Adopted Rulemaking

The MaineCare Benefits Manual (10-144, Department of Health and Human Services, Chapter 101) is available on the Secretary of State (SOS) website.

There is always a delay between the effective date the Office of MaineCare Services' adopts a rule and the date it is posted on the SOS website. Therefore, the Office of MaineCare Services posts recently adopted rules here until thay are posted on the SOS website.

Clarifications regarding adopted rules are also posted here.

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MaineCare Benefits Manual, Chapter II, Section 28, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations WORD  PDF 
Concise Summary: On June 25, 2019, the Department adopted an emergency Ch. II, Section 28 rule. The Department adopts these rule changes in order to make those changes permanent. Background: On November 8, 2018, the Department adopted an emergency major substantive rule for Ch. III, Sec. 28 (Allowances for Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations). The emergency major substantive rulemaking was done to comply with Public Law 2017, Ch. 460 which directed the Department to amend reimbursement rates for Section 28 providers to reflect final rates modeled in the April 2017 Burns report: Rate Study for Behavioral Health and Targeted Case Management Services: Final Proposed Rates for Formal Rulemaking, and also to increase the rate of reimbursement for all services by two percent. The legislation was enacted as an emergency, and directed the Department to make the rate increases effective July 1, 2018. Pursuant to the emergency major substantive rule, in order to comport with federal Medicaid law, the rate increases were made with an August 1, 2018 effective date. The November 8, 2018 emergency major substantive rule also added a new procedure code for Board Certified Behavior Analyst (BCBA) services (Procedure Code G9007), pursuant to the Act, which required the Department to establish new reimbursement rates in accordance with the 2017 Burns rate study. The Department proposed rules for Ch. III, Section 28, in accordance with 5 M.R.S. § 8072(1), to be provisionally adopted by the Department, pending legislative approval. The Department received comments during that rulemaking requesting clarification on the services that would be eligible for the August 1, 2018 BCBA services rate. Therefore, the Department determined that rulemaking for Ch. II, Section 28, is required in order to clarify the services that are eligible for the new BCBA service rate. As stated above, the Department adopted an emergency Ch. II Section 28 rule on June 25, 2019 which clarified the BCBA services. This adopted rulemaking will finalize Ch. II rule changes and provides for a new provision in the rule identifying BCBA services in the Covered Services section of the rule. In addition, the adopted rule identifies the requirements for BCBA providers, consistent with requirements set forth by the Behavioral Analyst Certification Board. These standards were originally in effect on the effective date of the emergency rule, June 25, 2019. BCBA services rendered between August 1, 2018, the effective date of the November 8, 2018, Ch. III, Section 28, emergency major substantive rule, and the effective date of the emergency rule, June 25, 2019, will be reimbursed in accordance with the emergency major substantive rule BCBA rate, and the Ch. II rule in effect at that time. In addition to the changes described above, this adopted rulemaking adds telemedicine language under Provider Requirements. As a result of public comments and review by the Office of the Attorney General, the Department amended the final rule to remove the EVV language. While Section 28 providers are subject to the EVV requirement, the Department removed the language requiring EVV as the Centers for Medicare and Medicaid Services has yet to approve the Department's Good Faith exemption request, and the Department has not yet determined when the EVV requirement will apply. Additionally, the Department amended 28.04-3 BCBA Services to add language supporting exceeding policy limits when medically necessary and supported by documentation and prior authorized by the Department or its Authorized Entity. Additional changes were made to the final rule and are outlined in the Summary of Comments and Responses document published with this rulemaking. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: September 23, 2019
View Comments: COMMENTS  Posted: September 20, 2019
 
MaineCare Benefits Manual, Chapter II, Section 90, Physician Services WORD  PDF 
Concise Summary: On June 18, 2019, the Department adopted an emergency Ch. II, Sec. 90 rule, which eliminated transsexual procedures from the list of non-covered services in § 90.07. Elimination of this prohibition on transgender medical procedures complies with Section 1557 of the Affordable Care Act (Pub. L. 111-148, title I, Sec. 1557), as codified in 42 U.S.C § 18116 and its enabling regulation, 45 C.F.R. Part 92, which prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs and activities. This adopted rule makes that change permanent. In addition, the Department is adopting the following changes in this rulemaking: 1. The addition of Appendix A as the last item on the Table of Contents, which was part of the rule previously but was not identified in the Table of Contents; 2. From the Supplies and Materials category, removal of language "that may be reimbursed as separate items" to add clarity as to what is reimbursable for medical supplies and materials under this section (90.01-5). Language about supply reimbursement already exists under Medical Supplies & Durable Medical Equipment (90.04-9); 3. Addition of language setting the reimbursement for physician's medical direction of anesthesia services at 50% of the allowance when a physician performs anesthesia services alone (90.04-1(B)) to more closely align with the Centers for Medicare and Medicaid Services (CMS) reimbursement methodology; 4. Amended the provision in the policy specifying how interns, residents, and locum tenens are enrolled to require that residents, locum tenens, and temporaries to enroll either under a physicians group or as a hospital-based professional in order to be reimbursed through MaineCare (90.04-10). The Department added the requirement that residents must have a medical license for best practices (per Title 32, ch. 48, § 3271(2)) to enroll and receive reimbursement through MaineCare; 5. Removal of mileage reimbursement language to create consistency across the MaineCare Benefits Manual and minimize abuse of mileage reimbursement. (90.04-11); 6. Addition of two new services: Diabetes Self-Management Training Services (DSMT) (90.04-13) and Medical Nutrition Therapy Services (MNT) (90.04-14). DSMT and MNT have been linked to improved clinical outcomes. 7. Addition of licensed dietician as an other professional that can work in association with Physician Services (90.04-15), and who can also provide the newly added DSMT or MNT services; 8. Addition of licensed clinical psychologists and licensed marriage and family therapists as other professionals practicing within the scope of their licensure that can work in association with Physician Services (90.04-15); 9. Addition of clarifying language for current and accurate prescribing criteria in the Prescriptions category of Covered Services (90.04-19); 10. Addition of transgender services (90.04-33) under Covered Services to identify coverage for medically necessary procedures. The Department had proposed to put this provision under Restricted Services, requiring prior authorization. In response to comments, the Department moved this provision to the covered services section so that prior authorization is not required for these non-surgical services; 11. Addition of (90.05-1 A (4)) Gender Dysphoria Related Surgeries to identify coverage for surgeries for the treatment of gender dysphoria. Commenters agreed that prior authorization should be required for surgeries; 12. Amendment to provider title under Restricted Services (90.05-2 A) Abortion Services, from physician to health care professional to comply with PL 2019, c. 262, An Act to Authorize Certain Health Care Professionals to Perform Abortions. This change is effective September 19, 2019; 13. The Reimbursement Rate for Drugs Administered by Other Than Oral Methods (90.09-3) has been amended to align MaineCare policy with the CMS Covered Outpatient Drug final rule by determining drug fee schedules as Average Sales Price (ASP), plus 6%, as set by Medicare Part B for Maine area 99; and 14. Removal of the Member Satisfaction category under the Primary Care Provider Incentive Payment (90.09-4) list of incentives. A separate category for this is not required because member satisfaction is a targeted indicator built into the scoring of the various categories. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: September 16, 2019
View Comments: COMMENTS  Posted: September 12, 2019
 
MaineCare Benefits Manual, Chapter III, Section 28, Allowances for Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations WORD  PDF 
Concise Summary: The Department of Health and Human Services finally adopts this major substantive rule to increase the rates of reimbursement for rehabilitative and community support services pursuant to Public Law 2017, ch. 460, An Act Making Certain Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government. The Act requires the Department amend its rules for reimbursement rates for rehabilitative and community support services provided under the provisions of 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapter III of Section 28, Allowances for Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations. Specific changes are as follows: •Part C of the Act directs the Department to amend the rates of reimbursement to providers of Section 28 services to reflect the final rates modeled in the April 24, 2017 report: Rate Study for Behavioral Health and Targeted Case Management Services: Final Proposed Rates for Formal Rulemaking prepared for the Department by Burns & Associates, Inc. Those rate changes were made. •Part D of the Act directs the Department to increase the rate of reimbursement for all services by two percent. Sec. D-1 and D-2 specifically require the increase in reimbursement be applied to the wages and benefits of employees providing direct services. The two percent rate increase was made to the rates as changed by the Burns study. •This rulemaking added a new procedure code, for BCBA Services (Proc. Code G9007), pursuant to the Act, which required the Department to "establish new reimbursement rates" in accordance with the 2017 Burns Rate Study. P.L. 2017, ch. 460, Part C, Sec. C-1 directed that rulemaking authorized by the Sec. C-1 law would be a major substantive rule. Sec. C-1 provided for certain rate increases, and rulemaking, for Section 28 services. Through the Act, the Legislature determined that these facts create an emergency within the meaning of the Constitution of Maine and require the following legislation as immediately necessary for the preservation of the public peace, health and safety. As such, the Act requires the Department to implement immediate rate increases, effective July 1, 2018. However, the Act did not become law until July 9, 2018, following a Legislative override of the Governor's veto. Because the Act involves MaineCare reimbursement, these rule changes are also governed by federal Medicaid law. 42 C.F.R. § 447.205(d) requires that public notice of changes in reimbursement for State Plan services must be published before the proposed effective date of the change. The Department published its notice of reimbursement methodology change for the Section 28 rates on July 31, 2018. Upon the advice of the Office of the Attorney General, the increased rates were effective August 1, 2018; this effective date comports with the federal law requirement. Pending approval of the proposed changes to the Section 28 State Plan Amendment that were submitted to the Centers for Medicare and Medicaid Services, the increased rates were implemented with an August 1, 2018 effective date. The retroactive application comports with 22 M.R.S. § 42(8), which authorizes the Department to adopt rules with a retroactive application (where there is no adverse impact on providers or members) for a period not to exceed eight calendar quarters. To remedy the difference between the July 1, 2018 effective date set forth in the Act, and the August 1, 2018 date that is permissible pursuant to federal Medicaid law, the Department has recalculated the annual appropriation of funds for this service into a temporary eleven month rate. As such, providers will, over the course of eleven months, receive equivalent aggregate payments as would have been received under a twelve month rate. Beginning on July 1, 2019, rates will be annualized (based upon a twelve month appropriation). This is not an effective rate decrease, but rather a redistribution of the annual appropriation over twelve months, rather than eleven months. In addition to the above, this final adopted rule amends the base rate of policy prior to August 1, 2018 to be compliant with the increase required via An Act to Increase Payments to MaineCare Providers that are Subject to Maines Service Provider Tax, P.L. 2015, ch. 477(eff. Apr. 15, 2016. The Department paid claims at increased rates but did not initiate rulemaking at that time. The Department previously implemented these same changes through emergency major substantive rulemaking, effective as of November 8, 2018 to comply with P. L. 2017, ch. 460, An Act Making Certain Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government. On April 26, 2019 the Department provisionally adopted these rules. Subsequently, the Department submitted the provisionally adopted rules to the Maine State Legislature for its review, in accordance with 5 M.R.S. § 8072. The Maine State Legislature authorized the final adoption of these rules. Resolves 2019, ch. 40, was signed by Governor Mills on May 30, 2019. These final adopted rules make the permanent changes to these rules as required by the Legislature. These final major substantive rules shall become effective thirty days after filing with the Secretary of States Office. 5 M.R.S. § 8072(8). http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. AGENCY CONTACT PERSON: Dean Bugaj, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 109 State St. 11 State House Station Augusta, Maine 04333-0011 EMAIL: Dean.Bugaj@maine.gov TELEPHONE: (207)-624-624-4045 FAX: (207) 287-6106 TTY users call Maine relay 711
View Comments: COMMENTS  Posted: August 7, 2019
 
MaineCare Benefits Manual, Chapter III, Section 97, Private Non-Medical Institution (PNMI) Services and Appendices B, C, D, E, and F WORD  PDF 
Concise Summary: These finally adopted major substantive rules effectuate a process by which an eligible PNMI Services provider may request an Extraordinary Circumstance Allowance ; allow for certain regulatory compliance costs incurred by Appendix C and F PNMI providers to be considered reasonable and necessary; and increase the limit for new construction, acquisitions, and renovations involving capital expenditures to $500,000 from $350,000 pursuant to Public Law 2017, ch. 304, An Act to Amend Principles of Reimbursement for Residential Care Facilities. In addition, the Department adopts these rule changes to Chapter III, Section 97, Private Non-Medical Institution Services to increase the MaineCare payment rates attributable to wages and salaries in routine services cost by an inflation factor in accordance with the United States Department of Labor, Bureau of Labor Statistics Consumer Price Index - medical care services index from the prior December for professional services, nursing home, and adult day care services. This rule change also allows Appendix C PNMI providers to request a supplemental wage allowance for increases in wages and wage-related benefits in the routine cost component pursuant to Public Law 2017, ch. 460, An Act Making Certain Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government. Further, as a result of comments on the proposed rule, the Department has provided that the cost of interpreter services for hearing impaired staff participating in training, supervision, and staff meetings may be an allowable cost subject to Department approval through submission of the annual budget in Chapter III, Section 97, Appendix E. The Department is authorized to finally adopt these changes retroactively under 22 M.R.S. § 42(8) because these changes increase reimbursement for providers and will have no adverse impact on either MaineCare providers or members. Additionally, the Change in Reimbursement Methodology Notice required by 42 C.F.R. § 447.205 relating to the Extraordinary Circumstance Allowance and Regulatory Compliance Costs was published on October 19, 2017 (for Appendices C and F). In regards to the Supplemental Wage Allowance and increased MaineCare payment rates for Appendix C PNMIs for the state fiscal year ending June 30, 2020, and each year after, the Department published its Notice of Change in Reimbursement Methodology on July 31, 2018. In addition to the changes required by the First and Second Act, other changes include, but are not limited to: •Procedure codes: S9484 and corresponding modifiers HA, HE, and HI for Temporary High Intensity Services, per report per hours, are added to Appendices D, E, and F to more effectively align with the current prior authorization process. •Temporary High Intensity Staffing Services are reimbursed based on individual member's direct care price. This direct care price is not subject to audit. The Temporary High Intensity Staffing Services remittances received will be removed from the total Direct Services Staff costs in determining the allowable cost for the PNMI rehabilitation and personal care direct service staff cost. •The Department will calculate each Appendix C PNMIs rate setting case mix index using the number of MaineCare residents in each case mix classification group in the facility as of March 1st for the July rate and September 1st for the January rate. The changes are provisionally adopted in order to issue provider rate letters in a timely manner. •The Department will send a roster of Appendix C residents and source of payment as of March 1st and September 1st to facilities for verification prior to rate setting. •Principle 2400.3: The cost of interpreter services for hearing impaired staff participating in supervision, training, and staff meetings may be an allowed cost for Appendix E providers. This allowance is subject to Department approval obtained through the annual budget submission process. The Department previously implemented these same changes through emergency major substantive rulemaking, effective November 20, 2018 to comply with P. L. 2017, ch. 460, An Act Making Certain Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government. Pursuant to 5 M.R.S. § 8073, emergency major substantive rules are effective up to 12 months or until the Legislature has completed review, and the Department thereafter finally adopts the rule changes. On March 20, 2019, the Department provisionally adopted these rules. Subsequently, the Department submitted the provisionally adopted rules to the Maine State Legislature for its review, in accordance with 5 M.R.S. § 8072. The Maine State Legislature authorized the final adoption of these rules without making any changes to what was provisionally adopted. Resolves 2019, ch. 39, was signed by Governor Mills on May 30, 2019. Given the emergency as set forth in Resolves 2019, ch. 39, the law takes effect when approved. These final adopted rules make the permanent changes to these rules as required by the Legislature. These final major substantive rules shall become effective thirty days after filing with the Secretary of States Office. 5 M.R.S. § 8072(8). 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 11, 2019
View Comments: COMMENTS  Posted: July 16, 2019
 
MaineCare Benefits Manual, Chapters II and III, Section 40, Home Health Services WORD  PDF 
Concise Summary: The Department of Health and Human Services finally adopts these major substantive rule changes to Chapters II and III, Section 40, Home Health Services to add the use of Telemonitoring Services, to be provided by home health agencies. Telemonitoring is the use of information technology to remotely monitor a member's health status through the use of clinical data while the member remains in the residential setting. Through telemonitoring, a home health agency sets up equipment that allows for a members vital statistics to be monitored daily. The addition of Telemonitoring Services is beneficial to members, allowing them to receive medically necessary home health covered services that can be delivered remotely at comparable quality in their own homes. In addition, these finally adopted major substantive rules are updated to state any home health service may be offered as the sole home health service and shall not be contingent upon the provision of another home health service. Other Chapter II changes include: •New definitions added: Health Care Provider and Telemonitoring Services. Authorized Agent is changed to Authorized Entity and updated throughout the policy. •Eligibility for Care changes: Medical Eligibility Requirements for Telemonitoring Services. •Additions to Covered Services: Telemonitoring Services. •Non-Routine Medical Supplies includes an updated link to billing instructions and list of supplies. •A typographical error in the header of Chapter II, which previously read Chapter III, has been corrected. •Pursuant to Section 12006, 21st Century CURES Act, Electronic Visit Verification (EVV) requirements for home health services providers, effective January 1, 2023, are added. •Limitations have been updated to reflect that members of Section 19, Home and Community-Based Services for the Elderly and Adults with Disabilities, may receive authorization for nursing services through Section 40, Home Health Services, should Section 19 nursing services be deemed insufficient to meet the members needs. •Throughout the policy, "mental retardation" has been updated to individuals with intellectual disabilities and severe and disabling mental illness. •MaineCare Services, Division of Customer Service has been updated to MaineCare Provider Services with an updated toll-free number. In addition, Chapter III updates some of the procedure codes to support Ch. II, Section 40, Covered Services, including the addition of Telemonitoring Services. Pursuant to 22 M.R.S. § 42(8), the Department shall apply certain of these procedure codes retroactively, effective eight calendar quarters from when the Department finally adopts these rule changes. Additionally, pursuant to Resolve 2017, ch. 61, To Support Home Health Services, the Department increases the following reimbursement rates, effective January 1, 2019: G0299, G0300, G0151, G0151 TF, G0152, G0152 TF, G0153, G0153 TF, G0155, and G0156. The Centers for Medicare and Medicaid Services already separately approved the State Plan Amendment for Telehealth and Telemonitoring Services. The Department is seeking, and anticipates receiving, CMS approval for the changes to Section 40, Chapters II and III, as noted specifically in the rules. Upon CMS approval, those changes shall be effective. On February 15, 2019, the Department provisionally adopted these rules. Subsequently, the Department submitted the provisionally adopted rules to the Maine State Legislature for its review, in accordance with 5 M.R.S. § 8072. The Maine State Legislature authorized the final adoption of these rules without making any changes to what was provisionally adopted. Resolves 2019, ch. 51, was signed by Governor Mills on June 6, 2019. Given the emergency as set forth in Resolves 2019, ch. 51, the law takes effect when approved. These final adopted rules make the permanent changes to these rules as required by the Legislature. These final major substantive rules shall become effective thirty days after filing with the Secretary of States Office. 5 M.R.S. § 8072(8). HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: August 11, 2019
View Comments: COMMENTS  Posted: July 16, 2019
 
MaineCare Benefits Manual, Chapter III, Section 29, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF 
Concise Summary: The Department of Health and Human Services finally adopts these major substantive rule changes to Ch. III, Section 29, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder to effectuate increased reimbursement rates for 18 procedure codes and services pursuant to P.L. 2017, ch. 459, An Act Making Certain Supplemental Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government, and to implement an increase for procedure code T2017 QC in conformance with Resolves 2019, ch. 17. The Department previously implemented these rule changes to effectuate reimbursement rate increases to comply with P.L. 2017, ch. 459, An Act Making Certain Supplemental Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government, retroactive to July 1, 2018, by emergency major substantive rulemaking effective September 12, 2018. In creating the reimbursement rates for the procedure codes shown below in conformance with P.L. 2017, ch. 459,, the Department examined utilization of these services, and then calculated rates to ensure parity between Section 29 and MBM Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities, to lessen administrative complications for providers. During the Legislative review of the provisionally adopted major substantive rule, the Legislature passed as an emergency measure Resolves 2019, ch. 17, Resolve, Regarding Legislation Review of Portions of Chapter 101: MaineCare Benefits Manual, Chapter III, Section 29: Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder, a Major Substantive Rule of the Department of Health and Human Services, authorizing final adoption of the provisionally adopted major substantive rule only if the following emergency change is made: The rule must be amended in Appendix I to increase the rate for procedure code T2017 QC from $1.63 per hour to $2.00 per hour. The Department has amended the rule accordingly. The Department finally adopts the following major substantive rule changes to Chapter III, Section 29, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder: •In Appendix I, the following rates have been increased: S5140 Shared Living (Foster Care, adult)-Shared Living Model-One member served S5140 UN Shared Living (Foster Care, adult)-Shared Living Model-Two members served T2017 Home Support-Quarter Hour T2017 GT Home Support-Remote Support-Interactive Support T2017 QC Home Support-Remote Support-Monitor Only T2021 Community Support (Day Habilitation) T2021 SC Community Support (Day Habilitation) with Medical Add-On T2019 Employment Specialist Services (Habilitation, Supported Employment waiver) T2019 SC Employment Specialist Services (Habilitation, Supported Employment waiver) with Medical Add-On H2023 Work Support (Supported Employment)-Individual H2023 SC Work Support (Supported Employment)-Individual with Medical Add-On H2023 UN Work Support (Supported Employment)-Group 2 members served H2023 UP Work Support (Supported Employment)-Group 3 members served H2023 UQ Work Support (Supported Employment)-Group 4 members served H2023 UR Work Support (Supported Employment)-Group 5 members served H2023 US Work Support (Supported Employment)-Group 6 members served T2015 Career Planning (Habilitation, prevocational) S5150 Respite Services-1/4 hour S5151 Respite Services-Per Diem •In Section 1400, the maximum amount that can be billed in a single day for Respite has been increased (to reflect the rate increases made in Appendix I). •In Section 1810, the group rates for Work Support have been increased (to reflect the rate increases made in Appendix I). The Maine State Legislature authorized final adoption of the rule. Resolves 2019, ch. 17, was signed by Governor Mills and immediately took effect on April 30, 2019. The final adopted rule makes the permanent changes to this rule as required by the Legislature. This final major substantive rule shall become effective thirty days after filing with the Secretary of State's Office. 5 M.R.S. § 8072(8). http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: July 28, 2019
View Comments: COMMENTS  Posted: July 3, 2019
 
MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF 
Concise Summary: The Department of Health and Human Services finally adopts these major substantive rule changes to 10-144 C.M.R. ch. 101, MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autism Spectrum Disorder to effectuate increased reimbursement rates for 33 procedure codes pursuant to P.L. 2017, ch. 459, An Act Making Certain Supplemental Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government. P.L. 2017 directed the Department to increase the rates for specific procedure codes in equal proportion to the funding allocated for this purpose. In addition to the rate increases required by P.L. 2017, ch. 459, the Department also increased the rate for a 34th procedure code, T2017 QC Home Support, Habilitation, residential, waiver - Remote Support Monitor only. Increasing the rate for this procedure code created consistency with the other codes, in line with the Section 21 service and reimbursement structure. These increased rates are effective retroactive to July 1, 2018. The Department previously implemented these rule changes to effectuate reimbursement rate increases through emergency major substantive rulemaking, effective September 11, 2018, to comply with P.L. 2017, ch. 459, An Act Making Certain Supplemental Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government. On December 16, 2018, the Department provisionally adopted the rule. Subsequently, the Department submitted the provisionally adopted rule to the Maine State Legislature for its review, in accordance with 5 M.R.S. 8072. The Maine State Legislature authorized final adoption of the rule. Resolves 2019, ch. 20, was signed by Governor Mills on April 30, 2019. The final adopted rule makes the permanent changes to this rule as required by the Legislature. This final major substantive rule shall become effective thirty days after filing with the Secretary of State's Office. 5 M.R.S. 8072(8). 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 20, 2019
View Comments: COMMENTS  Posted: June 21, 2019
 
MaineCare Benefits Manual, Chapters II and III, Section 109, Speech and Hearing Services WORD  PDF 
Concise Summary: The Department of Health and Human adopts these two rules. Chapter II: The Department adopts changes to the rule which add two new covered services for adult Members (Members over the age of 21). The added covered adult services are Hearing Aid Evaluation and Related Procedures, by Audiologist; and Hearing and/or Hearing Aid Periodic Recheck. In the previous rule, these two services were available for children Members only. The Department is adding them as adult service because hearing aids and replacement hearing aids are a covered service under Section 60 Medical Supplies and Durable Medical Equipment. The Department wanted to ensure that adult members received medical evaluations for the hearing aids. In addition to the changes above, the Department updated the definition for Hearing Aid Services. Chapter III: The Department adopts changes to this rule that increase specific rates pursuant to Resolves 2017, ch. 60, Resolve, Regarding Reimbursement for Speech and Language Pathology Services. The Resolve requires codes to be amended to increase agency rates, independent rates, speech-pathology assistant agency rates, and speech-language pathology assistant independent rates in Chapter 101, MBM, Chapter III, Section 109, Speech and Hearing Services. The Resolve provided funding to increase reimbursement for the increase to these rates. The Department adopts: •Adding Agency rates at 69% of Medicare for codes 92507 GN, 92521 GN, 92522 GN, 92523 GN, 92607 GN, 92608 GN, 92609 GN, and 92610. •Adding Independent rates at 90% of Agency rates for codes 92507 GN, 92507 TF,GN, 92508 HQ,GN, 92508 TF,HQ,GN, 92521 GN, 92522 GN, 92523 GN, 92524 GN, 92526 GN, 92607 GN, 92608 GN, 92609 GN, and 92610. The Resolve directed that these increased rates be effective retroactively to January 1, 2019. However, CMS has indicated to the Department that the rates can be increased no earlier than January 12, 2019, because of the notice of change in reimbursement methodology requirement in 42 CFR § 447.205. The retroactive application of these increased rates comports with 22 M.R.S. § 42(8) which authorizes the Department to adopt rules with a retroactive application for a period not to exceed 8 calendar quarters if there is no adverse financial impact on any MaineCare member or provider. The Department has submitted a State Plan Amendment to CMS to allow for the rate increases to be effective retroactive to January 12, 2019. The Resolve directed the Department to increase certain rates to a precise percentage of the federal Medicare rate for the same service. The final adopted rates are slightly lower than the proposed rates because for the proposed rule rates the Department inadvertently used the 2018 federal Medicare national reimbursement rates rather than the 2018 federal Medicare local reimbursement rates which is the same area/code the Department uses for other MaineCare rates. Upon advice from the Office of the Attorney General, the Department does not believe the change in rates require additional notice and public comment. In each instance, the final rate is higher than the rates in the former Ch. III regulation. The Department makes additional changes to the rule: •Removing the requirement of under age 21 only from codes 92592, 92593, and V5264. •Adding the following codes to allow them to be billed under Section 109, where currently they can be billed only under the MCBM, Section 90 Physician Services. The Department is seeking CMS approval for these changes, with a May 19, 2019 effective date. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: May 19, 2019
View Comments: COMMENTS  Posted: May 17, 2019
 
PROVISIONALLY ADOPTED MAJOR SUBSTANTIVE RULE: MaineCare Benefits Manual, Chapter III, Section 28 WORD  PDF 
Concise Summary: PROVISIONALLY ADOPTED MAJOR SUBSTANTIVE RULE: Chapter 101, MaineCare Benefits Manual, Chapter III, Section 28, ALLOWANCES FOR REHABILITATIVE AND COMMUNITY SUPPORT SERVICES FOR CHILDREN WITH COGNITIVE IMPAIRMENTS AND FUNCTIONAL LIMITATIONS
View Comments: COMMENTS  Posted: April 26, 2019
 
MaineCare Benefits Manual, Chapters II and III, Section 15, Chiropractic Services WORD  PDF 
Concise Summary: The Department of Health and Human Services is adopting this rule to add coverage of evaluation and management examinations performed by chiropractors, pursuant to Public Law 2017, ch. 421, An Act To Provide MaineCare Coverage for Chiropractic Treatment. P.L. 2017, ch 421 requires the Department under the MaineCare program to reimburse chiropractic evaluation and management examinations performed by a chiropractic doctor licensed under Title 32, Maine Revised Statutes, chapter 9, that are within the scope of practice of chiropractic doctors. The Legislature authorized the Department to adopt routine technical rules to implement P.L. 2017, ch. 421. MaineCare reimbursement for chiropractic services is regulated by 10-144 C.M.R. ch. 101, MaineCare Benefits Manual, Chapters II and III, Section 15, Chiropractic Services. In Chapter II, the Department added coverage for evaluations or re-evaluations of spinal conditions to determine the rehabilitative effectiveness of chiropractic manipulation by chiropractors as a covered service under Subsection 15.04 A. Eligibility for chiropractic services may be determined by members' primary care providers or a chiropractor, as set forth in Subsection 15.03 B. Additionally, the Department changed the term subluxation to spinal conditions throughout the rule to align with Medicaid requirements. In Subsection 15.05, the Department clarified that X-rays ordered or performed by or for a chiropractor that are not of the spine are non-covered services. Finally, the Department directed chiropractors to use evaluation and management codes 99201-99215 for the purposes of examining and diagnosing a spinal condition, in Subsection 15.07-1 A. In Chapter III, the Department identified evaluation and management codes 99201-99215 to be used for evaluations and management purposes. Additionally, the rule states that the rates for these codes are shown on the Physician Fee Schedule under MaineCare Usual and Customary Rates and a link was inserted to the Physician Fee Schedule for reimbursement purposes. Finally, the Department is adopting minor technical edits. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: April 12, 2019
View Comments: COMMENTS  Posted: April 12, 2019
 
PROVISIONALLY ADOPTED MAJOR SUBSTANTIVE RULE: Chapter 101, MaineCare Benefits Manual, Chapter III, Section 97, Private Non-Medical Institution Services WORD  PDF 
Concise Summary: The attached rule, Chapter III, Section 97, has been provisionally adopted. This is a major substantive rule and requires legislative approval prior to final adoption.
View Comments: COMMENTS  Posted: March 22, 2019
 
MaineCare Benefits Manual, Chapters II & III, Section 93, Opioid Health Home Services WORD  PDF 
Concise Summary: The Department of Health and Human Services adopts changes to Chapters II and III, Section 93, Opioid Health Home Services of the MaineCare Benefits Manual pursuant to P.L. 2017, ch. 460, Part G, An Act Making Certain Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government emergency, effective July 9, 2018, and in response to the ongoing opioid crisis. Part G of the Act amends the Maine Substance Abuse and Treatment Act, 5 M.R.S. § 20001-20078-A, by implementing new definitions and creating a hub-and-spoke model of treatment. The Department ’s current service delivery model for Opioid Health Homes under Section 93 largely abides by the hub-and-spoke model. However, to more closely align with the Legislature ’s directive, the Department is adopting the following rule changes: added a definition of Integrated Medication Assisted Treatment to describe OHH service expectations; added urine drug screening as an integral part of IMAT services, established levels of care, intensive, intermediate –stabilization, and maintenance that correspond to the member’s needs, and created a tiered reimbursement rate structure corresponding to these levels of care. In addition, the Department is adopting other changes to improve the Section 93 rules by making it easier for current and new providers to deliver IMAT services through the OHH model. These changes included: altering the current staffing requirements and adding a new patient navigator to the OHH team to ensure flexibility for provider organizations and expertise to meet members ’ needs; creating an allowance for members who meet eligibility for MaineCare Benefits Manual, Section 92, Behavioral Health Home Services, Section 91, Health Home Services, certain Section 13, Targeted Case Management Services, or Section 17, Community Support Services to receive these services in coordination with OHH services, easing requirements regarding the Electronic Health Record to allow provider flexibility in meeting OHH program requirements, providing clarification to covered services, and making minor and technical changes to the operation of OHH. With these changes, the reimbursement of OHH services at a Per Member Per Month rate will now be based on the level of care of services provided to the member and whether the OHH provides coordinated case management to the member. Urine drug screening will be part of the OHH bundled reimbursement. Medication costs will be excluded from the PMPM bundle and billed separately. This rule adoption follows emergency rulemaking which adopted the aforementioned changes effective November 27, 2018. With this rulemaking, the Department is permanently adopting the above changes with the exception of a few additional changes following public comment on the rule proposal. This includes removing the preference on substance use licensing for the OHH, easing the parameters for the Nurse Care Manager, expanding who can serve as the Patient Navigator, altering counseling requirements, removing interpretive language on the Prescription Monitoring Program rules, adding the requirement that member ’s must consent to and sign their treatment plans, and clarifying minimum requirements for OHH reimbursement. The rule changes are contingent upon approval from the Centers for Medicare and Medicaid Services which the Department is currently seeking through a State Plan Amendment. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: March 16, 2019
View Comments: COMMENTS  Posted: March 15, 2019
 
MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities WORD  PDF 
Concise Summary: The Department of Health and Human Services adopts these changes to Chapter III, Section 67, Principles of Reimbursement for Nursing Facility Services, to effectuate a number of changes to the reimbursement methodology to continue to ensure adequate funding for Nursing Facility Services and in conformance with Public Law 2017, ch. 460, LD 925, An Act Making Certain Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government, Sections B-1 and B-3. These changes required by P.L. 2017, ch. 460 include 1. Principles 18.9 and 22.2 A change in the Occupancy Adjustment to allow for reduced occupancy percentage ch. 460, Sec. B-3(2) 2. Principle 18.12 An increase in the High MaineCare Utilization payment ch. 460, Sec. B-3(3) 3. Principle 43 The adoption of a special wage allowance for fiscal year 2018-19. The final rule clarifies that this special allowance will be allowed and paid at final audit to the full extent that it does not cause reimbursement to exceed the facilitys allowable cost in that fiscal year. ch. 460, Sec. B-3(1) 4. Principle 1.4 Definition of Base Year: The Legislature further required that, for state fiscal year beginning July 1, 2018, the base year for each facility is its fiscal year that ended in calendar year 2016; for state fiscal years beginning on or after July 1, 2019, subsequent rebasing must be based on the most recent cost report filings available. Further, for the state fiscal year beginning July 1, 2018, the rates set for each rebasing year must include an inflation adjustment for a cost-of living percentage change in nursing facility reimbursement each year in accordance with the United States Department of Labor, Bureau of Labor Statistics Consumer Price Index - medical care services index from the prior December for professional services, nursing home, and adult day care services. (ch. 460, Sec. B-3(1), to be codified 22 M.R.S. § 1708(3)(F) 5. Principle 18.13: Finally, in compliance with ch. 460, Sec. B-3(4), the Department added an aggregate hold harmless provision to reflect that the revised method of rebasing a nursing facilitys base year may not result in the rate of reimbursement for direct and routine costs that is lower than the rate in effect June 30, 2018. Because the Act involves MaineCare reimbursement, these rule changes are also governed by federal Medicaid law. 42 C.F.R. sect 447.205(d) requires that public notice of changes in reimbursement for State Plan services must be published before the proposed effective date of the change. The Department published its notice of reimbursement methodology change for the Section 67 rates on August 1, 2018. Upon the advice of the Office of the Attorney General, the changes in reimbursement methodology will be effective August 2, 2018 this effective date comports with the federal law requirement. Pending approval of the proposed changes to the Section 67 State Plan Amendment that were submitted to the Centers for Medicare and Medicaid Services, the reimbursement methodology changes will be implemented with an August 2, 2018 effective date. On December 4, 2018, the Department adopted an emergency rule to effectuate the changes to the reimbursement methodology for Nursing Facilities with a retroactive effective date of August 2, 2018. This rulemaking makes permanent the emergency rule changes. Additional changes in this rulemaking include: Principle 1.1: The Department deleted non-essential and ambiguous language, so that the principle now reads: The purpose of these principles is to provide for payment of nursing facility services provided under the MaineCare program in accordance with Title XIX of the Social Security Act. Principle 13.4.1.3: Uniform desk review completion is extended from one hundred eighty days to three hundred and sixty-five days, in order to allow the Department sufficient time to do a comprehensive and accurate desk review Principle 18.5 Clarification is added to describe the conditions required for interest expenses to be allowable. Similarly, the Department elaborated upon when refinancing expenses may be allowable Principle 23.4 The Department is deleting this Principle. The purpose of this provision was to hold nursing facilities harmless from the calculation of the prospective rate in Principle 23.3 at less than 100% of the calculated Direct and Routine Cost components. Principle 23.4 is no longer necessary because the calculation of the prospective rate in Principle 23.3 is not at 100% of the calculated Direct and Routine Cost components Principle 39 Community-Based Specialty Nursing Facility Units The Department clarified that services provided are medical-psychiatric services. The Department removed the requirement of a contract between the nursing facility and the Department and replaced it with the requirement that in order to get reimbursement under this provision there needs to be a written approval by the Department for this service Throughout the policy CMS approves language has been removed, where applicable, based on approved State Plan Amendment status. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: March 5, 2019
View Comments: COMMENTS  Posted: March 5, 2019
 
MaineCare Benefits Manual Chapters II and III, Section 40, Provisionally Adopted Major Substantive Rule WORD  PDF 
Concise Summary: The attached rule, Section 40, has been provisionally adopted. This is a major substantive rule and requires legislative approval prior to final adoption.
View Comments: COMMENTS  Posted: February 20, 2019
 
Chapter 115, Principles of Reimbursement for Residential Care Facilities; Room and Board Costs WORD  PDF 
Concise Summary: The Department of Health and Human Services adopts changes in 10-144 C.M.R. Chapter 115, Principles of Reimbursement for Residential Care Facilities Room and Board Costs, in conformance with Public Law 2017, ch. 304, An Act to Amend Principles of Reimbursement for Residential Care Facilities now enacted as 22 M.R.S. 7863 to effectuate the following changes: A residential care facility that experiences an unforeseen and uncontrollable event during a year which results in unforeseen or uncontrollable increases in expenses may request an adjustment to a prospective rate in the form of an extraordinary circumstance allowance. Section 20.5 New Construction, Acquisitions, and Renovations involving capital expenditures is updated to $500,000 from $350,000. Costs incurred by residential care facilities to comply with changes in federal or state laws, regulations and rules, or local ordinances and not otherwise specified in rules adopted by the Department are considered reasonable and necessary. Reimbursement for additional regulatory costs shall be paid via a supplemental payment that is added to the per diem rate until the Department adjusts the routine limit, as applicable, to fairly and properly reimburse facilities for these costs. These changes were initially implemented via emergency rulemaking on November 20, 2018 and shall have a retroactive effective date of November 1, 2017. In addition, this adopted rule complies with Public Law 2017, ch. 460, An Act Making Certain Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government, The Second Act, and effectuates the following changes: For the state fiscal year ending June 30, 2020 and each year thereafter, the MaineCare payment rates attributable to wages and salaries in routine services costs for Section 97, Private Non-Medical Institution Appendix C providers must be increased by an inflation factor in accordance with the United States Department of Labor, Bureau of Labor Statistics Consumer Price Index – medical care services index from the prior December for professional services, nursing home, and adult day care services. Effective August 1, 2018, for the state fiscal year ending June 30, 2019, a special supplemental allowance shall be made to Appendix C PNMIs to provide for increases in wages and wage-related benefits in the routine cost component. An amount equal to ten percent of wages and associated benefits and taxes in the routine cost component as reported on each facility as filed cost report for its fiscal year ending in calendar year 2016 must be added to the cost per resident day in calculating each facility’s prospective rate, notwithstanding any otherwise applicable caps or limits on reimbursement. This supplemental allowance must also be allowed and paid at final audit to the full extent that it does not cause reimbursement to exceed the facilitys allowable cost per day in the routine cost component in that fiscal year. These changes were initially implemented via emergency rulemaking on November 20, 2018 and shall have a retroactive effective date of August 1, 2018. The First and Second Acts required the Department to amend Chapter 115 to include ECA, regulatory compliance costs, inflation factor, and the special wage allowance changes for Residential Care Facilities and MaineCare Section 97, Private Non-Medical Institution Services Appendix C providers. Separately, and in addition to the changes required in Chapter 115, the Department made changes in 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapter III, Section 97 and the Section 97 changes are major substantive. Pursuant to 5 M.R.S. 8072, regular major substantive rule changes are not legally effective until they are approved by the Legislature and finally adopted by an agency, which can take over a year. As such, because the Department sought to implement the Section 97 changes simultaneously with these State Rule changes in order to treat similar providers equitably, on November 20, 2018, it made changes to both rules through emergency rulemaking. This rulemaking makes permanent the emergency rule changes. In addition to the changes required by the First and Second Acts, pursuant to its general broad rulemaking authority set forth in, inter alia, 22 M.R.S. and 3173, the Department also revised the rule requirements regarding when providers may be approved for refinancing,Principle 20.4.3 d. As a result of comments and legal review by the Office of Attorney General, the Department finds that these changes should have been made solely through regular, not emergency routine technical rulemaking. The changes in Principle 20.4.3(d) shall be applied prospectively only, effective upon final adoption of this rule. The Department shall work with providers to equitably adjust reimbursement if necessary in the event that the Department utilized the language starting on November 20, 2018 through February 18, 2019, date of final rule. Other changes to Chapter 115 include, but are not limited to: Calculating depreciation recapture for residential care facilities that have been sold, the calculation of the credits for buildings and fixed equipment will be from the date the owner began operating the facility with the original license. For sales of residential care facilities, moveable equipment will accumulate credits as follows: for the first four years, the asset is placed into service, all but ten percent per year will be recaptured, and from the fifth and sixth years, all but thirty percent per year will be recaptured, not to exceed one hundred percent. The calculation of the credits for moveable equipment will be from the date the asset is placed into service by the provider. Defines moveable equipment credit accumulation and calculation for residential care facilities that have been sold. The following definitions have been added or clarified: Licensed Capacity, Proper Interest, Swap Investments, and Remote Island Facility. Computer hardware may be considered a capital cost; the Department will not consider software purchase or upgrades as an allowable capital expenditure. Computer software and associated ongoing support costs fall under Routine Costs, 30.1.3. Office names have been updated and/or inserted to provide clarity. Changes were made to the final rule as a result of comments and legal review, as set forth in detail in the Summary of Comments and List of Changes to the Final Rule, including: The Occupancy Level definition has reverted back to its pre-proposed language. Remote island facility supplemental payment has been added to Principle 14, Reimbursement Method in conformance s. Principle 20.1 language has been reinstated and amended to clarify routine and fixed costs. 20.4.3(c)(ii) has been removed as the proposed language was contradictory to Principle 20.2.2. Principle 34.7 has been amended to include Extraordinary Circumstance Allowance and Regulatory Compliance Costs administrative hearing and informal review process. Principle 34.7.3 has been amended to expand informal review request timeframe to sixty days from thirty days. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: February 18, 2019 AGENCY CONTACT PERSON: Heidi Bechard, Comprehensive Health Planner II AGENCY NAME: Office of MaineCare Services, Division of Policy ADDRESS: 242 State St. 11 State House Station Augusta, Maine 04333-0011 EMAIL: Heidi.bechard@maine.gov TELEPHONE: 207-624-4074, FAX: (207) 287-1864 TTY: 711 (Deaf or Hard of Hearing)
Effective Date: February 18, 2019
View Comments: COMMENTS  Posted: February 15, 2019
 
MaineCare Benefits Manual, Chapter III, Section 17, Allowances for Community Support Services WORD  PDF 
Concise Summary: The Department of Health and Human Services adopts this rule to finalize the increases in the rates of reimbursement for Community Support Services pursuant to Public Law 2017, ch. 460, An Act Making Certain Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government, Part D. The Act requires the Department to amend its rules for reimbursement rates for Community Support Services provided under the provisions of 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapter III, Section 17, Allowances for Community Support Services. Specific changes are as follows: • Part D of P.L. 2017, ch. 460 directs the Department to increase the rate of reimbursement for all services by two percent. Sec. D-1 and D-2 specifically require the increase in reimbursement to be applied to the wages and benefits of employees who provide direct services and not to administrators or managers. The Act requires the Department to implement immediate rate increases, effective July 1, 2018. However, the Act did not become law until July 9, 2018, following a Legislative override of the Governor ’s veto. Because the Act involves MaineCare reimbursement, these rule changes are also governed by federal Medicaid law. 42 C.F.R. § 447.205 d requires that public notice of changes in reimbursement for State Plan services must be published before the proposed effective date of the change. The Department published its notice of reimbursement methodology change for the Section 17 rates on July 31, 2018. Upon the advice of the Office of the Attorney General, the increased rates will be effective August 1, 2018; this date comports with the federal law requirement. Pending approval of the proposed changes to the Section 17 State Plan Amendment that were submitted to the Centers for Medicare and Medicaid Services, the increased rates will be implemented with an August 1, 2018 effective date. To remedy the difference between the July 1, 2018 effective date set forth in the Act and the August 1, 2018 date that is permissible pursuant to federal Medicaid law, the Department has recalculated the annual appropriation of funds for this service into a temporary eleven month rate. As such, providers will, over the course of eleven months, receive equivalent aggregate payments as would have been received under a twelve month rate. Beginning on July 1, 2019, rates will be annualized based upon a twelve month appropriation. This is not an effective rate decrease, but rather a redistribution of the annual appropriation over twelve months, rather than eleven months. The retroactive application of the rate increases to August 1, 2018, comports with 22 M.R.S. § 42(8), which authorizes the Department to adopt rules with a retroactive application where there is no adverse impact on providers or members for a period not to exceed eight calendar quarters. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: February 14, 2019 AGENCY CONTACT PERSON: Dean Bugaj, Comprehensive Health Planner II AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 EMAIL: Dean.Bugaj@maine.gov TELEPHONE: (207)-624-4045 FAX: (207) 287-1864 TTY users call Maine relay 711
Effective Date: February 14, 2019
View Comments: COMMENTS  Posted: February 14, 2019
 
MaineCare Benefits Manual, Chapter III, Section 13 Allowances for Targeted Case Management WORD  PDF 
Concise Summary: The Department of Health and Human Services adopts this rule to finalize the increase the rates of reimbursement for targeted case management services pursuant to Public Law 2017, ch. 460, An Act Making Certain Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government, Part D. The Act requires the Department to amend its rules for reimbursement rates for targeted case management services provided under the provisions of 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapter III, Section 13, Allowances for Targeted Case Management. Specific changes are as follows: • Part D of P.L. 2017, ch. 460 directs the Department to increase the rate of reimbursement for all services by two percent. Sec. D-1 and D-2 specifically require the increase in reimbursement to be applied to the wages and benefits of employees who provide direct services and not to administrators or managers. The Act requires the Department to implement immediate rate increases, effective July 1, 2018. However, the Act did not become law until July 9, 2018, following a Legislative override of the Governor ’ s veto. Because the Act involves MaineCare reimbursement, these rule changes are also governed by federal Medicaid law. 42 C.F.R. & 447.205 d requires that public notice of changes in reimbursement for State Plan services must be published before the proposed effective date of the change. The Department published its notice of reimbursement methodology change for the Section 13 rates on July 31, 2018. Upon the advice of the Office of the Attorney General, the increased rates will be effective August 1, 2018; this date comports with the federal law requirement. Pending approval of the proposed changes to the Section 13 State Plan Amendment that were submitted to the Centers for Medicare and Medicaid Services, the increased rates will be implemented with an August 1, 2018 effective date. To remedy the difference between the July 1, 2018 effective date set forth in the Act and the August 1, 2018 date that is permissible pursuant to federal Medicaid law, the Department has recalculated the annual appropriation of funds for this service into a temporary eleven month rate. As such, providers will, over the course of eleven months, receive equivalent aggregate payments as would have been received under a twelve month rate. Beginning on July 1, 2019, rates will be annualized based upon a twelve month appropriation. This is not an effective rate decrease, but rather a redistribution of the annual appropriation over twelve months, rather than eleven months. The retroactive application of the rate increases to August 1, 2018, comports with 22 M.R.S. & 42(8), which authorizes the Department to adopt rules with a retroactive application where there is no adverse impact on providers or members for a period not to exceed eight calendar quarters http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: February 14, 2019 AGENCY CONTACT PERSON: Dean Bugaj, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 EMAIL: Dean.Bugaj@maine.gov TELEPHONE: (207)-624-4045 FAX: (207) 287-1864 TTY users call Maine relay 711
Effective Date: February 14, 2019
View Comments: COMMENTS  Posted: February 14, 2019
 
MaineCare Benefits Manual, Chapters II & III, Section 96, Private Duty Nursing and Personal Care Services WORD  PDF 
Concise Summary: The Department of Health and Human Services adopts these Section 96, Private Duty Nursing and Personal Care Services rules to add or update definitions of Custodial Care, Private Duty Nursing, and Respite Care implement Electronic Visit Verification increase the maximum available Care Coordination units from 18 to 24 per eligibility period clarify that Section 96 services are not available to duplicate other personal care services require that the Plans of Care for members under the age of 21 show the medical necessity of school based nursing services are not provided by a school nurse and to adopt, finally, certain rate increases in conformance with Public Law 2017, An Act Making Certain Supplemental Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government, Part B. P.L. 2017, ch. 459, Part B, required the Department to amend its rules for reimbursement rates for the home-based and community-based personal care services under the provisions of 10-144 C.M.R. ch. 101, MaineCare Benefits Manual, Chapters II & III, Private Duty Nursing and Personal Care Services to reflect the final rates modeled in the February 1, 2016 report Rate Review for Personal Care and Related Services Final Rate Models prepared for the Department by Burns & Associates, Inc. Further, Part B-3 directs the Department to ensure that caps and limitations on home-based and community-based personal care and related services are increased to reflect the increase in reimbursement rates that result from this change, such that Section 96 recipients may not experience a reduction in hours solely as a result of increased reimbursement rates authorized by the Act. This Chapter III adopted rule increases the following rates: G0299 TD (0551)-RN Services G0299 TD UN (0551)-RN Services multiple patients (2) G0299 TD UP (0551)-RN Services-multiple patients (3) G0300 TE (0559)-LPN Services G0300 TE UN (0559)-LPN Services multiple patients (2) G0300 TE UP (0559)-LPN Services multiple patients (3) T1000 TD-Independent RNT1000 TD UN-Independent RN-multiple patients (2) T1000 TD UP-Independent RN multiple patients (3) T1004 (0571)-Home Health Aide/Certified Nursing Assistant Services T1004 UN (0571)-Home Health Aide/Certified Nursing Assistant Services-multiple patients (2) T1004 UP (0571)-Home Health Aide/Certified Nursing Assistant Services multiple patients (3) T1019 (0589)-Personal Support Services T1019-Personal Support Services (PCA Agencies only) T1019 UN-Personal Support Services (PCA Agencies only) multiple patients (2) T1019 UP-Personal Support Services (PCA Agencies only) multiple patients (3) S5125 TF (0589)-PCA Supervisit S5125 TF UN (0589)-PCA Supervisit-multiple patients (2) S5125 TF UP (0589)-PCA Supervisit multiple patients (3) S5125 TF-PCA Supervisit (PCA Agencies only) S5125 TF UN-PCA Supervist (PCA Agencies only) multiple patients (2) S5125 TF UP-PCA Supervisit (PCA Agencies only) multiple patients (3) This Chapter II adopted rule effectuates the following level of care limits in conformance with the rate increases: Level I Level II Level III Level IV Level Level VIII Level IX The Act required the Department to implement immediate rate increases, effective July 1, 2018. However, the Act did not become law until July 9, 2018, following a Legislative override of the Governors veto. Because the Act involves MaineCare reimbursement, the rate increases are also governed by federal Medicaid law. 42 C.F.R. 447.205(d) requires that public notice of changes in reimbursement for State Plan services must be published before the proposed effective date of the change. The Department published its notice of reimbursement methodology change for the Section 96 rates on July 31, 2018. Upon the advice of the Office of the Attorney General, the increased rates will be effective August 1, 2018; this effective date comports with the federal law requirement. Pending approval of the proposed changes to the Section 96 State Plan Amendment that were submitted to the Centers for Medicare and Medicaid Services, the increased rates will be implemented with an August 1, 2018 effective date. There are three separate rate changes and increased level of care limits pending before CMS: one submitted in July 2016 (effective July 29, 2016), one submitted in September 2017 (effective September 6, 2017), and one submitted in July 2018 (effective August 1, 2018); thus, there are three retroactive effective dates applicable for these rates included in Chapter III and level of care limits in Chapter II. To remedy the difference between the July 1, 2018 effective date set forth in the Act, and the August 1, 2018 date that is permissible pursuant to federal Medicaid law, the Department has recalculated the annual appropriation of funds for this service into a temporary eleven month rate. As such, providers will, over the course of eleven months, receive equivalent aggregate payments as would have been received under a twelve month rate. Beginning on July 1, 2019, rates will be annualized (based upon a twelve month appropriation). This is not a rate decrease, but rather a redistribution of the annual appropriation over twelve months, rather than eleven months. On November 13, 2018, the Department adopted an emergency rule to effectuate the increased Section 96 reimbursement rates with a retroactive effective date of August 1, 2018. This rulemaking makes permanent the emergency rule changes. Additional Chapter II changes are adopted and outlined below: 1) Electronic Visit Verification requirements as mandated by Section 12006 of the 21st Century CURES Act (P.L. 114-255) as codified in 42 U.S.C. 1396b(l)(1). 2) Care Coordination units are increased from eighteen to twenty-four hours annually. 3) Duration of Care and Non-Covered Services are updated to clarify that Section 96 services may not duplicate personal care services provided under other identified sections of the MaineCare Benefits Manual. 4) For any members under the age of 21 receiving 1:1 Nursing Services in conformance with the members authorized Plan of Care in a school-based setting, the medical necessity of the services being provided and the inability of the nurse, already on site or one at another district, to provide the medically necessary services must be documented on the members Plan of Care. 5) New definitions added are Custodial Care and Respite Care. 6) The Private Duty Nursing definition has been updated to state when normal life activities take the member outside of his or her residence from required life activities. 7) Grammatical and typographical corrections have been made throughout the policy. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: February 11, 2019 AGENCY CONTACT PERSON: Heidi Bechard, Comprehensive Health Planner AGENCY NAME: Office of MaineCare Services, Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 EMAIL: heidi.bechard@maine.gov TELEPHONE: (207)-624-4074 FAX: (207) 287-1864 TTY users call Maine relay 711
Effective Date: February 11, 2019
View Comments: COMMENTS  Posted: February 11, 2019
 
MaineCare Benefits Manual, Chapters II and III, Section 65, Behavioral Health Services WORD  PDF 
Concise Summary: The Department of Health and Human Services finally adopts these rule changes in 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapters II and III, Section 65, Behavioral Health Services to: (a) ensure broader access to crisis services for adults with intellectual disabilities; and (b) increase the rates of reimbursement for services pursuant to Public Law 2017, ch. 460, An Act Making Certain Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government, Parts D, E and I. Specific changes are as follows: ā€¢ Part D of the Act directs the Department to increase the rate of reimbursement for all Section 65 services to ensure a net increase in funding from fiscal year 2008-09 to fiscal year 2018-2019 of two percent as long as no rate for a service is lower than the rate reimbursed as of January 1, 2018. The Legislature required this increase in reimbursement to be applied to the wages and benefits of employees providing direct services to MaineCare members, and not to administrators or managers. Section 65 providers must document compliance with this requirement in their financial records and provide such documentation to the Department upon request. ā€¢ Part E of the Act directs the Department to increase the reimbursement rate for Section 65 Medication Management services by fifteen percent. This increase is in addition to the two percent increase required by Part D of the Act. ā€¢ Part I of the Act directs the Department to increase the reimbursement rates for Multi-Systemic Therapy (MST), Multi-Systemic Therapy for Problem Sexualized Behaviors (MST-PSB), and Functional Family Therapy by twenty percent. This twenty percent increase, which is in addition to the two percent increase, is effective until June 30, 2019. The Department shall publish a separate notice of change in reimbursement methodology, and seek approval from the Centers for Medicare and Medicaid Services for the Multi-Systemic Therapy and Functional Family Therapy rate changes that go into effect in 2019. Through the Act, the Legislature determined that these facts create an emergency within the meaning of the Constitution of Maine and require the following legislation as immediately necessary for the preservation of the public peace, health and safety. As such, the Act requires the Department to implement immediate rate increases,effective July 1, 2018. However, the Act did not become law until July 9, 2018, following a Legislative override of the Governorā€™s veto. Because the Act involves MaineCare reimbursement, these rule changes are also governed by federal Medicaid law. 42 C.F.R.  § 447.205(d) requires that public notice of changes in reimbursement for State Plan services must be published before the proposed effective date of the change. The Department published its notice of reimbursement methodology change for the Section 65 rates on July 31, 2018. Upon the advice of the Office of the Attorney General, the increased rates will be effective August 1, 2018; this date comports with the federal law requirement. Pending approval of the proposed changes to the Section 65 State Plan Amendment that were submitted to the Centers for Medicare and Medicaid Services, the increased rates will be implemented with an August 1, 2018 effective date. Pursuant to the Legislative determination regarding the urgent need for these reimbursement increases, the Department initially implemented these changes through emergency rulemaking. Similarly, an August 1, 2018 retroactive effective date is necessary to implement these changes as soon as possible. The retroactive application comports with 22 M.R.S.  § 42(8), which authorizes the Department to adopt rules with a retroactive application (where there is no adverse impact on providers or members) for a period not to exceed eight calendar quarters. To remedy the difference between the July 1, 2018 effective date set forth in the Act and the August 1, 2018 date that is permissible pursuant to federal Medicaid law, the Department has recalculated the annual appropriation of funds for this service into a temporary eleven month rate. As such, providers will, over the course of eleven months, receive equivalent aggregate payments as would have been received under a twelve month rate. Beginning on July 1, 2019, rates will be annualized (based upon a twelve month appropriation). Additionally, the Department added certain diagnoses to Crisis Services in Chapter II. The crisis services system for adult developmental services is stressed, as the agency that previously contracted for state funded beds has declined to renew their contract with the Department. The state offers a small amount of crisis beds, but the demand outweighs the supply. Current policy language does not support serving individuals with developmental disabilities. The Department thus broadened the language in Ch. II, Sections 65.06-1, 65.06-2, to extend eligibility to members with developmental disabilities. These rule changes allow any willing and qualified provider of crisis services under Section 65 to offer crisis beds to adult members with developmental disabilities. Additionally, the Department added allowable staff (Direct Support Professionals) to treat this population, as those currently available under Section 65 (MHRT) do not have the education or expertise to effectively treat this population. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: February 11, 2019 AGENCY CONTACT PERSON: Dean Bugaj Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 EMAIL: Dean.Bugaj@maine.gov TELEPHONE: (207)-624-4045 FAX: (207) 287-1864 TTY users call Maine relay 711
Effective Date: February 11, 2019
View Comments: COMMENTS  Posted: February 11, 2019
 
MaineCare Benefits Manual, Chapters II & III, Section 12, Consumer-Directed Attendant Services and Allowances for Consumer-Directed Attendant Services WORD  PDF 
Concise Summary: The Department of Health and Human Services adopts these rules to add a definition of Fiscal Intermediary; replace the phrase Authorized Agent with Authorized Entity; implement Electronic Visit Verification; clarify that personal care services provided under other rules may not be duplicated under Section 12; and to increase reimbursement rates in compliance with Public Law 2017, ch. 459, Part B, An Act Making Certain Supplemental Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government. These rule changes are consistent with P.L. 2017, ch. 459, Part B, which required the Department to amend its rules for reimbursement rates for personal care services provided under the provisions of 10-144 C.M.R. ch. 101, MaineCare Benefits Manual, Chapter III, Section 12, Allowances for Consumer-Directed Attendant Services to reflect the final rates modeled in the February 1, 2016 Rate Review for Personal Care and Related Services: Final Rate Models prepared for the Department by Burns & Associates, Inc. The Act required the Department to implement immediate rate increases, effective July 1, 2018. However, the Act did not become law until July 9, 2018, following a Legislative override of the Governorā€™s veto. Because the Act involves MaineCare reimbursement, the rate changes are also governed by federal Medicaid law. 42 C.F.R.  § 447.205(d) requires that public notice of changes in reimbursement for State Plan services must be published before the proposed effective date of the change. The Department published its notice of reimbursement methodology change for the Section 12 rates on July 31, 2018. Upon the advice of the Office of the Attorney General, the increased rates will be effective August 1, 2018; this effective date comports with the federal law requirement. Pending approval of the proposed changes to the Section 12 State Plan Amendment that were submitted to the Centers for Medicare and Medicaid Services, the increased rates will be implemented with an August 1, 2018 effective date. To remedy the difference between the July 1, 2018 effective date set forth in the Act, and the August 1, 2018 date that is permissible pursuant to federal Medicaid law, the Department has recalculated the annual appropriation of funds for this service into a temporary eleven month rate. As such, providers will, over the course of eleven months, receive equivalent aggregate payments as would have been received under a twelve month rate. Beginning on July 1, 2019, rates will be annualized based upon a twelve month appropriation. This is not a rate decrease, but rather a redistribution of the annual appropriation over twelve months, rather than eleven months. There are four separate rate change requests pending before CMS; one submitted in September 2015 (effective 10/1/15 to 7/28/16), one submitted in July 2016 (effective 7/29/16 to 2/21/17), one submitted in August 2017 (effective 7/1/17 to 6/30/18 and 7/1/18 to 7/31/18), and one submitted in July 2018 (effective from 8/1/18 on); thus, there are four retroactive effective dates applicable for these rates included in Chapter III. On November 13, 2018, the Department adopted an emergency Chapter III rule to effectuate the increased Section 12 reimbursement rates with a retroactive effective date of August 1, 2018. This rulemaking makes permanent the emergency rule changes. In addition, Chapter II changes are adopted, which were proposed on November 21, 2018, and are outlined below: 1) New Definition added for Fiscal Intermediary (FI), which is an organization that provides administrative and payroll services on behalf of members self-directing their personal care services. The FI must have an established contract with the Department. The services of the Fiscal Intermediary are not billable under this section. In addition, the definition of Fiscal Intermediary has been moved to 12.01-11 and subsequent definitions have been renumbered. 2) Authorized Agent is replaced with Authorized Entity throughout the policy. 3) Electronic Visit Verification (EVV) requirements are added effective January 1, 2020 pursuant to Section 12006 of the 21st Century CURES Act (P.L. 114-255), as codified in 42 U.S.C.  § 1396b(l)(1). 4) Clarification that personal care services provided under other Sections of the MaineCare Benefit Manual may not be duplicated under Section 12. 5) Grammatical and typographical corrections have been made throughout the policy. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: February 11, 2019 AGENCY CONTACT PERSON: Heidi Bechard, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 EMAIL: heidi.bechard@maine.gov TELEPHONE: (207)-624-4074 FAX: (207) 287-1864 TTY users call Maine relay 711
Effective Date: February 11, 2019
View Comments: COMMENTS  Posted: February 11, 2019
 
MaineCare Benefits Manual, Chapters II and III, Section 26 WORD  PDF 
Concise Summary: The Department adopts this rule pursuant to P.L. 2017, ch. 460, Part B-2, An Act Making Certain Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government. Part B-2 requires the Department to amend its rules to increase reimbursement rates for adult family services, adult day services, and homemaker services for the fiscal year ending June 30, 2019, by ten percent. Part B-2 also requires that effective July 1, 2019, payment rates attributable to wages and salaries for personal care and related services will be increased annually by an inflation adjustment cost-of-living percentage in accordance with the United States Department of labor, Bureau of Labor Statistics Consumer Price Index, medical care services (professional services, nursing home and adult day care services) from the prior December. These cost of living increases shall continue annually until the Department has completed a rate study for adult family care services, adult day services, or homemaker services and the rates in the rate study have been implemented. On November 20, 2018, the Department adopted emergency rules implementing the ch. 460 rate increases with a retroactive August 1, 2018 effective date. This rulemaking permanently adopts the emergency rule changes. In addition, this rulemaking adopts the ch. 460, Part B-2 requirement that effective July 1, 2019, payment rates attributable to wages and salaries for personal care and related services will be increased annually by an inflation adjustment cost-of-living percentage in accordance with the United States Department of Labor, Bureau of Labor Statistics Consumer Price Index, medical care services (professional services, nursing home and adult day care services) from the prior December. These cost of living increases shall continue annually until the Department has completed a rate study for adult family care services, adult day services, or homemaker services, and the rates in the rate study have been implemented. Through the Act, the Legislature determined that these facts create an emergency within the meaning of the Constitution of Maine and require the following legislation as immediately necessary for the preservation of the public peace, health, and safety. As such, the Act requires the Department to implement immediate rate increases effective July 1, 2018. However, the Act did not become law until July 9, 2018, following a Legislative override of the Governorā€™s veto. Because the Act involved MaineCare reimbursement, these rule changes are also governed by federal Medicaid law, 42 C.F.R. § 447.205(d) requires that public notice of changes in reimbursement for State Plan services must be published before the proposed effective date of the change. The Department published its notice of reimbursement methodology change for the Section 26 rate on July 31, 2018. Upon the advice of the Office of the Attorney General, the increased rates will be effective August 1, 2018, which effective date comports with the federal law requirement. Pending CMS approval of the rate increase, the increased rate will be implemented with an August 1, 2018 effective date. The retroactive effective date is allowable under 22 M.R.S. § 42(8), which authorizes the Department to adopt rules with a retroactive application where there is no adverse impact on providers or members for a period not to exceed eight calendar quarters. To remedy the difference between the July 1, 2018 effective date set forth in the Act, versus the August 1, 2018 date is permissible pursuant to federal Medicaid law, the Department has recalculated the annual appropriation of funds for this service into a temporary eleven-month rate. As such, providers will, over the course of eleven months, receive equivalent aggregate payments as would have been received under a twelve-month rate. Beginning on July 1, 2019, rates will be annualized (based upon a twelve-month appropriation). This is not an effective rate decrease, but rather a redistribution of the annual appropriation over twelve months, rather than eleven months. The Department is seeking, and anticipates receiving, approval from the Centers for Medicare and Medicaid Services for these rate changes. Pending CMS approval, the rate increase will be effective retroactive to August 1, 2018. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: February 12, 2019 AGENCY CONTACT PERSON: Anne E. Labonte, Comprehensive Health Planner II AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 EMAIL: Anne.Labonte@maine.gov TELEPHONE: (207)-624-4082 FAX: (207) 287-1864 TTY users call Maine relay 711
Effective Date: February 12, 2019
View Comments: COMMENTS  Posted: February 11, 2019
 
MaineCare Benefits Manual, Chapter II, Section 29, Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF 
Concise Summary: The Department is adopting this routine technical rule in accordance with P.L 2017, ch. 459, An Act Making Certain Supplemental Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government. This Act provides funding to increase rates for specific procedure codes in Chapter III, Section 29. Part B of the Act provided that the Department ensure that caps and limitations on services "are increased to reflect increases in reimbursements that result from this Part." On September 12, 2018, the Department adopted an emergency major substantive rule for Section 29, Ch. III, as directed in the Act, to increase reimbursement rates for eighteen procedure codes, with a retroactive effective date of July 1, 2018. In accordance with Part B of the Act, the Department adopted an emergency rule for Chapter II to increase caps in Section 29 to reflect those rate increases. The emergency rulemaking is effective for 90 days. This adopted rulemaking follows the rule proposal on November 6, 2018 to adopt these cap increases permanently. The increased caps will be effective retroactive to July 1, 2018. The retroactive application comports with 22 M.R.S. § 42(8), which authorizes the Department to adopt rules with a retroactive application for a period not to exceed eight calendar quarters, and there is no adverse financial impact on any MaineCare member or provider. In addition, the Department sought, and obtained approval, from the Centers for Medicare and Medicaid Services to submit a waiver amendment making the rate changes retroactive to July 1, 2018. The adopted rule includes the following cap changes: Limits • 29.07-2: Raised annual limit for members who receive Home Support, Community Support, or Shared Living from $52,425.00 to $58,168.50. • 29.07-6: Raised limit for Respite Services from $1,100.00 per year to $1,224.60. • 29.07-6: Raised the per diem limit for quarter hour Respite billing from $90.00 to $110.21 for each date of service. In addition, the Department adopts the following changes to this rule: Provider Qualifications and Requirements • 29.10: Added reference to Adult Protective reporting requirements. • 29.10-1(C): Updated reference to rules governing Reportable Events (14-197 CMR Ch. 12) and added Adult Protective Services System (10-149 CMR Ch. 1). • 29.10-1(C): Deleted the requirement for grievance training to occur before working with members. • 29.10-4, Electronic Visit Verification: Added a requirement for Electronic Visit Verification, consistent with the requirements of Section 12006 of the 21st Century CURES Act, as codified in § 42 U.S.C. 1396b(l)(1). THIS CHANGE REQUIRES CMS APPROVAL, BUT IS EFFECTIVE PENDING APPROVAL. • 29.10-5: Wording corrections for clarity. • 29.10-6: Sentence deleted to make Section 29 requirements consistent with those in Section 21. • 29.10-8: Reportable Events & Behavioral Treatment: o Updated reference to rules governing Reportable Events (14-197 CMR Ch. 12) and added Adult Protective Services System (10-149 CMR Ch. 1). Appendix IV • Reports of Abuse, Neglect, or Exploitation: Updated reference to rules governing Reportable Events (14-197 CMR Ch. 12) and Adult Protective Services System (10-149 CMR Ch. 1). The adopted rule also includes technical corrections and formatting updates for clarity. for rules and related rulemaking documents.
Effective Date: February 4, 2019
View Comments: COMMENTS  Posted: February 4, 2019
 
MaineCare Benefits Manual, Chapters II and III, Section 2, Adult Family Care Services WORD  PDF 
Concise Summary: The Department adopts this rule pursuant to P.L. 2017, ch. 460, An Act Making Certain Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government, Part B-2. The Act requires the Department to amend its rules to increase reimbursement rates for adult family services, adult day services, and homemaker services for the fiscal year ending June 30, 2019, by ten percent and directs that MaineCare payment rates for state fiscal year ending June 30, 2020 and each year thereafter be increased by an inflation adjustment cost-of-living percentage in accordance with the United States Department of Labor, Bureau of Labor Statistics Consumer Price Index medical care services index from the prior December for professional services, nursing home and adult day care services. These cost of living increases shall continue annually until the Department has completed a rate study for adult family care services and the rates in the rate study have been implemented. This rulemaking increases the rates for Adult Family Care Homes and Adult Family Care Homes Remote Island. The Act requires that the increased rates must be attributed directly to the wages and salaries of the professional staff delivering the personal care and related services to members. This rulemaking also clarifies that the increased reimbursement rates shall not negatively affect membersā€™ caps on services. As such, the Department implements changes in Chapter II, Section 2, Sections 2.05-2 and 2.05-3 to clarify that the increased reimbursement provided herein shall not be counted towards membersā€™ financial caps for services until Section 96 or under the waiver programs. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: February 4, 2019
View Comments: COMMENTS  Posted: February 4, 2019
 
MaineCare Benefits Manual, Chapter III, Section 23, Developmental and Behavioral Clinic Services WORD  PDF 
Concise Summary: The Department of Health and Human Services adopts this rule pursuant to P.L. 2017, ch. 460, Part D, An Act Making Certain Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government. Part D-1 requires the Department increase the rates of reimbursement for Section 23, Development and Behavioral Clinic Services, to ensure a net increase in funding from fiscal year 2008-2009 to fiscal year 2018-2019 of two percent as long as no rates for a service is lower than the rate reimbursed as of January 1, 2018. This adopted rulemaking requires that the increase in reimbursement rates must be applied to wages and benefits for employees who provide direct services as required by Part D-2 of P.L. 2017, ch. 460. In compliance with the law, providers must ensure that increase in reimbursement rates effective August 1, 2018, is applied in full to wages and benefits to employees who provide direct services. Providers must document compliance with this requirement in their financial records and provide such documentation to the Department upon request. On November 6, 2018, the Department adopted emergency rules adopting the rate increases. This rulemaking permanently adopts the emergency rule changes. Through the Act, the Legislature determined that these facts create an emergency within the meaning of the Constitution of Maine and require the following legislation as immediately necessary for the preservation of the public peace, health and safety. As such, the Act requires the Department to implement immediate rate increases,effective July 1, 2018. However, the Act did not become law until July 9, 2018, following a Legislative override of the Governorā€™s veto. Because the Act involves MaineCare reimbursement, these rule changes are also governed by federal Medicaid law. 42 C.F.R. 447.205 d requires that public notice of changes in reimbursement for state plan services must be published before the proposed effective date of the change. The Department published its notice of reimbursement methodology change for the Section 23 rates on July 31, 2018. Upon the advice of the Office of the Attorney General, the increased rates will be effective August 1, 2018, which effective date comports with the federal law requirement. Pending approval of the proposed changes to the Section 23 state plan amendment that were submitted to the Centers for Medicare and Medicaid Services, the increased rates will be implemented with an August 1, 2018 effective date. Pursuant to the Legislative determination regarding the urgent need for these reimbursement increases, the requirements of 5 M.R.S.  §8054(1) are satisfied and emergency rulemaking is appropriate. Similarly, an August 1, 2018 retroactive effective date is necessary to implement these changes as soon as possible. The retroactive application comports with 22 M.R.S. 42(8), which authorizes the Department to adopt rules with a retroactive application (where there is no adverse impact on providers or members) for a period not to exceed eight calendar quarters. To remedy the difference between the July 1, 2018 effective date set forth in the Act, versus the August 1, 2018 date that is permissible pursuant to federal Medicaid law, the Department has recalculated the annual appropriation of funds for this service into a temporary eleven month rate. As such, providers will, over the course of eleven months, receive equivalent aggregate payments as would have been received under a twelve month rate. Beginning on July 1, 2019, rates will be annualized (based upon a twelve month appropriation). This is not an effective rate decrease, but rather a redistribution of the annual appropriation over twelve months, rather than eleven months. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: February 3, 2019 AGENCY CONTACT PERSON: Thomas M Leet, Comprehensive Health Planner II AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 EMAIL: Thomas.Leet@maine.gov TELEPHONE: (207)-624-4068 FAX: (207) 287-1864 TTY users call Maine relay 711
Effective Date: February 3, 2019
View Comments: COMMENTS  Posted: February 1, 2019
 
MaineCare Benefits Manual, Section 19, Chapter III, Home and Community Benefits for the Elderly and Adults with Disabilities WORD  PDF 
Concise Summary: The Department is adopting this routine technical rule in accordance with P.L. 2017, ch. 459, Part B, An Act Making Certain Supplemental Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government. The Act requires the Department to amend its rules for reimbursement rates for home-based and community-based personal care and related services provided under the provisions of 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapter III, Section 19, Home and Community Benefits for the Elderly and for Adults with Disabilities and referenced in the February 1, 2016 report ā€œRate Review for Personal Care and Related Services: Final Rate Modelsā€ prepared for the Department by Burns & Associates, Inc. These increased rates will be effective retroactive to July 1, 2018. On October 9, 2018, the Department adopted these rate increases via emergency rulemaking, with a retroactive effective date of July 1, 2018. In this rulemaking the Department is now permanently adopting these Section 19 rule changes. The adopted rule increases rates for 30 procedure codes. In addition, the rule adds in the code and rate for Home Health Aide Visitā€”Home Health Services, which was inadvertently deleted during final adoption of this rule in January 2018. These increased rates will be effective retroactive to July 1, 2018. The Department has determined that a retroactive increase to the beginning of the state fiscal year is appropriate, since the appropriation is intended for the entire fiscal year. The retroactive application comports with 22 M.R.S. § 42(8) which authorizes the Department to adopt rules with a retroactive application for a period not to exceed eight calendar quarters and there is no adverse financial impact on any MaineCare member or provider. In addition, the Department sought, and obtained approval, from the Centers for Medicare and Medicaid Services to submit a waiver amendment making the rate changes retroactive to July 1, 2018. In addition to this adopted rulemaking for Section 19, Ch. III, the Department is simultaneously adopting rules for Sec. 19, Ch. II, which rulemaking raises the program cap, in accordance with the Act. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: January 7, 2019
View Comments: COMMENTS  Posted: January 7, 2019
 
MaineCare Benefits Manual, Section 19, Ch. II, Home and Community Benefits for the Elderly and Adults with Disabilities WORD  PDF 
Concise Summary: The Department is adopting this rule in accordance with P.L. 2017, ch. 459, An Act Making Certain Supplemental Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government. This Act provides funding to increase personal care and related services provided under Section 19. The Act further directs the Department to “ensure that caps and limitations on home-based and community-based services are increased to reflect increases in reimbursement rates that result from this Part,” and that “A recipient of services may not experience a reduction in hours solely as a result of increased reimbursement” (Act, Sec. B-3). The Department is adopting rules for Sec. 19, Ch. III, as directed in the Act, and increasing personal care and related rates, simultaneously with the adoption of these Ch. II rules. In accordance with the Act, therefore, this Ch. II rulemaking raises the program cap to $5,425.00 per member per month (Section 19.06(A)). On October 9, 2018, the Department adopted the increased cap through emergency rulemaking. This rulemaking permanently adopts the emergency cap increase. In addition, the Department adopts the following changes to this rule: 1. Adds a requirement for Electronic Visit Verification, consistent with the requirements of Section 12006 of the 21st Century CURES Act (P.L. 114-255), as codified in 42 U.S.C. 1396b(l)(1). THIS CHANGE REQUIRES CMS APPROVAL, BUT IS EFFECTIVE PENDING APPROVAL. 2. Adds an exception to the Limit of 40 hours week of service by an individual worker that is reimbursable. The exception is for a member who is at risk for institutionalization unless the individual worker can be reimbursed for more than 40 hour week. The provision sets forth criteria for the Department to consider in its evaluation of the request. The provision also adds that the Department’s decision must be in writing, and given to the member. Members can appeal an adverse decision. This exception language is required pursuant to the Settlement Agreement in Roy v. Dept. of Health and Human Services, U.S. Dist. Ct., D. Me., Civil No. 1:16-cv-00592-NT. THIS CHANGE REQUIRES CMS APPROVAL BUT IS EFFECTIVE PENDING APPROVAL. 3. Deletes a provision in 19.02-3(H) that provided that a portion of the member capacity for this Section 19 service would be reserved for members eligible and participating in the Department’s Follow the Money Homeward Bound program. The Department is deleting this provision since there is no waiting list for the Section 19 service, and so it is unnecessary to reserve capacity. In addition, the Department will shortly submit an amendment to the Section 19 waiver which will significantly increase the number of funded openings for Section 19 services over the next five years. CMS HAS APPROVED THIS CHANGE. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: January 7, 2019
View Comments: COMMENTS  Posted: January 7, 2019
 
PROVISIONALLY ADOPTED MAJOR SUBSTANTIVE RULE MaineCare Benefits Manual, Chapter III, Section 29, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF 
Concise Summary: This is a PROVISIONALLY ADOPTED MAJOR SUBSTANTIVE RULE and requires Legislative approval prior to final adoption. On September 12, 2018 the Department adopted an Emergency Major Substantive Rule to comply with P.L. 2017, ch. 459 An Act Making Certain Supplemental Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government, which required the Department to increase Ch. III, Sec. 29 reimbursement rates by rulemaking for the specific procedure codes in equal proportion to the funding provided for that purpose. These increased rates will be effective retroactive to July 1, 2018, as directed by the Act. The retroactive application of this rule comports with 22 M.R.S. Sec. 42(8) which authorizes the Department to adopt rules with a retroactive application for a period not to exceed 8 calendar quarters and there is no adverse financial impact on any MaineCare member or provider. In addition, the Department sought, and obtained, approval by the Center for Medicare and Medicaid Services, CMS, to be able to submit a waiver amendment that will make the rate increases for these Medicaid waiver services retroactive to July 1, 2018. In this rulemaking, the Department is provisionally adopting rules to make permanent the September 12, 2018 rate increases. Pursuant to 5 M.R.S. 8072, the Department will submit this provisionally adopted rule to the Maine Legislature for its review and action. Although this rule will not be effective until it is finally adopted by the Department pursuant to Legislative review and action, the September 12, 2018 emergency major substantive rule remains in effect pending Legislative action and final adoption. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: December 16, 2018 AGENCY CONTACT PERSON: Trista Collins, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 EMAIL: Trista.Collins@maine.gov TELEPHONE: (207)-624-4094 FAX: (207) 287-1864 TTY users call Maine relay 711
Effective Date: December 16, 2018
View Comments: COMMENTS  Posted: December 14, 2018
 
PROVISIONALLY ADOPTED Chapter III, Section 21, Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF 
Concise Summary: This is a PROVISIONALLY ADOPTED MAJOR SUBSTANTIVE RULE, and requires Legislative approval prior to final adoption. On September 11, 2018, the Department adopted an emergency major substantive rule to comply with P.L. 2017, ch. 459 An Act Making Certain Supplemental Appropriations and Allocations and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government, which required the Department to increase Ch. III, Sec. 21 rates by rulemaking for the specific procedure codes in equal proportion to the funding provided for that purpose. In addition to the 33 rate increases required by P.L. 2017, ch. 459, the Department has also increased the rate for a 34th procedure code ā€“ T2017 QC ,Home Support, Habilitation, residential, waiver ā€“ Remote Support ā€“ Monitor only. Pursuant to the September 11, 2018 emergency major substantive rule the increased rates are effective retroactive to July 1, 2018. In this rulemaking, the Department is provisionally adopting rules to make permanent the September 11, 2018 rate increases. Pursuant to 5 M.R.S. 8072, the Department will submit this provisionally adopted rule to the Maine Legislature for its review and action. Although this rule will not be effective until it is finally adopted by the Department pursuant to Legislative review and action, the September 11, 2018 emergency major substantive rule remains in effect pending Legislative action and final adoption. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: December 16, 2018 AGENCY CONTACT PERSON: Trista Collins, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 EMAIL: Trista.Collins@maine.gov TELEPHONE: (207)-624-4094 FAX: (207) 287-1864 TTY users call Maine relay 711
Effective Date: December 16, 2018
View Comments: COMMENTS  Posted: December 14, 2018
 
MaineCare Benefits Manual, Chapters II and III, Section 107 Psychiatric Residential Treatment Facility Services WORD  PDF 
Concise Summary: This rulemaking adopts a new section of policy describing Psychiatric Residential Treatment Facilities (PRTF) services and reimbursement for such services. PRTFs are Medicaid services authorized and governed under: 42 U.S.C.  § 1396d(a)(16) and (h) and 42 C.F.R. 441 Subpart D and 42 C.F.R.483 Subpart G. The services are offered only to members under the age of 21. NOTE: The Department will seek approval from CMS for the PRTF service. The service will not be offered, and this rule will not become effective, until CMS has approved. Upon CMS approval, the Department will issue notice to the Secretary of State and Interested Parties informing of CMS approval pursuant to Title 5  §8052(6). The rule describes the PRTFsā€™ covered services, policies and procedures, standards, and reimbursement methodology. This service is intended to address a current gap in Maineā€™s offering of behavioral health services to youth under the age of 21. The PRTF is being created to specifically support Maineā€™s most vulnerable youth, including: youth in out of state placement, youth stranded in psychiatric hospitalization with no safe discharge option, youth stranded in emergency rooms with no safe placement, and incarcerated youth in need of mental health treatment. This rule was developed by a multidisciplinary team including members from the Office of Child and Family Services, the Department of Education, the Department of Corrections, Maine Centers for Disease Control and Prevention, and the Office of MaineCare services. The development of this policy included stakeholder input. A public hearing was held on May 21, 2018, and, in addition, public comments were received. This service will be reimbursed using a statewide per diem rate for medical, clinical and direct care costs (direct care services) and using a facility-specific rate for routine and fixed costs (room and board costs). The routine and fixed costs facility rate is informed by annual cost reporting performed by providers using a state-developed cost report form. The medical, clinical and direct care per diem rate is not cost settled. The routine and fixed cost rate is cost settled by the Department based on allowable fixed and routine costs. The Department has issued notice to the Legislature prior to rulemaking adoption and complies with 34-B M.R.S.  § §15002 (Childrenā€™s Mental Health Services). As a result of public comments and review by the Office of the Attorney General, the Department has deleted the utilization of chemical restraints in this service. The Department added language for Medication Pro Re Nata (PRN), which clarifies that PRN medication may not be utilized as a chemical restraint. The Department added language to clarify that this rulemaking complies with the following regulations: the Rights of Recipients of Mental Health Services who are Children in Need of Treatment by a Provider, 14-172 C.M.R. ch. 1, and also the Rights of Recipients of Mental Health Services, 14-193 C.M.R. ch. 1. These changes were adapted to ensure compliance with all state and federal regulation and to ensure members are afforded the highest level of protections. At the same time it is adopting this rulemaking, the Department is also adopting new licensing rules, which will govern the licensing of PRTFs. Those rules are the Childrenā€™s Residential Care Facilities Licensing Rule, 10-144 C.M.R. ch. 36. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: The rule will become effective upon CMS approval AGENCY CONTACT PERSON: Dean Bugaj, Comprehensive Health Planner Dean.Bugaj@maine.gov AGENCY NAME: Division of Policy ADDRESS: 242 State Street, 11 State House Station Augusta, Maine 04333-0011 TELEPHONE: (207)-624-4045 FAX: (207) 287-1864 TTY users call Maine relay 711
Effective Date: October 3, 2018
View Comments: COMMENTS  Posted: October 3, 2018
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services WORD  PDF 
Concise Summary: The Department adopts this rule pursuant to Resolves 2017, ch. 41, Resolve, Regarding Medicaid Reimbursement for Rehabilitation Hospitals. The adopted rule amends the Department of Health and Human Services Rule, Chapter 101, MaineCare Benefits Manual, Chapter III, Section 45.06, to increase the Medicaid per discharge reimbursement rate provided to rehabilitation hospitals to fifteen-thousand, one-hundred, sixty-one dollars and forty-three cents ($15,161.43) and reduces the total hospital supplemental pool as described in Section 45.07, by four-hundred thousand dollars ($400,000). This rule also amends Section 45.13-2, Additional Eligibility Requirements for Acute Care Hospitals, reverting to the use of Interim Cost Reports, rather than Final Cost Reports, for purposes of determining whether a hospital is a Disproportionate Share Hospital in a payment year. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: October 1, 2018
View Comments: COMMENTS  Posted: October 1, 2018
 
MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures WORD  PDF 
Concise Summary: The Department of Health and Human Services (ā€œthe Departmentā€) adopts this rule pursuant to P.L. 2017, ch. 442, An Act To Clarify Liability Pertaining to the Collection of Debts of MaineCare Providers by the Department of Health and Human Services. This rulemaking removes the following language from Section 1.12-2: ā€œThe liability for debts owed to the Department by the Provider is enforceable against the Provider, including any person who has an ownership or control interest in the Provider, and against any officer, director, or member of the Provider who, in that capacity, is responsible for any control or any management of the funds or finances of the provider. Personal liability against an officer, director, or member of the Provider described in this section shall be limited to debts owed to the Department occurring or arising during that personā€™s employment or affiliation with the Provider or to any debts which become known to such a person and not voluntarily disclosed by that person to the Department. Individuals or entities with an ownership or control interest in the provider include: 1) Those with an ownership interest, meaning those in possession of equity in the capital, the stock, or the profits of the provider. 2) Those with an indirect interest, meaning those with an ownership interest in an entity that has an ownership interest in the provider.ā€ The Department has determined to not adopt the proposed change of adding an Appendix #3 (ā€œDuplication Tableā€) to this rule. Concerns and questions about this Duplication Table were raised in written comments to the rulemaking, as well as from the Office of the Attorney General during its review of the rule. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: September 17, 2018 AGENCY CONTACT PERSON: Thomas M Leet, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 Email: Thomas.Leet@maine.gov TELEPHONE: (207)-624-4068 FAX: (207) 287-1864 TTY users call Maine relay 711
Effective Date: September 17, 2018
View Comments: COMMENTS  Posted: September 12, 2018
 
Chapter II, Section 60, Medical Supplies and Durable Medical Equipment WORD  PDF 
Concise Summary: The Department is adopting changes in this rule, as set forth below. The changes include the following: a) Updates the definition of DME to align with 42 C.F.R §440.70 (b)(3)(ii); b) Adds a storefront exclusion and reimbursement methodology for manufacturers of specialty modified low protein foods and formulas for the purpose of allowing these manufacturers to bill the Department as the supplier of prescription metabolic foods; c) Removes language implying absolute exclusions of DME items as this is no longer allowable per 42 C.F.R §440.70; d) Adds repair/replacement language for APAP, CPAP and BiPAP devices greater than or equal to five (5) years old. e) Removes the list of items considered MaineCare-covered for members residing within a Nursing Facility (NF) or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) to eliminate confusion of covered and non-covered items for members residing within a NF or ICF-IID; f) Further defines limitations for orthopedic shoes and other supportive devices for members twenty-one (21) years of age and older to provide clarity of covered services; g) Updates limits and requirements for disposable non-sterile gloves when supplied in conjunction with incontinence supplies to cost-effectively manage this covered service; h) Increases the allowance of supplies per dispense to ninety-days (90) for items MaineCare considers to be disposable DME; i) Updates reimbursement methodology to align with Medicare for Medicare covered DME impacted by the 21st Century Cures Act, and further clarify the methodology by which other rates are set, including non-Medicare covered codes, Medicare covered codes not impacted by the 21st Century Cures Act, specialty modified low protein foods and incontinence supplies; j) Adds language surrounding guidelines, requirements and quality measures for incontinence supplies provided to MaineCare members; k) Removes parenteral solutions from section 60.05-13, Medical Supplies and DME Not Covered for Members in an NF or ICF- IID; l) Corrects and/or deletes outdated references and website addresses and, m) Edits and minor language updates for clarification purposes. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: June 13, 2018
View Comments: COMMENTS  Posted: June 12, 2018
 
MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF 
Concise Summary: The Department is finally adopting this major substantive rule in accordance with P.L. 2017, ch. 284, Sec. MMMMMMM-2. P.L. 2017, ch. 284 provides funding to increase reimbursement rates for 23 procedure codes in Chapter III, Section 21. The legislation directed the Department to increase the rates for the specific procedure codes in equal proportion to the funding provided for that purpose. In addition to the rate increases required by P.L. 2017, ch. 284, the Department is also increasing the rate for a 24th procedure code to create consistency among similar services within the waiver. These increased rates will be effective retroactive to July 1, 2017. The Legislature did not appropriate additional funding for these rate increases beyond June 30, 2018; therefore, rates will revert to their current levels (pre-July 1, 2017) on July 1, 2018. In creating the rates for the 24 codes, the Department examined utilization of these services, and then calculated rates to ensure parity between Section 21 and Section 29, to lessen administrative complications for providers. On September 29, 2017, the Department adopted an emergency major substantive rule which increased reimbursement rates with a retroactive application date of July 1, 2017. The Department then engaged in proposed rulemaking for Ch. III, Section 21, pursuant to 5 M.R.S. § 8072(1). On January 12, 2018 the Department provisionally adopted the rule. Subsequently, the Department submitted the provisionally adopted rule to the Maine State Legislature for its review, in accordance with 5 M.R.S. § 8072. The Maine State Legislature authorized final adoption of the January 12, 2018 provisionally adopted rule “only if in Section 2000 of the rule, relating to audit of services provided, the documentation requirement for staffing schedules per member is removed and replaced with a requirement that the documentation show the hours and the name of the direct care staff scheduled to work at the facility.” Resolves 2017, ch. 35, was approved by the Governor on March 26, 2018. The final adopted major substantive rule makes the permanent change to Section 2000 as required by the Legislature. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: June 1, 2018
View Comments: COMMENTS  Posted: May 16, 2018
 
MaineCare Benefits Manual, Section 29, Chapter III, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF 
Concise Summary: The Department is adopting this rule in accordance with P.L. 2017, ch. 284 (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, 2018 and June 30, 2019), §§§ ZZZZZZZ-9, MMMMMMM-2, which provided funding to increase reimbursement rates for 16 procedure codes in Chapter III, Section 29, and directed the Department – via major substantive rulemaking – to increase the rates for the specific procedure codes in equal proportion to the funding provided. The Department has also increased the rate for a 17th procedure code in order to create consistency among similar services within the waiver. These rates will be effective retroactive to July 1, 2017. Funding for these rate increases was only appropriated for SFY18. The Legislature did not appropriate additional funding for these rates beyond June 30, 2018; therefore, rates increased for SFY18 will revert to their current levels (pre-July 1, 2017) on July 1, 2018. In accordance with Part III, Sec. TTTT-1 of the Act and 5 M.R.S. §§ 8054, 8073, the Department adopted an emergency major substantive rule effective October 1, 2017, and retroactive to July 1, 2017. The Department then engaged in proposed rulemaking for Ch. III, Section 29, pursuant to 5 M.R.S. § 8072(1), provisionally adopting a rule on January 12, 2018, to make the emergency changes permanent. The Department submitted the provisionally-adopted rule to the Legislature, which authorized adoption of the rule pursuant to Resolves 2017, ch. 33. This emergency legislation was approved by the Governor and took effect on March 7, 2018. The October 1, 2017 Emergency Major Substantive Rule will expire upon the effective date of this rule — May 13, 2018. In creating the rates for the codes covered by this rate increase, the Department examined utilization of these services, and then calculated rates to ensure parity between Section 29 and Section 21, to lessen administrative complications for providers. In addition, the Department has added two procedure codes for Shared Living services. The Department adopted an emergency rule and subsequently a final adopted rule (effective December 28, 2017) for Chapter II, Section 29 to add this benefit as a covered service for members. These rates are consistent with the rates for the same services under Section 21, and include increased rates for SFY18 that will revert to their current levels (pre-July 1, 2017) pursuant to P.L. 2017, ch. 284. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: May 13, 2018
View Comments: COMMENTS  Posted: April 25, 2018
 
MaineCare Benefits Manual, Chapter II and III, Section 92, Behavioral Health Home Services WORD  PDF 
Concise Summary: This rule is being adopted to institute pay-for-performance in the Behavioral Health Home program by making one percent of Behavioral Health Home Organization (BHHO) total Per Member Per Month (PMPM) payments subject to recoupment if the BHHO does not achieve a minimum level of quality, as defined by performance on Department-defined quality measures related to chronic disease management. The rulemaking formally adopts an increased reimbursement rate for BHHOs. Effective retroactive to January 1, 2016, the reimbursement rate for BHHOs is $394.40 per member per month (PMPM) for both adult and child members. The new rates are the result of a comprehensive and public rate review conducted by Burns & Associates, Inc. Additional changes include: • Clarifications have been made to the provider requirements and how they are different from covered services. The Department believes these changes will assist providers in determining when they have met service delivery requirements. • Member Eligibility has been updated to require the Child and Adolescent Needs and Strengths (CANS) assessment to be reviewed and updated by the BHH a minimum of every one hundred and eighty (180) days. It also requires that all relevant CANS domains must be entered in the Maine ASO database, or approved equivalent data system, and that this information be used to inform and guide in the development of the plan of care. • Enrollment has been changed to an opt-in model with a certification process. This model and the new requirements are intended to ensure that members are counseled on the various services for which they are eligible and that duplicative services are avoided. The rule clarifies language around duplication of services, and adds Opioid Health Homes as a service which is considered duplicative for both adults and children. • More clearly defines what the Department expects to be core components of service delivery and removes separate reporting requirement of the Health Home Provider Functional Requirements. • The addition of Referral to Community and Social Support Services is made to align with the Maine State Plan. • Removes the one-hour minimum billable activity requirement from the minimum requirements for reimbursement and replaces it with the requirement that at least one of the monthly services must include a member encounter. The change to the one-hour minimal billable activity requirement was discussed in the 2015 independent rate study which resulted in the higher BHH PMPM payment. Please refer to the following hyperlink to view the adopted rule. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: April 21, 2018
Effective Date: April 21, 2018
View Comments: COMMENTS  Posted: April 17, 2018
 
MaineCare Benefits Manual, Chapter I, Section 4, Telehealth Services WORD  PDF 
Concise Summary: The Department is adopting the following changes to Chapter I, Section 4, Telehealth Services. First, in Section 4.07-2, Paragraph B(5), the Department formally changed the provision in order to allow Telehealth Services to be included in the scope of practice of a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Indian Health Center (IHC), as approved by Health Resources and Services Administration (HRSA) and the State. These facilities will now be able to serve as the provider site and bill under their encounter rate. The Department is adopting this change retroactive to April 16, 2016. Second, pursuant to P.L. 2017, ch. 307, which enacted 22 M.R.S. § 3173-H, the Department removed the telemonitoring requirement that members have had two or more hospitalizations or Emergency Department visits in the past year; instead, for telemonitoring services, a member’s record must only reflect a risk of hospitalization or admission to an emergency room. Finally, as a result of public comments and further review by the Department and the Office of the Attorney General, there were two terms removed and replaced in the rule for clarity. Also, there were additional technical changes, formatting updates, and changes to language in the rule. The Summary of Public Comments and Department Responses document identifies changes that were made to the final rule. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: April 9, 2018
View Comments: COMMENTS  Posted: April 6, 2018
 
MaineCare Benefits Manual, Chapter VII, Section 5, Estate Recovery WORD  PDF 
Concise Summary: This rulemaking adds new timeline language to different sections in the Estate Recovery policy to help the Third Party Liability unit enforce the policy. This rulemaking also rewrites the Hardship Waiver and Care Given Exemption sections to assure that there are no gaps in the policy allowing personal representatives to avoid liability or responsibility and increases the effectiveness of the policy. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: March 7, 2018
View Comments: COMMENTS  Posted: March 6, 2018
 
MaineCare Benefits Manual, Chapters II & III, Section 96, Private Duty Nursing and Personal Care Services WORD  PDF 
Concise Summary: The Department of Health and Human Services adopts these rule changes to Chapters II & III, Section 96, Private Duty Nursing and Personal Care Services to comply with Public Law 2017, ch. 284, Part MMMMMMM-1, 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, 2018 and June 30, 2019. These rule changes are consistent with P.L. 2017, ch. 284, Part MMMMMMM-1, which requires the Department to amend its rules for reimbursement rates for home-based and community-based personal care and related services referenced in the February 1, 2016 report “Rate Review for Personal Care and Related Services: Final Rate Models” prepared for the Department by Burns & Associates, Inc., which includes Section 96 services, and also increases level of care caps. Further, Part MMMMMMM-1 directs the Department that the increase in rates of reimbursement must be applied in equal proportion to all home-based and community-based personal care and related services referenced in the Burns & Associates, Inc., report using the funding provided for that purpose in Chapter 284. Chapter 284 provides funding to increase rates. See Part ZZZZZZ, Section ZZZZZZ-9. In addition, Part MMMMMMM-1 directs the Department to ensure caps and limitations in home-based and community-based personal care and related services are increased to reflect the increases in reimbursement rates that result from this section. On November 14, 2017, the Department adopted emergency rules to effectuate the increased reimbursement rates to Chapter III, with a retroactive application date of July 1, 2017, and also adopted increases to the level of care caps in Chapter II, also with a retroactive application date of July 1, 2017. These rulemakings make permanent the emergency rule changes. The Department determined that retroactive application dates for both the reimbursement rate increases and the increases to the level of care caps was appropriate, since the appropriation was intended for the entire fiscal year. The retroactive application of these rules comports with 22 M.R.S. § 42(8) which authorizes the Department to adopt rules with a retroactive application for a period not to exceed eight calendar quarters and if there is no adverse impact to any MaineCare member or provider. The increased reimbursement rates, and increased level of care caps will sunset on June 30, 2018, as the rate increases were funded by a single year appropriation. P.L. 2017, ch. 284, Part ZZZZZZ-9. On July 1, 2018, rates and level of care caps will revert back to the June 30, 2017, rates and caps. The Department is seeking, and anticipates receiving, approval, from the federal Centers for Medicare and Medicaid Services (“CMS”) for these changes. Pending approval, the increased reimbursement rates and level of care limits will be effective retroactive to July 1, 2017. In addition, in September 2015, July 2016, and September 2017, the Department proposed separate reimbursement rate changes to CMS, those rates are pending approval. As such, there are different effective dates for various rates and level of care limits, as set forth more specifically in Chapter II, Appendix 2, and Chapter III. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: February 12, 2018
View Comments: COMMENTS  Posted: February 9, 2018
 
MaineCare Benefits Manual, Chapter III, Section 12, Allowances for Consumer-Directed Attendant Services WORD  PDF 
Concise Summary: The Department of Health and Human Services adopts this rule change to Chapter III, Section 12, Allowances for Consumer-Directed Attendant Services to comply with Public Law 2017, ch. 284, Parts MMMMMMM-1 and ZZZZZZ-9, 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, 2018 and June 30, 2019. This rule change is consistent with P.L. 2017, ch. 284, Parts MMMMMMM-1 and ZZZZZZ-9, which requires the Department to amend its rules to increase reimbursement rates for the home-based and community-based personal care services referenced in the February 1, 2016 report “Rate Review for Personal Care and Related Services: Final Rate Models” prepared for the Department by Burns & Associates, Inc., which includes Section 12 services. Part MMMMMMM-1 directs the Department that the increase in rates of reimbursement must be applied in equal proportion to all home-based and community-based personal care and related services referenced in the Burns & Associates, Inc. report using the funding provided for that purpose in Chapter 284. On November 14, 2017, the Department adopted an emergency rule to effectuate the increased Section 12 reimbursement rates with a retroactive effective date of July 1, 2017. This rulemaking makes permanent the emergency rule changes. The Department determined that a retroactive rate increase to the beginning of the state fiscal year was appropriate, since the appropriation is intended for the entire fiscal year. The retroactive application fo this rule comports with 22 M.R.S. §42(8) which authorizes the Department to adopt rules with a retroactive application for a period not to exceed eight calendar quarters and there is no adverse financial impact on any MaineCare member or provider. The increased rate will sunset on June 30, 2018, as the rate increases were funded by a single year appropriation. P.L. 2017, ch. 284, Part ZZZZZZ-9. On July 1, 2018, rates will revert by to the June 30, 2017 rates. The Department is seeking, and anticipates receiving, approval from the federal Centers for Medicare and Medicaid Services (“CMS”) for these changes. Pending approval, the increased reimbursement rates will be effective retroactive to July 1, 2017. In addition, in September of 2015, July 2016, and August of 2017, the Department proposed separate reimbursement rate changes to CMS, those rates are pending approval. As such, there are different effective dates for various rates, as set forth more specifically in Chapter III. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: January 30, 2018
View Comments: COMMENTS  Posted: January 30, 2018
 
PROVISIONALLY ADOPTED MAJOR SUBSTANTIVE RULE, MaineCare Benefits Manual, Chapter III, Section 29 WORD  PDF 
Concise Summary: The attached Chapter III, Section 29 has been provisionally adopted. Chapter III, Section 29 is a major substantive rule and requires legislative approval prior to final adoption.
View Comments: COMMENTS  Posted: January 16, 2018
 
PROVISIONALLY ADOPTED MAJOR SUBSTANTIVE RULE, MaineCare Benefits Manual, Chapter III, Section 21 WORD  PDF 
Concise Summary: The attached Chapter III, Section 21 has been provisionally adopted. Chapter III, Section 21 is a major substantive rule and requires legislative approval prior to final adoption.
View Comments: COMMENTS  Posted: January 16, 2018
 
MaineCare Benefits Manual, Section 19, Chapter III, Home and Community Benefits for the Elderly and Adults with Disabilities WORD  PDF 
Concise Summary: On November 1, 2017, the Department adopted an emergency Ch. III, Section 19 rule to increase some home-based and community-based personal care and related services in Section 19 rates as required by P.L. 2017, ch. 284, §§MMMMMMM-1. Those increased rates were made effective retroactive to July 1, 2017, in accord with 22 M.R.S. § 42(8), since there was no adverse financial impact on any MaineCare members or providers. The Department determined that a retroactive increase to the start of the state fiscal year was appropriate, since the appropriation was intended for the entire fiscal year. This final rule will permanently adopt the emergency rule changes, with the retroactive effective date of July 1, 2017. Additionally, some procedure, modifier, and revenue code changes are being adopted at the same time for the system to correctly pay and track the new rates. The additional modifiers will be effective September 29, 2017. This retroactive effective date also comports with 22 M.R.S. § 42(8), since there was no adverse financial impact on any MaineCare members or providers. The Legislature did not appropriate additional funding for the rate increases beyond June 30, 2018; therefore, rates will revert to their pre-July 1, 2017 levels on July 1, 2018. A public hearing was held November 28, 2017 and comments were accepted until December 10, 2017. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: January 10, 2018
View Comments: COMMENTS  Posted: January 9, 2018
 
MaineCare Benefits Manual, Chapter II, Section 29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF 
Concise Summary: The Department is adopting amendments to this rule in accordance with P.L. 2017, ch. 284 (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, 2018 and June 30, 2019), which provided funding to increase the annual cap for services provided under Section 29 from $23,985 to $47,500. The Act funded Shared Living services as a new residential Covered Service available to eligible members under Section 29. The Department has increased the annual combined services cap from the $47,500 in the legislation to $52,425, to accommodate the annual cost of the newly-added Shared Living service, given the rate increase for this service for SFY18, as implemented in emergency major substantive rule amendments of Chapter III, Section 29, effective October 1, 2017 and retroactive to July 1, 2017. In addition, the Department has added Shared Living to, and removed Work Support from, this cap, which will now include Home Support, Community Support, and Shared Living. The Department has increased the annual cap on Respite services to accommodate the rate increase for this service for SFY18 in Chapter III, Section 29, which the Department also adopted in the same concurrent, emergency amendments. Both of these increases in the combined services cap are retroactive to July 1, 2017, pursuant to the increased rates for services in the legislation, and 22 M.R.S. § 42(8). These amendments adopt, finally, changes that were made to Section 29 on an emergency basis effective October 1, 2017, and which are effective for ninety (90) days. The final adopted rule implements these changes by adding definitions for Administrative Oversight Agency, Shared Living, and Shared Living Provider, and by adding Shared Living as a Covered Service. The combined services cap has been increased to $52,425, and Shared Living has been added to the services included under the cap. Work Support-Individual and Work Support-Group have been removed from the cap. Removing these services from the cap removes the limit on Work Support, and allows members flexibility to use the capped amount for the other services. The annual limit on Respite has been increased from $1,000 to $1,100. The weekly cap on Home Support-Remote Support has been removed to increase member flexibility. These changes are not expected to have an adverse effect on the administrative burdens of small businesses. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: December 28, 2017
View Comments: COMMENTS  Posted: December 27, 2017
 
MaineCare Benefits Manual, Chapter II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF 
Concise Summary: The adopted rule expands the number of members who are eligible as Priority 1 on the waitlist for Chapter II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder. The expansion of the Priority 1 waitlist applies to members who do not yet meet the need for adult protective services, but: (1) whose primary caregiver has reached the age of 65 or has a terminal illness; (2) who have no other responsible or willing caregiver; and (3) who satisfy at least one and are at risk of another additional risk factors. The Department is also adopting a definition of “Primary Caregiver” to address the reality that members may be receiving care from their parents or from extended family members when their parents are deceased, missing, or unable to care for the member. In addition, the Department is adopting changes to the rule regarding the Priority 2 criteria to clarify that this classification includes members who do not yet meet Priority 1, and to replace the term “parents” with “Primary Caregiver” in the examples of members who qualify for Priority 2. This rule adoption also implements a process for members on the waitlist to annually confirm their continued interest in Section 21 services. Members will be given the option to request that the Department re-evaluate their status on the waitlist at any time including at the time of the annual waitlist confirmation. The Department is in the process of seeking and anticipates receiving approval from the Centers for Medicare & Medicaid Services for these changes. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: December 24, 2017
View Comments: COMMENTS  Posted: December 21, 2017
 
MaineCare Benefits Manual, Chapter III, Section 2, Adult Family Care Services WORD  PDF 
Concise Summary: The Department of Health and Human Services (“the Department”) adopts this rule to increase the rates of reimbursement for Adult Family Care Services pursuant to Public Law 2015, ch. 481, Part C, An Act To Provide Funding to the Maine Budget Stabilization Fund and To Make Additional 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, 2016 and June 30, 2017. As required by that legislation, this adopted rule effectuates a three and a half (3.5) percent cost-of-living rate increase for adult family care services for the fiscal year ending June 30, 2018 based on the U.S. Department of Labor, Bureau of Labor Statistics Consumer Price Index medical care services index. The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services (CMS) for this change. Pending approval, the three and a half (3.5) percent rate increase will be effective retroactive to July 1, 2017. The Department is authorized to adopt these changes retroactively under 22 M.R.S. § 42(8) because these changes increase reimbursement for providers, and will have no adverse impact on either MaineCare providers or members. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: December 23, 2017
View Comments: COMMENTS  Posted: December 21, 2017
 
MaineCare Benefits Manual, Chapters II & III, Section 45, Hospital Services WORD  PDF 
Concise Summary: The Department is adopting changes in these rules, as set forth below. The Department is seeking and anticipates receiving approval from CMS for the rule changes. Pending CMS approval, the rule changes are effective November 14, 2017. The changes include the following: Chapter II: a) An amendment to Section 45.05-4, Restricted Services, clarifying that dental services which are medically necessary and done in a hospital setting are allowed. b) A clarification in Section 45.05-6, Restricted Physician Services Associated with Hospital Services, stating that all hospital-based providers are subject to the limitations in Chapter II, Section 90, Physician Services. c) An update to language in Section 45.13, Reporting Requirements for Acute Care Critical Access Hospitals and Private Psychiatric Hospitals, to reflect current reporting requirements; to provide additional guidance for updating 340B status changes when applicable; and include the requirement to have mechanisms in place to prevent duplicate discounts on drugs. d) The addition in Section 45.04-4, Supplies, Appliances and Equipment, of separate reimbursement for Long Acting Reversible Contraceptives (LARC) when the device is inserted during the postpartum inpatient hospital stay. The LARC will be covered in addition to the hospital Diagnosis-Related Group (DRG) payment to provide adequate reimbursement to providers for the device. e) An update to Section 45.04-8, Diabetes Self-Management Training Services, amending the language to accurately reflect the program’s current title and model. f) Correction and/or deletion of outdated references and minor language editing for clarification purposes. Chapter III: a) Updates throughout the rule of the term “radiology” to “imaging” to reflect prevalent terminology usage. b) Expansion of the definition of “Discharge” (Sec. 45.01-6) to include inpatient maintenance chemotherapy as an exception to the fourteen-day (14) readmission protocol due to the required planning for standards of care. c) The addition to Section 45.02-5, Reporting and Payment Requirements, of requirements for providers to submit mapping documents as part of the required documentation when filing the As-Filed Medicare Cost Report with the Department to aid the Department in payment methodology calculations.   d) Amend 45.02-5(E), Payment Requirements in the Event of an Overpayment to the Hospital, to require payment of 100% (instead of 50%) of the hospital-discovered overpayment as determined by the As-filed Medicare Cost Report. This change is required by federal law. (42 U.S.C. §1320a-7k) e) The addition of the Payment Window Rule (Sections 45.03-1(D)(1)(b) and 45.06-1(B)(2)) instructing hospitals, or entities wholly-owned or wholly-operated by a hospital, to bill the technical component of outpatient services provided within a 3-day (or 1-day) window preceding inpatient admission on the inpatient claim. The 1-day payment window applies to distinct rehabilitation, psychiatric, and substance abuse units. This provision is consistent with 42 C.F.R. §412.2(c)(5) and 42 C.F.R. §413.40(c)(2), and is currently in place by Medicare to treat certain technical components as operating costs of the inpatient hospital services. f) Added a new provision, Section 45.03-1(D)(3), Hospital Outpatient Provider-Based Departments (PBDs). This provision adopts the Medicare Outpatient Prospective Payment System/Ambulatory Surgical Center (OPPS/ASC) rule, which essentially requires that, with the exception of dedicated emergency department services, services furnished in off-campus provider-based hospital outpatient departments that began billing under the OPPS on or after November 2, 2015, no longer be paid under the OPPS. With the exception of these “excepted locations,” services provided in PBDs must use modifiers to identify non-excepted items and services. These non-excepted services are paid at a reduced MaineCare rate. g) In Section 45.07, an increase in the amount of the supplemental pool is being made to comply with P.L. 2017, ch. 284, Sec. ZZZZZZ-9. The Department is also adopting a restructuring of the supplemental pool methodology. The new methodology creates two supplemental pools; an inpatient supplemental pool and an outpatient supplemental pool. This change is to ensure that the annual supplemental payments can be issued to providers without exceeding the allowable upper payment limits as described in 42 C.F.R. §447.272 (upper payment limits for inpatient services) and §447.321 (upper payment limits for outpatient services). The new methodology is based on a calculation of a hospital’s relative share of inpatient or outpatient MaineCare payments (rather than a hospital’s relative share of inpatient MaineCare discharges) since the new methodology is utilizing both an inpatient and an outpatient supplemental pool. The data used to calculate the relative share of a hospital’s MaineCare payment is data from the state fiscal year 2014, which provides a consistent and more accurate basis with minimal risk of additional claim activity. h) Updating the prospective interim payment (Section 45.04-2) methodology used to identify the estimated departmental annual obligation relating to both inpatient and outpatient services. This change provides for more accuracy in estimating prospective interim payments. i) Addition of language in the Out-of-State Hospitals’ reimbursement, Section 45.10, clarifying that reimbursement for laboratory and imaging outpatient service shall not exceed the 100% of Medicare reimbursement rate for the Maine area ’99 locality, and that the hospitals are required to report and are subject to all applicable pricing modifiers. This change is to ensure payments do not exceed Medicare amounts. j) Clarification of language in the Clinical Laboratory and Imaging Services, Section 45.11, to more succinctly explain how services are covered and reimbursed in accordance with applicable sections of the MaineCare Benefits Manual. k) Revision of language in Section 45.13-2 to reflect that the Final, rather than Interim, Cost Report will be used by the Department when calculating a Disproportionate Share Hospital (DSH) settlement to more accurately reflect inpatient utilization rates. This is also consistent with the regulation which provides that hospitals within the category are assessed for DSH eligibility “after final settlement is complete for all hospitals in a category.” l) Addition of ICD-10 code H65.01, Acute serous otitis media, right ear, to Appendix B, which had been inadvertently left out during the last amendment to this rule. m) Minor corrections and editing of language and formatting for clarification and organizational purposes. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: November 14, 2017
View Comments: COMMENTS  Posted: November 14, 2017
 
MaineCare Benefits Manual, Ch. II, Sec. 80, Pharmacy Services WORD  PDF 
Concise Summary: This rulemaking adopts the following changes: 1. Definitions of “Acute Pain,” “Buprenorphine,” “Chronic Pain,” “Opioid Medication,” and “Prescription Monitoring Program” have been added to Section 80.01, Definitions. 2. In Section 80.07-6, Policies and Procedures, Dispensing Practices, language has been added requiring that generic drugs must be dispensed as a ninety (90) day supply for drugs identified as maintenance drugs after the initial thirty (30) day supply, with additional language excluding opioid medications from the requirement. 3. The addition of a new section, Section 80.07-12, Prescribing Opioids for Pain Management, which aligns MaineCare with Maine statutes and the Department’s Office of Substance Abuse and Mental Health Services rules governing the Controlled Substances Prescription Monitoring Program and Prescription of Opioid Medications. The section incorporates current best practice guidelines and includes subsections on prescribing requirements for treating chronic pain; limitations and exemptions; rules regarding prior authorization for both acute and chronic pain prescriptions; and medical record documentation requirements. 4. The addition of a new section, Section 80.07-13, Buprenorphine and Buprenorphine Combination Products for Substance Use Disorder (SUD) which provides best practices guidelines for Medication-Assisted Treatment (MAT) using buprenorphine and derivatives for individuals who have been diagnosed with SUD. This sections includes subsections associated with prescriber requirements; detailed protocols; limitations on members qualified to receive the drug; and rules regarding prior authorizations. The section also outlines requirements for medical records which follow the model established by the Drug Addiction Treatment Act of 2000 (DATA). 5. Section 80.09, the reimbursement sections for retail and specialty pharmacy providers, has been amended to align MaineCare policy with the CMS Covered Outpatient Drug final rule. The change to this section also includes changing the pharmacy dispensing fee from $3.35 to $11.89 following the New England States Consortium Systems Organization (NESCSO) pharmacy cost of dispensing survey. Finally, as a result of public comments and further review by the Department and the Office of the Attorney General, there were additional technical changes, formatting updates, and changes to language for clarity. The Summary of Public Comments and Department Responses document identifies changes that were made to the final rule. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: September 1, 2017
View Comments: COMMENTS  Posted: September 1, 2017
 
MaineCare Benefits Manual, Chapter III, Section 21 WORD  PDF 
Concise Summary: This regulation governs the reimbursement for a federal Medicaid 1915(c) waiver service. This regulation is a major substantive rule. On September 28, 2016, the Department adopted an emergency major substantive rule for Ch. III, Section 21, to comply with P.L. 2015, Ch. 477 (An Act to Increase Payments to MaineCare Providers that are Subject to Maine’s Service Provider Tax). The Maine Legislature enacted P.L. 2015, Ch. 477 on an emergency basis, and therefore the legislation took effect on the date that it was signed by Governor LePage; April 15, 2016. The September 28, 2016 emergency major substantive rule increased 23 codes/services by 1%, with a retroactive effective date of April 15, 2016. Pursuant to 5 M.R.S. Sec. 8073, the September 28, 2016, emergency major substantive rule – with the 1% rate increases - is effective for up to twelve months or until the Legislature has completed its review of the provisionally adopted rule. Pursuant to 5 M.R.S. Section 8072(1), the Department engaged in proposed rulemaking for Ch. III, Section 21. On February 24, 2017, the Department provisionally adopted the Chapter III, Section 21 major substantive rule. The Department submitted the provisionally adopted rule to the Legislature, which authorized adoption of the rule with some legislative changes. Resolves 2017, Ch. 15, approved by the Governor on June 8, 2017. This rulemaking makes the following changes, all of which were approved or initiated by the Legislature: • To match the current terminology in the DSM 5, renamed the Section from “Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder” to “Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autism Spectrum Disorder.” • In Appendix I changed “Consultation Services” for both Psychological and Speech Therapy to “Consultative Services” to be consistent with the approved service name in the waiver application. These changes have no impact on services or billing. • Make permanent the 1% rate increase to 23 codes/services that received a 1% rate increase in the September 28, 2016 Emergency Major Substantive rulemaking. These codes, and the increased rates, are listed in Appendix I. • To allow different billing options for different group sizes, replaced H023 HQ Work Support (supported employment) with the following modifiers below: • H2023 UN Work Support (supported employment)-Group 2 members served. • H2023 UP Work Support (supported employment)-Group 3 members served. • H2023 UQ Work Support (supported employment)-Group 4 members served. • H2023 UR Work Support (supported employment)-Group 5 members served. • H2023 US Work Support (supported employment)-Group 6 members served.  When proposing the rule the Department proposed removing the range methodology in Appendix IIA and IIB. The reason for this was that it is the expectation of the Department that providers bill only for the services they provide. The range methodology was originally included in the rule to allow for fluctuations in staffing. Based on the comments received, the Department decided to not go forward with that rule change. The Legislature, Resolves 2017, Ch. 15, approved the changes listed above, and in addition made the following changes to the Final Rule: 1. §1050 the definition of per diem has been changed to remove the requirement that a provider bill only for days on which a member is receiving per diem Home Support at 11:59 p.m. The definition of per diem has been changed to clarify that there is no requirement that a provider bill only for days on which a member is physically present in the home at 11:59 p.m. and that on days when a member is transitioning between providers of home support, only the provider providing home support services at 11:59 p.m. may bill for home support. 2. §2000 (Audit of Services) the Legislature removed the proposed change in the documentation requirement for staffing schedules, so that the documentation requirement remains as it is in current rules, which require documentation showing the hours and the name of the direct staff scheduled to work at the facility. The rule will be final 30 days after it is filed with the Secretary of State. See HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: September 6, 2017
View Comments: COMMENTS  Posted: August 9, 2017
 
MaineCare Benefits Manual, Chapter III, Section 29 WORD  PDF 
Concise Summary: The Department seeks to finally adopt these major substantive changes to the reimbursement rates in Chapter III, Section 29. Pursuant to 5 M.R.S. §8072, the Department submitted its provisionally adopted rule changes to the Legislature for review and authorization for final adoption. On May 31, 2017 the Legislature enacted “Resolve, Regarding Legislative Review of Portions of Chapter 101: MaineCare Benefits Manual, Chapter III, Section 29, Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder, a Late-filed Major Substantive Rule of the Department of Health and Human Services” (Resolves 2017, Ch. 10 (effective May 31, 2017), which authorized the Department to finally adopt the provisionally adopted rule changes, as submitted (i.e., without any changes). The law included authority for the Resolve to take place immediately, given the Legislature’s emergency findings, and thus it took effect upon the Governor’s signature. Most of the changes finally adopted in Section 29 were made pursuant to P.L. 2015, Ch. 477, An Act to Increase Payments to MaineCare Providers That Are Subject to Maine’s Service Provider Tax (eff. April 15, 2016). Through this law, the Legislature required a 1% increase in reimbursement for certain services to offset an increase in the service provider tax, which took effect January 1, 2016. In addition, the Department seeks to permanently adopt new codes and rates for Work Support provided to multiple members at one time. The Department is making these changes to allow for providers to bill for different group sizes. On September 28, 2016, the Department implemented the above-described changes through emergency major substantive rulemaking. Pursuant to 5 M.R.S. § 8073, emergency major substantive rules are effective for up to 12 months, or until the Legislature has reviewed and approved of the provisionally adopted rule. In addition, pursuant to 22 M.R.S. § 42(8), these emergency rule changes are effective retroactive to April 15, 2016. Additional changes to Chapter III, Section 29 that were not deemed emergency but were part of the proposed rule and the provisionally adopted rule include: o Updating Section 1400(3), reducing the reimbursement for respite care to provide that the amount billed for any single day cannot exceed a per diem rate of $90.00. The Department seeks to implement this change to make the rule consistent with the rates that are already in Appendix I and to be consistent with MIHMS. o Renaming of the Section from “Allowances for Support Services for Adults with Intellectual Disabilities or Autistic Disorder” to “Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder.” The Department seeks to implement this change as this is the current terminology used in the DSM 5. o Various clerical and formatting changes. These finally adopted major substantive rule changes will be effective 30 days after the rule is filed with the Secretary of State. See HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: August 25, 2017
View Comments: COMMENTS  Posted: August 9, 2017
 
MaineCare Benefits Manual, Chapter X, Section 1 WORD  PDF 
Concise Summary: The adopted rule changes set out the required co-payments for certain services in a more organized, easier to understand form, and removes the non-applicable 90-day supply co-pay. Additionally, the rule more specifically-defines actions that may lead to disenrollment, it simplifies disenrollment protocol, and clarifies the appeal rights language. The rule also updates references in the covered and non-covered services tables to reflect the current MaineCare Benefit Manual policies. For certain additions and removals of services, as noted in each instance in the rule, the Department is seeking and anticipates receiving CMS approval. This adopted rule updates many outdated references identifying Department agencies, MaineCare Benefit Manual policies and services, outdated internet website addresses, and contains minor grammar and punctuation changes. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: July 10, 2017
View Comments: COMMENTS  Posted: July 10, 2017
 
MaineCare Benefits Manual, Chapters II and III, Section 93 WORD  PDF 
Concise Summary: The Department adopts this rule pursuant to P.L. 2017, Ch. 2, Part P, Sec. P-1 (Establishment of Opioid Health Home Program). On April 11, 2017, the Department adopted an Emergency Rule which established the Opioid Health Home Service as a MaineCare service. This rule makes permanent the April 11, 2017 Emergency rule, with some changes. The MaineCare Opioid Health Home (OHH) Services program addresses the opioid crisis in Maine. The OHH initiative is an innovative model providing comprehensive, coordinated care focused on serving the MaineCare population. In addition to providing treatment for an individual’s substance abuse dependency, the OHH integrates physical, social, and emotional supports to provide holistic care. The model provides a community-based support system focused on team-based clinical care. MaineCare members diagnosed with opioid addiction and who have a second chronic condition or are at risk for having a second chronic condition are eligible for these services. The OHH services provide a multi-faceted approach and comprehensive treatment specifically targeted to the opioid dependent population. The program will increase access to treatment options, integrate health and dependency care, and promote stable recovery results. It is expected that this newly established OHH program will not only result in more individuals receiving the substance abuse treatment they need, but will also lead to improvements in the quality of care they are receiving. The Department has submitted a State Plan Amendment (SPA) request to CMS for approval, and anticipates that CMS will approve the Opioid Health Home SPA. Pending CMS approval, covered services will be provided as described in this rule. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: July 10, 2017
View Comments: COMMENTS  Posted: July 10, 2017
 
MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures WORD  PDF 
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 I, Section 1, General Administrative Policies and Procedures ADOPTED RULE NUMBER: CONCISE SUMMARY: This rulemaking adopts the following changes: 1. References to the “Office of Integrated Access and Support” were updated to the “Office for Family Independence.” The name of this agency has changed, and the policy should reflect the name change. 2. Section 1.02-4(B), “Covered Health Care Provider” definition has been expanded to include “a provider of medical or health services and any other person or organization that furnishes, bills, or is paid for health care in the normal course of business” to more accurately mirror federal language. 3. Section 1.02-4(G), added language to the definition of “National Provider Identifier (NPI)” to clarify that the NPI is issued by CMS. 4. Section 1.02-4(H)(3), changed the definition of “Ordering, Prescribing and Referring (OPR) provider” to “Non-Billing, Ordering, Prescribing and Referring Provider (NOPR)” to conform with current online MaineCare billing practices. 5. Section 1.03-1, change of language describing online provider enrollment. In the state of Maine, online enrollment is now the sole means through which providers enroll and update information. Therefore, language was added describing the online enrollment process through the Department’s Health PAS portal. This change is being made to institute the federally mandated revalidation requirements outlined in 42 CFR § 424.515. 6. Section 1.03-1(A), addition of language describing the requirement for providers to complete subsequent enrollment applications every three to five years, depending on provider type in order to institute the federally mandated revalidation requirements outlined in 42. CFR § 424.515. 7. Section 1.03-1, addition language authorizing the Department to request additional information which demonstrates the provider applicant’s ability to provide high-quality care, services, and supplies, and to be financially responsible. This change is being made to better help ensure MaineCare’s ability to align with federally mandated revalidation requirements in 42 CFR § 424.515. 8. Section 1.03-1(C), addition language describing the requirement for providers (with the exception of individual practitioners) to pay an enrollment fee for each provider site. Language was also added describing the option for providers to apply for a fee waiver, as well as the exemption from the fee for providers who have paid an enrollment fee for the site in question during the preceding 12 months to Medicare or another Medicaid agency. This enrollment fee language is being added to comply with 42 CFR §455.460.   9. Section 1.03-B, addition of language stating that providers must obtain a National Provider Identification (NPI) or Atypical Provider Identifier (API) plus three digit service location identifier and use this number in submitting all claims for payment. This change is being made to upgrade the provider enrollment process for efficiency purposes. 10. Section 1.03-2, addition of language stating that out-of-state providers are subject to the same enrollment requirements as in-state providers to ensure all MaineCare providers properly enroll. 11. Section 1.03-3, addition of a list of factors the Department must and may consider in determining whether to enroll or deny enrollment to a provider applicant. Certain situations will trigger automatic denial of enrollment. These changes are being added to conform with 42 CFR § 455.410. 12. Section 1.03-3, addition of subsections that set forth the criteria for MaineCare’s denial of provider enrollment or subsequent provider enrollment applications. These changes follow the federal regulations set forth in 42 CFR § 455.416. 13. Section 1.03-5, addition of language stating that providers who are terminated from MaineCare (whether involuntarily or voluntarily), have one year from the end date of enrollment to submit claims for services provided during the period of active enrollment. This change was added to be consistent with the one-year regular timely filing noted in Section 1.10-2. 14. Section 1.03-6, addition of language regarding changes of ownership, closures and disenrollment. Providers will be required to notify the Provider Enrollment Unit of any Change in Ownership (CHOW), closure, or intention to disenroll from the MaineCare program no less than thirty (30) days prior to the intended change. Providers undergoing a CHOW will be required to submit a CHOW questionnaire. These changes are being made to conform with federal regulations set forth in 42CFR § 455.104. 15. Section 1.03-7, addition of language stating that the Department will terminate the enrollment of any provider (other than NOPR providers) who has not submitted a claim within 365 days of enrollment. Such providers are eligible to re-enroll at any time. This change is being added to ensure that the MaineCare system has the most current and relevant provider information on record. 16. Section 1.03-8 (F), language was updated involving provider nondiscrimination requirements to conform with state and federal laws. The current policy contains an incomplete list of groups whom providers are barred from discriminating against. The Department has added sexual orientation, gender identity, ancestry, age and any other category protected by state and federal law. 17. Section 1.03-8(V), addition of language requiring disclosure of certain ownership or control interests. These requirements follow those of 42 C.F.R. §§ 455.101-105. 18. Section 1.06-2 (A), addition of language stating that the Department will not reimburse for interpreter travel time to help minimize abuse of the interpreter reimbursement.   19. Section 1.06-5, addition of language stating that providers may refuse to continue to see members who have repeatedly broken appointments without prior notice. In such situations, providers must provide advanced notice of office policies concerning no-shows to members before refusing to continue to see those members. This addition is being made to allow providers to refuse to continue to see members only in accordance with the provider’s standard office policies for broken appointments. 20. Section 1.07-1(C), addition of language describing Early and Periodic Screening, Diagnosis and Treatment Services. This additional information provides more detailed and clarifying language regarding the Early and Periodic Screening, Diagnosis and Treatment Services. 21. Section 1.07-3(C), addition of an exception to the requirement that providers appeal third party payer denials of services prior to billing MaineCare. The exception is when Medicare has denied services based on Local Coverage Determinations (LCDs) or National Coverage Determinations (NCDs), and also includes Licensed Marriage and Family Therapist (LMFTs), Licensed Professional Counselor (LCPCs), and Licensed Master Social Workers Clinical Conditional (LMSW-CCs) when the following criteria are met: 1) member has an established relationship with the provider; or 2) another provider is not available. This additional language is being added to allow for a more streamlined procedure for allowing for appeals because these provider types are not recognized by Medicare. 22. Section 1.09-2(J), addition of tobacco cessation products and services to the list of copayment exemptions. Copayments for tobacco cessation services are prohibited by 22 M.R.S. § 3174-WW. 23. Section 1.11-2, addition of language describing National Correct Coding Initiative (NCCI) edits, and a statement that MaineCare will reject claims not in conformity with NCCI requirements. This change is being made to mirror federal regulations set forth in National Correct Coding Initiative Policy Manual from CMS. 24. Section 1.06-2(I), removal of Private Non-Medical Institutions (PNMIs) from list of facilities that include interpreter services in their reimbursement calculations. Interpreter services are not included in the PNMI rate calculation. 25. Section 1.12-2 (D), addition of language stating that the liability for debts owed to the Department by the provider is enforceable against the provider, including any person who has an ownership or control interest in the provider, and against any officer, director or member of the provider who, in that capacity, is responsible for any control or any management of the funds or finances of the provider. Language has also been added defining “individuals or entities with an ownership or control interest.” These changes are being made to clarify that individuals with management or control over the funds or finances of the provider are personally liable. This addition also corresponds to the language of the MaineCare Provider Agreement, section (D)(3)(c). 26. Section 1.14-1(A), updating of the website address for information regarding prior authorizations.   27. Sections 1.14-2(A)(1) and 1.14-2(B)(3), removal of language allowing for MaineCare covered services to be rendered to members within five miles of the Maine/Canadian border. This language is pursuant to Section 6505 of the Affordable Care Act amending Section 1902(a) of the Social Security Act (the Act), and requires that a state shall not provide any payments for items or services provided under the State Plan or under a waiver to any financial institution or entity located outside of the United States (U.S.). 28. Section 1.15, removal of language regarding Section 113 Non-Emergency Transportation (NET) of the MaineCare Benefits Manual. Section 113 sets forth the policy for non-emergency transportation, so the duplicative language was removed from Section 1.15. 29. Termination from participation language that was in former Section 1.03-4 has been moved to new Section 1.19 entitled “Termination from Participation in MaineCare.” 30. Section 1.20(Z) & (AA), addition of two new grounds for sanctions: (1) an entity that is an HMO or is providing services under a Medicaid waiver program, and has a substantial contractual relationship with an entity that could be excluded from the Medicaid program; (2) if a provider has been convicted of a crime while performing services as a health care worker or provider. This change is being made to conform with the requirements of Section 1902 of the Social Security Act (42 USC 1396a). 31. Section 1.20-2(C), addition of a sanction action for limitation of services for which the provider is authorized to perform and receive payment. This change adds a sanction that may occur as a result of a grounds for sanction described in 1.20-1 (Grounds for Sanctions). 32. The Department is adopting a new provision, Section 1.21, entitled “Reinstatement from Termination or Exclusion.” Reinstatement language that was in former Section 1.19-4(F) has been moved to this new section. The Department is also making the change that requests for reinstatement from exclusion or termination be addressed to the Manager of Program Integrity, in writing. The language also sets forth factors that will be considered by the Department when making a decision to reinstate. The adopted language, in Subparagraph 2, also sets forth minimum periods of time before reinstatement can be considered, for certain violations of law or other exclusion or termination reasons. The time period requirements are consistent with the time period requirements imposed on the Federal Secretary of HHS in the Social Security Act Section 1128 (as codified in 42 U.S.C. 1320a-7) (Exclusion of Certain Individuals and Entities from Participation I Medicare and State Health Care Programs). 33. Removal of references to the term “mentally retarded.” This term was replaced by the term “intellectually disabled.” This change follows the direction of Rosa's Law, Public Law 111-256, which requires the federal government to change terminology in federal statute to eliminate use of the term “mental retardation.” 34. Replacement of the term “Authorized Agent” with the term “Authorized Entity.” This change is being adopted across the agency in order to more accurately describe the Department’s relationship with the aforementioned entities. Contractors with the state are not legal agents of the state, so the term was replaced with “entity” to avoid confusion.   36. 1.25, changes to the language describing the duties, role, and composition of the MaineCare Advisory Committee (MAC) in order to more closely align with federal requirements, as outlined in 42 C.F.R. § 431.12. 37. Minor grammar and punctuation edits have also been made. Finally, as a result of public comments and further review by the Department and the Office of the Attorney General, there were additional technical changes, formatting updates, and changes to language for clarity. The Summary of Public Comments and Department Responses document identifies changes that were made to the final rule. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
View Comments: COMMENTS  Posted: July 5, 2017
 
MaineCare Benefits Manual, Chapter III, Section 97, Private Non-Medical Institution Services WORD  PDF 
Concise Summary: This final adoption major substantive rulemaking implements a one (1) percent rate increase in the direct care component to PNMI Services providers who have experienced an increase in the Maine Service Provider Tax since January 1, 2016 pursuant to Public Law 2015, ch. 477, An Act to Increase Payments to MaineCare Providers That Are Subject to Maine’s Service Provider Tax. If CMS approves, the increased reimbursement rates will be effective retroactive to July 1, 2016. Also, this final adoption major substantive rule effectuates a supplemental payment of fifteen (15) percent, in addition to the MaineCare rate, to eligible Appendix C remote island facilities. This increase will apply only to facilities located on an island not connected to the mainland by a bridge. If CMS approves, the increased rates for remote island facilities will be effective retroactive to October 1, 2015. http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: July 16, 2017
View Comments: COMMENTS  Posted: June 20, 2017
 
MaineCare Benefits Manual, Chapters II and III, Section 19,Home and Community Benefits for the Elderly and Adults with Disabilities WORD  PDF 
Concise Summary: The Department is adopting changes to both Chapter II and Chapter III of Section 19, Home and Community Benefits for the Elderly and Adults with Disabilities, that seek to add services, clarify existing services, increase rates for personal care services, adjust rates and rate methodology for other services, more closely align the rule with federal requirements for waiver services, and make various clerical and formatting updates. This rule adoption adds three new services that enhance members’ opportunities to access necessary supports and services within their communities: Home Delivered Meals, Living Well for Better Health, and Matter of Balance (Falls Prevention). In addition, the Department is moving Adult Day Health Services from Section 19 to the State Plan. This change benefits members by increasing options for services under the program cap. Services under the State Plan also do not limit members in the same manner under the Section 19 waiver in terms of scope and duration. The Department is also increasing options for members by adding a definition of “Budget Authority” to allow members under the Participant-Directed Option to determine the wages of hired Attendants, and is adding a definition for “Fiscal Intermediary” so that the responsibilities of the Fiscal Management Services provider are also clear. In addition, the Department added language to the rule which clarifies that, under the Participant-Directed Option, the member is considered the employer of the Attendant. These changes give the member more autonomy in self-directing services under this waiver. Other changes to the Chapter II rule adoption include the addition of the Person-Centered Planning definition and requirement that the Service Coordination Agency follow this model when working with the member to develop and implement services. The adoption of these rule provisions helps move the Section 19 waiver program towards compliance with 42 C.F.R. § 431.301(c). The Department made a number of other changes to the rule adoption to help clarity and improve upon existing processes for determining eligibility. This includes removing the requirement that the member provides a physician’s letter to the Service Coordination Agency, as all services will be medically authorized by the Assessing Services Agency; adding language to the rule that emphasizes consideration of the member’s needs and preferences; and updating the timeframes in which the Assessing Services Agency must complete both assessments and re-assessments, as reflected in current Departmental contracts. The Department is increasing several rates under Chapter III. To correspond with these rate increases, the Department is increasing the waiver cap in Chapter II. With this rule adoption, the Department is making a number of changes to Chapter III: The Department is adopting rate increases for personal care and related services in accordance with Resolves 2015, ch. 83 (Resolve, Directing the Department of Health and Human Services To Increase Reimbursement Rates for Home-based and Community-based Services). Through this Resolve, the Legislature directed the Department to amend this rule “to reflect 50% of the increase in rates noted in the final rates modeled in the February 1, 2016 report ‘Rate Review for Personal Care and Related Services: Final Rate Models’ prepared for the department by Burns & Associates, Inc.” These rate increases will be retroactive to July 29, 2016, the effective date of the Resolve, and pursuant to 22 M.R.S. § 42(8). The Department is incorporating other changes to Chapter III as a result of other recommendations in the Burns & Associates rate study. The Department has decreased the rate for three procedure codes: Skilled Nursing Visit (RN), Other Nursing (LPN), and Home Health Aide Visit – Home Health services. In addition, the Department has added new rates and procedure codes in accordance, as set forth in the study, for personal care and related services provided to two and three members simultaneously. These changes will take effect on June 1, 2017. The Department also increased the rate for Respite Care Services, not in the home to match the rate under Section 19 with the current nursing facility rate elsewhere in the MaineCare Benefits Manual. This increase will be retroactive to July 1, 2016. Next, the Department has added procedure codes and rates for the three new services added under Chapter II: Home Delivered Meals, Living Well (Chronic Disease Management), and Matter of Balance (Falls Prevention). The Department has also removed the procedure code and rate for Adult Day Health Services, as this service will now be offered to members under the State Plan. These changes are effective June 1, 2017. Finally, the Department is adding columns to differentiate between procedure code, modifier, and revenue code in Chapter III, which should assist providers in billing appropriately.
Effective Date: June 1, 2017
View Comments: COMMENTS  Posted: June 1, 2017
 
PROVISIONALLY ADOPTED MAJOR SUBSTANTIVE RULE MaineCare Benefits Manual, Chapter III, Section 21 Allowances for Home and Community Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF 
Concise Summary: Chapter III, Section 21 is a companion rule to Chapter II, Section 21, Home and Community-Based Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder. Chapter III is a major substantive rule and requires legislative approval prior to final adoption. On September 28, 2016, the Department adopted an emergency major substantive rule for Ch. III, Section 21, to comply with P.L. 2015, Ch. 477 (An Act to Increase Payments to MaineCare Providers that are Subject to Maine’s Service Provider Tax). The Maine Legislature enacted P.L. 2015, ch. 477 on an emergency basis, and therefore the legislation took effect on the date that it was signed by Governor LePage; April 15, 2016. The September 28, 2016 emergency major substantive rule increased 23 codes/services by 1%, with a retroactive effective date of April 15, 2016. Pursuant to 5 M.R.S. Sec. 8073, the September 28, 2016, emergency major substantive rule – with the 1% rate increases - is effective for up to twelve months or until the Legislature has completed its review of this provisionally adopted rule. The Department engaged in proposed rulemaking for Ch. III, Section 21. The proposed rule was publically noticed on September 28, 2016 and a public hearing was held on October 19, 2016 in Augusta. There were 54 people in attendance for the hearing. The Department received comments from 67 individuals until the close of the commenting period on October 29, 2016. The purpose of the proposed rulemaking was to provisionally adopt the 1% rate increases mandated by P.L. 2015, Ch. 477, and make other changes to the rule. The Department is hereby provisionally adopting the following rule changes to Chapter III, Section 21: o To match the current terminology in the DSM 5, renamed the Section from “Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder” to “Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autism Spectrum Disorder.” o In Section 1050 added, “A provider shall only bill Agency Home Support per diem for days on which the member is receiving per diem home support at 11:59” to clarify which provider can bill when a member transitions or moves to a new residential provider. o In Section 2000 changed “staffing schedules per facility” to “staffing schedules per member” to clarify that staffing schedules should be based on the member rather than the facility. MaineCare billing is based on the member. o In Appendix I changed “Consultation Services” for both Psychological and Speech Therapy to “Consultative Services” to be consistent with the approved service name in the waiver application. This changes has no impact on services or billing. o Make permanent the 1% rate increase to 23 codes/services that received a 1% rate increase in the September 28, 2016 Emergency Major Substantive rulemaking. These codes, and the increased rates, are listed in Appendix I. o To allow different billing options for different group sizes, replaced H023 HQ Work Support (supported employment) with the following modifiers below: o H2023 UN Work Support (supported employment)-Group 2 members served. o H2023 UP Work Support (supported employment)-Group 3 members served. o H2023 UQ Work Support (supported employment)-Group 4 members served. o H2023 UR Work Support (supported employment)-Group 2 members served. o H2023 US Work Support (supported employment)-Group 2 members served. When proposing the rule the Department proposed removing the range methodology in Appendix IIA and IIB. The reason for this was that it is the expectation of the Department that providers bill only for the services they provide. The range methodology was originally included in the rule to allow for fluctuations in staffing. Based on the comments received, the Department has decided to not go forward with this rule change. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: PROVISIONALLY ADOPTED
View Comments: COMMENTS  Posted: March 2, 2017
 
MaineCare Benefits Manual, Chapter II, Section 21 Home and Community Services for Adults with ID or ASD WORD  PDF 
Concise Summary: This regulation governs a federal Medicaid home and community based federal Medicaid 1915C waiver service. In this rulemaking, the Department has made changes that help move the Section 21 waiver program towards compliance with 42 C.F.R. Sec. 431.301(c). This federal regulation, effective March 17, 2014, sets forth new provisions for Home and Community Based services (HCBS) waiver programs. The federal regulation requires states to engage in transition planning with the Centers for Medicare and Medicaid Services (CMS) to assure compliance with these provisions. The Department is currently engaged in this process with CMS. For this rulemaking, the Department has incorporated changes regarding the Person-Centered planning process. Attached to this Basis Statement is a copy of a portion of the federal regulation, 42 CFR 431.301(c)(1), which is incorporated into this rule by reference. Although the Department proposed changes (proposed 21.10-6 – Residential Settings Owned or Controlled by a Provider), in compliance with 42 C.F.R. Sec. 441.301(c)(4)((vi)(B), the Department has chosen to not go forward with the proposed language. In response to the many comments the Department received complaining about the inclusion of the federal HCBS settings standards [codified in 42 CFR 441.301(c)(4)(vi)(B – F)] the Department has made the decision to remove, and not adopt, these proposed requirements in the final rule. The Department made this determination in an effort to balance the important goals of the federal HCBS settings standards regulation, and concerns of the Section 21 providers that compliance would be burdensome and expensive. According to CMS guidance, “Home and Community-Based Setting Requirements: Systemic and Site-Specific Assessments and Remediation” posted online at https://www.medicaid.gov/medicaid/hcbs/downloads/q-and-a-hcb-settings.pdf, states have until March 17, 2019 to come into full compliance with the rule. The Department intends to re-propose these requirements in a future rulemaking. Chapter II, Section 21 is a routine technical rule and does not require legislative approval prior to final adoption of the rule. The companion rule, Chapter III, Section 21 is a major substantive rule and requires legislative approval. With regard to the Chapter III rule, the Department adopted an emergency major substantive rule on September 28, 2016. The Department also went through proposed rulemaking for Chapter III, and provisionally adopted the rule on 24 February, 2017. The provisionally adopted rule will be submitted to the Maine Legislature for its approval and action. This Chapter II proposed rule was publically noticed on September 28, 2016 and a public hearing was held on October 19, 2016 in Augusta. There were 54 people in attendance for the hearing. The Department received comments from 67 individuals until the close of the commenting period on October 29, 2016. Changes to Chapter II, Section 21 include: • Renamed the section from Home & Community Benefits for Members with Intellectual Disabilities or Autistic Disorder to Home & Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder to be consistent with the Diagnostic and Statistical Manual of Mental Disorders (DSM). • Throughout Section 21 to be consistent with the DSM, replaced the term “Mental Retardation” with “Intellectual Disabilities.” • In the Definitions section: o In the definition of “DSM” the Department deleted the reference to the fourth edition, and substituted “current edition” so that the definition will always refer to the current edition of the DSM o Added clarifying language to Administrative Oversight Agency to include language that OADS needs to approve these agencies o Updated definition for Autism Spectrum Disorder. o Added Clinical Review Team as the entity to review service requests, including medical add-on services, to ensure clinical oversight. o Added clarifying language Correspondent, to add spectrum disorder to the term autism . o Removed language from Direct Supports to make the definition clearer. o Added clarifying language to Family-Centered Support. o Updated the definition of Intellectual Disability to be consistent with the Diagnostic and Statistical Manual of Mental Disorders. o Added the role of the CRT in reference to Medical Add On. o Deleted the term Mental Retardation, since that term is no longer used by DSM. o Clarified Prior Authorization o Moved language from Shared Living definition to the definition of Shared Living Provider. • Under Determination of Eligibility, added clarifying language to Reserved Capacity o Updated General Eligibility Criteria added clarifying language and updated the diagnoses to be consistent with the DSM and added Rett Syndrome. o Under Redetermination of Eligibility added the requirement that every twelve months from the date of initial eligibility approval, the member’s case manager will need to resubmit an updated personal plan and a BMS 99. This is the codification of a current requirement. • 21.03-5 Substituted “annual cost” for “annual budget” in order to be consistent with the hearings (Calculating the Estimated Annual Cost) • 21.03-8. Added language regarding “Offers for funded opening” to the effect that at the time a member is offered a funded opening the member will be removed from the waiting list. The reason is that once the Department has determined an offer to meet the members needs has been offered, then the member no longer has to wait for an offer. • 21.03-9 (Redetermination of Eligibility). Added requirement that eligibility for the waiver for each member has to be redetermined every 12 months. This requirement ensures that the member continues to be eligible for the service. • 21.04-2 (Plan Requirements), adds language regarding conflict-free planning to ensure that members have informed choices, which is consistent with 42 CFR 441.301(c)(1). • 21.05 (Covered Services)/Duplicative Services, moved the introductory sentence which stated that duplicative services were not covered, to the 21.06.1 (Duplicative Services) which section elaborates on the services which would be considered duplicative. • Under Personal Plan and also Planning Team Composition, the language was updated throughout this section to ensure that the member is driving the process and that the process is more closely aligned with the CFR §441.301 and 34-B M.R.S.A. §5470-B(2). Direct references to the CFR were included. • 21.04-2 (Personal Plan), added the requirement that grievance training be provided to all staff, upon hire, and retraining every thirty six months. The reason for this is because the grievance process is a very important process, and staff members need this training, which benefits members. • In the Covered Services section: o Under Communication Aids, added Augmented communication services to replace Facilitated communication services as an update. o Under Community Supports, added language that will allow for career exploration as part of the service, and allows a member to also receive Work Support services. o Community Supports, the Department deleted the hour cap and replaced it with a dollar cap of $26,640.10 annually, for this service. This is not a reduction of community support services. o 21.05-6 (Consultation Services), the Department removed the cap on these services from this section and moved the cap to the Limit Section 21.07-7 (Consultation Services). o 21.05-9 (Employment Specialist Services), the Department deleted the limit that high school members could not receive this service, in order to help high school members transitioning from school to work. o 21.05-19 (Physical Therapy Maintenance), added new language so that this service may be provided up to three members at a time. o 21.05-20 (Shared living), added language to clarify that respite is not separate billable service because it is a component of the rate paid to the Administrative Oversight Agency. • In the Limits section: o Added language which disallows duplicative services covered by other sections in the MaineCare Benefits Manual. o Under Consultation Services, added information regarding limits. o Definition of annual limits for: Occupational Therapy (Maintenance). o 21.07-2, the Department increased the limit for combined cost of Community Support, Work Support-individual and Work Support-Group. o Deleted 21.07-4 and moved that language to 21.07-3 (Home Accessibility Adaptations). o Added a new limit for Occupational Therapy. o 21.07-14, added new language to state that if a member was in continuous care in a hospital or a nursing facility for over six months, that member would be terminated from Section 21 waiver services. This is consistent with the Section 21 limit for duplicative services. • In the Duration of Care Section, added requirements for Provider Termination of a Member’s Services. • 21.10 - In Provider Qualifications and Requirements, added language throughout to provide additional assurances for the health and safety of members as well as quality of services. These changes include updates to the following: o Requiring providers to train staff in identifying risks such as risk of abuse, neglect or exploitation; o Additional qualification for Direct Support Professionals. o Provider qualifications necessary to perform an Assistive Technology Assessment. o Shared Living (Foster Care, Adult), requiring that providers maintain a clean and healthy living environment for members. o Background Check Criteria, requiring background checks for any adult who may be providing direct or indirect services. o Reportable Events & Behavioral Treatment., requiring that providers provide staff with training on various Department regulations concerning reportable events, and rights of persons with intellectual disability. • Appendix I. Clarifies that it is the CRT which reviews all increased levels of support requests. The Department also added Physician Assistants to the list of providers who can write a recommendation for medical support. • Appendix II. Clarifies that it is the CRT that is responsible for review and approval of all Medical Add-ons. The Department also defined what medical conditions support the Medical Add on rate. • Appendix V- Added Requirements for Section 21 Providers of Home Support Services, Community Support Services, and Employment Specialist Services. This new section of policy was added to assure the health and safety of members as well as quality of services, by placing requirements on certain providers. The requirements include requiring providers to comply with Department regulations for individuals with Intellectual Disabilities, and to comply with Department regulations regarding reporting incidents of abuse, neglect and exploitation of members with intellectual disability. Additional requirements include requiring providers to make available financial information to the Department, and include requirements of homeowners and/or rental insurance. These requirements protect Section 21 members, who are among Maine’s most vulnerable citizens. Although the Department proposed a change (21.08-4 in the proposed rule) which would have prohibited providers from terminating members without written approval of the Department, the Department has determined to not adopt this change, in light of many public comments challenging this change. Although the Department proposed the change under 21.05-2 Career Planning which was quality oriented language, the Department has removed from the rule the language requiring that plans will need to be sent into the Department at 3 intervals as those intervals were not defined clearly in the proposed rule. For a list of changes made from the proposed rule to the Adopted Rule, please review the Summary of Comments and Department’s Responses that were filed with this rule. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
View Comments: COMMENTS  Posted: March 2, 2017
 
PROVISIONALLY ADOPTED MAJOR SUBSTANTIVE RULE, MaineCare Benefits Manual, Chapter III, Section 29 Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF 
Concise Summary: PROVISIONALLY ADOPTED MAJOR SUBSTANTIVE RULE AGENCY: Department of Health and Human Services, MaineCare Services CHAPTER NUMBER AND TITLE: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter III, Section 29 Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder ADOPTED RULE NUMBER: CONCISE SUMMARY: The Department seeks to provisionally adopt changes to the reimbursement rates in Chapter III, Section 29, pursuant to P.L. 2015, ch. 477, An Act to Increase Payments to MaineCare Providers That Are Subject to Maine’s Service Provider Tax (eff. April 15, 2016). Through this law, the Legislature required a 1% increase in reimbursement for certain services to offset an increase in the service provider tax, which took effect January 1, 2016. In addition, the Department seeks to provisionally adopt new codes and rates for Work Support provided to multiple members at one time. The Department is making these changes to allow for providers to bill for different group sizes. On September 28, 2016, the Department implemented the above-described changes through emergency major substantive rulemaking. Pursuant to 5 M.R.S. § 8073, emergency major substantive rules are effective for up to 12 months, or until the Legislature has reviewed and approved of the provisionally adopted rule. In addition, pursuant to 22 M.R.S. § 42(8), these emergency rule changes are effective retroactive to April 15, 2016. Following provisional adoption, the Department shall submit the changes in Chapter III Section 29 to the Legislature for review, pursuant to 5 M.R.S. § 8072. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: PROVISIONALLY ADOPTED
View Comments: COMMENTS  Posted: March 2, 2017
 
MaineCare Benefits Manual, Chapter II, Section 29 Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder WORD  PDF 
Concise Summary: The Department is adopting various changes in its rule that help move the Section 29 waiver program towards compliance with 42 C.F.R. § 431.301(c). This federal regulation, effective March 17, 2014, sets forth new provisions for Home and Community Based Services (HCBS) waiver programs, including provisions outlining the person-centered planning process and provisions outlining the qualities of HCBS settings. In addition, to protect members and increase the quality of the Covered Services, the Department is implementing various new provider requirements in Section 29. Significant Updates and Changes to Chapter II, Section 29 include the following: Changes were made to ensure consistency with the current version of the Diagnostic and Statistical Manual of Mental Disorders (the “DSM”), the DSM 5. Specifically, the reference in the title of this section was changed from “Autistic Disorder” to “Autism Spectrum Disorder.” In addition, throughout Section 29, the term “Mental Retardation” with the term “Intellectual Disability.” Language was added to the Introduction, Section 29.01, to clarify the purpose of the rule and its intended impact. This change provides more detailed language than existed previously regarding the relationship of the rule to other MaineCare benefits and explains that the benefit is limited in scope. Multiple changes were made to the Definitions, Section 29.02, including the following: o A definition of Clinical Review Team (the “CRT”) was added at 29.02-7. The CRT is a newly formed entity that will handle Medical Add On requests. The definition describes the role of the CRT and its responsibilities. o The definition of Direct Supports at 29.02-10 was amended to remove specific examples of particular Covered Services to preclude the interpretation that Direct Support could be utilized only for those particular Covered Services. o A definition of Exploitation was added at 29.02-12, as this is one of the circumstances in which providers are expected to report to the Department. o Language was added to the definition of Medical Add On at 29.02-16 in order to specify the meaning of the term and the services to which it applies, and to explain how it is determined whether to grant Medical Add On. o Language was added to the “On Behalf Of” section at 29.02-19 in order to specify the that it is a billable activity and to remove unnecessary language. Subpart F was removed from Section 29.03-2, General Eligibility Criteria, Subpart F had specified “lives with family or on their own,” as an eligibility requirement. The Department determined that this language was too limiting, in that people have a variety of living scenarios, including living with   unrelated roommates, or with paid staff or residing in a boarding or group home separate from the waiver. Under Section 29.03-5, Waiting List and Offers for Funding Openings, language was added to specify that once a member receives an offer, he or she moves from the waiting list to a different status, of offer received. The intent is to clarify that such a member is no longer part of the waiting list, thereby freeing up a spot on the waiting list for placement of a new member, with the goal of getting Covered Services to more eligible members more quickly. Under Section 29.04, Personal Plan, the language was updated to ensure that the member is driving the process and that the process is more closely aligned with 42 CFR §§ 441.301 and 441.303 (eff. March 17, 2017). Direct references to the CFR were included and the Department shall file copies of the incorporated regulations with the Secretary of State’s Office pursuant to 5 M.R.S. § 8056(B)(1)-(3). Multiple changes were made to Section 29.05, Covered Services, including, • Under Section 29.05-2, Career Planning, quality-oriented language was added so that the Department could review plans more frequently for appropriateness for the member. • Under Section 29.05-3, Community Support, language was added to reinforce the fact that career exploration is included as part of this Covered Service and to stress the importance of employment related activities. • Where applicable, dollar caps were increased to reflect the reimbursement increases implemented by this rule. • At 29.05-4, Employment Specialist Services, 29.05-11 and Work Support-Individual the limits were removed that prevented members from receiving Employment Specialist Services and Work Support Services while enrolled in high school. This will allow members in transition to begin receiving services sooner, to help them prepare for changes after high school and, ideally, attain employment. Under Section 29.06, Non Covered Services, the provision excluding certain family members and guardians from providing direct and indirect services to members was removed. Some members receive services from family members, and the Department seeks to continue this practice, which makes services more accessible for members and offers greater member choice. A number of changes were made to Section 29.07, Limits, including, o At 29.07-2, Assistive Technology and Career Planning were removed from the annual dollar cap. These services are subject to separate limits as described at 29.07-14 for Assistive Technology and 29.07-15 for Career Planning. o At 29.07-4 the limit for Home Accessibility Adaptions was increased from $5,000 in a three year period to $10,000 in a five year period. This provides more services and greater flexibility to members. o At 29.07-10, the limit was removed that prevented members from receiving Work Support Services while enrolled in high school. This will allow members in transition to begin receiving services sooner, to help them prepare for changes after high school and, ideally, attain employment. o At 29.07-15, the cap of 60 hours of services must be delivered within a six month period, instead of annually. The Department believes this will improve the quality and effectiveness of this Covered Service. o At 29.07-16, language was added in order to prevent individuals living out of state from receiving MaineCare services, which is contrary to state and federal law. o Throughout, the Department increased various dollar caps to reflect the 1% increase in reimbursement for providers. At 29.10, Provider Qualifications and Requirements, new provisions were added to provide additional safeguards for member health and safety, improve quality of services and to increase training and the qualifications for providers. The following changes were made: o Additional qualifications for Direct Support Professionals. o Additional qualifications for Employment Specialist. o Clarification of Background Check Criteria. o Clarification of Reportable Events & Behavioral Treatment. At 29.12, Reimbursement, language was added to ensure compliance with the MaineCare rules as regards provider billing requirements. In Appendix I, language was added to provide details regarding the role and composition of the Clinical Review Team, the types of services that would be appropriate for Medical Add On, and the requirements for Medical Add On determinations and approvals. The Department removed authority to approve Medical Add On retroactively to the date of application because Medical Add on is effectively a prior authorization, which by its nature cannot be backdated. A new Appendix, Appendix IV- Additional Requirements for Section 29 Providers of Community Support Services, and Employment Specialist Services was added. The Department is adding these requirements to help ensure high quality services to members. The following is a summary of significant changes that were made to the final rule as a result of the public comments and review by the Office of the Attorney General. A complete list of all changes to the final rule is contained in the Summary of Comments and Responses document. At Sections 29.05-10 and 29.07-2, the program dollar cap was increased from $23,771.00 to $23,985.00, which reflects the 1% increase in reimbursement and assures no effective service reduction. Also, hourly caps were removed to make clear that the Department intends only to use the dollar caps. Elimination of the hourly caps removes redundancy and potential confusion from the rule, as the monetary cap accomplishes the same purpose as hourly caps. As a result of comments as well as review by the Office of Attorney General, changes from proposed rule were removed so as to retain the requirement that various services must be implemented within ninety (90) days of assessment. See Sec. 29.04 (Personal Plan), 29.05-1 (Home Support Remote Support). At 29.04-4, the term “Guardian” was added to make it clear that a member’s guardian may also request an update to the Personal Plan. At 29.04-2, to be consistent with Section 21, citations to 42 CFR § 441.301(c)(1) and 34-B M.R.S.A. § 5470-B(2) were added. Also, to ensure consistency with Section 21, at 29.04-2 and 21.10-1, clarification of policy mandating that Grievance Training must take place prior to working with members was added. At 29.05-5, the limit for adaptations was changed from $5,000 in a three year period to $10,000 in a five year period in order to allow greater flexibility for members using this benefit. At 29.05-7, Home Support-Remote Support the restriction that “sub-contracting is not permissible under this service” was removed. This will allow providers to subcontract with entities that specialize in technology and provider greater access to Covered Services for members. Section 29.08-4 (Provider Termination of a Member’s Service) was removed as a result of concerns raised by commenters and the Office of the Attorney General. • At 29.10-4, Background Check Criteria, the reference to “prospective” employees was removed as a result of concerns raised by commenters and the Office of Attorney General. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: March 4, 2017
View Comments: COMMENTS  Posted: March 2, 2017
 
MaineCare Benefits Manual, Chapters II and III, Section 20, Home and Community Based Services for Adults with Other Related Conditions WORD  PDF 
Concise Summary: The Department has made changes to Chapter II that help move the Section 20 waiver program towards compliance with 42 C.F.R. § 431.301(c), which sets forth new provisions for Home and Community Based Services (HCBS) waiver programs, including provisions outlining the person-centered planning process and provisions outlining the qualities of HCBS settings. The Department has updated Chapter II to expand eligibility criteria and services for Section 20 members. The Department added Muscular Dystrophy, Huntington’s, Spina Bifida or other rare developmentally based conditions to General Eligibility Criteria at Section 20.03-2, and removed the provision that “any other condition will be reviewed for eligibility by the Office of MaineCare Services Medical Director.” The Department is also adding Career Planning as a new service, consistent with other developmental services waiver programs. The Department is seeking approval from CMS to add Licensed Audiologists to the list of providers of Communication Aids services. Although this was not contained in the Chapter II rule proposal, this change is being adopted in Chapter II on the basis that it will benefit members by expanding the number of professionals qualified to provide this service. The Department is also making changes to Chapter II that CMS has already approved in the current waiver, including clarifying the limits on the reimbursement of Assistive Technology Devices. The rule clarifies that there is a combined limit of $6,000.00 annually for devices and certain services associated with leasing, purchasing, and maintaining the devices; and that data transmission utility costs are covered up to $50.00 per month. Consistent with the current waiver, the adopted rule also clarifies that for Home Support Services in Section 20.05-9, an individual Personal Care Assistant, Personal Support Specialist, or Direct Support Professional shall not be reimbursed for more than forty hours per week for any one waiver member. This provision follows other developmental services waiver programs, and this change helps ensure that individual providers are able to deliver services in a focused and safe manner. Other changes to Chapter II include updating the Quality Reporting requirements in Section 20.14 to help ensure members are receiving quality services under this waiver. The Department has also made a number of formatting and clerical changes to Chapter II for rule clarity. For Chapter III, the rule adoption increases rates in accordance with P.L. 2015, ch. 477 (An Act to Increase Payments to MaineCare Providers That Are Subject to Maine’s Service Provider Tax). Effective April 15, 2016, this law provides additional appropriations to certain MaineCare providers that are subject to the service provider tax and that have experienced an increase in the tax from 5% to 6% since January 1, 2016. The Chapter III rule adoption also clarifies reimbursement limits for Assistive Technology Devices, and adds the appropriate procedure codes. The Department also added a procedure code for Career Planning, which was inadvertently left out of the proposed rule, and is consistent with Chapter II provisions. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: March 01, 2017
View Comments: COMMENTS  Posted: March 1, 2017
 
MaineCare Benefits Manual, Chapter III, Section 18, Allowances for Home and Community Based Services for Adults with Brain Injury WORD  PDF 
Concise Summary: This adopted rule includes rate increases to comply with P.L. 2015, ch. 477 (eff. April 15, 2016), consistent with changes adopted in emergency rulemaking. The adopted rule results in a 1% rate increase for the following services: o T2019 U9, Employment Specialist Services (Habilitation, supported employment waiver), from $7.42 to $7.49 per ¼ hour. o T2016 U9, Home Support (Residential Habilitation) Level II, from $298.35 to $301.39 per diem. o T2016 U9 TG, Home Support (Residential Habilitation) Level III – Increased Neurobehavioral, from $485.00 to $489.61 per diem. o T2017 U9, Home Support (Residential Habilitation) Level I, from $6.27 to $6.33 per ¼ hour. o T2017 U9 QC, Home Support (Residential Habilitation)-Remote Support-Monitor Only, from $1.62 to $1.63 per ¼ hour. o T2017 U9 GT, Home Support (Residential Habilitation)-Remote Support-Interactive Support, from $6.27 to $6.33 per ¼ hour. o 97535 U9 Self Care/Home Management Reintegration-Individual, from $14.39 to $14.52 per ¼ hour. o 97535 U9 HQ Self Care/Home Management Reintegration-Group, from $9.59 to $9.68 per ¼ hour. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: February 27, 2017
View Comments: COMMENTS  Posted: February 27, 2017
 
MaineCare Benefits Manual, Chapters II & III, 101, Section 17, Community Support Services and Allowances for Community Support Services WORD  PDF 
Concise Summary: The Department adopts this rule to effectuate the following changes: 1. This rule adoption will finalize the addition of transition language for members receiving services within Section 17 who no longer meet clinical criteria for services due to the rule change adopted March 22, 2016 with effective date of April 26, 2016. Following various changes to Chapter II, Section 17, Community Support Services adopted by the Department on March 22, 2016, certain members no longer met clinical criteria for Community Support Services. This prompted a legislative review of the Section 17 rule changes, after which the Legislature enacted Resolves 2015, ch. 82 (eff. Apr. 26, 2016). This Resolve requires the Department to extend the authorized service period for certain individuals who no longer meet clinical criteria for Section 17 services after the rule changes adopted on March 22, 2016. For members affected by the March 22nd rule change, the Department shall authorize a 120 day extension for the member’s Section 17 services. Additionally, 90-day extensions may be granted, provided the member is able to reasonably demonstrate to the Department, or Authorized Entity, that he or she has attempted to, and has been unable to, access medically necessary covered services under any other section of the MaineCare Benefits Manual. The Chapter II changes shall be effective retroactive to April 26, 2016. The temporary transition period shall end on June 30, 2017. 2. Separately, the Legislature enacted An Act to Increase Payments to MaineCare Providers that are Subject to Maine’s Service Provider Tax, P.L. 2015, ch. 477 (eff. Apr. 15, 2016). Certain MaineCare providers subject to the service provider tax have experienced an increase in the tax to 6% since January 1, 2016. The Legislature thus provided additional appropriations to certain MaineCare providers, including Section 17 providers, in an effort to offset the increase in the provider tax. The Department is seeking and anticipates CMS approval of the reimbursement changes for Section 17 providers. Pending approval, the Department will reimburse providers under the new increased rates retroactively to July 1, 2016 pursuant to P.L. 2015, ch. 477 (eff. Apr. 15, 2016). 3. The Department notes that on April 29, 2016, the Legislature overrode the Governor’s veto of LD 1696, Resolve, To Establish a Moratorium on Rate Changes Related to Rule Chapter 101: MaineCare Benefits Manual, Sections 13, 17, 28 and 65 (Resolves 2015, ch. 88). That law imposes a moratorium on rulemaking to change reimbursement rates, including Section 17, until after a rate study has been completed and presented to the Legislature. The Department consulted with the Office of Attorney General and the Office of the Attorney General determined and has advised the Department that Resolves 2015, ch. 88 does not prevent the rule changes because (1) the separate law, P.L. 2015, ch. 477, is more specific in regard to changing reimbursement for providers impacted by the Service Provider Tax increase; and (2) these are reimbursement rate increases, thus providing a benefit to MaineCare providers. 4. This rule adoption will remove Clubhouse services and Specialized Group Services as covered services and for reimbursement from this section of policy, as those services are now available via Section 65: Behavioral Health Services. A limitation has been added to ensure Clubhouse services could no longer be provided via this section of policy. Additionally, a limitation has been added in response to comment to prohibit Section 17 Community Support Services from being provided concurrently with Clubhouse or Specialized Group services available within Section 65, Behavioral Health Services. 5. This rule adoption adds the definition of the Adult Needs and Strengths Assessment (ANSA), as well as provider requirements to complete, update, and document the assessment at regular intervals. In response to comments, 17.08-2 has been updated since the proposed rule to add specificity of when the initial ANSA will be completed (initial thirty (30) days of treatment), who will complete it (ANSA certified staff), and under which service (Community Integration). 6. This rule adds language giving members the option to request to hold for service if providers are unable to meet the seven (7) day face-to-face requirement of new referrals per 17.03. Members may elect to hold for service only after an agency has adequately informed the member of their options. The member must be advised of alternative service providers and must have the option to wait given available information. 7. The rule also adds language to the Individualized Service Plan in 17.04-1.E requiring a goal on a member’s access to primary care, specialty care, and routine appointments. This also requires the MHRT to document evidence of the visit as described in 17.04-1.N. This has been updated since the proposed rule to modify language from “Primary care physician” to “primary care provider.” 8. Lastly, this rule updates language of CMS approval about the inclusion of Certified Peer Support Specialists (CIPSS) as part of the ACT Team defined in 17.04-3.A-5. 9. Additional changes have been made via feedback from the comment period and AAG review, which are noted at the conclusion of the Comments documents. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: February 26, 2017
View Comments: COMMENTS  Posted: February 26, 2017
 
MaineCare Benefits Manual, Chapter III, Section 96, Private Duty Nursing and Personal Care Services WORD  PDF 
Concise Summary: The Department of Health and Human Services adopts these rule changes to Chapters II & III, Section 96, Private Duty Nursing and Personal Care Services to change reimbursement rates and level of care caps for personal care and related services to comply with Resolves 2015, ch. 83, Resolve, Directing the Department of Health and Human Services To Increase Reimbursement Rates for Home-based and Community-based Services. This resolve went into effect on July 29, 2016, without the Governor’s signature. The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services (“CMS”) for these changes. Pending approval, the increased reimbursement rates will be effective retroactive to July 29, 2016. In addition, in September of 2015, the Department proposed separate reimbursement rate changes to CMS; those rates are pending approval. As such, there are different effective dates for various rates, as set forth more specifically in Chapter II, Appendix 2, and in Ch. III. The Department is authorized to adopt certain of these changes retroactively under 22 M.R.S. §42(8) because the changes increase reimbursement for providers, and will have no adverse impact on either MaineCare providers or members. Where the reimbursement rates decrease, the Department shall apply them prospectively only. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: February 22, 2017
View Comments: COMMENTS  Posted: February 21, 2017
 
MaineCare Benefits Manual, Chapter II, Section 96, Private Duty Nursing and Personal Care Services WORD  PDF 
Concise Summary: The Department of Health and Human Services adopts these rule changes to Chapters II & III, Section 96, Private Duty Nursing and Personal Care Services to change reimbursement rates and level of care caps for personal care and related services to comply with Resolves 2015, ch. 83, Resolve, Directing the Department of Health and Human Services To Increase Reimbursement Rates for Home-based and Community-based Services. This resolve went into effect on July 29, 2016, without the Governor’s signature. The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services (“CMS”) for these changes. Pending approval, the increased reimbursement rates will be effective retroactive to July 29, 2016. In addition, in September of 2015, the Department proposed separate reimbursement rate changes to CMS; those rates are pending approval. As such, there are different effective dates for various rates, as set forth more specifically in Chapter II, Appendix 2, and in Ch. III. The Department is authorized to adopt certain of these changes retroactively under 22 M.R.S. §42(8) because the changes increase reimbursement for providers, and will have no adverse impact on either MaineCare providers or members. Where the reimbursement rates decrease, the Department shall apply them prospectively only. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: February 22, 2016
View Comments: COMMENTS  Posted: February 21, 2017
 
Chapters II & III, Section 12, Consumer-Directed Attendant Services and Allowances for Consumer-Directed Attendant Services WORD  PDF 
Concise Summary: The Department of Health and Human Services adopts these rule changes to Chapters II & III, Consumer-Directed Attendant Services and Allowances for Consumer-Directed Attendant Services to increase reimbursement rates to comply with Resolves 2015, ch. 83, Resolve, Directing the Department of Health and Human Services To Increase Reimbursement Rates for Home-based and Community-based Services. This resolve went into to effect on July 29, 2016, without the Governor’s signature. These changes are consistent with Resolves 2015, ch. 83, which requires the Department to change its reimbursement rates in Section 12 to reflect 50% of the increase as set forth in a final February 1, 2016 report by Burns & Associates, Inc., and approved by the Legislature. The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services (“CMS”) for these changes. Pending approval, the increased reimbursement rates will be effective retroactive to July 29, 2016. In addition, in September of 2015, the Department proposed separate reimbursement rate changes to CMS, those rates are pending approval. As such, there are different effective dates for various rates, as set forth more specifically in Ch. III. The Department is authorized to adopt certain of these changes retroactively under 22 M.R.S. §42(8) because these changes increase reimbursement for providers, and will have no impact on either MaineCare providers or members. Reimbursement rates for multiple member visits, the Department shall apply them prospectively only. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: February 22, 2017
View Comments: COMMENTS  Posted: February 21, 2017
 
Provisionally Adopted Chapter III, Section 97 WORD  PDF 
Concise Summary: The Department of Health and Human Services provisionally adopts these rule changes to Chapter III, Section 97, Private Non-Medical Institution (PNMI) Services to effectuate a one (1) percent rate increase in the direct care component to PNMI Services providers who have experienced an increase in the Maine Service Provider Tax since January 1, 2016 pursuant to Public Law 2015, ch. 477, An Act to Increase Payments to MaineCare Providers That Are Subject to Maine’s Service Provider Tax. PNMIs are in need of increased funding to continue providing these services to Maine’s vulnerable citizens, including children, individuals with intellectual disabilities and autistic disorder. The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Service (CMS) for these changes. Pending approval, the increased reimbursement rates will be effective retroactive to July 1, 2016. In addition, Chapter III, Section 97 (the “Main Rule”) and Chapter III, Section 97, Appendix C only, the Department repeals and replaces the March 8, 2016 emergency major substantive rule, which made changes pursuant to Resolves 2015, ch. 45, Resolve, To Require the Department of Health and Human Services to Provide Supplemental Reimbursement to Residential Care Facilities in Remote Island Locations. These changes are incorporated into this provisionally adopted rulemaking. The Department is seeking and anticipates receiving approval from CMS for the remote island facility reimbursement increases. Pending CMS approval, those changes shall be effective retroactive to October 1, 2015. The Department is authorized to provisionally adopt these changes retroactively under 22 M.R.S. § 42(8) because these changes increase reimbursement for providers and will have no adverse impact on either MaineCare providers or members. Additionally, the Change in Reimbursement Methodology Notices required by 42 C.F.R. § 447.205 relating to the Service Provider Tax reimbursement increases were published on June 16, 2016 (for Appendices B and D) and August 11, 2016 (for Appendices C, E, and F). In regard to the remote island facility rule changes, in the “Main Rule” and Appendix C, the Department published its Notice of Change in Reimbursement Methodology on September 30, 2015. All of these changes were enacted on an emergency basis on October 25, 2016. The emergency rule changes shall remain effective for one year or until the Legislature has reviewed and approved the provisionally adopted rule, and the Department thereafter finally adopts the major substantive rule changes. 5 M.R.S. §§ 8072, 8073.
  Posted: January 19, 2017
 
MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facility Services WORD  PDF 
Concise Summary: The Department of Health and Human Services adopts this rule change to Chapter III, Section 67, Principles of Reimbursement for Nursing Facility Services to increase the Nursing Facility Services’ prospective and final prospective rate to one hundred percent (100%) of all calculated direct care and routine cost components. The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services for this change. Pending approval, the increased rate will be effective retroactive to July 1, 2016. The Department is authorized to adopt these changes retroactively under 22 M.R.S. §42(8) because these changes increase reimbursement for providers, and will have no adverse impact on either MaineCare providers or members. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: January 18, 2017
View Comments: COMMENTS  Posted: January 18, 2017
 
MaineCare Benefits Manual, Chapter III, Section 2, Adult Family Care Services WORD  PDF 
Concise Summary: The Department of Health and Human Services (“the Department”) adopts this rule to increase the rates of reimbursement for Adult Family Care Services pursuant to: 1) Public Law 2015, Chapter 481, Part C, An Act To Provide Funding to the Maine Budget Stabilization Fund and To Make Additional 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, 2016 and June 30, 2017. This adopted rule effectuates a four (4) percent cost-of-living rate increase for adult family care homes for the fiscal year ending June 30, 2017. The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services (CMS) for this change. Pending approval, the four (4) percent rate increase will be effective retroactive to July 1, 2016. 2) Resolves 2015, ch. 45, Resolve, To Require the Department of Health and Human Services To Provide Supplemental Reimbursement to Adult Family Care Home and Residential Care Facilities in Remote Island Locations. The Department previously engaged in emergency rulemaking followed by routine technical rulemaking that added language to the rule providing for a supplemental rate payment of fifteen (15) percent to adult family care homes that satisfy the definition of remote island facilities. The Department did not include a case mix chart specific to remote island facilities that identified the increased rates and now seeks to do so with this rule adoption. As noted previously, the Department is seeking and anticipates receiving CMS approval for the change so that the supplemental rate payment will be retroactive to October 1, 2015. The Department is authorized to adopt these changes retroactively under 22 M.R.S. §42(8) because these changes increase reimbursement for providers, and will have no adverse impact on either MaineCare providers or members. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: January 2, 2017
View Comments: COMMENTS  Posted: December 30, 2016
 
MaineCare Benefits Manual, Chapters II and III, Section 65, Behavioral Health Services WORD  PDF 
Concise Summary: This adopted rule makes two major changes: (1) the incorporation of standards for Medication-Assisted Treatment (MAT) with Methadone for opioid dependence; and (2) the transfer of certain services from Section 17, Community Support Services, to Section 65, Behavioral Health Services. For MAT with Methadone services, the Department is adopting these rule changes to more closely align the provision of these services with existing federal regulations governing opioid treatment programs, federal Substance Abuse and Mental Health Services Administration guidelines, and State licensing rules for these facilities. The vast majority of the adopted rule provisions coincide with these existing requirements, including staff credentials, responsibilities of the medical director, member assessments, the development of an individualized service plan, testing for drug use disorder, and medication administration. Some service requirements in this rule adoption are new, such as how counseling with methadone treatment is structured, the addition of MaineCare-specific forms, and the prior authorization criteria for services beyond 24-months. The Department has made some changes to the rule adoption as a result of public comment and further review. These changes are explained in the basis statement and summary of public comments documents. Second, the Department is moving Clubhouse Services and Specialized Group Services from Section 17 to Section 65, as changes in clinical criteria for Section 17 services may restrict member access to these particular services. Rates for these services are not changing and have also been incorporated under the Chapter III rule. Finally, in addition to these two substantive rule changes, the Department has made a number of technical edits. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: November 23, 2016
View Comments: COMMENTS  Posted: November 23, 2016
 
MaineCare Benefits Manual, Chapter III, Section 109, Speech and Hearing Services WORD  PDF 
Concise Summary: The adopted rule makes the following changes: (1) it reduces the agency rate for code 92587 (distortion product); (2) it reduces both the agency and independent rate for code 92588 (distortion product); (3) it adds a new code 92586 (limited auditory evoked potentials); and (4) it clarifies the description for some codes. The Department is seeking, and anticipates receiving, approval from the federal Center for Medicare and Medicaid Services (CMS) for the rate changes, and the addition of the new code. Pending approval, the rate changes and the new code will be effective as of November 28, 2016. A methodology change notice was published on March 4, 2016. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: November 28, 2016
View Comments: COMMENTS  Posted: November 23, 2016
 
MaineCare Benefits Manual, Chapters II and III, Section 103, Rural Health Clinic Services WORD  PDF 
Concise Summary: This rule amends the rate setting and rate-adjustment processes for the Prospective Payment System (PPS) used to reimburse Rural Health Clinic Services (RHCs). This rulemaking clarifies and expands the current RHC policy and procedures as follows: • Provides additional guidance in the methodology for adjustments of PPS rates; • Amends the process of rate establishment for newly qualifying RHCs; • Provides specific guidance in what constitutes “a change in scope of services”; and • Expands the reporting requirements to support requests for rate adjustments due to a change in scope of services. • Additional changes to the rule include broadening the tobacco cessation treatment services to comply with 22 M.R.S. § 3174-WW, and expanding current contraceptive coverage to include all federally approved intrauterine devices. The Centers for Medicare and Medicaid Services (“CMS”) has approved a Maine State Plan Amendment related to initial rate-setting and “change in scope of services.” The payment methodology for RHCs conforms to Section 702 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: December 1, 2016
View Comments: COMMENTS  Posted: November 23, 2016
 
MaineCare Benefits Manual, Chapters II and III, Section 31,Federally Qualified Health Center Services WORD  PDF 
Concise Summary: This rule amends the rate setting and rate-adjustment processes for the prospective payment system (PPS) used to reimburse Federally Qualified Health Centers (FQHCs). This rulemaking clarifies and expands the current FQHC policy and procedures as follows: • Provides additional guidance and consistency in the methodology for adjustments of PPS rates; • Amends the process of rate establishment for newly qualifying FQHCs; • Provides specific guidance in what constitutes a “change in scope” of services; and • Expands the reporting requirements in conjunction with a request for rate adjustment due to a “change in scope” of services. • Additional changes to the rule include broadening the tobacco cessation treatment services to comply with 22 M.R.S. § 3174-WW, and expanding current contraceptive coverage to include all federally approved intrauterine devices. The Centers for Medicare and Medicaid Services (“CMS”) has approved a Maine State Plan Amendment related to initial rate-setting and “change in scope” of services. The payment methodology for FQHCs conforms to Section 702 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000. See: HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: December 1, 2016
View Comments: COMMENTS  Posted: November 23, 2016
 
MaineCare Benefits Manual, Section 55, Chapter II, Laboratory Services WORD  PDF 
Concise Summary: This rule was adopted to limit and align urine drug testing to current industry standards. The Department adopted the following from the proposed rule: • Drug testing must be supported by documentation in the medical record. • The frequency and choice of assay used should be based on an assessment of the individual member’s risk potential. • Separate payment for testing of adulterants or specimen validity is not reimbursable. • Substance abuse treatment is to be measured by random testing rather than scheduled testing. • Routine urine drug screening should focus on detecting specific drugs of concern. • Standing orders for presumptive testing must be signed and dated no more than sixty (60) days prior to the date of specimen collection. Standing orders for conformation and/or quantitative testing is prohibited. • The Department clarifies what is considered not medically necessary. • The Department added language for Prior Authorization to the Definitions. The Department made the following changes to the final rule based on public comments: • Confirmation testing is covered only to: 1. Confirm an unexpected result; or 2. Identify specific drugs or metabolites that cannot be detected on a urine drug screen. Confirmation tests should be based on the member’s presentation and history and only include what is needed for safe patient management. The definitive test(s) must be supported by documentation that specifies the rationale for each definitive test ordered. Drug confirmation testing must be performed by a second method. A presumptive test cannot be performed to confirm a presumptive test. Confirmation testing must be requested in writing by the ordering provider. • Urine drug testing is limited to three (3) specimens per rolling month. Additional test(s) may be requested with a Prior Authorization to be issued in six (6) month authorizations. Individuals meeting the following criteria are exempt from this limitation, and are not required to seek Prior Authorization for testing beyond three (3) specimens per month: 1. Pregnant members; 2. Members involved with an active Office for Child and Family Services (OCFS) case; 3. Members in Intensive Outpatient Treatment (IOP); 4. Members being established in Medicated Assistant Treatment (MAT) up to six months (including methadone, suboxone, and other MAT treatments); 5. Members receiving services in an Emergency Department; and 6. Members in Residential Treatment for substance abuse (Chapter 97 Appendix B facilities) • The Department removed the limit of reflex testing by the lab based on standing order. • The Department removed the limit of urine drug testing for the courts. Finally, the Department made minor clerical edits to the final rule. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: November 9, 2016
View Comments: COMMENTS  Posted: November 9, 2016
 
MaineCare Benefits Manual, Chapter X, Section 4, Limited Family Planning Benefit WORD  PDF 
Concise Summary: This rule establishes the Limited Family Planning Benefit. Under the Limited Family Planning Benefit, the Department provides for the delivery of federally approved Medicaid services to qualified individuals when their income is equal to or below 209% of the nonfarm income official poverty line for reproductive health care and family planning services. The goal is to improve the health of individuals and families in Maine by improving access to family planning services and decreasing the overall costs of healthcare by helping to prevent or delay pregnancies and to improve overall reproductive health of enrollees. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: October 1, 2016
View Comments: COMMENTS  Posted: September 30, 2016
 
MaineCare Benefits Manual, Chapters II & III, Section 43, Hospice Services WORD  PDF 
Concise Summary: This adopted rule implements hospice payment reforms to comply with the CMS September 1, 2015, Directive regarding annual changes in the Medicaid Hospice payment rate. This CMS directive reflects changes made under the final Medicare hospice rule published on August 6, 2015 (CMS-1629-F)(42 CFR §§ 418.302, 418.306). This rule changes the payment methodology for Routine Home Care to implement two rates that will result in 1) a higher base payment for the first sixty (60) days of hospice care and 2) a reduced base rate for days thereafter. This adopted rule requires hospice providers to set their charge rate to appropriately reflect the transition to the lower Routine Home Care rate after sixty (60) days. A new Service Intensity Add-on (SIA) payment for services provided by a registered nurse (RN) or clinical social worker during a visit during the last seven (7) days of a member’s life has also been added. The rulemaking also updates the policy titles and section numbers listed in § 43.05-4, Coverage Restrictions during Hospice Election, to correlate with the current version of the MaineCare Benefits Manual, and includes Physician Assistant in the list of Professional and other Qualified Staff in § 43.06-3. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: August 26, 2016
View Comments: COMMENTS  Posted: August 26, 2016
 
MaineCare Benefits Manual, Chapter III, Section 15, Chiropractic Services WORD  PDF 
Concise Summary: This rule is being adopted to update current billing practices by removing the basic value language that utilizes the units system and replaces the units with rates. Additionally, chiropractic codes were updated to align with current 2016 CPT codes. These changes include the elimination of code 72090 and the addition of codes 72081, 72082, 72083, and 72084. On March 16, 2016, the Department submitted proposed State Plan Amendment changes to the Centers for Medicare and Medicaid Services (CMS), with a requested retroactive effective date of January 1, 2016. Those changes remain pending. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents. EFFECTIVE DATE: Retroactive to January 01, 2016. AGENCY CONTACT PERSON: Cari Bernier, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 Email: Cari.Bernier@maine.gov TELEPHONE:(207)-624-4031 FAX: (207)-287-1864 TTY users call Maine relay 711
Effective Date: Retroactive to January 01, 2016
View Comments: COMMENTS  Posted: August 1, 2016
 
MaineCare Benefits Manual (MBM), Chapter II, Section 90, Physician Services WORD  PDF 
Concise Summary: This rulemaking includes the following changes: • Allows for coverage of comprehensive tobacco cessation treatment without limitations, including individual and group counseling and products for all members. These change are effective retroactive to August 1, 2014 for members who are eighteen (18) years and older or who are pregnant. Members under the age of eighteen (18) had already been receiving these benefits at no cost. The amended rule adoption language from the proposal reminds providers of existing legal requirements for the submission of any retroactive claims. • Adds coverage for Oral Evaluations by a medical provider for children under the age of three (3) and amends coverage of topical application of fluoride varnish to align with MBM, Ch. II and III, Section 25, Dental Services. • Removes current limits for outpatient Psychiatric Services on the number of allowable services in any consecutive seven (7) day period and on the number of emergency therapy visits. This rulemaking also removes the requirement that providers delivering psychiatric services within their scope of licensure and state law must be under direct supervision of a board-eligible or certified psychiatrist. • Amends the anesthesia time unit used for billing anesthesia services to one (1) minute intervals, rather than fifteen (15) minutes, in order to comply with HIPAA Version 5010. The rule adoption clarifies the start and end times of anesthesia services in line with Centers for Medicare and Medicaid Services (CMS) rules. This rulemaking also clarifies the components of anesthesiology services and more closely aligns MaineCare policy to CMS regulations regarding medically-directed and medically-supervised anesthesia services. • The time periods indicated in surgical services for post-operative treatment have been amended to comply with the CMS standard fee schedule for durational global surgical periods of 0, 10, or 90 days. The rule adoption also clarifies what services are included in the global surgical package in accordance with CMS standards. • Aligns with current MBM, Section 94, Early and Periodic Screening, Diagnosis, and Treatment Services (EPSDT) practice and reimbursement policies so that providers are no longer required to submit Well Child Visit (“Bright Futures”) forms in order to receive MaineCare reimbursement for services. • Amends provider qualifications for obstetrical services to ensure that any appropriately licensed or certified, qualified professional working within their scope of licensure or certification may deliver obstetrical services to MaineCare members. Providers are expected to engage in collaborative management of individual members with appropriate consultation, referrals and transfers of care including, but not limited to, transfer of care for the purpose of specialized treatment and admission to an approved MaineCare hospital, with such treatment including maternity services. • Updates the methods the Department uses to set rates in the MaineCare Fee Schedule to include an option to obtain an average from other state Medicaid agencies when a code is not priced by Medicare. • The rulemaking also incorporates the Primary Care Increased Payment initiative, effective January 1, 2015. This initiative replaces expiring funds provided through the federal Affordable Care Act (ACA), Pub. L. 111-148 and Pub. L. 111-152, that have been extended through the State’s biennial budget, P.L. 2015, Ch. 267, Part A. Providers who were enrolled prior to January 1, 2015 have continued to receive the increased reimbursement and new providers have been eligible to enroll through completing a self-attestation form since January 1, 2015. Eligible providers are physicians practicing with a specialty designation of family medicine, internal medicine, or pediatric medicine or with a subspecialty within these three primary care categories that is recognized by the American Board of Medical Specialties, the American Board of Physician Specialties, or the American Osteopathic Association. Advanced Practice Registered Nurses and Physician Assistants who work under the direct supervision of an eligible physician are also eligible. Hospital-based physicians and physicians in Federally Qualified Health Centers or Rural Health Clinics remain ineligible. • Clarifies Section 90.09-3, Reimbursement Rate for Drugs Administered By Other Than Oral Methods, without any change in coverage, reimbursement, or procedures. • Deletes the separate Computerized Axial Tomography Scan subsection under Covered Services and includes the same information in Medical Imaging Services subsection. • States that audiologists, physical therapists, and occupational therapists must follow the expectations and limitations in their applicable sections of policy when rendering services in a physician’s practice. • Removes language referencing “provinces” and “provincial law” for consistency with MBM, Ch. 1, Section 1.03-2, which provides that MaineCare will not provide payment to any entity outside the United States, and as required by Section 6505 of the ACA, Pub. L. 111-148. • Makes a number of non-substantive technical changes to the rule as a result of public comments and further review by the Department and the Office of the Attorney General. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: July 20, 2016
View Comments: COMMENTS  Posted: July 20, 2016
 
MaineCare Benefits Manual, Chapters II & III, Section 2, Adult Family Care Services WORD  PDF 
Concise Summary: This adopted rule complies with Resolves 2015, ch. 45 Resolve, To Require the Department of Health and Human Services to Provide Supplemental Reimbursement to Adult Family Care Homes in Remote Island Locations. This law went into effect on July 12, 2015 without the Governor’s signature. This rule effectuates a supplemental payment to Adult Family Care Homes located on an island not connected to the mainland by a bridge. The supplemental payment to eligible Adult Family Care Homes represents a fifteen (15) percent rate increase from the MaineCare rate as established in Chapter III. The Department is seeking approval from the Centers for Medicare and Medicaid Services (CMS) for the State Plan Amendment. Pursuant to 22 M.R.S. §42(8), if CMS approves, the supplemental payment for Adult Family Care Homes that satisfy the definition of “remote island facility” will be effective retroactive to October 1, 2015. A Change in Reimbursement Methodology Notice was published on September 30, 2015. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: June 22, 2016
View Comments: COMMENTS  Posted: June 22, 2016
 
MaineCare Benefits Manual, Chapter II, Section 4, Ambulatory Surgical Center Services WORD  PDF 
Concise Summary: This rulemaking more closely aligns ASC policy with the reimbursement methodology of ASC facility and non-facility services, as defined by the Centers for Medicare and Medicaid Services (CMS). This includes a change that MaineCare will no longer reimburse ASCs separately for prosthetic devices that are outside the all-inclusive rate for covered surgical procedures, as defined by the CMS. This rulemaking also adds a general description of which surgical procedures are approved for delivery in an ASC, deletes components of the all-inclusive rate that were listed twice, more closely aligns reimbursement language with the CMS approved State Plan, removes the disclaimer that the section is dependent upon approval from CMS because approval has been granted, further clarifies which services and supplies are Non-Covered Services under this Section, updates the MaineCare provider website URL, and makes minor formatting edits. Also, as part of this rulemaking, physicians delivering covered services in an ASC will be reimbursed for their professional services at the “facility rate” listed in the MaineCare Fee Schedule (https://mainecare.maine.gov/) under MBM, Section 90, Physician Services. As a result of public comments, the adopted rulemaking improved language around physician reimbursement to clarify that physician and anesthetists professional services are still separately billable under MBM, Section 90, Physician Services. In addition, the Department added citations to the Code of Federal Regulations to assure that the Department’s interpretation of “implantable prosthetic devices” will be aligned with CMS. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: June 15, 2016
View Comments: COMMENTS  Posted: June 15, 2016
 
Chapter III, Section 97, Private Non-Medical Institution Services WORD  PDF 
Concise Summary: This provisionally adopted major substantive rule, which follows an emergency rule adopted March 8, 2016, effectuates an increase in the reimbursement rate for Appendix C PNMIs located in remote island locations, pursuant to Resolves 2015, ch. 45, Resolve, To Require the Department of Health and Human Services to Provide Supplemental Reimbursement to Residential Care Facilities in Remote Island Locations. This increase will apply only to Appendix C facilities located on an island not connected to the mainland by a bridge. Coincident, pursuant to Public Law 2015, Chapter 267, Parts A, Section A-32, & UU, the Department of Health and Human Services is increasing the Appendix C and F PNMIs’ assisted living reimbursement rate by four (4) percent. The four (4) percent increase will be accomplished through contract and is not specifically referenced in the rule. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents. EFFECTIVE DATE: June 6, 2016 AGENCY CONTACT PERSON: Heidi Bechard, Comprehensive Health Planner AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 Email: heidi.bechard@maine.gov TELEPHONE: (207)-624-4074 FAX: (207) 287-1864 TTY users call Maine relay 711
Effective Date: June 6, 2016
View Comments: COMMENTS  Posted: June 6, 2016
 
MaineCare Benefits Manual, Chapter III, Section 12, Allowances for Consumer Directed Attendant Services WORD  PDF 
Concise Summary: This adopted rule increases the reimbursement rate for Attendant Care Services under Chapter III, Section 12 to $2.93 per quarter hour. This increase is a result of Resolves 2015, Chapter 50, To Increase the Reimbursement Rate for Direct-care Workers Serving Adults with Long-term Care Needs. The Department is seeking approval from the Centers for Medicare and Medicaid Services for this rate increase, with an effective date retroactive to October 1, 2015. In addition to the rate increase, outdated procedures codes (S5125, S5125 TF and S5125 TG) have been removed from Chapter III, since a single procedure code (S5125 U2) is used for all three levels of service. The three levels of care are based on hours of need, as determined by the assessment process, and remain referenced in Chapter II, Section 12. References to the Maine Integrated Health Management Solution (MIHMS), which was implemented on September 1, 2010, have also been removed from Chapter III. Procedure codes H2014, G9001, and G9002 have not been utilized since that time. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: April 18, 2016
View Comments: COMMENTS  Posted: April 15, 2016
 
MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures WORD  PDF 
Concise Summary: This adopted rule removes the Telehealth section from Chapter 101, MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures concurrent with the implementation of Chapter 101, MaineCare Benefits Manual, Chapter I, Section 4, Telehealth Services. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: April 17, 2016
View Comments: COMMENTS  Posted: April 15, 2016
 
MaineCare Benefits Manual, Chapter I, Section 4, Telehealth Services WORD  PDF 
Concise Summary: This adopted rule develops a new standalone Telehealth policy, as opposed to a subsection of Chapter I, Section 1, as it was previously. This rule adoption follows the Legislature passing LD 1596 in 2014. LD 1596 directed the Department to “convene a working group to review the MaineCare rules regarding the definition of telehealth and the technologies used for provider patient interaction involving MaineCare patients” and to amend its rules regarding telehealth based upon the review by the working group. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: April 16, 2016
View Comments: COMMENTS  Posted: April 15, 2016
 
MaineCare Benefits Manual, Chapters II & III, Section 17, Community Support Services and Allowances for Community Support Services WORD  PDF 
Concise Summary: The Department adopts this rule to effectuate the following changes: 1. The Table of Contents has been updated to reflect new page numbers and includes 17.01-18, Primary Diagnosis. 2. List of Definitions now includes: a. Primary Diagnosis, 17.01-18 which now reads “for the purposes of this policy, primary diagnosis shall mean the diagnosis that results in qualifying functional deficits.” In response to public comments, Primary Diagnosis has been added to clarify 17.02-3 Specific Requirements for eligibility. b. 17.01-5, Clinician now reads “is an individual appropriately licensed or certified in the state or province in which he or she practices, practicing within the scope of that licensure or certification, and qualified to deliver treatment under this section. A clinician includes the following: Licensed Clinical Professional Counselor (LCPC); Licensed Clinical Professional Counselor-conditional (LCPC-conditional); Licensed Clinical Social Worker (LCSW); Licensed Master Social Worker conditional (LMSW-conditional clinical); physician; psychiatrist; Advance Practice Registered Nurse Psychiatric and Mental Health Practitioner (APRN-PMH-NP); Advance Practice Registered Nurse Psychiatric and Mental Health Practitioner (APRN-PMH-CNS); Physician Assistant (PA); or licensed psychologist.” Clinical has been removed from Licensed Clinical Psychologist as it appeared in proposed language, as suggested by a commenter. c. 17.01-21, Substance Abuse Counselor now reads “means an individual who is licensed by the Maine State Board of Alcohol and Drug Counselors as a Certified Alcohol and Drug Counselor (CADC), Licensed Alcohol and Drug Counselor (LADC); or an Advanced Practice Registered Nurse (APRN), Licensed Physician (MD or DO), Physician Assistant (PA), Licensed Psychologist, Licensed Clinical Social Worker (LCSW), Licensed Clinical Professional Counselor (LCPC), or Licensed Marriage and Family Therapist (LMFT), who has a minimum of one (1) year of clinical experience providing substance abuse treatment.” Physician Assistant has been added to this definition based on public comment. 3. 17.02-3(A)(2) Specific Requirements for Eligibility now reads “has a written opinion from a clinician, based on documented or reported history, stating that he/she is likely to have future episodes, related to mental illness, with a non-excluded DSM 5 diagnosis, that would result in or have significant risk factors of homelessness, criminal justice involvement or require mental health inpatient treatment greater than 72 hours, or residential treatment unless community support program services are provided; based on documented or reported history; for the purposes of this section, reported history shall mean an oral or written history obtained from the member, a provider or caregiver; or…” The additional language of “significant risk factors: and “reported history” have been included to clarify eligibility criteria based on comments received. 4. 17.02-3(A)(2)(f), As a result of comments, the Department changed the eligibility criteria to make it a less restrictive criteria (more generous to recipients). The changed provision now reads “until the age of 21, the recipient was eligible as a child with severe emotional disturbance, and the recipient has a written opinion from a clinician, in the last 12 months, stating that the recipient had risk factors for mental health inpatient treatment or residential treatment, unless ongoing case management or community support services are provided.” The proposed language read “and the recipient has a written opinion from a clinician, in the last 12 months, stating that he/she is reasonably likely to have future episodes requiring mental health inpatient or residential treatment, unless ongoing case management or community support services are provided,” and thus was more restrictive. 5. 17.02-3(B), now reads: “Has significant impairment or limitation in adaptive behavior or functioning directly related to the primary diagnosis and defined by the LOCUS or other acceptable standardized assessment tools approved by the Department.” This language was added to clarify the need for significant impairment or limitation in adaptive behavior or functioning as it relates to the primary diagnosis. 6. 17.02-4(C), now reads: “For Community Integration Services, only, verify that a member meets specific Eligibility Requirements under 17.02-3 within thirty (30) days of the start date of services. If Eligibility Verification is not submitted by close of business on day thirty (30), MaineCare will cease paying for services, under this section, on day thirty one (31).” In response to public comments indicating that the proposed language was confusing, additional language has been included. 7. 17.04-3, Assertive Community Treatment (Medication services), now reads: “capacity to administer medications daily in a member’s home or community by an appropriately licensed/certified ACT team professional.” In response to public comment “CRMAs are allowed to administer medications as delegated by the RN or other licensed medical providers” has been removed. 8. 17.07-1(B), now reads: “A psychologist who is a licensed psychologist by the Maine Board of Examiners of Psychologists or by the state or province where services are provided, as documented by written evidence from that Board.” Proposed language read “a licensed clinical psychologist”. In response to public comment clinical has been removed. 9. 17.07-1(J), now reads: “A registered nurse, under the direction of a psychiatrist, who is a graduate of an accredited nursing program and holds a valid license to practice in the state or province in which services are to be provided.” Proposed language read “a registered nurse, under the supervision of a psychiatrist”. In response to public comment “under the supervision” has been changed to “under the direction of”. 10. Changing the eligibility so that individuals with a sole diagnosis of either autism or intellectual disability (“neurodevelopmental disorders”), are no longer eligible for Section 17 services. However, individuals with neurodevelopmental disorders who also have a qualifying or co-occurring diagnosis, would remain eligible for Section 17 services. 11. Deletion of AMHI Consent Decree Class Member as a stand-alone criterion for eligibility to receive Community Integration Services. 12. Deletion of Intensive Case Management as a covered service. 13.Exceptions for face to face visit requirements through Assertive Community Treatment includes: a. All attempts to reach and meet with the member, including if the member was unavailable or the contact occurred through a closed door. b. Contacts to transition the member to another level of care. c. Variations in the number of weekly face-to-face contacts i.e. two (2) contacts in one week and four (4) the next. In response to public comment, “contacts assessed to be clinically inappropriate” has been removed as an exception. Changes made to the eligibility for Section 17 services were made so that only those individuals for whom Section 17 was clinically appropriate would be eligible. Section 17 services are designed to serve those most in need of intensive support. The Department believes that some of the individuals currently receiving Section 17 services are more appropriately served under other sections of the MaineCare manual, such as Section 65 (Behavioral Health Services), or Section 21 (Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorder), Section 29 (Support Services for Adults with Intellectual Disabilities or Autistic Disorder), or Section 92 (Behavioral Health Homes). The Department carefully evaluated the need for changes to Section 17 rule and spent nearly a year meeting with a group that included a psychiatrist and other clinicians. The Department spent a great deal of time reviewing and discussing clinical criteria for the appropriate treatment of individuals with severe mental illness and concluded that treating individuals with mild or moderate mental illness (individuals with conditions such as anxiety, mild or moderate depression, and PTSD) with the types of community supports provided in Section 17 is not clinically appropriate and can even be counter indicated. These individuals are better served with counseling and/or medication, and those services are available in Section 65, or through the holistic support provided in the Behavioral Health Home model, Section 92. Individuals with severe and persistent mental illness do benefit from intensive community supports, and they will remain eligible for these Section 17 services. The Department determined that it was in the best interest of the MaineCare population to make these changes to the eligibility criteria. As such, the Department tailored the eligibility criteria to meet the needs of the individuals for whom Section 17, is clinically appropriate. Intensive Case Management services were deleted because the Department determined after conducting studies, that this service was not being utilized. Case Management services continue to be available under Section 13. The Department deleted the status of an AMHI Consent Decree class member as a stand-alone criterion for eligibility for Section 17 Community Integration services, because that is not a standard recognized or authorized in federal Medicaid law or regulation. It is likely that there will be many Consent Decree class members who will remain eligible for Section 17 Community Integration services. For those class members who will no longer be eligible for Section 17 Community Integration services, the Department acknowledges its duty to provide services required under the Consent Decree, as provided and funded through non-MaineCare state contracts. The fiscal impact of this rulemaking is largely indeterminable. While the Department is unable to estimate how many recipients will no longer be eligible for Section 17 services because of these rule changes, the Department also cannot accurately predict how many of those recipients will seek out other services most notably Section 92, Behavioral Health Homes and Section 65, Behavioral Health Services, or Section 29 Community Support Services for Adults with Intellectual Disabilities or Autistic Disorders. In additions, regarding the Consent Decree, if individuals in this group do not meet Section 17 Community Integration eligibility criteria, they will no longer be eligible for Section 17 Community Integration services. However, they would remain eligible to receive Community Integration services, as required by the Consent Decree, and as provided and funded through non-Medicaid state contracts. It is anticipated that this rulemaking will not impose any costs on municipal or county governments, or on small businesses employing fewer than twenty employees. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: March 22, 2016 AGENCY CONTACT PERSON: Heidi Bechard, Health Planner AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 TELEPHONE: (207) 624-4074 FAX: (207) 287-1864 TTY: 711 (Deaf/Hard of Hearing)
Effective Date: March 22, 2016
View Comments: COMMENTS  Posted: March 22, 2016
 
MaineCare Benefits Manual, Chapters II and III, Section 19, Home and Community Benefits for the Elderly and for Adults with Disabilities WORD  PDF 
Concise Summary: This rule adoption effectuates rate increases as well as adjustments to monthly caps for Section 19 services. First, the Department adopts reimbursement rate increases under Chapter III, Section 19, for the following services: (1) Attendant Care Services (Personal Care Services, Participant Directed Option), billing code S5125, from $2.93 per quarter hour to $3.21 per quarter hour; and (2) Personal Care Services (Agency PSS), billing code T1019, from $3.75 per quarter hour to $4.10 per quarter hour. So as to not adversely affect members’ receipt of services as a result of these rate increases, the Department is also adopting an increase in the monthly cap for services under Chapter II from $4,200/month to $4,603/month. These changes have been made retroactive to July 1, 2015, in conjunction with the state’s biennial budget, Public Law 2015, Chapter 267 (702 – L.D. 109) (Sec. A-32), and pursuant to 22 M.R.S. § 42(8). In addition to engaging in routine rulemaking, the Department also adopted these changes to Chapters II and III on an emergency basis on October 28, 2015, with an effective date retroactive to July 1, 2015. Second, the Department adopts a rate increase in Chapter III, Section 19, for Adult Day Health Services, billing code S5100, from $2.34 to $3.14 per quarter hour. This rate increase is retroactive to November 1, 2014, pursuant to 22 M.R.S. § 42(8), and is consistent with the rates for the same services provided under the MaineCare Benefits Manual, Chapter III, Section 26, Day Health Services, as well as under the state-funded Office of Aging and Disability Services rule, 10 C.M.R. 149, Ch. 5, Section 61, Adult Day Services. To avoid adversely impacting members, costs for Section 19 Adult Day Health services will no longer be counted towards the monthly program cap in Chapter II retroactive to November 1, 2014. Section 19 services are governed by a Section 1915(c) waiver approved by the Centers for Medicare and Medicaid Services (CMS). The Department is in the process of submitting a waiver amendment for approval by CMS that reflects these rate increases. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: March 15, 2016
View Comments: COMMENTS  Posted: March 15, 2016
 
MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities WORD  PDF 
Concise Summary: The Department adopts this rule to effectuate the following changes: (1) Increase the final prospective per diem rate to be paid to each facility by increasing the reimbursement calculation, excluding fixed costs, from 95.12 percent to 97.44 percent of all of the calculated direct care cost components and all of the routine cost components; and (2) Include the cost of continuing education for direct care staff as a direct care cost component rather than a routine cost component. These changes are in accordance with Public Law 2015, Chapter 267, Part A, and Resolves 2015, Chapter 34, Resolve, To Implement the Recommendations of the Commission to Continue the Study of Long-term Care Facilities. If the Centers for Medicare and Medicaid Services approves, these changes will be effective retroactive to July 1, 2015. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: February 15, 2016
View Comments: COMMENTS  Posted: February 15, 2016
 
MaineCare Benefits Manual, Chapter III, Section 2, Adult Family Care Services WORD  PDF 
Concise Summary: This adopted rule retroactively increases reimbursement rates by 4% for Adult Family Care Services at residential care facilities provided under MaineCare Benefits Manual, Chapter III, Section 2, Adult Family Care Services. This rule adoption follows the enactment of the State’s biennial budget, which among other MaineCare rate increases, increased the rates for Section 2 services effective July 1, 2015. P.L. 2015, ch. 267, 702 – L.D. 1019, Part A, Sec. A-32, and Part UUUU, Sec. UUUU-1. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: Retroactive to July 1, 2015
View Comments: COMMENTS  Posted: February 4, 2016
 
MaineCare Benefits Manual, Chapters II and III, Section 96, Private Duty Nursing and Personal Care Services WORD  PDF 
Concise Summary: This rule increases the reimbursement rates for Personal Support Services (PSS) provided under the MBM, Chapters II and III, Section 96, Private Duty Nursing and Personal Care Services. This rule adoption follows the enactment of the State’s biennial budget, which increased the rates for PSS effective July 1, 2015 (P.L. 2015, ch. 267, Part A, Sec. A-32). To avoid a reduction in services available to members as a result of the increase in reimbursement rates for PSS, this rulemaking also includes a proportional increase in the monthly cost caps for affected members’ levels of care. The Department submitted a State Plan Amendment for this change to the Centers for Medicare and Medicaid Services with a proposed effective date of July 1, 2015. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents
Effective Date: January 25, 2016
View Comments: COMMENTS  Posted: January 25, 2016
 
MaineCare Benefits Manual, Section 55, Chapter II, Laboratory Services WORD  PDF 
Concise Summary: The Department has adopted changes to this rule in order to align the language in Section 55 with the language of the Department’s State Plan Amendment (SPA). In particular, the adopted changes increase the reimbursement rate from fifty-three percent (53%) of the lowest level in the current Medicare fee schedule for Maine in effect at that time, to seventy percent (70%) of the 2009 CMS rate or seventy percent (70%) of the rate in the year CMS assigns a rate for that code. The Department will seek approval from CMS for an amendment to its SPA to reflect that the provider’s usual and customary charge is one of the several benchmarks utilized by the Department to determine reimbursement for laboratory services. In addition, the Department has updated several provisions, including Sections 55.04-1, 55.04-2, 55.07, and 55.09, to add an updated reference to the current rates in the Maine HealthPAS Portal Provider Fee Schedule and to remove outdated references such as Section 90, Chapter III, Physician Services. The Department also updated 55.02 to reflect current eligibility provisions to be consistent with other policies and current practice. It additionally updated the language in various other provisions, including Sections 55.05-3, 55.05-6, and 55.08-2, to make them consistent with current terminology. It further eliminates language referencing the diagnosis code “EMR” in Section 55.09 to align with current Medicaid billing practices. Finally, the Department removed Section 55.08-3 (Copayment Disputes), given that those requirements are set forth in Chapter I, Section 1 of the MaineCare Benefits Manual. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: Jan 2, 2016
View Comments: COMMENTS  Posted: January 2, 2016
 
MaineCare Benefits Manua, Chapter III, Section 45, Hospital Services WORD  PDF 
Concise Summary: In compliance with the State’s biennial budget, the adopted rule reduces reimbursement for non-emergent use of the Emergency Department (“ED”). The Department of Health and Human Services (the “Department”) will reduce the payment for Department-defined, non-emergent use of the ED for in-state Acute Care Non-Critical Access Hospitals only. Specifically, the hospital will be paid the outpatient physician’s professional evaluation and management service fee schedule rate. This will be determined by using the current physician’s payment rate listed in the MaineCare Fee Schedule associated with the ED CPT code reported on the UB04 claim. Non-emergent use of the ED will be identified by the primary diagnosis, as indicated by the ICD-10 codes in MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services, Appendix B. On October 1, 2015, pursuant to 5 M.R.S. §8054, and the authority provided in the biennial budget (P.L. 2015, ch. 267, Part UU), the Department implemented these changes on an emergency basis. That rule expires on December 30, 2015, and this rule adoption will take effect on December 31, 2015. The Department is also awaiting approval from the Centers for Medicaid and Medicare Services for these rate reductions. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: December 31, 2015
View Comments: COMMENTS  Posted: December 31, 2015
 
MaineCare Benefits Manual, Chapters II and III, Section 32, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders WORD  PDF 
Concise Summary: The Department is adopting the repeal of this rule which, since its July 1, 2011, implementation – has existed without any member enrollment. No members have ever received services under Section 32. The Department originally promulgated the rule after receiving approval from the Centers for Medicare and Medicaid Services (CMS) to operate a Section 1915(c) Home and Community-Based Services waiver for children with Intellectual Disabilities and/or Pervasive Developmental Disorders. The waiver has since expired and, through CMS guidance, the Department determined not to renew the waiver as all waiver services are currently being offered to this population elsewhere. With the expired waiver, the Department is no longer authorized to operate this program. No members will be affected by the repeal of Chapter II, Section 32. Children who would have been eligible for these waiver services already receive and will continue to receive these services through other sections of the Medicaid State Plan, through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and through state-funded programs at the Office of Child and Family Services. The Department is concurrently provisionally adopting the repeal of Chapter III, Section 32, on the same basis. This rule, Chapter II, Section 32 is a routine technical rule. Chapter III, Section 32 is a major substantive rule and requires authorization from the Legislature. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: December 9, 2015
View Comments: COMMENTS  Posted: December 2, 2015
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services WORD  PDF 
Concise Summary: This adopted rule has deleted the Wholesale Acquisition Cost (WAC) from the reimbursement rate options. Furthermore, in order to be consistent with state statute 22 M.R.S. § 3174-WW, the no co-payment requirement for smoking cessation products has been added to the pharmacy benefits retroactive to August 1, 2014, for members eighteen (18) years of age or older or who are pregnant. CMS approved these changes December 9, 2014. In addition, some terms have been replaced with nationally recognized language that is considered more respectful of the individual. The term ICF-MR (Intermediate Care Facility for Persons with Mental Retardation) has been changed to ICF-IID (Intermediate Care Facility for Individuals with Intellectual Disabilities).
Effective Date: November 29, 2015
View Comments: COMMENTS  Posted: November 25, 2015
 
MaineCare Benefits Manual, Chapters II & III, Section 67, Nursing Facility Services WORD  PDF 
Concise Summary: The adopted rule will provide a new methodology for calculating recapture of depreciation upon the sale of a nursing facility to comply with Public Law 2014, Chapter 582. The Department is awaiting CMS approval on the SPA changes specific to depreciation recapture. The Department seeks to have those changes effective retroactive to November 1, 2014. The adopted rule adds Ventilator Care Services as a covered service to eligible MaineCare members. The adopted rule allows for reimbursement through a prior authorization process to ensure nursing facilities may be reimbursed for members in need of Ventilator Care Services. This change is not expected to have an adverse effect on the administrative burdens of small businesses. The Department will seek approval from CMS to add Ventilator Care as a separately reimbursed service authorized through a prior authorization. The Department seeks to have this change effective retroactive to July 1, 2015. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: September 15, 2015
View Comments: COMMENTS  Posted: September 14, 2015
 
Chapter III, Section 29, Allowances for Support Services for Adults with Intellectual Disabilities or Autistic Disorder WORD  PDF 
Concise Summary: This is a final adoption of a major substantive rule. Section 29 services are governed by a Centers for Medicare and Medicaid Services (CMS) Medicaid Waiver. On April 18, 2014, CMS approved changes to the Section 29 waiver, effective July 1, 2014, adding new services as requested by the Department. In order to add these additional services to the MaineCare Benefits Manual, the Department amended Section 29, Chapter II through routine rulemaking with changes to these services effective September 1, 2014. However, Chapter III, Section 29 is a major substantive rule and requires the approval of the Legislature. Pursuant to 5 M.R.S.A. § 8072, the Department engaged in the rulemaking process set forth under 5 M.R.S.A. § 8052 up until the point of adoption. This included conducting a public hearing on April 15, 2014, and accepting public comments until April 25, 2014. The Commissioner provisionally adopted the Chapter III, Section 29 rule on August 22, 2014. Thereafter, the Department submitted the provisionally adopted rule to the Legislature for its review. In order to be able to reimburse for the new services found in Chapter II, Section 29, effective September 1, 2014, and in order to comply with the CMS-approved waiver, the Department adopted changes to Chapter III, Section 29 through the emergency rule-making process pending the Legislature’s approval of the provisional adoption. On April 28, 2015 the Legislature enacted “Resolve, Regarding Legislative Review of Portions of Chapter 101: MaineCare Benefits Manual, Chapter III, Section 29: Allowances for Support Services for Adults with Intellectual Disabilities or Autistic Disorder, a Major Substantive Rule of the Department of Health and Human Services” (Resolves 2015, Ch. 13). The law took effect May 10, 2015. Given the Legislature’s authorization for final adoption, as well as the limit on the application of an emergency rule, the Department now finally adopts the Chapter III, Section 29 major substantive rule the Commissioner had provisionally adopted on August 22, 2014. This final adopted rule mirrors those changes currently in place since September 1, 2014, under the emergency major substantive rule. These changes correspond to the CMS-approved Section 29 waiver and include: 1. Allowances for Assistive Technology services, including (a) Assistive Technology-Assessment; (b) Assistive Technology – Transmission (Utility Services); and (c) Assistive Technology – Devices. Adding these services complied with P.L. 2013, Ch. 368, § SS, which authorized MaineCare “reimbursement for the use of appropriate electronic technology as a means of reducing the costs of supporting people currently being served [on the Section 29 waiver.” Assistive Technology – Devices are limited to a cap of $6,000 per year, and Assistive Technology – Transmission (Utility Services) are limited to a cap of $50.00 per month. 2. Allowances for Home Support services, including (a) Home Support – Quarter Hour; (b) Home Support – Remote Support – Monitor Only; and (c) Home Support – Remote Support – Interactive Support. Adding these services complied with Resolves 2013, Ch. 24 (“Resolve, Directing the Department of Health and Human Services To Provide Coverage under the MaineCare Program for Home Support Services for Adults with Intellectual Disabilities or Autistic Disorder”). Additionally, the Department clarified the reimbursement and billing for Work Support – Group services so that the exact reimbursement rate, depending on the number of members in the group, is indicated. Finally, the Department deleted Home Accessibility Adaptation services from the calculation for the Standard Unit Rate, since this service is paid per invoice, as indicated in Appendix I. See HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: August 8, 2015
View Comments: COMMENTS  Posted: August 7, 2015
 
MaineCare Benefits Manual, Chapter 101, MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services WORD  PDF 
Concise Summary: The adoption of this rule increases the time span to fourteen (14) days for hospital readmissions that are not reimbursed, excluding conditions with complications or co-morbidity, and, if CMS approves, excludes readmissions for behavioral health conditions, including substance abuse. Additionally, if CMS approves, due to comments received, the Department will not adopt the proposed change of “the same primary diagnosis” in the definition of “discharge”, so that the rule will continue to use “a diagnosis within the same DRG”. The final rule also reduces the supplemental pool for non-critical access hospitals and hospitals reclassified to a wage area outside Maine and rehabilitation hospitals from $65,321,301 to $64,769,417. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: July 7, 2015
View Comments: COMMENTS  Posted: July 7, 2015
 
MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment WORD  PDF 
Concise Summary: The Department amends several sections of Chapter 101, MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment (DME). The changes adopted in this rulemaking maintain or increase the level of services available to members. These changes include the addition of medically necessary hearing aids as a covered service for members age twenty-one (21) and older, the inclusion of hearing aid services for members under age twenty-one (21) in Section 60, and coverage for medically necessary Continuous Glucose Monitors (CGM). The Department makes these changes in order to assure that members have access to the most appropriate cost effective treatment available. In order to assure minimal changes to providers currently providing hearing aids, the Department adds an exemption to the provider requirements listed in Section 60.01-12 (C), stating that audiologists are not required to maintain a storefront. In addition, this rule adoption replaces all references to the term “Mentally Retarded” or “MR” with “Individual with Intellectual Disability” or “IID” as required by P.L. 2012, Ch. 542, §B (5), An Act to implement the recommendations of the Department of Health and Human Services and the Maine Developmental Disabilities Council regarding respectful language. The Department also replaced the term: “Authorized Agent” with the term “Authorized Entity.” This change is being adopted across the agency in order to more accurately describe the Department’s relationship with the aforementioned entities. Contractors with the state are not legal agents of the state, so the term was replaced with “entity” to avoid confusion. The Department also increased the limits for orthopedic modifications and inserts classified with HCPCS Level II codes as Medical and Surgical Supplies (i.e. diabetic shoes, fittings and modifications), as identified in Section 60.07-1(A), to allow eligible members to receive up to a combined total of six (6) units of modifications and/or inserts per year. This change was made to maintain consistency with established Medicare limits. Additionally, the Department made a number of technical changes in an effort to provide clarity and eliminate duplicative language. These changes include the following: 1. The list of equipment under Section 60.05-13 Medical Supplies and DME not covered for Members in a Nursing Facility (NF) or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID), have been reorganized and defined to provide clarity (no equipment has been added or eliminated); 2. Definitions for the terms Aesthetic or Deluxe Durable Medical Equipment, Hearings Aids and Prior Authorization have been added to the definition section; 3. The term “store” has been revised to “storefront” in Section 60.01-12(C) in order to assure consistency with other language within this section; 4. Website addresses have been updated to assure accuracy; and, 5. To be consistent with Section 1.03-2 which provides that MaineCare will not provide payment to any entity outside the United States, and is required by Section 6505 of the Patient Protection and Affordable Care Act, P.L. 111-148 (March 23, 2010) the following language will be removed from the policy: “or within five (5) miles of the Maine border in Canada”. Following the rule proposal, the Department conducted a public hearing on February 2, 2015. Comments were received through February 12, 2015. As a result of the public comments, the following additional changes were made to the rule: 1. The Department clarified the provisions affecting the replacement of hearing aids by inserting the word “all” in the heading for Section 60.05-8(A) so that the rule reads: “Replacement of all DME is allowed for the following reasons . . .”; and by reformatting a subsection (B) with the title “Additional Rules for Hearing Aids.” 2. To clarify the face-to-face encounter requirements under Section 60.05, the Department deleted the word “physician’s” before “written orders” and added a sentence to make clear that the physician, physician assistant, nurse practitioner, or clinical nurse specialist who performs the face-to-face encounter may also write the prescription for the DME. 3. In Section 60.12, Appendix I, part (K)(2), the Department added criteria for MaineCare members under twenty-one (21) years old to receive binaural hearing aids which tracks the criteria for this member population to receive monaural hearing aids. 4. The Department corrected the criteria found in Section 60.12, Appendix I, part (Y)(1)(e)(vi) and (Y)(2)(f)(vi) to read: “Patient with HgbA1c > 7.5 . . .” instead of “< 7.5.” 5. The Department replaced the word “prosthetics” with “prosthetist” in Section 60.12, Appendix I, part (L). 6. Where necessary, the Department clarified the two affected age groups under this Section: (1) under twenty-one (21) years old and (2) age twenty-one and over. 7. Consistent with the face-to-face encounter requirements at Section 60.05, the Department inserted the word “Physician” and replaced the term “Certified Nursing Assistant” with “Clinical Nurse Specialist” in Section 60.05-1(J) as provider types who can perform the encounter. 8. Corrections have been made to the numbering format in Section 60.12, Appendix I, part (Y). Concurrent with this adoption, the Department is also repealing MaineCare Benefits Manual, Chapters II and III, Section 35, Hearing Aids and Services. The Section 60 rule adoption and the Section 35 rule repeal are dependent upon approval to the Medicaid State Plan by the Centers for Medicare and Medicaid Services (CMS). See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: June 13, 2015
View Comments: COMMENTS  Posted: June 11, 2015
 
MaineCare Benefits Manual, Chapters II & III, Section 35, Hearing Aids and Services WORD  PDF 
Concise Summary: Pending the approval by the Centers for Medicare and Medicaid Services (CMS), the adoption of this rule will repeal Section 35, Hearing Aids and Services, Chapters II & III. The services covered under this section will transition to Chapter II, Section 60, Medical Supplies and Durable Medical Equipment. In addition, all reimbursement rates will be set forth per the fee schedule located at the following website: http://www.maine.gov/dhhs/audit/rate-setting/documents/S60MedSuppandDME_002.pdf. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: June 13, 2015
View Comments: COMMENTS  Posted: June 11, 2015
 
MaineCare Benefits Manual, Chapters II and III, Section 5, Ambulance Services WORD  PDF 
Concise Summary: This rule is being adopted in order to comply with P.L. 2013, ch. 441, § 1, An Act to Sustain Emergency Medical Services throughout the State, codified at 22 M.R.S.A. §3174-JJ, which requires that MaineCare change reimbursement rates for Medicare reimbursable ambulance codes to 65% of Medicare rates beginning March 1, 2015. Additionally, the rule is being adopted to remove references to outdated telephone numbers and to provide updated instructions for out-of-state providers to request prior authorization through the MaineCare portal. Finally, Chapter III of the rule adoption deletes a clarifying sentence contained in the fee schedule that does not appear in the HCPCS manual. Following public hearing and further review by the Department, the Department made additional non-substantive changes to the rule proposal, including: (1) replacement of the outdated terms “Intermediate Care Facility for People with Mental Retardation” and “ICF-MR” with the terms “Intermediate Care Facility for Individuals with Intellectual Disabilities” and “ICF-IID”; (2) clarification of the prior authorization requirements in Chapter II, Sections 5.05-1 and 5.08-2 to be consistent with changes in the rule proposal about the MaineCare portal; (3) removal of the provisions in Chapter III, Section 5.05 which address MaineCare’s billing system to align with the reimbursement changes set forth in P.L. 2013, ch. 441, § 1 and 22 M.R.S.A. § 3174-JJ; and (4) correction of a clerical error in the fee schedule in Chapter III, Section 5.06 to properly reflect that the fixed fee of $285.00 for HCPCS code A0428 is associated with ambulance services associated with an involuntary admission to a psychiatric facility. A detailed list of all changes made between the rule proposal and the rule adoption can be found in the Summary of Comments. If the Centers for Medicare and Medicaid Services (CMS) approves the Department’s State Plan Amendment, and pursuant to 22 M.R.S.A. § 42(8), changes to the reimbursement rates under Section 5 will be effective retroactive to March 1, 2015. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: June 3, 2015
View Comments: COMMENTS  Posted: June 4, 2015
 
MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorder WORD  PDF 
Concise Summary: This is a final adoption of a major substantive rule. The following outlines the procedural history of this rule adoption as well as the specific changes to the rule. By way of background, Section 21 services are governed by the Centers for Medicare and Medicaid Services (CMS). On April 18, 2014, CMS approved changes to the Section 21 waiver, effective July 1, 2014, adding new services and clarifying other services, as requested by the Department. In order to add these new services, the Department promulgated a routine technical rulemaking for Chapter II, Section 21. The Commissioner adopted the Chapter II, Section 21 rulemaking on or about August 22, 2014, with an effective date of the changes to services of September 1, 2014. However, Chapter III, Section 21, which governs the reimbursement of services under Chapter II, is a major substantive rule. As such, Chapter III, Section 21 needs approval by the Legislature before becoming effective. Pursuant to 5 M.R.S.A. § 8072, the Department engaged in the rulemaking process set forth under 5 M.R.S.A. § 8052 up until the point of adoption. This included conducting a public hearing on April 14, 2014, and accepting public comments until April 24, 2014. Thereafter, the Commissioner provisionally adopted the Chapter III, Section 21 rule on August 22, 2014. The Department submitted the provisionally adopted rule to the Legislature for its review on or about August 29, 2014. Meanwhile, because federal law requires that provider claims for Medicaid services be submitted within one year of providing the Medicaid service (42 CFR 447.45), and because Medicaid reimbursement must be made timely, the Department determined to concurrently adopt an emergency major substantive rule for Chapter III, Section 21. The emergency major substantive rule became effective on September 1, 2014. Thus, the Department has been able to reimburse for new services under Chapter II, Section 21 pending the Legislature’s review of the provisionally adopted major substantive rule. On March 17, 2015, the Legislature authorized the final adoption of the major substantive rule in Resolve, Regarding Legislative Review of Portions of Chapter 101, MaineCare Benefits Manual, Chapter III, Section 21: Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder, a Major Substantive Rule of the Department of Health and Human Services (Resolves 2015, Ch. 1). Given the Legislature’s authorization for final adoption, as well as the limit on the application of an emergency rule, the Department now finally adopts the Chapter III, Section 21 major substantive rule the Commissioner had provisionally adopted on August 22, 2014. This final adopted rule mirrors those changes currently in place since September 1, 2014, under the emergency major substantive rule. These changes correspond to the CMS-approved Section 21 waiver and include: MaineCare reimbursement for the following services: Home Support – Remote Support services which includes: (a) Home support- Remote Support – Monitor Only; and (b) Home support – Remote Support – Interactive Support, Assistive Technology services, which includes: (a) Assistive Technology – Assessment services; (b) Assistive Technology – Transmission (Utility Services); and (c) Assistive Technology – Devices services. Adding these services complies with P.L. 2013, Ch. 368, PART SS, which authorized MaineCare “reimbursement for the use of appropriate electronic technology as a means of reducing the costs of supporting people currently being served…” To comply with the waiver amendment, the Department added a new modifier (“U5”) to the code for Home Support – Family Centered Support – which indicates that the services are Family Centered Support services. The Department also added: Career Planning services. This adopted major substantive rule also separates Home Support Services into four different services: 1) Home Support-Agency Home Support (Per Diem), 2) Home Support-Quarter Hour (1/4 hour), 3) Home Support-Family Centered Support and 4) Home Support-Shared Living. The Department deleted some of the language in the second paragraph of Principle 1900 (Billing Procedure), that relates to rates for Work Support Services – Group, and replaced the language with the actual rates per unit, depending on the number of members in a group. This adopted major substantive rule also added: Occupational Therapy (Maintenance) – which can be provided by a Certified Occupational Therapy Assistant (COTA) under the supervision of an Occupational Therapist Registered (OTR). This final adoption of a major substantive rule shall take effect upon the Commissioner’s final adoption and filing with the Secretary of State, at which time the emergency major substantive rule in effect since September 1, 2014 will expire. This change is not expected to have an adverse effect on the administrative burdens of small businesses. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: June 14, 2015
View Comments: COMMENTS  Posted: May 28, 2015
 
MaineCare Benefits Manual, Chapters II & III, Section 65, Behavioral Health Services WORD  PDF 
Concise Summary: This rule is being adopted to comply with LD 386, An Act to Reduce Tobacco-related Illness and Lower Health Care Costs in MaineCare (22 M.R.S.A. § 3174-WW). The rule adds comprehensive tobacco cessation treatment including counseling and products as a covered service for all members, regardless of age, who wish to cease the use of tobacco. Tobacco cessation products are “Covered Drugs,” reimbursable pursuant to Ch. II, Section 80.05 of the MBM. As Covered Drugs, tobacco cessation products are included on the Department’s Preferred Drug List (PDL), as set forth in Ch. II, Section 80.07-5. The PDL may be accessed via the Department’s website. There are no annual or lifetime dollar limits on tobacco cessation treatment, nor are there any limits on attempts to quit. Members may not be charged a co-pay for tobacco cessation treatment and they may not be required to participate in counseling to receive products. The following four Current Procedural Terminology (CPT) codes are to be added to Ch. III, Section 65: 99406 (smoking and tobacco use cessation counseling; individual, greater than 3 minutes up to 10 minutes), 99407 (smoking and tobacco use cessation counseling; individual, greater than 10 minutes), 99411 (preventive medicine, group counseling; 30 minutes) and 99412 (preventive medicine, group counseling; 60 minutes). If the Centers for Medicare and Medicaid Services (CMS) approves the Department’s State Plan Amendments, and pursuant to 22 M.R.S.A. § 42(8), these changes to Section 65 will be effective retroactively to August 1, 2014. As of December 11, 2014, CMS has approved the Department’s State Plan Amendment related to the provision of tobacco cessation treatment services for non-pregnant members. The Department is awaiting CMS’s approval of the State Plan Amendment offering such services to pregnant members. Three additional technical changes are also included in this rulemaking: 1. Update of language referencing the former Children’s Behavioral Health Services (CBHS) and Office of Adult Mental Health Services (OAMHS) to the current Office of Child and Family Services (OCFS) and Office of Substance Abuse and Mental Health Services (SAMHS), to reflect current Departmental structure; 2. Replacement of the term “Authorized Agent” to “Authorized Entity”; and 3. In Ch. III, a change to the rate listed for CPT code H2012 with HN UQ TL and HN UQ TM modifiers from $16.65 to $14.65. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: April 13, 2015
View Comments: COMMENTS  Posted: April 13, 2015
 
MaineCare Benefits Manual, Chapter II, Section 15, Chiropractic Services WORD  PDF 
Concise Summary: The adopted rules will change the limit calculation methodology from “rolling year” to a calendar year, for purposes of clarity. This rule removes the current hard cap of 12 visits per year and allow for additional visits when medically necessary. The Department will impose a prior authorization requirement for additional visits for members over the age of twenty-one (21). In addition, these adopted changes clarify the types of medical providers that are required to be involved in determining a member’s eligibility for Chiropractic Services. X-ray services that are medically necessary for diagnosis and treatment of a subluxation shall be a covered service in Section 15. This rulemaking language explains the reimbursement for chiropractic x-rays. X-ray services provided through this section do not require prior authorization. Additionally, the Department has made a number of technical changes in an effort to provide clarity and eliminate duplicative language. These changes include the elimination of Sec. 15.04 “Specific Eligibility for Care”; elimination of the reference to the Division of Program Integrity (Sec. 15.08); and elimination of other unnecessary language regarding reimbursement, co-pays, and dispute resolution. Following the public comment period, the Department made several non-substantive changes to the rule as a result of further review. These changes include the elimination of redundant language in Section 15.02-3; clarification to language in Section 15.03; and the relocation of certain provisions to best reflect the responsibilities of different providers under the Section and to emphasize that medical necessity is a requirement for all members to be eligible for services. Finally, the Department inserted language in the final rule to reflect provisions that are subject to approval by the Centers for Medicare and Medicaid Services (CMS). Chiropractic services are currently covered under the Department’s State Plan. However, the Department is awaiting State Plan Amendment approval from CMS for changes it seeks to make to these services as reflected in the rule.
Effective Date: April 10, 2015
View Comments: COMMENTS  Posted: April 10, 2015
 
MaineCare Benefits Manual, Chapter II, Section 113, Non-Emergency Transportation (NET) Services WORD  PDF 
Concise Summary: This rule is being adopted in order to bring the policy into conformity with Department-negotiated contracts with transportation Brokers. In August of 2013, MaineCare began delivering non-emergency transportation (NET) services using regional, risk-based, pre-paid ambulatory health plan brokerages, in alignment with Maine’s eight (8) transit regions, pursuant to a §1915(b) waiver that was approved by the Centers for Medicare and Medicaid Services (CMS). NET Brokers were selected through a competitive procurement process, following the Department’s Request for Proposals (RFP). During the first year of implementation, there were significant problems in several NET regions. As a result, the Department re-issued the RFP for NET services in six of the eight regions. In two regions, the original NET Brokers’ contracts were renewed. For the other six regions, the Department selected new NET Brokers, based on the bids they submitted in response to the RFP. On July 7, 2014, CMS approved the Department’s request to renew its NET waiver for a two year period, beginning July 1, 2014 and ending on June 30, 2016. The Department negotiated new contracts with its NET Brokers, effective August 1, 2014, and these contracts include several important changes. Therefore, MaineCare’s NET policy has been changed to conform to the NET waiver and the contracts. These changes include: the allowance of pharmacy trips, including those required on an urgent basis; revisions to the map of NET regions that more clearly delineate all eight regions and reflect a slight change in the geographic distribution of one region; addition of the requirement that parents or guardians of minors under the age of 12 years old authorize the specific type of transportation when minors travel unaccompanied; addition of language requiring prior authorization for out-of-state NET trips; addition of the requirement that the NET Broker contacts a member’s assigned care coordinator to verify services for members receiving Home and Community Based Services under Sections 18 and 20 of the MaineCare Benefits Manual; as well as several other changes designed to help clarify existing requirements of the NET program. Additionally, the Department made a number of changes to the rule as a result of comments made during the rulemaking and subsequent Departmental findings. These changes include: the addition of and clarification to certain definitions; clarification of provisions regarding related travel expenses; amendment to the NET advisory committee meeting requirement to every six months; addition of “Autism Spectrum Disorder” to the rule permitting the accompaniment of an Escort without the need for a Departmental determination; further explanation of the reimbursement rules; clarification on the limited circumstances for out-of-region Broker cooperation; as well as several other non-substantive technical, grammatical, and formatting changes. All changes subsequent rule are detailed in the Department’s Summary of Public Comments.
Effective Date: April 5, 2015
View Comments: COMMENTS  Posted: April 5, 2015
 
MaineCare Benefits Manual, Chapter III, Section 26, Day Health Services WORD  PDF 
Concise Summary: This rule is being adopted to provide financial stability to Day Health Services providers. The rule is being adopted to have a retroactive application to November 1, 2014. These changes are subject to approval by the Centers for Medicare and Medicaid Services.
Effective Date: March 31, 2015
View Comments: COMMENTS  Posted: March 30, 2015
 
MaineCare Benefits Manual, Ch. II, Section 14, Advanced Practice Registered Nursing Services WORD  PDF 
Concise Summary: The purpose of this rulemaking is to change by rule the amount of reimbursement for Advanced Practice Registered Nurses (APRNs). The rule previously stated that MaineCare reimburses APRNs providing psychological or psychiatric services at 60% of the amount reimbursed for physicians’ services, leaving the policy inconsistent with Maine’s State Plan and MaineCare’s practice in adherence to that Plan. The adopted rule changes that rate to the amount reimbursed for physicians’ services as set forth in Section 90, Physician Services. The rule change is being made retroactive to January 1, 2013. This rulemaking also makes technical changes. In addition, the rule reimburses Certified Registered Nurse Anesthetists (CRNAs) at 75% of the amounts of reimbursement for services as set forth in Section 90. This is the reimbursement rate that MaineCare has been paying CRNAs. This change is also made retroactively. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: January 1, 2013
View Comments: COMMENTS  Posted: January 2, 2015
 
MaineCare Benefits Manual, Ch. II, Section 103, Chapter, Rural Health Clinic Services WORD  PDF 
Concise Summary: The adopted rule makes the following changes: 1. Per Public Law 2014, Chapter 444 (An Act to Reduce Tobacco-Related Illness and Lower Health Care Costs in MaineCare), effective August 1, 2014, eliminates the three times per year limit on tobacco cessation counseling and specifies that smoking cessation counseling is exempt from any copayment requirement. This change is made effective August 1, 2014, a retroactive application date. The Department is authorized to adopt rules with retroactive application, pursuant to 22 MRSA 42(8), when necessary to conform to the State Plan and to maximize federal Medicaid funding, and where there is no adverse financial impact on any MaineCare provider or member. Here, there is a positive impact on MaineCare providers and members, since the Department is eliminating limits and copayments for tobacco cessation counseling. Please note that, pursuant to P.L. 2014 Ch. 444 and section 2502 of the Affordable Care Act, smoking cessation products are unrestricted covered services for eligible members, effective as of August 1, 2014. Tobacco cessation products are “Covered Drugs,” reimbursable pursuant to Ch. II Section 80.05 of the MaineCare Benefits Manual. As Covered Drugs, tobacco cessation products are included on the Department’s Preferred Drug List (PDL), as set forth in Ch. II Section 80.07-5, which PDL may be accessed via the Department’s website. There are no co pays or other limits on tobacco cessation products, and MaineCare members are not required to participate in tobacco cessation counseling in order to receive tobacco cessation products. 2. The Department deleted language that identified a specific ICD-9 diagnosis code (ICD-9 diagnosis code of 305.1 [tobacco use disorder]), and in its place is more general language referencing “a nicotine or tobacco dependence code from the applicable version of the ICD Manual required by CMS.” Federal law, 45 CFR Sec 162.1000, requires covered entities such as the Office of MaineCare Services, to utilize the Medical data code sets (including ICD Manuals) as specified in the federal regulation that are valid at the time the health care is provided. As of the date this rule became effective, CMS, and the Office of MaineCare Services, utilized the International Classification of Diseases, 9th Edition, Clinical Modification, (ICD-9-CM), and Volume 3 Procedures (including The Official ICD-9-CM Guidelines for Coding and Reporting). CMS has notified states that it intends to switch to the ICD-10 Manual at some time in the future.
Effective Date: December 28, 2014
View Comments: COMMENTS  Posted: December 28, 2014
 
MaineCare Benefits Manual, Chapters II and III, Section 22, Home and Community Benefits for the Physically Disabled WORD  PDF 
Concise Summary: This rule is being repealed and incorporated into Section 19, Home and Community Based Benefits for the Elderly and for Adults with Disabilities. This rule is being adopted in order to comply with Resolve 2011, ch 71. This rule blends services from Section 19, Home and Community Benefits for the Elderly and for Adults with Disabilities and Section 22, Home and Community Benefits for the Physically Disabled and is being adopted simultaneously with the repeal of Section 19. These changes are subject to CMS approval, a waiver amendment was submitted March 14, 2014. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: December 27, 2014
View Comments: COMMENTS  Posted: December 27, 2014
 
Chapters II & III, Section 19, Home and Community Benefits for the Elderly and for Adults with Disabilities WORD  PDF 
Concise Summary: This rule is being adopted in order to comply with Resolve 2011, ch 71. This rule blends services from Sections 19 and Section 22, Home and Community Benefits for the Physically Disabled and is being proposed simultaneously with the repeal of Section 22.These changes are subject to CMS approval, and a waiver amendment was submitted March 14, 2014.
Effective Date: December 15, 2014
View Comments: COMMENTS  Posted: December 15, 2014
 
MaineCare Benefits Manual, Chapter I, Section 2, State Medicaid Health Information Technology (HIT) Program WORD  PDF 
Concise Summary: The adoption of this rule brings Maine into compliance with federal law (42 USC §1396(b); 42 C.F.R. §§ 495.300-370). The rule regulates the State’s Health Information Technology (HIT) Electronic Health Record (EHR) Incentive Payment Program. The changes to the rule include clarifications about which entities are deemed as having a “fully implemented” EHR as well as clarifications regarding the Department’s role in conducting pre-payment reviews and post-payment audits. The Department, or its agent, conducts pre-payment reviews on all participants and may conduct post-payment audits of hospitals that participate exclusively in the Medicaid incentive payment program. These activities are ongoing, and the rule is amended to reflect these practices. Finally, a number of technical formatting edits have been made. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: November 23, 2014
View Comments: COMMENTS  Posted: November 23, 2014
 
MaineCare Benefits Manual, Chapters II & III, Section 30, Family Planning Agency Services WORD  PDF 
Concise Summary: This rule is being adopted in order to conform with industry billing standards and covered services. The Department is required to utilize certain applicable medical data code sets, pursuant to 45 C.F.R. §§ 162.1000 and 162.1002. Each code set is valid within the dates specified by the organization responsible for maintaining that code set pursuant to 45 C.F.R. § 162.1011. The updates include the addition of the code for the administration of medroxyprogesterone acetate (DepoProvera), and the addition of codes for the following new Family Planning Agency Services in Chapter III: 1) Removal of an IUD 2) Administration of the HPV vaccine 3) Insertion of the IUD Skyla® Finally, these changes remove language referring to retroactive code dates from 2010. The revisions to Chapter II include a reference to a rate setting website in Chapter III and the addition of language stating that family planning agencies will be reimbursed at the same fee-for-service rate as other providers, when applicable. Between proposal and adoption the code 11981, “Insertion, non-biodegradable drug delivery implant” was added to the Chapter III, Section 30, and the codes 11975 and 11977 were removed in order to comply with federal coding standards. A note was also added to the beginning of Chapter III, Section 30, to indicate that the code 11981 is dependent on CMS approval. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: November 18, 2014
View Comments: COMMENTS  Posted: November 18, 2014
 
MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities WORD  PDF 
Concise Summary: On August 15, 2014, the Department adopted an emergency rule, which increased MaineCare nursing facility reimbursement, as required by P.L. 2013, ch. 594 (“An Act to Implement the Recommendations of the Commission to Study Long-term Care Facilities”). The August 15, 2014 emergency rule had a retroactive application date of July 1, 2014 for the changes. This rule seeks to make permanent those changes to nursing facility reimbursement made in the August 15, 2014 emergency rule. The August 15, 2014 emergency rule had an effective application date for the rule changes of July 1, 2014. This rule also uses the same effective application date for the changes of July 1, 2014. This rule adopts the following changes: 1. Establishes a new base year for nursing facilities which is the fiscal year of each nursing facility ending in calendar year 2011. The base year will be updated every two years. 2. For the routine care cost and for the direct care cost, the peer group upper limit was increased to 110% of the median. 3. Eliminates the Administration and Management Expense ceiling, although those costs are still subject to allowability standards. 4. Establishes a payment to nursing facilities that have a high MaineCare Utilization rate (defined as greater than 70% MaineCare days of care). This payment is cost settled. 5. Changes the methodology for calculating each nursing facility’s specific case mix index for the base year to the following: (1) the Department calculates the nursing facility’s 2011 average direct care case mix adjusted rate by dividing each nursing facility’s gross direct care payments received for their 2011 base year by the 2011 base year MaineCare direct care resident days; (2) the Department calculates the nursing facility’s 2011 case mix index by dividing the nursing facility’s 2011 average direct care case mix adjusted rate as calculated in (1) by the nursing facility’s 2005 base year direct care rate. 6. Eliminates the 2009 CMS Nursing Home without Capital Market Basket Index for inflation adjustments, and substitutes : (1) the United States Department of Labor, Bureau of Labor Statistics, Consumer Price Index for Medical Care Services – Nursing Homes and Adult Day Care Services to adjust for inflation for the Routine Cost Component; and (2) the United States Department of Labor, Bureau of Labor Statistics, Consumer Price Index, Historical Consumer Price Index for Urban Wage Earners and Clerical Workers – Nursing Home and Adult Day service for the Direct care Component. 7. Adds a provision that the inflation adjustments will be done every year. 8. Amends the Direct Care Add-on Principle so that December 31, 2013, rather than July 1, 2008, is used for the inflation calculation, and the facility-specific average case mix index for the base year is used as the applicable case mix index for this calculation. 9. Amends the Direct Care Hold Harmless Provision so that the differential which will be applied is the difference between each nursing facility’s direct care rate for the first fiscal year to which the July 1, 2014 amendments to the rule apply, and the nursing facility’s direct care rate in effect on April 1, 2014. 10. Amends the Routine Hold Harmless Provision so that the differential which will be applied is the difference between each nursing facility’s routine rate for the first fiscal year to which the July 1, 2014, amendments to the rule apply, and the nursing facility’s routine rate in effect on April 1, 2014. 11. Changes the heading for Principle 81 from “Interim and Subsequent Rates” to “Interim, Subsequent, and Prospective Rates” because Principle 81 was amended to add a provision defining Prospective Rate. 12. Adds Principle 81.3 (Prospective Rate), which provides that the prospective rate, excluding fixed costs, will be calculated to be 95.12% of all the calculated Direct Care cost components and all of the Routine Care cost components. Principle 82, the Final Prospective Rate, is also defined as being no more than 95.12%. 13. Adds Principle 81.4 (Funding Adjustment), which provides that in the case of an individual nursing facility, whose rebased, adjusted direct and routine care rates totaled together are less than that nursing facility’s April 1, 2014, direct and routine rates, totaled together, then the Department will make a Funding Adjustment, by adding the difference to the rebased routine rate. This language has been changed between the adoption of the emergency rule and this rule in order to clarify the process used to set the rate by breaking down the steps used to calculate the rate and setting when the Funding Adjustment will be used. 14. Added Principle 83 (August 15, 2014 Emergency Rule), to provide that for the retroactive application period of July 1, 2014, through August 15, 2015, the reimbursement to nursing facilities must be equal to or greater than the reimbursement that they had received under the rules previously in effect. P.L. 2013, ch. 594’s requirement that the rule be amended to increase the specific resident classification group case mix weight that is attributable to a nursing home resident who is diagnosed with dementia is not directly applicable to the case mix methodology which is set forth in the rule, which is function or level-of-service based, and not based on diagnosis. The rule’s case mix methodology already provides that a dementia patient whose condition worsens, and needs a higher level of care, is put in a case mix with a greater weight. The Department carefully reviewed this issue but made no changes for this rulemaking. Between the proposal and adoption, the following changes were made in response to comments: The sentence, “This occupancy adjustment does not apply to High MaineCare Utilization or the Nursing Facility Health Care Provider Tax.” was added to Principle 44.10, Occupancy Adjustment. A second paragraph was added to Principle 44.13, High MaineCare Utilization, to explain how the payment will be audited. The Department added the phrases, “as described in Principle 41” and “base year,” to Principle 80.3.3(1), Source of Base Year Cost Data, as suggested by the commenter. The phrase, “unless the facility qualifies for High MaineCare Utilization,” was added to the end of Principles 80.3.5, Direct Care Cost Settlement, and 80.5.7, Routine Cost Settlement, as suggested by the commenter. The Department added the tool used to inflate rates, the Consumer Price Index, to Principle 91.1, and specified section (4) within Principle 80.3.3 as the location in which the tool is mentioned. CMS approval is needed for these changes. Accordingly, the Department has submitted a State Plan Amendment. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: November 13, 2014
View Comments: COMMENTS  Posted: November 13, 2014
 
MaineCare Benefits Manual, Section 18, Chapters II and III, Home and Community-Based Services for Adults with Brain Injury WORD  PDF 
Concise Summary: The adopted rule creates a new section of the MaineCare Benefits Manual outlining the covered services, program requirements, and reimbursement rates for a home and community-based program for adults with Brain Injury (BI). This new MaineCare program, provided to eligible members through a Home and Community Based Waiver approved by the Centers for Medicare and Medicaid Services, provides supports necessary to assist individuals with BI to live in the community rather than in institutional settings. Chapter II of Section 18 (titled “Home and Community-Based Services for Adults with Brain Injury”) details the program requirements and services offered under the waiver. Those services include: Assistive Technology Devices and Services, Care Coordination Services, Career Planning, Community/Work Reintegration, Employment Specialist Services, Home Support, Non-Medical Transportation Services, Self-Care/Home Management Reintegration, Work Ordered Day Club House and Work Support Services-Individual. Chapter III of Section 18 (titled “Allowances for Home and Community-Based Services for Adults with Brain Injury”) establishes billing procedure codes (based on HIPAA compliant CPT coding) and reimbursement rates for the waiver services. This change is not expected to have an adverse effect on the administrative burdens of small businesses. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: November 1, 2014
View Comments: COMMENTS  Posted: November 3, 2014
 
MaineCare Benefits Manual, Chapter II, Section 4, Ambulatory Surgical Center Services WORD  PDF 
Concise Summary: This rule provides reimbursement for medically necessary services that can be performed at a freestanding facility that operates exclusively for the purpose of providing surgical services to persons not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following admission. It is dependent upon approval of a State Plan Amendment by the Centers for Medicare and Medicaid Services. This rule restores coverage for services provided through a section of the MaineCare Benefits Manual, Section 4, Ambulatory Surgical Center Services, that was previously eliminated pursuant to Public Law 2011, Ch. 657. This rule will finally adopt the July 1, 2014 emergency rule that provided for the reimbursement of ambulatory surgical centers (ASCs) under the MaineCare program, under rules that are identical to the rules that were in effect on January 1, 2012. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: September 29, 2014
View Comments: Comments  Posted: September 29, 2014
 
Chapter II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorder. WORD  PDF 
Concise Summary: The Department added three new services: Assistive Technology, Career Planning and Home Support-Remote Support. The Department split the existing Home Support service into four separate services: Home Support-Agency Per Diem, Home Support-Family Centered Support, Home Support-Quarter Hour, and Shared Living. Additionally, the Department split Work Support into two separate services: Work Support-Individual and Work Support-Group. The Department added performance measures. The primary goal of performance measurement is to use data to determine the level of success a service is achieving in improving the health and wellbeing of members. Performance goals and performance measures have been established to monitor quality, inform, and guide reimbursement decisions and conditions of provider participation across MaineCare services. This focus on performance measurement is anticipated to enhance the overall quality of services provided and raise the level of public accountability for both the Department and MaineCare providers. Other changes to the rule included: • The addition of Licensed Audiologists and Assistive Technology Professionals as qualified providers for the Communication Aids service. • The addition of Certified Occupational Therapy Assistants (COTA) under the supervision of an Occupational Therapist Registered (OTR) as qualified providers for the Occupational Therapy (Maintenance) service. • The addition of six (6) new definitions: Activities of Daily Living, Administrative Oversight Agency, Independent Contractor, Instrumental Activities of Daily Living, Prior Authorization and Utilization Review. • The removal of the definition of Summary of Authorized Services. • The addition of a reserved capacity category to meet the needs of members under 21 in out-of-state residential placements funded by MaineCare or State funds. • The phase-out of the Home Support-Family Centered Support services. • New procedures for filling vacancies in two-person agency-operated homes. • A requirement for Section 21 applicants and their planning teams to estimate the annual budget for services in the course of applying for waiver services. • A requirement that the Personal Plan for members electing the Home Support-Remote Support service incorporate a safety/risk plan. • The addition of limits on Community Support services, Counseling services, Consultation services, and Employment Specialist Services. • The addition of new provider qualifications for those Direct Support staff that provide Work Support-Individual services, Work Support-Group services, Employment Specialist Services and Career Planning services. Other technical language changes were also adopted. The reason for the rule changes are to comply with the budget bill P.L. 2013, chapter 368 directing the Department to add Assistive Technology. The Department is complying also with a CMS directive to separate Home Support into separate services. The work support and career planning changes are to comply with LD 8, Resolve, Directing the Department of Health and Human Services to provide coverage under the MaineCare program for Home Support Services for Adults with Intellectual Disabilities or Autistic Disorder. A public hearing was held on April 14, 2014. The comment deadline was April 14, 2014. This change is not expected to have an adverse effect on the administrative burdens of small businesses. The Department made numerous changes to the Final Rule from the Proposed Rule, in response to comments, and also on the advice of the Office of the Attorney General. A list of the changes and the reasons for the changes can be found in the MAPA document, “Summary of Comments and Responses”. These rule changes are not anticipated to impose any burden on small businesses or any costs on counties or municipalities. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: 09-01-2014
View Comments: Comments  Posted: August 25, 2014
 
MaineCare Benefits Manual, Chapter II, Section 29, Support Services For Adults With Intellectual Disabilities or Autistic Disorder WORD  PDF 
Concise Summary: The Department is adopting four new services: Assistive Technology, Career Planning, Home Support-Quarter Hour and Home Support-Remote Support. Additionally, the Department split Work Support into two separate services: Work Support-Individual and Work Support-Group. The Department is also adopting performance measures. The primary goal of performance measurement is to use data to determine the level of success a service is achieving in improving the health and well-being of members. Performance goals and performance measures have been established to monitor quality, inform, and guide reimbursement decisions and conditions of provider participation across MaineCare services. The focus on performance measurement is anticipated to enhance the overall quality of services provided and raise the level of public accountability for both the Department and MaineCare providers. Other changes to the rule include: • The addition of seven (7) new definitions: Activities of Daily Living, Agency Home Support, Independent Contractor, Instrumental Activities of Daily Living, Medical Add On, Prior Authorization and Utilization Review. • Removal of the definition of Summary of Authorized Services. • A requirement for Section 29 applicants and their planning teams to estimate the annual budget of services in the course of applying for waiver services. • A requirement that the Personal Plan for members electing the Home Support-Remote Support Service incorporate a safety/risk plan. • The addition of limits on Community Support Services, Assistive Technology Services, Career Planning Services, Counseling Services, Consultation Services, Employment Specialist Services and Home Support-Remote Support Services. • The addition of new provider qualifications for those Direct Support staff that provide Home Support Services, Work Support-Individual Services, Work Support-Group Services, Employment Specialist Services and Career Planning Services. Other technical language changes are also being adopted. The reason for the rule changes are to comply with the budget bill P.L. 2013, chapter 368 directing the Department to add Assistive Technology to this waiver. The Department is complying with Resolve, Chapter 24, LD 8, Resolve, Directing the Department of Health and Human Services to Provide Coverage under the MaineCare Program for Home Support Services for Adults with Intellectual Disabilities or Autistic Disorder. This Resolve directs the Department to add Home Support as a covered Service to this waiver. The Department is also complying with a CMS directive to separate Home Support into separate services. The Work Support and Career Planning changes are to comply with LD 8, Resolve, Directing the Department of Health and Human Services to provide coverage under the MaineCare program for Home Support Services for Adults with Intellectual Disabilities or Autistic Disorder. This rule change is not anticipated to have any adverse impact on small businesses or impose any additional costs on counties or municipalities. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: 09-01-2014
View Comments: Comments  Posted: August 25, 2014
 
MaineCare Benefits Manual, Chapter II, Section 67, Nursing Facility Services WORD  PDF 
Concise Summary: The Department recently received CMS approval for a new Home and Community Based Services waiver for individuals with brain injury, aged 18 and over. In conjunction with same, the Department is developing a new section of the MaineCare Benefits Manual, Section 18. The purpose of the new waiver and Section 18 is to provide more non-institutional services and options for individuals with Acquired Brain Injury. The changes to Section 67 are being adopted in order to make brain injury eligibility and the providers’ requirements for Section 67: Nursing Facility Services consistent with the new Section 18: Home and Community Based Services for Members with Brain Injury. Individuals with Acquired Brain Injury will be eligible for Nursing Facility services if they score three or higher in two items on the Mayo-Portland Adaptability Inventory and score a 0.1 or higher on the Brain Injury Health and Safety Assessment. The changes also require, for Nursing Facilities receiving an enhanced rate for their work with individuals with acquired brain injury, that all direct care staff have expertise in brain injury rehabilitation as demonstrated by achieving the Certified Brain Injury Specialist (CBIS) designation from the Academy of Certified Brain Injury Specialists, or through a Department-approved equivalent training program. This rulemaking also: a) Updates the Brain Injury definition in Section 67.01-22 to be consistent with the definition developed in 22 MRS § 3086 and the definition used in the new Section 18; b) Adds the word “Acquired” to “Brain Injury” in various places where the term is used, to be consistent with 22 MRS § 3086; c) Changes “Brain Injury” to “Acquired Brain Injury,” and “BI” to “ABI” in the table of contents and on pages 4, 14, 27, 28, 45, 46, 47, 51; d) Reorganizes Section 67.02-5; e) Corrects a numbering error in Section 67.05-13. In response to comments, the Department has clarified that all ‘direct care’ staff, rather than all nursing facility staff are expected to be CBIS compliant. Additionally, the Department is making the following technical change in the adopted rule by correcting the term “Mentally Retarded” to “Intellectually Disabled” as required by P.L. 2012, ch. 542, § B(5), removing “If CMS approves” language for changes that have been approved in sections 67.05-11(C), 67.05-12 and 67.05-14(B); and changing the formatting of the Acquired Brain Injury definition from that of the proposed to more closely match 22 MRS 3086.. The Department held a public hearing on Monday, April 7, 2014, and accepted comments until Thursday April 17, 2014.
Effective Date: August 3, 2014
View Comments: Comments  Posted: August 3, 2014
 
MaineCare Benefits Manual, Chapter 101, Chapters II & III, Section 35, Hearing Aids & Services WORD  PDF 
Concise Summary: The Department is adopting changes to this rule to add digital hearing aids as a covered service for eligible members through MaineCare. A public hearing on the proposed rule was held on June 2, 2014. There were no attendees. The comment deadline was June 12, 2014. One comment was received. No changes were made to the rule based on comments. These changes reflect current industry standards and ensure compliance with the federal requirements for Early and Periodic Screening, Diagnostic and Treatment Services, pursuant to 42 U.S.C. §§ 1396a(a)(43) and 1396d(r), and 42 CFR §§ 440.110 and 441.56. This rule requires that providers use the State of Maine Division of Purchases’ vendors that are contracted through the Hearing Aid Procurement Program as the sole suppliers of all digital hearing aids for MaineCare members under the age of 21. Contracted hearing aid vendors and pricing information can be found at: http://www.maine.gov/purchases/contracts/hearingaids.shtml. The Department is also adopting the following changes: a) Adding digital hearing aid codes V5246, V5252, V5253, V5256, V5257, V5260, and V5261; b) Allowing current dispensing fee codes V5090, V5110, V5160, V5200, V5240, and V5241 to be billed for digital hearing aids; and c) Adding a definition for Prior Authorization.
Effective Date: July 27, 2014
View Comments: Comments  Posted: July 27, 2014
 
MaineCare Benefits Manual, Chapter III, Section 109, Speech & Hearing Services WORD  PDF 
Concise Summary: The Department is adopting changes to implement new rates and codes for Section 109, Speech & Hearing Services, subject to approval by the Centers for Medicare and Medicaid Services. The Department utilizes federal Medicare rates as the basis for its rates of reimbursement for Medicaid services. In addition, pursuant to 45 C.F.R. §§ 162.1000 and 162.1002, the Department uses the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) code sets for the coding of its Medicaid services. The code sets and Medicare rates are periodically updated by the American Medical Association CPT Editorial Panel and the federal Department of Health and Human Services, respectively. Pursuant to 45 C.F.R. §162.1001, each code set is valid within the dates specified by the organization responsible for maintaining that code set. The codes utilized for Speech and Hearing Services were recently updated by the American Medical Association CPT Editorial Panel, in October of 2013, with a generally intended effective date of January 1, 2014. In addition, the Medicare rates for Speech and Hearing Services also changed, and the Department received notice of those rates from CMS on or about January 6, 2014. The adopted changes made to this rule align with current 2014 CPT codes and current Medicare rates for Speech and Hearing Services. These changes include the elimination of code 92506 with the addition of codes 92521, 92522, 92523, and 92524.
Effective Date: July 6, 2014
View Comments: Comments  Posted: July 6, 2014
 
Chapter 104, Maine State Services Manual, Section 6, Independent Practice Dental Hygienist (IPDH) Services WORD  PDF 
Concise Summary: This rule implements a state-only funded program to provide reimbursement for Independent Practice Dental Hygienists (IPDHs) services and to Federally Qualified Health Centers (FQHCs) employing IPDHs for certain services, provided to MaineCare Members during the period October 1, 2012 through September 30, 2013. This state-only funded service reimburses IPDHs and FQHCs who employed IPDHs providing such services, during the period October 1, 2012 through September 30, 2013, for the following services provided to individuals who were eligible MaineCare members at the time of service: prophylaxis performed on a person who was 21 years of age or younger; topical application of fluoride performed on a person who was 21 years of age or younger; provision of oral hygiene instructions; the application of sealants; temporary fillings; and processing and exposing radiographs (X-rays). To be reimbursed, IPDHs and FQHCs must be enrolled as MaineCare providers on the date they submit claims. Additionally, FQHC’s must have been enrolled as MaineCare providers on the date of the service. If the FQHC had been reimbursed by MaineCare for an ambulatory clinic visit for the MaineCare Member, on the same date as the IPDH service, the FQHC is ineligible for IPDH reimbursement under this rule. Providers must submit claims on or before December 31, 2014, in order to be reimbursed. The Department made numerous changes to the Final Rule from the Proposed Rule, in response to comments, and also on the advice of the Office of the Attorney General. A list of the changes and the reasons for the changes can be found in the MAPA document, “Summary of Comments and Responses.”
Effective Date: July 1, 2014
View Comments: Comments  Posted: July 1, 2014
 
MaineCare Benefits Manual, Chapter II, Section 31, Federally Qualified Health Center Services WORD  PDF 
Concise Summary: This rulemaking makes the following changes to Chapter II Section 31, Federally Qualified Health Center Services: 1. The addition of three dental provider types: o Independent Practice Dental Hygienists (IPDHs), as required by per P.L. 2011, Chap. 457 “An Act To Include Independent Practice Dental Hygienists in MaineCare.” o Dental Externs. Adding this provider type will increase access to dental services by MaineCare beneficiaries. o Dental Residents. Adding this provider type will increase access to dental services across the state. IPDHs are added effective October 1, 2013, subject to approval by CMS. Dental Externs are added as a MaineCare provider, effective July 1, 2013. The July 1, 2013 effective date for Dental Externs is consistent with the proposed rule, which proposed adding this provider type “effective 365 days before date of adoption”. The adopted rule clarifies precisely what the effective date is of this change. Dental Residents are added as a MaineCare provider effective July 1, 2013, although the proposed rule added them as a provider type effective September 1, 2011. As a result of advice from the Office of the Attorney General, the Department changed the effective date to July 1, 2013. Federal Medicaid law requires state Medicaid agencies like MaineCare to “require [Medicaid] providers to submit all claims no later than 12 months from the date of service.” 42 CFR 447.45(d)(Timely processing of claims). Accordingly, MaineCare cannot add a provider type retroactively beyond the 12 months, since claims from an earlier period could not legally be processed as MaineCare claims. 2. Tobacco cessation codes were updated to reflect the upcoming national change from ICD-9 to ICD-10. 45 CFR Sec 162.1000 requires covered entities such as the Maine Office of MaineCare Services, to utilize the Medical data code sets as specified in the federal regulation that are valid at the time the health care is provided. As of the date this rule became effective, CMS, and the Office of MaineCare Services, utilized the International Classification of Diseases, 9th Edition, Clinical Modification, (ICD-9-CM), and Volume 3 Procedures, (including The Official ICD-9-CM Guidelines for Coding and Reporting). CMS has notified states that it intends to switch to the ICD-10 Manual at some time in the future. 3. The Department added a sentence: “Dental services rendered under this policy must be performed in accordance with the Maine Board of Dental Examiners requirements” to clarify that this is a legal requirement. 4. Per Public Law 2014, Chapter 444, eliminates the three times per year limit on tobacco counseling and specifies that Smoking cessation counseling is exempt from the copayments required by 31.08 (A). This change was not in the proposed rule because the Legislature enacted the change after the rule was proposed. The Department has determined that it is appropriate to include this change in the adopted rule due to the fact that: (1) the changes required by statute should be effective by August 1, 2014 (90 days upon the Legislature’s adjournment), and it would not be possible to meet that deadline without including it in this adopted rule; (2) the public had an opportunity to comment on this change during the legislative process; and (3) the changes have a positive impact on both members and providers. This rule has retroactive application effective dates for adding the three new provider types. The Department is authorized to adopt rules with retroactive application, pursuant to 22 MRSA 42(8), when necessary to conform to the State plan and to maximize federal Medicaid funding, and where there is no adverse financial impact on any MaineCare provider or Member. Here, because there is a positive impact on MaineCare providers and Members, since the Department is adding new provider types, and access to dental services should be improved, the retroactive application of those provider types is appropriate.
Effective Date: July 1, 2014
View Comments: Comments  Posted: July 1, 2014
 
MaineCare Benefits Manual, Chapters II & III, Section 25, Dental Services WORD  PDF 
Concise Summary: The rulemaking makes the following changes: (1) adds three dental provider types: Independent Practice Dental Hygienists (effective October 1, 2013 subject to approval from CMS), Dental Externs (effective July 1, 2013), and Dental Residents (effective July 1, 2013); (2) eliminates the limit on tobacco counseling; (3) adds partial dentures to services reimbursable to denturists; (4) updates policy to conform to changes in the American Dental Association’s 2014 CDT Dental Procedure Codes (this includes addition, deletion, and renaming of codes, as appropriate); and (5) changes limitations for a number of specific procedures. The Department made numerous changes to the Final Rule from the Proposed Rule, in response to comments, and also on the advice of the Office of the Attorney General. A list of the changes and the reasons for the changes can be found in the MAPA document, “Summary of Comments and Responses.”
Effective Date: July 1, 2014
View Comments: Comments  Posted: July 1, 2014
 
MaineCare Benefits Manual, Chapters II and III, Section 20, Home and Community-Based Services for Adults with Other Related Conditions WORD  PDF 
Concise Summary: The rules have been amended to make a number of clarifications and technical changes, as follows: • Clarification of the prioritization categories for members on the waitlist for Section 20 services; • Clarification that the rate for the Community Support service includes the cost of transportation, i.e., that transportation costs are a component of the rate paid for the service; • Clarification that a member may receive some 1:1 direct care under the Home Support service, and that the need for 1:1 support must be specified in the care plan; and, • Clarification that Assistive Technology devices and Communication Aids will be reviewed based on medical necessity, efficiency and compatibility with safety needs. Additionally, the Department made changes to comply with amendments to the Section 20 waiver program that were approved by the Centers for Medicare and Medicaid (CMS) on May 5, 2014. These include the following: • An increase in the limit for the Community Support and Work Support services from 64 units each to allowing the member a combination of 128 units of either service, subject to an annual limit of 6,656 units on the total combined expenditures for both services; • An increase in the limit for the Home Support –Remote Support service from 44 units per day to 64 units per day; • An increase in the limit for the Home Support-Quarter Hour service from 44 units per day to 64 units per day; • An increase in the limit for Communication Aids from $2,000.00 to $6,000.00 per year; • An increase in the limit for the Care Coordination service from 144 units to 400 units per year; • Clarification that the Consultation service is limited to 64 units per each type of consultation annually; • Clarification that Remote Support-Interactive Support and Remote Support-Monitor are two separate components of Remote Support and are reimbursed separately; and, • The addition of Licensed Speech Language Pathologists (SLP) as qualified providers of Communication Aids. The Department made numerous changes to the Final Rule from the Proposed Rule, in response to comments, and also on the advice of the Office of the Attorney General. A list of the changes and the reasons for the changes can be found in the document, “Summary of Comments and Responses.” A public hearing was held on April 15, 2014. The comment deadline was April 25, 2014. This change is not expected to have an adverse effect on the administrative burdens of small businesses.
Effective Date: July 1, 2014
View Comments: Comments  Posted: July 1, 2014
 
MaineCare Benefits Manual, Chapter III, Section 97, Private Non-Medical Institution Services Word  PDF 
Concise Summary: This final adopted major substantive rule eliminates Private Non-Medical Institution Services (PNMI), Appendix D (Child Care Facilities), Model 3 (Intensive Mental Health Services for Infants and/or Toddlers) reimbursement rate. In a separate rulemaking, the Department permanently adopted the elimination of PNMI, Appendix D, Child Care Facilities, Model 3, Intensive Mental Health Services for Infants and/or Toddlers, effective October 11, 2013. Although eligible infants and toddlers no longer have access to PNMI Appendix D, Model 3, Intensive Mental Health Services, they remain eligible for medically necessary Behavioral Health Services through Chapter II, Section 65, Behavioral Health Services. Additionally, the rule corrects prior rules and amends the reimbursement rates for PNMI, Appendix D, Child Care Facilities to agree with the correct rates configured in the MaineCare claims system. The rates in the prior rules were lower than the correct rates.
Effective Date: June 30, 2014
View Comments: Comments  Posted: June 30, 2014
 
MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities Word  PDF 
Concise Summary: This rule permanently adopts changes already made on an emergency basis. In this rulemaking, the Department adopts the changes required by Resolve 2013, ch. 72, to clarify the timeframe during which nursing facilities must demonstrate their compliance with the October 1, 2011, 2% Cost-Of-Living Adjustment (COLA) for front-line staff. If CMS approves, the following applies for the 2%, October 2011, COLA that the Department gave to nursing facilities: nursing facilities must demonstrate, to the satisfaction of the Department, a 2% increase in the average wage and benefit rate per hour for front-line employees for their first fiscal years ending after July 1, 2013, from the average wage and benefit rate per hour for front-line employees that was in effect for their fiscal years ending 2008. If the nursing facilities cannot demonstrate that 2% increase to the satisfaction of the Department, then the Department will recoup, at time of audit, the difference between what the average wage and benefit rate per hour for front line employees for the first fiscal years ending after July 1, 2013, should have been if it had been increased by 2% from what it was. This rulemaking also: (1) Removes the word “Care” from “Routine Care Cost Component” (2) Removes obsolete language – from Section 41.2.3(D), regarding how sanctions were calculated in the period of time leading up to MIHMS implementation and language referring to MIHMS in the future tense. MIHMS went live on 9/1/2010. (3) Removes obsolete language – from Section 80.3.4, regarding how the “Direct Care Component” was calculated in the period of time leading up to MIHMS implementation and language referring to MHIMS in the future tense. MIHMS went live on 9/1/2010. (4) Changes ‘Brain Injury’ to Acquired Brain Injury and ‘BI’ to ‘ABI’ to use the same definitions set forth in 22 M.R.S. § 3086 and to be consistent with terminology utilized in Chapter II, Sec. 67.
Effective Date: May 29, 2014
  Posted: May 28, 2014
 
MaineCare Benefits Manual Chapter III, Section 32, Allowances for Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders Word  PDF 
Concise Summary: This rule adopts changes in the reimbursement of services to members with Intellectual Disabilities and Autistic Disorders by deleting the reimbursement of transportation services, since transportation services are provided under the MaineCare Benefits Manual, Section 113 Non-Emergency Medical Transportation waiver transportation services. An emergency rule took effect 8/1/13; this is the final adoption of a permanent rule. A public hearing was held on June 3, 2013. The comment deadline was June 13, 2013. This change is not expected to have any adverse impact on small businesses or impose any additional costs on municipalities or counties. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: May 1, 2014
  Posted: April 3, 2014
 
MaineCare Benefits Manual, Chapter III, Section 29, Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorder Word  PDF 
Concise Summary: This major substantive rule changes the reimbursement of services to members with Intellectual Disabilities and Autistic Disorders by deleting the reimbursement of transportation services, as transportation services are provided under the MaineCare Benefits Manual, Section 113 Non-Emergency Transportation Services (NET) Waiver transportation services. An emergency rule took effect 8/1/13; this is the final adoption of a permanent rule. A public hearing was held on June 3, 2013. The comment deadline was June 13, 2013. This change is not expected to have any adverse impact on small businesses or impose any additional costs on municipalities or counties. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: May 1, 2014
  Posted: April 3, 2014
 
MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder Word  PDF 
Concise Summary: The Department has adopted changes to this major substantive rule to provide services for members with Intellectual Disabilities and Autistic Disorders (Section 21) concurrently with the operation of a 1915 (b) Non-Emergency Transportation Waiver. Members who receive services under this policy are provided Non-Emergency Transportation under Section 113 of the MaineCare Benefits Manual. The Department contracts with Brokers to establish, manage, authorize, coordinate and reimburse the provision of Non-Emergency Transportation services for eligible MaineCare members. The Brokers are responsible for establishing a network of Non-Emergency Transportation drivers to deliver Non-Emergency Transportation services to eligible members who live in their assigned region. The Chapter III change includes removal of the procedure code, as the reimbursement will be handled by the broker. Additionally, the Department added a HCPCS procedure code for Behavioral Consultation, G9007 HI, which is $14.85 per fifteen-minute unit. The Department added HI to the modifier table based on comments. An emergency rule took effect 8/1/13; this is the final adoption of a permanent rule. A public hearing was held on June 3, 2013. The comment deadline was June 13, 2013. This change is not expected to have any adverse impact on small businesses or impose any additional costs on municipalities or counties. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: May 1, 2014
  Posted: April 3, 2014
 
MaineCare Benefits Manual, Chapters II & III, Section 92, Behavioral Health Home Services Word  PDF 
Concise Summary: This rulemaking creates Behavioral Health Homes, effective April 1, 2014, (conditional upon Centers of Medicare and Medicaid Services approval of a state plan amendment) which will provide a comprehensive system of care coordination for members with Serious Emotional Disorders (SED), and Serious and Persistent Mental Illness (SPMI). Members eligible for Section 92 services may also be eligible for services under Section 13 (Targeted Case Management), Section 17 (Community Integration Services) and/or Section 91 (Health Home Services); such members may not receive those services at the same time that they receive Section 92 services, and must choose among the different types of services for which they are eligible. Section 92 services shall be provided to eligible members by a Behavioral Health Home Organization (BHHO) that partners with one or more Health Home Practices (HHPs). BHHOs and HHPs shall integrate and coordinate all primary, acute, behavioral health and long term services and supports for eligible members. BHHOs shall develop and implement a comprehensive Plan of Care for each member. Section 92 services are expected to result in improved physical and behavioral health outcomes for members, reduced hospital admissions and emergency room use, better transitional care, improved communication between health care providers, and the increased use of preventive services, community supports, and self-management tools. Section 92 Behavioral Health Homes are implemented pursuant to section 2703 of the Affordable Care Act, 42 U.S.C. § 1396w-4. The Department is seeking approval of a State Plan Amendment from the Centers for Medicare and Medicaid Services. Section 2703 provides an enhanced federal matching rate of 90% for the first eight (8) quarters following the effective date of the program. The rule has been amended to reflect public comments received, including the following: • 92.01 Definitions: o 92.01-3 Electronic Health Record (EHR): Additional language has been added to this section to clarify the EHR definition. o 92.01-7 Plan of Care: deleted language that required all clinical data to be in the Plan of Care. • 92.02-1 Provider Requirements (BHHO): o Clarified the role of the Psychiatric Consultant o Added additional language regarding the type of nurse that can provide the service o Added language that permitted the use of Licensed Master Social Worker Conditional II licensure o Amended Certified Intentional Peer Support Specialist language to clarify certification requirements o Added language to clarify that an individual who provides peer support services for children will be called a “Family or Youth Support Specialist,” rather than a CIPSS, and added language clarifying such individuals’ certification requirements o Amended language regarding the role of the HH Coordinator to specify that the HH Coordinator “supports and encourages” o Removed language regarding “SPMI member” o Added Physician’s Assistant to list of professionals that can serve as Medical Consultant o Clarified that the Medical Consultant role may be pro-rated o Amended language regarding co-occurring capability o Amended language to align with/reference licensing standards o Specified that the HHP and BHHO may have an executed contract or a Memorandum of Agreement (MOA), and provided detail regarding the required contents of the contract or MOA o Deleted language requiring that EHRs be used to share information o Deleted language requiring that BHHO protocols with hospitals must require prompt notification to the BHHO of a member’s admission and discharge o Clarified language regarding team-based approach to care o Clarified language on enhanced access o Included language on recovery o Deleted language that BHHO would be held accountable for savings resulting from reductions in wasteful spending o Clarified that member and family participation in leadership and/or advisory activities includes, but is not limited to, serving on agency’s Board of Directors, involvement in internal advisory committees that solicit and support the engagement of consumers and families in identifying needs and solutions, etc. • 92.02-2 Provider Requirements (HHP): o Deleted language requiring that EHRs be used to share information o Specified that the HHP and BHHO may have an executed contract or a Memorandum of Agreement (MOA), and provided detail regarding the required contents of the contract or MOA o Deleted language requiring that HHP protocols with hospitals must require prompt notification to the HHP of a member’s admission and discharge o Clarified language on site assessment o Clarified that open access scheduling means that the organization leaves some percentage of its appointment hours open for same-day/next day appointments o Replaced the term “behavioralist” with a “behavioral health professional” • 92.03 Member Eligibility o Made changes to this section to reflect that information on the member shall be stored only in the member’s record and not the member’s record and the Plan of Care o Updated (Diagnostic and Statistical Manual of Mental Disorders) DSM title • 92.04 Policies And Procedures For Member Identification And Enrollment o Clarified that members will be identified based on current prior authorizations and not via a 12-month look back period o Clarified that the time period to identify an HHP is six months and not 180 days o Amended to use “enrollment” and not “assignment” throughout o Amended to refer to “members’ clinical documentation,” as opposed to “medical documentation” • 92.05 Covered Services o Amended that BHH services may be delivered “in any community location where confidentiality can be maintained” as opposed to “in any appropriate location” o Amended to include additional language about member strengths o Deleted requirement that all clinical data would need to be contained in the member’s Plan of Care o Amended to reflect documentation required in member record and not Plan of Care o Clarified the meaning of “crisis provider” o Clarified that the BHHO shall facilitate access to psychiatric services, not provide access o Clarified that the BHHO shall facilitate access to referral services, not ensure successful referral o Added language – consistent with Section 91 – to clarify that as part of care management, HHPs shall conduct certain screenings and assessments for all of their assigned BHH members • 92.06 Non-Covered Services and Limitations o Deleted language that referenced direct delivery of underlying services o Amended language to reflect that the member may only have one BHHP Team • 92.07 Reporting Requirements o Deleted the list of quality measures • 92.08 Documentation and Confidentiality o Amended language to reference current licensing standards o Deleted 92.08 (B) “Record Retention,” because it is redundant with the requirements of MaineCare Benefit Manual Chapter 1, Section 1 o Deleted “The disclosure of information regarding members receiving services herein is strictly limited to purposes directly connected with the administration of the MaineCare program” because it would preclude any other sharing of information permitted by state and federal law • 92.09 Minimum Requirements for Reimbursement o Amended language to reflect provider requirement to submit cost and utilization reports upon request by the Department, in a format determined by the Department See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: April 1, 2014
View Comments: Comments  Posted: April 1, 2014
 
MaineCare Benefits Manual, Chapter II, Section 13, Targeted Case Management Services Word  PDF 
Concise Summary: This rule will permanently adopt the emergency rule effective December 20, 2013, that updates the Targeted Case Management (TCM) policy to include the Child and Adolescent Needs and Strengths (CANS) assessment as an approved TCM eligibility tool. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: March 20, 2014
View Comments: Comments  Posted: March 30, 2014
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services Word  PDF 
Concise Summary: This rule permanently adopts an emergency rule adopted on November 15, 2013. This rulemaking permanently updates the amount available for reimbursement in the hospital pool for the privately owned and operated Acute Care Non-Critical Access hospitals, hospitals reclassified to a wage area outside Maine by the Medicare Geographic Classification Review Board and rehabilitation hospitals, from fifty-one million six hundred-forty-two thousand thirty five dollars ($51,642,035) to sixty-five million three hundred-twenty-one thousand three hundred and one dollars ($65,321,301) for the 2013-2014 fiscal year. This change was submitted in the fourth-quarter 2013 State Plan Amendment and is awaiting CMS Approval. This rulemaking will not impose any costs on municipal or county governments, or have any adverse impact on small businesses employing twenty or fewer employees. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: February 13, 2014 AGENCY CONTACT PERSON: Rachel Thomas, Health Planner AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 TELEPHONE 207) 624-4001 FAX: (207) 287-1864 TTY: 711 (Deaf/Hard of Hearing)
Effective Date: February 13, 2014
View Comments: Comments  Posted: February 12, 2014
 
MaineCare Benefits Manual Chapter 101, Chapter X, Non Categorical Adults Word   
Concise Summary: The MaineCare Childless Adults section 1115 demonstration waiver that provided health care coverage to childless adults and non-custodial parents with incomes at or below 100% of the Federal Poverty Level (FPL), expires on December 31, 2013. Therefore, the Department is repealing Chapter X, Section 2, Non-Categorical Adults. This population of adults will no longer be eligible for MaineCare benefits as of December 31, 2013. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: January 1, 2014
View Comments: Comments  Posted: January 3, 2014
 
MaineCare Benefits Manual, Chapter II, Section 85 Physical Therapy Services Word  Comments 
Concise Summary: The Department is adopting changes to this rule to require prior authorization for all Physical Therapy Services for persons age 21 and older. The Department is also adopting the following changes: a. Adding a definition for Long-Term Chronic Pain and Terminal Illness; b. Adding new covered services and clarifying covered services and their limits; c. Limiting supplies to splinting only and adding the link to the Department’s Rate Setting website; and, d. Adding language and clerical changes to clarify the policy. Additionally, changes to the final rule include: a. Language regarding the intent of requiring prior authorization on all services before payment was removed from section 85.07-3 for clarification, as recommended by the Attorney General’s office; and b. Due to comments 1-2, 4-6, and 8-9, section 85.07-2 was changed to remove language requiring services to be ordered by a physician. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: January 1, 2014
  Posted: January 3, 2014
 
MaineCare Benefits Manual, Chapter II, Section 68 Occupational Therapy Services Word  Comments 
Concise Summary: The Department is adopting changes to this rule to require prior authorization for all Occupational Therapy Services for persons age 21 and older. The Department is also adopting the following changes: a. Adding a definition for Long-Term Chronic Pain and Terminal Illness; b. Adding new covered services and clarifying covered services and their limits; c. Limiting supplies to splinting only and adding the link to the Department’s Rate Setting website; and, d. Adding language and clerical changes to clarify the policy. Additionally, changes to the final rule include: a. Language regarding the intent of requiring prior authorization on all services before payment was removed from section 68.07-3 for clarification, as recommended by the Attorney General’s office; and, b. Due to comments 1-2, and 4-10, section 68.07-2 was changed to remove language requiring services to be ordered by a physician. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: January 1, 2014
  Posted: January 3, 2014
 
MaineCare Benefits Manual, Chapter I, Section 1 General Administrative Policies and Procedures Word   
Concise Summary: The adopted rule amends several sections of Chapter 101, MaineCare Benefits Manual, Chapter 1, Section 1, General Administrative Policies and Procedures. The Department is adopting the following changes to the rule, for the following reasons: 1. Removed references to DirigoChoice, since the Maine Legislature dissolved the Dirigo Health Agency (P.L. 2013, ch. 368, Sec. A-19). 2. As required by 45 C.F.R. 162. 410, any MaineCare provider that is a “covered health care provider” must obtain a National Provider Identifier (NPI). 3. Requires that MaineCare providers must include their NPI on their MaineCare Provider Agreements and MaineCare enrollment applications, and requires updates for new or changed NPIs. 4. Requires that all MaineCare providers must include their NPI on all MaineCare claims, pursuant to the Affordable Care Act, Section 6402(a), as codified in 42 CFR 431.107, or those claims will be denied. 5. Pursuant to 42 CFR 455.410, specifies that, in order for MaineCare to reimburse for services or medical supplies or prescriptions resulting from a provider’s order, prescription or referral, the ordering, prescribing or referring (OPR) provider must be enrolled in MaineCare, and the OPR provider’s NPI must be on the claim. This change will be effective when the Maine Medicaid Management Information System (MMIS) is able to process this change, and the Department will notify all providers via the listserve, and also serve notice to the Secretary of State’s office, as required by 5 MRSA § 8052(6). 6. Pursuant to P.L. 2013, c. 368, Part A-34, effective January 1, 2014, if approved by CMS, the Department will limit cost sharing payments for the Qualified Medicare Beneficiary without other Medicaid (QMB only) population to hospital and nursing facility providers, to the amountnecessary to provide a total payment equal to the amount MaineCare would pay for these services under the State Plan. The Department is seeking CMS approval to amend its State Plan for this change. The Department will serve notice to all providers via the listserve, and also notify the Secretary of State’s office upon CMS approval, pursuant to 5 MRSA § 8052(6). 7. The Department makes some additional changes to Section 1.07-5 (Medicare provision), all to comport with the current State Plan, and these changes also reflect the Department’s current practice: (a) adding hospitals and nursing facilities to the list of MaineCare providers who may bill MaineCare for cost sharing (however, the cost sharing is limited in that it cannot exceed the lowest rate that Medicare determines to be the allowed amount); (b) deleting references to “Medicare Part B” in provisions where the provisions related both to Medicare A and B, pursuant to the State Plan; (c) deleting a provision regarding claims received from January 1, 1997 to February 29, 2000, since that time period has long passed. 8. As a result of public comments regarding the proposed rule, and pursuant to 42 U.S.C. § 1396a(n)(3), added subpart (E) to Section 1.07-5, which strictly prohibits providers from seeking to collect any amount from a QMB for Medicare deductibles or coinsurance, even if the MaineCare payment is less than the total amount of the Medicare deductible and coinsurance. Providers are, however, allowed to collect from the QMB Member any MaineCare copayment for the service. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: January 1, 2014
View Comments: Comments  Posted: January 3, 2014
 
MaineCare Benefits Manual, Chapter 101, Section 2, Chapter VI MaineCare DirigoChoice Initiatives PDF   
Concise Summary: CONCISE SUMMARY: The Department of Health and Human Services is permanently adopting a repeal of MaineCare Benefits Manual, Chapter VI, Section 2, MaineCare DirigoChoice Initiatives, in accordance with Public Law 2013, Chapter 368, Section A-19. The Department anticipates that this rule adoption will have no impact on MaineCare enrolled providers. This rulemaking will not yield new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. No changes were made from the proposed rule to this rule adoption.
Effective Date: December 31, 2013
View Comments: Word  Posted: December 16, 2013
 
MaineCare Benefits Manual, Ch 101 Sec 45, Ch II, Hospital Services PDF   
Concise Summary: CONCISE SUMMARY: This rulemaking permanently adopts changes made on an emergency basis to implement a provision in the 2014-15 budget law (P.L. 2013 Chap. 368), as amended by P.L. 2013 Chap. 423. Specifically, this rulemaking, retroactive to April 1, 2013, increases the number of days that MaineCare will reimburse a hospital for therapeutic Leave of Absence-During Days Awaiting Nursing Facility Placement from one (1) day to twenty (20) days per state fiscal year. The rulemaking also makes clerical clarifications and corrections in several places: on pages 8 and 10 changing “days waiting” to “days awaiting” to be consistent with language elsewhere in the rule; and inserting the words “Therapeutic Leave of Absence During Days Awaiting Nursing Facility Placement” on page 7 and changing that entry in the Table of Contents so that it conforms to the language on page 7. The Department is seeking approval from the Centers for Medicare and Medicaid Services for a state plan amendment for this change.
Effective Date: November 25, 2013
View Comments: Word  Posted: December 2, 2013
 
MaineCare Benefits Manual, Ch 101, Sec 67, Ch II, Nursing Facility Services PDF   
Concise Summary: CONCISE SUMMARY: This rulemaking permanently adopts changes made on an emergency basis to implement a provision in the 2014-15 budget law (P.L. 2013, Chap. 368), as amended by P.L. 2013, Chap. 423. Specifically, this rulemaking, retroactive to April 1, 2013, increases the number of days that MaineCare will reimburse a nursing facility for: (a) Therapeutic Leave of Absence from one (1) day to twenty (20) days per state fiscal year, and (b) Bed Hold Days from four (4) per year to seven (7) per inpatient hospitalization. The rulemaking also makes the following clerical changes: (1) inserts the word “Therapeutic” before “Leave Days for a MaineCare Member” on page 39, (2) changes that entry in the Table of Contents so that it conforms to the language on page 39. The Department is seeking approval from the Centers for Medicare and Medicaid Services for a state plan amendment for this change.
Effective Date: November 25, 2013
View Comments: Word  Posted: December 2, 2013
 
MaineCare Benefits Manual, Ch 101, Ch II, Sec 32, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders PDF   
Concise Summary: CONCISE SUMMARY: The Department made changes to the rule to comply with the concurrent operation of a 1915(b) Non-Emergency Transportation Waiver. The changes to Section 32 included referencing the regional, risk-based, Pre-Paid Ambulatory Health Plan (PAHP) Brokerages operating under a 1915(b) waiver (see 42 U.S.C. §1396n) approved by the Centers for Medicare and Medicaid Services (CMS). Under risk-based contractual agreements, the Department contracted with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of Non-Emergency Transportation (NET) services for eligible MaineCare members. The Broker(s) are responsible for establishing a network of NET drivers to deliver NET transportation services to eligible members within assigned region. The Department has also made a number of other changes: 1. The Department made changes to the definitions of “seclusion” and “restraint” to conform to the definitions employed in the Department of Education’s regulations (5-71 C.M.R. ch. 33). The Department of Health and Human Services was directed by the Legislature’s Committee on Health and Human Services to amend Chapter II to mirror the definitions of seclusion and restraint in the Department of Education’s regulations. 2. The Department replaced the term “aggression” throughout the rule with “self-injurious behavior and/or aggression.” 3. The Department added language that clarified, for purposes of initial and continuing eligibility, that the annual cost of a member’s services under Section 32 may not exceed the statewide average annual cost of care for an individual in either (a) an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or (b) an Inpatient Psychiatric Facility for individuals age 21 and under, depending upon the level of care at which the individual qualified for the waiver. This is not a new limit; the Department made the changes to clarify that these limits are not fixed numbers, but instead change each year based upon the prior year’s statewide average annual cost of care for the respective facility type. 4. The Department added a number of definitions (including Authorized Agent, Intellectual Disability, and Pervasive Developmental Disorders), and changed the term “Mentally Retarded” to “Intellectual Disabilities,” as required by P.L. 2012, ch. 542, § B(5), An Act To Implement the Recommendations of the Department of Health and Human Services and the Maine Developmental Disabilities Council Regarding Respectful Language. 5. The Department clarified the requirements for providers of Section 32 services. These changes included clarification of the circumstances under which Behavioral Health Professionals may assist with administration of medication, requirements for Respite Service providers, and a requirement that providers put in place a Department-approved informed consent policy. 6. Performance Measures were adopted in Section 32.11. The primary goal of Performance Measurement is to use data to determine the level of success a service is achieving in improving the health and wellbeing of members. Performance Goals and Performance Measures have been established to monitor quality, inform and guide reimbursement decisions and conditions of provider participation across MaineCare services. This focus on Performance Measurement is anticipated to enhance the overall quality of services provided and raise the level of public accountability for both the Department and MaineCare providers. Additionally, changes to the final rule were made based on the recommendation of the Attorney General’s office. 1. 32.02-1, “means” was inserted into the definition. 2. 32.03-2(B), there was an incorrect citation; 34-B MRSA § 6001 has been changed to 5001. 3. In 32.05-1, a comma was added after the reference to the MaineCare Benefits Manual and a reference to (14 472 CMR 1) was inserted. 4. In 32.05-1(C), a typographical error “has an change” was changed to “has any change.” 5. In 32.-05-1(F), a hyphen was inserted in DHHS-sponsored. 6. In 32.05-1(N), the reference to SAMHSA‘s system of care principles was modified to refer to an appendix added containing a copy of the principles and called APPENDIX I- Federal Substance Abuse and Mental Health Services Administration’s (SAMHSA) System of Care Principles.
Effective Date: November 17, 2013
View Comments: Word  Posted: November 12, 2013
 
10-144 C.M.R. Chapter 115, Principles of Reimbursement for Residential Care Facilities Room and Board Costs PDF   
Concise Summary: CONCISE SUMMARY: This final rule permanently adopts rule changes mandated by Resolves 2011, Ch. 106. In the proposed rule, Chapter 115, Section 20.21(e)(4) continued to impose a prior approval requirement for energy efficiency improvements which exceeded $35,000 in cost. As a result of public comments and upon reviewing L.D. 790, the bill that became Resolve 2011, Chapter 106, the Department determined that retaining the prior approval for energy efficiency improvements was contrary to the Legislature’s intent. Therefore, in response to the public comment and to conform with Resolve 2011, Chapter 106, the Department has eliminated the prior approval requirements for energy efficiency improvements as follows: (1) Effective November 13, 2013, in order for an energy efficient improvement to be reimbursable, the energy efficiency improvement must be recommended as a cost- effective energy efficiency improvement in an energy audit conducted by an independent energy audit firm, as evidenced in a written document, or must be determined to be cost- effective by the Efficiency Maine Trust, established in 35-A MRSA Sec. 10103, as evidenced in a written document; and (2) Effective July 8, 2011, the rule retroactively raises the threshold beyond which providers must seek prior approval of capital expenditures for new construction, acquisitions, or renovations from $35,000 to $350,000. The rule also excludes costs for energy efficiency improvements, replacement equipment, information systems, communications systems, parking lots and garages from the cost of the project for the purpose of determining whether prior approval is required. However, all such costs will continue to be reviewed and audited for allowable costs, in compliance with Chapter 115 regulations. Providers should also note that the Department is engaged in discussions with the Centers for Medicare and Medicaid Services (CMS) concerning for Private Non-Medical Institutions (PNMI) funding. If the MaineCare PNMI regulations change, that may impact the reimbursement of room and board for PNMIs under this Chapter 115, which is a solely state-funded program. The Department advised providers to consider these factors in making their investment decisions. Note that the $350,000 prior approval provision is retroactive to July 8, 2011 – the date the Governor signed the resolve into law. The retroactive application of this provision is lawful under the Maine Administrative Procedures Act since: (a) it provides a benefit to providers and (b) it was the intent of the Legislature that it take effect immediately. The energy efficiency project provision, however, cannot be applied retroactively since it places a burden on providers to obtain written documentation of cost-effectiveness. The Department does not anticipate that this rulemaking will cause any actual or potential public controversy. This rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments.
Effective Date: November 13, 2013
View Comments: Word  Posted: November 12, 2013
 
MaineCare Benefits Manual, Ch 104, Sec 4, Maine Part D Wrap Benefits PDF  Word 
Concise Summary: CONCISE SUMMARY: This rule will permanently adopt the provisions now in place by the emergency rule that eliminated coverage of Medicare Part D copayments for members of the Medicare Savings Program who are not eligible for, or receiving the full MaineCare benefit. This change is being made pursuant to PL 2013, Chapter 368, Part A, Section A-34, the Maine Biennial Budget.
Effective Date: November 06, 2013
View Comments: Word  Posted: November 4, 2013
 
MaineCare Benefits Manual, Ch101, Sec 45, Ch III Hospital Services    
Concise Summary: CONCISE SUMMARY: This rulemaking permanently adopts changes made on an emergency basis, effective July 1, 2013, to implement provisions in the 2014-15 budget law (LD 1509, P.L. 2013, ch. 368). Specifically, this rulemaking: a) Increases the reimbursement rate per psychiatric discharge for members under 18 years of age from hospitals in the Lewiston/Auburn area to $9,128.31; b) Reduces the outpatient Ambulatory Payment Classification (APC) rate for Acute Care Non-Critical Acess Hospitals and Rehabilitation Hospitals from 93% to 83.7% of the adjusted Medicare APC rate for outpatient services; if multiple procedures are performed, the Department will pay 83.7%, rather than 93%, of Medicare’s single bundled APC rate; calculations for outlier payments will follow Medicare rules and also be paid at 83.7%, rather than 93%, of the Medicare payment. The rulemaking also corrects two clerical errors: (1) on page 15, the proper heading should be “Section 45.04 Acute Care Critical Access Hospitals;” and, (2) on pages 11 and 18, removes “un” from “unadjusted” so the proper word is “adjusted.” The Department is seeking approval from the Centers for Medicare and Medicaid Services for a State Plan Amendment for this change.
Effective Date: October 11, 2013
View Comments: Word  Posted: October 17, 2013
 
MaineCare Benefits Manual, Ch 101 Sec 97 Ch II Private Non-Medical Institution Services PDF   
Concise Summary: CONCISE SUMMARY: This final adopted rule eliminates Private Non-Medical Institution Services (PNMI), Appendix D (Child Care Facilities), Model 3 (Intensive Mental Health Services for Infants and/or Toddlers). The reimbursement rate is being eliminated in a separate provisionally adopted rulemaking for Chapter III, Section 97. Although eligible infants and toddlers will no longer be able to access PNMI Appendix D, Model 3 intensive mental health services, they will be eligible for medically necessary behavioral health services through Section 65, Behavioral Health Services.
Effective Date: 06-26-2013
View Comments: Word  Posted: October 15, 2013
 
MaineCare Benefits Manual, Ch 101, Sec 65, III, Behavioral Health Services-Restorative PDF   
Concise Summary: CONCISE SUMMARY: This rule is permanently adopting the emergency rule that restores the reimbursement rates for Licensed Clinical Professional Counselors (LCPCs) and Licensed Marriage and Family Therapists (LMFTs) to levels in place prior to March 1, 2013 for MaineCare Benefits Manual, Chapter III, Section 65, Behavioral Health Services beginning July 1, 2013. The Legislature mandated this rule in P.L. 2013, Ch. 368 § WWWW-1 and authorized the Department to do emergency rulemaking. This change in rates requires a State Plan Amendment to be approved by the Centers for Medicare and Medicaid Services (CMS). The Department will request approval of a State Plan Amendment.
Effective Date: 09-28-2013
View Comments: Word  Posted: September 26, 2013
 
MaineCare Benefits Manual, Chapter II, Section 65, Behavioral Health Services PDF   
Concise Summary: CONCISE SUMMARY: The Department seeks to adopt this rule in accordance with P.L. 2011, ch. 657, (L.D. 1746), Part A, S, § S-1 (125th Legis.) effective January 1, 2013 that limits MaineCare reimbursement for methadone for the treatment of addiction to opioids to a maximum of twenty-four (24) months per lifetime, except as permitted with prior authorization beyond twenty-four (24) months. Only treatment after January 1, 2013 will count toward the limit.
Effective Date: 08-31-2013
View Comments: Word  Posted: August 27, 2013
 
MaineCare Benefits Manual, Ch III, Sec. 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder WORD  PDF 
Concise Summary: The Department is adopting a major substantive final rule, Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder, adopting a 5% reduction in Agency Home Support. The change in reimbursement was directed by the Maine Legislature in P.L.2011, Chapter 477, § M-1. This final rule was approved by the Legislature in Resolves 2012, Chapter 15. This rule will be effective 30 days after the final filing with the Secretary of State.
Effective Date: August 1, 2013
  Posted: July 22, 2013
 

 

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