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Home > Medicaid Rules Changes: Questions and AnswersBelow are answers to questions posed to the Departments of Health and Human Services and Education about how federal Medicaid rules changes will affect Maine. The departments continue to review the changes. These are our best understanding at this time of the impacts. Targeted Case Management Will there be a list of criteria for what constitutes a billable 15-minute service? Prior to the time the rule becomes effective, MaineCare will provide training in documentation and billing for providers. [4/8/2008] When will the TCM agencies know what the 15-minute rate will be and how will we interface with APS Healthcare? Will we still bill monthly? The 15-minute billing rate has been set at $21.52 per quarter hour. If you are involved with APS that relationship will not change. Once the rule becomes final you will be required to bill in 15-minute increments rather than monthly. [4/8/2008] What is the expectation for documentation per 15-minute interval? Prior to the time the rule becomes effective MaineCare will provide training in documentation and billing for providers. [4/8/2008] What happens if there are glitches in the MaineCare payment to providers due to these changes? We are a small agency and require our payment in a timely manner in order to meet payroll. MaineCare is working to assure that the change in billing methods will proceed smoothly and providers will be paid in a timely manner. Agencies will need to be sure that they bill in accordance with the new rules to help facilitate timely payments. [4/8/2008] MaineCare will provide training to providers and the expectation is that providers will inform their clients about the new rules as appropriate. Because the changes primarily affect billing there should be little impact on the relationship between the provider and the client. [4/8/2008] Is there a plan to cross-train case managers in system resources given the intent of this rule to have only one case manager? As the date for the single case manager gets closer, the Departments will work with providers to determine how the single case manager will be determined and what training will be necessary to facilitate that change. [4/8/2008] Has a rate been determined for providers given that we have less than 30 days now to move from our currently monthly rate to the new quarter hour billings rate? The rate has been set at $21.52 per quarter hour for case management.[4/8/2008] How and when are CDS sites going to be given new procedures for documenting TCM and for billing TCM? Will we receive training for their new documentation and billing procedures? Yes, prior to the time the rules become effective. [4/8/2008] Who decides and how will it be determined who will be the single case manager? Both Departments of Education and Health and Human Services will examine the most effective manner for the determination of the single case manager. Realistically, this will have to occur over time with consideration of other federal statues and regulations Regarding Child Development Services, the Department of Education will consider the responsibilities of CDS and school administrative units under the Individuals with Disabilities Education Act [IDEA]. Under Part C (for children Birth through age 2)of the Act case management is an entitlement as an early intervention service, regardless of the source of payment. Likewise, under Part B case management is an entitlement as a related service. Therefore, these services will need to continue to be provided to eligible children, pursuant to IDEA. [3/3/08] How will the single case manager requirement affect Student Assistance Teams? The Departments will examine the most effective manner for the determination of the single case manager. Given the complexity and need for time for the conversion from current practice this will not be in place until end of the state legislative session in 2009.[3/3/08] Do the Targeted Case Management (TCM) changes apply to only Section 13 services, or to other case/care management services? If other case management services are included, what is the impact in those areas? At this point, we are only looking at the case management services provided under Section 13. It is likely, however, that we will also have to unbundle case management from other services. [3/3/08] If the one case manager per-person becomes a fact, what is the plan on how to train these case managers to meet the multiple needs of their clients? The Departments affected by this part of the rule change are working on a plan to determine the most appropriate case manager and then determine the necessary training. [3/3/08] Has new TCM rate per 15 minutes been established? Will this new rate apply to CDS, too? The rate that has been established is $21.52 per 15-minute interval. This rate may be adjusted at a later date.[3/3/08] Since TCM date is 3/3/08, has DHHS been working on conversion for billing? DHHS will continue to work to assure that all of our systems are ready for the change in as timely a manner as possible. [3/3/08] How will unbundling affect ACT teams, particularly in terms of case management? We are currently looking at that issue to comply with the new rule without dismantling this evidence-based successful service delivery model. [3/3/08] What do these rules mean in terms of the various case management services provided by DHHS? The full impact of the rule changes are unknown at this time, but it is clear that billing will be in 15-minute segment. In addition, only one case manager will be allowed per member and case management cannot be billed if it is considered an integral part of another non-medical program, such as child welfare/child protective services, probation and parole, public guardianship or special education. [3/3/08] Are there any differences regarding case management services for children vs. adults? The regulations do not differentiate between case management services for adults and children. However, there are differences in the eligibility criteria. [3/3/08] If a child has Case Manager and parent has a Case Manager, can there be two Case Managers? Are state ‘rainy day funds’ being considered to close the gap? The Governor stated that he would not use ‘rainy day funds’ to close the $95 million budget shortfall. [3/3/08] Will current child welfare contracts under DHHS be null and void as of 3/3? All contracted services may continue to bill as they have for case management while we work toward compliance. Providers will be notified when they can no longer bill for these services. [3/3/08] Does the entire ACT team have to bill in 15-minute increments? Not at this time. [3/3/08] If someone has a guardian, is the guardian the case manager? The role of a case manager is much different from that of a guardian. [3/3/08] Will providers be involved in the plan? We have notified CMS of our desire to submit a compliance work plan, stating that we will likely not be in full compliance on March 3. We will ask for comments and input from providers while working to be incompliance in as timely a manner as possible. [3/3/08] Right now TCM is billed in one unit, per person per month. How will the number of 15-minute increments be decided for each person? The cap on billable units has not been determined, but the intent is that there will be flexibility to allow case managers to meet the needs of their clients. [3/3/08] Is the State of Maine able to reconstitute the job descriptions in TCM so that case managers will know the dos and don’ts? The targeted case management policy will be refined to articulate the new federal regulatory language. In particular, the new policy will be clear that the case manager cannot be a provider of services to the child. [3/3/08] Can two TCM managers share units up to the cap? Because each member will be allowed only one case manager after July 2009, there would be no ability to share units. [3/3/08] Can an agency that provides case management for children birth to five provide case management for ages 5-20? Yes, if they meet the provider qualifications. [3/3/08] Rehabilitative Services How does this change affect MaineCare patients in long term care facilities (LTC) that required rehabilitative services such as PT, OT and SLP? Are these patients not going to have this benefit covered? Therapy services to MaineCare eligible clients that are provided by qualified providers are not at risk and will continue to be billable to MaineCare.[4/8/2008] Rehab services rendered to patients in psychiatric hospitals will not be covered. Does this include psychiatric units within a hospital? Please clarify. As far as we can tell, the changes in the rehabilitation rule do not have any effect on hospitals or the way they bill. [4/8/2008] The presentation spoke of disallowance for Adult Protective Services function. Could you spell those out? On the mental retardation side of things, there are agency Medicaid-funded Certified Investigators who do APS investigations and other associated work. Is there any threat to their funding? Is there any threat to the mental retardation adult protective services within central and regional offices? The change in the Adult Protective Services program is limited to billing for targeted case management services by those state employees who work for Adult Protective Services as CMS believes that the case management services provided by those employees is “intrinsic to” the APS program and cannot be billed separately. [4/8/2008] Are day habilitation services to people living in an ICF/MR nursing facility affected by these rule changes? There is an expectation that people living in an ICF/MR nursing facility are expected to improve and are NOT considered maintenance services. Day habilitation services are provided in ICF/MR facilities are disallowed in the new rule, however that part of the rule does not become effective until at least some time in 2010, depending upon when the proposed rehabilitation rule goes into effect. [4/8/2008] How will the proposed federal changes affect billing for School-based Rehabilitative Services? Which services are under the rehabilitative option and which are under EPSDT? The following services are included in the rehabilitative services section of the Maine State Plan (and not under EPSDT):
The new proposed regulations, 42 CFR Parts 440 and 441, appear to have significant implications for the Maine Department of Education due to a significant change in policy on the federal level. Rehabilitative services can not be “maintenance” services. The preamble to the proposed rule takes the position that the rehabilitation benefit “is not a custodial care benefit” but “should result in a change in status.” This means that the rehabilitation plan must have objectives expressed “in terms of measurable reductions in a diagnosed physical or mental disability and in terms of restored functional abilities.” While CMMS recognizes that “rehabilitation goals are often contingent on the individual’s maintenance of a current level of functioning,” the proposed rule states that: “services that provide assistance in maintaining functioning may be considered rehabilitative only when necessary to help an individual achieve a rehabilitation goal as defined in the rehabilitation plan.” 440.130(d)(1)(vi). Such a definition would appear to preclude any use of the rehabilitation benefit to provide services to an individual over an extended period of time, as it appears that there must be continual progress made to an identifiable goal, not simply the maintenance of a state that would otherwise deteriorate in the absence of the service” It is possible that very few of our children eligible under IDEA criteria could be served, thereby increasing the cost to the state and also appearing to conflict with the federal IDEA statute about accessing public insurance before expending IDEA funds. [3/3/08] How will the federal changes affect billing for Day Treatment programs? Day treatment is part of the Rehabilitative services section of Maine’s State Plan and therefore is impacted by the CMMS proposed regulation. [3/3/08] What does Commissioner Gendron mean when she speaks of the impact on “maintenance of effort” in the Essential Programs and Services (EPS) special education formula? The Essential Programs and Services (EPS) formula for special education takes into account the “maintenance of effort” necessary for each school administrative unit (SAU). The potential change in Medicaid reimbursement will impact SAUs differently in the EPS formula. [3/3/08] Will providers of developmental therapy be impacted by the changes? Specialized instruction or developmental therapy is an entitlement service under IDEA. If the federal Medicaid policy will not permit the service as a covered service the Department of Education will need to seek additional state general funds to pay the community providers for those services that are on children’s IFSPs and IEPs, that were formerly reimbursed through Medicaid. [3/3/08] How and when will the funding of Developmental Therapy, occupational therapy, physical therapy and speech therapy services be impacted for Medicaid eligible children served within the CDS System? Developmental therapy is covered under the Early Intervention services policy contained within the Rehabilitative services section of the Maine State Plan. Developmental Therapy will be impacted by the implication that specialized instruction will no longer be a covered service for purposes of Medicaid reimbursement. However, developmental therapy, which is known as specially designed instruction under Part C of IDEA for birth through 2 year olds and which is known as special education under Part B of IDEA for children 3-5 years of age, is considered an entitlement service under the federal IDEA statute when the team has determined that the service is necessary for a child. Occupational therapy, physical therapy and speech therapy known as related services under IDEA will be impacted by the changes in the rehabilitative definition, which will impact Medicaid reimbursement. Services to eligible children pursuant to IDEA contained on each child’s individualized plan would continue to be provided by alternative means of funding if Medicaid will no longer be the funding source. [3/3/08] Why isn’t Developmental Therapy being billed to EPSDT? Developmental therapy is covered under the Early Intervention services policy, which is contained within the Rehabilitative services section of the Maine State Plan, not under EPSDT. [3/3/08] Where can we get information on how the rehabilitation services affect agencies, schools, and citizens? We need clear, concise information that is understandable to everyone. We have begun the analysis on the impact of these rehab rules, which are complex and take effect in July. That analysis will be shared as soon as it is completed. [3/3/08] Over the past several months I have heard Rehabilitation Services often referred to as ‘optional services,’ specifically OT and Speech. Is there a thought process out there that these services are not necessary? Optional services, as defined by Medicaid, are: Podiatrists What is the definition of “maintenance service?” A “maintenance service” is one that maintains a person’s skills, but does not lead to measurable progress and change. [3/3/08] What is the impact regarding Private Non-Medical Institutions (PNMI)? PNMIs have been billed using a bundled daily rate. This service will need to be unbundled and each component billed separately. There are components of the rate that may not fit into any other billing section and will not be able to be billed to Medicaid. To accurately answer this question requires a great deal of analysis, which is underway. Service providers will be kept informed as we complete this analysis. Currently, the extent of the impact of the rule change is not well defined. [3/3/08] Administrative and Transportation Services Will the transportation cuts only impact schools? Yes. the proposed transportation regulation will impact both schools and day treatment facilities, as that is where some of the students receive their specialized services. [3/3/08] Is transportation to medical appointments being eliminated? Is it eliminated from CAP programs or schools – neither or both? Transportation for school age children to and from school is not permitted. However transportation for children under school age will continue to be reimbursable for transportation to and from medically related services. Transportation to specially designed instruction (for Birth to 2 year olds) or special education (for 3 to 5 year olds)will not be reimbursable under the proposed Medicaid regulations. [3/3/08] General
Yes. We have been in close communication with Multi State Billing and they assure us of their continuing commitment to providing data to SAU’s regarding potential impact specific to their current billing records. [3/3/08] How should schools prepare their budgets with so many unknowns regarding funding? Unless the moratorium extensions are successful, each SAU should proceed as if the School-based Rehabilitation and Targeted Case Management Medicaid will no longer be reimbursable and budget accordingly. Education Commissioner Gendron has proposed to the Legislature’s Appropriations Committee funding to address the state’s share of School-based Rehabilitation costs. The Appropriations Committee continues to deliberate the FY09 supplemental budget which includes that proposal. [3/3/08] Will the DOE continue to be responsible for services for children birth to 5-years old that are required by IDEA? There are two parts to this response. Yes, both the SAU and the DOE must continue to provide services that are contained in appropriately developed IFSPs or IEPs even if the CMMS regulations would not permit them as covered services. [3/3/08] Are MR, Autism, PDD defined as ‘medically necessary’ conditions? Yes. All of the above will be eligible for case management services if the individual is Medicaid-eligible. [3/3/08] What is your timetable for implementing the rule changes? Most of the CMS regulations, with the exception of some parts of Targeted Case management are to go into effect on July 1, 2008. Targeted Case Management dates are March 3, 2008 and July, 2009. [3/308] How are consumers going to be updated? This web page, which is linked to both the Department of Health and Human Services and the Department of Education, will offer updates. In addition, our provider listserv will keep providers informed. [3/3/08] Why was there such a lag time between the president’s veto and the announcement of the cuts? There was less than two weeks between the President’s veto of the SCHIP which had an 18-month moratorium in place and the President’s signing of the Omnibus budget bill which had a 6-month moratorium. There are three new Congressional bills that would extend the moratoriums into 2009. [3/3/08] Are the other states appealing? Many states, including Maine, are evaluating the new rules to see if a legal challenge should be made. [3/3/08]
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