015. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: November 12, 2015 Posted: October 7, 2015
 
MaineCare Benefits Manual, Section 55, Chapter II, Laboratory Services WORD  PDF   
Concise Summary: These changes are being proposed in order to align the language in Section 55 with the language of the Department’s State Plan Amendment (SPA). In particular, the proposed changes increase the reimbursement rate from fifty-three percent (53%) of the lowest level in the current Medicare fee schedule for Maine in effect at that time, to seventy percent (70%) of the 2009 CMS rate or seventy percent (70%) of the rate in the year CMS assigns a rate for that code. The Department shall seek approval from CMS for an amendment to its SPA to reflect that the provider’s usual and customary charge is one of the several benchmarks utilized by the Department to determine reimbursement for laboratory services. In addition, the Department proposes to update several provisions, including Sections 55.04-1, 55.04-2, 55.07, and 55.09, to add a reference to the Division of Audit Rate Setting Fee Schedule and to remove outdated references. The Department also proposes updating 55.02 to reflect current eligibility provisions to be consistent with other policies and current practice. It additionally proposes to update the language in various other provisions, including Sections 55.05-3, 55.05-6, and 55.08-2, to make it consistent with current terminology. It further proposes to eliminate language referencing usage of the diagnosis code “EMR” in Section 55.09 to align with current Medicaid billing practices. Finally, the Department proposes to remove Section 55.08-3 (Copayment Disputes), given that those requirements are set forth in Chapter I, Section 1 of the MaineCare Benefits Manual. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: September 22, 2015 Time: 1:00 PM Location: Room 110, 19 Union Street, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before September 14, 2015.
Submit Comments (Opens in new window) - Comment Deadline: October 2, 2015 Posted: September 1, 2015
 
MaineCare Benefits Manual, Chapter III, Section 32, Allowances for Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders WORD  PDF   
Concise Summary: The Department is proposing to repeal Chapter III, Section 32 in conjunction with the proposed repeal of Chapter II, Section 32. Chapter III, Section 32 is a major substantive rule. Chapter II, Section 32 is a routine technical rule. The Department is proposing to repeal these two rules which – since their July 1, 2011, implementation – have existed without any member enrollment. This means that no members have ever received services under Chapter II, Section 32. And no providers have ever been reimbursed for services under Chapter III, Section 32. The Department originally promulgated the Chapter II and Chapter III rules after the Centers for Medicare and Medicaid Services (CMS) approved a Section 1915(c) Home and Community-Based Services waiver for children with Intellectual Disabilities and/or Pervasive Developmental Disorders who would otherwise require an institutionalized level of care. The waiver has been terminated with CMS effective March 27, 2015. Through CMS guidance, the Department determined not to renew the waiver as all waiver services are currently being offered to this population elsewhere. With the expired waiver, the Department is no longer authorized to operate this program. No members and no providers will be affected by the repeals of Chapters II and III, Section 32. Children who would have been eligible for these waiver services have already been receiving – and will continue to receive – these services through other sections of the Medicaid State Plan, through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and through state-funded programs at the Office of Child and Family Services. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: September 23, 2015 Time: 9:00 AM Location: 19 Union Street, Augusta ME, Room 110 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before September 11, 2015.
Submit Comments (Opens in new window) - Comment Deadline: October 3, 2015 Posted: August 26, 2015
 
MaineCare Benefits Manual, Chapter II, Section 32, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders WORD  PDF   
Concise Summary: The Department is proposing to repeal this rule which, since its July 1, 2011, implementation – has existed without any member enrollment. This means no members have ever received services under Section 32. The Department originally promulgated the rule after receiving approval from the Centers for Medicare and Medicaid Services (CMS) to operate a Section 1915(c) Home and Community-Based Services waiver for children with Intellectual Disabilities and/or Pervasive Developmental Disorders. The waiver has since expired and, through CMS guidance, the Department determined not to renew the waiver as all waiver services are currently being offered to this population elsewhere. With the expired waiver, the Department is no longer authorized to operate this program. No members will be affected by the repeal of Chapter II, Section 32. Children who would have been eligible for these waiver services already receive and will continue to receive these services through other sections of the Medicaid State Plan, through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and through state-funded programs at the Office of Child and Family Services. The Department is concurrently proposing to repeal Chapter III, Section 32, on the same basis. Chapter II, Section 32 is a routine technical rule. Chapter III, Section 32 is a major substantive rule and requires authorization from the legislature. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: September 23, 2015 Time: 9:00 AM Location: 19 Union Street, Augusta ME, Room 110 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before September 11, 2015.
Submit Comments (Opens in new window) - Comment Deadline: October 3, 2015 Posted: August 26, 2015
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services WORD  PDF   
Concise Summary: This proposed rulemaking seeks to delete the Wholesale Acquisition Cost (WAC) from the reimbursement rate options. Furthermore, in order to be consistent with state statute 22 M.R.S. § 3174-WW, the no co-payment requirement for smoking cessation products has been added to the pharmacy benefits retroactive to August 1, 2014, for members eighteen (18) years of age or older or who are pregnant. In addition, some terms have been replaced with nationally recognized language that is considered more respectful of the individual. The term ICF-MR (Intermediate Care Facility for Persons with Mental Retardation) has been changed to ICF-IID (Intermediate Care Facility for Individuals with Intellectual Disabilities). See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: September 15, 2015 Time: 10:00 A.M. Location: Department of Health and Human Services 242 State Street, Conference Room 1 Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before September 8, 2015.
Submit Comments (Opens in new window) - Comment Deadline: September 25, 2015 Posted: August 24, 2015
 
MaineCare Benefits Manual, Chapters II & III, Section 67, Nursing Facility (NF) Services WORD  PDF   
Concise Summary: This proposed rulemaking would: (1) provide a new methodology for calculating recapture of depreciation upon the sale of a nursing facility, and (2) add reimbursement for Ventilator Care Services as a separately reimbursable service (i.e., above and beyond the daily NF rate). The purpose of providing a new methodology for calculating recapture of depreciation upon the sale of a nursing facility is to comply with Public Law 2014, Chapter 582. The purpose of adding reimbursement for Ventilator Care Services as a separately reimbursable service is to ensure that nursing facilities may be reimbursed for members that need Ventilator Care Services. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. DATE AND PLACE OF PUBLIC HEARING: Date: May 4, 2015 Time: 10:00 am Location: 19 Union St., Rm. 110, Augusta, Maine 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed above before April 27, 2015.
Submit Comments (Opens in new window) - Comment Deadline: May 14, 2015 Posted: April 9, 2015
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services WORD  PDF   
Concise Summary: This proposed rulemaking seeks to increase the time span from 72 hours to 14 days for which hospital readmissions for the same condition are not reimbursed by MaineCare. It also reduces the supplemental pool for Non-Critical Hospitals Reclassified to a Wage Area Outside Maine and Rehabilitation Hospitals from $65,321,301 to $64,769,417. The hospital readmission change is being proposed as a recommendation of the MaineCare Redesign Task Force, established pursuant to PL 2011, Ch. 657, Part T, “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.” See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: March 30, 2015 Time: 2:00 P.M. Location: Department of Health and Human Services 19 Union St., Rm. 110 Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before March 23, 2015.
Submit Comments (Opens in new window) - Comment Deadline: April 9, 2015 Posted: March 4, 2015
 
MaineCare Benefits Manual, Section 26, Chapter III, Day Health Services WORD  PDF   
Concise Summary: This rule is being proposed to provide financial stability to Day Health Service providers. The rule is being proposed to be retroactive to November 1, 2014. These changes are subject to CMS approval. THIS RULE WILL __ WILL NOT X HAVE A FISCAL IMPACT ON MUNICIPALITIES. STATUTORY AUTHORITY: 22 MRSA §§ 42, 3173 DATE AND PLACE OF PUBLIC HEARING: Date: February 9, 2015 10:00 AM Location: Room 300, Cross Office Building 111 Sewell Street Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed above before 5PM, February 1, 2015.
Submit Comments (Opens in new window) - Comment Deadline: February 19, 2015 Posted: January 13, 2015
 
MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment WORD  PDF   
Concise Summary: The Department proposes to amend several sections of Chapter 101, MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment (DME). The changes proposed in this rule will maintain or increase the level of services available to members. The proposed changes will be amended as follows: 1. Removal of references to the term “mentally retarded” or “MR”; 2. Replacement of the term “Authorized Agent’ with the term “Authorized Entity”; 3. Addition of definitions of the following: a. Aesthetic or DME b. Hearing Aids c. Prior Authorization (PA) 4. Adding coverage criteria for hearing aids; 5. Adding coverage criteria for Continuous Glucose Monitor; 6. The word “front” has been added to Section 60.01-12 (C) in order to be consistent with other language/requirements throughout the rule; 7. Update to Limitations; Incontinence Supplies: Disposable personal pads to include size and quantity; 8. Update to Limitations for members of all ages to include: hearing aids eligibility and supplies; 9. Update to the Appendix I- Medical Criteria: to include Hearing Aids and Continuous Glucose Monitors; 10. Language updates to Policies and Procedures; Replacement of DME: Hearing Aid criteria and Combining and providing language examples related to Medical Supplies and DME, Not Covered for members in a Nursing Facility (NF) or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID), Section 60.05-13; 11. Adding hearing aids as a DME covered service for members residing in a NF or ICF-IID under Section 60.05-12; 12. Increase of the limits for orthopedic modifications and inserts with Healthcare Common Procedure Coding System (HCPCS) Level II codes as Medical Supplies (i.e. diabetic shoes, fittings and modifications), as identified in Section 60.07-1(A) to allow combined total of six units per year; 13. The Department proposes the following technical changes to include: a. To be consistent with Section 1.03-2 provides that MaineCare will not provide payment to any entity outside the United States, the following language will be removed from the policy: “or within five (5) miles of the Maine border in Canada”. This is required by Section 6505 of the Patient Protection and Affordable Care Act, P.L. 111-148 (March 23, 2010); b. Added the word ‘physician’s” written order to Face-to-Face Encounter Section 65.05 to clarify the face-to-face requirement for Durable Medical Equipment within the six (6) month time period; c. Updates to website address locations; 14. The Department is also proposing to repeal Chapter II and III, Section 35, Hearing Aids and Services in a separate rulemaking. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. DATE AND PLACE OF PUBLIC HEARINGS: Subject: Chapter II, Section 60, Medical Supplies and Durable Medical Equipment Date: February 2, 2015 Time: 8:30 – 10:30 a.m. Location: Department of Health and Human Services Conference Room #110 19 Union St. Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before Tuesday, January 20, 2015.
Submit Comments (Opens in new window) - Comment Deadline: February 12, 2015 Posted: January 2, 2015
 
MaineCare Benefits Manual, Chapters II & III, Section 35, Hearing Aids and Services WORD     
Concise Summary: The Department is proposing to repeal MaineCare Benefits Manual, Chapters II & III, Section 35, Hearing Aids and Services. The services covered under this section will be transitioned to Chapter II, Section 60, Medical Services and Durable Medical Equipment. In addition, all reimbursement requirements will be set forth per the fee schedule found at the following website: http://www.maine.gov/dhhs/audit/rate-setting/documents/S60MedSuppandDME_002.pdf THIS RULE WILL NOT HAVE A FISCAL IMPACT ON MUNICIPALITIES. Cost Neutral STATUTORY AUTHORITY: 22 MRSA §§ 42, 3173 DATE AND PLACE OF PUBLIC HEARING: Date: February 2, 2015 Time: 10:30-11:30 a.m. Location: Large Conference Room # 110 Department of Health and Human Services 19 Union Street Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before Tuesday, January 20, 2015.
Submit Comments (Opens in new window) - Comment Deadline: February 12, 2015 Posted: January 2, 2015
 
MaineCare Benefits Manual, Chapters II and III, Section 5, Ambulance Services WORD  PDF   
Concise Summary: The Department is seeking to make several changes in this rulemaking. The proposed changes are as follows: 1. In Chapter II, remove two references to a telephone number provided for out-of-state providers to request prior authorization. This number is no longer in service. Instead of calling the number, providers are instructed to obtain Prior Authorization (PA) through the MaineCare portal. 2. In Chapter III, change reimbursement rates for Medicare reimbursable ambulance codes to 65% of Medicare rates. This change is being proposed pursuant to the directive in LD 1274, Public Law Ch. 441, 22 MRSA §3174-JJ, Sec. 1. 3. In Chapter III, remove a clarifying sentence from HCPCS code A0998 “Ambulance Response and Treatment, No Transport.” The sentence states, “Patient is treated but refuses transport or is deceased and therefore requires no transport.” This clarifier does not appear in the HCPCS manual and should be removed. SEE http://www.maine.gov/dhhs/oms/rules/provider_rules_policies.html for rules and related rulemaking documents. THIS RULE WILL NOT HAVE A FISCAL IMPACT ON MUNICIPALITIES. STATUTORY AUTHORITY: 22 MRSA §§ 42, 3173; LD 1274, Public Law Ch. 441, 22 MRSA §3174-JJ, Sec. 1 PUBLIC HEARING: Date: January 21, 2015, 12:00 PM Location: Conference Room 110 Department of Health and Human Services 19 Union Street Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed above before 5 pm on January 14, 2015.
Submit Comments (Opens in new window) - Comment Deadline: January 31, 2015 Posted: December 30, 2014
 
MaineCare Benefits Manual, Chapter II & III, Section 65, Behavioral Health Services WORD  PDF   
Concise Summary: These proposed rule changes seek to add tobacco cessation treatment as a covered service. These changes are being proposed in order to comply with LD 386, An Act to Reduce Tobacco-related Illness and Lower Health Care Costs in MaineCare (22 MRSA §3174-WW), which requires MaineCare to provide comprehensive tobacco cessation treatment to all MaineCare members over the age of eighteen and those who are pregnant. The proposed rule changes add comprehensive tobacco cessation treatment including counseling and products as a covered service for all members, regardless of age, who wish to cease the use of tobacco. Tobacco cessation products are “Covered Drugs,” reimbursable pursuant to Ch. II, Section 80.05 of the MBM. As Covered Drugs, tobacco cessation products are included on the Department’s Preferred Drug List (PDL), as set forth in Ch. II, Section 80.07-5. The PDL may be accessed via the Department’s website. There are no annual or lifetime dollar limits on tobacco cessation treatment, nor are there any limits on attempts to quit. Members may not be charged a co-pay for tobacco cessation products, and they may not be required to participate in counseling to receive medications. The following four Current Procedural Terminology (CPT) codes are proposed to be added to Ch. III, Section 65: 99406 (smoking and tobacco use cessation counseling; individual, greater than 3 minutes up to 10 minutes), 99407 (smoking and tobacco use cessation counseling; individual, greater than 10 minutes), 99411 (preventive medicine, group counseling; 30 minutes) and 99412 (preventive medicine, group counseling; 60 minutes). If the Centers for Medicare and Medicaid Services (CMS) approve the Department’s State Plan Amendment, and pursuant to 22 M.R.S.A. § 42(8), these proposed changes to Section 65 will be effective retroactively to August 1, 2014. Three additional technical changes are also included in this proposed rulemaking: 1. Update of language referencing the former Children’s Behavioral Health Services (CBHS) and Office of Adult Mental Health Services (OAMHS) to the current Office of Child and Family Services (OCFS) and Office of Substance Abuse and Mental Health Services (SAMHS), to reflect current Departmental structure; 2. Replacement of the term “Authorized Agent” to “Authorized Entity” and, 3. In Ch. III, a change to the rate listed for CPT code H2012 with HN UQ TL and HN UQ TM modifiers from $16.65 to $14.65. The additional proposed technical changes are intended to keep policy language updated and reflect correct rate allowances. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: Monday, December 1, 2014 Time: 10:00 AM Location: Room 302, Cross Office Building 111 Sewall Street Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before 5:00 PM, on Monday, November 24, 2014.
Submit Comments (Opens in new window) - Comment Deadline: December 11, 2014 Posted: November 7, 2014
 
MaineCare Benefits Manual, Chapter II, Section 15, Chiropractic Services WORD  PDF   
Concise Summary: The Department is proposing to change the limit calculation methodology from “rolling year” to a calendar year, for purposes of clarity. This rule also proposes to remove the current hard cap of 12 visits per year and allow for additional visits when medically necessary. The Department proposes to impose a prior authorization requirement for additional visits for members over the age of twenty-one (21). In addition, the proposed changes clarify the types of medical providers that are required to be involved in determining a member’s eligibility for Chiropractic Services. If approved by the Centers for Medicare and Medicaid (CMS), x-ray services that are medically necessary for diagnosis and treatment of a subluxation shall be a covered service in Section 15. This rulemaking proposes language that explains the reimbursement for chiropractic x-rays. X-ray services provided through this section do not require prior authorization. Finally, the Department proposes to make a number of technical changes in an effort to provide clarity and eliminate duplicative language. These proposed changes include the elimination of Sec. 15.04 “Specific Eligibility for Care”; elimination of the reference to the Division of Program Integrity (Sec. 15.08); and elimination of other unnecessary language regarding reimbursement, co-pays, and dispute resolution. SEE: http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. THIS RULE WILL NOT HAVE A FISCAL IMPACT ON MUNICIPALITIES. STATUTORY AUTHORITY: 22 MRSA §§ 42, 3173 DATE AND PLACE OF PUBLIC HEARING: Date: December 1, 2014 Time: 8:30 a.m. Location: Large Conference Room # 110 Department of Health and Human Services 19 Union Street Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before Monday, November 17, 2014.
Submit Comments (Opens in new window) - Comment Deadline: December 11, 2014 Posted: November 6, 2014
 
MaineCare Benefits Manual, Chapter II, Section 113, Non-Emergency Transportation (NET) Services WORD  PDF   
Concise Summary: In August of 2013, MaineCare began delivering NET services using regional, risk-based, pre-paid ambulatory health plan brokerages, in alignment with Maine’s eight (8) transit regions, pursuant to a §1915(b) waiver that was approved by the Centers for Medicare and Medicaid (CMS). NET Brokers were selected through a competitive procurement process, following the Department’s Request for Proposals (RFP). During the first year of implementation, significant problems were experienced in several NET regions. As a result, the Department decided to re-issue the RFP for NET services in six of the eight regions. In two regions, the original NET brokers’ contracts were renewed. For the other six regions, the Department selected new NET brokers, based on the bids they submitted in response to the RFP. On July 7, 2014, CMS approved the Department’s request to renew its NET waiver for a two year period, beginning July 1, 2014 and ending on June 30, 2016. The Department negotiated new contracts with its NET brokers, effective August 1, 2014, and these contracts include several important changes. As a result, MaineCare’s NET policy must be changed to conform to the NET waiver and the contracts. Proposed changes include: 1. The allowance of trips to the pharmacy with no other trips involved. Previously, trips exclusively to visit a pharmacy were excluded from coverage under this policy. In addition, trips to the pharmacy will now be allowed on an urgent basis. 2. Edit of the map of NET regions to reflect a slight change in the geographic distribution of one region. Unity Township, Troy and Burnham were previously incorrectly depicted as being part of Region 4, though they are actually in Region 5. This has been corrected in the updated map, which also more clearly delineates all eight regions. 3. Addition of requirement that parents or guardians of minors 12 years old and younger must authorize the specific type of transportation utilized for the minor. 4. Addition of language requiring prior authorization for out-of-state NET trips. 5. Addition of language requiring, for members with Other Related Conditions receiving Home and Community Based Services (HCBS) under Section 20 of the MaineCare Benefits Manual, or for members with Brain Injury receiving Home and Community Benefits under Section 18 of the MaineCare Benefits Manual, that the broker contact the member’s assigned care coordinator to confirm that the service or activity to which the member is requesting transportation is a covered HCBS waiver service under the member’s plan of care. Additional changes are proposed that are not new, but have been made to clarify the current requirements of the NET program, which include: 1. Clarification of the types of Non-Emergency Transportation and covered services for which MaineCare will provide reimbursement. 2. Addition of language detailing the procedures utilized in the transport of minors. 3. Clarification regarding the types of non-covered services. 4. Addition of detailed language limiting broker self-referral for NET services. 5. Addition of language requiring the broker to provide timely access to NET services. The proposed language requires the broker to make services available to members 24 hours a day, 7 days a week and to contact the member in the event that a trip cannot be made. The language also requires members to be at the point of pickup within 10 minutes of the scheduled time. 6. Addition of language regarding certain requirements of brokers. Brokers are required to have NET contracts in place with the Department, to establish a reliable network of transporters, to ensure adequate transportation at all times, and to notify the Department in the event of the termination of a transporter’s Service Agreement. 7. Clarification of the policy around urgent trips and description of the circumstances in which an urgent trip must be granted. 8. Addition of language describing the requirements for standing orders and stating that a standing order for a member must be re-affirmed by the member’s broker at least once every 90 days 9. Addition of language pertaining to federally recognized Native Tribes. Proposed language states that Broker(s) are required to enter into a Service Agreement with any federally recognized Native Tribe that resides within the broker’s region, that would like to be a Transporter, and that meets the driver and vehicle requirements and all other applicable requirements. 10. Addition of description of requirements for drivers and attendants. 11. Addition of language briefly stating that brokers are responsible for related travel expenses. 12. Addition of language around denial of services and member complaint and appeal rights. 13. Addition of language describing confidentiality and privacy expectations. Proposed language outlines what is expected of brokers regarding member confidentiality. 14. Addition of language describing the broker’s requirements to provide wheelchair accessible transportation to members. Finally, the Department proposes several changes to Section 113 to ensure consistency with the NET broker contracts, as well as other technical changes: 1. Addition and removal of a number of definitions to provide greater clarification to the policy and to match language in the Department’s contracts with brokers. 2. Change of references from the term “mental retardation” to the term “intellectual disability.” This change is required by both state and federal law, to eliminate use of the term “mental retardation.” 3. Removal of reimbursement rates for lodging, meals, and privately owned vehicle mileage. It is proposed that this language be removed to allow for changes to be made efficiently and easily, via contract amendment. 4. Grammatical and technical edits were made to improve the readability of the policy. SEE http://www.maine.gov/dhhs/oms/rules/provider_rules_policies.html for rules and related rulemaking documents. THIS RULE WILL NOT HAVE A FISCAL IMPACT ON MUNICIPALITIES. STATUTORY AUTHORITY: 22 M.R.S.A. §§ 42, 3173; Social Security Act § 1915(b), 42 U.S.C. 1396n; Rosa’s Law, Pub. L. 111-256; P.L. 2012, ch. 542, § B(5). PUBLIC HEARING: Date: Friday, November 21, 2014, 10 AM Location: Conference Room 110 Department of Health and Human Services MaineCare Services 19 Union Street Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before 5 pm on Friday, November 14, 2014.
Submit Comments (Opens in new window) - Comment Deadline: December 1, 2014 Posted: October 28, 2014
 
MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities WORD  PDF   
Concise Summary: On August 15, 2014, the Department adopted an emergency rule, which increased MaineCare nursing facility reimbursement, as required by P.L. 2014, ch. 594 (“An Act to Implement the Recommendations of the Commission to Study Long-term Care Facilities”). The August 15, 2014 Emergency Rule had a retroactive application date of July 1, 2014 for the changes. This proposed rule seeks to make permanent those changes to nursing facility reimbursement made in the August 15, 2014 emergency rule. The August 15, 2014, Emergency rule had an effective application date for the rule changes of July 1, 2014. This proposed rule also uses the same effective application date for the changes of July 1, 2014. This rule proposes to make the following changes: 1. Establishes a new base year for nursing facilities which is the fiscal year of each nursing facility ending in calendar year 2011. The base year will be updated every two years. 2. For the routine care cost and for direct care cost, the peer group upper limit will be increased to 110% of the median. 3. Eliminates the Administration and Management Expense ceiling, although those costs are still subject to allowability standards. 4. Establishes a payment to nursing facilities that have a high MaineCare utilization rate (defined as greater than 70% MaineCare days of care). This payment is cost settled. 5. Changes the methodology for calculating each nursing facility’s specific case mix index for the base year to the following: (1) the Department calculates the nursing facility’s 2011 average direct care case mix adjusted rate by dividing each nursing facility’s gross direct care payments received for their 2011 base year by the 2011 base year MaineCare direct care resident days; (2) the Department calculates the nursing facility’s 2011 case mix index by dividing the nursing facility’s 2011 average direct care case mix adjusted rate as calculated in (1) by the nursing facility’s 2005 base year direct care rate. 6. Eliminates the 2009 CMS Nursing Home without Capital Market Basket Index for inflation adjustments, and substitutes : (a) the United States Department of Labor, Bureau of Labor Statistics, Consumer Price Index for Medical Care Services – Nursing Homes and Adult Day Care Services to adjust for inflation for the Routine Cost Component; and (b) the United States Department of Labor, Bureau of Labor Statistics, Consumer Price Index, Historical Consumer Price Index for Urban Wage Earners and Clerical Workers – Nursing Home and Adult Day service for the Direct care Component. 7. Adds a provision that the inflation adjustments will be done every year. 8. Amends the Direct Care Add-on Principle so that December 31, 2013, rather than July 1, 2008, is used for the inflation calculation, and the facility-specific average case mix index for the base year is used as the applicable case mix index for this calculation. 9. Amends of the Direct Care Hold Harmless Provision so that the differential which will be applied is the difference between each nursing facility’s direct care rate for the first fiscal year to which the July 1, 2014 amendments to the rule apply, and the nursing facility’s direct care rate in effect on April 1, 2014. 10. Amends the Routine Hold Harmless Provision so that the differential which will be applied is the difference between each nursing facility’s routine rate for the first fiscal year to which the July 1, 2014 amendments to the rule apply, and the nursing facility’s routine rate in effect on April 1, 2014. 11. Changes of the heading for Principle 81 from “Interim and Subsequent Rates” to “Interim, Subsequent, and Prospective Rates” because Principle 81 was amended to add a provision defining Prospective Rate. 12. Adds Principle 81.3 (Prospective Rate), which provides that the prospective rate, excluding fixed costs, will be calculated to be 95.12% of all the calculated Direct Care cost components and all of the Routine Care cost components. Principle 82, the Final Prospective Rate, is also defined as being no more than 95.12%. 13. Adds Principle 81.4 (Funding Adjustment), which provides that in the case of an individual nursing facility, whose rebased, adjusted direct and routine care rates totaled together are less than that nursing facility’s April 1, 2014, direct and routine rates, totaled together, then the Department will make a Funding Adjustment, by adding the difference to the rebased routine rate. This language has been changed between the adoption of the emergency rule and the proposed rule in order to clarify the process used to set the rate by breaking down the steps used to calculate the rate and setting when the Funding Adjustment will be used. 14. Adds Principle 83 (August 15, 2014 Emergency Rule), to provide that for the retroactive application period of July 1, 2014 through August 15, 2015, the reimbursement to nursing facilities must be equal to or greater than the reimbursement that they had received under the rules previously in effect. P.L. 2014, ch. 594’s requirement that the rule be amended to increase the specific resident classification group case mix weight that is attributable to a nursing home resident who is diagnosed with dementia is not directly applicable to the case mix methodology which is set forth in the rule, which is function or level-of-service based, and not based on diagnosis. The rule’s case mix methodology already provides that a dementia patient whose condition worsens, and needs a higher level of care, is put in a case mix with a greater weight. The Department carefully reviewed this issue, but is not proposing to make any changes for this rulemaking. CMS approval is needed for these changes, and the Department is seeking to amend its State Plan accordingly. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: October 6, 2014 Time: 9:00 AM Location: 400 Cross Office Building 111 Sewell St, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before close of business on Monday, September 29, 2014.
Submit Comments (Opens in new window) - Comment Deadline: October 16, 2014 Posted: September 16, 2014
 
MaineCare Benefits Manual, Chapter II, Section 14, Advanced Practice Registered Nursing Services WORD  PDF   
Concise Summary: The purpose of this rulemaking is to clarify the amount of reimbursement for Advanced Practice Registered Nurses (APRNs). The policy currently states that MaineCare will reimburse APRNs providing psychological or psychiatric services at 60% of the amount reimbursed for physicians’ services, leaving the policy inconsistent with both practice and Maine’s State Plan. The proposed rule seeks to change that rate to the amount reimbursed for physicians’ services as set forth in Section 90, Physician Services. The rule change is being made retroactive to January 1, 2013. This rulemaking also makes technical changes. In addition, if the Centers for Medicare and Medicaid Services (CMS) approves, the rule proposes to reimburse Certified Registered Nurse Anesthetists (CRNAs) at 75% of the amounts of reimbursement for services as set forth in Section 90. This is the reimbursement rate that MaineCare has been paying CRNAs. The Department shall submit proposed State Plan changes to CMS to reflect these clarifications. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. PUBLIC HEARING: Date: Monday, September 22, 2014 Time: 9:00 A.M. Location: Room DHHS-2, DHHS Building, 221 State Street, Augusta, ME The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed above before September 15, 2014.
Submit Comments (Opens in new window) - Comment Deadline: October 3, 2014 Posted: August 26, 2014
 
MaineCare Benefits Manual, Chapter II, Section 103, Rural Health Clinic Services WORD  PDF   
Concise Summary: To comply with Public Law 2014, Chapter 444 (An Act to Reduce Tobacco-Related Illness and Lower Health Care Costs in MaineCare), effective 8/1/14, this proposed rulemaking will eliminate the existing limit of three tobacco counseling visits per year and specifies that there is no co-pay for such counseling. Also, given the upcoming conversion from the ICD-9 to ICD-10, the rule replaces references to the ICD-9 with language that will not need to be revised for future conversions. DATE AND PLACE OF PUBLIC HEARING: 9:00 am, August 26, 2014; 242 State St, Conference Room 1, Augusta, ME 04333
Submit Comments (Opens in new window) - Comment Deadline: September 5, 2014 Posted: July 31, 2014
 
MaineCare Benefits Manual, Chapter I, Section 2, State Medicaid Health Information Technology (HIT) Program WORD  PDF   
Concise Summary: Chapter I, Section 2 regulates the State HIT Electronic Health Record (EHR) Incentive Payment Program. These changes are being made to fully comply with 42 C.F.R. §§ 495.300-370. The proposed changes include clarifications about which entities are deemed as having a “fully implemented” EHR. The Department’s role in conducting pre-payment reviews and post-payment audits is also clarified. Specifically, the Department or its agent conduct pre-payment reviews on all participants and may conduct post-payment audits of hospitals that participate exclusively in the Medicaid incentive payment program. Finally, a number of technical formatting edits have been made. PUBLIC HEARING: Date: Tuesday, August 19, 10:00 AM Location: Conference Room 1 Department of Health and Human Services MaineCare Services 242 State Street Augusta, ME 04330 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before 5 pm on August 12, 2014.
Submit Comments (Opens in new window) - Comment Deadline: August 29, 2014 Posted: July 30, 2014
 
MaineCare Benefits Manual, Section 19, Ch. II & III, Home and Community Benefits for the Elderly and for Adults with Disabilities WORD Chapter II  PDF  | WORD Chapter III
Concise Summary: This rule is being proposed in order to comply with Resolve 2011, ch 71. This rule blends services from Sections 19 and Section 22, Home and Community Benefits for the Physically Disabled and is being proposed simultaneously with the repeal of Section 22.These changes are subject to CMS approval, and a waiver amendment was submitted March 14, 2014. The changes proposed in this rule will maintain or increase the level of services available to members, specifically: • The Department is proposing to remove Homemaker Services as a stand-alone service; members will receive instrumental activities of daily living as part of Personal Care or Attendant Services instead. • Assistive Technology, Assistive Technology-Remote Monitoring and Assistive Technology-Transmission are being proposed to be added as new services and are included under the program cap. • The Department is proposing to make changes to the terminology, definitions and requirements for “Self-Direction” and “Family Provider Services Option” (FPSO). These terms are being proposed to be eliminated and replaced with the term “Participant Directed Option.” • The term “Supports Brokerage” is being proposed to be removed and the term “Care Coordination” will be used exclusively. • The requirement for individual managing services under the FPSO to register as an agency with the Division of Licensing and Regulatory Services is being proposed to be eliminated, and the requirements for a Representative under this service delivery option have changed. • The term “Attendant” is being proposed to be added to define the worker providing services for members using the Participant Directed Option and qualifications have been clarified for Attendants. • The Department is proposing to modify eligibility and termination reasons that relate solely to the Participant Directed Option. • Qualifications for Skills Training are being proposed to be added. • Provider requirements for out-of-state services are being proposed to be clarified. • The Department is clarifying the number of hours weekly an individual worker may provide to an individual member or household. • The Department is proposing to standardize requirements regarding face-to-face visits from the Service Coordination Agency. • The Department is proposing to clarify qualifications for Care Coordination staff. • The Department is proposing to change certain definitions. • The Department is proposing to clarify the components of the Attendant rate and Financial Management Service. • The Department is proposing to clarify the responsibilities of the Financial Management Service regarding background checks and Office of Inspector General checks. • The Department is proposing to allow certain individuals who meet specific eligibility to exceed a monthly cap by a certain percentage. • The Department is increasing the limit for Care Coordination to 24 hours annually. • The Department is proposing to clarify the dollar month cap allowable per member per month under this waiver. • The Department is modifying the licensed settings which qualify for reimbursement for respite services. • The Department is proposing to change rates to be consistent between the former Section 19 and Section 22 programs in Chapter III.   THIS RULE WILL NOT HAVE A FISCAL IMPACT ON MUNICIPALITIES. STATUTORY AUTHORITY: 22 MRSA  42, 3173, Resolve 2011, ch 71. DATE AND PLACE OF PUBLIC HEARING: Date: August 12, 2014 9:00 AM Location: Conference Room 110 Department of Health and Human Services 19 Union Street Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed above before August 4, 2014.
Submit Comments (Opens in new window) - Comment Deadline: August 22, 2014 Posted: July 22, 2014
 
MaineCare Benefits Manual, Section 18, Chapter II and III, Home and Community-Based Services for Adults with Brain Injury WORD  PDF   
Concise Summary: The Department is creating a new section of the MaineCare Benefits Manual outlining the covered services, program requirements, and reimbursement rates for a home and community-based program for adults with Acquired Brain Injury (ABI). This new MaineCare program, provided to eligible members through a Home and Community Based Waiver program approved by the Centers for Medicare and Medicaid Services, will provide supports necessary to assist individuals with an ABI to live in the community rather than in institutional settings. Chapter II of Section 18 (titled “Home and Community-Based Services for Adults with Brain Injury”) will detail the program requirements and services offered under the waiver. Those services include Assistive Technology, Care Coordination, Career Planning, Community/Work Reintegration, Employment Specialist Services, Home Support, Non-Medical Transportation Services, Self-Care/Home Management Reintegration, Work Ordered Day Club House and Work Support-Individual. Chapter III of Section 18 (titled “Allowances for Home and Community-Based Services for Adults with Brain Injury”) establishes billing procedure codes (based on HIPAA compliant CPT coding) and reimbursement rates for the waiver services. PUBLIC HEARING: Date: August 4, 2014, 9:00-11:00 am Location: Conference Room #110 Department of Health and Human Services 19 Union Street Augusta, ME 04333 The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed above before July 25, 2014.
Submit Comments (Opens in new window) - Comment Deadline: August 14, 2014 Posted: July 10, 2014
 
MaineCare Benefits Manual, Chapters II & III, Section 30, Family Planning Agency Services WORD  PDF   
Concise Summary: This rulemaking is being proposed in order to conform with industry billing standards and covered services. The Department is required to utilize certain applicable medical data code sets, pursuant to 45 C.F.R. §§ 162.1000 and 162.1002. Each code set is valid within the dates specified by the organization responsible for maintaining that code set pursuant to 45 C.F.R. § 162.1011. The proposed updates include adding the code for the administration of medroxyprogesterone acetate (DepoProvera), and the addition of codes for the following new Family Planning Agency Services in Ch. III: 1) Removal of an IUD; 2) Administration of the HPV vaccine; 3) Insertion of the IUD Skyla®. Finally, these proposed changes remove language referring to retroactive code dates from 2010. The revisions to Ch. II include a reference to a rate setting website in Ch. III and add language stating that Family Planning Agencies will be reimbursed at the same fee-for-service rate as other providers when applicable. PUBLIC HEARING: Date: August 4, 2014 Time: 9:00 AM Location: 302 Cross Office Building, 111 Sewall Street, Augusta, ME 04330 The Department requests that any interested party requiring special arrangements planning to attend the hearing contact the agency person listed below before Wednesday, July 23rd, 2014.
Submit Comments (Opens in new window) - Comment Deadline: August 14, 2014 Posted: July 9, 2014
 
MaineCare Benefits Manual, Chapter II, Section 29, Support Services for Adults with Intellectual Disabilities or Autistic Disorder Word  PDF   
Concise Summary: The Department is proposing many changes in this rulemaking. The Department is proposing to add four new services: Assistive Technology, Career Planning, Home Support-Quarter Hour and Home Support-Remote Support. Additionally, the Department is proposing to split Work Support into two separate services: Work Support-Individual and Work Support-Group. Additionally, the Department is proposing to add performance measures. The primary goal of performance measurement is to use data to determine the level of success a service is achieving in improving the health and wellbeing of members. Performance goals and performance measures have been established to monitor quality, inform, and guide reimbursement decisions and conditions of provider participation across MaineCare services. This focus on performance measurement is anticipated to enhance the overall quality of services provided and raise the level of public accountability for both the Department and MaineCare providers. Other proposed changes to the rule include: • The addition of seven (7) new definitions: Activities of Daily Living, Agency Home Support Authorized Agent, Instrumental Activities of Daily Living, Medical Add On, Prior Authorization and Utilization Review. • Removing the definition of Summary of Authorized Services. • A requirement for Section 29 applicants and their planning teams to estimate the annual cost of services in the course of applying for waiver services. • A requirement that the Personal Plan for members electing the Home Support-Remote Support service incorporate a safety/risk plan. • The addition of limits on Community Support services, Assistive Technology services, Career Planning services, Counseling services, Consultation services, Employment Specialist Services and Home Support-Remote Support services. • The addition of new provider qualifications for those Direct Support staff that provide Home Support services, Work Support-Individual services, Work Support-Group services, Employment Specialist Services and Career Planning services. Other technical language changes are also being proposed. The reason for the rule changes are to comply with the budget bill P.L. 2013, chapter 368 directing the Department to add Assistive Technology. The Department is complying with Resolve, Chapter 24, LD 8, Resolve, Directing the Department of Health and Human Services to Provide Coverage under the MaineCare Program for Home Support Services for Adults with Intellectual Disabilities or Autistic Disorder. This Resolve directs the Department to add Home Support as a covered Service to this waiver. The Department is also complying with a CMS directive to separate Home Support into separate services. The Work Support and Career Planning changes are to comply with LD 8, Resolve, Directing the Department of Health and Human Services to provide coverage under the MaineCare program for Home Support Services for Adults with Intellectual Disabilities or Autistic Disorder. SEE http://www.maine.gov/dhhs/oms/rules/provider_rules_policies.html for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: April 25, 2014 Posted: March 19, 2014
 
MaineCare Benefits Manual, Chapter II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorder Word  PDF   
Concise Summary: The Department is proposing many changes in this rulemaking. The Department is proposing to add three new services: Assistive Technology, Career Planning and Home Support-Remote Support. The Department is also proposing to split the existing Home Support service into four separate services: Home Support-Agency Per Diem, Home Support-Family Centered Support, Home Support-Quarter Hour, and Shared Living. Additionally, the Department is proposing to split Work Support into two separate services: Work Support-Individual and Work Support-Group. The Department is also proposing to add performance measures. The primary goal of performance measurement is to use data to determine the level of success a service is achieving in improving the health and wellbeing of members. Performance goals and performance measures have been established to monitor quality, inform, and guide reimbursement decisions and conditions of provider participation across MaineCare services. This focus on performance measurement is anticipated to enhance the overall quality of services provided and raise the level of public accountability for both the Department and MaineCare providers. Other proposed changes to the rule include: • The addition of Licensed Audiologists and Assistive Technology Professionals as qualified providers for the Communication Aids service. • The addition of Certified Occupational Therapy Assistants (COTA) under the supervision of an Occupational Therapist Registered (OTR) as qualified providers for the Occupational Therapy (Maintenance) service. • The addition of six (6) new definitions: Activities of Daily Living, Administrative Oversight Agency, Authorized Agent, Instrumental Activities of Daily Living, Prior Authorization and Utilization Review. • Removing the definition of Summary of Authorized Services. • The addition of a reserved capacity category to meet the needs of members under 21 in out-of-state residential placements funded by MaineCare or State funds. • The addition of clarifying language regarding the phase-out of the Home Support-Family Centered Support services. • New procedures for filling vacancies in two-person agency-operated homes. • A requirement for Section 21 applicants and their planning teams to estimate the annual cost of services in the course of applying for waiver services. • A requirement that the Personal Plan for members electing the Home Support-Remote Support service incorporate a safety/risk plan. • The addition of limits on Community Support services, Assistive Technology services, Career Planning services, Counseling services, Consultation services, Employment Specialist Services and Home Support-Remote Support services. • The addition of new provider qualifications for those Direct Support staff that provide Work Support-Individual services, Work Support-Group services, Employment Specialist Services, and Career Planning services. Other technical language changes are also being proposed. The reason for the rule changes are to comply with the budget bill P.L. 2013, chapter 368 directing the Department to add Assistive Technology. The Department is also complying with a CMS directive to separate Home Support into separate services. The work support and career planning changes are to comply with LD 8, Resolve, Directing the Department of Health and Human Services to provide coverage under the MaineCare program for Home Support Services for Adults with Intellectual Disabilities or Autistic Disorder. SEE http://www.maine.gov/dhhs/oms/rules/provider_rules_policies.html for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: April 24, 2014 Posted: March 19, 2014
 
MaineCare Benefits Manual, Chapter II, Section 67, Nursing Facilities Services Word  PDF   
Concise Summary: This rule is being proposed in order to make brain injury eligibility for Section 67: Nursing Facility Services and Section 18: Home and Community Based Services for Members with Brain Injury consistent between policies. Individuals with Acquired Brain Injury will be eligible for Nursing Facility services if they score three or higher in two items on the Mayo-Portland Adaptability Inventory and score a 0.1 or higher on the Brain Injury Health and Safety Assessment. This rulemaking also: a) Updates the Brain Injury definition in Section 67.01-22 to be consistent with the definition developed in Title 22 § 3086; b) Adds the word “Acquired” to “Brain Injury” to be consistent with Title 22 § 3086; c) Changes “Brain Injury” to “Acquired Brain Injury,” and “BI” to “ABI” in the table of contents and on pages 4, 14, 32, 47, 48, 53; d) Requires, for Nursing Facilities working with individuals with brain injury, that all staff have expertise in brain injury rehabilitation as demonstrated by achieving the Certified Brain Injury Specialist (CBIS) designation from the Academy of Certified Brain Injury Specialists, or through an approved equivalent training program; e) Reorganizes Section 67.02-5; and, f) Corrects a numbering error in Section 67.05-13 See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: April 17, 2014 Posted: March 12, 2014
 
MaineCare Benefits Manual, Chapter II, Section 13, Targeted Case Management Services Word  PDF   
Concise Summary: This proposed rule seeks to permanently adopt the emergency rule effective December 20, 2013, that updates the Targeted Case Management (TCM) policy to include the Child and Adolescent Needs and Strengths (CANS) assessment as an approved TCM eligibility tool. The Department will no longer fund the Child and Adolescent Functional Assessment Scales (CAFAS) as of January 31, 2014, and must have the CANS in place to assure that providers who cannot self fund the CAFAS have an approved tool to evaluate members for TCM eligibility.
Submit Comments (Opens in new window) - Comment Deadline: February 20, 2014 Posted: January 16, 2014
 
MaineCare Benefits Manual, Ch 101, Sec 45, Ch III, Hospital Services PDF     
Concise Summary: CONCISE SUMMARY: On November 15, 2013, the Department adopted an emergency rule which increased the MaineCare hospital supplemental pool for Acute Care Non-Critical Access hospitals, hospitals reclassified to a wage area outside Maine and rehabilitation hospitals, to $65.321 million, because the Legislature appropriated an additional $10.472 for this purpose. P.L. 2013, ch. 368, PART A, Sec. A-34. This rulemaking proposes to make the changes in the November 15, 2013 Emergency Rule permanent.
Submit Comments (Opens in new window) - Comment Deadline: January 2, 2014 Posted: November 27, 2013
 
MaineCare Benefits Manual, Ch 101, Sec 1 Ch I, General Administrative Policies and Procedures PDF     
Concise Summary: CONCISE SUMMARY: The Department is proposing the following changes to this rule, for the following reasons: (1) Removed references to DirigoChoice, since the Maine Legislature has dissolved the Dirigo Health Agency (P.L. 2013, ch. 368, Sec. A-19); (2) As required by 45 CFR 162.410, requires that any MaineCare provider that is a “covered health care provider” must obtain a National Provider Identifier (NPI); (3) Requires that MaineCare providers must include their NPI on their MaineCare Provider Agreements and MaineCare enrollment applications, and requires updates for new or changed NPIs; (4) Requires that all MaineCare providers must include their NPI on all MaineCare claims, pursuant to the Affordable Care Act, Section 6402(a) as codified in 42 CFR 431.107, or those claims will be denied; (5) Pursuant to 42 CFR 455.410, specifies that, in order for MaineCare to reimburse for services or medical supplies or prescriptions resulting from a provider’s order, prescription or referral, the ordering, prescribing or referring (OPR) provider must be enrolled in MaineCare, and the OPR provider’s NPI must be on the claim. This change will be effective when the Maine Medicaid Management Information System (MMIS) is able to process this change, and the Department will notify all providers via the Listserve, and also serve notice on the Secretary of State’s office as required by 5 MRSA 8052(6); (6) Pursuant to P.L. 2013, c. 368, Part A-34, effective January 1, 2014, if approved by CMS, the Department will limit cost sharing payments, for the Qualified Medicare Beneficiary without other Medicaid (QMB Only) population, to hospital and nursing facility providers to the amount necessary to provide a total payment equal to the amount MaineCare would pay for these services under the State Plan. The Department will seek CMS approval to amend its State Plan for this change. (7) Finally, the Department made some additional changes to the 1.07-5 (Medicare provision), all to comport with the current State Plan, and these changes also reflect the Department’s current practice: (a) adding hospitals and nursing facilities to the list of MaineCare providers who may bill MaineCare for cost sharing, however, the cost sharing is limited in that it cannot exceed the lowest rate that Medicare determines to be the allowed amount; (b) deleting references to “Medicare Part B” in provisions where the provisions related both to Medicare A and B, pursuant to the State Plan; (c) deleting a provision regarding claims received from January 1, 1997 to February 29, 2000, since that time period has long passed.
Submit Comments (Opens in new window) - Comment Deadline: December 5, 2013 Posted: November 12, 2013
 
MaineCare Benefits Manual, Chapter 101, Chapter II, Section 85, Physical Therapy Services PDF     
Concise Summary: CONCISE SUMMARY: The Department is proposing changes to this rule to require Prior Authorization for all Physical Therapy Services for persons age 21 and over. The Department also proposes the following changes: a. Adding a definition for Terminal Illness, b. Adding new covered services and clarifying covered services and their limits, c. Limiting supplies to splinting and adding the link to the Department’s Rate Setting website, d. Adding some language and clerical changes to clarify the policy.
Submit Comments (Opens in new window) - Comment Deadline: November 7, 2013 Posted: October 2, 2013
 
MaineCare Benefits Manual, Chapter 101, Chapter II, Section 68, Occupational Therapy Services PDF     
Concise Summary: CONCISE SUMMARY: The Department is proposing changes to this rule to require Prior Authorization for all Occupational Therapy Services for persons age 21 and over. The Department also proposes the following changes: a. Adding a definition for Long-Term Chronic Pain and Terminal Illness, b. Adding new covered services and clarifies covered services and their limits, c. Limiting supplies to splinting only and adds the link to the Department’s Rate Setting website, d. Adding some language and clerical changes to clarify the policy.
Submit Comments (Opens in new window) - Comment Deadline: November 7, 2013 Posted: October 2, 2013
 
MaineCare Benifits, Ch 101, Ch X, Sec 2. Non-Categorical PDF     
Concise Summary: CONCISE SUMMARY: The MaineCare Childless Adults Section 1115 demonstration project that provided health care coverage to childless adults and non-custodial parents with incomes at or below 100% of the Federal Poverty Level (FPL) expires on December 31, 2013. Due to the expiration of the waiver (P.L. 2011, ch. 477, Part M, sec. M-1), the Department of Health and Human Services (DHHS) must repeal Chapter 101, MaineCare Benefits Manual, Chapter X, Section 2, Non-categorical Adults to defund the program.
Submit Comments (Opens in new window) - Comment Deadline: November 07, 2013 Posted: September 30, 2013
 
MaineCare Benefits Manual, Ch 101, Sec 45, Ch II-Hospital Services PDF     
Concise Summary: CONCISE SUMMARY: This proposed rulemaking seeks to permanently adopt changes already made on an emergency basis, implementation of budget initiative of P.L. 2013, ch. 368, as amended by P.L. 2013, ch. 423. This rulemaking will, retroactive to April 1, 2013, increase the number of days that MaineCare reimburse a hospital for Therapeutic Leave of Absence- During Days Awaiting Nursing Facility Placement from one (1) day to twenty (20) days per state fiscal year. The rulemaking also makes clerical clarifications and corrections in several places: on pages 8 and 10 changing “days waiting” to “days awaiting” to be consistent with language elsewhere in the rule; and inserting the words “Therapeutic Leave of Absence During Days Awaiting Nursing Facility Placement” on page 7 and changing that entry in the Table of Contents so that it conforms to the language on page 7.
Submit Comments (Opens in new window) - Comment Deadline: October 3, 2013 Posted: August 30, 2013
 
MaineCare Benifits Manual, Ch 101, Sec 67, Ch II-Nursing Facility Services PDF     
Concise Summary: CONCISE SUMMARY: This proposed rulemaking seeks to permanently adopt changes already made on an emergency basis, implementation of budget initiative of P.L. 2013, ch. 368, as amended by P.L. 2013, ch. 423. This rulemaking will, retroactive to April 1, 2013, increase the number of days that MaineCare will reimburse a nursing facility for: (a) Therapeutic Leave of Absence from one (1) day to twenty (20) days per state fiscal year, and (b) Bed Hold Days from four (4) per year to seven (7) per inpatient hospitalization. The rulemaking also makes the following clerical changes: (1) inserts the word “Therapeutic” before “Leave Days for a MaineCare Member” on page 39, (2) changes that entry in the Table of Contents so that it conforms to the language on page 39. The Department is seeking approval from the Centers for Medicare and Medicaid Services for a state plan amendment for this change.
Submit Comments (Opens in new window) - Comment Deadline: October 3, 2013 Posted: August 30, 2013
 
MaineCare Benefits Manual, Ch 104, Sec 4 Part D Wrap Benefits PDF  Word   
Concise Summary: CONCISE SUMMARY: This rule is proposed to permanently adopt the provisions now in place by emergency rule that eliminate coverage of Medicare Part D copayments for members of the Medicare Savings Program who are not eligible for, or receiving the full MaineCare benefit. This change is being made pursuant to PL 2013, Chapter 368, Part A, Section A-34, the Maine Biennial Budget.
Submit Comments (Opens in new window) - Comment Deadline: October 3, 2013 Posted: August 30, 2013
 
MaineCare Benefits Manual, Ch 101 Sec 97 Ch II, Private Non-Medical Institution Services, Intensive Mental Health Services for Infants and/or Toddlers PDF     
Concise Summary: CONCISE SUMMARY: This proposed rule eliminates Private Non-Medical Institution Services (PNMI), Appendix D (Child Care Facilities), Model 3 (Intensive Mental Health Services for Infants and/or Toddlers). In a separate rulemaking for Chapter III, Section 97, the Department seeks to provisionally adopt the emergency major substantive rule that eliminates the reimbursement rate for these services. Although eligible infants and toddlers will no longer have access to PNMI Appendix D, Model 3 intensive mental health services, they remain eligible for medically necessary Behavioral Health Services through Chapter II, Section 65, Behavioral Health Services.
Submit Comments (Opens in new window) - Comment Deadline: September 5, 2013 Posted: August 16, 2013
 

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