Recently Adopted Rules

All adopted rules are maintained by the Secretary of State and are available in the

  • Notice of Agency Rule-making Adoption, MaineCare Benefits Manual, Chapter II, Section 65
  • Notice of Agency Rule-making Adoption, MaineCare Benefits Manual, Chapter III, Section 65
  • Notice of Agency Rule-making Adoption, MaineCare Benefits Manual, Chapters II and III, Section 45
  • MaineCare Benefits Manual, 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Services (repeal), Chapter II, Section 25, Dental Services and Reimbursement Methodology (this rule replaces the two repealed rule
  • MaineCare Benefits Manual, MaineCare Benefits Manual, Chapter II, Section 93, Opioid Health Home Services, and Chapter III, Section 93, Reimbursement for Opioid Health Home Services
  • MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder
  • MaineCare Benefits Manual, Chapter III, Section 29, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder
  • MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures
  • MaineCare Benefits Manual, Chapter II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder
  • MaineCare Benefits Manual, Chapters II and III, Section 91, Health Home Services
  • MaineCare Benefits Manual, Chapter II, Section 90, Physician Services
  • REPEAL of MaineCare Benefits Manual, Ch. VI, Sec. 1, Primary Care Case Management
  • MaineCare Benefits Manual, Chapter VI, Section 3, Primary Care Plus
  • REPEAL OF EMERGENCY MAJOR SUBSTANTIVE RULE: MaineCare Benefits Manual, Section 29, Chapter III, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder
  • REPEAL OF EMERGENCY MAJOR SUBSTANTIVE RULE: MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder
  • PROVISIONALLY ADOPTED MAJOR SUBSTANTIVE RULE: Chapter 101, MaineCare Benefits Manual, Chapter III, Section 97, Private Non-Medical Institution Services
  • MaineCare Benefits Manual, Chapter VII, Section 5, Estate Recovery
  • MaineCare Benefits Manual, Chapter I, Section 6, Global HCBS Waiver Person-Centered Planning and Settings Rule
  • MaineCare Benefits Manual, Chapter II Section 97, Private Non-Medical Institution Services
  • MaineCare Benefits Manual, Chapter II, Section 92, Behavioral Health Home Services
  • MaineCare Benefits Manual, Chapter II, Section 17, Community Support Services
  • MaineCare Benefits Manual, Chapter II, Section 97, Private Non-Medical Institution Services
  • MaineCare Benefits Manual, Chapters II and III, Section 19, Home and Community Benefits for the Elderly and Adults with Disabilities
  • MaineCare Benefits Manual, Chapter II, Section 103, Rural Health Clinic Services
  • MaineCare Benefits Manual, Section 5, Estate Recovery
  • MaineCare Benefits Manual, Chapter III, Section 45, Principles of Reimbursement, Hospital Services
  • MaineCare Benefits Manual, Chapter III, Section 5, Ambulance Services
  • MaineCare Benefits Manual, Chapters II and III, Section 65, Behavioral Health Services
  • 10/ch1

    Notice of Agency Rule-making Adoption, MaineCare Benefits Manual, Chapter II, Section 65

    WORD | PDF  | COMMENTS   

    Concise Summary:

    AGENCY: Department of Health and Human Services, MaineCare Services

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

    CONCISE SUMMARY:

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

    The Department adopts 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 adopted 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 adopts language in Chapter II replacing the term Medication Assisted Treatment with Methadone (MAT), with the term, Opioid Treatment Program (OTP) with Methadone. The adopted 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 adopts a change in the definition of 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, for up to a sixty-day period after the first face-to-face visit. Additionally, the Department adopts the removal of language from Section 65.07-5(B) that limited substance use individual and family outpatient therapy to three (3) hours per week, for thirty (30) weeks in a forty (40) week period. Each of these changes provide broader access to these Section 65 services. The rule also adopts clarifications on 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 for the population being served. As a result of comments, the Department determined not to adopt a rule change that would have removed the requirement that licensed Mental Health Agencies and Substance Use Agencies must separately contract with the Office of Child and Family Services and/or the Office of Behavioral Health. The adopted rule reorganizes requirements related to Individualized Treatment Plans in 65.08-4(B) and updates requirements for treatment plans for members receiving OTP services.
    In addition and separately, the Department is adopting rulemaking to repeal and replace the former Ch. III of Section 65. The changes in Chapter III, Section 65 make it consistent with the Chapter II-related updates, and related budget initiatives that require reimbursement increases for Section 65 providers, per 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 these changes in Chapter II, Section 65 are finally adopted. Throughout the rule, the Department adopted 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 adopted rule changes.

    Considering public comment, in addition to the changes to the adopted rule described above, the Department made the following changes to the adopted rule:

    1. Pursuant to Comment #4, The Department updated its definition of Serious Emotional Disturbance in 65.01-41 to align with national standards through SAMHSA.

    2. Pursuant to Comment #11, 65.05-5.A.2.a has been updated from Intake and Comprehensive Assessment to Intake and service assessment to reflect the purpose of the assessment under the IOP program.

    3. Pursuant to Comment #1, 65.07-6 has been updated to remove the prohibition of billing the Comprehensive Assessment separately from final rule.

    4. Pursuant to Comment #12, 65.07-6 has been updated to add Members may receive additional outpatient services as medically necessary when the treating condition(s) is distinct from the condition(s) addressed by the IOP.

    5. Pursuant to Comment #16, 65.05-1 been amended to change specific to the population being served to read ...at the level appropriate for the services being delivered and appropriate for the population being served to allow for staff types to serve members when appropriate to do so.

    6. Pursuant to Comment #21, 65.05-5.B.2.a has been updated to note the physician evaluation must be clinically indicated. The change is as follows:

    Assessment by a Clinician; and evaluation by a physician (MD/DO) as clinically indicated, as part of the service assessment; and

    1. Pursuant to Comment #24, 65.05-6.C.2 has been updated to add or after each of the at risk criterion to clearly state a member meet one of a-d.

    2. Pursuant to Comment #25, to 65.05-5.D.5 was updated to add Otherwise Specified Feeding or Eating Disorder and Unspecified Feeding or Eating Disorder in the final rule.

    3. Pursuant to Comment #31, 65.05-9.A.1.e was updated to add or caregiver involvement, when appropriate.

    4. Pursuant to Comment #38, 65.08-4.A.1-3 was updated to fix the numbering error.

    5. Pursuant to Comment #39, the final rule updated references to amend the title of the Diagnostic Classification of Mental Health and Development Disorders of Infancy and Early Childhood and to update to the current version 5 (DC: 0-5).

    6. As a result of legal review, the Department finds that it must update the definition of Affected Other has been updated to more clearly state the Affected Other have a familial relationship to the member.

    7. As a result of legal review, the Department finds that it must make technical edits to 65.05-9.A for clarity and readability.

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

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

    EFFECTIVE DATE: November 9, 2022

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

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

    Comment deadline past No comment deadline | Posted: November 9, 2022

    Notice of Agency Rule-making Adoption, MaineCare Benefits Manual, Chapter III, Section 65

    WORD | PDF  | COMMENTS   

    Concise Summary:

    AGENCY: Department of Health and Human Services, MaineCare Services

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

    CONCISE SUMMARY:

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

    The Department adopts this rule to comply with P.L. 2021, Ch. 398 (the Budget) and P.L. 2021, Ch. 635 (the Supplemental Budget). Per the Budget, the rule adopts increased 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. The Department received CMS approval for these rate changes in January 2022.

    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). On March 31, 2022, the Department submitted a request for changes to its SPA to implement these changes.

    Also, pursuant to Legislative directive and funding, from the Budget as well as the Supplemental Budget, the rule adopts 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). On September 30, 2022, the Department submitted a request for changes to its SPA to implement these changes.

    The Department is adopting a separate rule for Chapter II, Section 65, simultaneous with this adopted rule. The adopted 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). The Department also adopted a new modifier (ST) for use with the H2021 code, for reimbursement tracking purposes of the Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) treatment modality, which is already allowable under Children's Comprehensive Community Support Services - HCT-Masters Level. This Chapter III rulemaking will adopt rates from an independent rate study for the new IOP Services pursuant to Legislative directive and funding from the Budget. These reimbursement rates shall be effective prospectively, upon the legal effective date of the adopted rule.

    Throughout the rule, the Department adopts language consistent with the adopted 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 made the following change to the final rule:

    As a result of the Departments review, the Department finds that it must delete the term LADC because it was erroneously included in the proposed rule under the designated Substance Use Agency codes of H0004 (Outpatient Services Individual/Family Therapy) and H0004 HQ (Outpatient Services Group Therapy).
    See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.

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

    EFFECTIVE DATE: November 9, 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)

    Comment deadline past No comment deadline | Posted: November 9, 2022

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    Notice of Agency Rule-making Adoption

    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 II, Section 45, Hospital Services and Chapter III, Section 45, Principles of Reimbursement for Hospital Services

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: This letter gives notice of adopted rule: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter II, Section 45, Hospital Services and Chapter III, Section 45, Principles of Reimbursement for Hospital Services.

    The Department adopts the following changes:

    A. CHAPTER II, SECTION 45, HOSPITAL SERVICES

    The adopted rule adds Outpatient Partial Hospitalization Services as a covered service for MaineCare members. These services may be offered by Acute Care Non-Critical Access Hospitals, Acute Care Non-Critical Access hospital-based clinics, or in a distinct part of the Acute Care Non-Critical Access Hospital, if allowed by the Hospital's license. These programs provide intensive psychiatric care that is more intensive than outpatient day treatment but less intensive than an inpatient program. Upon admission, a physician must certify that the member would need inpatient hospitalization services if the partial hospitalization services were not provided. The certification must include the diagnosis and psychiatric need for partial hospitalization. The adopted rule also allows for Certified Intentional Peer Support Specialist (someone who has undergone the training for this specialty and who maintains their certification) to be part of the multi-disciplinary team that provides Outpatient Partial Hospitalization Services.

    After public comment, the Department declined to adopt the proposed rule change that required Hospital Emergency Departments to make referrals to designated Health Home providers. Instead, the adopted rule requires that Hospital Emergency Departments include discharge instructions for eligible individuals with chronic conditions to contact designated Health Home providers as required under the Social Security Act (SSA), Title 19, 42 U.S.C. Section 1945 (d).

    After public comment, the Department received CMS approval for several changes to the rule and updated the language in the adopted rule to reflect these approvals. The Department finds that these changes are necessary to improve clarity in the rules and to accurately reflect CMS approval.

    B. CHAPTER III, SECTION 45, PRINCIPLES OF REIMBURSEMENT FOR HOSPITAL SERVICES

    The adopted rule adds Ch. III, Sec. 45.07, Value-Based Purchasing (VBP) Supplemental Sub-Pool, pursuant to P.L. 2021, ch. 398. The VBP Supplemental Sub-Pool distributes $600,000 annually, to eligible hospitals (acute care non-critical access, critical access, and hospitals reclassified to a wage area outside of Maine) that participate in the MaineCare Accountable Communities initiative (defined by Ch. III, Sec. 45.01-1). The funds are distributed based on performance of one or more quality measures. The Department ranks each eligible hospital based on the quality measures and allocates the funds according to performance, weighted by its Hospital Service Area.

    Pursuant to Resolves 2021, Ch. 119, the adopted rule also provides reimbursement for members discharged from Southern Maine Health Cares psychiatric inpatient unit in the amount of $10,166 per distinct discharge effective retroactively to October 1, 2021.

    The adopted rule also eliminates the need for annual rulemaking to update the supplemental pool amounts. The specific dollar amounts for the supplemental pools have been removed from the rule and replaced with a link to the MaineCare website and a phone number, which the public can call for detailed information on annual supplemental pool amounts. Ch. III, Sec. 45.04-1(C); 45.08.

    The proposed rule included a change to Ch. III, Sec. 45.03(3), which would have removed payments for graduate medical education costs in non-rural hospitals. After reviewing the public comments, the Department declines to adopt this provision of the proposed rule. The original language of this section remains unaltered in the adopted rule.

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

    EFFECTIVE DATE: October 24, 2022

    AGENCY CONTACT PERSON: Derrick Grant, Special Projects AGENCY NAME: Division of Policy ADDRESS: 109 Capitol Street 11 State House Station Augusta, Maine 04333-0011 EMAIL: derrick.grant@maine.gov TELEPHONE: (207)-624-6931 FAX: (207) 287-6106 TTY users call Maine relay 711

    Comment deadline past No comment deadline | Posted: October 24, 2022

    MaineCare Benefits Manual, 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 rule

    WORD | PDF  | COMMENTS   

    Concise Summary:

    Notice of Agency Rule-making Adoption

    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 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)

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY:

    The Department adopts this rule, which repeals Ch. II and Ch. III, Section 25, and replaces them with a new Ch. II rule, "Dental Services and Reimbursement Methodology."

    On July 1, 2022, the Department implemented the vast majority of changes in this adopted rule 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.

    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 adopted rule adds a comprehensive array of dental services for adult members, per 22 MRS 3174-F(1).

    Additionally, this adopted 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 adopted rule. The dental code benchmarks shall undergo updates every two years, per the methodology included in the adopted 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 adopted rule and the former, now repealed 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 amounts listed in Chapter III, Section 25, the adopted 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, preventive, and limited orthodontic treatment 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 (except for limited orthodontic treatment), 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 and to leverage the 'percent of Medicare methodology in Section 90, the adopted 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 removed services from the adopted 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 adopted 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 adopted 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 adopted 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 adopted rule adds or increases coverage for many existing services for members under 21, 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 q. Nutritional counseling r. Preventive resin restorations

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

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

    b. The adopted rule establishes medically appropriate limits 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 adopted rule adds and removes PAs to align with other payers and based on recommendations from clinical consultation and rule commenters. The emergency rule did not contain PAs for scaling and root planing (SRP), crowns, and sedation, but the proposed rule included PAs for all three to allow for further public comment and Department deliberation. As a result of comments, the Department removed the PA for crowns for members under age 21, removed the PA for the first unit of SRP delivered to each quadrant, and removed the PA for sedation, which only applied to members 21 and over. Also as a result of comments, the Department removed the PAs in the proposed rule for replacement of a lost or broken retainer and for a third prophylaxis treatment.

    d. The adopted 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 adopted 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 M.R.S. Ch. 147. d. Prescriptive descriptions of services that are overly detailed for the rule. e. Section 25.03-9, Temporomandibular Joint Services, because these services are covered under Section 90, Physician Services, and they are billed for using Common Procedural Terminology (CPT) codes. 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 adopted 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 M.R.S. Ch. 143 18375, and practice requirements outlined in Board rule 02-313 C.M.R. Ch. 12, and it would be redundant to list either in this rule. In addition, the requirement for IPDHs delivering temporary fillings to have a dentist who can treat the member within 60 calendar days is not required in statute or Board rules.

    l. The appendix because the forms either exist on the HealthPAS Portal, will no longer be required, or the documents are required by the Board, not the Department.

    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.

    As described in detail in the List of Changes to the Final Rule at the end of the Summary of Comments and Responses document, the Department made the following changes in the adopted rule (compared to the changes that were included in the proposed rule):

    1. The Department added coverage for sealants on premolars (bicuspids) for members under age 21 in Section 25.03-2(C).

    2. In Section 25.03-2(H), the Department added coverage for preventive resin restorations (PRRs) once per eligible tooth per three years for members with a moderate to high caries risk when an active cavitated lesion in a pit or fissure does not extend into the dentin.

    3. The Department clarified in Section 25.03-2(C) that sealants are covered for permanent and primary first and second molars.

    4. The Department added coverage for CDT code D1310, nutritional counseling for control of dental disease, in Section 25.03-2(I) with a limit of once per member per year when delivered in addition to another covered service. The Department also added a description of the service.

    5. The Department changed the reimbursement methodology used to set rates for limited orthodontic treatment from the 50% of commercial median benchmark methodology described in Section 25.06(B)(2) to the 67% of commercial median benchmark methodology described in Section 25.06(B)(1), to reflect evidence indicating that limited orthodontic treatment is an effective preventive approach to avoid severe malocclusion.

    6. The Department updated Section 25.03-5(E) to not require a PA for the first unit of SRP delivered to each quadrant but will require PA for the second unit and any additional units of SRP delivered to each quadrant. For example, SRP delivered for the first time to the first quadrant will not require PA, but a PA is required to deliver SRP again to the first quadrant.

    7. The Department will no longer require risk assessment results and a PA that includes those results to authorize a third prophylaxis treatment. Instead, a third prophylaxis treatment per year will be permissible without PA if the member meets the criteria added to Section 25.03-2(A).

    8. The Department clarified in Section 25.03-9(F) that behavior management is covered when behavior delays, as well as prevents, a covered service from being delivered, meaning providers may bill behavior management whether a covered service is delivered or not. The Department also increased the limit from three times per member per lifetime per service location to three times per member per year per service location.

    9. The Department clarified the limit for bitewings in Section 25.03-1(B).

    10. The Department re-added coverage for diagnostic casts (CDT code D0470) in Section 25.03-1(F) because they enable orthodontic treatment planning.The Department removed the PA requirement for replacement of lost or broken retainers in Section 25.03-8(G).

    11. As a result of comments, in Section 25.05-3, the Department clarified that year in the context of service limits defined on a per year basis means calendar year. For any limit that is defined on a multi-year basis, each year means a rolling 365-day period or the 365 days following the date of the delivery of the first covered service subject to the limit. For example, a two per three years limit means a member cannot receive more than two of the specified services in any given 1,095-day period.

    12. The Department removed the PA requirement for sedation in Section 25.03-9(A).

    13. The Department removed the PA requirement for crowns for members under the age of 21 in Section 25.03-3(B).

    14. The Department revised the definition for dental extern because the Board no longer issues permits to dental externs.

    15. The Department redefined dental resident to mean any person with a resident dental license, as defined in 32 M.R.S. 18302.

    16. The Department clarified in Section 25.03-6(A) that replacement dentures are covered when they are no longer sufficiently functional and there is not a cost-efficient way to repair them, not when they are medically necessary, because dentures are not technically medically necessary.

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

    EFFECTIVE DATE: September 28, 2022

    STATUTORY AUTHORITY: 22 M.R.S. 42, 3173; P.L. 2021, Ch. 398, Sec. A-17, Part CCC

    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 No comment deadline | Posted: September 28, 2022

    MaineCare Benefits Manual, MaineCare Benefits Manual, Chapter II, Section 93, Opioid Health Home Services, and Chapter III, Section 93, Reimbursement for Opioid Health Home Services

    WORD | PDF  | COMMENTS   

    Concise Summary:

    AGENCY: Department of Health and Human Services, MaineCare Services

    CHAPTER NUMBER AND TITLE: 10-144 C.M.R., Chapter 101, MaineCare Benefits Manual (MBM), Chapter II, Section 93, Opioid Health Home Services, and Chapter III, Section 93, Reimbursement for Opioid Health Home Services

    ADOPTED RULE NUMBER: 2022-P031

    CONCISE SUMMARY:

    The Department of Health and Human Services (the "Department") finally adopts these rule changes in 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapter II, Section 93, Opioid Health Home Services, and Chapter III, Section 93, Reimbursement for Opioid Health Home Services, to improve access to treatment, reduce administrative barriers to providing treatment for Opioid Use Disorder (OUD), promote evidence-based treatment standards, and reinforce the importance of Opioid Health Home (OHH) integration with primary care. The Department received approval of a state plan amendment (SPA) from the Centers for Medicare & Medicaid Services (CMS) for some of these changes. The Department will publish notice of changes in reimbursement methodology pursuant to 42 C.F.R. 447.205.

    These rules will be legally effective on August 21, 2022.

    The adopted rules consist of the following changes in Chapter II, Section 93, Opioid Health Home Services, and Chapter III, Section 93, Reimbursement for Opioid Health Home Services:

    A. CHAPTER II, SECTION 93, OPIOID HEALTH HOME SERVICES

    The adopted rule makes various changes to the Medication for Opioid Use Disorder (MOUD) prescriber position. It allows practitioners licensed under state and federal law to order, administer, or dispense opioid agonist treatment medications to be MOUD prescribers for members in the Methadone Level of Care who receive OHH services from an Opioid Treatment Program (OTP). It requires the MOUD 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 MOUD prescribers to be involved in providing the services described under Chapter II, Section 93.05-1, Health Home Services.

    The adopted rule makes various changes to the nurse care manager position on the OHH team. In response to requests from providers, the adopted 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 OUD counseling. The final rule specifies that the nurse care manager position may be filled by another appropriately 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 adopted rule adds methadone to the medications included in the OHH model and enables an OTP to provide methadone to OHH members. The adopted rule also adds a statement encouraging the co-prescribing of naloxone for OHH members, as appropriate, in alignment with best practice guidelines.

    The adopted 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. The final rule 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 adopted rule makes various changes to the reimbursement section. The adopted rule 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 final 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, Reimbursement for Opioid Health Home Services, including an active release of information and a contractual agreement between the OHH and additional support provider.

    The adopted rule also adds a pay-for-performance provision which withholds four percent of total OHH per member per month (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 the Department anticipates that no more than 30% of eligible OHHs would not meet the minimum performance threshold and thus would not receive the four percent payment. Those four percent withhold amounts will be combined and distributed to OHH providers that meet the excellent performance threshold. If all OHH providers do 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 adopted 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 adopted rule 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 Chapter II, Section 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 starting to deliver 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. Replaces Medication Assisted Treatment (MAT), which insinuates that medication assists treatment, with MOUD, a more current term that insinuates medication is its own form of treatment. Adds Section 93.02-1(K) which contains the requirement that OHHs shall refer members to another OHH or appropriate provider when a member requires treatment or a level of care that the OHH does not offer. Changes the term dosage plan to medication plan. Changes Section 93.02-1(G) to require OHHs to establish and maintain a relationship with a primary care provider when an OHH member has a primary care provider, rather than require OHHs to establish and maintain a relationship with a primary care provider for each member served, which did not accurately reflect the requirement the Department intended to establish.

    B. CHAPTER III, SECTION 93, REIMBURSEMENT FOR OPIOID HEALTH HOME SERVICES

    The adopted 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 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 must reimburse the additional support provider via a pass-through payment. Hence, this final rule 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 final 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 MOUD, 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.

    As a result of the cost-of-living-adjustment implemented through P.L. 2021, ch. 635, Part A, the Department increased the proposed reimbursement rates in the final Chapter III, Section 93, rule by 4.94%.

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

    EFFECTIVE DATE: August 21, 2022

    STATUTORY AUTHORITY: 22 M.R.S. 42, 3173; P.L. 2021, ch. 635, Part A

    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- FAX: (207)-287-6106 TTY users call Maine relay 711

    Comment deadline past No comment deadline | Posted: August 11, 2022

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    Notice of Agency Rule-making Adoption

    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 III, Section 21, Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder.

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: This letter gives notice of adopted rule: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder.

    In response to the statewide staffing crisis and to comply with P.L. 2021, ch. 398 (the "Act"), the Department is adopting 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 changes are beneficial for the providers. This adopted routine technical rulemaking seeks to make permanent the increases to the reimbursement rates enacted via emergency rule.

    As noted in detail in the Summary of Comments and Responses, certain commenters incorrectly asserted that (1) the final rule, Sec. 1300(3), implements a reduction in per diem rates, and (2) the changes in reimbursement do not fully include rates equal to at least 125% of the minimum wage.

    With regard to (1), this rule continues the previous policy of lower reimbursement for hours in excess of 168; the actual rate for hours in excess of 168 has increased by $3.95. Hence there is no reduction and no violation of the Maintenance of Effort required under Section 9817 of the American Rescue Plan.

    With regard to (2), per P.L. 2021, ch. 635, An Act To Make Supplemental Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and To Change 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 Legislature has approved 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.

    The Department had previously implemented rates to include these labor component amounts (that are all equal to at least 125% of the minimum wage) in the emergency rule and also proposed the same rates. This final adopted rule includes rates with labor components that are all at least equal to 125% of the minimum wage.

    The Department received temporary approval on March 7, 2022 and intends to seek permanent approval from the Centers for Medicare & Medicaid Services (CMS) for the adopted increased reimbursement rates with a retroactive effective date of January 1, 2022.

    The Department did not make any additional changes to the adopted rule as a result of public comments.

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

    EFFECTIVE DATE: June 15, 2022

    AGENCY CONTACT PERSON: Heather Bingelis, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 109 Capitol Street 11 State House Station Augusta, Maine 04333-0011 EMAIL: heather.bingelis@maine.gov TELEPHONE: (207)-624-6951 FAX: (207) 287-6106 TTY users call Maine relay 711

    Comment deadline past No comment deadline | Posted: June 15, 2022

    MaineCare Benefits Manual, Chapter III, Section 29, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder

    WORD | PDF  | COMMENTS   

    Concise Summary:

    Notice of Agency Rule-making Adoption

    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, Section 29, Chapter III, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder.

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: This letter gives notice of adopted rule: 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Section 29, Chapter III, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder.

    In response to the statewide staffing crisis and to comply with P.L. 2021, ch. 398 (the "Act"), the Department is adopting 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. In addition, per P.L. 2021, ch. 635, An Act To Make Supplemental Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and To Change 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 Legislature has approved 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.

    The Department had previously implemented rates to include these labor component amounts (that are all equal to at least 125% of the minimum wage) in the emergency rule and also proposed the same rates. This final adopted rule includes rates with labor components that are all at least equal to 125% of the 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 changes are beneficial for the providers. This adopted routine technical rulemaking seeks to make permanent the increases to the reimbursement rates enacted via emergency rule.

    The Department received temporary approval on March 7, 2022 and intends to seek permanent approval from the Centers for Medicare & Medicaid Services (CMS) for the adopted increased reimbursement rates with a retroactive effective date of January 1, 2022.

    The Department did not make any additional changes to the adopted rule as a result of public comments.

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

    EFFECTIVE DATE: June 15, 2022

    AGENCY CONTACT PERSON: Heather Bingelis, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: heather.bingelis@maine.gov TELEPHONE: (207)-624-6951 FAX: (207) 287-6106 TTY users call Maine relay 711

    Comment deadline past No comment deadline | Posted: June 15, 2022

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    Notice of Agency Rule-making Adoption

    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 (MBM), Chapter I, Section 1, General Administrative Policies and Procedures

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: This final rule 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. The changes in this final rule are listed below.

    The previous rule did not address retroactive enrollment for providers other than federally qualified health centers, rural health centers, and Indian health centers. This final rule 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 dates but will not grant a retroactive enrollment date that is more than 365 days prior to the date of providers MaineCare application submissions.

    To comply with 42 CFR 455.434, the final 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. The new Section 1.03-1(J) includes relevant criteria for provider termination or denial of enrollment and outlines which providers and suppliers have high categorical risk.

    The current "rounding rule" in 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. The current version of this rule will remain in effect until December 31, 2022. To encourage better alignment between the amount of covered, medically necessary services delivered and billed, the final rule 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. As a result of comments, these changes will be effective January 1, 2023 to allow providers time to change their billing systems in order to comply with the changes. The final rule also adds misuse of the rounding rule to examples of conduct that could constitute fraud.

    This final rule 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, tasks performed for the providers own administrative purposes, and similar activities. The final rule includes an exception explaining that certain administrative tasks may be covered if addressed in an appropriate section of the MaineCare Benefits Manual. 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, the final rule removes Section 1.07-3(F)(1) to reflect that the Department will no longer pay and then seek reimbursement, commonly known as pay and chase, from liable third parties for prenatal services. In Section 1.19-1(C)(2), the final rule clarifies 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. This change was made because providers may not be reimbursed after termination of a provider agreement. The final rule 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, the final rule 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 the Department may consider when assessing this type of provider request.

    In order to correct provider deficiencies, the final rule adds a sanction permitting the Department to require providers to submit a detailed plan of correction for review and approval. This will allow the OMS Program Integrity Unit to ensure providers comply with MaineCare rules and monitor providers who experience rapid growth or changes. Providers that grow rapidly may not have adequate infrastructure to maintain quality of service provision. The final rule allows providers to satisfy the plan of correction requirement by submitting a plan that was approved by another Division within the Department if it addresses identical violations. The additional sanctions added to Section 1.20-2 provide that the Department may:

    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.

    The final rule clarifies the provisions in Sec. 1.21 regarding reinstatement following termination or exclusion to make the provisions easier to understand and apply.

    The final rule adds Section 1.24-4 on expedited member appeals that includes: (1) the procedure to request an expedited appeal, (2) criteria for the Division of Administrative Hearings (DAH) to consider when deciding whether to grant requests, (3) deadlines for when the Department must take final agency action, and (4) other requirements, per 42 CFR 431.224. The final rule amends Section 1.24-3 to provide that 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) developed structural and process changes to improve its function and efficiency. The final rule implements these changes in Section 1.25. The MAC changes include, among others, increasing MAC membership and including at least two Medicaid beneficiaries as members.

    The final rule also makes the following changes:

    Defines the ownership and control relationships that are subject to an offset and/or recoupment; Establishes a 10-day timeframe for when providers need to update OMS of changes to their National Provider Identifier or other enrollment information; Requires providers who change their name or doing business as name to change their MaineCare Provider Agreement; Clarifies 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; Adds 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; Changes 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, increases 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; Adds 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; Adds 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; Changes 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; Clarifies 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; Adds 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; Clarifies that providers may request an informal review within 60 calendar days from the date of written notification of the Departments alleged grievance and extends the deadline to the next business day if it falls on a weekend or holiday; and Makes minor grammatical and technical changes.

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

    EFFECTIVE DATE: May 29, 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 No comment deadline | Posted: May 27, 2022

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    Notice of Agency Rule-making Adoption

    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 21, Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: This letter gives notice of adopted rule: 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.

    The Department is adopting comprehensive amendments of 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual ("MBM"), Chapter II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder.

    This Section 21 rule implements and regulates a Section 1915(c) home and community-based services (HCBS) Medicaid waiver approved by the Centers for Medicare and Medicaid (CMS) in the U.S. Dept. of Health and Human Services. Under this Section 21 waiver program, the Department provides comprehensive services to support eligible adult MaineCare Members with an intellectual disability or autism living in the community. MBM Chapter II, Section 21 is a routine technical rule pursuant to 34-B M.R.S. 5432(3).

    On September 25, 2020,CMS approved the request of the Maine Department of Health and Human Services (DHHS or the Department) to renew the Section 21 HCBS waiver for a five-year period, with an effective date of July 1, 2020. The Section 21 waiver was further amended effective January 1, 2021, April 1, 2021, and July 1, 2021, and the Department will prepare and request CMS approval of additional amendments of the waiver authorizing additional changes made as part of this rulemaking.

    On or about December 29, 2021, the Office of the Secretary of State gave notice of proposed amendments of MBM Chapter II, Section to the Executive Director of the Legislative Council, and published notice of the rulemaking. The Department gave notice of the rulemaking to known interested parties, and held a remote public hearing pursuant to 34-B M.R.S. 5465(4) on January 19, 2022 and accepted other public comment regarding the proposed rulemaking pursuant to 5 M.R.S. 8057-A(3) until the close of business on January 31, 2022. A summary of public comments, the Department's responses, and changes made to the rule after it was published for public comment will be filed with the Secretary of State in conjunction with this rulemaking.

    In conformance with the CMS-approved Section 21 waiver, the Department now:

    Adds a definition of Competitive Integrated Employment in 21.02; Updates the definitions of Autism Spectrum Disorder, Intellectual Disability, Activities of Daily Living, Instrumental Activities of Daily Living, Person-Centered Service Plan, and Shared Living; Eliminates Counseling as a Section 21 Covered Service. Counseling services are available to Section 21 Members under Section 65 of the MaineCare Benefits Manual (MBM). All Section 21 Members who were receiving Counseling services under Section 21 received written notice of this change in October 2020; Updates, expands, and/or clarifies the description of the following Covered Services in 21.05: - 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 be present and awake at all time one or more Members are at home, 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.).

    U.S. Department of Justice (DOJ) Settlement Agreement: On June 4, 2021, the Department entered into a Settlement Agreement with the DOJ (DJ No. 204-34-72). The Department agreed to adopt a rule which establishes an exceptions process that provides 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 Title II of the Americans with Disabilities Act (ADA). This rulemaking adopts this exceptions process as Requests for Exceptions in 21.14.

    On January 19, 2022 the Department adopted a new rule which implements the federal requirements for Maines Section 1915(c) home and community-based waiver programs set forth in 42 C.F.R. 441.301(c). This adopted rule is codified 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 Global HCBS Rule. The Global HCBS Rule includes requirements for person-centered service planning and for settings in which home and community-based waiver services are provided, including requirements for provider-owned or controlled residential settings. Consistent with the Global HCBS Rule, MBM Chapter II, Section 21 rule incorporates applicable HCBS planning and settings requirements (See, e.g., 21.04-2 [Person Centered Service Planning Process] and 21.05-1 [Home and Community Based Settings]).

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

    Plan of Corrective Action (POCA): The Department adopts a new provision which expands upon the quality assurance activities authorized under Appendix V of the rule. This new 21.14 authorizes the Department to issue written Notices of Deficiency, and to require providers to submit and implement Plans of Corrective Action as approved by the Department. Providers have the right to appeal written Notices of Deficiency. This POCA process provides increased protections for Members and ensures 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 clarifies this provision by expressly notifying providers of the MBM Ch. I, Sec. 1 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 they serve of any intent to terminate participation in the MaineCare program.

    21.10-1 (Direct Support Professional Qualifications): The Department requires all DSPs, regardless of capacity and prior to provision of services to a Member, to receive training regarding the Global HCBS Waiver Person Centered Planning and Settings Rule, MaineCare Benefits Manual, Chapter I, Section 6; eliminates the requirement for grievance process training prior to working with Members; and adds a requirement for DSPs who provide Crisis Intervention to receive behavioral intervention training. Within six (6) months of hire and annually thereafter, the adopted rule requires DSPs to comply with the Departments regulations: Reportable Events System (14-197 C.M.R. ch. 12) and the Adult Protective Services System (10-149 C.M.R. ch. 1). The Department changes Provider Qualifications and Requirements for Direct Support Professionals (DSPs) for Career Planning and Employment Specialist Services.

    21.10-9 (Electronic Visit Verification): The Department requires providers of Home Support-Quarter Hour services to 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).

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

    Appendix IV (Performance Measures): The Department eliminates 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.

    With this rulemaking, the Department adopts and will seek CMS approval of the following additional changes:

    Community Support services are 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.

    21.07-2 (Limits): The Department changes 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 authorized under 22 M.R.S. 42(8), as the change is a benefit to both Members and Providers.

    As a result of public comments and further review by the Department and the Office of the Attorney General, the adopted rule includes clarifying language for various Covered Services, including: 21.05-1, Home and Community-Based Settings, 21.05-11, Community Support Services, 21.05-13, Home Support-Quarter Hour Services, 21.05-14, Home Support-Remote Support Services, and 21.05-20 (Shared Living / Foster Care, Adult).

    Additionally, as a result of public comment the adopted rule includes a definition for Competitive Integrated Employment ( 21.02-9) consistent with the Departments CMS-approved waiver, a revised definition for 21.02-5, Autism Spectrum Disorder, to align with the most current edition of the Diagnostic and Statistical Manual of Mental Disorders, (American Psychiatric Association), and a clarified definition for 21.02-4, Agency Home Support. Finally, as a result of public comment, the Department has revised the Plan of Corrective Action (POCA) process, specifically 21.10-14 (D), to align with Chapter I, Section 1 of the MBM in allowing providers 60 days to appeal a Notice of Deficiency and including the mailing address of the Clinical Review Team at 21.14-2(C).

    The Summary of Public Comments and Responses identifies more specifically all changes that were made to the final rule.

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

    EFFECTIVE DATE: May 22, 2022

    AGENCY CONTACT PERSON: Heather Bingelis, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: heather.bingelis@maine.gov TELEPHONE: (207)-624-6951 FAX: (207) 287-6106 TTY users call Maine relay 711

    Comment deadline past No comment deadline | Posted: May 20, 2022

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    Notice of Agency Rule-making Adoption

    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

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: This adopted rule will have a future effective date of June 21, 2022, and will not be effective five days after filing the adopted rule with the Secretary of State's Office, as is typical.

    This adopted rule eliminates 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, rules 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 adopted rule, the Department eliminates HHPs as providers 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 repealed 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 were 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.

    On April 21, 2022, the Department received approval from the Centers for Medicare and Medicaid Services (CMS) for the state plan amendment (SPA) to implement the PCPlus program. The Department shall seek approval from CMS for SPAs to repeal and revise any other programs necessary to implement the PCPlus program. The Department will publish notice of changes in reimbursement methodology pursuant to 42 CFR 447.205.

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

    Community Care Teams

    Under the adopted 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 rule expands, simplifies, clarifies, and removes redundancies from the covered service requirements.

    Under the adopted rule, CCTs are 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 originally designed for and applied to HHPs, 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 adopted 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 are also now 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 adopted rule also adds new risk factors that make a member at risk for a chronic condition.

    Housing Outreach and Member Engagement 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, the adopted rule 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.

    EFFECTIVE DATE: June 21, 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 No comment deadline | Posted: May 11, 2022

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    Notice of Agency Rule-making Adoption

    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

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: This final rule makes 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, this final 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 final 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 final rule adds a new provision, Section 90.04-7(B), Physician-Administered Drugs that have Biosimilar Equivalents and/or Prior Authorization (PA) 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 adopted 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 PA process is in addition to the requirements for PA in 90.04-7(A).

    The final 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 final rule also removes the list of allowable providers who may provide topical fluoride varnish and has replaced eligible providers and providers with qualified providers. The adopted 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. In addition, the final rule adds dental hygienists to the list of providers in association with physician services in Section 90.04-15.

    The final 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 final rule replaces the term 'handicapped with person with disabilities pursuant to P.L. 2021, Ch. 348.

    Effective June 21, 2022, this Section 90 rulemaking also eliminates 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 also significantly revises MBM, Ch. II, Sec. 91 (adopted 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 adopted 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.

    On April 21, 2022, the Department received approval from the Centers for Medicare and Medicaid Services (CMS) for the state plan amendment (SPA) to implement the PCPlus program. The Department shall seek approval from CMS for SPAs to repeal and revise any other programs necessary to implement the PCPlus program. The Department will publish notice of changes in reimbursement methodology pursuant to 42 CFR 447.205.

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

    EFFECTIVE DATE: May 14, 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 No comment deadline | Posted: May 11, 2022

    REPEAL of MaineCare Benefits Manual, Ch. VI, Sec. 1, Primary Care Case Management

    WORD | PDF  | COMMENTS   

    Concise Summary:

    Notice of Agency Rule-making Adoption

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

    CHAPTER NUMBERS AND TITLES: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter VI, Section 3, Primary Care Plus and 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter VI, Section 1, Primary Care Case Management (PCCM).

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: This adopted rule will have a future effective date of June 21, 2022, and will not be effective five days after filing the adopted rule with the Secretary of State's Office, as is typical.

    This adopted 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 MaineCares current primary care programs. To complete the transition to PCPlus, the Maine Department of Health and Human Services (the Department) also repealed MBM, Ch. II, Sec. 90.09-4 (Primary Care Provider Incentive Payment) and significantly revised MBM, Ch. II, Sec. 91 (titled Health Home Services - Community Care Teams), which includes repealing Health Home Practices. All of these rulemakings relate to the PCPlus initiative and have the same effective date.

    On April 21, 2022, the Department received approval from the Centers for Medicare and Medicaid Services (CMS) for the state plan amendment (SPA) to implement the PCPlus program. The Department shall seek approval from CMS for SPAs to repeal and revise any other programs necessary to implement the PCPlus program. The Department will publish notice of changes in reimbursement methodology pursuant to 42 CFR 447.205.

    As a result of comments, the Department determined that it would delay the effective date of the PCPlus rule until June 21, 2022. The removal of the Primary Care Provider Incentive Payment in Section 90 and the final adopted changes in Section 91 (described below and in separate MAPA documents) shall also be effective June 21, 2022.

    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 to 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 both 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 preventive 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 adopted rulemaking for Section 90, the Department eliminated the Primary Care Provider Incentive Payment because it would duplicate the reimbursement model of the new PCPlus program. Physicians who received 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 removed Health Home Practices (HHPs) because payment for these Health Home services would be duplicative of the reimbursement the PCPs will receive and the covered services they provide via PCPlus. HHPs that received 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))

    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 No comment deadline | Posted: May 11, 2022

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    Notice of Agency Rule-making Adoption

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

    CHAPTER NUMBERS AND TITLES: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter VI, Section 3, Primary Care Plus and 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter VI, Section 1, Primary Care Case Management (PCCM).

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: This adopted rule will have a future effective date of June 21, 2022, and will not be effective five days after filing the adopted rule with the Secretary of State's Office, as is typical.

    This adopted 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 MaineCares current primary care programs. To complete the transition to PCPlus, the Maine Department of Health and Human Services (the Department) also repealed MBM, Ch. II, Sec. 90.09-4 (Primary Care Provider Incentive Payment) and significantly revised MBM, Ch. II, Sec. 91 (titled Health Home Services - Community Care Teams), which includes repealing Health Home Practices. All of these rulemakings relate to the PCPlus initiative and have the same effective date.

    On April 21, 2022, the Department received approval from the Centers for Medicare and Medicaid Services (CMS) for the state plan amendment (SPA) to implement the PCPlus program. The Department shall seek approval from CMS for SPAs to repeal and revise any other programs necessary to implement the PCPlus program. The Department will publish notice of changes in reimbursement methodology pursuant to 42 CFR 447.205.

    As a result of comments, the Department determined that it would delay the effective date of the PCPlus rule until June 21, 2022. The removal of the Primary Care Provider Incentive Payment in Section 90 and the final adopted changes in Section 91 (described below and in separate MAPA documents) shall also be effective June 21, 2022.

    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 to 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 both 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 preventive 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 adopted rulemaking for Section 90, the Department eliminated the Primary Care Provider Incentive Payment because it would duplicate the reimbursement model of the new PCPlus program. Physicians who received 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 removed Health Home Practices (HHPs) because payment for these Health Home services would be duplicative of the reimbursement the PCPs will receive and the covered services they provide via PCPlus. HHPs that received 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))

    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 No comment deadline | Posted: May 11, 2022

    REPEAL OF EMERGENCY MAJOR SUBSTANTIVE RULE: MaineCare Benefits Manual, Section 29, Chapter III, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder

    WORD | PDF     

    Concise Summary:

    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

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: The Department is repealing an emergency major substantive rule that was effective on April 7, 2021 that included reimbursement rate increases for certain services under MaineCare Benefits Manual, Chapter III, Section 29, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder, pursuant to P.L. 2019, ch. 616. Per 5 M.R.S. 8072, emergency major substantive rules are effective for up to 12 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 this repeal of the April 2021 emergency major substantive rule changes. The Department is repealing this emergency major substantive rule because of additional Section 29 reimbursement rate changes that were required by P.L. 2021, ch. 398 (the "Act").

    Simultaneous with the repeal of the emergency major substantive rule, pursuant to the Act, the Department will implement separate emergency routine technical rule changes that increase rates for Section 29 providers. As set forth in the MAPA documents for the separate rulemaking, the Act authorized the Department to make those specific Section 29 reimbursement rate changes on an emergency basis via routine technical rulemaking, even though Chapter III, Section 29 rulemaking is typically major substantive. All of the Section 29 reimbursement rates that were increased via the April 7, 2021, emergency major substantive rule (that is now being repealed) are included in the rate increases for the separate emergency routine technical rule. Because of the separate routine technical emergency rule, the repeal of the emergency major substantive rule will not have the effect of causing the reimbursement rates to revert to the lower rates that were in the current permanent major substantive Chapter III Section 29 (eff. 7/28/2019).

    The separate routine technical emergency rule changes shall be effective for up to 90 days. The Department intends to proceed with proposed routine technical rulemaking to make permanent the increases to reimbursement rates enacted through the emergency rule changes. These increased rates in the separate routine technical rulemaking will be effective retroactive to January 1, 2022, as directed by the Act, per 22 M.R.S. 42(8).

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

    EFFECTIVE DATE: March 22, 2022 AGENCY CONTACT PERSON: Heather Bingelis, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: heather.bingelis@maine.gov TELEPHONE: (207)-624-6951 FAX: (207) 287-6106 TTY users call Maine relay 711

    Comment deadline past No comment deadline | Posted: March 23, 2022

    REPEAL OF EMERGENCY MAJOR SUBSTANTIVE RULE: MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder

    WORD | PDF     

    Concise Summary:

    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 21, Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: The Department is repealing an emergency major substantive rule that was effective on April 7, 2021, that included reimbursement rate increases for certain services under MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder pursuant to P.L. 2019, ch. 616. Per 5 M.R.S. 8072, emergency major substantive rules are effective for up to 12 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 this repeal of the April 2021 emergency major substantive rule changes. The Department is repealing this emergency major substantive rule because of additional Section 21 reimbursement rate changes that were required by P.L. 2021, ch. 398 (the "Act").

    Simultaneous with the repeal of the emergency major substantive rule, pursuant to the Act, the Department will implement separate emergency routine technical rule changes that increase rates for Section 21 providers. As set forth in the MAPA documents for the separate rulemaking, the Act authorized the Department to make those specific Section 21 reimbursement rate changes on an emergency basis via routine technical rulemaking, even though Ch. III, Section 21 rulemaking is typically major substantive. All of the Section 21 reimbursement rates that were increased via the April 7, 2021, emergency major substantive rule (that is now being repealed) are included in the rate increases for the separate emergency routine technical rule. Because of the separate routine technical emergency rule, the repeal of the emergency major substantive rule will not have the effect of causing the reimbursement rates to revert to the lower rates that were in the current permanent major substantive Chapter III Sec. 21 (eff. 7/28/2019).

    The separate routine technical emergency rule changes shall be effective for up to 90 days. The Department intends to proceed with proposed routine technical rulemaking to make permanent the increases to reimbursement rates enacted through the emergency rule changes. These increased rates in the separate routine technical rulemaking will be effective retroactive to January 1, 2022, as directed by the Act, per 22 M.R.S. 42(8).

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

    EFFECTIVE DATE: March 22, 2022

    AGENCY CONTACT PERSON: Heather Bingelis, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: heather.bingelis@maine.gov TELEPHONE: (207)-624-6951 FAX: (207) 287-6106 TTY users call Maine relay 711

    Comment deadline past No comment deadline | Posted: March 23, 2022

    PROVISIONALLY ADOPTED MAJOR SUBSTANTIVE RULE: Chapter 101, MaineCare Benefits Manual, Chapter III, Section 97, Private Non-Medical Institution Services

    WORD | PDF  | COMMENTS   

    Concise Summary:

    Chapter III, Section 97, has been provisionally adopted. This is a major substantive rule and requires legislative approval prior to final adoption.

    Notice of Agency Rule-making Provisional Adoption

    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, Section 97, Private Non-Medical Institution Services, Ch. III

    PROVISIONALLY ADOPTED RULE

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY:

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

    These changes were originally implemented in Chapter III through emergency major substantive rules, effective Nov. 1, 2021, which imposed reimbursement increases in Ch. III in order to support final adopted routine technical Ch. II, Section 97 rule changes, also effective Nov. 1, 2021. The Ch. II changes implemented various new requirements on Appendix D providers per the Family First Prevention Services Act (FFPSA), and also added new covered MaineCare services. Ch. II also imposed new requirements on Appendix B providers and broadened those covered services. Emergency major substantive rule changes are effective for up to one year or until Legislative review. To make these reimbursement rate increases and other changes permanent, shortly after issuance of the emergency rule, the Department initiated proposed major substantive rulemaking for Ch. III. This provisionally adopted major substantive rule shall now go to the Legislature for review and authorization for final adoption, per 5 M.R.S. 8072.

    The new reimbursement rates were authorized by the Legislature pursuant to P.L. 2021, Ch. 29 (the Budget) and P.L. 2021, Ch. 398 (the Supplemental Budget). The rates are also consistent with independent rate studies completed for Appendix B and Appendix D services. 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 changes names 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. The rule also ensures 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. The name of Appendix D shall change from Childcare Facilities to Children's Residential Care Facilities in order to align with changes adopted in Chapter II.

    This rulemaking seeks to create two tiers of reimbursement, one tier accounting for all medical personnel, and another tier as an exception rate for low nursing staff, in the case of substantial workforce challenges. Lastly, service components of the rate in 2400.1 clarify that social workers are licensed clinical social workers and add licensed marriage and family therapists, to align with changes adopted in Chapter II. Similarly, in Appendix D, Section 2400.1, board certified behavioral analyst services, board certified assistant behavior analyst services, and registered behavior technician services are added to align with changes in Chapter II. The independent rate study recommended that Mental Health Level I and Level II services be consolidated into a single Mental Health level of reimbursement, and that Intellectual Disabilities and Autism Spectrum Disorder Levels I and II be consolidated into a single Intellectual Disabilities/Developmental Disabilities residential treatment rate. This rule removes language from Section 6000 because the referenced member assessment is no longer required. The Main Rule also adds reimbursement rates for a new MaineCare covered service, Aftercare Services, for the service itself and for mileage reimbursement. Aftercare is a required component of the FFPSA. The Department shall seek approval from CMS for the new Aftercare Services and the additional practitioners allowable under this Appendix.

    The Department implemented 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.

    Finally, pursuant to public comment, this provisionally adopted rule makes changes from the proposed major substantive Main Rule and Appendix D to update reimbursement for Aftercare Services from hourly to quarter-hour reimbursement, to provide greater flexibility in reimbursement for the services provided, and has updated CMS approval language in the Main Rule, Appendix B, and Appendix D to reflect current standards. Please note that the emergency major substantive rule reimburses based on an hourly rate for Aftercare services, and that shall continue to be effective until such time that the Legislature authorizes and the Department finally adopts these major substantive rule changes, per 5 M.R.S. 8072(8). The Department plans to retain the hourly reimbursement in the future final adopted rule so providers may know how to seek reimbursement for Aftercare Services from November 1, 2021 to the effective date of the final adopted rule.

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

    EFFECTIVE DATE:

    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 No comment deadline | Posted: March 7, 2022

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    AGENCY: Department of Health and Human Services, MaineCare Services

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

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: This adopted rule implements P.L. 2021, ch. 398, Part A, A-1, pg. 99 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).

    These rule changes were originally implemented via an emergency rule, effective November 24, 2021; routine technical emergency rules are effective for 90 days. This final adopted rule permanently changes the Department's estate recovery claim so that it 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. The effective date of this change is November 24, 2021, since that is when the emergency rule was implemented.

    Additionally, this adopted rule clarifies the definition of life estate, including how life estates are valued.

    Finally, this adopted rule removes language regarding CMSs pending approval of changes that are approved and includes minor typographical corrections.

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

    EFFECTIVE DATE: February 20, 2022

    AGENCY CONTACT PERSON: Nicole Jurdak AGENCY NAME: Division of Policy ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 Nicole.Jurdak@maine.gov TELEPHONE: (207)-624-4058 FAX: (207)-287-6106 TTY users call Maine relay 711

    Comment deadline past No comment deadline | Posted: February 18, 2022

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    This new rule implements 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. Adoption of this rulemaking means that the rule is judicially enforceable. See 5 M.R.S. 8002(9). The Department adopted this rule implementing these requirements in order to be in compliance with federal Medicaid law and regulations, so that the Department can continue to receive federal funding for HCBS waiver programs. The adopted 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 adopted rule and any rule listed above, the terms of the adopted rule will supersede and shall apply.
    The 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 rule outlines what must be contained in the person-centered service plan, requires that it must be understood and agreed to by the Member, and provides when and how a modification may be made to the person-centered service plan. The 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 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 adopted 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. The adopted rule outlines requirements for provider qualifications as well as Department 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 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). The rule provides for a prospective application date for HCBS settings that were approved as settings prior to March 17, 2014, for Sections 6.04(A) (Home and Community- Based Settings - General Requirements) and 6.04(B) (Additional Requirements for Provider-Owned or Controlled Residential Settings) which will have a prospective application date of September 30, 2022.
    Finally, as a result of public comments and further review by the Department and the Office of the Attorney General, there were additional minor grammatical and formatting changes to the adopted rule language. The Summary of Public Comments and Department Responses document identifies more specifically all changes that were made to the final rule. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.

    EFFECTIVE DATE: 1/19/2022

    AGENCY CONTACT PERSON: Heather Bingelis, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: heather.bingelis@maine.gov TELEPHONE: (207)-624-6951 FAX: (207) 287-6106 TTY users call Maine relay 711

    Comment deadline past No comment deadline | Posted: January 19, 2022

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    Notice of Agency Rule-making Adoption

    AGENCY: Department of Health and Human Services, MaineCare Services

    CHAPTER NUMBER AND TITLE: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual (MBM), Chapter II, Section 97, Private Non-Medical Institution Services

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY:

    The Department of Health and Human Services (the "Department") adopts the following changes to 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual (MBM), Chapter II, Section 97, Private Non-Medical Institution Services.

    The Department adopts these rule changes to align Section 97 requirements with the Family First Prevention Services Act (FFPSA), which establishes standards for children's residential treatment programs in order to improve quality and oversight of services. The adopted 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 adopted 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 amended Appendix D language referring to Child Care Facility Services and Models of Child Care Facilities, to be replaced with the term, Childrens Residential Care Facilities (CRCFs). The adopted rule distinguishes models of residential care that address specific treatment needs of different member populations. CRCF models include Intellectual Disabilities/Developmental Disabilities (ID/DD-CRCF), Mental Health (MH-CRCF), Crisis Stabilization (CS-CRCF), and Child and Adolescent Therapeutic Foster Care. This rule further adopts amended 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 adopts the use of Department-approved, age appropriate Level of Care/Service Intensity tools, which is required as a component of eligibility determination for ID/DD, MH, and CS CRCFs. The Level of Care/Service Intensity tools 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 adopts 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 MH and ID/DD CRCFs. The Department is additionally requiring a new 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 adopted rule clarifies Appendix D requirements for the CRCF assessment, Individual Treatment Plan, progress notes, and discharge summary as well as adding various new defined terms.The Department additionally adopted language that requires providers operating under Appendix D and Adolescent Residential Rehabilitation Services operating under Appendix B, to demonstrate utilization of the Federal Substance Abuse and Mental Health Services Administrations (SAMHSA) System of Care Principles. The rule requires 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 adopts specific requirements regarding background checks for providers operating under Appendix D and Adolescent Residential Rehabilitation Services providers operating under Appendix B. 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 adopted 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 adopts, 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. The Department is requiring confirmation that prospective BHPs are not annotated in the registry (per 10-144 C.M.R. ch. 128, Certified Nursing Assistant and Direct Care Worker Registry Rule) prior to qualifying as a staff member under this rule.

    In addition to the above adopted changes, the Department adopted language increasing 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 adopted 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 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 adopted rule changes.

    In addition, the Department intends to implement corresponding changes as needed in the MBM, Chapter III, Section 97, to ensure adequate reimbursement for providers to deliver all new covered services and meet QRTP standards and other Chapter II-related updates. For example, Chapter III Appendix D Section 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 Chapter III, Section 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 Chapter II, Section 97 are finally adopted.

    Considering public comment and legal advice from the Office of Attorney General, the Department made various changes to the final rule from what was proposed.

    Changing requirements for Appendix D providers, service delivery, and provisions of treatment to provide more specificity and allow for more flexibility for providers, include:

    Updating language related to accreditation, under 97.07-2(F)(h)(2) to allow for accreditation to be completed within 12 months.

    Extending the Prior Authorization for Temporary High Intensity Services (97.02-5(C)) from a seven (7) day authorization to up to thirty (30) days.

    Including language under 97.08-2.G(6) to address exemptions related to Aftercare Support Services.Adding language under 97.06-3 (Non-Reimbursable Days), to include, Members receiving services in an emergency department are exempt from this provision when emergency treatment is sought at 8:00pm or later and the member returns to the facility the following day.

    Removing references that limit telehealth services and reducing the frequency of required in-person contact for Aftercare Support Services.

    Clarifying that both ITPs and FBAs are reviewed minimally every thirty (30) days.

    Updating language, under 97.08-2(C)(2), to include more flexibilities for behavioral and/or rehabilitative therapies.

    Clarifying language related to family involvement in treatment under Appendix D CRCFs to include more involvement by the Departments Office of Child and Family Services (OCFS) and specific requirements.

    Changing requirements for Appendix D CRCF staff include:

    Allowing for, under 97.07-2(H)(3), a bachelors degree in an unrelated field with at least one (1) year of related professional experience, and extending time for staff to obtain BHP certification for new hires to six (6) months from the date of hire and staff currently employed to one (1) year from the effective date of the rule.

    Updating CRCF staff supervision requirements to include a minimum of three (3) hours per month includes one (1) hour of individual and one (1) hour of clinical supervision conducted by a Clinician as defined in 97.01-4.

    All changes are specifically listed in the separate document, Summary of Comments and Responses and List of Changes to the Final Rule.

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

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

    EFFECTIVE DATE: November 1, 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)

    Comment deadline past No comment deadline | Posted: October 28, 2021

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    This letter gives notice of an adopted rule: 10-144 C.M.R Chapter 101, MaineCare Benefits Manual, Chapter II, Section 92, Behavioral Health Home Services.

    The Department of Health and Human Services ("the Department") adopted the following changes to 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapter II, Section 92, Behavioral Health Home Services.

    This adopted rule enhances safeguards and protections of client rights under the Bates, et al. v. Commissioner, DHHS, et al, consent decree. The rule addresses 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 added 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 gives 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.

    The Department also updated 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 Maine's opioid task force and legislation passed in 2018 to minimize stigma (P.L. 2017, ch. 407).

    Considering public comment, in addition to the changes to the final rule described above, the Department made the following change to the final rule:

    The Department has amended the term Department referrals to referrals under 92.02-3 D in the adopted rule.

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

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

    EFFECTIVE DATE: July 1, 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)

    Comment deadline past No comment deadline | Posted: July 1, 2021

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    This letter gives notice of an adopted rule: 10-144 C.M.R Chapter 101, MaineCare Benefits Manual, Chapter II, Section 17, Community Support Services.

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

    This adopted rule enhances safeguards and protections of client rights under the Bates, et al. v. Commissioner, DHHS, et al, consent decree. The rule addresses 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 adopted rule also removed 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.

    This rule additionally removed 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 updated formatting, citations, and references where necessary, including changing Office of Substance Abuse and Mental Health Services to Office of Behavioral Health and removed 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).

    Considering public comment, in addition to the changes to the final rule described above, the Department made the following changes to the final rule:

    The Department has amended the term Department referrals to referrals under 17.08-5 D in the adopted rule.

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

    EFFECTIVE DATE: July 1, 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)


    Comment deadline past No comment deadline | Posted: July 1, 2021

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    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 97, Private Non-Medical Institution Services

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: The Department of Health and Human Services (the "Department") adopts these rule changes to 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapter II, Section 97 to enhance safeguards and protections of client rights under the Bates, et al. v. Commissioner, DHHS, et al, consent decree by creating new provisions addressing terminations from and referrals to Appendix E Private Non-Medical Institutions.

    First, under Section 97.07-10, Termination, 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. Adoption of this rule will protect members from inappropriate discharge from these services.

    Second, under Section 97.07-11, Referrals, 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 adopted language will assist members in receiving timely access to Appendix E services.

    This adopted rule also provides clarity and consistency in record-keeping processes to align with other MaineCare policies. Specifically, the adopted rule changes the frequency requirement for entering and signing progress notes from a monthly to a daily expectation within Appendix E facilities. This adoption will improve accuracy and quality within member records.

    In addition, as a result of further review by the Department and the Office of the Attorney General following the comment period, this adopted rule updates offensive terminology throughout the rule. This includes replacing references to substance abuse with substance use per Public Law 2017, Ch. 407, Part B, Sec. B-1.

    Finally, this adopted rule include non-substantive technical, grammatical, and other minor changes, including updating the outdated references to current Department office names. The Summary of Public Comments and Department Responses document identifies changes that were made to the final rule following the comment period.

    This rulemaking will take effect on July 1, 2021 to coincide with the anticipated adoption of changes to the MaineCare Benefits Manual, Section 17 and Section 92, which similarly enhance and safeguard client rights under the Bates consent decree.

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

    EFFECTIVE DATE: July 1, 2021

    AGENCY CONTACT PERSON: Heather Bingelis, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: heather.bingelis@maine.gov TELEPHONE: (207) 624-6951 FAX: (207) 287-6106 TTY users call Maine relay 711

    Comment deadline past No comment deadline | Posted: July 1, 2021

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    This adopted rule aligns and complies with 42 C.F.R. 441.301(c), the federal Home and Community Based Settings (HCBS) rule (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 Personal Support Specialists 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 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 adopted rule adds 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 Settings Rule.

    Additionally, the adoption 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. Many of the changes are effective retroactive to April 1, 2020. 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 adopted rule also transitions 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 seeks to remove the limits on care coordination in Section 19.06; members may receive care coordination services as appropriate to their medical needs, without limits to the amount.

    Additionally, the adopted rule to clarifies roles and responsibilities of the SCA, the Fiscal Intermediary (FI), and the ASA Assessor. The rule outlines the responsibilities of the SCA to promote the Person-Centered Planning process and clarifies the authority of the SCA to reduce, suspend, and deny members services. Additionally, the adopted 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 adopted rules, certain changes in the rule have a retroactive effective date of either April 1, 2020, or July 1, 2020, while the remainder are effective with this final adoption of the rule pursuant to 5 M.R.S. 8052(6). Further, the Department has received final approval from the Centers for Medicare and Medicaid Services (CMS) on amendments to the Section 1915(c) waiver to implement same. Finally, as a result of public comments and further review by the Department and the Office of the Attorney General, there were additional minor changes to the adopted rule language for purposes of clarity. Importantly, the Department increased the reimbursement for Respite Services in Chapter III from $163.49 to $219.76, in order to be consistent with the waiver amendment approved by CMS. The Summary of Public Comments and Department Responses document identifies more specifically all changes that were made to the final rule.

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

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

    EFFECTIVE DATE: May 2, 2021

    AGENCY CONTACT PERSON: Heather Bingelis, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 109 Capitol Street, 11 State House Station Augusta, Maine 04333-0011 EMAIL: heather.bingelis@maine.gov TELEPHONE: (207)-624-6951 FAX: (207) 287-6106 TTY users call Maine relay 711

    Comment deadline past No comment deadline | Posted: April 30, 2021

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

    Notice of Agency Rule-making Adoption

    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, Section 103, Rural Health Clinic Services, Ch. II

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: This rule is adopted 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 submitted to CMS and anticipates approval of a State Plan Amendment (SPA) related to these provisions effective retroactive to January 1, 2020. A retroactive effective date is permissible under federal Medicaid law because the SPA was submitted in February, and pursuant to 22 M.R.S. 42(8) because these changes benefit providers.

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

    EFFECTIVE DATE: December 8, 2020

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

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

    MaineCare Benefits Manual, Section 5, Estate Recovery

    WORD | PDF  | COMMENTS   

    Concise Summary:

    Notice of Agency Rule-making Adoption

    AGENCY: Department of Health and Human Services, MaineCare Services

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

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: The Department of Health and Human Services ("the Department") adopts this rule 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 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-hour 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 and the requirement the decedents property was vacant. Finally, the Department is proposing minor language, clerical, and reference number edits.

    Following review as to form and legality, the Department is adding language in various provisions of the final rule to indicate that the Department shall submit and anticipates CMS approval of the changes via a State Plan Amendment.

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

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

    EFFECTIVE DATE: November 30, 2020

    Comment deadline past No comment deadline | Posted: November 30, 2020

    MaineCare Benefits Manual, Chapter III, Section 45, Principles of Reimbursement, Hospital Services

    WORD | PDF  | COMMENTS   

    Concise Summary:

    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, Section 45, Hospital Services, Ch. III, Principles of Reimbursement

    ADOPTED RULE NUMBER:

    CONCISE SUMMARY: The Department adopts the following changes to 10-144 C.M.R. ch. 101, MaineCare Benefits Manual, Chapter III, Section 45, Principles of Reimbursement, Hospital Services:

    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 adopts the following changes:

    1. Pursuant to Sec. C-2, the Department establishes two subsets of Private Acute Care Non-Critical Access Hospitals; Rural Hospitals and Non-Rural Hospitals. The Department's definition of "Rural Hospital" follows 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 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 will 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 is 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 will 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 non-emergency room hospital-based physician costs. Pursuant to Legislative directive and funding, this provision is 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 will reimburse Acute Care Critical Access Hospitals for 100% for all hospital-based physician costs. Pursuant to Legislative directive and funding, this provision is 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. 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 adopting 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 has clarified that each hospitals year, as used for the calculation, is the hospitals fiscal year that ended during calendar year 2016.

    The Department updated Appendix B by removing invalid ICD-10 codes for non-emergency use of the emergency department.

    Between the filing of the proposed rule and the adoption of this final rule, in June 2020, the Department obtained CMS approval of various SPA requests. As such, various changes to the rule from what was proposed were made to remove references to CMS approval of SPA changes. Where references to CMS remain in the rule, in order to be consistent, the Department updated the language to reflect current standard format for such references that is being used in all MaineCare rules.

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

    EFFECTIVE DATE: November 23, 2020

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

    Comment deadline past No comment deadline | Posted: November 18, 2020

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

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

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

    EFFECTIVE DATE: October 12, 2020

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

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

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

    WORD | PDF  | COMMENTS   

    Concise Summary:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    EFFECTIVE DATE: August 19, 2020

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

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

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

    01.htm">MaineCare Benefits Manual.