Proposed Rules

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

Chapter II, Section 25, Dental Services (repeal), Chapter III, Section 25, Allowances for Dental Services (repeal), Chapter II, Section 25, Dental Services and Reimbursement Methodology (this rule replaces the two repealed rules)

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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 25, Dental Services (repeal) 10-144 C.M.R. Chapter 101, Chapter III, Section 25, Allowances for Dental Services (repeal) 10-144 C.M.R. Chapter 101, Chapter II, Section 25, Dental Services and Reimbursement Methodology (this rule replaces the two repealed rules)

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This rulemaking proposes to repeal Ch. II and Ch. III, Section 25, and replace them with a new Ch. II, Section 25 rule. On July 1, 2022, the Department implemented these changes via emergency rulemaking, pursuant to P.L. 2021, Ch. 398 (eff. July 1, 2021), Sec. A-17 (the "Budget"), Part CCC, Sec. CCC-1, Part GGGG, and Section GGGG-1. Following notice and comment on the proposed routine technical rule, the Department shall permanently adopt the new Ch. II, Section 25.

Between August 2021 and May 2022, the Department met with the dental subcommittee of the MaineCare Advisory Committee (MAC) ten times and with the full MAC once. The Department also held two stakeholder forums to receive input on the benefit design and reimbursement methodology. Stakeholders included MaineCare dental providers and various oral health advocates, including representatives from Maine Equal Justice, Maine Primary Care Association, and Children's Oral Health Network of Maine. This rule incorporates recommendations from this stakeholder engagement, invests $45 million to increase rates and expand the adult dental benefit, as well as fully integrates the children and adult benefits and rates into a single rule. The proposed rule adds a comprehensive array of dental services for adult members, per 22 MRS 3174-F(1).

Additionally, this proposed rule implements the recommendations from the Departments Comprehensive Rate System Evaluation, conducted by the firm Myers and Stauffer. The new Section 25 dental reimbursement rates will be posted on a website, and those rates will be set based on either the Commercial Median Benchmark or the All-States Medicaid Average Benchmark, as defined by the proposed rule. The dental code benchmarks shall undergo updates every two years, per the methodology included in the proposed rule. Since April 11, 2022, the Department has conferred multiple times with providers and the MAC regarding this new reimbursement methodology.

The differences between the proposed rule and the former Chapters II and III, Section 25, rules include the following:

  1. Section 25.06 (Reimbursement Methodology). The rule replaces specified rates with a reimbursement methodology. Whereas the former Chapter II, Section 25, rule stated rates would be the amount listed in Chapter III, Section 25, the proposed rule implements a reimbursement methodology that increases overall reimbursement consistent with recommendations from the comprehensive rate setting evaluation.

The reimbursement methodology sets rates for diagnostic, endodontic, periodontic, and preventive services based on 67% of the Commercial Median Benchmark or 133% of the Medicaid State Average Benchmark, if the Commercial Median Benchmark rate is unavailable or unreliable.

The reimbursement methodology sets rates for adjunctive, oral and maxillofacial surgery, orthodontics, prosthodontics, and restorative services based on 50% of the Commercial Median
Benchmark or 100% of the Medicaid State Average Benchmark if the Commercial Median Benchmark rate is unavailable or unreliable.

  1. In addition, the rule eliminates inconsistent payment for services billed as medical versus dental services. To ensure that there is not a rate disparity between CDT and CPT codes that represent the same service, the proposed rule removes coverage of some oral and maxillofacial surgery and maxillofacial prosthetic services so that they are solely covered under Section 90, Physician Services. The Department removes services from the proposed rule that have a CPT code equivalent, that are medical in nature, and are primarily delivered by oral surgeons who already bill the services under Section 90, Physician Services.

  2. Replaces emergency-only adult dental coverage with comprehensive adult dental coverage. To implement the new comprehensive adult dental benefit, the proposed rule adds coverage for adults for diagnostic, preventive, restorative, endodontic, periodontic, prosthodontic, oral and maxillofacial surgery, and adjunctive services. To enable this comprehensive adult coverage, the proposed rule removes the Section 25.04 requirement that adult dental care be limited to acute surgical care directly related to an accident; oral medical procedures not involving the dentition and gingiva; extraction of teeth that are severely decayed and pose a serious threat of infection during cardiovascular surgery; or treatment necessary to relive pain, eliminate infection, or prevent imminent tooth loss.

  3. Replaces separate adult and child coverage provisions with a single covered services description generally applicable to all members. As a result of removing the restrictions on adult dental coverage, the proposed rule contains one Covered Services provision, which includes the services, limits, and other requirements for all members, regardless of age, unless otherwise specified. Some services will continue to be age-limited, and they are noted as such in the rule.

  4. In addition to adding broad coverage for adult dental services, the proposed rule adds or increases coverage for many existing services, including the following:

a. Comprehensive periodontal evaluations b. Counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use c. Removable unilateral space maintainers d. Multiple types of crowns e. Prefabricated crowns f. Apicoectomies g. Immediate partial dentures h. Complete denture repairs i. Partial denture relines j. Multiple types of pontics and prosthodontic retainers k. Re-cement or re-bond and repairs of fixed partial dentures l. Dental case management m. Single bitewings n. Panoramic radiographs o. Topical fluoride p. Denture adjustments

  1. Aligns limits and prior authorization requirements with other state Medicaid agencies, commercial payers, and stakeholder recommendations. Because of the limited scope of the adult dental benefit in the current rule, the proposed rule makes changes to align the covered services and limits with typical comprehensive dental coverage. Specifically:

a. The proposed rule removes the requirement that adults have a qualifying medical condition to receive removable prosthodontics (dentures).

b. The proposed rule establishes medically appropriate limitations where none previously existed, based on recommendations from clinical consultation and alignment with other comprehensive dental coverage (commercial payers and other Medicaid agencies).

c. The proposed rule adds and removes prior authorizations to align with other payors and based on recommendations from clinical consultation. Additionally, the proposed rule adds certain prior authorization requirements that were not in the emergency Section 25 rule: Sec. 25.03-3(B) (Crowns); 25.03-5(E) (periodontal scaling and root planning); and 25.03-9(A) (sedation for members 21 and over). There was not clear consensus from pre-rulemaking consultation with stakeholders and Department clinical resources on whether these services should require PA and including the PA requirements in the proposed rule allows for further public comment and Department deliberation to determine whether to adopt the requirements in the final rule.

d. The proposed rule removes the more than once every 150 days requirement for detailed and extensive and periodic oral evaluations and prophylaxis treatments.

  1. Removes unnecessary and overly detailed provisions. The proposed rule removes the following from the rule:

a. Unnecessary and unused definitions. b. Reference to coverage for members residing in an Intermediate Care Facility for Persons with Mental Retardation (ICF-IID) because these members will now receive the services covered for members 21 and over (adults). c. Requirements that address the covered services certain provider types can provide under their scope of practices because providers scope of practices are already defined in 32 MRS Ch. 147. d. Prescriptive descriptions of services that are overly detailed for the rule. e. Section 25.03-9, Temporomandibular Joint Services, because it is not clear what specific services this provision encompasses and because services that are related to the temporomandibular joint are listed in the new covered services Section. f. Section 25.06-1, Members Records, because Chapter I, Section 1.03-8(M) and Board rule 02-313 CMR Chapter 12 both contain member/patient record requirements. g. Section 25.06-2, The Division of Program Integrity, because it only refers providers to Chapter I, which already applies to all providers. h. Requirements and instructions in Section 25.06-3, Prior Authorization of Dental Services, because they either exist in Chapter I of the MBM or in MaineCares Prior Authorization Manual on the HealthPAS Portal. i. Section 25.06-5, Case Management, because it describes standard health care provider practices and because the proposed rule adds coverage for a dental case management service. j. Sections 25.07-4, Denturist Services, and 25.07-5, Dental Hygienist Services, because it is unnecessary to include the services that these providers can deliver under their scopes of practice, which are defined in 32 MRS Ch. 147. Section 25.07-5 also includes outdated guidance. k. Section 25.07-6, Independent Practice Dental Hygienist (IPDH) Services, because IPDHs must comply with their scope of practice, as defined in 32 MRS Ch. 143 18375, and it is redundant to list services that IPDHs can deliver in rule. In addition, the requirements for IPDHs delivering temporary fillings no longer have a basis in Board rules and have been a roadblock to delivering this service. The requirements for processing and exposing radiographs are also no longer in effect. l. The appendix because the forms either exist on the HealthPAS Portal or will no longer be required.

The Department shall seek approval from the Centers for Medicare and Medicaid Services (CMS) of state plan amendments (SPAs) for the changes in this rulemaking. In addition, on June 29, 2022, the Department published a notice of change in reimbursement methodology pursuant to 42 C.F.R. 447.205.

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. 2021, Ch. 398, Sec. A-17, Part CCC and Part GGGG

PUBLIC HEARING: 1:00pm; Monday, August 8, 2022

Due to the ongoing threat posed by COVID-19, DHHS has determined that its public hearing will be conducted solely remotely, via Zoom. This is in accordance with the DHHS Remote Rulemaking Hearings Policy issued September 10th, 2021.

(link to Remote Hearings Policy: https://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/9%209%2021%20Remote%20Rulemaking%20Hearings%20Policy.pdf)

Zoom Meeting link: https://mainestate.zoom.us/j/88309744257 Meeting ID: 883 0974 4257

Some devices may require downloading a free app from Zoom prior to joining the public hearing event. The Department requests that any individual requiring special arrangements to participate in the hearing contact the person listed for this filing 5 days in advance of the hearing.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on August 18, 2022.

AGENCY CONTACT PERSON: Henry Eckerson, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: henry.eckerson@maine.gov TELEPHONE: 207-624-4085 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 Comment Deadline: August 18, 2022 | Posted: July 20, 2022

Notice of Agency Rule-making Proposal, MaineCare Benefits Manual, Chapter II, Section 65, Behavioral Health Services

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Notice of Agency Rule-making Proposal

AGENCY: Department of Health and Human Services, MaineCare Services

CHAPTER NUMBER AND TITLE: 10-144, C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter II, Section 65, Behavioral Health Services

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, Chapter II, Section 65, Behavioral Health Services. The Department proposes this rule to incorporate various new Intensive Outpatient Program (IOP) Services to be covered in Chapter II, including Mental Health, Developmental Disabilities/Behavioral Health, Geriatric, Dialectical Behavior Therapy, and Eating Disorder (Level I and Level II) IOPs. The proposed rule updates Substance Use IOP requirements and establishes requirements for new IOP services to include: IOP service and staff requirements, general and specific member eligibility criteria, as well as program requirements. To align with federal regulations under 42 C.F.R. Part 8, the Department proposes to amend language in Chapters II and Chapter III referring to Medication Assisted Treatment with Methadone (MAT), to be replaced with the term Opioid Treatment Program (OTP) with Methadone. The proposed Chapter II rule also updates requirements for OTPs, under Section 65.05-11, to align with the federal regulation including Counseling, Substance Use Disorder Testing, Medication Administration, and Facility Operation requirements in 42 C.F.R. 8.12. To reduce barriers to services and administrative burden to providers, the Department proposes to extend the Crisis Resolution Services "treatment episode" under 65.05-1, from limiting the service to six (6) face-to-face visits and related follow up phone calls over a thirty (30) day period after the first face-to-face visit, to face-to face visits and related follow up phone calls, as clinically indicated, up to a sixty-day period after the first face-to-face visit. Additionally, the Department proposes to remove language from Section 65.07-5(B) that limits substance use individual and family outpatient therapy to three (3) hours per week, for thirty (30) weeks in a forty (40) week period. The rule also proposes to clarify qualified staff allowed to provide Crisis Resolution Services (65.05-1) and Crisis Residential Services (65.05-2) to include Clinicians (as defined in 65.01-11), Mental Health Rehabilitation Technicians (MHRTs), Behavioral Health Professionals (BHPs), or Direct Support Professionals (DSPs) with Certification at the level appropriate for the services being delivered and specific to the population being served. The Department has also updated provider qualifications for licensed Mental Health Agencies and Substance Use Agencies to remove the requirement that providers must separately contract with the Office of Child and Family Services and/or the Office of Behavioral Health. The proposed rule reorganizes requirements related to Individualized Treatment Plans in 65.08-4(B) and proposes updated requirements for treatment plans for members receiving OTP services.

In addition, the Department is proposing rulemaking to Ch. III of Section 65, to meet all Chapter II-related rulemaking updates and related budget initiatives identified in P.L. 2021, ch. 398. The Chapter III, Section 65 rulemaking shall be filed simultaneously, so that the upcoming changes will be effective at the same time as the changes in Chapter II, Section 65 are finally adopted. Throughout the rule, the Department proposes edits to language to make updates to formatting, citations, and references where necessary, including changes to address potentially stigmatizing language based on recommendations from the Maine opioid task force and legislation passed in 2018 to minimize stigma (P.L. 2017, ch. 407). The Department shall seek CMS approval for the new covered services and provider requirements, as specifically noted in various proposed rule changes.

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

STATUTORY AUTHORITY: 22 M.R.S. 42, 3173; 42 C.F.R. Part 8; P.L. 2019, ch. 407; P.L. 2021, Ch. 398

DATE, TIME, AND LOCATION OF PUBLIC HEARING: Tuesday, June 28th, 2022; 1:00pm

Due to the ongoing threat posed by COVID-19, DHHS has determined that its public hearing will be conducted solely remotely, via Zoom. This is in accordance with the DHHS Remote Rulemaking Hearings Policy issued September 10th, 2021. (Link to Remote Hearings Policy: https://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/9%209%2021%20Remote%20Rulemaking%20Hearings%20Policy.pdf )

Zoom Meeting link: https://mainestate.zoom.us/j/85325347788 Meeting ID: 853 2534 7788

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Some devices may require downloading a free app from Zoom prior to joining the public hearing event. The Department requests that any individual requiring special arrangements to participate in the hearing

DATE FILED WITH THE SECRETARY OF STATE'S OFFICE: Tuesday, May 31, 2022.

COMMENT DEADLINE: Comments must be received by 11:59 pm on July 8th, 2022.

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

TELEPHONE: 207-624-4087 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 8, 2022 | Posted: June 8, 2022

Notice of Agency Rule-making Proposal, MaineCare Benefits Manual, Chapter III, Section 65, Behavioral Health Services

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Notice of Agency Rule-making Proposal

AGENCY: Department of Health and Human Services, MaineCare Services

CHAPTER NUMBER AND TITLE: 10-144, C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter III, Section 65, Behavioral Health Services

PROPOSED RULE NUMBER:

CONCISE SUMMARY:

The Department of Health and Human Services (the "Department") is proposing to repeal and replace 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapter III, Section 65, Behavioral Health Services.

The Department proposes this rule to comply with P.L. 2021, Ch. 398, 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, 2021, June 30, 2022 and June 30, 2023 (the Budget). Per the Budget, the rule proposes to increase medication management rates. This provision will be effective retroactive to October 1, 2021, as directed by the Supplemental Budget, and in alignment with 22 M.R.S. 42(8) which authorizes the Department to adopt retroactive rules that do not have any adverse financial impact on any MaineCare provider or member. Additionally, pursuant to Legislative directive and funding, the rule will incorporate updates to Chapter III from an independent rate study recommending increases to rates for Substance Use Disorder Intensive Outpatient Program (IOP) services. This provision will be effective retroactive to January 1, 2022, pursuant to 22 M.R.S. 42(8). Also, pursuant to Legislative directive and funding, from the Budget as well as P.L. 2021, Ch. 635 (the Supplemental Budget), the rule proposes to include cost-of-living adjustments (COLAs) for services that have not received a rate adjustment in the prior 12 months, according to appropriate criteria for calculating COLAs. This provision will be effective retroactive to July 1, 2022 pursuant to 22 M.R.S. 42(8).

The Department is pursuing a separate rulemaking for Chapter II, Section 65, simultaneous with this proposed rule. The proposed changes in Chapter II include the addition of various new IOP Services including Mental Health, Developmental Disabilities/Behavioral Health, Geriatric, Dialectical Behavior Therapy, and Eating Disorder (Level I and Level II) IOPs. This Chapter III rulemaking will incorporate proposed rates from an independent rate study for the new IOP Services pursuant to Legislative directive and funding (P.L. 2021, Ch. 398).

Throughout the rule, the Department proposes language consistent with the proposed Chapter II rule to address potentially stigmatizing language based on recommendations from the Maine opioid task force and legislation passed in 2018 to minimize stigma (P.L. 2017, ch. 407).

The Department shall seek CMS approval for the new covered services and rates, as specifically noted in various proposed rule changes.

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

STATUTORY AUTHORITY: 22 M.R.S. 42, 42(8), 3173; 42 C.F.R. Part 8; P.L. 2019, ch. 407; P.L. 2021, Ch. 398; P.L. 2021, Ch. 635.

DATE, TIME, AND LOCATION OF PUBLIC HEARING: Tuesday, June 28th, 2022; 3:00pm

Due to the ongoing threat posed by COVID-19, DHHS has determined that its public hearing will be conducted solely remotely, via Zoom. This is in accordance with the DHHS Remote Rulemaking Hearings Policy issued September 10th, 2021.

(Link to Remote Hearings Policy: https://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/9%209%2021%20Remote%20Rulemaking%20Hearings%20Policy.pdf )

Zoom Meeting link: https://mainestate.zoom.us/j/87144359805 Meeting ID: 871 4435 9805

One tap mobile +13017158592,,87144359805# US (Washington DC) +13126266799,,87144359805# US (Chicago) Dial by your location +1 301 715 8592 US (Washington DC) +1 312 626 6799 US (Chicago) +1 646 876 9923 US (New York) +1 669 900 6833 US (San Jose) +1 253 215 8782 US (Tacoma) +1 346 248 7799 US (Houston) +1 408 638 0968 US (San Jose) Meeting ID: 871 4435 9805 Find your local number: https://mainestate.zoom.us/u/kcMhQouOSg

Some devices may require downloading a free app from Zoom prior to joining the public hearing event. The Department requests that any individual requiring special arrangements to participate in the hearing contact the person listed for this filing 5 days in advance of the hearing.

DATE FILED WITH THE SECRETARY OF STATE'S OFFICE: Tuesday, May 31, 2022.

COMMENT DEADLINE: Comments must be received by 11:59 pm on July 8th, 2022.

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

TELEPHONE: 207-624-4087 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 8, 2022 | Posted: June 8, 2022

Notice of Agency Rule-making Proposal, MaineCare Benefits Manual, Chapters II and III, Section 45

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Notice of Agency Rule-making Proposal

AGENCY: Department of Health and Human Services, Office of MaineCare Services

CHAPTER NUMBER AND TITLE: (1) 10-144 C.M.R., Chapter 101, Ch.II, Section 45, Hospital Services (2) 10-144 C.M.R. Chapter 101, Ch. III, Section 45, Principles of Reimbursement for Hospital Services

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This rulemaking proposes the following changes.

Ch. II

Adds language to Chapter II, 45.07-1, Discharge Planning, that requires Hospital Emergency Departments to establish procedures for referring eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated Health Home providers as required under the Social Security Act (SSA), Title 19, 42 U.S.C. Section 1945 (d).

Adds language for a new service, Partial Hospitalization Services.

Ch. III

Amends Chapter III, Section 45.01, Definitions, to include Accountable Communities (AC) Initiative.

Adds Section 45.02-9, Value-Based Purchasing (VBP) Supplemental Sub-Pool, pursuant to P.L. 2021, ch 398. The Value-Based Supplemental Sub-Pool distributes $600,000 to eligible hospitals (acute care non-critical access, critical access, and hospitals reclassified to a wage area outside of Maine) that participate in MaineCare programs that incent improved health outcomes and reduced cost of care for the MaineCare program. Standards for distribution of the pool funds can be found on the OMS website, and the public can obtain a printed copy by calling OMS.

Amends Chapter III, Section 45.03 to provide reimbursement for members discharged from Southern Maine Health Care's psychiatric inpatient unit in the amount of $10,166 per distinct discharge effective October 1, 2021, pursuant to Resolves 2021, ch. 119, Resolve, Regarding Reimbursement for Providing Inpatient Care to Individuals with Acute Mental Health Care Needs. This change can be made retroactively pursuant to 22 M.R.S. Sec. 42(8), as the change has a positive impact on the provider.

Additionally, in order to eliminate the need for annual rulemaking to update supplemental pool amounts, the Department proposes the following changes to Chapter III, Sections 45.04 and 45.07.

Section 45.04-1(C): Removal of supplemental pool dollar amounts from the rule and addition of a link to the MaineCare website and a phone number which the public can call for detailed information on annual supplemental pool amounts.

Section 45.07: Removal of supplemental pool dollar amounts and addition of a link to the MaineCare website and a phone number which the public can call for detailed information on annual supplemental pool amounts.

Replaces references to "substance abuse" with references to "substance use disorder" pursuant to P.L. 2017, ch. 407, An Act To Implement the Recommendations of the Task Force To Address the Opioid Crisis in the State Regarding Respectful Language, Part B.

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

STATUTORY AUTHORITY: Resolves 2021, ch. 119; P.L. 2017, ch. 407, Part B; and P.L. 2021, ch. 398. DATE FILED WITH THE SECRETARY OF STATES OFFICE: May 25, 2022 DATE, TIME. AND PLACE OF PUBLIC HEARING: June 14, 2022, 09:00 AM Eastern Time (US and Canada)

Due to the ongoing threat posed by COVID-19, DHHS has determined that its public hearing will be conducted solely remotely, via Zoom. This is in accordance with the DHHS Remote Rulemaking Hearings Policy issued September 10, 2021.

Zoom Meeting Link: https://mainestate.zoom.us/j/84162152721

Meeting ID: 841 6215 2721 One tap mobile +13017158592,,84162152721# US (Washington DC) +13126266799,,84162152721# US (Chicago)

Dial by your location

+1 301 715 8592 US (Washington DC) +1 312 626 6799 US (Chicago) +1 646 876 9923 US (New York) +1 669 900 6833 US (San Jose) +1 253 215 8782 US (Tacoma) +1 346 248 7799 US (Houston) +1 408 638 0968 US (San Jose) Meeting ID: 841 6215 2721

Find your local number: https://mainestate.zoom.us/u/kdNityBE7z

In addition to the public hearing, individuals may submit written comments to DHHS by the date listed in this notice.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on June 24, 2022.

AGENCY CONTACT PERSON: Derrick Grant, MaineCare Policy derrick.grant@maine.gov AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 TELEPHONE: 207-624-6931 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: June 24, 2022 | Posted: May 25, 2022

Notice of Agency Rule-making Proposal, Chapter III, Section 29, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder

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AGENCY: Department of Health and Human Services, Office of MaineCare Services

CHAPTER NUMBER AND TITLE: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter III, Section 29, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder

PROPOSED RULE NUMBER:

CONCISE SUMMARY: In response to the statewide staffing crisis and to comply with P.L. 2021, ch. 398 (the "Act"), the Department is proposing routine technical rule changes to increase rates for providers of services under Ch. III, Section 29, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder.

Section AAAA-1 of the Act enacts 22 M.R.S. Chapter 1627, Essential Support Worker Reimbursement. The new law requires that, effective January 1, 2022, the labor components of MaineCare reimbursement rates for specified services delivered by essential support workers must equal at least 125% of the minimum wage established in Title 26, section 664, subsection 1. Essential support workers are individuals who by virtue of employment generally provide to individuals direct contact assistance with activities of daily living or instrumental activities of daily living or have direct access to provide care and services to clients, patients or residents regardless of the setting. 22 M.R.S. 7401. In addition, Part AAAA states that the reimbursement rate must include an amount necessary to reimburse the provider for taxes and benefits related to the wages. 22 M.R.S. 7402(2). Section AAAA-2 of the Act specifies that the 125% of minimum wage requirement for essential support workers applies to Ch. III, Section 29 services.

Additionally, Part OOO of the Act authorizes the Department to implement cost of living increases (COLAs). In calculating the rate increases necessary to comply with Part AAAA of the Act, the Legislature and the Department took into consideration the impact of the planned COLAs on ensuring the labor components of the reimbursement rates for Section 29 and other services specified under Part AAAA are equal to at least 125 percent of minimum wage.

Rulemaking required for these particular rule changes are routine technical per 22 M.R.S. 7404 (for the essential support worker increases), and Part OOO of the Act (for the COLA-related increases) even though Ch. III, Section 29 is generally a major substantive rule. See, e.g., 22 M.R.S. 3195.

On March 22, 2022, the Department implemented these increased rates via an emergency routine technical rule, which shall be effective for up to 90 days. The rates are effective retroactive to January 1, 2022, as directed by the Act. The retroactive application of this rule comports with 22 M.R.S. 42(8), which provides state authority for the Department to adopt rules with a retroactive application for a period not to exceed eight (8) calendar quarters where there is no adverse financial impact on any MaineCare member or provider. Here, the rule change is a beneficial change for the providers. This proposed routine technical rulemaking seeks to make permanent the increases to the reimbursement rates enacted via emergency rule.

Separately, effective December 31, 2021, and coinciding with the adoption of the emergency routine technical rule, the Department shall repeal an emergency major substantive rule that was adopted on April 7, 2021, and that included reimbursement rate increases for certain services under Ch. III, Section 29 pursuant to P.L. 2019, ch. 616; emergency major substantive rules are effective for up to twelve months, or until Legislative review. The Department has not yet initiated the proposed major substantive rulemaking associated with the April 7, 2021, emergency major substantive rule, and thus there is no provisional major substantive rule pending for review before the Legislature. There is no decrease in reimbursement for any service affected by the repeal of the April 2021 emergency major substantive rule.

The Department shall seek approval from the Centers for Medicare & Medicaid Services (CMS) for the proposed increased reimbursement rates. In addition, the Governor's proposed budget will ask the legislature for additional funds to support these increases and to meet the intent of Part AAAA of the Act ensuring labor components of all rates are at least equal to 125% of minimum wage.

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

STATUTORY AUTHORITY: 22 M.R.S. 42 and 42(8), 3173; P.L. 2021, ch. 398 DATE FILED WITH THE SECRETARY OF STATES OFFICE: March 22, 2022 DATE, TIME AND PLACE OF PUBLIC HEARING: Apr 19, 2022, 02:00 PM Eastern Time (US and Canada)

Due to the ongoing threat posed by COVID-19, DHHS has determined that its public hearing will be conducted solely remotely, via Zoom. This is in accordance with the DHHS Remote Rulemaking Hearings Policy issued September 10, 2021.

Zoom Meeting link: https://mainestate.zoom.us/j/81883583119 Meeting ID: 818 8358 3119

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Meeting ID: 818 8358 3119 Find your local number: https://mainestate.zoom.us/u/kbyCBfayV5

In addition to the public hearing, individuals may submit written comments to DHHS by the date listed in this notice.

DEADLINE FOR COMMENTS: Comments must be received by 11:59PM on April 29, 2022.

AGENCY CONTACT PERSON: Heather Bingelis, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 TELEPHONE: 207-624-6951 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: April 29, 2022 | Posted: March 30, 2022

Notice of Agency Rule-making Proposal, MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder

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AGENCY: Department of Health and Human Services, Office of MaineCare Services

CHAPTER NUMBER AND TITLE: 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder

PROPOSED RULE NUMBER:

CONCISE SUMMARY: In response to the statewide staffing crisis and to comply with P.L. 2021, ch. 398 (the "Act"), the Department is proposing routine technical rule changes to increase rates for providers of services under Ch. III, Section 21, Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder.

Section AAAA-1 of the Act enacts 22 M.R.S. Chapter 1627, Essential Support Worker Reimbursement. The new law requires that, effective January 1, 2022, the labor components of MaineCare reimbursement rates for specified services delivered by essential support workers must equal at least 125% of the minimum wage established in Title 26, section 664, subsection 1. Essential support workers are individuals who by virtue of employment generally provide to individuals direct contact assistance with activities of daily living or instrumental activities of daily living or have direct access to provide care and services to clients, patients or residents regardless of the setting. 22 M.R.S. 7401. In addition, Part AAAA states that the reimbursement rate must include an amount necessary to reimburse the provider for taxes and benefits related to the wages. 22 M.R.S. 7402(2). Section AAAA-2 of the Act specifies that the 125% of minimum wage requirement for essential support workers applies to Ch. III, Section 21 services.

Additionally, Part OOO of the Act authorizes the Department to implement cost of living increases (COLAs). In calculating the rate increases necessary to comply with Part AAAA of the Act, the Legislature and the Department took into consideration the impact of the planned COLAs on ensuring the labor components of the reimbursement rates for Section 21 and other services specified under Part AAAA are equal to at least 125 percent of minimum wage.

Rulemaking required for these particular rule changes are routine technical per 22 M.R.S. 7404 (for the essential support worker increases), and Part OOO of the Act (for the COLA-related increases) even though Ch. III, Section 21 is generally a major substantive rule. See, e.g., 22 M.R.S. 3195.

On March 22, 2022, the Department implemented these increased rates via an emergency routine technical rule, which shall be effective for up to 90 days. The rates are effective retroactive to January 1, 2022, as directed by the Act. The retroactive application of this rule comports with 22 M.R.S. 42(8), which provides state authority for the Department to adopt rules with a retroactive application for a period not to exceed eight (8) calendar quarters where there is no adverse financial impact on any MaineCare member or provider. Here, the rule change is a beneficial change for the providers. This proposed routine technical rulemaking seeks to make permanent the increases to the reimbursement rates enacted via emergency rule.

Separately, effective December 31, 2021, and coinciding with the adoption of the emergency routine technical rule, the Department shall repeal an emergency major substantive rule that was adopted on April 7, 2021, and that included reimbursement rate increases for certain services under Ch. III, Section 21 pursuant to P.L. 2019, ch. 616; emergency major substantive rules are effective for up to twelve months, or until Legislative review. The Department has not yet initiated the proposed major substantive rulemaking associated with the April 7, 2021, emergency major substantive rule, and thus there is no provisional major substantive rule pending for review before the Legislature. There is no decrease in reimbursement for any service affected by the repeal of the April 2021 emergency major substantive rule.

The Department shall seek approval from the Centers for Medicare & Medicaid Services (CMS) for the proposed increased reimbursement rates. In addition, the Governor's proposed budget will ask the legislature for additional funds to support these increases and to meet the intent of Part AAAA of the Act ensuring labor components of all rates are at least equal to 125% of minimum wage.

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

STATUTORY AUTHORITY: 22 M.R.S. 42 and 42(8), 3173; P.L. 2021, ch. 398 DATE FILED WITH THE SECRETARY OF STATES OFFICE: March 30, 2022 DATE, TIME AND PLACE OF PUBLIC HEARING: April 19, 2022, 09:00 AM Eastern Time (US and Canada)

Due to the ongoing threat posed by COVID-19, DHHS has determined that its public hearing will be conducted solely remotely, via Zoom. This is in accordance with the DHHS Remote Rulemaking Hearings Policy issued September 10, 2021. (link to Remote Hearings Policy:

Zoom Meeting link: https://mainestate.zoom.us/j/87058388564 Meeting ID: Meeting ID: 870 5838 8564

One tap mobile +13126266799,,87058388564# US (Chicago) +16468769923,,87058388564# US (New York) Dial by your location +1 312 626 6799 US (Chicago) +1 646 876 9923 US (New York) +1 301 715 8592 US (Washington DC) +1 253 215 8782 US (Tacoma) +1 346 248 7799 US (Houston) +1 408 638 0968 US (San Jose) +1 669 900 6833 US (San Jose) Meeting ID: 870 5838 8564

Find your local number: https://mainestate.zoom.us/u/kfBdl37XE

In addition to the public hearing, individuals may submit written comments to DHHS by the date listed in this notice.

COMMENT DEADLINE: April 29, 2022 by:11:59PM, EST

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

TELEPHONE: 207-624-6951 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: April 29, 2022 | Posted: March 30, 2022

MaineCare Benefits Manual, Chapters II and III, Section 93, Opioid Health Home Services

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Notice of Agency Rule-making Proposal

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, Chapters II & III, Section 93, Opioid Health Home Services

PROPOSED RULE NUMBER:

CONCISE SUMMARY: The Department of Health and Human Services (the "Department") proposes this rule change in 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapters II & III, Section 93, Opioid Health Home Services, to improve access to treatment, reduce administrative barriers to providing Medication Assisted Treatment (MAT), promote evidence-based treatment standards, and reinforce the importance of Opioid Health Home (OHH) integration with primary care. The Department will submit a State plan amendment (SPA) to the Center for Medicare and Medicaid Services (CMS) for some of these changes and expects it to be approved. The proposed rule and the SPA will have the same effective date.

This rulemaking consists of the following changes in Chapters II and III, Section 93, Opioid Health Home Services:

The proposed rule makes various changes to the MAT prescriber position. It allows practitioners licensed under state and federal law to order, administer, or dispense opioid agonist treatment medications to be MAT prescribers for members in the Methadone Level of Care who receive OHH services from an Opioid Treatment Program (OTP). It requires the MAT prescriber to coordinate with the OTP OHH when members in the Methadone Level of Care receive OHH services from a non-OTP OHH. It also requires MAT prescribers to be involved in providing the services described under 93.05-1, Health Home Services.

The proposed rule makes various changes to the nurse care manager position on the OHH team. In response to requests from providers, the proposed rule allows licensed practical nurses to be nurse care managers. It requires any person serving as the nurse care manager to complete the eight-hour training for buprenorphine prescribing by physicians within six months of initiating service delivery for OHH members, unless the individual is an Advanced Practice Registered Nurse with a X-Drug Enforcement Administration (DEA) license. It no longer requires the nurse care manager to oversee and/or participate in all aspects of OHH services because the nurse care manager would not oversee opioid use disorder (OUD) counselling. It specifies that the nurse care manager position may be filled by another appropriate licensed medical professional on the OHH team, as long as the individual completes training for an X-DEA license within six months of initiating service delivery for OHH members.

The proposed rule adds methadone to the medications included in the OHH model and allows an OTP to provide methadone to members. The rule also adds a statement encouraging the co-prescribing of naloxone for OHH members, as appropriate, in alignment with best practice guidelines.

The proposed rule makes a number of changes to the counseling requirement. It clarifies that counseling is not required for the Medication Plus Level of Care and is not part of the OHH bundle for the Methadone Level of Care. It changes the counseling requirement to be assessed on a monthly instead of weekly basis, which is in response to feedback that weekly requirements are too stringent for this service and are challenged by normal life events. It clarifies that counseling requirements for each clinical phase are based on a billable month (in alignment with standard billing practice), which does not always equate to a full 60 minutes of counseling. It requires OHH members in Intensive Outpatient (IOP) and Induction Levels of Care to engage in individual or group counseling for four billable hours per month;
members in the Stabilization Level of Care for two hours; and members in the Maintenance Level of Care for one hour.

The proposed rule makes various changes to the reimbursement section. This rulemaking allows providers to bill the new Medication Plus and Methadone Levels of Care if the member is enrolled for at least one day during the billing month. It adds that OHH providers will not be reimbursed for an OHH member if that member also receives Section 97, Private Non-Medical Institution Services; Section 13, Targeted Case Management Services; Section 17, Community Support Services; or Section 92, Behavioral Health Homes, unless the Section 13, 17, or 92 provider has a contract with the OHH to provide Health Home Services. The rule also adds an Additional Provider Support provision for OHH members with additional community support needs related to mental health, HIV, medical concerns and/or utilization, and/or homelessness. The Department or its authorized entity must approve additional supports provided to eligible members and reimbursed through the pass-through payment described in Chapter III, Section 93, Opioid Health Home Services, including an active release of information and a contractual agreement between the OHH and additional support provider.

The rule also adds a pay-for-performance provision which withholds four percent of total OHH PMPM payments. This amount shall be paid to providers every six months if they satisfy the minimum performance threshold, and providers who meet the excellent performance threshold are eligible to receive any additional available amount. The Department shall set the performance thresholds so that no less than 70% of eligible OHHs are expected to be above the minimum performance threshold and no less than 20% of OHHs are expected to be above the excellent performance threshold. This means that 30% of eligible OHHs are not expected to meet the minimum performance threshold and thus will not receive the four percent payment. Those four percent amounts will be combined and distributed to OHH providers that meet the excellent performance threshold. If all OHH providers satisfy the minimum performance threshold, then no amounts would be distributed to OHH providers who satisfy the excellent performance threshold. Performance calculations shall be based on the composite score of three performance measures, as set forth in the rule. Providers shall receive reports quarterly to inform them about whether they satisfied the minimum or excellent performance threshold standards, what their reimbursement shall be, as well as instructions for appeal if they disagree with the Department's determinations.

This rulemaking also makes the following changes:

Clarifies that the clinical counselor provides behavioral health expertise and contributes to care planning, assessment of individual care needs, and identification of and connection to behavioral health services, as part of the services described in 93.05-1. Allows community health workers to be patient navigators, in response to requests from providers. A definition and certification/training requirements for community health workers is also added. Requires Connecticut Community for Addiction Recovery (CCAR) or other Department approved recovery coach training for recovery coaches. OHHs will have six months from rule adoption to train existing staff, and each new recovery coach will have six months to complete the applicable training upon start of delivery OHH services. Encourages people with lived experience to serve as recovery coaches but also allows recovery allies to serve as recovery coaches. Requires the OHH to adopt processes to identify and classify patients across their population served who are missing critical preventive services and/or other health screenings. Adds that members must be assessed for appropriateness of OHH services in alignment with American Society of Addiction Medicine guidelines.

Requires OHHs to retain a signed consent form for all OHH members in the member record. The documentation must indicate that the individual has received information in writing, and verbally as appropriate, that explains the OHH purpose and the services provided and indicates that the individual has consented to receive the OHH services and understands their right to choose, change, or disenroll from their OHH provider at any time. Requires OHH providers to provide and document efforts to connect each OHH member to a primary care provider. Adds that health promotion activities may include health education and referral support for health-related risk factors (e.g. oral health, contraceptive counseling, preventive screenings). Removes language that referred to coordinated case management to align with language for the approved MaineCare SPA for these services, which instead utilizes an expanded team-based approach for the provision of additional supports, reimbursed through pass-through payments. Requires OHHs to conduct a comprehensive biopsychosocial assessment annually.

This rulemaking also consists of the following changes in Chapter III, Section 93, Opioid Health Home Services:

The proposed rule introduces the Medication Plus and Methadone Levels of Care. The Medication Plus Level of Care reimburses for all OHH covered services except for OUD counseling, which allows members to receive OUD medication without electing to participate in OUD counseling. The Methadone Level of Care allows members who receive Methadone Medication Assisted Treatment (MAT) from Chapter II, Section 65, Behavioral Health Services, providers to receive Health Home services from the team-based care delivery model of the OHH.

Under the current rule, when members receiving OHH services elect to receive comprehensive care management and comprehensive transitional care from an additional support provider, the Department reimburses both providers separately. CMS advised that the OHH should reimburse the additional support provider via a pass-through payment. Hence, this rulemaking increases the reimbursement amount to the OHH provider to include a pass-through payment of $394.40 for the IOP, Induction, Stabilization, and Maintenance Levels of Care when members elect to receive services from an additional support provider.

In alignment with the Departments goal to implement value-based payment models tied to quality, the proposed rule adds a pay-for-performance provision that will withhold four (4) percent of OHH payments, pending the OHHs performance on three measures of OHH quality and effectiveness of service. The measures include assessing whether members in Maintenance and Stabilization Levels of Care have attended an annual primary care visit, had continuous pharmacotherapy as part of their MAT, and are involved in regular employment or other forms of community engagement. While the methodology for this pay-for-performance provision is detailed in rule, MaineCare will evaluate the need for adjustments to ensure OHH providers are not inappropriately penalized for the costs or changes in quality/utilization that result from COVID-19. Performance measure thresholds and the performance of other providers will determine if OHHs receive the full four percent and if they are eligible for a pay-for-performance surplus payment.

The proposed rules also make minor technical corrections.

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

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

DATE, TIME AND PLACE OF PUBLIC HEARING: 1:00pm; Monday, April 4th, 2022

Due to the ongoing threat posed by COVID-19, DHHS has determined that its public hearing will be conducted solely remotely, via Zoom. This is in accordance with the DHHS Remote Rulemaking Hearings Policy issued September 10th, 2021.

(link to Remote Hearings Policy: https://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/9%209%2021%20Remote%20Rulemaking%20Hearings%20Policy.pdf)

Zoom Meeting link: https://mainestate.zoom.us/j/82913607531 Meeting ID: 829 1360 7531

Some devices may require downloading a free app from Zoom prior to joining the public hearing event. The Department requests that any individual requiring special arrangements to participate in the hearing contact the person listed for this filing 5 days in advance of the hearing.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on April 14th, 2022.

AGENCY CONTACT PERSON: Henry Eckerson, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: Henry.Eckerson@maine.gov TELEPHONE: 207-624-4085 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 Comment Deadline: April 14, 2022 | Posted: March 16, 2022

UPDATED TO REFLECT REMOTE PUBLIC HEARING, MaineCare Benefits Manual, Chapter VI, Section 3, Primary Care Plus

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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 VI, Section 3, Primary Care Plus

PROPOSED RULE NUMBER: 2021-P236

CONCISE SUMMARY: This proposed rulemaking repeals 10-144 CMR Ch. 101, MaineCare Benefits Manual (the "MBM"), Ch. VI, Sec. 1, Primary Care Case Management (PCCM), and replaces it with MBM, Ch. VI, Sec. 3, Primary Care Plus (PCPlus), a single integrated program for MaineCare's current primary care programs. To complete the transition to PCPlus, the Maine Department of Health and Human Services (the Department) shall also propose to repeal MBM, Ch. II, Sec. 90.09-4 (Primary Care Provider Incentive Payment) and shall propose to significantly revise MBM, Ch. II, Sec. 91 (proposed to be titled Health Home Services - Community Care Teams), which includes repealing Health Home Practices. All of these rulemakings make up the PCPlus initiative, will be proposed simultaneously, and will have the same effective date.

The Department shall seek approval from the Centers for Medicare and Medicaid Services (CMS) of state plan amendments (SPAs) to repeal the aforementioned programs and implement the PCPlus program. Additionally, the Department will publish a notice of change in reimbursement methodology pursuant to 42 C.F.R. 447.205.

Overview of the PCPlus Initiative

The Department and the Office of MaineCare Services (OMS) are committed to improving health care access and outcomes for MaineCare members, demonstrating cost-effective use of resources, and creating an environment where providers can innovate in delivering high-value care. PCPlus is part of OMS commitment to have 40% of MaineCare expenditures paid through Alternative Payment Models (APMs) by the end of 2022. APMs are health care payment methods that use financial incentives to promote or leverage greater value, indicated by higher quality care and/or lower costs.

PCPlus is considered an Integrated Care Model by CMS under State Medicaid Director Letter #12-002, aligns with the Center for Medicare and Medicaid Innovations (CMMI) Primary Care First Model (See also: https://innovation.cms.gov/innovation-models-options), and operates under the authority of Section 1905(t)(1) of the Social Security Act (SSA). The PCPlus program is intended to give primary care providers (PCPs) greater flexibility and incentives to effectively meet MaineCare members health care needs by transitioning away from a volume-based (fee-for-service) payment system with little connection to value, toward an approach that provides risk-adjusted Population-Based Payments tied to cost- and quality-related outcomes.

Participation in PCPlus is voluntary for PCPs. For PCPs that elect to participate, the Department will share quality and utilization data, offer a new value-based payment model, and provide technical assistance to assist practices transform care delivery and achieve performance outcomes. The new payment model is risk-based, meaning reimbursement will increase or decrease depending on the PCPlus providers performance, as set forth in Section 3.08 of the rule. Providers may appeal Departmental actions, pursuant to Chapter I, Section 1.

Member participation in this model is based on which PCP the member visited for health care services or by the members identification of a PCP through calling MaineCare Member Services. Member participation is voluntary and does not interfere with MaineCare members freedom of choice to access other MaineCare providers. If a member identified their PCP for attribution through MaineCare Member Services but does not receive at least one primary care service from their selected PCP within one year, then DHHS will notify and reattribute the member in accordance with the primary care services-based attribution methodology. Members may change their PCP or opt out of PCPlus at any time.

To receive reimbursement under PCPlus, providers are required to locate, coordinate, and monitor health care services for members who are attributed to them, as set forth in Section 3.04. All covered services rendered by PCPlus providers must be documented in the members electronic health record. The Department will continue to reimburse other MaineCare covered services under the fee-for-service system.

Differences Between PCPlus and PCCM

CMS considers PCCM to be a form of managed care, which operates under Section 1905(a)(25) of the SSA and 42 CFR 438.6 with mandatory member participation for the majority of MaineCare members. PCPlus operates under 1905(t)(1) of the SSA and is not a managed care program. Since PCPlus is not a managed care program, it does not include many of the managed care requirements that PCCM follows. For example, except as set forth in the rule, member participation in PCPlus is based on members selection of a PCP, members may opt out of this program, and this program has no bearing on MaineCare members freedom of choice to access services from any qualified MaineCare provider. In addition, PCPlus, unlike PCCM, does not include the PCCM provisions on member participation or complaints, and PCP selection, change, and reassignment.

Under PCCM and PCPlus, providers locate, coordinate, and monitor health care services. However, PCPlus expands service and practice requirements to support whole-person coordination and transitions of care; completing timely prior authorizations; providing, tracking, and following up on referrals; and closing care gaps, including a focus on preventative services.

PCCM providers who choose to participate in PCPlus will benefit from a new value-based payment model, which includes a risk-adjusted population-based payment tied to cost- and quality-related outcomes, rather than the flat per member per month management fee provided under PCCM. Given the additional requirements and support for providers, PCPlus should improve health outcomes for members.

Section 90 and 91 Rulemakings for PCPlus Initiative

Regarding the related proposed rulemaking for Section 90, the Department is eliminating the Primary Care Provider Incentive Payment because it would duplicate the reimbursement model of the new PCPlus program. Physicians who currently receive the Incentive Payment may apply to be PCPs under the PCPlus program, and, if approved, will receive reimbursement based on the PCPlus service expectations and performance for members attributed to their practice.

For Section 91, as it relates to the PCPlus initiative, the Department is removing Health Home Practices (HHPs) because they would be duplicative of the reimbursement the PCPs will receive and the covered services they provide via PCPlus. HHPs that currently receive reimbursement through Section 91 may apply to participate in the PCPlus program, and, if approved, PCPs will receive reimbursement based on the PCPlus service expectations and performance for members attributed to their practice.

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

STATUTORY AUTHORITY: 22 M.R.S. 42, 3173; Social Security Act 1905(t)(1) (42 U.S.C. 1396d(t)(1))
DATE, TIME, AND LOCATION OF PUBLIC HEARING: 8:30am; Tuesday, January 18th, 2022 Due to the ongoing threat posed by COVID-19, DHHS has determined that its public hearing will be conducted solely remotely, via Zoom. This is in accordance with the DHHS Remote Rulemaking Hearings Policy issued September 10th, 2021. (link to Remote Hearings Policy: https://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/9%209%2021%20Remote%20Rulemaking%20Hearings%20Policy.pdf )

Zoom Meeting link: https://mainestate.zoom.us/j/89474720387 Meeting ID: 894 7472 0387

Some devices may require downloading a free app from Zoom prior to joining the public hearing event. The Department requests that any individual requiring special arrangements to participate in the hearing contact the person listed for this filing 5 days in advance of the hearing.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on Friday, January 28th, 2022.

AGENCY CONTACT PERSON: Henry Eckerson, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street
11 State House Station Augusta, Maine 04333-0011 EMAIL: henry.eckerson@maine.gov TELEPHONE: 207-624-4085 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

STATUTORY AUTHORITY FOR THIS RULE: 22 M.R.S. 42, 3173; Social Security Act 1905(t)(1) (42 U.S.C. 1396d(t)(1))

Comment deadline past Comment Deadline: January 28, 2022 | Posted: December 29, 2021

UPDATED TO REFLECT REMOTE PUBLIC HEARING, MaineCare Benefits Manual, Chapters II and III, Section 91, Health Home 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, MaineCare Benefits Manual, Chapters II and III, Section 91, Health Home Services

PROPOSED RULE NUMBER: 2021-P235

CONCISE SUMMARY: This Section 91 rulemaking proposes to eliminate Health Home Practices (HHP) from the Section 91 rule, makes various changes to Community Care Teams (CCTs), establishes the Housing Outreach and Member Engagement Provider (HOME Provider) as a provider of specialized CCT services and adds affiliated reimbursement rates to Chapter III, Section 91, and changes the names of the Chapters II and III, Section 91, policies to Health Home Services - Community Care Team.

Health Home Practices and the PCPlus Initiative HHPs are primary care practices that have been approved by MaineCare to provide Health Home Services. In this Section 91 rulemaking, the Department eliminates HHPs as providers in Section 91 because it would be duplicative of the covered services and reimbursement which the members and primary care providers (PCPs), respectively, will receive via the new Primary Care Plus (PCPlus) program. To complete the transition to PCPlus, the Department shall also propose to repeal Primary Care Case Management (Ch. VI, Sec. 1) and the Primary Care Provider Incentive Payment within Ch. II, Sec. 90 (Physician Services).

The PCPlus program is intended to give PCPs greater flexibility and incentives to effectively meet MaineCare members' health care needs by transitioning away from a volume-based (fee-for-service) payment system with little connection to value, toward an approach that provides risk-adjusted Population-Based Payments tied to cost- and quality-related outcomes. To receive reimbursement under PCPlus, providers are required to locate, coordinate, and monitor health care services for members who are attributed to them, as set forth in the PCPlus rule, Section 3.04. The Department will continue to reimburse other MaineCare-covered services under the fee-for-service system. PCPs who are currently HHPs may apply to participate in the soon-to-be-implemented PCPlus program and, if approved, will receive reimbursement based on their practice level characteristics and performance for members attributed to their practice. Interested parties should refer to the new PCPlus rule (MBM, Ch. VI, Sec. 3) for more details.

The Department is seeking and anticipates approval from the Centers for Medicare and Medicaid Services (CMS) of state plan amendments (SPAs) to repeal and/or alter these programs and implement the PCPlus program. Additionally, the Department will publish notices of the changes in reimbursement methodology pursuant to 42 C.F.R. 447.205.

Members currently attributed to an HHP panel will not experience any direct impacts once the HHP rule provisions are repealed. Members will keep their PCPs, but those PCPs that were HHPs will no longer be held to the HPP provider and covered service requirements. Members will be notified of the HHP repeal if their PCP is currently an HHP and if their PCP becomes a PCPlus provider.

Community Care Teams Under the proposed rule, CCTs support PCPs, rather than HHPs, by providing services to members who are high-risk and/or high-cost and whose health care needs are more intense than can be managed by a PCP. The proposed rule expands, simplifies, clarifies, and removes redundancies from the covered service requirements.

Under this proposed rule, CCTs will be subject to new provider requirements. CCTs must implement an electronic health record, participate in Department-required technical assistance and educational opportunities, maintain a Participant Agreement for data sharing with Maines Health Information Exchange, follow ten core standards currently designed for and applied to HHPs under the current rule, have a documented relationship with one or more PCPs, and have a multidisciplinary team of at least three health care professionals whose roles have been clarified.

The proposed rule also changes member eligibility requirements for CCT services to be more inclusive by decreasing the number of chronic medications, hospital admissions, and emergency department visits that are needed to qualify a member. Members would also now be eligible if they are transitioning from an institutional setting and if members are identified by risk-stratification as at risk for deteriorating health; high-risk or high-cost due to severity of illness or high social needs; or higher health care needs than is expected for their clinical risk group. To receive CCT services Members must still have two or more chronic conditions or have one chronic condition and be at risk for another. The proposed rule also adds new risk factors that would make a member at risk for a chronic condition.

Housing Outreach and Member Engagement (HOME) Services and Providers Via Resolve, To Increase Access to Housing-related Support Services, LD 1318 (129th Legislature 2019), the Legislature directed the Department to examine federal opportunities to provide housing-related services to persons experiencing chronic homelessness who have mental health conditions or substance use disorder and other vulnerable populations. In addition, the Office of MaineCare Services, Maine State Housing Authority (MSHA), and various housing and homeless services providers applied for and were accepted into a Medicaid Innovation Accelerator Program (IAP) for State Medicaid-Housing Agency Partnerships with technical assistance from the Corporation for Supportive Housing (CSH) and the Center for Health Care Strategies (CHCS). The collaborative group focused on improving outcomes for MaineCare members with disabilities and chronic health conditions, including Substance Use Disorder (SUD), who are experiencing homelessness and developing a Medicaid benefit to support housing sustainability, improved health outcomes, and reduced overall costs of care. The group proposed to use Section 2703 of the Affordable Care Act to develop a new type of CCT, a "HOME Provider," that would provide comprehensive care management and medical and behavioral health care coordination with intensive levels of transitional care and individual supports to meet the needs of MaineCare members with long-term homelessness.

HOME Providers shall conduct outreach to underserved populations in need of intensive HOME services due to high emergency services utilization, chronic conditions, complex care coordination needs, and long-term homelessness. The HOME Provider shall be comprised of a manager, clinical leader, case manager, peer support staff, and housing navigator. HOME Providers shall receive and review referrals for HOME service eligibility and enrollment from any point of care, including but not limited to hospitals, medical and behavioral health providers, and community service organizations. HOME Providers shall provide comprehensive care management, care coordination, health promotion, comprehensive transitional care, individual and family support services, and referral to community and social support services. There are three HOME service tiers in which members can be enrolled. Members must first meet the Intensive Tier criteria before entering the Stabilization and Maintenance Tiers. Each tier represents an intensity level of covered services and has a different per member per billing month reimbursement amount. Eligible members who are children may receive covered HOME services, as long as the HOME Provider obtains written consent from a parent or legal guardian.

Lastly, this rulemaking requires both CCTs and HOME Providers to submit data necessary to compile and report on performance measures, as identified by the Department. This will aid in the development of value-based metrics to include in future iterations of rulemaking and to ensure that the services provided are high-quality. The rulemaking also defines billing month as the period from the 21st of a month to the 20th of the following month and, when appropriate, replaces month and calendar month with billing month to clarify the reimbursement period for providers.

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

STATUTORY AUTHORITY: 22 M.R.S. 42, 3173; Section 2703 of the Affordable Care Act; LD 1318 (129th Legislature 2019), Resolve, To Increase Access to Housing-related Support Services; P.L. 2021, ch. 398, Sec. A-17, 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, 2021, June 30, 2022 and June 30, 2023

DATE, TIME, AND LOCATION OF PUBLIC HEARING: 11am; Tuesday, January 18th, 2022 Due to the ongoing threat posed by COVID-19, DHHS has determined that its public hearing will be conducted solely remotely, via Zoom. This is in accordance with the DHHS Remote Rulemaking Hearings Policy issued September 10th, 2021. (link to Remote Hearings Policy: https://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/9%209%2021%20Remote%20Rulemaking%20Hearings%20Policy.pdf )

Zoom Meeting link: https://mainestate.zoom.us/j/84981478440 Meeting ID: 849 8147 8440

Some devices may require downloading a free app from Zoom prior to joining the public hearing event. The Department requests that any individual requiring special arrangements to participate in the hearing contact the person listed for this filing 5 days in advance of the hearing.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on Friday, January 28th, 2022.

AGENCY CONTACT PERSON: Henry Eckerson, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street
11 State House Station Augusta, Maine 04333-0011 EMAIL: Henry.Eckerson@maine.gov TELEPHONE: 207-624-4085 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

STATUTORY AUTHORITY FOR THIS RULE: 22 M.R.S. 42, 3173; Section 2703 of the Affordable Care Act; LD 1318 (129th Legislature 2019), Resolve, To Increase Access to Housing-related Support Services; P.L. 2021, ch. 398, Sec. A-17, 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, 2021, June 30, 2022 and June 30, 2023

Comment deadline past Comment Deadline: Friday, January 28 | Posted: December 29, 2021

UPDATED TO REFLECT REMOTE PUBLIC HEARING , MaineCare Benefits Manual, Chapter II, Section 90, Physician 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, MaineCare Benefits Manual, Chapter II, Section 90, Physician Services

PROPOSED RULE NUMBER: 2021-P234

CONCISE SUMMARY: This proposed rulemaking seeks to make the following changes:

Pursuant to P.L. 2021, Ch. 398, Sec. A-17, 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, 2021, June 30, 2022 and June 30, 2023 (the "Budget"), and in alignment with the recommendations from the comprehensive rate setting evaluation conducted by Myers and Stauffer at the request of the Department, the proposed rule increases the reimbursement rate from 70% of the lowest level in the 2009 Medicare fee schedule to 72.4% of the current year's Medicare rate per code. In addition, the proposed rule sets the reimbursement rates for select primary care services at 100% of current Medicare rates, from 100% of 2014 Medicare rates, for eligible primary care providers, which is an additional reimbursement increase. These reimbursement changes shall be effective July 1, 2022, as authorized and required by the Budget.

Also per the Budget, the proposed rule adds a new provision, Section 90.04-7(B), Physician-Administered Drugs that have Biosimilar Equivalents and/or Prior Authorization Criteria. This provision implements a Biosimilar Preferred Drug List which establishes preferred and non-preferred drug statuses based on cost and biosimilar equivalency for physician-administered drugs. Physician-administered drugs are those that satisfy the criteria in 90.04-7(A), but they also may be drugs administered orally. For drugs that are not administered orally, the proposed changes require providers not only to go through the steps set forth in 90.04-7(A), but also to use physician-administered biosimilar drugs when a physician-administered drug has a Food and Drug Administration- (FDA) approved, biosimilar equivalent that the Department identifies as more affordable. Annually, the Department shall identify drugs that have a more affordable FDA-approved biosimilar equivalent on the Biosimilar Preferred Drug List on the MaineCare Health PAS Online Portal. Physicians shall submit a PA request to administer the original drug. For physician-administered drugs that are administered orally, providers must satisfy the requirements in 90.04-7(B).

Section 90.04-7 also requires that some physician-administered drugs may require PA to ensure members meet age, clinical, or other requirements for MaineCare to provide payment and that the MaineCare Health PAS Online Portal contains a complete list of physician-administered drugs that require PA and corresponding PA criteria sheets. Providers must make requests for PA on the Departments approved form and get approval prior to the date of service. This new proposed PA process is in addition to the requirements for PA in 90.04-7(A).

The proposed rule (Sec. 90.04-30) allows members under the age of 21 to receive the application of topical fluoride varnish up to four times per calendar year from eligible providers, rather than two times per calendar year or three times for members with a high caries rate or new restorations placed in the last 18 months. This change aligns with other states Medicaid program limitations on fluoride treatment and the current American Academy of Pediatrics recommendation on fluoride treatment. The proposed rule (Sec. 90.04-31) also allows all members to receive an oral health risk assessment if they do not have a dental home and/or have not seen a dentist in the past year, rather than restricting the service to members under three years of age.

The proposed rule (Sec. 90.05-2(A)) clarifies that medication abortions are covered and shall be performed in compliance with applicable Food and Drug Administration law and guidelines.

The 130th Maine Legislature enacted P.L. 2021, Ch. 348, An Act to Discontinue the Use of the Terms "Handicap," "Handicapped" and "Hearing Impaired" in State Laws, Rules and Official Documents. The proposed rule replaces the term 'handicapped with person with disabilities pursuant to P.L. 2021, Ch. 348.

This Section 90 rulemaking also proposes to eliminate Sec. 90.09-4, Primary Care Provider Incentive Payment (PCPIP), as part of the new Primary Care Plus (PCPlus) initiative. PCPIP authorizes an incentive payment to primary care practices (PCP) based on their performance on several access, utilization, and quality measures. Retaining this payment after PCPlus takes effect would be duplicative of the reimbursement PCPs will receive under the new PCPlus rule. PCPs who currently receive the Incentive Payment may instead apply to participate in PCPlus and, if approved as part of the program, will receive reimbursement based on their performance for members attributed to their practice.

To complete the transition to PCPlus, the Department shall also propose to significantly revise MBM, Ch. II, Sec. 91 (proposed to be titled Health Home Services - Community Care Teams), which includes repealing Health Home Practices. All of these rulemakings make up the PCPlus initiative, will be proposed simultaneously, and will have the same effective date.

The PCPlus program is intended to give primary care providers (PCPs) greater flexibility and incentives to effectively meet MaineCare members health care needs by transitioning away from a volume-based (fee-for-service) payment system with little connection to value, toward an approach that provides risk-adjusted Population-Based Payments tied to cost- and quality-related outcomes To receive reimbursement under PCPlus, providers are required to locate, coordinate, and monitor health care services for members who are attributed to them. The Department will continue to reimburse other MaineCare covered services under the fee-for-service system. Interested parties should refer to the new PCPlus rule (MBM, Ch. VI, Sec. 3) for more details.

The Department shall seek approval from the Centers for Medicare and Medicaid Services (CMS) of state plan amendments (SPAs) to repeal and revise the aforementioned programs and implement the PCPlus program. Additionally, the Department will publish notice of the changes in Section 90 reimbursement methodology pursuant to 42 C.F.R. 447.205.

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. 2021, Ch. 398, Sec. A-17; P.L. 2021, Ch. 348

DATE, TIME, AND LOCATION OF PUBLIC HEARING: 1:30pm; Tuesday, January 18th, 2022 Due to the ongoing threat posed by COVID-19, DHHS has determined that its public hearing will be conducted solely remotely, via Zoom. This is in accordance with the DHHS Remote Rulemaking Hearings Policy issued September 10th, 2021. (link to Remote Hearings Policy: https://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/9%209%2021%20Remote%20Rulemaking%20Hearings%20Policy.pdf )

Zoom Meeting link: https://mainestate.zoom.us/j/86873386512 Meeting ID: 868 7338 6512

Some devices may require downloading a free app from Zoom prior to joining the public hearing event. The Department requests that any individual requiring special arrangements to participate in the hearing contact the person listed for this filing 5 days in advance of the hearing.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on Friday, January 28th, 2022.

AGENCY CONTACT PERSON: Henry Eckerson, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: henry.eckerson@maine.gov TELEPHONE: 207-624-4085 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

STATUTORY AUTHORITY FOR THIS RULE: 22 M.R.S. 42, 3173; P.L. 2021, Ch. 398, Sec. A-17; P.L. 2021, Ch. 348

Comment deadline past Comment Deadline: January 28, 2022 | Posted: December 29, 2021

UPDATED TO REFLECT REMOTE PUBLIC HEARING , MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures

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REVISED Notice of Agency Rule-making Proposal

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 I, Section 1, General Administrative Policies and Procedures

PROPOSED RULE NUMBER: 2021-P217

CONCISE SUMMARY: This proposed rulemaking makes various, complex changes, including changes to comply with federal regulations, make updates to reflect current practices, clarify ambiguous and vague sections of policy, and increase the MaineCare Program Integrity Unit's ability to safeguard against fraud, waste, and abuse. All the changes in this rulemaking are listed below:

The current rule does not address retroactive enrollment for providers other than federally qualified health centers, rural health centers, and Indian health centers. This rulemaking broadens Sec. 1.03-1(F) to allow for retroactive enrollment for other eligible providers, subject to review and approval by the Department of Health and Human Services (the Department) in accordance with 42 CFR 431.108. A request for retroactive enrollment is subject to the Departments review and discretion and is not a guarantee of claim payment or prior authorization. The Department may grant retroactive enrollment back to providers Medicare enrollment effective date but will not grant a retroactive enrollment date that is more than 365 days prior to the date of providers MaineCare application submission.

To comply with 42 CFR 455.434, this rule adds a section on fingerprint-based criminal background checks (FCBC), mandating that providers or applicants whose categorical risk level meets the federal definition of high risk must consent to a FCBC. This new section 1.03-1(J) includes relevant criteria for termination or denial of enrollment and outlines which providers and suppliers constitute high categorical risk.

The current 'rounding rule (Sec. 1.03-8(J)) allows providers to round up a unit of service if the unit of service delivered is equal to or greater than fifty percent. To encourage clarity and precision in delivering the amount of covered services that are medically necessary, this rulemaking makes changes so when a partial unit of service is delivered, the provider may either bill for the partial unit of service provided, or round up if eighty percent of the unit of service was delivered. The rule retains the ability to round up if fifty percent of the unit of service was delivered, but only when unforeseen circumstances prevent a provider from delivering a whole unit of service. This rulemaking also adds misuse of the "rounding rule" to examples of conduct that could constitute fraud.

MaineCare Benefits Manual, Chapter II, Section 80, which primarily applies to retail pharmacies, previously housed language on the 340B Drug Price Program (340B Program). However, the 340B Program language is better suited in this rule because it applies to all provider types except pharmacies. Hence, this rulemaking adds a section, 1.03-14, on the 340B Program that requires providers or entities who purchase drugs under the 340B program to sign a 340B agreement with the Department and to comply with federal and Health Resources & Services Administration 340B rules and regulations. The Department shall seek and anticipates approval of a state plan amendment related to these changes. Additionally and separately, the Department shall repeal the 340B Program provisions that are in Ch. II, Sec. 80.09-1(D).

This rulemaking expands the definition of non-covered services to include administrative tasks (Sec. 1.06-4(B)(8)), including verification of MaineCare eligibility, updating member contact information, scheduling of appointments, and similar activities. This provision strengthens the Office of MaineCare
Services (OMS) Program Integrity Units enforcement of the prohibition on billing for administrative tasks, which already exists per current MaineCare rules.

To comply with section 53102 of the Bipartisan Budget Act of 2018, P.L. No. 115-123, this rulemaking updates that the Department will no longer pay and then seek reimbursement, commonly known as pay and chase, from liable third parties for prenatal services.

This rulemaking clarifies (Sec. 1.19-1(C)(2)) that the Department may reimburse providers for covered services rendered during the period following a notice of termination up to the effective date of termination, instead of for a period not to exceed thirty days after the date of receipt of the notice of termination, because providers may not be reimbursed after termination of a provider agreement. The rulemaking also adds that providers must follow the provisions of their provider agreements and the MaineCare Benefits Manual to continue to receive reimbursement for services.

To enable the OMS Program Integrity Unit to implement appropriate sanctions, this rulemaking allows the Department, in its discretion, to consider a request from a provider to impose a lower percentage than 20% recoupment. The rulemaking adds a list of factors in Sec. 1.20-2 for the Department to consider when assessing this type of provider request.

This rulemaking adds other sanctions, such as submitting a plan of correction, so the OMS Program Integrity Unit can ensure providers comply with MaineCare rules and monitor providers who experience rapid growth or changes. Providers who grow rapidly may not have adequate infrastructure to maintain quality of service provision. The additional sanctions are: Impose a suspension of referrals to a provider; Deny or pend any enrollment applications submitted by a provider; Limit the number of service locations a provider may enroll; and Limit the number of MaineCare members the provider may serve.

This rulemaking clarifies the provisions in Sec. 1.21 regarding reinstatement following termination or exclusion. The current rule regarding, for example, the time period for reinstatement may be confusing and difficult to apply.

The Department adds a section, 1.24-4, on expedited member appeals that includes the procedure to request an expedited appeal, criteria for the Division of Administrative Hearings (DAH) to consider when deciding whether to grant requests, deadlines for when the Department must take final agency action, and other requirements, per 42 CFR 431.224. MaineCare Member Services shall send all expedited hearing requests to a hearings representative and the DAH within 24 hours of identifying the request.

The MaineCare Advisory Committee (MAC) has developed structural and process changes to improve its function and efficiency, which must be put into Sec. 1.25. The MAC proposed changes include increasing MAC membership, including at least two Medicaid beneficiaries as members, and other changes.

This proposed rulemaking also makes the following changes:

Define the ownership and control relationships that are subject to an offset; Establish a timeframe for when providers need to update OMS of changes to their National Provider Identifier or other enrollment information; Require providers who change their name or doing business as name to change their MaineCare Provider Agreement; Clarify that providers must take all reasonable and appropriate steps requested by the Department to transition members before changes of ownership, closures, and disenrollment, except in the case of reasonably unforeseen circumstances, and, upon request, submit a transition plan to the Department for review and approval; Update the rule in accordance with 10-144 Code of Maine Rules, Chapter 128, Certified Nursing Assistant and Direct Care Worker Registry Rule, to require agencies hiring direct care workers (DCWs) to check the Maine Certified Nursing Assistant and Direct Care Worker Registry to ensure DCWs are eligible for employment in Maine and comply with all requirements stipulated in the rule; Add that providers may not bill MaineCare for an interpreter service supplied by an entity in which the providers, any owner of the providers, or an immediate family member of the providers or any of their owners has any direct or indirect ownership or financial interest, unless the provider also reimburses other entities for the provision of interpreter services and the entity providing the interpreting service makes those services commercially available to MaineCare providers or other businesses that do not share a direct or indirect familial ownership interest with the interpreting entity; Change the billable amount for interpreter services to be the lesser of the interpreters usual and customary charge and the rate authorized by the Department; To comply with section 53102 of the Bipartisan Budget Act of 2018, increase the number of days, from 30 to 100, that providers must wait for a response from an absent parents third party insurance before billing MaineCare; Add that the Department may impose sanctions on providers who fail to provide information to the Department or to otherwise respond to Departmental requests for information within a reasonable timeframe established by the Department; Add a penalty of 25% of MaineCare payments for covered goods and services where the providers records lack a required signature by a member or the members guardian; Change penalties to equal 20%, as opposed to not exceeding 20%, when mandated records are missing but providers are able to demonstrate by a preponderance of the evidence that the disputed goods or services were medically necessary; Make clear the Departments authority to exclude individuals, entities, and providers from participation in MaineCare for any reason identified in 42 C.F.R. Part 1001 or 1003; Add considerations for reinstatement from termination or exclusion to include the conduct of the individual or entity prior to and after the date of the notice of exclusion; and Clarify that providers may request an informal review within 60 calendar days from the date of written notification of the Departments alleged grievance and extend the deadline to the next business day if it falls on a weekend or holiday.

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

STATUTORY AUTHORITY: 22 M.R.S. 42, 42(7)(H), 3173; 42 CFR 431.108, 455.434, 447.56, 431.224, 431.12; 42 CFR Parts 1001 and 1003; Bipartisan Budget Act of 2018, Sec. 53102, P.L. No. 115-123

DATE, TIME, AND LOCATION OF PUBLIC HEARING: 1pm; Thursday, January 20th, 2022 Due to the ongoing threat posed by COVID-19, DHHS has determined that its public hearing will be conducted solely remotely, via Zoom. This is in accordance with the DHHS Remote Rulemaking Hearings Policy issued September 10th, 2021. (link to Remote Hearings Policy: https://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/9%209%2021%20Remote%20Rulemaking%20Hearings%20Policy.pdf )

Zoom Meeting link: https://mainestate.zoom.us/j/83872072632 Meeting ID: 838 7207 2632

Some devices may require downloading a free app from Zoom prior to joining the public hearing event. The Department requests that any individual requiring special arrangements to participate in the hearing contact the person listed for this filing 5 days in advance of the hearing.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on Sunday, January 30th, 2022.

AGENCY CONTACT PERSON: Henry Eckerson, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: henry.eckerson@maine.gov TELEPHONE: 207-624-4085 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

STATUTORY AUTHORITY FOR THIS RULE: 22 M.R.S. 42, 42(7)(H), 3173; 42 CFR 431.108, 455.434, 447.56, 431.224, 431.12; 42 CFR Parts 1001 and 1003; Bipartisan Budget Act of 2018, Sec. 53102, P.L. No. 115-123

Comment deadline past Comment Deadline: January 30, 2022 | Posted: December 29, 2021

MaineCare Benefits Manual, Chapter II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder

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AGENCY: Department of Health and Human Services, MaineCare Services

CHAPTER NUMBER AND TITLE: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This Section 21 rule provides home and community-based services (HCBS) that are authorized by a federal Medicaid 1915(c) home and community-based waiver that meets federal standards.

On September 25, 2020, CMS approved the Department's request to renew the Home and Community Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder waiver for a five-year period, with an effective date of July 1, 2020. In accordance with this CMS approval, the Department proposes the following changes to this rule:

Eliminates Counseling as a Section 21 service. Counseling services are available to Section 21 Members under Section 65 of the MaineCare Benefits Manual. All Section 21 Members who were receiving Counseling services under Section 21 received written notice of this change in October 2020. The description for the following Covered Services has been updated, expanded and/or clarified: Career Planning Community Support Crisis Intervention Services (Requires additional documentation by the Planning Team) Home Support - Agency Per Diem (Requires that at least one staff person is in the same residence 24/7 in order to respond immediately to Member requests for assistance) Home Support Family Centered Support Home Support Quarter Hour Non-Medical Transportation Service Shared Living (Foster Care Adult) Specialized Medical Equipment Speech Therapy (Maintenance) (clarifies the intent is to prevent regression, loss of movement, injury and medical complications that would result in a higher level of skilled care).
Work Support Individual (clarifies the primary focus of the service is job related and encompasses adherence to workplace policies and safety). The following definitions were updated: Autism Spectrum Disorder, Intellectual Disability, Activities of Daily Living, Instrumental Activities of Daily Living, Person-Centered Service Plan and Shared Living.

The Department proposes the following additional changes:

Community Support services are proposed to be separated into three tiers of service delivery: Community Only-Individual, Community Only-Group, and Center-Based, to support individualized needs of the participant population more broadly. The Department will seek CMS approval for this change.
DOJ Settlement Agreement: On June 4, 2021, the Department entered into a Settlement Agreement with the U.S. Department of Justice (DJ No. 204-34-72). The Department agreed to adopt a rule which established an exceptions process which provides that Section 21 Members, and Members applying to receive Section 21 benefits, may request services in excess of otherwise applicable Section 21 monetary and/or unit caps, where necessary to ensure that Section 21 Members receive adequate and appropriate services and supports in the most integrated setting appropriate to their needs, consistent with the Americans with Disabilities Act (ADA). This rulemaking proposes the Requests for Exceptions provision (See Sec. 21.14).

On August 10, 2021 the Department proposed a new rule which implements the federal requirements for Maines Section 1915(c) home and community-based waiver programs as required by 42 C.F.R. Sec. 441.301(c). This proposed rule is cited as:10-144 C.M.R., ch 101, MaineCare Benefits Manual, Chapter I, Section 6, Global HCBS Waiver Person-Centered Planning and Settings Rule, referred to as the HCBS Global Rule. The HCBS Global Rule includes requirements for person-centered service planning and for settings in which home and community-based waiver services ("HCBS") are provided, including requirements for provider-owned or controlled residential settings. This proposed Section 21 rule includes provisions that incorporate the requirements of the Global rule (See Sec. 21.04-2 [Person Centered Service Planning Process] and Sec. 21.05-1 [Home and Community Based Settings]).

This proposed rule notifies providers and the public that all Section 21 providers must comply with all applicable federal and state law, which includes applicable Maine licensing laws and regulations as well as Ch I, Section 1 of the MaineCare Benefits Manual including maintaining current licenses, as applicable.

21.07-2 (Limits): The Department proposes to change the limit from $26,640 to $39,875 for the combined annual cost of Work Support Group, Work Support-Individual, and Community Support Services, retroactive to January 1, 2021. This retroactive application is lawful under 22 M.R.S. Sec. 42(8), as the change is a benefit to both Members and Providers. The Department received CMS approval for this change.

POCA: The Department proposes a new provision which authorizes the Department to issue written notices of deficiencies, and requires providers to submit and implement Plans of Corrective Action (POCA) as approved by the Department. Providers have the right to appeal written notices of deficiencies in service provision. This POCA process will provide increased protections for Members and ensure that providers are in compliance with service requirements, have sufficient clinical and administrative capability to carry out the intent of the service, and have taken steps to assure the safety, quality, and accessibility of the service for Members.

21.08-3 (Termination from Participation as a MaineCare Provider): The Department proposes to clarify this provision by expressly notifying providers of the MaineCare Benefits Manual, Ch. I, Sec. I requirement that providers must give written notice of their intent to terminate all participation in the MaineCare Program. In addition, this provision requires Section 21 providers to notify all Section 21 members that they serve of any intent to terminate participation in the MaineCare program.

21.10-1 (Direct Support Professional): The Department proposes changes to Provider Qualifications and Requirements for Direct Support Professionals (DSPs) for Career Planning and Employment Specialist Services. For DSPs, the proposed rule eliminates the requirement for grievance training prior to working with Members and adds a requirement for DSPs who provide Crisis Intervention to receive behavioral intervention training.

Appendix IV (Performance Measures): The Department proposes to eliminate Appendix IV because the Department utilizes data available through the Department of Labor, Person Centered Service Plans, and authorization data as part of the Departments commitment to quality assurance and quality improvement system. Additionally, specific performance measures are either no longer relevant or necessary to measure the performance of specifically listed employment services, or have been met.

21.10-9 (Electronic Visit Verification): The Department proposes to require that providers of Home Support-Quarter Hour services comply with Maine DHHS Electronic Visit Verification (EVV) system standards and requirements. This complies with the 21st Century Cures Act (P.L. 114-255), Section 12006, as codified in 42 U.S.C. 1396b(l).

21.10-1(DSP qualification): The Department proposes to require all DSPs, regardless of capacity and prior to provision of services to a Member, receive training regarding the Global HCBS Waiver Person Centered Planning and Settings Rule, MaineCare Benefits Manual, Chapter 1, Section 6. Moreover, within six (6) months of hire and annually thereafter, the proposed rule requires that DSPs comply with the Departments regulations; Reportable Events System (14-197 CMR ch 12) and the Adult Protective Services System (10-149 CMR ch. 1).

21.11 (Member Appeals): The Department proposes adding a sentence to provide that Members have the right to appeal decisions made regarding priority level and waitlist determinations.

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

STATUTORY AUTHORITY: 22 M.R.S. 42, 42(8), 3173, 42 C.F.R. Sec. 441.301(c), 42 U.S.C. 1396b(l)

DATE FILED WITH THE SECRETARY OF STATES OFFICE: December 29, 2021

PUBLIC HEARING: 1pm; Wednesday, January 19, 2022 Due to the ongoing threat posed by COVID-19 (see below), DHHS has determined that its public hearing will be conducted solely remotely, via Zoom.

Zoom Meeting link: https://mainestate.zoom.us/j/84195696775 Meeting ID: 841 9569 6775

In addition to the public hearing, individuals may submit written comments to DHHS by the date listed in this notice.

COMMENT DEADLINE: Comments must be received by 11:59 PM on January 31, 2022

AGENCY CONTACT PERSON: Heather Bingelis, Comprehensive Health Planner II Heather.Bingelis@maine.gov AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 TELEPHONE: 207-624-6951 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: January 31, 2022 | Posted: December 29, 2021

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 final rule is proposed to implement P.L. 2021, ch. 398, Part A, A-1, pg. 99, which provided funding to modify MaineCare estate recovery rules to conform with the minimum mandatory federal requirements, which are set forth in 42 U.S.C. 1396p(b).

Chapter VII, Section 5, Estate Recovery, of the MaineCare Benefits Manual (MBM), has been modified by emergency rulemaking, filed November 24, 2021. The permanent rule is as follows: Effective November 24, 2021, the Department's estate recovery claim is limited to the amount paid by MaineCare for all nursing facility services, home and community-based services, and related hospital and prescription drug services paid on behalf of the Member. This proposed rule makes the emergency rule permanent with an effective date of November 24, 2021.

In addition, the Department proposes to update language regarding life estates to clarify the definition, as well as how life estates are valued.

The Department has also removed conditional language regarding CMSs pending approval of previous changes if those changes have since been approved and has made minor typographical corrections.

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

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

PUBLIC HEARING: A public hearing will not be held for this rulemaking. The Department will accept email and standard mail comments for 30 days following rule filing with the Secretary of State. Email to Nicole.Jurdak@maine.gov and standard mail to Nicole Jurdak, 11 SHS, 109 Capitol Street, Augusta, ME 04330.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on January 21, 2022.

AGENCY CONTACT PERSON: Nicole Jurdak, Comprehensive Health Planner AGENCY NAME: Office of MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: Nicole.Jurdak@Maine.gov TELEPHONE: 207-624-4058 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 Comment Deadline: January 21, 2022 | Posted: December 22, 2021

REPEAL of MaineCare Benefits Manual, Chapter VI, Section 1, Primary Care Case Management

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Concise Summary:

Notice of Agency Rule-making Proposal

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 VI, Section 3, Primary Care Plus

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This proposed rulemaking repeals 10-144 CMR Ch. 101, MaineCare Benefits Manual (the "MBM"), Ch. VI, Sec. 1, Primary Care Case Management (PCCM), and replaces it with MBM, Ch. VI, Sec. 3, Primary Care Plus (PCPlus), a single integrated program for MaineCare's current primary care programs. To complete the transition to PCPlus, the Maine Department of Health and Human Services (the Department) shall also propose to repeal MBM, Ch. II, Sec. 90.09-4 (Primary Care Provider Incentive Payment) and shall propose to significantly revise MBM, Ch. II, Sec. 91 (proposed to be titled Health Home Services - Community Care Teams), which includes repealing Health Home Practices. All of these rulemakings make up the PCPlus initiative, will be proposed simultaneously, and will have the same effective date.

The Department shall seek approval from the Centers for Medicare and Medicaid Services (CMS) of state plan amendments (SPAs) to repeal the aforementioned programs and implement the PCPlus program. Additionally, the Department will publish a notice of change in reimbursement methodology pursuant to 42 C.F.R. 447.205.

Overview of the PCPlus Initiative

The Department and the Office of MaineCare Services (OMS) are committed to improving health care access and outcomes for MaineCare members, demonstrating cost-effective use of resources, and creating an environment where providers can innovate in delivering high-value care. PCPlus is part of OMS commitment to have 40% of MaineCare expenditures paid through Alternative Payment Models (APMs) by the end of 2022. APMs are health care payment methods that use financial incentives to promote or leverage greater value, indicated by higher quality care and/or lower costs.

PCPlus is considered an Integrated Care Model by CMS under State Medicaid Director Letter #12-002, aligns with the Center for Medicare and Medicaid Innovations (CMMI) Primary Care First Model (See also: https://innovation.cms.gov/innovation-models-options), and operates under the authority of Section 1905(t)(1) of the Social Security Act (SSA). The PCPlus program is intended to give primary care providers (PCPs) greater flexibility and incentives to effectively meet MaineCare members health care needs by transitioning away from a volume-based (fee-for-service) payment system with little connection to value, toward an approach that provides risk-adjusted Population-Based Payments tied to cost- and quality-related outcomes.

Participation in PCPlus is voluntary for PCPs. For PCPs that elect to participate, the Department will share quality and utilization data, offer a new value-based payment model, and provide technical assistance to assist practices transform care delivery and achieve performance outcomes. The new payment model is risk-based, meaning reimbursement will increase or decrease depending on the PCPlus providers performance, as set forth in Section 3.08 of the rule. Providers may appeal Departmental actions, pursuant to Chapter I, Section 1.

Member participation in this model is based on which PCP the member visited for health care services or by the members identification of a PCP through calling MaineCare Member Services. Member participation is voluntary and does not interfere with MaineCare members freedom of choice to access other MaineCare providers. If a member identified their PCP for attribution through MaineCare Member Services but does not receive at least one primary care service from their selected PCP within one year, then DHHS will notify and reattribute the member in accordance with the primary care services-based attribution methodology. Members may change their PCP or opt out of PCPlus at any time.

To receive reimbursement under PCPlus, providers are required to locate, coordinate, and monitor health care services for members who are attributed to them, as set forth in Section 3.04. All covered services rendered by PCPlus providers must be documented in the members electronic health record. The Department will continue to reimburse other MaineCare covered services under the fee-for-service system.

Differences Between PCPlus and PCCM

CMS considers PCCM to be a form of managed care, which operates under Section 1905(a)(25) of the SSA and 42 CFR 438.6 with mandatory member participation for the majority of MaineCare members. PCPlus operates under 1905(t)(1) of the SSA and is not a managed care program. Since PCPlus is not a managed care program, it does not include many of the managed care requirements that PCCM follows. For example, except as set forth in the rule, member participation in PCPlus is based on members selection of a PCP, members may opt out of this program, and this program has no bearing on MaineCare members freedom of choice to access services from any qualified MaineCare provider. In addition, PCPlus, unlike PCCM, does not include the PCCM provisions on member participation or complaints, and PCP selection, change, and reassignment.

Under PCCM and PCPlus, providers locate, coordinate, and monitor health care services. However, PCPlus expands service and practice requirements to support whole-person coordination and transitions of care; completing timely prior authorizations; providing, tracking, and following up on referrals; and closing care gaps, including a focus on preventative services.

PCCM providers who choose to participate in PCPlus will benefit from a new value-based payment model, which includes a risk-adjusted population-based payment tied to cost- and quality-related outcomes, rather than the flat per member per month management fee provided under PCCM. Given the additional requirements and support for providers, PCPlus should improve health outcomes for members.

Section 90 and 91 Rulemakings for PCPlus Initiative

Regarding the related proposed rulemaking for Section 90, the Department is eliminating the Primary Care Provider Incentive Payment because it would duplicate the reimbursement model of the new PCPlus program. Physicians who currently receive the Incentive Payment may apply to be PCPs under the PCPlus program, and, if approved, will receive reimbursement based on the PCPlus service expectations and performance for members attributed to their practice.

For Section 91, as it relates to the PCPlus initiative, the Department is removing Health Home Practices (HHPs) because they would be duplicative of the reimbursement the PCPs will receive and the covered services they provide via PCPlus. HHPs that currently receive reimbursement through Section 91 may apply to participate in the PCPlus program, and, if approved, PCPs will receive reimbursement based on the PCPlus service expectations and performance for members attributed to their practice.

See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. 42, 3173; Social Security Act 1905(t)(1) (42 U.S.C. 1396d(t)(1))

PUBLIC HEARING: No public hearing is scheduled. The Department will provide a 30-day comment period instead of a public hearing.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on January 21st, 2022.

AGENCY CONTACT PERSON: Henry Eckerson, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: henry.eckerson@maine.gov TELEPHONE: 207-624-4085 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

STATUTORY AUTHORITY FOR THIS RULE: 22 M.R.S. 42, 3173; Social Security Act 1905(t)(1) (42 U.S.C. 1396d(t)(1))

Comment deadline past No comment deadline | Posted: December 22, 2021

MaineCare Benefits Manual, Chapters II and III, Section 91, Health Home Services

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Concise Summary:

Notice of Agency Rule-making Proposal

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, Chapters II and III, Section 91, Health Home Services

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This Section 91 rulemaking proposes to eliminate Health Home Practices (HHP) from the Section 91 rule, makes various changes to Community Care Teams (CCTs), establishes the Housing Outreach and Member Engagement Provider (HOME Provider) as a provider of specialized CCT services and adds affiliated reimbursement rates to Chapter III, Section 91, and changes the names of the Chapters II and III, Section 91, policies to Health Home Services - Community Care Team.

Health Home Practices and the PCPlus Initiative

HHPs are primary care practices that have been approved by MaineCare to provide Health Home Services. In this Section 91 rulemaking, the Department eliminates HHPs as providers in Section 91 because it would be duplicative of the covered services and reimbursement which the members and primary care providers (PCPs), respectively, will receive via the new Primary Care Plus (PCPlus) program. To complete the transition to PCPlus, the Department shall also propose to repeal Primary Care Case Management (Ch. VI, Sec. 1) and the Primary Care Provider Incentive Payment within Ch. II, Sec. 90 (Physician Services).

The PCPlus program is intended to give PCPs greater flexibility and incentives to effectively meet MaineCare members' health care needs by transitioning away from a volume-based (fee-for-service) payment system with little connection to value, toward an approach that provides risk-adjusted Population-Based Payments tied to cost- and quality-related outcomes. To receive reimbursement under PCPlus, providers are required to locate, coordinate, and monitor health care services for members who are attributed to them, as set forth in the PCPlus rule, Section 3.04. The Department will continue to reimburse other MaineCare-covered services under the fee-for-service system. PCPs who are currently HHPs may apply to participate in the soon-to-be-implemented PCPlus program and, if approved, will receive reimbursement based on their practice level characteristics and performance for members attributed to their practice. Interested parties should refer to the new PCPlus rule (MBM, Ch. VI, Sec. 3) for more details.

The Department is seeking and anticipates approval from the Centers for Medicare and Medicaid Services (CMS) of state plan amendments (SPAs) to repeal and/or alter these programs and implement the PCPlus program. Additionally, the Department will publish notices of the changes in reimbursement methodology pursuant to 42 C.F.R. 447.205.

Members currently attributed to an HHP panel will not experience any direct impacts once the HHP rule provisions are repealed. Members will keep their PCPs, but those PCPs that were HHPs will no longer be held to the HPP provider and covered service requirements. Members will be notified of the HHP repeal if their PCP is currently an HHP and if their PCP becomes a PCPlus provider.

Community Care Teams

Under the proposed rule, CCTs support PCPs, rather than HHPs, by providing services to members who are high-risk and/or high-cost and whose health care needs are more intense than can be managed by a PCP. The proposed rule expands, simplifies, clarifies, and removes redundancies from the covered service requirements. Under this proposed rule, CCTs will be subject to new provider requirements. CCTs must implement an electronic health record, participate in Department-required technical assistance and educational opportunities, maintain a Participant Agreement for data sharing with Maines Health Information Exchange, follow ten core standards currently designed for and applied to HHPs under the current rule, have a documented relationship with one or more PCPs, and have a multidisciplinary team of at least three health care professionals whose roles have been clarified.

The proposed rule also changes member eligibility requirements for CCT services to be more inclusive by decreasing the number of chronic medications, hospital admissions, and emergency department visits that are needed to qualify a member. Members would also now be eligible if they are transitioning from an institutional setting and if members are identified by risk-stratification as at risk for deteriorating health; high-risk or high-cost due to severity of illness or high social needs; or higher health care needs than is expected for their clinical risk group. To receive CCT services Members must still have two or more chronic conditions or have one chronic condition and be at risk for another. The proposed rule also adds new risk factors that would make a member at risk for a chronic condition.

Housing Outreach and Member Engagement (HOME) Services and Providers

Via Resolve, To Increase Access to Housing-related Support Services, LD 1318 (129th Legislature 2019), the Legislature directed the Department to examine federal opportunities to provide housing-related services to persons experiencing chronic homelessness who have mental health conditions or substance use disorder and other vulnerable populations. In addition, the Office of MaineCare Services, Maine State Housing Authority (MSHA), and various housing and homeless services providers applied for and were accepted into a Medicaid Innovation Accelerator Program (IAP) for State Medicaid-Housing Agency Partnerships with technical assistance from the Corporation for Supportive Housing (CSH) and the Center for Health Care Strategies (CHCS). The collaborative group focused on improving outcomes for MaineCare members with disabilities and chronic health conditions, including Substance Use Disorder (SUD), who are experiencing homelessness and developing a Medicaid benefit to support housing sustainability, improved health outcomes, and reduced overall costs of care. The group proposed to use Section 2703 of the Affordable Care Act to develop a new type of CCT, a "HOME Provider," that would provide comprehensive care management and medical and behavioral health care coordination with intensive levels of transitional care and individual supports to meet the needs of MaineCare members with long-term homelessness.

HOME Providers shall conduct outreach to underserved populations in need of intensive HOME services due to high emergency services utilization, chronic conditions, complex care coordination needs, and long-term homelessness. The HOME Provider shall be comprised of a manager, clinical leader, case manager, peer support staff, and housing navigator. HOME Providers shall receive and review referrals for HOME service eligibility and enrollment from any point of care, including but not limited to hospitals, medical and behavioral health providers, and community service organizations. HOME Providers shall provide comprehensive care management, care coordination, health promotion, comprehensive transitional care, individual and family support services, and referral to community and social support services. There are three HOME service tiers in which members can be enrolled. Members must first meet the Intensive Tier criteria before entering the Stabilization and Maintenance Tiers. Each tier represents an intensity level of covered services and has a different per member per billing month reimbursement amount. Eligible members who are children may receive covered HOME services, as long as the HOME Provider obtains written consent from a parent or legal guardian.

Lastly, this rulemaking requires both CCTs and HOME Providers to submit data necessary to compile and report on performance measures, as identified by the Department. This will aid in the development of value-based metrics to include in future iterations of rulemaking and to ensure that the services provided are high-quality. The rulemaking also defines billing month as the period from the 21st of a month to the 20th of the following month and, when appropriate, replaces month and calendar month with billing month to clarify the reimbursement period for providers.

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

STATUTORY AUTHORITY: 22 M.R.S. 42, 3173; Section 2703 of the Affordable Care Act; LD 1318 (129th Legislature 2019), Resolve, To Increase Access to Housing-related Support Services; P.L. 2021, ch. 398, Sec. A-17, 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, 2021, June 30, 2022 and June 30, 2023

PUBLIC HEARING: No public hearing is scheduled. The Department will provide a 30-day comment period instead of a public hearing.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on January 21st, 2022.

AGENCY CONTACT PERSON: Henry Eckerson, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: Henry.Eckerson@maine.gov TELEPHONE: 207-624-4085 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

STATUTORY AUTHORITY FOR THIS RULE: 22 M.R.S. 42, 3173; Section 2703 of the Affordable Care Act; LD 1318 (129th Legislature 2019), Resolve, To Increase Access to Housing-related Support Services; P.L. 2021, ch. 398, Sec. A-17, 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, 2021, June 30, 2022 and June 30, 2023

Comment deadline past Comment Deadline: January 21, 2022 | Posted: December 22, 2021

MaineCare Benefits Manual, Chapter VI, Section 3, Primary Care Plus

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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 VI, Section 3, Primary Care Plus

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This proposed rulemaking repeals 10-144 CMR Ch. 101, MaineCare Benefits Manual (the "MBM"), Ch. VI, Sec. 1, Primary Care Case Management (PCCM), and replaces it with MBM, Ch. VI, Sec. 3, Primary Care Plus (PCPlus), a single integrated program for MaineCare's current primary care programs. To complete the transition to PCPlus, the Maine Department of Health and Human Services (the Department) shall also propose to repeal MBM, Ch. II, Sec. 90.09-4 (Primary Care Provider Incentive Payment) and shall propose to significantly revise MBM, Ch. II, Sec. 91 (proposed to be titled Health Home Services - Community Care Teams), which includes repealing Health Home Practices. All of these rulemakings make up the PCPlus initiative, will be proposed simultaneously, and will have the same effective date.

The Department shall seek approval from the Centers for Medicare and Medicaid Services (CMS) of state plan amendments (SPAs) to repeal the aforementioned programs and implement the PCPlus program. Additionally, the Department will publish a notice of change in reimbursement methodology pursuant to 42 C.F.R. 447.205.

Overview of the PCPlus Initiative

The Department and the Office of MaineCare Services (OMS) are committed to improving health care access and outcomes for MaineCare members, demonstrating cost-effective use of resources, and creating an environment where providers can innovate in delivering high-value care. PCPlus is part of OMS commitment to have 40% of MaineCare expenditures paid through Alternative Payment Models (APMs) by the end of 2022. APMs are health care payment methods that use financial incentives to promote or leverage greater value, indicated by higher quality care and/or lower costs.

PCPlus is considered an Integrated Care Model by CMS under State Medicaid Director Letter #12-002, aligns with the Center for Medicare and Medicaid Innovations (CMMI) Primary Care First Model (See also: https://innovation.cms.gov/innovation-models-options), and operates under the authority of Section 1905(t)(1) of the Social Security Act (SSA). The PCPlus program is intended to give primary care providers (PCPs) greater flexibility and incentives to effectively meet MaineCare members health care needs by transitioning away from a volume-based (fee-for-service) payment system with little connection to value, toward an approach that provides risk-adjusted Population-Based Payments tied to cost- and quality-related outcomes.

Participation in PCPlus is voluntary for PCPs. For PCPs that elect to participate, the Department will share quality and utilization data, offer a new value-based payment model, and provide technical assistance to assist practices transform care delivery and achieve performance outcomes. The new payment model is risk-based, meaning reimbursement will increase or decrease depending on the PCPlus providers performance, as set forth in Section 3.08 of the rule. Providers may appeal Departmental actions, pursuant to Chapter I, Section 1.

Member participation in this model is based on which PCP the member visited for health care services or by the members identification of a PCP through calling MaineCare Member Services. Member participation is voluntary and does not interfere with MaineCare members freedom of choice to access other MaineCare providers. If a member identified their PCP for attribution through MaineCare Member Services but does not receive at least one primary care service from their selected PCP within one year, then DHHS will notify and reattribute the member in accordance with the primary care services-based attribution methodology. Members may change their PCP or opt out of PCPlus at any time.

To receive reimbursement under PCPlus, providers are required to locate, coordinate, and monitor health care services for members who are attributed to them, as set forth in Section 3.04. All covered services rendered by PCPlus providers must be documented in the members electronic health record. The Department will continue to reimburse other MaineCare covered services under the fee-for-service system.

Differences Between PCPlus and PCCM

CMS considers PCCM to be a form of managed care, which operates under Section 1905(a)(25) of the SSA and 42 CFR 438.6 with mandatory member participation for the majority of MaineCare members. PCPlus operates under 1905(t)(1) of the SSA and is not a managed care program. Since PCPlus is not a managed care program, it does not include many of the managed care requirements that PCCM follows. For example, except as set forth in the rule, member participation in PCPlus is based on members selection of a PCP, members may opt out of this program, and this program has no bearing on MaineCare members freedom of choice to access services from any qualified MaineCare provider. In addition, PCPlus, unlike PCCM, does not include the PCCM provisions on member participation or complaints, and PCP selection, change, and reassignment.

Under PCCM and PCPlus, providers locate, coordinate, and monitor health care services. However, PCPlus expands service and practice requirements to support whole-person coordination and transitions of care; completing timely prior authorizations; providing, tracking, and following up on referrals; and closing care gaps, including a focus on preventative services.

PCCM providers who choose to participate in PCPlus will benefit from a new value-based payment model, which includes a risk-adjusted population-based payment tied to cost- and quality-related outcomes, rather than the flat per member per month management fee provided under PCCM. Given the additional requirements and support for providers, PCPlus should improve health outcomes for members.

Section 90 and 91 Rulemakings for PCPlus Initiative

Regarding the related proposed rulemaking for Section 90, the Department is eliminating the Primary Care Provider Incentive Payment because it would duplicate the reimbursement model of the new PCPlus program. Physicians who currently receive the Incentive Payment may apply to be PCPs under the PCPlus program, and, if approved, will receive reimbursement based on the PCPlus service expectations and performance for members attributed to their practice.

For Section 91, as it relates to the PCPlus initiative, the Department is removing Health Home Practices (HHPs) because they would be duplicative of the reimbursement the PCPs will receive and the covered services they provide via PCPlus. HHPs that currently receive reimbursement through Section 91 may apply to participate in the PCPlus program, and, if approved, PCPs will receive reimbursement based on the PCPlus service expectations and performance for members attributed to their practice.

See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. STATUTORY AUTHORITY: 22 M.R.S. 42, 3173; Social Security Act 1905(t)(1) (42 U.S.C. 1396d(t)(1))

PUBLIC HEARING: No public hearing is scheduled. The Department will provide a 30-day comment period instead of a public hearing.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on January 21st, 2022.

AGENCY CONTACT PERSON: Henry Eckerson, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: henry.eckerson@maine.gov TELEPHONE: 207-624-4085 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

STATUTORY AUTHORITY FOR THIS RULE: 22 M.R.S. 42, 3173; Social Security Act 1905(t)(1) (42 U.S.C. 1396d(t)(1))

Comment deadline past Comment Deadline: January 21, 2022 | Posted: December 22, 2021

MaineCare Benefits Manual, Chapter II, Section 90, Physician 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 II, Section 90, Physician Services

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This proposed rulemaking seeks to make the following changes:

Pursuant to P.L. 2021, Ch. 398, Sec. A-17, 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, 2021, June 30, 2022 and June 30, 2023 (the "Budget"), and in alignment with the recommendations from the comprehensive rate setting evaluation conducted by Myers and Stauffer at the request of the Department, the proposed rule increases the reimbursement rate from 70% of the lowest level in the 2009 Medicare fee schedule to 72.4% of the current year's Medicare rate per code. In addition, the proposed rule sets the reimbursement rates for select primary care services at 100% of current Medicare rates, from 100% of 2014 Medicare rates, for eligible primary care providers, which is an additional reimbursement increase. These reimbursement changes shall be effective July 1, 2022, as authorized and required by the Budget.

Also per the Budget, the proposed rule adds a new provision, Section 90.04-7(B), Physician-Administered Drugs that have Biosimilar Equivalents and/or Prior Authorization Criteria. This provision implements a Biosimilar Preferred Drug List which establishes preferred and non-preferred drug statuses based on cost and biosimilar equivalency for physician-administered drugs. Physician-administered drugs are those that satisfy the criteria in 90.04-7(A), but they also may be drugs administered orally. For drugs that are not administered orally, the proposed changes require providers not only to go through the steps set forth in 90.04-7(A), but also to use physician-administered biosimilar drugs when a physician-administered drug has a Food and Drug Administration- (FDA) approved, biosimilar equivalent that the Department identifies as more affordable. Annually, the Department shall identify drugs that have a more affordable FDA-approved biosimilar equivalent on the Biosimilar Preferred Drug List on the MaineCare Health PAS Online Portal. Physicians shall submit a PA request to administer the original drug. For physician-administered drugs that are administered orally, providers must satisfy the requirements in 90.04-7(B).

Section 90.04-7 also requires that some physician-administered drugs may require PA to ensure members meet age, clinical, or other requirements for MaineCare to provide payment and that the MaineCare Health PAS Online Portal contains a complete list of physician-administered drugs that require PA and corresponding PA criteria sheets. Providers must make requests for PA on the Departments approved form and get approval prior to the date of service. This new proposed PA process is in addition to the requirements for PA in 90.04-7(A).

The proposed rule (Sec. 90.04-30) allows members under the age of 21 to receive the application of topical fluoride varnish up to four times per calendar year from eligible providers, rather than two times per calendar year or three times for members with a high caries rate or new restorations placed in the last 18 months. This change aligns with other states Medicaid program limitations on fluoride treatment and the current American Academy of Pediatrics recommendation on fluoride treatment. The proposed rule (Sec. 90.04-31) also allows all members to receive an oral health risk assessment if they do not have a dental home and/or have not seen a dentist in the past year, rather than restricting the service to members under three years of age. The proposed rule (Sec. 90.05-2(A)) clarifies that medication abortions are covered and shall be performed in compliance with applicable Food and Drug Administration law and guidelines.

The 130th Maine Legislature enacted P.L. 2021, Ch. 348, An Act to Discontinue the Use of the Terms "Handicap," "Handicapped" and "Hearing Impaired" in State Laws, Rules and Official Documents. The proposed rule replaces the term 'handicapped with person with disabilities pursuant to P.L. 2021, Ch. 348.

This Section 90 rulemaking also proposes to eliminate Sec. 90.09-4, Primary Care Provider Incentive Payment (PCPIP), as part of the new Primary Care Plus (PCPlus) initiative. PCPIP authorizes an incentive payment to primary care practices (PCP) based on their performance on several access, utilization, and quality measures. Retaining this payment after PCPlus takes effect would be duplicative of the reimbursement PCPs will receive under the new PCPlus rule. PCPs who currently receive the Incentive Payment may instead apply to participate in PCPlus and, if approved as part of the program, will receive reimbursement based on their performance for members attributed to their practice.

To complete the transition to PCPlus, the Department shall also propose to significantly revise MBM, Ch. II, Sec. 91 (proposed to be titled Health Home Services - Community Care Teams), which includes repealing Health Home Practices. All of these rulemakings make up the PCPlus initiative, will be proposed simultaneously, and will have the same effective date.

The PCPlus program is intended to give primary care providers (PCPs) greater flexibility and incentives to effectively meet MaineCare members health care needs by transitioning away from a volume-based (fee-for-service) payment system with little connection to value, toward an approach that provides risk-adjusted Population-Based Payments tied to cost- and quality-related outcomes To receive reimbursement under PCPlus, providers are required to locate, coordinate, and monitor health care services for members who are attributed to them. The Department will continue to reimburse other MaineCare covered services under the fee-for-service system. Interested parties should refer to the new PCPlus rule (MBM, Ch. VI, Sec. 3) for more details.

The Department shall seek approval from the Centers for Medicare and Medicaid Services (CMS) of state plan amendments (SPAs) to repeal and revise the aforementioned programs and implement the PCPlus program. Additionally, the Department will publish notice of the changes in Section 90 reimbursement methodology pursuant to 42 C.F.R. 447.205.

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. 2021, Ch. 398, Sec. A-17; P.L. 2021, Ch. 348

PUBLIC HEARING: No public hearing is scheduled. The Department will provide a 30-day comment period instead of a public hearing.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on January 21st, 2022.

AGENCY CONTACT PERSON: Henry Eckerson, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: henry.eckerson@maine.gov TELEPHONE: 207-624-4085 FAX: (207) 287-6106 TTY: 711 (Deaf or Hard of Hearing)

Comment deadline past Comment Deadline: January 21, 2022 | Posted: December 22, 2021

MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures

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Notice of Agency Rule-making Proposal

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 I, Section 1, General Administrative Policies and Procedures

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This proposed rulemaking makes various, complex changes, including changes to comply with federal regulations, make updates to reflect current practices, clarify ambiguous and vague sections of policy, and increase the MaineCare Program Integrity Unit's ability to safeguard against fraud, waste, and abuse. All the changes in this rulemaking are listed below:

The current rule does not address retroactive enrollment for providers other than federally qualified health centers, rural health centers, and Indian health centers. This rulemaking broadens Sec. 1.03-1(F) to allow for retroactive enrollment for other eligible providers, subject to review and approval by the Department of Health and Human Services (the Department) in accordance with 42 CFR 431.108. A request for retroactive enrollment is subject to the Departments review and discretion and is not a guarantee of claim payment or prior authorization. The Department may grant retroactive enrollment back to providers Medicare enrollment effective date but will not grant a retroactive enrollment date that is more than 365 days prior to the date of providers MaineCare application submission.

To comply with 42 CFR 455.434, this rule adds a section on fingerprint-based criminal background checks (FCBC), mandating that providers or applicants whose categorical risk level meets the federal definition of high risk must consent to a FCBC. This new section 1.03-1(J) includes relevant criteria for termination or denial of enrollment and outlines which providers and suppliers constitute high categorical risk.

The current 'rounding rule (Sec. 1.03-8(J)) allows providers to round up a unit of service if the unit of service delivered is equal to or greater than fifty percent. To encourage clarity and precision in delivering the amount of covered services that are medically necessary, this rulemaking makes changes so when a partial unit of service is delivered, the provider may either bill for the partial unit of service provided, or round up if eighty percent of the unit of service was delivered. The rule retains the ability to round up if fifty percent of the unit of service was delivered, but only when unforeseen circumstances prevent a provider from delivering a whole unit of service. This rulemaking also adds misuse of the "rounding rule" to examples of conduct that could constitute fraud.

MaineCare Benefits Manual, Chapter II, Section 80, which primarily applies to retail pharmacies, previously housed language on the 340B Drug Price Program (340B Program). However, the 340B Program language is better suited in this rule because it applies to all provider types except pharmacies. Hence, this rulemaking adds a section, 1.03-14, on the 340B Program that requires providers or entities who purchase drugs under the 340B program to sign a 340B agreement with the Department and to comply with federal and Health Resources & Services Administration 340B rules and regulations. The Department shall seek and anticipates approval of a state plan amendment related to these changes. Additionally and separately, the Department shall repeal the 340B Program provisions that are in Ch. II, Sec. 80.09-1(D).

This rulemaking expands the definition of non-covered services to include administrative tasks (Sec. 1.06-4(B)(8)), including verification of MaineCare eligibility, updating member contact information, scheduling of appointments, and similar activities. This provision strengthens the Office of MaineCare
Services (OMS) Program Integrity Units enforcement of the prohibition on billing for administrative tasks, which already exists per current MaineCare rules.

To comply with section 53102 of the Bipartisan Budget Act of 2018, P.L. No. 115-123, this rulemaking updates that the Department will no longer pay and then seek reimbursement, commonly known as pay and chase, from liable third parties for prenatal services.

This rulemaking clarifies (Sec. 1.19-1(C)(2)) that the Department may reimburse providers for covered services rendered during the period following a notice of termination up to the effective date of termination, instead of for a period not to exceed thirty days after the date of receipt of the notice of termination, because providers may not be reimbursed after termination of a provider agreement. The rulemaking also adds that providers must follow the provisions of their provider agreements and the MaineCare Benefits Manual to continue to receive reimbursement for services.

To enable the OMS Program Integrity Unit to implement appropriate sanctions, this rulemaking allows the Department, in its discretion, to consider a request from a provider to impose a lower percentage than 20% recoupment. The rulemaking adds a list of factors in Sec. 1.20-2 for the Department to consider when assessing this type of provider request.

This rulemaking adds other sanctions, such as submitting a plan of correction, so the OMS Program Integrity Unit can ensure providers comply with MaineCare rules and monitor providers who experience rapid growth or changes. Providers who grow rapidly may not have adequate infrastructure to maintain quality of service provision. The additional sanctions are:

Impose a suspension of referrals to a provider; Deny or pend any enrollment applications submitted by a provider; Limit the number of service locations a provider may enroll; and Limit the number of MaineCare members the provider may serve.

This rulemaking clarifies the provisions in Sec. 1.21 regarding reinstatement following termination or exclusion. The current rule regarding, for example, the time period for reinstatement may be confusing and difficult to apply.

The Department adds a section, 1.24-4, on expedited member appeals that includes the procedure to request an expedited appeal, criteria for the Division of Administrative Hearings (DAH) to consider when deciding whether to grant requests, deadlines for when the Department must take final agency action, and other requirements, per 42 CFR 431.224. MaineCare Member Services shall send all expedited hearing requests to a hearings representative and the DAH within 24 hours of identifying the request.

The MaineCare Advisory Committee (MAC) has developed structural and process changes to improve its function and efficiency, which must be put into Sec. 1.25. The MAC proposed changes include increasing MAC membership, including at least two Medicaid beneficiaries as members, and other changes.

This proposed rulemaking also makes the following changes:

Define the ownership and control relationships that are subject to an offset; Establish a timeframe for when providers need to update OMS of changes to their National Provider Identifier or other enrollment information; Require providers who change their name or doing business as name to change their MaineCare Provider Agreement; Clarify that providers must take all reasonable and appropriate steps requested by the Department to transition members before changes of ownership, closures, and disenrollment, except in the case of reasonably unforeseen circumstances, and, upon request, submit a transition plan to the Department for review and approval; Update the rule in accordance with 10-144 Code of Maine Rules, Chapter 128, Certified Nursing Assistant and Direct Care Worker Registry Rule, to require agencies hiring direct care workers (DCWs) to check the Maine Certified Nursing Assistant and Direct Care Worker Registry to ensure DCWs are eligible for employment in Maine and comply with all requirements stipulated in the rule; Add that providers may not bill MaineCare for an interpreter service supplied by an entity in which the providers, any owner of the providers, or an immediate family member of the providers or any of their owners has any direct or indirect ownership or financial interest, unless the provider also reimburses other entities for the provision of interpreter services and the entity providing the interpreting service makes those services commercially available to MaineCare providers or other businesses that do not share a direct or indirect familial ownership interest with the interpreting entity; Change the billable amount for interpreter services to be the lesser of the interpreters usual and customary charge and the rate authorized by the Department; To comply with section 53102 of the Bipartisan Budget Act of 2018, increase the number of days, from 30 to 100, that providers must wait for a response from an absent parents third party insurance before billing MaineCare; Add that the Department may impose sanctions on providers who fail to provide information to the Department or to otherwise respond to Departmental requests for information within a reasonable timeframe established by the Department; Add a penalty of 25% of MaineCare payments for covered goods and services where the providers records lack a required signature by a member or the members guardian; Change penalties to equal 20%, as opposed to not exceeding 20%, when mandated records are missing but providers are able to demonstrate by a preponderance of the evidence that the disputed goods or services were medically necessary; Make clear the Departments authority to exclude individuals, entities, and providers from participation in MaineCare for any reason identified in 42 C.F.R. Part 1001 or 1003; Add considerations for reinstatement from termination or exclusion to include the conduct of the individual or entity prior to and after the date of the notice of exclusion; and Clarify that providers may request an informal review within 60 calendar days from the date of written notification of the Departments alleged grievance and extend the deadline to the next business day if it falls on a weekend or holiday.

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

STATUTORY AUTHORITY: 22 M.R.S. 42, 42(7)(H), 3173; 42 CFR 431.108, 455.434, 447.56, 431.224, 431.12; 42 CFR Parts 1001 and 1003; Bipartisan Budget Act of 2018, Sec. 53102, P.L. No. 115-123

PUBLIC HEARING: No public hearing is scheduled. The Department will provide a 30-day comment period instead of a public hearing.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on Friday, December 24th, 2021.

AGENCY CONTACT PERSON: Henry Eckerson, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: henry.eckerson@maine.gov TELEPHONE: 207-624-4085 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

STATUTORY AUTHORITY FOR THIS RULE: 22 M.R.S. 42, 42(7)(H), 3173; 42 CFR 431.108, 455.434, 447.56, 431.224, 431.12; 42 CFR Parts 1001 and 1003; Bipartisan Budget Act of 2018, Sec. 53102, P.L. No. 115-123

Comment deadline past Comment Deadline: December 24, 2021 | Posted: November 24, 2021

MaineCare Benefits Manual, Chapter III, Section 97, Private Non-Medical Institutions

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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, MaineCare Benefits Manual, Section 97, Private Non-Medical Institutions, Ch. III

PROPOSED RULE NUMBER:

CONCISE SUMMARY:

The Department of Health and Human Services (the "Department") proposes the following major substantive rule changes in 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapter III, Section 97, Private Non-Medical Institution Services, including Ch. III (the Main Rule) and Appendices B (Substance Abuse Treatment Facilities) and D (Child Care Facilities).

In Chapter III, the Department proposes to update the Main Rule and corresponding Appendices B and D to support the final adopted changes in Chapter II, Section 97 (effective Nov. 1, 2021), with the emergency major substantive rules intended to be filed simultaneously. The Ch. II rule changes implement various new requirements on Appendix D providers per the Family First Prevention Services Act (FFPSA), and also add new covered MaineCare services. Ch. II also imposes new requirements on Appendix B providers and broadens those covered services.

In recognition of these new requirements, the Department proposes these major substantive reimbursement rate increases. The new rates were authorized by the Legislature pursuant to P.L. 2021, Ch. 29, 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, 2022 and June 30, 2023 (the Budget) and P.L. 2021, Ch. 398, 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, 2021, June 30, 2022 and June 30, 2023 (the Supplemental Budget). The rates are also consistent with independent rate studies completed for Appendix B and Appendix D services.

Section GGGG-1 of the Supplemental Budget provided the Department with authority to enact these changes on an emergency basis, without the need to make findings in support of an emergency per 5 M.R.S. 8054. The Department filed the emergency major substantive rule changes on November 1, 2021, which shall be effective for up to 12 months or until the Legislature has completed review of the provisionally adopted major substantive rule per 5 M.R.S. 8073. Through this major substantive rule proposal, the Department is taking the first step toward making the emergency changes permanent. Following review of comments on the proposed rule changes, the Department shall send the provisionally adopted major substantive rule to the Legislature for review, per 5 M.R.S. 8072. The Department shall seek approval from the Centers for Medicare and Medicaid Services (CMS) for the increased Appendix B and Appendix D rates.

In addition to the above, the Main Rule and relevant Appendices propose name changes to certain services in order to gain consistency with Chapter II, including updating Crisis Residential services to Crisis Stabilization services, Treatment Foster Care to Therapeutic Foster Care, and Substance Abuse treatment to Substance Use treatment.

Appendix B proposes rate updates from an independent rate study, recommending substantial increases, consistent with appropriations approved in the Supplemental Budget. Additional changes are proposed to ensure that the terminology in Appendix B is consistent with what is utilized in the finally adopted Ch. II rule, for example, Detoxification programs are now referred to as Medically Supervised Withdrawal Services. This rulemaking proposes creating two tiers of reimbursement, one tier accounting for all medical personnel, and another tier as an exception rate for low nursing staff, given substantial workforce challenges. Lastly, service components of the rate in 2400.1 are proposed to clarify that social workers are licensed clinical social workers and to add licensed marriage and family therapists, to align with changes adopted in Chapter II.

Appendix D proposes changing the name from Childcare Facilities to Children's Residential Care Facilities in order to align with changes adopted in Chapter II. In Section 2400.1, board certified behavioral analyst services, board certified assistant behavior analyst services, and registered behavior technician services are proposed to align with changes in Chapter II. Following the independent rate study, rate recommendations are proposed, including consolidating Mental Health Level I and Level II services into a single Mental Health level of reimbursement, and consolidating Intellectual Disabilities and Autism Spectrum Disorder Levels I and II into a single Intellectual Disabilities/Developmental Disabilities residential treatment rate. Due to the rate changes and finally adopted changes in Chapter II, Section 97, this rule proposes removing language from Section 6000 because the referenced member assessment is no longer required. Chapter III also proposes rates for a proposed new MaineCare covered service, Aftercare Services, for the service itself and for mileage reimbursement. Aftercare is a required component of the FFPSA, and establishing the rate is necessary in order to meet the requirements of the FFPSA and the changes adopted in Chapter II, Section 97 . The Department shall seek approval from CMS for the new Aftercare Services and the additional practitioners allowable under this Appendix.

Finally, in order to be consistent with the changes that will be finally adopted in Ch. II, effective Nov. 1, 2021, this rule proposes necessary updates to further address potentially stigmatizing language pursuant to P.L. 2017, ch. 407, and to update references to the Office of Behavioral Health from the Office of Substance Abuse.

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

STATUTORY AUTHORITY: 22 M.R.S. 42, 3173; 22 M.R.S. 8110; 42 U.S.C. 671(20); P.L. 2019, ch. 407; The Family First Prevention Services Act, Public Law 115-123 (as part of Division E in the Bipartisan Budget Act of 2018 (H.R. 1892) (eff. Feb. 9, 2018) (as Amended through P.L. 116-260, enacted December 27, 2020); P.L. 2021, Ch. 398

PUBLIC HEARING: No public hearing scheduled. The Department will be providing a 30-day comment period instead of a public hearing.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM December 10, 2021.

AGENCY CONTACT PERSON: Dean Bugaj, Childrens and Behavioral Health Manager AGENCY NAME: Division of Policy ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: Dean.Bugaj@maine.gov TELEPHONE: (207)-624-4045 FAX: (207) 287-6106 TTY users call Maine relay 711

Comment deadline past Comment Deadline: December 10, 2021 | Posted: November 10, 2021

UPDATED TO REFLECT REMOTE PUBLIC HEARING _MaineCare Benefits Manual, Chapter I, Section 6

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REVISED Notice of Agency Rule-making Proposal

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 I, Section 6, Global HCBS Waiver Person-Centered Planning and Settings Rule

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This new rule proposes to implement the federal requirements for Maine's Section 1915(c) home and community-based waiver programs as set forth in 42 C.F.R. 441.301(c), and includes requirements for person-centered service planning and for settings in which home and community-based waiver services ("HCBS") are provided, including requirements for provider-owned or controlled residential settings. The proposed rule implements additional requirements or changes to HCBS waiver programs under the following sections of the MaineCare Benefits Manual:

Section 18: Home and Community-Based Services for Adults with Brain Injury;

Section 19: Home and Community Benefits for the Elderly and Adults with Disabilities;

Section 20: Home and Community-Based Services for Adults with Other Related Conditions;

Section 21: Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder; and

Section 29: Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder.

In the event of conflict between the requirements of this proposed rule and any rule listed above, the terms of the proposed rule will supersede and shall apply.

The proposed rule tracks closely the federal requirements set forth in 42 C.F.R. 441.301(c). It clarifies that the Member leads the person-centered planning process and that the process should reflect the Members cultural considerations and provide necessary information to allow the Member to make informed choices and decisions. The proposed rule establishes general requirements for HCBS settings so that the setting ensures the Members rights of privacy, dignity and respect, freedom from coercion and restraint, and facilitates individual choice regarding HCBS waiver services and settings.

There are additional proposed requirements for provider-owned or controlled residential settings. These include Members having privacy in their sleeping or living unit; Members having freedom to access food at any time; and Members having the ability to have visitors at any time. The proposed rule also contains a provision related to certain disability-specific settings (such as Sec. 18 Work Ordered Club House Services). The rule leaves open the Departments ability to amend Sec. 18, Sec. 20, Sec. 21 and/or Sec. 29 regulations through rulemaking to impose additional requirements.

Finally, the proposed rule outlines requirements for provider qualifications as well as oversight and enforcement to ensure full compliance with HCBS waiver services and related sections of the MaineCare Benefits Manual including Ch. I, Sec. I, General Administrative Policies and Procedures.

The Department shall submit to CMS and anticipates CMS approval of Waiver amendments related to this rule.
The proposed rule will become effective 5 days after the finally adopted rule is filed with the Secretary of States office, per 5 M.R.S. 8052(6), except that for those HCBS settings that were approved as settings prior to March 17, 2014, Sections 6.04 (Home and Community-Based Settings General Requirements) and 6.04(B) (Additional Requirements for Provider-Owned or Controlled Residential Settings) will be effective on July 31, 2022.

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

STATUTORY AUTHORITY: 22 M.R.S. 42, 3173, 42 C.F.R. 441.301(c)

Date, time and location of PUBLIC HEARING: 11am; Tuesday, September 28, 2021

Due to the ongoing threat posed by COVID-19 (see below), DHHS has determined that its public hearing will be conducted solely remotely, via Zoom.

Zoom Meeting link: https://mainestate.zoom.us/j/89675358898 Meeting ID: 896 7535 8898

Some devices may require downloading a free app from Zoom prior to joining the public hearing event. The Department requests that any individual requiring special arrangements to participate in the hearing contact the person listed for this filing 5 days in advance of the hearing.

Rationale for remote public hearing: Cases of COVID-19 have increased over 1,000% nationally between June 18, 2021 and August 25, 2021. This increase has been driven by the highly transmissible B.1.617.2 (Delta) variant of SARS-CoV-2, the virus that causes COVID-19. DHHS is concerned about this increase in COVID-19 and seeks to avoid the threat to public health and safety by conducting this public hearing solely remotely. There is an ongoing federal public health emergency due to COVID-19. The Secretary of the United States Department of Health and Human Services first declared a public health emergency (PHE) due to COVID-19 on January 31, 2020, and most recently renewed the PHE on July 20, 2021. On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak constitutes a national emergency, which was most recently continued on February 24, 2021. As of August 30, 2021, 11 counties in Maine were designated as high risk.

In addition to the public hearing, individuals may submit written comments to DHHS by the date listed in this notice.

PUBLIC NOTICED: September 8, 2021

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on October 8, 2021

AGENCY CONTACT PERSON: Heather Bingelis, Comprehensive Health Planner II Heather.Bingelis@maine.gov AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 TELEPHONE: (207)-624-6951 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: October 8, 2021 | Posted: September 8, 2021

MaineCare Benefits Manual, Chapter I, Section 6, Global HCBS Waiver Person-Centered Planning and Settings Rule

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Concise Summary:

Notice of Agency Rule-making Proposal

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 I, Section 6, Global HCBS Waiver Person-Centered Planning and Settings Rule

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This new rule proposes to implement the federal requirements for Maine's Section 1915(c) home and community-based waiver programs as set forth in 42 C.F.R. 441.301(c), and includes requirements for person-centered service planning and for settings in which home and community-based waiver services ("HCBS") are provided, including requirements for provider-owned or controlled residential settings.

The proposed rule implements additional requirements or changes to HCBS waiver programs under the following sections of the MaineCare Benefits Manual:

Section 18: Home and Community-Based Services for Adults with Brain Injury;

Section 19: Home and Community Benefits for the Elderly and Adults with Disabilities;

Section 20: Home and Community-Based Services for Adults with Other Related Conditions;

Section 21: Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder; and

Section 29: Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder.

In the event of conflict between the requirements of this proposed rule and any rule listed above, the terms of the proposed rule will supersede and shall apply.

The proposed rule tracks closely the federal requirements set forth in 42 C.F.R. 441.301(c). It clarifies that the Member leads the person-centered planning process and that the process should reflect the Members cultural considerations and provide necessary information to allow the Member to make informed choices and decisions. The proposed rule establishes general requirements for HCBS settings so that the setting ensures the Members rights of privacy, dignity and respect, freedom from coercion and restraint, and facilitates individual choice regarding HCBS waiver services and settings.

There are additional proposed requirements for provider-owned or controlled residential settings. These include Members having privacy in their sleeping or living unit; Members having freedom to access food at any time; and Members having the ability to have visitors at any time. The proposed rule also contains a provision related to certain disability-specific settings (such as Sec. 18 Work Ordered Club House Services). The rule leaves open the Departments ability to amend Sec. 18, Sec. 20, Sec. 21 and/or Sec. 29 regulations through rulemaking to impose additional requirements.

Finally, the proposed rule outlines requirements for provider qualifications as well as oversight and enforcement to ensure full compliance with HCBS waiver services and related sections of the MaineCare Benefits Manual including Ch. I, Sec. I, General Administrative Policies and Procedures.

The Department shall submit to CMS and anticipates CMS approval of Waiver amendments related to this rule.

The proposed rule will become effective 5 days after the finally adopted rule is filed with the Secretary of States office, per 5 M.R.S. 8052(6), except that for those HCBS settings that were approved as settings prior to March 17, 2014, Sections 6.04 (Home and Community-Based Settings General Requirements) and 6.04(B) (Additional Requirements for Provider-Owned or Controlled Residential Settings) will be effective on July 31, 2022.

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

STATUTORY AUTHORITY: 22 M.R.S. 42, 3173, 42 C.F.R. 441.301(c)

PUBLIC HEARING: For this rulemaking, a public hearing will not be held. The Department will accept email and standard mail comments for 30 days following rule filing with the Secretary of State.

PUBLIC NOTICED: August 18, 2021

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on September 16, 2021.

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

TELEPHONE: (207)-624-6951 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

STATUTORY AUTHORITY FOR THIS RULE: 22 M.R.S. 42, 3173

Comment deadline past Comment Deadline: September 16, 2021 | Posted: August 18, 2021

MaineCare Benefits Manual, Chapter II Section 97, Private Non-Medical Institution 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, MaineCare Benefits Manual, Chapter II Section 97, Private Non-Medical Institution Services

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, Chapter II, Section 97, Private Non-Medical Institution Services.

The Department proposes this rule to align requirements with the Family First Prevention Services Act (FFPSA), which establishes standards for children in residential treatment programs in order to improve quality and oversight of services. These proposed changes are specific to Private Non-Medical Institution (PNMI) Appendix D Facilities, and are reflected in the definitions, eligibility for care, covered services and policies and procedures sections of this rule. Additionally, as directed under the FFPSA, the proposed rule includes requirements for Appendix D providers to meet Qualified Residential Treatment Programs (QRTP) standards which include obtaining and maintaining specified licensing and accreditation standards, as well as delivering trauma-informed treatment.

For compliance with the FFPSA related to improving quality and oversight of services, the Department proposes to amend Appendix D language referring to Child Care Facility Services and Models of Child Care Facilities, to be replaced with the term Children's Residential Treatment Facilities (RTFs). The proposed rule distinguishes models of residential care that address specific treatment needs of different member populations. RTF models will include Intellectual Disabilities/Developmental Disabilities (ID/DD-RTF), Mental Health (MH-RTF), Crisis Stabilization (CS-RTF), and Child and Adolescent Therapeutic Foster Care. This rule further proposes amending language referring to Intensive Temporary Residential Treatment Services by replacing this with the term Temporary High Intensity Services and including language clarifying the covered services while also establishing the requirement for a Prior Authorization process.

The rule also proposes the use of Department-approved, age appropriate Level of Care/Service Intensity tools, which will be required as a component of eligibility determination for ID/DD, MH, and CS RTFs. The Level of Care/Service Intensity tools will replace outdated instruments, to include the Child and Adolescent Functional Assessment Scale (CAFAS), the Childrens Global Assessment Scale (C-GAS), the Global Assessment Functioning (GAF), and the Childrens Habilitation Assessment Tool (CHAT); and streamline the process by utilizing one tool that is evidence based and clinically appropriate by age, to include the Early Childhood Service Intensity Instrument (ECSII), the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII) and the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS).

Additionally, this rule proposes various new covered services, including Aftercare Support Services, which are designed to promote a continuation of treatment gains with the goal of supporting the child in their home and community environment, and must be provided to youth for at least six (6) months post discharge from an RTF. The Department is additionally proposing a new required position, a Family Transition Specialist (FTS), to aid in the delivery of aftercare and transition services for the youth and family.

To further align with the FFPSA to achieve improved quality and oversight of services, this proposed rule clarifies Appendix D requirements for disclosure and informed consent, RTF assessment, Individual Treatment Plan, progress notes, and discharge summary as well as adding various new defined terms.

The Department additionally proposes that providers operating under Appendix D and Adolescent Residential Rehabilitation Services providers operating under Appendix B demonstrate utilization of the Federal Substance Abuse and Mental Health Services Administrations (SAMHSA) System of Care Principles and delivery of trauma-informed care through the completion of a Trauma-Informed Agency Assessment, staff training and incorporation of these principles into program policy and procedures.

The Department also proposes specific requirements regarding background checks for providers operating under Appendix D and Adolescent Residential Rehabilitation Services providers operating under Appendix B. The Department proposes that childrens residential facility providers must follow the requirements set forth in 22 M.R.S. 8110 and 42 U.S.C. 671(20). Behavioral Health Services providers must conduct background checks every five (5) years and fingerprinting. The proposed rule requires completed background checks for all staff and all adults providing services to a member within ninety (90) days of the effective date of this rule and that all background checks are to be completed every five (5) years thereafter.

The Department further proposes, under Appendix D, the addition of Behavioral Health Professionals (BHP) and Family Transitional Specialists (FTS) as Other Qualified Residential Treatment Facility Staff as well as including Board Certified Behavior Analyst services, Registered Behavior Technician services and Board Certified Assistant Behavior Analyst services. As a requirement under 10-144 C.M.R. ch. 128, Certified Nursing Assistant and Direct Care Worker Registry Rule, the Department is requiring confirmation that prospective BHPs are not annotated in the registry prior to qualifying as a staff member under this rule.

In addition to the above proposed changes, the Department proposes to increase access to necessary services by removing the 'single admission limitation and increasing the number of allowable covered days for Halfway House and Extended Care Services under PNMI Appendix B of this rule. The Department also proposes edits to language to accurately reflect current practices as well as updates to formatting, citations, and references where necessary, including changes to address potentially stigmatizing language based on recommendations from the Maines opioid task force and legislation passed in 2018 to minimize stigma (P.L. 2017, ch. 407).

The Department shall seek CMS approval for the new covered services and provider requirements, as specifically noted in various proposed rule changes.

In addition, the Department intends to implement corresponding changes as needed in the MBM, Ch. III, Section 97, to ensure adequate reimbursement for providers to deliver all new covered services and meet QRTP standards and other Ch. II-related updates. For example, Ch. III Appendix D Sec. 2400.1 must be updated in order to ensure that rates cover the costs of Board Certified Behavior Analysts and the other new types of direct service staff. The Ch. III, Sec. 97 rule is major substantive, and the upcoming changes shall be filed as an emergency rule no later than Nov. 1, 2021, so that they will be effective at the same time the changes in Ch. II, Sec. 97 are finally adopted.

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

STATUTORY AUTHORITY: 22 M.R.S. 42, 3173; 22 M.R.S. 8110; 42 U.S.C. 671(20); P.L. 2019, ch. 407; The Family First Prevention Services Act, Public Law 115-123 (as part of Division E in the Bipartisan Budget Act of 2018 (H.R. 1892) (eff. Feb. 9, 2018) (as Amended through P.L. 116-260, enacted December 27, 2020)

Comment deadline past Comment Deadline: September 10, 2021 | Posted: August 11, 2021

MaineCare Benefits Manual, Chapter II, Section 92, Behavioral Health Home Services

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Concise Summary:

144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapter II, Section 92, Behavioral Health Home Services.

This rule is proposed in order to enhance safeguards and protections of client rights under the Bates, et al. v. Commissioner, DHHS, et al, consent decree. The proposed changes address referrals to and terminations from Behavioral Health Home Services for members with Serious and Persistent Mental Illness. Prior to terminating a member's services, providers must receive written approval from the Office of Behavioral Health (OBH); must issue a 30-day advanced written termination notice to the member, with an exception for cases involving imminent harm; and must assist the member in obtaining clinically necessary services from another provider prior to termination. In addition, providers must accept Department referrals within seven (7) calendar days and may only decline referrals with written approval from OBH.

Additionally, in furtherance of consent decree principles, this rule proposes to add language for timeliness standards for Adults with Serious and Persistent Mental Illness, consistent with those in Section 17 Community Support Services for this population. These standards require that providers must conduct an initial face-to-face intake or initial assessment visit within seven (7) calendar days of the date of referral. This rule also proposes giving members the option to request to "hold for service" if providers are unable to meet the seven (7) calendar day face-to-face requirement of new referrals but the member would still like to wait until that provider can accept their referral. Members may elect to hold for service only after an agency has adequately informed the member of their other area service options.

Lastly, the Department proposes updates to formatting, citations, and references where necessary, including changing Office of Substance Abuse and Mental Health Services to Office of Behavioral Health and removing potentially stigmatizing language based on recommendations from the Maine's opioid task force and legislation passed in 2018 to minimize stigma (P.L. 2017, ch. 407).

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

STATUTORY AUTHORITY: 22 M.R.S. 42(1), 3173; P.L. 2017, ch. 407

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.

30-DAY DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on May 21, 2021.

AGENCY CONTACT PERSON: Melanie Miller, Comprehensive Health Planner II Melanie.Miller@maine.gov AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 TELEPHONE: 207-624-4087 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.

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

Comment deadline past Comment Deadline: May 21, 2021 | Posted: April 21, 2021

MaineCare Benefits Manual, Chapter II, Section 17, Community Support Services

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The Department of Health and Human Services ("the Department") proposes the following changes to 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapter II, Section 17, Community Support Services.

This rule is proposed in order to enhance safeguards and protections of client rights under the Bates, et al. v. Commissioner, DHHS, et al, consent decree. The proposed changes address referrals to and terminations from Community Integration Services and Assertive Community Treatment (ACT) Services for members with Serious and Persistent Mental Illness. Prior to terminating a member's services, providers must receive written approval from the Office of Behavioral Health (OBH); must issue a 30-day advanced written termination notice to the member, with an exception for cases involving imminent harm; and must assist the member in obtaining clinically necessary services from another provider prior to termination. In addition, providers must accept Department referrals for services within seven (7) calendar days and may only decline referrals with written approval from OBH.

The proposed rule also removes the temporary transition period from the timeliness and duration of care provisions that were added in a prior rulemaking pursuant to Resolves 2015, ch. 82 and are now permanent.

This rule additionally proposes to remove the definition and requirement to complete the Adult Needs and Strengths Assessment (ANSA). The Department has determined the ANSA is no longer a viable option for assessment and treatment, and this assessment is not being used in practice.

The Department also proposes updates to formatting, citations, and references where necessary, including changing Office of Substance Abuse and Mental Health Services to Office of Behavioral Health and removing potentially stigmatizing language based on recommendations from the Maine's opioid task force and legislation passed in 2018 to minimize stigma (P.L. 2017, ch. 407).

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

STATUTORY AUTHORITY: 22 M.R.S. 42(1), 3173; P.L. 2017, ch. 407

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.

DATE FILED WITH THE SECRETARY OF STATES OFFICE: April 21, 2021

30-DAY DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on May 21, 2021.

AGENCY CONTACT PERSON: Melanie Miller, Comprehensive Health Planner II Melanie.Miller@maine.gov AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 TELEPHONE: 207-624-4087 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 Comment Deadline: May 21, 2021 | Posted: April 21, 2021

MaineCare Benefits Manual, Chapter II, Section 101, Medical Imaging Services

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Notice of Agency Rule-making Proposal

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 II, Section 101, Medical Imaging Services

PROPOSED RULE NUMBER:

CONCISE SUMMARY: The Department is proposing to add Section 101.04-8 Low Dose Computed Tomography (LDCT) to cover the screening of lung cancer to provide earlier detection with smaller amounts of radiation than a traditional Computed Tomography scan. The Department will cover the screening when the member meets the following criteria:

1) Is 55-77 years of age; 2) Is asymptomatic; 3) Has a tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes); 4) Is a current smoker or one who has quit smoking within the last 15 years; and 5) Has received a written order for lung cancer screening with LDCT.

Also, the Department is proposing Section 101.01-5 to add a definition for LDCT. Additionally, Section 101.03-2 Prior Authorization Requirements is being updated. Finally, the Department proposes minor and technical edits.

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

STATUTORY AUTHORITY: 22 M.R.S. 42, 3173; 22-A M.R.S. 205

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.

PUBLIC NOTICED: February 3, 2021

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on March 5, 2021.

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

TELEPHONE: 207-624-4031 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 Comment Deadline: March 5, 2021 | Posted: February 3, 2021

MaineCare Benefits Manual, Chapter II, Section 97, Private Non-Medical Institution Services

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Notice of Agency Rule-making Proposal

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 II, Section 97, Private Non-Medical Institution Services

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This rule is proposed in order to provide clarity and consistency in processes and record-keeping across MaineCare policies and to enhance safeguards and protections of client rights under the Bates, et al. v. Commissioner, DHHS, et al, consent decree. The proposed changes address referrals to and terminations from Appendix E Private Non-Medical Institutions with the addition of Section 97.07-10, Termination, and Section 97.07-11, Referrals, as well as increasing frequency for progress note writing in 97.07-4.

Prior to terminating a member's services, providers must receive written approval from the Office of Behavioral Health (OBH); must issue a 30-day advanced written termination notice to the member, with an exception for cases involving imminent harm; and must assist the member in obtaining clinically necessary services from another provider prior to termination.

Providers must acknowledge receipt of Department referrals within three business days for members eligible for Appendix E services and must accept or request permission to decline referrals in accordance with a Department-defined process within five business days of receipt of referral. Providers can only decline a referral with written approval from OBH, otherwise they must admit members within thirty days of receipt of the referral.

This proposed rule also changes the frequency requirement for entering and signing progress notes from a monthly to a daily expectation within Appendix E facilities. This change is made to improve accuracy and quality within member records.

Finally, this proposed rule makes technical, grammatical, and punctuational edits, including updating references to current Department office names.

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

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

DATE FILED WITH THE SECRETARY OF STATES OFFICE: January 12, 2021

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.

Date and Time: N/A
Location: N/A

The Department requests that any interested party requiring special arrangements to attend the hearing contact the agency person listed below before N/A- no hearing.

DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on February 19, 2021.

AGENCY CONTACT PERSON: Heather Bingelis, Comprehensive Health Planner II Heather.Bingelis@maine.gov AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 TELEPHONE: 207-624-6951 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 Comment Deadline: February 19, 2021 | Posted: January 20, 2021

MaineCare Benefits Manual, Chapter II and III, Section 19, Home and Community Benefits for the Elderly and Adults with Disabilities

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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., ch. 101, MaineCare Benefits Manual, Chapter(s) II and III, Section 19, Home and Community Benefits for the Elderly and Adults with Disabilities

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This rule is proposed to align and comply with 42 C.F.R. 441.301(c), the federal Home and Community Based Settings rule, referred to as the Settings Rule. Additionally, the changes update certain Personal Support Services (PSS) and other reimbursement rates pursuant to the State supplemental budget, P.L. 2019, ch. 616. Pursuant to Resolves 2019, ch. 104, the changes permit spouses to be reimbursed as a Personal Support Specialist for eligible members that need extraordinary care. The rule clarifies roles and responsibilities of the Service Coordination Agency (SCA), the Fiscal Intermediary (FI), and the Assessing Services Agency (ASA) Assessor. It adds or clarifies definitions for Extraordinary Care, and the Person-Centered Planning Process.

The Settings Rule specifies that service planning for Home and Community Based Services (HCBS) waiver members must be developed through a Person-Centered Planning (PCP) process that addresses health and long-term services and support needs in a manner that reflects individual preferences and goals. Moreover, the rule requires that this process be member-directed. This proposed rule will add language to further define the PCP process as it relates to recipients of Section 19 services. Separately, the Department is developing a Global HCBS Settings Rule that will make changes to all the HCBS MaineCare rules to implement in more detail the requirements of the federal Settings Rule.

Additionally, the proposal defines Extraordinary Care to support comprehensive planning and service delivery processes and more readily meet member's needs.

Furthermore, the rule updates Section 19 rates to comply with 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 the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2020 and June 30, 2021. In light of this increased reimbursement for providers, to protect members, the program cap in Section 19.06(A) has been increased to $6,565, effective retroactive to April 1, 2020.

The proposed rule will also transition reimbursement for the SCA, which provides care coordination services, from fee for service to a per member per month reimbursement; this shall take effect prospectively. Due to this change in reimbursement, the Department is removing the limits on care coordination in Section 19.06; members may receive unlimited care coordination services based on their medical needs.

Additionally, the rule proposes to clarify roles and responsibilities of the SCA, the Fiscal Intermediary (FI), and the ASA Assessor. The proposed rule outlines the responsibilities of the SCA to promote the Person-Centered Planning process and to clarify the authority of the SCA to reduce, suspend, and deny members services. Additionally, the proposed rule outlines the qualifications and role of the ASA Assessor. Further, the rule identifies and outlines the data and reports required of the SCA and the FI to ensure collection and tracking of quality data in support of the transition to Per Member Per Month reimbursement for care coordination.

As reflected in the proposed rules, certain changes in the rule will have a retroactive effective date of either April 1, 2020, or July 1, 2020, while the remainder shall be effective upon final adoption of the rule pursuant to 5 M.R.S. 8052(6). Further, various changes require approval by the Centers for Medicare and Medicaid Services (CMS), and the Department is working with CMS on amendments to the Section 1915(c) waiver to implement same.

Finally, this proposed rule makes technical and grammatical edits.

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

STATUTORY AUTHORITY: 22 M.R.S. 42, 42(8), 3173; P.L. 2019, ch. 616 (emergency, effective Mar. 20, 2020); Resolves 2019, ch. 104

DATE FILED WITH THE SECRETARY OF STATES OFFICE: December 8, 2020

30 DAY DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on January 15, 2021.

AGENCY CONTACT PERSON: Heather Bingelis, Comprehensive Health Planner II AGENCY NAME: MaineCare Services ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 Heather.Bingelis@maine.gov TELEPHONE: 207-624-6951 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 Comment Deadline: January 15, 2021 | Posted: December 16, 2020

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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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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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