Proposed and Recently Adopted

All adopted rules are maintained by the Secretary of State and are available in the MaineCare Benefits Manual.

Please Note: If you are unable to submit a comment, please contact the policy writer identified in the rule directly.

Proposed Rules

MaineCare Benefits Manual, Chapter II, Section 103, Rural Health Clinic Services

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AGENCY: Department of Health and Human Services, MaineCare Services, Division of Policy

CHAPTER NUMBER AND TITLE: 10-144 C.M.R., Chapter 101, Chapter II, Section 103, Rural Health Clinic Services

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This rule is proposed to comply with P.L. 2019, Ch. 530, An Act to Prevent and Reduce Tobacco Use with Adequate Funding and by Equalizing the Taxes on Tobacco Products and To Improve Public Health. Part C, Sec. C-4, of the Act requires the Department to amend the rural health clinic services reimbursement methodology to provide rural health clinics with an alternative payment methodology option. Each rural health clinic must be given the option to be reimbursed under the existing prospective payment system methodology, or as of January 1, 2020, the alternative payment methodology of being reimbursed on the basis of 100% of the average of the reasonable costs of providing MaineCare-covered services during calendar years 2016 and 2017, as long as reimbursement is no less than reimbursement received under the current prospective payment system.

The current reimbursement method is based on 100% of the average of the reasonable costs of providing MaineCare-covered services during calendar years 1999 and 2000, with historical Medicare Economic Index (MEI) adjustments.

The resulting average, under both methods, is adjusted to account for any increase or decrease in the approved scope of services furnished during the provider's fiscal year 2001 or 2018, respectively, calculating the amount of payment on a per visit basis.

The Department shall submit to CMS and anticipates approval for a State Plan Amendment related to these provisions effective retroactive to January 1, 2020.

See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.

STATUTORY AUTHORITY: 22 M.R.S. 42, 3173, P.L. 2019, Ch. 530

PUBLIC HEARING: For this rulemaking, a public hearing will not be held due to the COVID-19 public health emergency. The Department will accept email and standard mail comments for 30 days from the publication date of the notice of rulemaking by the Secretary of State.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 p.m. August 28, 2020.

AGENCY CONTACT PERSON: Anne E. Labonte, Comprehensive Health Planner II AGENCY NAME: Office of MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: Anne.Labonte@Maine.gov TELEPHONE: 207-624-4082 FAX: (207) 287-6106 TTY: 711 (Deaf or Hard of Hearing)

IMPACT ON MUNICIPALITIES OR COUNTIES (if any): The Department anticipates that this rulemaking will not have any impact on municipalities or counties.

Comment deadline past Comment Deadline: August 28, 2020 | Posted: July 29, 2020

MaineCare Benefits Manual, Chapter VII, Section 5, Estate Recovery

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Concise Summary:

AGENCY: Department of Health and Human Services, MaineCare Services, Division of Policy

CHAPTER NUMBER AND TITLE: 10-144 C.M.R., Chapter 101, MaineCare Benefits Manual, Chapter VII, Section 5, Estate Recovery

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This rule is being proposed to clarify when an estate recovery claim is subject to recovery in accordance with guidance from the federal Centers for Medicare and Medicaid Services (CMS). Specifically, it changes the requirement in Section 5.04-1, Processing Claims Against Assets, part D, to state that any surviving child who is blind or permanently and totally disabled, be disabled at the time the Department seeks recovery. The previous marker was set at the time of the member's death.

The Department also proposes the following changes:

  • Adding language to 5.04-1(D) to define the phrase, "the time the Department seeks recovery" to mean the earlier of (1) the date of the Departments notice of claim to the legally authorized representative of the estate or known family members or heirs; or (2) the date on which the Department files a claim in Probate Court.
  • Adding numbering to 5.07(A) to clarify the application process requirements for all waivers.
  • Adding language to 5.08(A)(1)(b) to provide guidance on how the 180% of the Federal Poverty Income level is determined by the Department and what income and asset information is required by the applicant for evaluation.
  • Adding language for clarification to 5.08(B)(2)(a) to specify 24 hours a day care must be provided to the member and adding an additional requirement that the member could not be receiving in home services.
  • Adding clarification to 5.08(B)(2) that an applicant will receive the highest allowable waiver in instances when an applicant may qualify for more than one care given hardship waiver.
  • Updating language in 5.09(B) for clarification of the current Departmental reference.
  • Adding clarification to 5.10(A) to incorporate limits of allowable expenses following the Members death.
  • Finally, the Department is proposing minor language, clerical, and reference number edits.

See https://www.maine.gov/dhhs/oms/about-us/policies-rules for rules and related rulemaking documents.

STATUTORY AUTHORITY: 22 M.R.S. 42, 3173


PUBLIC HEARING: No public hearing scheduled.

Note: During the Civil State of Emergency declared by the Governor, public hearings are now closed to the public physically attending. During this State of Emergency, the Department will be providing a 30-day comment period instead of a public hearing.

PUBLIC NOTICED: July 8, 2020

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on August 7, 2020.

Comment deadline past Comment Deadline: August 7, 2020 | Posted: July 8, 2020

MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services

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Concise Summary:

AGENCY: Department of Health and Human Services, MaineCare Services, Division of Policy

CHAPTER NUMBER AND TITLE: 10-144 C.M.R., Chapter 101, MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This rulemaking proposes to make the following changes:

As directed by P.L. 2019, ch. 530, An Act to Prevent and Reduce Tobacco Use with Adequate Funding and by Equalizing the Taxes on Tobacco Products and To Improve Public Health, the Department is proposing the following changes:

  1. Pursuant to Sec. C-2, the Department proposes to establish two subsets of Private Acute Care Non-Critical Access Hospitals; rural hospitals and non-rural hospitals. The Department's proposed definition of "rural hospital" followed the Legislative directive so that the definition reflects the regional access to hospital care and the population density of the public health district in which the hospital is located. The proposed definition of a private acute care non-critical access rural hospital is a hospital, as reported on the hospitals Medicare cost report, which is either: a Sole Community Hospital, OR a Medicare -Dependent Hospital, OR is a hospital participating in the Medicare Rural Community Hospital Demonstration. As required by the law, the following hospitals meet the rural hospital definition: Northern Light A.R. Gould Hospital in Presque Isle; Cary Medical Center in Caribou; Franklin Memorial Hospital in Farmington; Northern Light Inland Hospital in Waterville; Northern Light Maine Coast Hospital in Ellsworth; and Northern Maine Medical Center in Fort Kent.

  2. Pursuant to Sec. C-2, the Department proposes to reimburse Private Acute Care Non-Critical Access Rural Hospitals at 100% of inpatient hospital- based physician costs, outpatient emergency room hospital- based physician costs, outpatient non-emergency room hospital-based physician costs and graduate medical education costs. Pursuant to Legislative directive and funding, this provision will be effective retroactive to January 1, 2020. The retroactive application of this provision is authorized pursuant to 22 M.R.S. 42(8), which allows retroactive application where there is a benefit to a provider, as is the case with this rule.

  3. Pursuant to Sec. C-2, the Department proposes to reimburse Private Acute Care Non-Critical Access Non-Rural Hospitals at 93.3% of inpatient hospital-based physician costs, 93.4% of outpatient emergency room hospital-based physician costs and 83.8% of outpatient nonemergency room hospital- based physician costs. Pursuant to Legislative directive and funding, this provision will be effective retroactive to January 1, 2020. The retroactive application of this provision is authorized pursuant to 22 M.R.S. 42(8), which allows retroactive application where there is a benefit to a provider, as is the case with this rule.

  4. Pursuant to Sec. C-3, the Department proposes to reimburse Acute Care Critical Access Hospitals for 100% for all hospital-based physician costs. Pursuant to Legislative directive and funding, this provision will be effective retroactive to January 1, 2020. The retroactive application of this provision is authorized pursuant to 22 M.R.S. 42(8), which allows retroactive application where there is a benefit to a provider, as is the case with this rule.

The Department has submitted State Plan Amendment requests to CMS and anticipates approval of the SPA requests.

As directed by P.L. 2019, ch. 343, An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund, and Other Funds, and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years ending June 30, 2019, June 30, 2020, and June 30, 2021, Part A, Sec. 129, the Department is proposing the following change:

The Supplemental Pool for the Acute Care Critical Access Hospitals and also for Non-Critical Access Hospitals, Hospitals Reclassified to a Wage Area Outside Maine, and Rehabilitation Hospitals was increased.

In addition: The Department is proposing to clarify that each hospitals year, as used for the calculation, is the hospitals fiscal year that ended during calendar year 2016.

See https://www.maine.gov/dhhs/oms/about-us/policies-rules for rules and related rulemaking documents.

STATUTORY AUTHORITY: 22 M.R.S. 42(1) & (8), 3173

PUBLIC HEARING: No public hearing is scheduled.

NOTE: During the Civil State of Emergency declared by the Governor, public hearings are now closed to the public physically attending. During this State of Emergency, the Department will be providing a 30-day comment period in lieu of a public hearing.

PUBLIC NOTICE: June 17, 2020

COMMENT DEADLINE: Comments must be received by 11:59 PM on July 17, 2020.

AGENCY CONTACT PERSON: Anne E. Labonte, Comprehensive Health Planner II
AGENCY NAME: MaineCare Services
ADDRESS: 109 Capitol Street, 11 State House Station
Augusta, Maine 04333-0011
EMAIL: Anne.Labonte@Maine.gov
TELEPHONE: (207)-624-4082 FAX: (207) 287-6106
TTY: 711 (Deaf or Hard of Hearing)

IMPACT ON MUNICIPALITIES OR COUNTIES (if any): The Department anticipates that this rulemaking will not have any impact on municipalities or counties.

CONTACT PERSON FOR SMALL BUSINESS INFORMATION (if different): N/A

Comment deadline past No comment deadline | Posted: June 17, 2020

MaineCare Benefits Manual, Chapter III, Section 5, Ambulance Services

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Concise Summary:

AGENCY: 10-144 - Department of Health and Human Services, Office of MaineCare Services

CHAPTER NUMBER AND TITLE: 10-144 C.M.R. ch. 101, MaineCare Benefits Manual (MBM), Chapter III, Section 5, Ambulance Services

PROPOSED RULE NUMBER:

CONCISE SUMMARY: The Department proposes to amend Chapter III, Section 5, Ambulance Services to comply with P.L. 2019, ch. 530, Part B, An Act to Prevent and Reduce Tobacco Use with Adequate Funding and by Equalizing the Taxes on Tobacco Products and To Improve Public Health, by increasing the MaineCare reimbursement rate for ambulance services to a level that is not less than the average allowable reimbursement rate under Medicare for such services and to reimburse for neonatal transport services under MaineCare at the average rate for critical care transport services under Medicare effective retroactive to January 1, 2020.

See https://www.maine.gov/dhhs/oms/about-us/policies-rules for rules and related rulemaking documents.

STATUTORY AUTHORITY: 22 M.R.S. 42, 3173; P.L. 2019, ch. 530, Part B

PUBLIC HEARING: No public hearing is scheduled.

NOTE: During the Civil State of Emergency declared by the Governor, public hearings are now closed to the public physically attending. During this State of Emergency, the Department will be providing a 30-day comment period in lieu of a public hearing.

COMMENT DEADLINE: Comments must be received by 11:59 PM on July 17, 2020, and can be submitted by email, regular mail, or online at https://www.maine.gov/dhhs/oms/rules/proposed.shtml

AGENCY CONTACT PERSON: Anne E. Labonte, Comprehensive Health Planner II
AGENCY NAME: MaineCare Services
ADDRESS: 11 State House Station, 109 Capitol Street
Augusta, Maine 04333-0011 EMAIL: Anne.Labonte@Maine.gov
TELEPHONE: (207) 624-4082 FAX: (207) 287-6106
TTY: 711 (Deaf or Hard of Hearing)

IMPACT ON MUNICIPALITIES OR COUNTIES (if any): The Department does not anticipate this rulemaking will have an impact on municipalities or counties.

Comment deadline past Comment Deadline: July 17, 2020 | Posted: June 17, 2020

MaineCare Benefits Manual, Chapters II and III, Section 65, Behavioral Health Services

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Concise Summary:

AGENCY: Department of Health and Human Services, MaineCare Services, Division of Policy CHAPTER NUMBER AND TITLE: 10-144 C.M.R., Chapter 101, Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 65, Behavioral Health Service PROPOSED RULE NUMBER: CONCISE SUMMARY: The Department of Health and Human Services ("the Department") proposes the following changes to 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapters II and III, Section 65, Behavioral Health Services. In Chapter II, the Department proposes to remove the twenty-four (24) month lifetime limit for reimbursement for Medication Assisted Treatment (MAT) with Methadone for opioid addiction to align with changes in state law which took effect on March 14, 2019 under P.L. 2019 Ch. 4, An Act To Make Supplemental Appropriations and Allocations for the Expenditures of State Government and To Change Certain Provisions of Law Necessary to the Proper Operations of State Government for the Fiscal Year Ending June 30, 2019, and which were previously announced via the Department's list serv to interested parties on March 22, 2019. The Act repealed 22 M.R.S.A. 3174-SS and 3174-VV which had set limitations on these services. By removing the lifetime limit, members may access MAT with Methadone for as long as medically necessary, with no lifetime cap of services. The Departments removal of the 24- month cap has already been approved by the Centers for Medicare and Medicaid Services (CMS). Additionally, in Chapter III the Department proposes this rule to seek to increase the rate of reimbursement for MAT with Methadone retroactive to July 1, 2019. Pursuant to P.L. 2019, Ch. 343, An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds, and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2019, June 30, 2020 and June 30, 2021, (effective June 17, 2019), the Legislature increased funding for the weekly reimbursement rate for MAT services for the FY2020 and FY2021 state budgets. In light of the states ongoing opioid crisis, the Department has found that the immediate adoption of the MAT rate increase is necessary to avoid an immediate threat to public health, safety, or general welfare under 5 M.R.S. 8054, and will be adopting an emergency rule concurrent with this rule proposal. The emergency rate increase and the Departments intended adoption of the increase following this routine technical rulemaking will benefit both providers and members and will further support the delivery of these critical services to those in need. The Department is seeking and anticipates approval from the CMS for the MAT rate increase. The Department published a Notice of MaineCare Reimbursement Methodology Change on June 28, 2019 notifying providers of this increase and is awaiting approval of a state plan amendment. Pending that approval, the Department will reimburse MAT services at the increased rate retroactive to July 1, 2019. Additionally, the Department proposes to increase of the rates of reimbursement in Chapter III for Functional Family Therapy (FFT), Multisystemic Therapy (MST), Multisystemic Therapy for Problem Sexualized Behaviors (MST-PSB) by 20% effective January 1, 2020 in accordance with Resolves 2019, Ch. 110, Resolve, To Increase Funding for Evidence-based Therapies for Treating Emotional and Behavioral Problems in Children (effective January 12, 2020). In approving this legislation (which became law without the Governors signature), the Legislature determined that an immediate effective date was necessary given the rates had not been adjusted in more than 8 years and the rates were insufficient to enable some providers to continue to provide services. The Department agrees with and incorporated these findings in support of this emergency rulemaking under 5 M.R.S. 8054. The Department is seeking and anticipates CMS approval for the 20% rate increases for FFT, MST, and MST-PSB services. The Department published a Notice of MaineCare Reimbursement Methodology Change on June 28, 2019 of the intended 20% rate increases with the expectation that the Legislature would approve the increases effective July 1, 2019. The Department believes this notice is sufficient despite the legislation not taking effect until January 12, 2020. Pending CMS approval, the Department will reimburse FFT, MST, and MST-PSB services at increased rates retroactive to January 1, 2020. Additionally, following the completion of the rate study directed by Resolves 2019, Ch. 110 and completed by Burns and Associates, the Department is proposing new increased rates for MST, MST-PSB, and FFT. The additional funding has been approved for the FY2021 state budget pursuant to P.L. 2019, Ch. 616, An Act Making Supplemental Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2020 and June 30, 2021 (effective March 18, 2020). Through the rate study process and in line with the Legislatures directive in the Resolve, the Department has made the determination to switch reimbursement from quarter hour billing to a weekly case rate to reflect the requirements for the evidence-based models. In Chapter II, the Department has ended Collateral Contacts for MST, MST-PSB, and FFT as these services have been incorporated into the new weekly case rate, and the Department has also proposed minimum contact standards for providers accessing this new weekly case rate. In Chapter III, the Department has deleted the prior quarter hour codes and added in the new weekly codes and rates. In response to financial challenges and civil emergency created by the COVID-19 pandemic, the Department has advanced the increased rates from the anticipated July 1, 2020 start date approved in the FY2021 budget retroactively to May 1, 2020, in order to provide financial relief, to support stability in the workforce, and to increase access to members in need. The Department has further found that the immediate adoption of the MST, MST-PSB, and FFT rate increases is necessary to avoid an immediate threat to public health, safety, or general welfare under 5 M.R.S. 8054, and will be adopting an emergency rule concurrent with this rule proposal. The emergency rate increase and the Departments intended adoption of the increase following this routine technical rulemaking will benefit both providers and members and will further support the delivery of these critical services to those in need. The Department published a Notice of MaineCare Reimbursement Methodology Change on April 30, 2020 of the intended rate increases and intends to file a State Plan Amendment within the quarter. Pending CMS approval, the Department will reimburse MST, MST-PSB, and FFT at increased weekly rates retroactive to May 1, 2020. The rate study described above additionally developed a rate for an evidence-based modality of outpatient therapy, Trauma Focused Cognitive Behavioral Therapy (TF-CBT). The Department is proposing a service description, and provider requirements in Chapter II and rate in Chapter III for thisevidence-based practice. The Department will be seeking and anticipates CMS approval for these new services that are intended to benefit providers and members alike. In addition, this rulemaking proposes coverage in Chapter II and reimbursement in Chapter III for three evidence-based parenting programs for children with disruptive behavior disorders: Positive Parenting Program (Triple P), the Incredible Years (IY), and Parent-Child Interaction Therapy (PCIT). The Department will be seeking and anticipates CMS approval for these new services that are intended to benefit providers and members alike. With this rule proposal, the Department proposes coding changes to comport with coding updates per the National Correct Coding Initiative for certain Neuropsychological testing services effective January 1, 2019. The reimbursement table for these codes in Chapter III have been adjusted to reflect billing as of January 1, 2019. The changes were made in the system and the public notified via list serve of the coding changes on January 31, 2019, and now the Department wishes to update policy for consistency. Coverage language in Chapter II has been updated to reflect the intent of the new codes. Additionally, the Department proposes changes to the educational requirements for Behavioral Health Professionals in accordance with Resolves 2019, Ch. 99, Resolve, To Change the Educational Requirements of Certain Behavioral Health Professionals (effective Sept. 19, 2019), creating three educational levels: high school diploma or equivalent with a minimum of 3 years direct experience working with children in a behavioral health with a specific plan for supervision and training; a minimum of 60 higher education credit hours in a related field of social services, human services, health or education; and a minimum of 90 higher education credit hours in an unrelated field with a specific plan for supervision and training. The Department has received CMS approval for these changes. The Department proposes to increase rates for certain services in accordance with P.L. 2019 Ch. 616. In response to the COVID emergency and hardships created during this period of civil emergency, the Department has made the decision to advance these rate increase to be effective retroactively to April 1, 2020. The rate changes include an increase for physicians delivering medication management, and an increase for Behavioral Health Professionals providing Home and Community-based Treatment (HCT) services. In order for physicians to access the increased rate of reimbursement, they will be required to use the AF modifier on their claims. Department has found that the immediate adoption of the medication management and HCT rate increases is necessary to avoid an immediate threat to public health, safety, or general welfare under 5 M.R.S. 8054, and will be adopting an emergency rule concurrent with this rule proposal. The emergency rate increases, and the Departments intended adoption of the increase following this routine technical rulemaking will benefit both providers and members and will further support the delivery of these critical services to those in need. The Department published a Notice of MaineCare Reimbursement Methodology Change on March 31, 2020 of the intended rate increases and intends to file a State Plan Amendment within the quarter. Pending CMS approval, the Department will reimburse Behavioral Health Professionals delivering HCT and physicians delivering Medication Management at increased rates retroactive to April 1, 2020. The Department is also proposing to add coverage for Adaptive Assessments, namely the Vineland, ABAS, Bayley, and Battelle rating scales, proposing coverage language within Chapter II and coding within Chapter III of this section. The Department has been allowing coverage for these assessments via the Comprehensive Assessment (code H2000) and wishes to clarify coverage, coding, and rate per assessment. In addition to the above changes, the Department proposes in Chapter II to: Add protections for Adults with Serious and Persistent Mental Illness regarding providers terminating services and accepting referrals for this population as defined in the rule; Modify HCT required team language to allow for flexibility when clinically appropriate; Add background check requirements for staff having direct interaction with members within the provision of services; Update the Comprehensive Assessment and Individualized Treatment Plan (ITP) sections to clearly note what services do not require these documents, and to include in the ITP section a schedule of development and review of the new services; Update Appendix I and II to reflect the changes proposed in this rulemaking; and Update formatting, citations, and references where necessary, including changing Office of Substance Abuse and Mental Health Services to Office of Behavioral Health throughout the rule. For Chapter III, the Department is additionally proposing to add a modifier to Medication Management for Treatment with Suboxone to more clearly show coverage of that medication, which will aid in the Departments licensing efforts for these programs. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. 42, 3173; 5 M.R.S. 8053; P.L. 2019, Ch. 4; P.L. 2019 Ch. 343; Resolves 2019, Ch. 99; Resolves 2019, Ch. 110; P.L. 2019, Ch. 616 PUBLIC HEARING: No public hearing scheduled. During the Civil State of Emergency declared by the Governor, public hearings are now closed to the public physically attending. During this State of Emergency, the Department will be providing a 30-day comment period instead of a public hearing. COMMENT DEADLINE: Comments must be received by 11:59 pm on July 3, 2020. AGENCY CONTACT PERSON: Dean Bugaj, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 TELEPHONE: 207-624-4045 FAX: (207) 287-1864 TTY: 711 (Deaf or Hard of Hearing) IMPACT ON MUNICIPALITIES OR COUNTIES (if any): The Department anticipates that this rulemaking will not have any impact on municipalities or counties.

Comment deadline past Comment Deadline: July 3, 2020 | Posted: June 3, 2020

Recently Adopted Rules

MaineCare Benefits Manual, Chapter III, Section 5, Ambulance Services

WORD | PDF  | COMMENTS   

Concise Summary:

The Department adopts changes to Chapter III, Section 5, Ambulance Services to comply with P.L. 2019, ch. 530, Part B, An Act to Prevent and Reduce Tobacco Use with Adequate Funding and by Equalizing the Taxes on Tobacco Products and To Improve Public Health, by increasing the MaineCare reimbursement rate for ambulance services to a level that is not less than the average allowable reimbursement rate under Medicare for such services and to reimburse for neonatal transport services under MaineCare at the average rate for critical care transport services under Medicare effective retroactive to January 1, 2020.

http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.

EFFECTIVE DATE: October 12, 2020

AGENCY CONTACT PERSON: Anne E. Labonte, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: Anne.Labonte@Maine.gov TELEPHONE: (207)-624-4082 FAX: (207) 287-6106 TTY users call Maine relay 711

Comment deadline past No comment deadline | Posted: October 8, 2020

MaineCare Benefits Manual, Chapters II and III, Section 65, Behavioral Health Services

WORD | PDF  | COMMENTS   

Concise Summary:

The Department of Health and Human Services ("the Department") adopted this rule to finalize the following changes to 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapters II and III, Section 65, Behavioral Health Services.

In Chapter II, the Department proposes to remove the twenty-four (24) month lifetime limit for reimbursement for Medication Assisted Treatment (MAT) with Methadone for opioid addiction to align with changes in state law which took effect on March 14, 2019 under P.L. 2019 Ch. 4, An Act To Make Supplemental Appropriations and Allocations for the Expenditures of State Government and To Change Certain Provisions of Law Necessary to the Proper Operations of State Government for the Fiscal Year Ending June 30, 2019, and which were previously announced via the Department's list serv to interested parties on March 22, 2019. The Act repealed 22 M.R.S.A. 3174-SS and 3174-VV which had set limitations on these services. By removing the lifetime limit, members may access MAT with Methadone for as long as medically necessary, with no lifetime cap on services. The Departments removal of the 24- month cap has already been approved by the Centers for Medicare and Medicaid Services (CMS).

Additionally, in Chapter III the Department adopts this rule to finalize the increased rate of reimbursement for MAT with Methadone retroactive to July 1, 2019. Pursuant to P.L. 2019, Ch. 343, An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds, and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2019, June 30, 2020 and June 30, 2021 (effective June 17, 2019), the Legislature increased funding for the weekly reimbursement rate for MAT services for the FY2020 and FY2021 state budgets. The Department emergency adopted the rate increase on May 21, 2020 after finding the adoption of the MAT rate increase was necessary to avoid an immediate threat to public health, safety, or general welfare under 5 M.R.S. 8054.

The Department is seeking and anticipates approval from CMS for the MAT rate increase. The Department published a Notice of MaineCare Reimbursement Methodology Change on June 28, 2019 notifying providers of this increase and is awaiting approval of a state plan amendment. Pending that approval, the Department will reimburse MAT services at the increased rate retroactive to July 1, 2019.

Additionally, the Department finalized adoption of increases of the rates of reimbursement in Chapter III for Functional Family Therapy (FFT), Multisystemic Therapy (MST), Multisystemic Therapy for Problem Sexualized Behaviors (MST-PSB) by 20% effective January 1, 2020 in accordance with Resolves 2019, Ch. 110, Resolve, To Increase Funding for Evidence-based Therapies for Treating Emotional and Behavioral Problems in Children (effective January 12, 2020). In approving this legislation (which became law without the Governors signature), the Legislature determined that an immediate effective date was necessary given the rates had not been adjusted in more than 8 years and the rates were insufficient to enable some providers to continue to provide services.

The Department is seeking and anticipates CMS approval for the 20% rate increases for FFT, MST, and MST-PSB services. The Department published a Notice of MaineCare Reimbursement Methodology Change on June 28, 2019 of the intended 20% rate increases with the expectation that the Legislature would approve the increases effective July 1, 2019. The Department believes this notice is sufficient despite the legislation not taking effect until January 12, 2020. The Department will reimburse FFT, MST, and MST-PSB services at increased rates retroactive to January 1, 2020.

Additionally, following the completion of the rate study directed by Resolves 2019, Ch. 110 and completed by Burns and Associates, the Department adopted new increased rates for MST, MST-PSB, and FFT. The additional funding has been approved for the FY2021 state budget pursuant to P.L. 2019, Ch. 616, An Act Making Supplemental Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2020 and June 30, 2021 (effective March 18, 2020). Through the rate study process and in line with the Legislatures directive in the Resolve, the Department has made the determination to switch reimbursement from quarter hour billing to a weekly case rate to reflect the requirements for the evidence-based models. In Chapter II, the Department has ended Collateral Contacts for MST, MST-PSB, and FFT as these services have been incorporated into the new weekly case rate, and the Department has also adopted minimum contact standards for providers accessing this new weekly case rate. Following public comment, the Department reviewed and updated the minimum contact requirements to add flexibility and consistency to the evidence based model for the final rule.

In Chapter III, the Department has finalized adoption of deleting the prior quarter hour codes and adding in the new weekly codes and rates. In response to financial challenges and civil emergency created by the COVID-19 pandemic, the Department has advanced the increased rates from the anticipated July 1, 2020 start date approved in the FY2021 budget retroactively to May 1, 2020, in order to provide financial relief, to support stability in the workforce, and to increase access to members in need. The Department further found that the immediate adoption of the MST, MST-PSB, and FFT rate increases was necessary to avoid an immediate threat to public health, safety, or general welfare under 5 M.R.S. 8054, and adopted an emergency rule May 21, 2020.

The Department published a Notice of MaineCare Reimbursement Methodology Change on April 30, 2020 of the intended rate increases and filed a State Plan Amendment with CMS on June 30, 2020. The Department will reimburse MST, MST-PSB, and FFT at increased weekly rates retroactive to May 1, 2020.

The rate study described above also developed a rate for an evidence-based modality of outpatient therapy, Trauma Focused Cognitive Behavioral Therapy (TF-CBT). The Department has adopted a service description and provider requirements in Chapter II and rate in Chapter III for this evidence-based practice. Following public comment, the Department added psychiatrists to the list of qualified professionals delivering TF-CBT. The Department will be seeking and anticipates CMS approval for these new services that are intended to benefit providers and members alike.

In addition, this rulemaking adopts coverage in Chapter II and reimbursement in Chapter III for three evidence-based parenting programs for children with disruptive behavior disorders: Positive Parenting Program (Triple P), the Incredible Years (IY), and Parent-Child Interaction Therapy (PCIT). Following public comment, the Department added language for fidelity monitoring, updated the eligibility criteria for consistency with the evidence-based models and to add the other specified and unspecified disorders to aid in qualifying young children where it may otherwise be inappropriate to render a full diagnosis. The Department has also updated the rate methodology to assure the rate assumptions use current wage data for the appropriate education level determined by the model. This update in methodology resulted in an increase to the final rates for all three services. The Department will be seeking and anticipates CMS approval for these new services that are intended to benefit providers and members alike.

With this rule, the Department adopted coding changes to comport with coding updates per the National Correct Coding Initiative for certain Neuropsychological testing services effective January 1, 2019. The reimbursement table for these codes in Chapter III have been adjusted to reflect billing as of January 1, 2019. The changes were made in the system and the public notified via list serve of the coding changes on
January 31, 2019, and now the Department wishes to update policy for consistency. Coverage language in Chapter II has been updated to reflect the intent of the new codes.

Additionally, the Department adopted changes to the educational requirements for Behavioral Health Professionals in accordance with Resolves 2019, Ch. 99, Resolve, To Change the Educational Requirements of Certain Behavioral Health Professionals (effective Sept. 19, 2019), creating three educational levels: high school diploma or equivalent with a minimum of 3 years direct experience working with children in a behavioral health with a specific plan for supervision and training; a minimum of 60 higher education credit hours in a related field of social services, human services, health or education; and a minimum of 90 higher education credit hours in an unrelated field with a specific plan for supervision and training. The Department has received CMS approval for these changes.

The Department finalized adoption of increased rates for certain services in accordance with P.L. 2019 Ch. 616. In response to the COVID emergency and hardships created during this period of civil emergency, the Department made the decision to advance these rate increases to be effective retroactively to April 1, 2020. The rate changes include an increase for physicians delivering medication management, and an increase for Behavioral Health Professionals providing Home and Community-based Treatment (HCT) services. In order for physicians to access the increased rate of reimbursement, they will be required to use the AF modifier on their claims. The Department found that the immediate adoption of the medication management and HCT rate increases was necessary to avoid an immediate threat to public health, safety, or general welfare under 5 M.R.S. 8054, and adopted this change through an emergency rule on May, 21, 2020.

The Department published a Notice of MaineCare Reimbursement Methodology Change on March 31, 2020 of the intended rate increases and filed a State Plan Amendment with CMS on June 30, 2020. The Department will reimburse Behavioral Health Professionals delivering HCT and physicians delivering Medication Management at increased rates retroactive to April 1, 2020.

The Department also adopted new coverage for Adaptive Assessments, namely the Vineland, ABAS, Bayley, and Battelle rating scales, adding coverage language within Chapter II and coding within Chapter III of this section. The Department has been allowing coverage for these assessments via the Comprehensive Assessment (code H2000) and wishes to clarify coverage, coding, and rate per assessment.

In addition to the above changes, the Department adopted changes in Chapter II which:

Added protections for Adults with Serious and Persistent Mental Illness regarding providers terminating services and accepting referrals for this population as defined in the rule; Modified HCT language regarding team requirements to allow for flexibility when clinically appropriate; Added background check requirements for staff having direct interaction with members within the provision of services; Updated the Comprehensive Assessment and Individualized Treatment Plan (ITP) sections to clearly note what services do not require these documents, and to include in the ITP section a schedule of development and review of the new services; Updated Appendix I and II to reflect the changes proposed in this rulemaking; and Updated formatting, citations, and references where necessary, including changing Office of Substance Abuse and Mental Health Services to Office of Behavioral Health throughout the rule.

For Chapter III, the Department adopted a modifier to Medication Management for Treatment with Suboxone to more clearly show coverage of that medication, which will aid in the Departments licensing efforts for these programs.Considering public comment, in addition to the changes to the final rule described above, the Department made the following changes to the final rule:

The Department has added Providers shall participate with the Department in fidelity monitoring according to the Department determined process to 65.06-17.

The Department updated the contact standard for MST and MST-PSB as follows:

MST Providers must meet a minimum of two (2) contacts per week, met by one (1) face-to-face or interactive telehealth contact, and either a second face-to-face or interactive telehealth contact or clinically substantive telephonic contact.

MST-PSB Providers must meet a minimum of three (3) contacts per week, met by one (1) face-to-face or interactive telehealth contact per week with MST clinician (masters or bachelor-level) and additional contacts met by a combination of face-to-face or interactive telehealth, or clinically substantive telephonic contact. Contacts may include individual therapy sessions for identified child, family therapy sessions, scheduled team meetings, or home or community-based skill-building sessions.

The Department struck home or community skill building sessions from the contact minimums stated in 65.08-9.

The Department amended 65.08-9 to reflect clinical intervention vs session and has amended the description of qualifying contacts in this section.

The Department added FFT therapists to the list of Other qualified Staff in 65.09-1.

The Department updated the minimum contact standards in 65.08-9 to reflect minimum contacts delivered on an average of required weekly contacts per month.

The Department amended the minimum contact language for MST and MST-PSB to update language from sessions to contacts and scheduled team meetings to clinically necessary team or stakeholder meetings.

The Department updated 65.02-22, the definition of Functional Family Therapy, as recommended by the commenter.

The Department updated 65.03-2 and 65.03-4 to clarify agencies are licensed by the Division of Licensing and Certification and to add that notification of changes in the level of licensure must go to DHHS, including the Office of MaineCare Services, the Office of Child and Family Services, and/or the Office of Behavioral Health.

The Department updated 65.09-7 to remove inconsistencies and to reflect the current requirements of 22 MRS 9051-9065 (the Maine Background Check Center Act), and the Maine Background Check Center rule, 10-144 CMR Ch. 60.

The Department updated 65.02-40 to reflect the current version of the Diagnostic and Statistical Mental of Mental Disorders (DSM).

The Department updated 65.06-7 to remove the formal training in the ethical administration, scoring, and interpretation of clinical assessments requirements of this section, focusing more on licensed clinicians acting within their scope of practice.The Department updated 65.06-9.A to update the list of assessment tools currently approved by the Department for determining eligibility for Home and Community Based Treatment.

The Department updated Chapter III and the description of H2021 HN, HN U1, and G9007 HN to reflect Behavioral Health Professional, and not a specific education level.

The Department added and current employees to the Background Check requirements in 65.09-7.

The Department added with the members consent as suggested for 65.09-A.1.

See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.

HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.

EFFECTIVE DATE: August 19, 2020

AGENCY CONTACT PERSON: Dean Bugaj, Comprehensive Health Planner II Dean.Bugaj@maine.gov AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011

TELEPHONE: 207-624-4045 FAX: (207) 287-1864 TTY: 711 (Deaf or Hard of Hearing)

Comment deadline past No comment deadline | Posted: August 19, 2020

Please Note: If you are unable to submit a comment, please contact the policy writer identified in the rule directly.