Maine Medicaid State Plan

The Maine Medicaid State Plan outlines how the Medicaid program is implemented in Maine. The State Plan covers many topics, from program administration to reimbursement, and is updated regularly through State Plan Amendments.  The Centers for Medicare and Medicaid Services (CMS) is the federal agency responsible for overseeing the Medicaid program in each state, including approval of changes to the State Plan. Please visit the CMS Medicaid State Plan Amendment site for a complete searchable listing of Maine’s recently approved State Plan Amendments.

Methodology Notices

MaineCare Benefits Manual, Section 92, Chapters II and III, Behavioral Health Home (BHH) Services WORD  PDF   
Concise Summary: The Department plans to request approval from the Centers for Medicare and Medicaid Services related to Section 92, Behavioral Health Homes reimbursement. Other changes encompassed surround Pay-for-Performance and minimum billable activities. Please see the attachment for a full description. Please submit any comments or concerns related to these changes via the “Submit Comments” function below, or by contacting Kristin Cook by email at Kristin.cook@maine.gov; by phone at (207) 624-4006 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or by mail at 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: April 11, 2018 Posted: April 3, 2018
 
MaineCare Benefits Manual, Section 25, Dental Services WORD  PDF   
Concise Summary: The Department of Health and Human Services will request approval from the Centers for Medicare and Medicaid Services to amend coverage of Section 25 dental services by including reimbursement for the procedure codes included in the attached document. Please see the attachment for a full description. Please submit any comments or concerns related to these changes via the “Submit Comments” function below, or by contacting Tom Leet by email at Thomas.leet@maine.gov; by phone at (207) 624-4068 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or by mail at 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: January 8, 2018 Posted: December 28, 2017
 
MaineCare Benefits Manual, Section 97, Private Non-Medical Institution Services (Appendices C and F) WORD  PDF   
Concise Summary: The Department of Health and Human Services will request approval from the Centers for Medicare and Medicaid Services to allow Appendix C and Appendix F, Private Non-Medical Institutions to request an adjustment to a prospective rate and/or a temporary supplemental payment for certain costs related to regulation compliance and/or extraordinary circumstances. Please submit any comments or concerns related to these changes via the “Submit Comments” function below, or by contacting Olivia Alford by email at Olivia.alford@maine.gov, phone (207)624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or by mail at 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: October 26, 2017 Posted: October 19, 2017
 
MaineCare Benefits Manual, Section 45, Chapters II and II, Hospital Services WORD  PDF   
Concise Summary: The Department of Health and Human Services will request approval from the Centers for Medicare and Medicaid Services to make a number of reimbursement and administrative changes to Section 45, Hospital Services. Please see the attached document for a full description. Please submit any comments or concerns related to these changes via the “Submit Comments” function below, or by contacting Olivia Alford by email at Olivia.alford@maine.gov, phone (207)624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or by mail at 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: October 13, 2017 Posted: October 3, 2017
 
MaineCare Benefits Manual, Section 96 Private Duty Nursing and Personal Care Services WORD  PDF   
Concise Summary: The Department of Health and Human Services will request approval from the Centers for Medicare and Medicaid Services to increase the monthly costs caps for Section 96, Private Duty Nursing and Personal Care Services to account for recent reimbursement increases for certain Section 96 services. Please submit any comments or concerns related to this change via the “Submit Comments” function below, or by contacting Olivia Alford by email at Olivia.alford@maine.gov, phone (207)624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or by mail at 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: October 10, 2017 Posted: October 2, 2017
 
MaineCare Benefits Manual, Section 12, CDA Services and Section 96, PDN and PCS WORD  PDF   
Concise Summary: Concise summary: In accordance with P.L. 2017 Ch. 284 Sec. MMMMMMM-1, the Department plans to request approval from the Centers for Medicare and Medicaid Services to increase reimbursement for certain personal care and related services under Section 12, Consumer Directed Attendant Services and Section 96, Private Duty Nursing and Personal Care Services. As part of these changes, the Department will implement the corresponding recommendation from the rate study referenced in the budget to change billing of the PCA Supervisit from a 15-minute/unit service to a “per visit” service. Please submit any comments or concerns related to this change via the “Submit Comments” function below, or by contacting Olivia Alford by email at Olivia.alford@maine.gov, phone (207)624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or by mail at 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: September 8, 2017 Posted: September 5, 2017
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services WORD  PDF   
Concise Summary: This SPA aligns the MaineCare Benefits Manual, Section 80, Pharmacy Services with the CMS Covered Outpatient Drug Final Rule (CMS-2345-FC), provides updated reimbursement methodologies, increases the professional dispensing fee for most medications to $11.89, and clarifies existing pharmacy coverage parameters. Please submit any comments or concerns related to this change via the “Submit Comments” function below, or by contacting Olivia Alford by email at Olivia.alford@maine.gov, phone (207)624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or by mail at 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: August 23, 2017 Posted: August 15, 2017
 
MaineCare Benefits Manual, Section 45, Chapter III, Hospital Services WORD  PDF   
Concise Summary: The Department plans to submit a State Plan Amendment to increase the supplemental pool dollar amount for Non-Critical Access hospitals, hospitals classified to a wage area outside of Maine by the Medicare Geographic Classification Review Board, and Rehabilitation hospitals in accordance with P.L. 2017 Ch. 284 Sec. ZZZZZZ-9. The Department also seeks to amend the supplemental pool allocation methodology to ensure that the annual supplemental payments do not exceed the allowable upper payment. Please submit any comments or concerns related to this change via the “Submit Comments” function below, or by contacting Olivia Alford by email at Olivia.alford@maine.gov, phone (207)624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or by mail at 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: August 5, 2017 Posted: July 26, 2017
 
MaineCare Benefits Manual, Chapter II, Section 75, Vision Services WORD  PDF   
Concise Summary: The Department will submit a State Plan Amendment (SPA) to add 65778, Placement of amniotic membrane on the ocular surface; without sutures, (reimbursed at $629.73) to the Vision Services section of the State Plan. This SPA will also add the existing reimbursement methodology for MaineCare Benefits Manual, Chapter II, Section 75, Vision Services, into the State Plan. Please submit any comments or concerns related to this change via the “Submit Comments” function below, or by contacting Olivia Alford by email at Olivia.alford@maine.gov, phone (207)624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or by mail at 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: July 9, 2017 Posted: June 29, 2017
 
MaineCare Benefits Manual, Section 97, Private Non-Medical Institution Services, Appendix C; Section 2, Adult Family Care Services WORD  PDF   
Concise Summary: This State Plan Amendment seeks to implement a three and a half (3.5) percent cost-of-living rate increase for Section 2, Adult Family Care Services and Section 97, Appendix C, Private Non-Medical Institution Services for fiscal year ending June 30, 2018. Please submit any comments or concerns related to this change via the “Submit Comments” function below, or by contacting Olivia Alford by email Olivia.alford@maine.gov, phone (207)-624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or mail 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: June 30, 2017 Posted: June 28, 2017
 
MaineCare Benefits Manual, Section 93, Opioid Health Home Services WORD  PDF   
Concise Summary: The Department plans to request approval from the Centers for Medicare and Medicaid Services to implement an Opioid Health Home (OHH) for members with opioid dependency who are receiving Medication-Assisted Treatment (MAT) in the form of buprenorphine, buprenorphine derivatives, and/or naltrexone. OHH care management/care coordination (“health home”) services will be reimbursed at $394.40 per member per month. However, the OHH providers will receive this as part of a bundled rate. Eligible OHH providers must bundle a monthly office visit with the MAT prescriber and counseling related to opioid dependency. The OHH provider may bundle in the reimbursement of the buprenorphine, buprenorphine derivatives, and/or naltrexone medications. The full bundled rate will be $1,000 per member per month. The rate without the medications is $496.00. Please submit any comments or concerns related to this change via the “Submit Comments” function below, or by contacting Olivia Alford by email Olivia.alford@maine.gov, phone (207)-624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or mail 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: April 10, 2017 Posted: April 5, 2017
 
MaineCare Benefits Manual, Section 25, Dental Services WORD  PDF   
Concise Summary: The Department will request approval to add the following dental procedures codes at the given rates: D1575 ($95.00); D3221 ($88.00), D4346 ($40.00), D9248 ($98.50). Please submit any comments or concerns related to this change via the “Submit Comments” function below, or by contacting Olivia Alford by email at Olivia.alford@maine.gov, phone (207)-624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or mail 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: February 26, 2017 Posted: February 16, 2017
 
MaineCare Benefits Manual, Section 96, Private Duty Nursing and Personal Care Services WORD  PDF   
Concise Summary: The Department of Health and Human Services (DHHS) previously requested approval from the Centers for Medicare and Medicaid Services to increase reimbursement for personal care and related services, pursuant to Public Law 2016, Chapter 83 Resolves. Through the corresponding rulemaking process, the Department determined another code in MBM, Section 96, should see a rate increase. This code is T1019 0589, and the rate will be increased to $4.62. The correction of this clerical error is consistent with the rate for the same service under Procedure Code T1019 that was set forth in the rule proposal, and is a benefit to both providers and members. Please submit any comments or concerns related to this change via the “Submit Comments” function below, or by contacting Olivia Alford by email Olivia.alford@maine.gov, phone (207)-624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or mail 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: January 13, 2017 Posted: January 9, 2017
 
MaineCare Benefits Manual, Section 68, Occupational Therapy Services and Section 85, Physical Therapy Services WORD  PDF   
Concise Summary: Effective January 1, 2017, the Current Procedural Terminology coding manual Occupational Therapy codes 97003 and 97004 are being eliminated and replaced with codes 97165, 97166, 97167, and 97168. Effective the same date, the Current Procedural Terminology Physical Therapy coding manual codes 97001, 97002, are being eliminated and replaced with codes 97161, 97162, 97163, and 97164. Please see attachment for proposed rates. Please submit any comments or concerns related to this change via the “Submit Comments” function below, or by contacting Olivia Alford by email Olivia.alford@maine.gov, phone (207)-624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or mail 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: January 2, 2017 Posted: December 22, 2016
 
MaineCare Benefits Manual, Chapter III, Section 5, Ambulance Services WORD  PDF   
Concise Summary: The Department will request approval to institute the following reimbursement rates for Ambulance Services. Medicare-covered codes will be reimbursed at 65% of the current published Maine Medicare area ‘99’ rates, except for the following services which will continue to be reimbursed at current levels: A0430, A0431, A0434, A0436 . Non-Medicare covered ambulance services will continue to be reimbursed based on the current fee schedule. The public may review the proposed methodology changes and written comments at any Maine DHHS office in every Maine County. To find out where the Maine DHHS offices are, call 1-800-452-1926. Please submit any comments or concerns related to this change via the “Submit Comments” function below, or by contacting Olivia Alford by email Olivia.alford@maine.gov, phone (207)-624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or mail 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: December 30, 2016 Posted: December 15, 2016
 
MaineCare Benefits Manual, Section 109, Speech and Hearing Services (UPDATED NOTICE) WORD  PDF   
Concise Summary: This entry contains an updated fiscal impact estimate for the addition of the following code to the State Plan: 92586: Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; limited (see below).
Submit Comments (Opens in new window) Comment Deadline: December 9, 2016 Posted: December 8, 2016
 
MaineCare Benefits Manual, Section 109, Speech and Hearing Services WORD  PDF   
Concise Summary: The Department of Health and Human Services will request approval from the Centers for Medicare and Medicaid Services to add the following procedure code to the Speech and Hearing Services’ fee schedule in the State Plan: 92586: Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; limited. Agency Rate: $37.14 per session, Independent Rate $26.82 per session. The additional code allows providers to bill for limited audiometry and/or testing of the central nervous system; comprehensive audiometry and/or testing is already a covered service. The public may review the proposed methodology changes and written comments at any Maine DHHS office in every Maine county. To find out where the Maine DHHS offices are located, call 1-800-452-1926. Please submit any comments or concerns related to this change via the “Submit Comments” function below, or by contacting Olivia Alford by email Olivia.alford@maine.gov, phone (207)-624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or mail 242 State St., SHS#11, Augusta, ME 04333.
Submit Comments (Opens in new window) Comment Deadline: December 9, 2016 Posted: December 6, 2016
 
MaineCare Benefits Manual, Section 95, Podiatric Services WORD  PDF   
Concise Summary: The Department of Health and Human Services will request approval from the Centers for Medicare and Medicaid Services to describe the reimbursement methodology for Podiatric Service. The following language does not reflect a change in reimbursement: The fee schedule reimburses at the lowest of the following for covered services: 1) The lowest amount allowed by Medicare Part B for Maine area “99” fee, 2) 47.70% of the 2005 Medicare Part B for Maine area “99” fee or 47.70% of the rate in the first year that Medicare assigned a rate for the code, or 3) Where no other options are applicable, the Department will research other State Medicaid agencies that cover the relevant service/code and base its rates on the average cost of the relevant services/codes from those other agencies. If the provider’s usual and customary charge for a service is lower than the fee schedule rate, the provider’s usual and customary charge will be reimbursed. In addition, the following code will be added to Section 95, Podiatric Services: 97762, Checkout for orthotic/prosthetic use, established patient, each 15 minutes. Reimbursement will be $11.48 for non-facilities, and $7.79 facilities. The public may review the proposed methodology changes and written comments at any Maine DHHS office in every Maine county. To find out where the Maine DHHS offices are located, call 1-800-452-1926. Please submit any comments or concerns related to this change via the “Submit Comments” function below, or by contacting Olivia Alford by email Olivia.alford@maine.gov, phone (207)-624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or mail 242 State St., SHS#11, Augusta, ME 04333. Comments are due by 11:59 PM on Monday, September 19, 2016.
Submit Comments (Opens in new window) Comment Deadline: September 19, 2016 Posted: September 8, 2016
 
CLARIFICATION TO POSTING BELOW: MaineCare Benefits Manual Section 12, Consumer Direct Attendant Services and Section 96, Private Duty Nursing and Personal Care Services      
Concise Summary: The comment deadline for MaineCare Benefits Manual Section 12, Consumer Direct Attendant Services and Section 96, Private Duty Nursing and Personal Care Services is 11:59 p.m. Tuesday, September 13th.
Submit Comments (Opens in new window) Comment Deadline: September 13, 2016 Posted: September 8, 2016
 
MaineCare Benefits Manual Section 12, Consumer Direct Attendant Services and Section 96, Private Duty Nursing and Personal Care Services WORD  PDF   
Concise Summary: The Department of Health and Human Services (DHHS) will request approval from the Centers for Medicare and Medicaid Services to increase reimbursement for personal care and related services, pursuant to Public Law 2016, Chapter 83 Resolves. Please see the attachment for how rates in MaineCare Benefits Manual, Section 12, Consumer Direct Attendant Services and Section 96, Private Duty Nursing and Personal Care Services will be restructured. To avoid a reduction in services available to members receiving services under Section 96, Private Duty Nursing and Personal Care Services, DHHS will increase the applicable monthly cost caps to account only for the increase in reimbursement. The public may review the proposed methodology changes and written comments at any Maine DHHS office in every Maine county. To find out where the Maine DHHS offices are located, call 1-800-452-1926. The Department will hold a hearing for the proposed rulemaking and will be publishing a notice which includes information on the hearing date and location. Please submit any comments or concerns related to this change via the “Submit Comments” function below, or by contacting Olivia Alford by email Olivia.alford@maine.gov, phone (207)-624-4059 or TTY: 711 Maine Relay (Deaf or Hard of Hearing), Fax (207) 287-1864, or mail 242 State St., SHS#11, Augusta, ME 04333. Comments are due by 11:59 PM on Tuesday, September 6, 2016. Note: This methodology notice was originally published in state newspapers on July 28, 2016.
Submit Comments (Opens in new window) Comment Deadline: September 13, 2016 Posted: September 2, 2016
 

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