Proposed Rulemaking

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MaineCare Benefits Manual, Chapter III, Section 67, Reimbursement Principles For Nursing Facilities Word  PDF   
Concise Summary: In this rulemaking, the Department proposes the changes required by Resolve 2013, ch. 72 (LD 1189), to clarify the timeframe during which nursing facilities must demonstrate their compliance with the October 1, 2011, 2% Cost-Of-Living Adjustment (COLA) for front line staff. If CMS approves, the following applies for the 2%, October 2011, COLA that the Department gave to nursing facilities: nursing facilities must demonstrate, to the satisfaction of the Department, a 2% increase in the average wage and benefit rate per hour for front line employees for their first fiscal years ending after July 1, 2013, from the average wage and benefit rate per hour for front line employees that was in effect for their fiscal years ending 2008. If the nursing facilities cannot demonstrate that 2% increase to the satisfaction of the Department, then the Department will recoup, at time of audit, the difference between what the average wage and benefit rate per hour for front line employees for the first fiscal years ending after July 1, 2013 should have been if it had been increased by 2% from what it was. This rulemaking also: (1) Removes the word “Care” from ‘Routine Care Cost Component” on pg. 3 (2) MIHMS went live on 9/1/2010. Removes old language – from Section 41.2.3(D), regarding how sanctions were calculated in the period of time leading up to MIHMS implementation and language referring to MIHMS in the future tense (3) MIHMS went live on 9/1/2010. Removes old language – from Section 80.3.4, regarding how the “Direct Care Component” was calculated in the period of time leading up to MIHMS implementation and language referring to MHIMS in the future tense. (4) Changes ‘Brain Injury’ to Acquired Brain Injury and ‘BI’ to ‘ABI’ on pages 71 and 72 to use the same definitions set forth in 22 M.R.S. 3086 and to be consistent with terminology utilized in Sec. 67, Ch. II. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: Midnight, May 5, 2014 Posted: March 27, 2014
 
MaineCare Benefits Manual, Section 29, Chapter III, Allowances for Support Services for Adults with Intellectual Disabilities or Autistic Disorder Word  PDF   
Concise Summary: The Department is proposing to add procedure codes and modifiers for the new services proposed to be added to the corresponding Chapter II of Section 29. These include: • New procedure codes for Assistive Technology services, which has three components: the Assessment and Training, the Assistive Technology Devices and the monthly cost of the internet or cable transmission. • New procedure codes for Career Planning services, Home Support-Quarter Hour services, Home Support-Remote Support services, Work Support-Group services and Work Support-Individual services. • Modifiers for Home Support-Remote Support services to indicate whether interactive support is being delivered or the member is only being monitored. Additionally, the Department proposes the addition of billing instructions to Work Support-Group to describe how to submit for reimbursement when services are delivered in a group setting. 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: Midnight, Thursday April 25, 2014 Posted: March 19, 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: Midnight, Thursday April 25, 2014. Posted: March 19, 2014
 
MaineCare Benefits Manual, Chapters II & III, Section 20, Home and Community Based Services for Adults with Other Related Conditions Word  PDF   
Concise Summary: There are some technical changes that the Department is proposing. The Department is proposing to clarify the definitions of Priority 1 and Priority 2 members. The Department is proposing to clarify that the rate for Community Support includes the cost of transportation and is a component of the rate paid for the service. A clarification is needed to Home Support to state a member may have some 1:1 direct care and it must be specified in the care plan. The Department is also proposing to add clarifying language to Assistive Technology and Communication Aids to state: “Each system or device will be revised based on medical necessity, efficiency and meets compatibility with safety needs.” Additionally, the Department has submitted a waiver amendment to CMS and is proposing changes to the policy to coincide with CMS approval. The following changes are dependent on CMS approval. The Department is proposing to increase the limit of Community Support and Work Support from 64 units each to allowing the member a combination of 128 units of either service. The maximum weekly allowance for Community Support is 128 units, for an annual total of 6,656 units. The maximum weekly allowance for Work Support Services is 128 units, for an annual total of 6,656 units. When members use a combination of both services, there is an annual limit of 6,656 units on the total combined expenditures for the services. The Department is proposing a new limit of 64 units per day from 44 per day of Home Support –Remote Support and 64 units per day from 44 per day of Home Support-Quarter hour. The Department is proposing to clarify Remote Support-Interactive Support and Remote Support-Monitor only as two separate components of Remote Support and reimbursed separately. The Department is proposing to change the limit of Communication Aids from $2,000.00 to $6,000.00 per year. A Licensed Speech Language Pathologist (SLP) is being proposed to be added as a qualified provider of Communication Aids. This proposes that Care Coordination limits to change to 400 from 144 units every year, instead of just the first year. The Department is also proposing to add clarifying language that Consultation is limited to 64 units per each type of consultation annually. The waiver is being amended to update the effective date, clarify limits and to update the annual coast of an ICF/IID to the current amount of $200,000.00 per member. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Submit Comments (Opens in new window) - Comment Deadline: Midnight, Friday, April 25, 2014 Posted: March 19, 2014
 
MaineCare Benefits Manual, Section 21, Chapter III, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder Word  PDF   
Concise Summary: The Department is proposing to add procedure codes and modifiers for the new services proposed to be added to the corresponding Chapter II of Section 21. These include: • New procedure codes for Assistive Technology services, which has three components: the Assessment and Training, the Assistive Technology Devices and the monthly cost of the internet or cable transmission. • New procedure codes for Career Planning services, Home Support-Remote Support services, Shared Living services, Work Support-Group services and Maintenance Occupational Therapy services delivered by a Certified Occupational Therapy Assistant (COTA). • Modifiers for Home Support-Remote Support services to indicate whether interactive support is being delivered or the member is only being monitored. • A new modifier for Home Support-Family Centered Support to indicate that the service is Home Support-Family Centered Support. Additionally, the Department proposes the addition of billing instructions to Work Support-Group to describe how to submit for reimbursement when services are delivered in a group setting. 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: Midnight, Thursday, April 24, 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: Midnight, Thursday, 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: Saturday, April 17, 2014 Posted: March 12, 2014
 
Chapter 104, Maine State Services Manual, Section 6, Independent Practice Dental Hygienist Services Word  PDF   
Concise Summary: 22 M.R.S. 3174-RR requires that by October 1, 2012, the Department shall provide for the reimbursement under the MaineCare program of IPDHs practicing as authorized under Title 32 M.R.S. 1094-I for the following procedures: A. Prophylaxis performed on a person who is 21 years of age or younger; B. Topical application of fluoride performed on a person who is 21 years of age or younger; C. Provision of oral hygiene instructions; D. The application of sealants; E. Temporary fillings; and, F. X-rays. 22 M.R.S. 3174-RR also specifies that reimbursement must be provided to IPDHs directly or to a federally qualified health center pursuant to 22 M.R.S. 3174-V when an IPDH is employed as a provider at the center, and that the department shall adopt rules to implement this section. This rule serves to implement state-only reimbursement of IPDHs as set forth above pending approval by the Centers for Medicare and Medicaid Services of a State Plan Amendment (SPA) to add IPDHs as a MaineCare provider under Maine’s State Plan. These rules will expire upon the effective date of that SPA and shall be superseded at that time by the IPDH subsection of Chapter 101, MaineCare Benefits Manual (MBM), Chapters II & III, Section 25, Dental Services and by the addition of IPDHs to MBM Chapter II, Section 31, Federally Qualified Health Center Services.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by midnight Saturday, March 1, 2014. Posted: January 27, 2014
 
MaineCare Benefits Manual Chapter 101, Chapter II, Section 31, Federally Qualified Health Center Services Word  PDF   
Concise Summary: This proposed rulemaking seeks to make the following changes: 1. Adds three dental provider types -- Independent Practice Dental Hygienists (IPDHs), Dental Externs, and Dental Residents -- that are concurrently being proposed in MaineCare Benefits Manual, Chapter II, Section 25 Dental Services; and clarifies that dental services rendered in FQHCs must be performed in accordance with Maine Board of Dental Examiners requirements. IPDHs are added effective October 1, 2013, subject to approval by CMS; Dental Externs are added effective September 1, 2011; and Dental Residents are added effective 365 days before the rule’s date of adoption. 2. In the tobacco cessation paragraph makes an update to reflect the upcoming national change from ICD-9 to ICD-10.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by midnight Saturday, March 1, 2014. Posted: January 27, 2014
 
MaineCare Benefits Manual Chapter 101, Section 25, Chapters II & III Dental Services Word  PDF  | PDF's of Standardized IPDH Forms
Concise Summary: This proposed rulemaking seeks to: 1. Update policy to conform to changes in the American Dental Association’s 2014 CDT Dental Procedure Codes (this includes addition, deletion, and renaming of codes, as appropriate). 2. Add IPDHs as a qualified provider, per P.L. 2011 Chap. 457 “An Act To Include Independent Practice Dental Hygienists in MaineCare.” 3. Add partial dentures to services reimbursable to denturists, in order to be consistent with changes to Title 32 pursuant to per P.L. 2009 Chap. 227 “An Act To Allow Qualified, Licensed Denturists To Practice to the Level of Their Educational Training.” 4. Specify that MaineCare will reimburse for procedures performed by dental residents and externs under the supervision of a dentist, in accordance with the rules of the Maine Board of Dental Examiners. 5. Make clerical, technical, and administrative corrections and updates. 6. Lower the rate for intravenous sedation in order to pay for the addition of non-IV-sedation as a covered service. 7. Change limitations for a number of specific procedures, including, but not limited to: a. changing the limits on the following services from once per six (6) months or twice per year to twice per calendar year, but no more than once every 150 days: prophylaxis, oral evaluations, application of fluoride and fluoride varnish; b. changing the limit on panoramic radiographs from “billable with pre-orthodontic visit” to “separately billable without PA once per five (5) years when used in conjunction with any preventative and/or diagnostic service” (to be consistent with an October 2010 policy clarification letter); c. adding a new limit that the Department will reimburse for one (1) comprehensive orthodontic treatment per member per lifetime, and the orthodontic retention phase shall not exceed 24 months. The Department will seek required approval from the Centers for Medicare and Medicaid Services for a SPA to add IPDHs as a qualified provider and to add new codes and limits.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by midnight Saturday, March 1, 2014. Posted: January 27, 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 Chapter 101, Section 92, Chapters II & III Behavioral Health Home PDF     
Concise Summary: CONCISE SUMMARY: This proposed rulemaking seeks to create Behavioral Health Homes, effective April 1, 2014, which will provide comprehensive system of care coordination for members with Serious Emotional Disorders (SED), and Serious and Persistent Mental Illness (SPMI). Members eligible for Section 92 services may also be eligible for services under Section 13 (Targeted Case Management), Section 17 (Community Integration Services) and/or Section 91 (Health Home Services); such members may not receive those services at the same time that they receive Section 92 services, and must choose among the different types of services for which they are eligible. Section 92 services shall be provided to eligible members by a Behavioral Health Home Organization (BHHO) that partners with one or more Health Home Practices (HHPs). BHHOs and HHPs shall integrate and coordinate all primary, acute, behavioral health and long term services and supports for eligible members. BHHOs shall develop and implement a comprehensive Plan of Care for each member. Section 92 services are expected to result in improved physical and behavioral health outcomes for members, reduced hospital admissions and emergency room use, better transitional care, improved communication between health care providers, and the increased use of preventive services, community supports, and self-management tools. Section 92 Behavioral Health Homes are implemented pursuant to section 2703 of the Affordable Care Act, 42 U.S.C. 1396w-4. The Department is seeking approval of a State Plan Amendment from the Centers for Medicare and Medicaid Services. Section 2703 provides an enhanced federal matching rate of 90% for the first eight (8) quarters following the effective date of the program.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by midnight January 24, 2014 Posted: December 19, 2013
 
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: Comments must be received by midnight, Thursday, 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: Comments must be received by midnight December 5, 2013 Posted: November 12, 2013
 
MaineCare Benefits Manual, Chapter 101, Section 2, Chapter VI MaineCare DirigoChoice Initiatives PDF     
Concise Summary: CONCISE SUMMARY: By direction of legislative action (P.L. 2013, ch. 368, Sec. A-19), the Department of Health and Human Services (DHHS) is proposing to repeal, in its entirety, MaineCare Benefits Manual, Chapter VI, Section, 2, MaineCare Dirigo Initiative by December 31, 2013. The Department anticipates that this proposed rulemaking will have no impact on MaineCare enrolled members.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by midnight November 14, 2013 Posted: October 9, 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: Comments must be received by midnight 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: Comments must be received by midnight 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: Comments must be received by midnight 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: Comments must be received by midnight 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: Comments must be received by midnight 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: Comments must be received by midnight October 3, 2013 Posted: August 30, 2013
 
MaineCare Benefits Manual, Ch 101, Sec 97, III, Private Non-MedicalInstitution Services, Intensive Mental Health Services for Infants and/or Toodlers PDF     
Concise Summary: CONCISE SUMMARY: This proposed major substantive rule eliminates the reimbursement rate for Private Non-Medical Institution Services (PNMI), Appendix D (Child Care Facilities), Model 3 (Intensive Mental Health Services for Infants and/or Toddlers). The Department seeks to provisionally adopt the changes made by an emergency major substantive rule, effective on June 26, 2013. The Department seeks to eliminate intensive Mental Health Services for infants and/or toddlers through a separate rulemaking for Chapter II, Section 97. 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 Section 65, Behavioral Health Services, which services shall be reimbursed at the rates set forth in Chapter III, Section 65.
Submit Comments (Opens in new window) - Comment Deadline: Comments must be received by midnight September 5, 2013. Posted: August 16, 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: Comments must be received by midnight September 5, 2013. Posted: August 16, 2013
 
Chapter 101, MaineCare Benefits Manual, Section 32, Chapter II, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders Word  PDF   
Concise Summary: The Department is proposing changes to the rule to comply with the concurrent operation of a 1915 (b) Non-Emergency Transportation Waiver. These proposed changes to Section 32 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. The proposed changes to Section 32 include referencing the regional, risk-based, Pre-Paid Ambulatory Health Plan (PAHP) Brokerages operating under a 1915(b) waiver approved by the Centers for Medicare and Medicaid Services (CMS). Under risk-based contractual agreements, the Department will contract with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of Non-Emergency Transportation (NET) services for eligible MaineCare members. The Broker(s) will be responsible for establishing a network of NET drivers to deliver NET transportation services to eligible members who live in their assigned region. The Department is also proposing a number of other changes: 1. The Department is proposing changes to the definitions of “seclusion” and “restraint” to conform to the definitions employed in the Department of Education’s regulations (5-71 C.M.R. ch. 33). The Department of Health and Human Services was directed by the Legislature’s Committee on Health and Human Services to amend Chapter II to mirror the definitions of seclusion and restraint in the Department of Education’s regulations. 2. The Department is proposing to replace the term “aggression” throughout the rule with “self-injurious behavior and/or aggression.” 3. The Department is proposing to add language clarifying that, for purposes of initial and continuing eligibility, the annual cost of a member’s services under Section 32 may not exceed the statewide average annual cost of care for an individual in either (a) an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or (b) an Inpatient Psychiatric facility for individuals age 21 and under, depending upon the level of care at which the individual qualified for the waiver. This is not a new limit; the Department is proposing the changes to clarify that these limits are not fixed numbers, but instead change each year based upon the prior year’s statewide average annual cost of care for the respective facility type. 4. The Department is proposing to add a number of definitions (including Authorized Agent, Intellectual Disability, and Pervasive Developmental Disorders), and to change the term “Mentally Retarded” to “Intellectually Disabled,” as required by P.L. 2012, ch. 542, B(5), An Act To Implement the Recommendations of the Department of Health and Human Services and the Maine Developmental Disabilities Council Regarding Respectful Language. 5. The Department is proposing clarification of, and additions to, the requirements for providers of Section 32 services. These include, among others, clarification of the circumstances under which Behavioral Health Professionals may assist with administration of medication, requirements for Respite Service providers, and a requirement that providers put in place a Department-approved informed consent policy.
Submit Comments (Opens in new window) - Comment Deadline: 09/05/2013 Posted: August 6, 2013
 
MaineCare Benefits Manual, Section 29, Chapter II, Support Services for Adults with Intellectual Disabilities or Autistic Disorder WORD  PDF   
Concise Summary: The Department is proposing a number of unrelated changes to this rule. The Department is proposing changes to the rule to comply with the concurrent operation of a 1915 (b) Non-Emergency Transportation Waiver. These proposed changes to Section 29 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. The proposed change to Section 29 includes referencing the regional, risk-based, pre-paid ambulatory health plan (PAHP) Brokerages operating under a 1915(b) waiver approved by the Centers for Medicare and Medicaid Services (CMS). Under risk-based contractual agreements, the Department will contract with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of Non-Emergency Transportation (NET) services for eligible MaineCare members. The Broker(s) will be responsible for establishing a network of NET drivers to deliver NET transportation services to eligible members who live in their assigned region. The Department is also proposing a number of other technical changes. 1. The Department is proposing to add language clarifying that, for purposes of initial and continuing eligibility, the annual cost of a member’s services under the Section 29 waiver may not exceed fifty percent (50%) of the statewide average annual cost of care for an individual in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), as determined by the Department. The rule will also clarify that reimbursement for Employment Specialist Services is limited to ten hours per month. Neither of these limits is new; each was included in the waiver application approved by CMS, but had not previously been identified in the Section 29 policy. 2. The website for The Maine College of Direct Support is being updated to a current link and can be accessed on the internet at: http://www.maine.gov/dhhs/oads/disability/ds/cds/index.shtml 3. The proposed rule makes technical changes to language and names when usage has changed or has been deemed inappropriate by the Maine Legislature. Specifically, the changes: a. Replace references to “mental retardation” with references to “intellectual disability” as required by P.L. 2012, ch. 542, B(5), An Act To Implement the Recommendations of the Department of Health and Human Services and the Maine Developmental Disabilities Council Regarding Respectful Language; b. Replace references to “Office of Integrated Access and Support” with references to “Office of Family Independence”; c. Replace references to “Office of Adults with Cognitive and Physical Disabilities Services” with references to “Office of Aging and Disability Services”; d. Clarify the definitions of Correspondent, Case manager, Intellectual Disability and Autism. This change is to align this policy with services provided under Section 21 of the MaineCare Benefits Manual; and, e. Remove language making certain provisions contingent on approval by CMS, as CMS has now granted approval. 4. The Department is proposing to add language clarifying that the assessment referral form may be the BMS 99 form currently in use or some other form approved by the Department. This change is in anticipation of a move to a new functional assessment tool, the Supports Intensity Scale (SIS). 5. Requirements for Direct Support Professionals are being added, requiring DSPs to complete four specific modules prior to being left alone with a member. 6. The Department is proposing language requiring providers to put in place an informed consent policy and comply with the Department’s regulations governing reportable events. These are not new requirements, but had previously been included directly in the contracts between the Department and individual providers. 7. The Department is proposing various clarifications to the planning process. 8. The Department is proposing to delete Appendix III and replace it with a more simple statement of the combined limits on Work Support and Community Support in the main text of the rule.
Submit Comments (Opens in new window) - Comment Deadline: June 13, 2013 Posted: May 13, 2013
 
MaineCare Benefits Manual, Chapters II & III, Section 20, Home and Community Based Services for Adults with Other Related Conditions 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 “Related Conditions.” A “Related Condition” (defined in full at 42 C.F.R. 435.1010) is a condition that causes impairment of general intellectual functioning or adaptive behavior similar to the impairment characteristic of an intellectual disability. 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 a Related Condition to live in the community rather than in institutional settings. Chapter II of Section 20 (titled “Home and Community Based Services for Adults with Other Related Conditions Services”) will detail the program requirements and services offered under the waiver. Those services include Assistive Technology, Care Coordination, Communication Aids, Community Support, Consultation and Assessment, Employment Specialist Services, Home Accessibility Adaptations, Home Support, Non-Medical Transportation Services, Non-Traditional Communication Assessment, Non-Traditional Communication Consultation, Occupational Therapy (Maintenance) Service, Personal Care, Physical Therapy (Maintenance) Service, Specialized Medical Equipment, Speech Therapy (Maintenance) Service, and Work Support. Chapter III of Section 20 (titled “Allowances for Home and Community Based Services for Adults with Other Related Conditions“) establishes billing procedure codes (based on HIPAA compliant CPT coding) and reimbursement rates for the waiver services.
Submit Comments (Opens in new window) - Comment Deadline: May 11, 2013 Posted: April 4, 2013
 
Credible Allegation of Fraud Word     
Concise Summary: This letter gives notice of an emergency rule which amends MaineCare Benefits Manual (MBM), Chapter 1, Section 1, 1.18 (H), Program Integrity; 1.19-6, Suspension or Withholding of Payments; 1.20-3, Suspension of Payments Upon Credible Allegation of Fraud. The federal Patient Protection and Affordable Care Act of 2010 (PPACA) requires the suspension of payments to providers who are the subject of a credible allegation of fraud. The 125th Maine Legislature, Second Regular Session, enacted 22 MRSA 1714-D to conform with PPACA requirements regarding the suspension of payments, in whole or in part, to providers who are subject to credible allegations of fraud. The rule defines the term “credible allegations of fraud” and provides for exceptions and expedited relief from suspension of payments. The effective date of the emergency rule is December 28, 2012. Before the emergency rule is adopted, the Department will give notice of the emergency rulemaking to interested parties and providers through a MaineCare provider listserv notification. Public comments regarding the emergency rule will be accepted from December 7, 2012 through December 12, 2012.
Submit Comments (Opens in new window) - Comment Deadline: December 12, 2012 Posted: December 6, 2012
 
MaineCare Redesign Task Force Word     
Concise Summary: The MaineCare Redesign Task Force will hold a public hearing on the draft of the “MaineCare Redesign Task Force, Recommendation Report” that was written pursuant to Public Law 2011, Chapter 657, Part T. The hearing will be held on December 11, 2012 from 1 – 3 pm in Statehouse, Room 228 (Appropriations Committee Room). Interested parties are encouraged to provide testimony on the draft report, which can be viewed at http://www.maine.gov/dhhs/mainecare-task-force/. To ensure all interested parties are able to provide input, oral testimony will be limited to 3 minutes per participant. For those who would like to submit written testimony it can be emailed to nick.adolphsen@maine.gov; mailed to Nick Adolphsen, Department of Health and Human Service, 11 State House Station, Augusta, ME 04333; or delivered to the Task Force at the hearing on 12/11.
Submit Comments (Opens in new window) - Comment Deadline: December 11, 2012 Posted: December 4, 2012
 
MaineCare Benefits Manual, Chapters II & III, Section 65, Behavioral Health Services WORD  PDF   
Concise Summary: This rule is being proposed, in part, to comply with Public Law 2011, Chapter 477, (the Maine State Supplemental Budget) passed by the 125th Maine State Legislature and signed into law by Governor Paul R. LePage on February 23, 2012, section M-1 of which required that MaineCare Services reduce reimbursement of Opioid Treatment (Methadone) from $72.00 per week to $60.00. This change is currently in effect through an emergency rule, effective June 29, 2012. PLEASE NOTE THAT DEADLINE FOR RECEIVING COMMENTS IS SEPTEMBER 14, 2012
Submit Comments (Opens in new window) - Comment Deadline: September 14, 2012 Posted: August 16, 2012
 
MaineCare Benefits Manual, Ch II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorders WORD  PDF   
Concise Summary: The Department is proposing a number of unrelated changes to this rule. First, the Department proposes, as required by Resolves 2011, ch. 49, to remove language from 21.02-7 (Employment Setting) stating that “Members with disabilities should constitute no more than 50% of the business’s workforce at any given worksite or location.” Second, the Department proposes to add language to clarify that a Licensed Clinical Social Worker (LCSW) or Licensed Clinical Professional Counselor (LCPC) can provide psychological or behavioral consultation. Additionally, if approved by CMS, the Department is proposing to expand the list of qualified providers who can provide psychological or behavioral consultation to include Board Certified Behavior Analysts (BCBAs). Third, the Department is proposing several limits on Section 21 services. Under the proposed rule, no one-member Agency Home Support placements will be approved after the rule has been adopted. Also, the Home Support hour- T2017 will be limited to three hundred and thirty six (336) quarter hour units or eighty four (84) hours a week. The proposed rule would also limit authorizations for services to be provided out-of-state to (60) days of service within a given fiscal year and sixty (60) days within any six (6) month period. Fourth and lastly, language that had previously been in provider contracts or riders is being proposed to be added to the policy, and various technical language changes are also being proposed. PLEASE NOTE THAT DEADLINE FOR RECEIVING COMMENTS IS AUGUST 26, 2012.
Submit Comments (Opens in new window) - Comment Deadline: August 26, 2012 Posted: July 19, 2012
 
MaineCare Benefits Manual, Chapter III, Section 2, Adult Family Care Services Word   PDF    
Concise Summary: This proposed rule seeks to reduce rates paid under this section by 10%. These changes would permanently adopt changes already made on an emergency basis that took effect April 1, 2012. The reduction in rates was directed in the supplemental budget, P.L. 2011, ch. 477, part M-1.
Submit Comments (Opens in new window) - Comment Deadline: June 1, 2012 Posted: May 1, 2012
 

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