bjbjt+t+ - Maine.gov Web viewThis rule is proposed to permanently adopt the provisions now in place by emergency rule that eliminate coverage of Medicare Part D copayments for members

DHHS - Office of MaineCare ServicesRule, State Plan Amendment, and Waiver Status Report

August, 2013In APA Process*

Maine State Services Manual, Chapter 104, Section 4 Maine Part D Wrap BenefitsThis rule is proposed to permanently adopt the provisions now in place by emergency rule that eliminate 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.

Proposed: August 27, 2013 Public Hearing: September 23, 2013

Staff: Ann O'Brien Comment Deadline: October 3, 2013

Chapter II, Section 45, Hospital ServicesThis proposed rulemaking seeks to implement rules emergency rules that became effective August 27, 2013, which implement provisions in the 2014-15 budget law (P.L. 2013, ch. 368 LD 1509). Specifically, this rulemaking will increase reimbursement for therapeutic leave during days awaiting nursing facility placement from one per year to twenty per year.

Estimated Fiscal Impact: The combined General Fund impact of this policy change and the policy change to Chapter II, Section 67, and Nursing Facility Services (which was part of the same budget initiative) is an increase of $21,702 in SFY 2013, and savings of $112,760 and $113,513 in SFYs 2014 and 2015, respectively.

Proposed: August 27, 2013 Public Hearing: September 23, 2013Staff: Peter Kraut Comment Deadline: October 3, 2013

Chapter II, Section 67, Nursing Facility ServicesThis emergency rulemaking seeks to implement rules emergency rules that became effective August 27, 2013, which implement provisions in the 2014-15 budget law (P.L. 2013, ch. 368 LD 1509). Specifically, this rulemaking will increase reimbursement for: (1) therapeutic leave from one per year to twenty per year, and (2) bed holds from four days per year to seven days per inpatient hospitalization.

Estimated Fiscal Impact: The combined General Fund impact of this policy change and the policy change to Chapter II, Section 45, and Hospital Services (which was part of the same budget initiative) is an increase of $21,702 in SFY 2013, and savings of $112,760 and $113,513 in SFYs 2014 and 2015, respectively.

Proposed: August 27, 2013 Public Hearing: September 23, 2013Staff: Peter Kraut Comment Deadline: October 3, 2013

Chapter II, Section 97 Private Non-Medical Institution ServicesThis proposed rule seeks to permanently adopt the changes made by an emergency rule, effective on June 26, 2013, which eliminates Private Non-Medical Institution Services (PNMI), Appendix D (Child Care Facilities), Model 3 (Intensive Mental Health Services

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August, 2013for Infants and/or Toddlers). In a separate rulemaking, the Department is seeking to provisionally adopt a major substantive rule for Chapter III, Section 97, which eliminates the reimbursement rate for this service. 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.

Proposed: July 30, 2013 Public Hearing: August 26, 2013Staff: Ann O'Brien Comment Deadline: September 5, 2013

Chapter III, Section 97 Private Non-Medical Institution ServicesThis proposed major substantive rule eliminates the reimbursement rate for Private Non-Medical Institution Services (PNMI), Appendix D (Child Care Facilities), Model 3 (Intensive Mental Health Services for Infants and/or Toddlers). The Department seeks to provisionally adopt the changes made by an emergency major substantive rule, effective on June 26, 2013. The Department seeks to eliminate intensive Mental Health Services for infants and/or toddlers through a separate rulemaking for Chapter II, Section 97. Although eligible infants and toddlers will no longer have access to PNMI Appendix D, Model 3 Intensive Mental Health services, they remain eligible for medically necessary Behavioral Health Services through Section 65, Behavioral Health Services, which services shall be reimbursed at the rates set forth in Chapter III, Section 65.

Proposed: July 30, 2013 Public Hearing: August 26, 2013Staff: Ann O'Brien Comment Deadline: September 5, 2013

Chapter III, Section 65, Behavioral Health Services The Department is seeking to permanently adopt 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.

Proposed: July 24, 2013 Public Hearing: August 12, 2013Staff: Ann O'Brien Comment Deadline: August 22, 2013

Chapter III, Section 45, Hospital ServicesThis proposed rulemaking seeks to permanently adopt the emergency rulemaking that implemented provisions in the 2014-15 budget law (P.L. 2013, ch. 368 LD 1509) by:

increasing the reimbursement rate per psychiatric discharge for members under 18 years of age from hospitals in the Lewiston-Auburn area to $9,128.31; and

reducing the outpatient Ambulatory Payment Classification (APC) rate for Acute Care Non-Critical Hospitals and Rehabilitation Hospitals from 93% to 83.7% of the adjusted

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August, 2013Medicare 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) 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. The Department estimates that the cost of increasing the reimbursement rate per psychiatric discharge is $259,911 in each state fiscal year 2014 and 2015. The savings from reducing outpatient APC rates is $6,055,500 in each state fiscal year 2014 and 2015. The aggregate impact of these two changes is a savings of $5,795,589 in each state fiscal year 2014 and 2015. All of the funds for this methodology change have been approved by the Legislature and signed into law.

Proposed: July 23, 2013 Public Hearing: August 19, 2013Staff: Peter Kraut Comment Deadline: August 29, 2013

Maine State Services Manual, Chapter 104, Section 4 Maine Part D Wrap Benefits – Will not be finally adopted until after New Emergency rule is finally adoptedThis rule will amend the description of prescription drug rate changes for Maine Part D Wrap Benefits and eliminate the need to annualize changes through rulemaking. The Department pays 100% of the member's co-payment for generic drugs, and 50% of the member's co-payment for brand name drugs up to $10.00.Effective January 1, 2013, the co-payment for generic drugs will increase from $2.50 to $2.65, and the cost of brand name drugs will increase from $6.50 to $6.60, which means the State share is changing from $3.25 to $3.30. The new co-payments will increase State expenditures by $0.15 for generic drugs and $0.05 for brand name drugs for an additional cost of $130,532 for six months of SFY13 and six months of SFY14. The members participating in Maine Part D Wrap benefits will experience an increase or decrease annually depending on the parameters set by CMS.

Proposed: April 30, 2013 Public Hearing: May 29, 2013Staff: Ann O’Brien Comment Deadline: June 8, 2013

Chapter II, Section 32, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental DisordersThe Department is proposing changes to the rule to comply with the concurrent operation of a 1915 (b) Non-Emergency Transportation Waiver. These proposed changes to Section 32 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. The proposed changes to Section 32 include referencing the regional, risk-based, Pre-Paid Ambulatory Health Plan (PAHP) Brokerages operating under a 1915(b) waiver approved by the Centers for Medicare and Medicaid Services (CMS). Under risk-based contractual agreements, the Department will contract 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) will be responsible for establishing a network of NET

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August, 2013drivers to deliver NET transportation services to eligible members who live in their assigned region. The Department is also proposing a number of other changes:

1. The Department is proposing 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 is proposing to replace the term “aggression” throughout the rule with “self-injurious behavior and/or aggression.”

3. The Department is proposing to add language clarifying that, for purposes of initial and continuing eligibility, 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 is proposing 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 is proposing to add a number of definitions (including Authorized Agent, Intellectual Disability, and Pervasive Developmental Disorders), and to change the term “Mentally Retarded” to “Intellectually Disabled,” 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 is proposing clarification of, and additions to, the requirements for providers of Section 32 services. These include, among others, 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.

Proposed: August 3, 2013 Public Hearing: August 26, 2013Staff: Ginger Roberts-Scott Comment Deadline: September 5, 2013

Chapter II, Section 80, Pharmacy ServicesThe proposed rule will impose limits on opioid medications used for the treatment of pain. This rule includes definitions of acute and non-acute pain, the establishment of exclusions as

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August, 2013described in the legislation, language to mandate the use of a pain management care plan when a member requires the use of opioid medications for the treatment of pain beyond the prescribed limits, and the identification of therapeutic treatment options that must be utilized for members who are prescribed opioid medications to treat non-acute pain.

Estimated Fiscal Impact: The Department expects that the changes made in the proposed rule will be cost neutral. The fiscal impact associated with the emergency rule, effective 1/1/13 was a savings of approximately $1,000,000 in SFY 12-13.

Staff: Amy Dix

10-144 Chapter 115, Principles of Reimbursement for Residential Care Facilities-Room and Board Costs, Sections 20-21(e) and 20.5. This proposed rule will implement Resolve 2011, ch. 106, LD 790, which was signed into law by the Governor on July 8, 2011. The proposed rule makes these changes to the current rule: 1.) Effective October 25, 2013, for an energy efficient improvement to be reimbursable, in addition to any other standards required in Chapter 115, the energy efficient improvement must be recommended as a cost-effective energy efficient 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; 2.) Effective July 8, 2011, for all proposed new construction, acquisitions or renovations involving capital expenditures, in the aggregate, that exceed Three Hundred and Fifty Thousand Dollars ($350,000) or more in one fiscal year, providers must submit plans, financial proposals, and projected operating costs to the Department for approval in order for costs to be reimbursed (Section 20.5); and 3.) Effective July 8, 2011, capital expenditures for energy efficiency improvements, replacement equipment, information systems, communication systems and parking lots and garages must be excluded from the cost of the project in determining whether it is subject to prior written approval for energy efficiency improvements. This proposed rule will benefit providers to the extent they will not need to seek prior Department approval for capital projects that are under $350,000. However, all such costs will continue to be reviewed and audited for allowability of the costs, in compliance with the Chapter 115 regulations. The proposed rulemaking documents are under review and approval by the Commissioner’s office. Public hearing is scheduled for September 9, 2013. The comment deadline is September 19, 2013.

Staff: Michael Dostie Effective Date: October 25, 2013

Rules Adopted or Provisionally-Adopted Since Last Status Update Chapter II, Section 65, Behavioral Health Services

This rule is adopted in accordance with P.L. 2011, ch. 657, (L.D. 1746), Part A, S § S-1 (125th Legis.) and will limit MaineCare reimbursement for methadone 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.

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August, 2013Effective: August 31, 2013 Staff: Ann O’Brien Chapter II, Section 45, Hospital ServicesThis emergency rulemaking, effective August 27, 2013, implements provisions in the 2014-15 budget law (P.L. 2013, ch. 368 LD 1509). Specifically, this rulemaking will increase reimbursement for therapeutic leave during days awaiting nursing facility placement from one per year to twenty per year.

Estimated Fiscal Impact: The combined General Fund impact of this policy change and the policy change to Chapter II, Section 67, Nursing Facility Services (which was part of the same budget initiative) is an increase of $21,702 in SFY 2013, and savings of $112,760 and $113,513 in SFYs 2014 and 2015, respectively.

Staff: Peter Kraut

Chapter II, Section 67, Nursing Facility ServicesThis emergency rulemaking, effective August 27, 2013 implements provisions in the 2014-15 budget law (P.L. 2013, ch. 368 LD 1509). Specifically, this rulemaking will increase reimbursement for: (1) therapeutic leave from one per year to twenty per year, and (2) bed holds from four days per year to seven days per inpatient hospitalization.

Estimated Fiscal Impact: The combined General Fund impact of this policy change and the policy change to Chapter II, Section 45, Hospital Services (which was part of the same budget initiative) is an increase of $21,702 in SFY 2013, and savings of $112,760 and $113,513 in SFYs 2014 and 2015, respectively.

Staff: Peter Kraut

Maine State Services Manual, Chapter 104, Section 4 Maine Part D Wrap BenefitsThe Department of Health and Human Services is adopting the emergency rule that will eliminate 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, and Part UU, Section UU-1, of the State of Maine Biennial Budget.

Effective: August 9, 2013 Staff: Ann O'Brien

MaineCare Benefits Manual, Chapter II, Section 113, Non-Emergency Transportation (NET) Services: The Department permanently adopted this final rule, Chapter 101, MaineCare Benefits Manual (MBM), Chapter II, Section 113, which will implemented MaineCare’s Non-Emergency Transportation (NET) Service system, in order to achieve compliance with the Centers for Medicare and Medicaid Services (CMS) waiver. Upon adoption, this rule repealed the current Section 113, chapters II and III, and replaced it with the adopted rule.

The rule previously included language which limited the age of unescorted youth to 16 years old. However, after further review, the Department and the Attorney General’s Office agreed to restore the original language to the final rule in order to address concerns about limiting access to services for

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August, 2013members. Therefore, the Department now changed Section 113.04 (F) regarding Escort and Attendant Services to state the following: The Broker must allow, without charge to the Escort or Member, one (1) Escort to accompany a Member or group of Members who are residents of a nursing home, blind, deaf, have an intellectual disability, are less than 12 years of age, or as otherwise determined by MaineCare staff require an Escort to a covered service. The Broker is not responsible for arranging or compensating an Escort for services rendered except, upon request, for the cost of public transportation. The Broker must send tokens, vouchers or passes to Members and escorts, when necessary to enable the escort to travel with the Member.

On April 23, 2013, CMS approved a one year extension of Maine's 1915(b) waiver to provide NET services using regional, risk-based, Pre-Paid Ambulatory Health Plan (PAHP) Brokerages in alignment with Maine’s eight (8) transit regions. The Department received responses to an RFP for the transportation waiver and is in the process of executing risk-based contracts with the transportation Brokers, who coordinated MaineCare transportation services for eligible members regionally, throughout the state. The Brokers are responsible for establishing a network of transporters to deliver NET services to eligible members who live in their assigned region. The Department will reimburse the Brokers on a per Member/per month fee basis. MaineCare members eligible to receive NET services under this waiver include members who receive Home and Community-Based Waiver Services.

Effective Date: August 1, 2013Staff: Michael J. Dostie

Maine State Services Manual, Chapter 104, Section 4 Maine Part D Wrap Benefits

MaineCare Benefits Manual, Chapter 1, Section 1, Administrative Policies and Procedures,Credible Allegations of Fraud.

The federal Patient Protection and Affordable Care Act of 2010 (PPACA) requires the suspension of payments to providers who are the subject of a credible allegation of fraud. The 125 th Maine Legislature, Second Regular Session enacted 22 MRSA § 1714-D to conform with PPACA requirements regarding the suspension of payments, in whole or in part, to providers who are subject to credible allegations of fraud. The rule defines the term “credible allegations of fraud” and provides for exceptions and expedited relief from suspension of payments.

The rule, which will bring the MaineCare program rules into compliance with the federal requirements, will affect only providers who are the subject of credible allegations of fraud and whose payments may be suspended. The Department does not anticipate that this rulemaking will adversely impact members, other Departments, DHHS offices or others.

Notwithstanding Maine Revised Statutes, Title 5, section 8054, the Legislature authorized the Department to adopt emergency rules to implement Title 22, MRSA Section 1714-D without the necessity of demonstrating that immediate adoption is necessary to avoid a threat to public health or safety or the general welfare, if notice is given through a MaineCare provider listserv notification and five (5) days or more are allowed for comment prior to adoption of the rule.

The effective date of the emergency rule was March 26, 2013. Before the emergency rule was adopted, the Department gave notice of the emergency rulemaking to interested parties and providers through a MaineCare provider listserv notification. Public comments regarding the emergency rule were accepted

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August, 2013from November 29, 2012 through December 5, 2012. The emergency rule was finally adopted June 30, 2013.

Chapter III, Section 45, Hospital ServicesThis emergency rulemaking, effective July 1, 2013, implements provisions in the 2014-15 budget law (P.L. 2013, ch. 368 LD 1509). Specifically, this rulemaking:

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; and

reduces the outpatient Ambulatory Payment Classification (APC) rate for Acute Care Non-Critical 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) 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. The Department estimates that the cost of increasing the reimbursement rate per psychiatric discharge is $259,911 in each state fiscal year 2014 and 2015. The savings from reducing outpatient APC rates is $6,055,500 in each state fiscal year 2014 and 2015. The aggregate impact of these two changes is a savings of $5,795,589 in each state fiscal year 2014 and 2015. All of the funds for this methodology change have been approved by the Legislature and signed into law.

Staff: Peter Kraut

Chapter II, Section 45, Hospital ServicesThis rulemaking permanently adopts the emergency rulemaking that implemented a budget savings initiative of LD 250, An Act To Make Supplemental Appropriations and Allocations for the Expenditures of State Government and To Change Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Year Ending June 30, 2013. This change reduces reimbursement for days awaiting placement to a nursing facility from thirty-six days in a twelve-month period to one.

Estimated Fiscal Impact: This policy change will result in an estimated $78,500 in General Fund savings for State Fiscal Year 2013.

Proposed: May 7, 2013 Public Hearing: June 3, 2013Staff: Derrick Grant Comment Deadline: June 13, 2013Effective: June 23, 2013

Chapter III, Section 45, Hospital ServicesThis rulemaking permanently adopts the emergency rulemaking that implemented a budget savings initiative of LD 250, An Act To Make Supplemental Appropriations and Allocations for

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August, 2013the Expenditures of State Government and To Change Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Year Ending June 30, 2013. This rule, beginning April 1, 2013, changes reimbursement for inpatient substance abuse services to a case mix index multiplied by the psychiatric discharge rate, resulting in a rate of $4,898 per discharge.

Estimated Fiscal Impact: This policy change will result in an expenditure of $149,200 in General Fund dollars for State Fiscal Year 2013.


Chapter II, Section 67, Nursing Facility ServicesThis rulemaking permanently adopts the emergency rulemaking that implemented a budget savings initiative of LD 250, An Act To Make Supplemental Appropriations and Allocations for the Expenditures of State Government and To Change Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Year Ending June 30, 2013. This change reduces reimbursement for a leave of absence from thirty-six days in a twelve-month period to one, and reduces payments for bed holds from ten days to four days in a twelve-month period.

Estimated Fiscal Impact: This policy change will result in an estimated $78,500 in General Fund savings for State Fiscal Year 2013.


Chapter II, Section 85, Physical Therapy ServicesThis rule is being submitted for final adoption of the an emergency rulemaking in order to comply with PL 2011, ch. 657, Part O, the Department of Health and Human Services’ 3rd Supplemental Budget. This proposed rule will increase the limits for Physical Therapy Services to allow for up to five (5) treatment visits and one (1) evaluation within twelve (12) months, when provided pursuant to a pain management care plan.

Estimated Fiscal Impact: The Department expects that the changes made to the proposed rule will be cost neutral. The fiscal impact associated with the emergency rule effective 1/1/13 was a cost of approximately $234,457.50 in SFY 12-13.

Staff: Amy Dix

Chapter III, Section 21, Home and Community-Based Benefits for Adults with Intellectual Disabilities or Autistic Disorder - 5% reduction of Agency Home Support effective 7/1/12

Estimated Fiscal Impact: $685,244.07 SFY12 and 3,654,635.00 SFY13.

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August, 2013Proposed: July 4, 2012 Public Hearing: July 24, 2012Staff: Ginger Roberts-Scott Comment Deadline: August 3, 2012

Effective: August 1, 2013.

Legislature approval Resolves 2012, ch 15. Final Adoption.

Section 20, Chapters II & III – Other Related ConditionsThe Department is creating 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 “Related Conditions.” A “Related Condition” (defined in full at 42 C.F.R. § 435.1010) is a condition that causes impairment of general intellectual functioning or adaptive behavior similar to the impairment characteristic of an intellectual disability. This new MaineCare program, provided to eligible members through a Home and Community Based Waiver program approved by the Centers for Medicare and Medicaid Services, will provide supports necessary to assist individuals with a Related Condition to live in the community rather than in institutional settings. Chapter II of Section 20 (titled “Home and Community Based Services for Adults with Other Related Conditions Services”) will detail the program requirements and services offered under the waiver. Those services include Assistive Technology, Care Coordination, Communication Aids, Community Support, Consultation and Assessment, Employment Specialist Services, Home Accessibility Adaptations, Home Support, Non-Medical Transportation Services, Non-Traditional Communication Assessment, Non-Traditional Communication Consultation, Occupational Therapy (Maintenance) Service, Personal Care, Physical Therapy (Maintenance) Service, Specialized Medical Equipment, Speech Therapy (Maintenance) Service, and Work Support. Chapter III of Section 20 (titled “Allowances for Home and Community Based Services for Adults with Other Related Conditions“) establishes billing procedure codes (based on HIPAA compliant CPT coding) and reimbursement rates for the waiver services.Fiscal Impact: $ 2,386,761.00 in SFY 14Proposed: April 2, 2013 Public Hearing: May 1, 2013Staff: Ginger Roberts-Scott Comment Deadline: Saturday May 11, 2013Effective Date 7/1/2013

Section 21, Chapter III, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder 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.

Chapter II, Section 21, Home and Community-Based Benefits for Adults with Intellectual Disabilities or Autistic DisorderThe Department is proposing a number of unrelated changes to this rule. The Department is proposing changes to the rule to comply with the concurrent operation of a 1915 (b) Non-Emergency Transportation Waiver. These proposed changes to Section 21 will be effective only

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August, 2013upon implementation of the 1915(b) Non-Emergency Transportation Waiver. The proposed change to Section 21 includes referencing the regional, risk-based, pre-paid ambulatory health plan (PAHP) Brokerages operating under a 1915(b) waiver approved by the Centers for Medicare and Medicaid Services (CMS). Under risk-based contractual agreements, the Department will contract 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) will be responsible for establishing a network of NET drivers to deliver NET transportation services to eligible members who live in their assigned region. The Department is also proposing other technical changes. 1. The website for The Maine College of Direct Support is being updated to a current link

and can be accessed on the internet at: http://www.maine.gov/dhhs/oads/disability/ds/cds/index.shtml

2. The Department is proposing to add language clarifying that the assessment referral form may be the BMS 99 form currently in use or some other form approved by the Department. This change is in anticipation of a move to a new functional assessment tool, the Supports Intensity Scale (SIS).

3. Requirements for Direct Support Professionals are being added, requiring DSPs to complete four specific modules prior to being left alone with a member.

4. The Department is proposing to delete Appendix IV and replace it with a more simple statement of the combined limits on Work Support and Community Support in the main text of the rule.

Staff: Ginger Roberts-ScottPublic Hearing June 3, 2013Effective Date 8/3/2013

Chapter III, Section 21, Allowances for Home and Community-Based Benefits for Adults with Intellectual Disabilities or Autistic Disorder

The Department of Health and Human Services (DHHS) is proposing two substantive changes to Chapter III, Section 21 of the MaineCare Benefits Manual. First, the Department is proposing to remove the procedure code for Transportation Services, in order to comply with the concurrent operation of a new 1915(b) Non-Emergency Transportation Waiver. These proposed changes to Section 21 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. Going forward, members who receive services under the Section 21 waiver will be provided non-emergency transportation through Section 113 of the MaineCare Benefits Manual. Under risk-based contractual agreements, the Department will contract with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of non-emergency transportation services for eligible MaineCare members. The Broker(s) will be 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.

Second, the Department is proposing to add a HCPCS procedure code for Behavioral Consultation, G9007 HI. The proposed reimbursement rate for Behavioral Consultation is

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http://www.maine.gov/dhhs/oads/disability/ds/cds/index.shtml


August, 2013$14.85 per fifteen minute unit. The Centers for Medicare and Medicaid have approved the addition of Board Certified Behavior Analyst to provide Behavioral Consultation. Lastly, the Department is also proposing to update several internet addresses that appear through Chapter III, Section 21.

Staff: Ginger Roberts-ScottPublic Hearing June 3, 2013Provisionally Adopted 7/31/13

Chapter III, Section 32, Allowances for Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental DisordersThis rule is to permit MaineCare members to access transportation services along with their 1915(c) Home and Community Benefits. The Department is proposing changes to this rule to provide services for members with Intellectual Disabilities and Autistic Disorders concurrently with the operation of a 1915(b) Non-Emergency Transportation Waiver. These proposed changes to Section 32 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. Members who receive services under this policy will be provided Non-Emergency Transportation under Section 113 of the MaineCare Benefits Manual. The Department will contract with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of Non-Emergency Transportation services for eligible MaineCare members. The Broker(s) will be 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. Staff: Ginger Roberts-ScottPublic Hearing June 3, 2013Provisionally Adopted 7/29/13

Chapter II, Section 29, Support Services for Adults with Intellectual Disabilities or Autistic DisorderThe Department is proposing a number of unrelated changes to this rule. The Department is proposing changes to the rule to comply with the concurrent operation of a 1915 (b) Non-Emergency Transportation Waiver. These proposed changes to Section 29 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. The proposed change to Section 29 includes referencing the regional, risk-based, pre-paid ambulatory health plan (PAHP) Brokerages operating under a 1915(b) waiver approved by the Centers for Medicare and Medicaid Services (CMS). Under risk-based contractual agreements, the Department will contract 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) will be responsible for establishing a network of NET drivers to deliver NET transportation services to eligible members who live in their assigned region. The Department is also proposing a number of other technical changes. 1. The Department is proposing to add language clarifying that, for purposes of initial and

continuing eligibility, the annual cost of a member’s services under the Section 29 waiver may not exceed fifty percent (50%) of the statewide average annual cost of care for an individual in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), as determined by the Department. The rule will also clarify that

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August, 2013reimbursement for Employment Specialist Services is limited to ten hours per month. Neither of these limits is new; each was included in the waiver application approved by CMS, but had not previously been identified in the Section 29 policy.

2. The website for The Maine College of Direct Support is being updated to a current link and can be accessed on the internet at:

http://www.maine.gov/dhhs/oads/disability/ds/cds/index.shtml3. The proposed rule makes technical changes to language and names when usage has

changed or has been deemed inappropriate by the Maine Legislature. Specifically, the changes:a. Replace references to “mental retardation” with references to “intellectual disability”

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;

b. Replace references to “Office of Integrated Access and Support” with references to “Office of Family Independence”;

c. Replace references to “Office of Adults with Cognitive and Physical Disabilities Services” with references to “Office of Aging and Disability Services”;

d. Clarify the definitions of Correspondent, Case manager, Intellectual Disability and Autism. This change is to align this policy with services provided under Section 21 of the MaineCare Benefits Manual; and,

e. Remove language making certain provisions contingent on approval by CMS, as CMS has now granted approval.

4. The Department is proposing to add language clarifying that the assessment referral form may be the BMS 99 form currently in use or some other form approved by the Department. This change is in anticipation of a move to a new functional assessment tool, the Supports Intensity Scale (SIS).

5. Requirements for Direct Support Professionals are being added, requiring DSPs to complete four specific modules prior to being left alone with a member.

6. The Department is proposing language requiring providers to put in place an informed consent policy and comply with the Department’s regulations governing reportable events. These are not new requirements, but had previously been included directly in the contracts between the Department and individual providers.

7. The Department is proposing various clarifications to the planning process. 8. The Department is proposing to delete Appendix III and replace it with a more simple

statement of the combined limits on Work Support and Community Support in the main text of the rule.


Chapter III, Section 29, Support Services for Adults with Intellectual Disabilities or Autistic Disorder

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http://www.maine.gov/dhhs/oads/disability/ds/cds/index.shtml


August, 2013The Department of Health and Human Services (DHHS) is proposing to amend Chapter III, Section 29 of the MaineCare Benefits Manual, by removing the procedure code for Transportation Services. This change is necessary to comply with the concurrent operation of a new 1915(b) Non-Emergency Transportation Waiver. These proposed changes to Section 29 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. Going forward, members who receive services under the Section 29 waiver will be provided non-emergency transportation through Section 113 of the MaineCare Benefits Manual. Under risk-based contractual agreements, the Department will contract with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of non-emergency transportation services for eligible MaineCare members. The Broker(s) will be 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. Staff: Ginger Roberts-ScottPublic Hearing June 3, 2013Provisionally Adopted 7/29/13

Chapters II and III, Section 19, Home and Community-Based Benefits for the Elderly and for Adults with DisabilitiesThe Department is proposing changes to this rule to provide services for members using Home and Community Benefits for the Elderly and for Adults with Disabilities (Section 19) concurrently with the operation of a 1915(b) Non-Emergency Transportation Waiver. These proposed changes to Section 19 will be effective only upon implementation of the 1915(b) Non-Emergency Transportation Waiver. Members who receive services under this policy will be provided Non-Emergency Transportation under Section 113 of the MaineCare Benefits Manual. The Department will contract with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of Non-Emergency Transportation services for eligible MaineCare members. The Broker(s) will be 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 proposed rule also makes technical changes to language and names when usage has changed or has been deemed inappropriate by the Maine Legislature. Specifically, the changes:

a. Replace references to “mental retardation” with references to “intellectual disability”, 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;

b. Replace references to “Office of Integrated Access and Support” with references to “Office of Family Independence,”;

c. Replace references to “Office of Adults with Cognitive and Physical Disabilities Services” with references to “Office of Aging and Disability Services”; and,

d. Remove “if CMS approves” language, as CMS approved the changes, effective 9/1/10.


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August, 2013

Section 21, Chapter III Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic DisorderThe Department of Health and Human Services is adopting an Emergency Major Substantive Rule to delete the reimbursement codes for transportation, since transportation for Section 21 services will be provided and reimbursed only through Section 113, effective on August 1, 2013, the date that the Department is implementing its Section 113 Transportation Services Waiver. The Section 113 Transportation Waiver, approved by the Centers for Medicare & Medicaid Services (CMS) on April 23, 2013, provides all Non-Emergency Transportation (NET) for all MaineCare members, including transportation for Section 21 Waiver services. On October 2, 2012, CMS approved an amendment to the Section 21 Waiver (the "Section 21 Waiver"), limiting Section 21 members’ transportation choice to require them to utilize transportation only under the Section 113 Transportation Waiver.In addition, the Section 21 Waiver added Board Certified Behavioral Analysts (BCBAs) as qualified providers for consultation with eligible members.As such, this emergency rule deletes the reimbursement codes for transportation, since transportation for Section 21 services will be provided and reimbursed only through Section 113, effective on August 1, 2013. Providers may no longer be reimbursed for transportation services under Section 21. Through this emergency rule, the Department is also adding a HCPCS procedure code for Behavioral Consultation, G9007 HI which will be $14.85 per fifteen minute unit. EFFECTIVE DATE: August 1, 2013Staff-Ginger Roberts-Scott

Chapter III, Section 29, Allowances for Support Services for Adults with Intellectual Disabilities or Autistic DisorderThe Department of Health and Human Services is adopting an Emergency Major Substantive Rule to delete the reimbursement codes for transportation, since transportation for Section 29 services will be provided and reimbursed only through Section 113, effective on August 1, 2013, the date that the Department is implementing its Section 113 Transportation services waiver. The Section 113 transportation waiver, approved by the Centers for Medicare & Medicaid Services (CMS) on April 23, 2013, provides all Non-Emergency Transportation (NET) for all MaineCare members, including transportation for Section 29 waiver services. On October 2, 2012, CMS approved an amendment to the Section 29 waiver, limiting Section 29 members’ transportation choice to require them to utilize transportation only under the Section 113 transportation waiver.This emergency rule deletes the reimbursement codes for transportation, since transportation for Section 29 services will be provided and reimbursed only through Section 113, effective on August 1, 2013. Providers may no longer be reimbursed for transportation services under Section 29.

EFFECTIVE DATE: August 1, 2013Staff-Ginger Roberts-Scott

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August, 2013Chapter III, Section 32, Allowances for Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders

The Department of Health and Human Services is adopting an Emergency Major Substantive Rule to delete the reimbursement codes for transportation, since transportation for Section 32 services will be provided and reimbursed only through Section 113, effective on August 1, 2013, the date that the Department is implementing its Section 113 Transportation services waiver. The Section 113 transportation waiver, approved by the Centers for Medicare & Medicaid Services (CMS) on April 23, 2013, provides all Non-Emergency Transportation (NET) for all MaineCare members, including transportation for Section 32 waiver services. On October 2, 2012, CMS approved an amendment to the Section 32 waiver, limiting Section 32 members’ transportation choice to require them to utilize transportation only under the Section 113 transportation waiver.

This emergency rule deletes the reimbursement codes for transportation, since transportation for Section 32 services will be provided and reimbursed only through Section 113, effective on August 1, 2013. Providers may no longer be reimbursed for transportation services under Section 32. EFFECTIVE DATE: August 1, 2013Staff-Ginger Roberts-Scott

In Draft (And Governor’s Office Approval Received)

10-144 Chapter 115, Principles of Reimbursement for Residential Care Facilities-Room and Board Costs, Sections 20-21(e) and 20.5 - This proposed rule will implement Resolve 2011, ch. 106, LD 790, which was signed into law by the Governor on July 8, 2011. The proposed rule makes three changes to the current rule: 1.) Effective September 2013, for an energy efficient improvement to be reimbursable, in addition to any other standards required in Chapter 115, the energy efficient improvement must be recommended as a cost-effective energy efficient 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; 2.) Effective July 8, 2011, for all proposed new construction, acquisitions or renovations involving capital expenditures, in the aggregate, that exceed Three Hundred and Fifty Thousand Dollars ($350,000) or more in one fiscal year, providers must submit plans, financial proposals, and projected operating costs to the Department for approval in order for costs to be reimbursed (Section 20.5); and 3.) Effective July 8, 2011, capital expenditures for energy efficiency improvements, replacement equipment, information systems, communication systems and parking lots and garages must be excluded from the cost of the project in determining whether it is subject to prior written approval for energy efficiency improvements. This proposed rule will benefit providers to the extent they will not need to seek prior Department approval for capital projects that are under $350,000. However, all such costs will continue to be reviewed and audited for allowability of the costs, in compliance with the Chapter 115 regulations. Staff: Michael Dostie Effective Date: September 4, 2013

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August, 2013

In Draft (And Governor’s Office Approval not yet requested)

Chapter II, Section 85, Physical Therapy Service

The Department is proposing changes to this rule to require Prior Authorization for members using Physical Therapy Services. The Department will also be adding some language and clerical changes to clarify the policy. Specifically, the changes:

a. Adds Prior Authorization requirement for adults receiving Physical Therapy, b. Adds definitions for Physical Therapy and Medical Necessity and removes the

definition for Physical Therapy Services,c. Requires treatment to be specific to the diagnosis and provided within 6 months,d. Requires treatment to be a new condition or event,e. Limits supplies to just splinting and adds the link to the Department’s Rate Setting

website,f. Moves pain management language in Limited Services from All Ages to Adults as it

was originally intended.g. Other technical and clerical clarifications.

Effective Date: 1/1/14Staff: Cari Bernier

Chapter II, Section 68, Occupational; Therapy Service

The Department is proposing changes to this rule to require Prior Authorization for members using occupational Therapy Services. The Department will also be adding mirroring the pain Management and clerical changes to clarify the policy. Specifically, the changes:

a. Adds Prior Authorization requirement for adults receiving Physical Therapy, b. Adds definitions for Physical Therapy and Medical Necessity and removes the

definition for Physical Therapy Services,c. Requires treatment to be specific to the diagnosis and provided within 6 months,d. Requires treatment to be a new condition or event,e. Limits supplies to just splinting and adds the link to the Department’s Rate Setting

website,f. Moves pain management language in Limited Services from All Ages to Adults as it

was originally intended.g. Other technical and clerical clarifications.


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August, 2013

Proposed: Chapter 101, MaineCare Benefits Manual, Chapter X, entitled Non-categorical Adults

The Department of Health and Human Services (DHHS) is proposing to repeal Chapter 101, MaineCare Benefits Manual, Chapter X, entitled Non-categorical Adults. The repeal of this Medicaid optional service is in accordance with LD 1816, Chapter 477, Part AA, Section AA-1, and the Maine State Budget which mandates an end date of 12/31/13.


Chapter II, Section 90, Physician Services

The Department is proposing numerous changes to this rule. The proposed rule will implement a CMS requirement that anesthesiology services be billed in one (1) minute rather than fifteen (15) units of value and that anesthesia administered by a Certified Registered Nurse Anesthetist (CRNA) be supervised by the operating doctor of medicine or osteopathy in accordance with 42 C.F.R. § 482.52 (a)(4). Also, the proposed rule will delete Section 90A-04 regarding prior authorization for transplants, establish new criteria for reimbursement and require the nationally accredited United Network for Organ Sharing (UNOS) to recommend that a transplant be performed. The rule will allow In-State kidney and corneal transplants to be performed without prior authorization. When medically necessary, bone marrow or stem cell transplants are covered. Moreover, the following changes have been proposed:

Definitions for the terms “Face-to-Face Encounter” for Durable Medical Equipment (DME) and Home Health Services were added,

Provider qualifications for obstetrical services have been amended Orthognathic surgery will only be approved where there is a medical necessity. Certified Nurse Midwives, Dentists (General, Orthodonture, Pedodontist) and Dental

Hygienists practicing within the scope of their certification and licensures can be employed in a physician’s practice,

Surgical services for post-operative treatment will be amended to comply with the CMS standard fee schedule for durational global surgical periods (0-10-90 days).

Bariatric procedures must be performed at a nationally certified center recognized by the American College of Surgeons or the Surgical Review Corporation.

In general, BRCA1 and BRCA2 testing are covered. Restricted services for circumcision will be covered if medically necessary and not

cosmetic, except when deformities are the result of cancer, disease, trauma or birth defects.

Disclosure requirements in Section 90.08-1 will be amended to ensure confidentiality and comply with the Health Insurance Portability and Accountability Act (HIPAA) and Privacy Rule.

Protection of privacy when using Qualified Electronic Health Records (EHR). Also within Sec 90 is the ACA’s Primary Care Physicians Payment Rate Increase. This mandatory ACA initiative will increase the current Medicaid Rate for certain primary care

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August, 2013physicians to 100% of the Medicare fee schedule in calendar years 2013 and 2014. This will apply to specified primary care services furnished by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. This initiative will also apply to all subspecialties related to those three specialty categories to the extent that they provide E&M services.

Eligible services provided by advance practice clinicians providing services within their scope of practice and under the supervision of an eligible physician will be eligible for higher payment; this includes those not specifically mentioned in the proposed rule such as nurse midwives; independently practicing advance practice clinicians (i.e., those not under the supervision of an eligible physician) are not eligible for increased payment.

Physicians will be required to self-attest that they are either board certified in family medicine, general internal medicine or pediatric medicine or a subspecialty within those specialties or that 60% of all Medicaid services they bill for are specified E&M or vaccine administration codes. Physicians recognized by the American board of physician specialties, the American osteopathic association and the American board of medical specialties are included. In order to receive the higher payment, qualifying physicians and advance practice clinicians must be providing services under the following pay-to/service location provider types: 35-Hospital/062-Hospital Based Professionals; 51-Physicians; and 54-Physician Group.

Estimated Fiscal Impact:The Department expects that this rulemaking will cost the Department approximately $150,000 in SFY 2013. This Fiscal impact is the high end of the expected cost of BRCA testing. BRCA1 and BRCA2 are human gene mutations that have been linked to hereditary breast and ovarian cancer. Based on cost estimates, BRCA testing ranges from $300 to $3,000, depending on whether a patient has a limited test or a full test. The cost will not go higher than $150,000, but will be much lower. Not all data required for a full analysis is available, as family history is a big factor in the determination of the need of the BRCA test. With no history in the system of this new testing, the Department is limited in the amount of data it can analyze.This proposed rulemaking will have no other impact on the regulated community.Staffs: Michael J. Dostie and Peter Kraut

Chapter 1, Section 3, Ordering and Referring Providers

The proposed draft rule will implement the Patient Protection Affordable Care Act (PPACA) which specifies that Medicaid cannot pay eligible rendering providers for any health care service requiring a referral, order, or prescription from a physician or other health care professional unless the ordering, referring or prescribing provider is enrolled in MaineCare. Furthermore, the proposed rule requires all providers of medical or other items or services that qualify for a National Provider Identifier (NPI) to include their NPI on all Medicare and Medicaid enrollment applications and on all claims for payment submitted under the Medicare and Medicaid programs. If a claim fails to include the NPI, or the legal name of the physician or health care professional that ordered or prescribed the service, or referred the client for service, Medicaid reimbursement will be denied.

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August, 2013Staff: Michael J. Dostie Effective Date: December 23, 2013

Chapter X, Section 1, Benefit for People Living with HIV/AIDS Renewal

Maine is requesting to renew the Maine HIV/AIDS Section 1115 Demonstration Waiver under the Social Security Act effective January 1, 2014. The objective of this waiver is to provide more effective and earlier treatment, improve access to continuous health care, provide a comprehensive package of services to people living with HIV/AIDS, to assist in enhancing compliance with treatment and medication regiments, and to meet cost-effectiveness as required by federal regulations. The key feature of this waiver which allows for the objectives to be successfully accomplished is the care management services. Maine is not anticipating any impact on enrollment or spending unless a Medicaid expansion occurs. If so, some enrollees would move from the waiver to full MaineCare benefits. Maine does not anticipate asking for any substantial modifications to the existing Section 1115 Demonstration waiver. Maine does not anticipate asking for any substantial modifications to the existing Section 1115 Demonstration waiver. Maine has continued to make improvements with care management and cost saving initiatives. Member satisfaction rates with the program have continued to increase. Two public hearings have been held and favorable comments have been received. A third public hearing was held on April 3, 2013 for public comment and input to coincide with the submission of the application. No comments were received. The HIV Sec. 1115 Demonstration renewal narrative is in final draft and will be vetted internally before it will be submitted to CMS.Staff: Michael Dostie Effective: January 1, 2014

Chapters II and III, Section 25, Dental ServicesThis rule is being proposed in order to update the principles of reimbursement (Chapter III) to include 2012 /2013 CDT codes. This rule change will also add Independent Practice Dental Hygienists, Dental Externs, and Dental Residents as qualified providers.

Staff: Peter Kraut

Chapter II Section 31, Federally Qualified Health Center ServicesThis rule is being proposed in order to add Independent Practice Dental Hygienists, Dental Externs, and Dental Residents as qualified providers.

Staff: Peter Kraut

Maine State Services Manual, Chapter 104, Section 6, Independent Practice Dental Hygienist Service for MaineCare MembersThis new rule will provide that the Department will reimburse Independent Practice Dental Hygienist (IPDHs) for providing certain services to MaineCare members from 10/1//12 through the effective date of a forthcoming State Plan Amendment to add IPDHs under Maine’s State Plan. The services are: prophylaxis performed on a person who is 21 years of age or younger; topical application of fluoride performed on a person who is 21 years of age or younger; provision of oral hygiene instructions; the application of sealants; temporary fillings; and x-rays

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August, 2013(under a temporary geographically limited pilot program overseen by the Maine Board of Dental Examiners).

Staff: Peter Kraut

MaineCare Benefits Manual (MBM), Chapter 1, Section 1.01 (F) and 1.04 (D), Individuals Covered under Dirigo Choice

The proposed rule will repeal MaineCare Benefits Manual, Chapter 1, Section 1.01 (F) and Section 1.04 (D) entitled Individuals Covered under Dirigo Choice, in accordance with Public Law Chapter 368, Part A, Section A-1, Appropriations, pp. 182-184, 357. The 126th Maine Legislature enacted P.L. 368 to eliminate, as of December 31, 2013, Dirigo Choice and payment for services for members who are enrolled through their employer under the Dirigo Choice Plan and MaineCare.

Staff: Michael Dostie

MaineCare Benefits Manual (MBM), Chapter VI, Section 2, MaineCare DirigoChoice Initiatives

This proposed rule repeals in its entirety MaineCare Benefits Manual, Chapter V, Section 2, MaineCare DirigoChoice Initiatives. The repeal of MaineCare Benefits Manual, Chapter V, Section 2, MaineCare DirigoChoice Initiatives is necessary to help supplement appropriations and allocations for the expenditures of State Government and to amend certain provisions of law necessary to the proper operations of State Government. Public Law, Chapter 368, under the Dirigo Health Fund eliminates positions and reduces funding to reflect the dissolution of the DirigoHealth Agency in fiscal year 2013-14. It also reduces funding to reflect that the Dirigo Health program is no longer required and transfers funding related to a new, separate and distinct fund for the Fund for a Healthy Maine from other special revenue funds.

Staff: Michael Dostie

State Plan Amendment Status:

09-016 Transportation, Bus Passes - This SPA adds bus passes as a covered service when transportation providers find this the most cost effective method to provide transportation to medically necessary services.Status: Submitted 9/30/09 “Off Clock”, as CMS is reviewing a related 1915B waiver.

10-013 Coverage of PNMI Services - This SPA adds more detail, at request of CMS, of what is covered and who are qualified providers in PNMI facilities. No changes in coverage or benefit.Status: Submitted September 24, 2010. RAI Issued December 2010, responses submitted

to CMS March 17, 2011. Additional questions received last week of April, and a conference call was held in May, 2011 to start working through CMS questions. Responses withdrawn 5/6, currently Off Clock, IMD analysis required.

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August, 201310-014 Coverage of Behavioral Health Services - This SPA adds more detail, at the request of CMS, of what is covered and who are qualified providers for behavioral health services. No changes in coverage or benefit are made.Status: Submitted September 24, 2010. RAI issued December 2010, responses submitted

to CMS March 17, 2011. Additional questions received last week of April. Withdrew responses 5/6. Currently off clock, IMD analysis required.

10-015 Coverage of Rehabilitative Services - This SPA adds more detail, at the request of CMS, of what is covered and who are qualified providers for rehabilitative services. No changes in coverage or benefit are made.Status: Submitted September 24, 2010. RAI Issued December 2010, responses submitted

to CMS March 17, 2011. Additional questions received last week of April. Responses Withdrawn 5/6, currently Off Clock, IMD analysis required.

10-016 Coverage of Personal Care Services - This SPA adds more detail, at the request of CMS, of what is covered and who are qualified providers for personal care services. No changes in coverage or benefit are made. Status: Submitted September 24, 2010. RAI Issued December 2010, Responses

submitted to CMS March 17, 2011. Additional questions received last week of April. Responses withdrawn 5/6. Currently off clock, IMD analysis required.

12-006 Increase of limits for Chiropractic and Vision Services - The state is requesting approval to increase the limits for Chiropractic and Vision services, pursuant to the 1st Supplemental Budget, P.L. 2011, CH. 477.

Status: Submitted June 29, 2012. Informal RAI questions received on August 8, 2012. Informal RAI responses submitted to CMS on September 10, 2012. Formal RAI received September 20, 2012.Formal RAI responses submitted December 22, 2012

12-007 Pharmacy Coverage and Reimbursement - The state is requesting approval to revise and add several reimbursement methodologies for Pharmacy services. The reduction of reimbursement for brand-name drugs to AWP minus (-) 16%, the request to impose a mandatory generic substitution and eliminate coverage of smoking cessation products for all members except for pregnant women is made pursuant to the 1st and 3rd Supplemental Budgets.

Status: Submitted June 29, 2012. Informal RAI questions received on August 13, 2012. Informal RAI responses submitted to CMS on September 10, 2012. Formal RAI received September 26, 2012.Formal RAI extension received December 31, 2012

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August, 201312-008 Reimbursement for Services other than Inpatient Hospital - The state is requesting approval to decrease the rates of reimbursement for Podiatry, Occupational Therapy, Physical Therapy and Opioid Treatment pursuant to the 1st Supplemental Budget, P.L. 2011, CH. 477.

Status: Submitted June 29, 2012Informal RAI questions received on August 8, 2012. Informal RAI responses submitted to CMS on September 10, 2012. Formal RAI received September 20, 2012.Formal RAI responses submitted December 22, 2012

12-009 Hospital Inpatient - The state is requesting approval to exempt Critical Access Hospitals from the requirement to count readmissions within 72 hours as part of the initial discharge to parallel, Medicare; reduce the amount of supplemental pool for Non-CAHs by approximately $200,000; change the methodology for distributing the pool to take into account the switch to DRG payment methodology; and revise reimbursement methodology for Provider Preventable Conditions.

Status: Submitted June 29, 2012Formal RAI received September 18, 2012Extension received January 7, 2013

12-011 Hospital Outpatient - The state is requesting approval to reimburse hospital outpatient services under Ambulatory Patient Classification (APC) based methodology for private, non-critical access hospitals effective July 1, 2012.

Status: Submitted September 28, 2012Formal RAI received December 20, 2012Responses due March 20, 2013Budget neutralApproved on June 18, 2013

12-015 Mandatory Pharmacy Co-Pays – this State Plan Amendment (SPA) is made to assure that Maine’s State Plan is updated to be consistent with policy changes that will need to be made to implement LD 346-An Act Regarding Pharmacy Reimbursement in MaineCare, which will implement mandatory co-payments for certain MaineCare members. In accordance with 42 CFR 447.76, the Department published notices in five (5) local papers, on the Departments website and held a public hearing regarding the proposed SPA. The Department did not receive any comments regarding the proposed SPA and there were no attendees at the public hearing.

Status: Submitted: 12/7/12Informal RAI received 1/2/13Informal responses submitted to CMS 1/15/13Formal responses submitted to CMS 6/3/13

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August, 2013Budget neutral

12-017 PCP Increase -Medically Underserved Areas The Department received a request to increase the rate paid to physician-owned primary care medical practices that are located in Governor’s Designated Medically Underserved Areas. The requester provided information that, over the years, MaineCare reimbursement to other types of providers has steadily increased while reimbursement rates for physician-owned medical practices have steadily fallen behind. Section 1202 of the Affordable Care Act requires Medicaid programs to increase rates for Primary Care Physicians to 100% of the Medicare fee schedule, effective January 1, 2013. This rate increase will provide the additional financial support needed to assure that members have a free choice of providers and are able to access all medically necessary Primary Care services within their geographic area.

Status: Submitted 12/31/12Informal RAI received 2/5/13Informal responses submitted to CMS 2/22/13

Formal RAI received 3/28/13Fiscal Impact: If the State Plan Amendment is approved, the proposed rate increase will cost $440,058 for 3 months, in State and Federal funds. If the State Plan Amendment is not approved, the proposed rate increase will be $440,058 for 3 months, in State general funds.

13-001 ACA’s Primary Care Physicians Payment Rate Increase This SPA will request approval for the methodology used by the State to implement the mandatory ACA rate increase initiative for certain primary care physicians to 100% of the Medicare fee schedule in calendar years 2013 and 2014. Status Submitted 3/29/13

Informal RAI received 4/24/13Informal responses submitted to CMS 5/8/13Approved

13-003 Recovery Audit Contractor – The State is seeking an exception to the three (3) year look back period for the Recovery Audit Contractor (RAC) to review providers. RACs have been encountering problems when reviewing more recent claims that providers have not had a chance to adjust or void. Therefore, the State is seeking an exception allowing the RACs to look back five (5) years instead of the three (3) year look back period in order to address these issues and comply with existing State policy. Status Submitted 3/29/13

Approved 5/31/13

13-004 Substance Abuse Service – The State will be requesting approval to impose MaineCare reimbursement for methadone for the treatment of addiction to opioids to a lifetime maximum of twenty four (24) months, except as permitted with prior authorization beyond twenty-four (24) months. Status Submitted 3/29/13

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August, 2013Informal RAI received 05/14/13Informal responses submitted 6/24/13Formal RAI received 6/26/13

13-005 Physical Therapy services – The State will be requesting approval to increase the limits for Physical Therapy Services to allow for up to five (5) treatment visits and one (1) evaluation within twelve (12) months, when provided pursuant to a pain management care plan.Status Submitted 3/29/13

Informal RAI received 5/22/13Informal responses submitted 6/25/13Formal RAI received 6/27/13

13-006 Pharmacy Services/ Pain Management – The State will be requesting approval for limits on opioid medication used for the treatment of paintStatus Submitted 3/29/13

Formal RAI received 6/20/13

13-007 Primary Care Case Management -- The Department is deleting references to the Patient Centered Medical Home program, because it is being replaced by the Health Home Initiative described in the new/proposed MaineCare Benefits Manual, Chapters II & III, Section 91 (“Health Home Services”) that is concurrently going through the rulemaking process.Status: Submitted 3/29/13

Informal RAI received 5/2/13Informal responses submitted to 06/03/13Approved 6/12/13

13-008 Behavioral Health -- The Maine State Legislature in P.L. 2013, Ch. 1, § A-23 (“An Act To Make Supplemental Appropriations and Allocations for the Expenditures of State Government and To Change Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Year Ending June 30, 2013”) directed the Department to reduce reimbursement rates by 5% for LCPC and LMFT. 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 retroactive to March 5, 2013. Status: Submitted 3/29/13

Informal RAI received 5/13/13Formal RAI received 6/28/13

13-009 Inpatient Leave Days -- Payment of bed holds for a semi-private room for a short-term hospitalization of the member is proposed to change to four (4) days (midnights) absence through June 30, 2013, as long as the member is expected to return to the nursing facility. Effective July 1, 2013, payment for these bed holds would be granted up to four (4) days (midnights) absence during the twelve (12) month period from July 1 through June 30. The Department will also, if CMS approves, reduce reimbursement for a leave of absence from thirty-six days in a twelve-month period to no more than one (1) day in leave of absence from

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August, 2013March 25, 2013 through June 30, 2013; and, effective July 1, 2013, one (1) day of leave of absence during the twelve (12) month period from July 1 through June 30.Status: Submitted 3/29/13

Informal RAI received 5/13/13Informal responses submitted to CMS 6/3/13

Approved 6/13/13

13-010 Free-standing Birth Centers -- The proposed Freestanding Birth Center Services amendment is being submitted to comply with Section 2301 of the Affordable Care Act. The SPA clarifies that the State of Maine does not currently license and/or approve Freestanding Birth Centers as a place of service.

Submitted 5/2/13Approved 5/9/13

13-013 Excluded Drugs, Barbiturates, and Benzodiazepine - The proposed Pharmacy Services amendment is being submitted to comply with Section 175 of the Medicare Improvement for Patient and Providers Act of 2008 which amended section 1860D-2(e)(2)(A) of the act to included Medicare Part D drug coverage of barbiturates “used in the treatment of epilepsy, cancer, or a chronic mental health disorder” and benzodiazepines for all medically accepted indications.

The State of Maine asks that this SPA be retroactive to the effective date of April 1, 2013. The Department of Health and Human (The Department) has made edits to its system to implement this change effective January 1, 2013. However, the submission of this SPA has been delayed in order to meet notice requirements.

Submitted 5/10/13Formal RAI received 8/7/13

13-015 Inpatient Leave Days -- Payment of bed holds for a semi-private room for a short-term hospitalization of the member is proposed to change to seven (7) days (midnights) absence each fiscal year, as long as the member is expected to return to the nursing facility. Payment for these bed holds would be granted up to seven (7) days (midnights) absence during each twelve (12) month period. The Department will also, if CMS approves, increase reimbursement for a leave of absence from one (1) day in a twelve-month period to no more than twenty (20) day in leave of absence each fiscal year, and twenty (20) day of leave of absence during the twelve (12) month period each fiscal year.Status: Submitted 6/28/13

13-012 Health Home – The Department is seeking to update the deadline by which a Health Home must achieve National Committee for Quality Assurance certification.

Submitted June 28, 2013Approved July 8, 2013

13-002 Personal Care - The Department will be submitting this SPA to CMS. This SPA will request approval to consolidate all personal care services including consumer directed personal care services into one part of the Medicaid State Plan. This SPA will also establish standard

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August, 2013levels of medical eligibility and acuity for all personal care services and propose a minimum standard staffing qualification across all personal care services. Finally it will establish a standard rate for home based personal care services provided by independent providers and agency providers and Maintains a per diem case mix adjusted rate for personal care services delivered in residential care settings.

Submitted 6/25/13

In Draft

Recovery Audit Contractor Medical Director -The Department of Health and Human Services is seeking an exception to the requirement that a RAC have a full time Medical Director on staff. The Department requests that CMS allow a half-time (½) Medical Director rather than a full-time Medical Director under the Recovery Audit Contractor (RAC) Program. The basis for this request is that Maine is a small state and the need for a full-time equivalent RAC Medical Director should be reduced accordingly.

Hospital Services Outpatient – The Department will be requesting approval to reduce the outpatient Ambulatory Payment Classification (APC) rate for Acute Care Non-Critical 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.

Hospital Services Inpatient - The Department will be requesting approval to increase the reimbursement rate per psychiatric discharge for members under 18 years of age from hospitals in the Lewiston-Auburn area to $9,128.31.

Behavioral Health Maine’s Legislature directed the Department to reduce restore rates by 5% for LCPC and LMFT. 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 retroactive to July 1, 2013.

Pharmacy Services - The proposed Pharmacy Services amendment is being submitted to comply with Section 175 of the Medicare Improvement for Patient and Providers Act of 2008 which amended section 1860D-2(e)(2)(A) of the act to included Medicare Part D drug coverage of barbiturates “used in the treatment of epilepsy, cancer, or a chronic mental health disorder” and benzodiazepines for all medically accepted indications

Waivers RENEWAL-Section 19, Home and Community-Based Benefits for the Elderly and for Adults with Disabilities (CMS control #0276) - This waiver will be renewed for 7/1/13, the only anticipated changes are updating the performance measures in the quality sections of the waiver application.

Staff: Ginger Roberts-Scott

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August, 2013Status: Submitted to CMS 3/29/2013, RAI received 4/26/13. RAI submitted to CMS 5/31/13.Renewed effective 7/1/13.

Waiver AmendmentsSection 21, Home and Community-Based Benefits for Adults with Intellectual Disabilities or Autistic Disorder (CMS control # 0159) - The waiver will be amended to reflect Work Support, Home Support and Assistive Technology changes. For Communication Aids, ATP/OT/Audiologists will be added as qualified providers. Staff: Ginger Roberts-ScottStatus: in draftSection 32, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders (CMS control # 0864) - This amendment will update the start date of the waiver. Staff: Ginger Roberts-ScottStatus: in draftSection 29, Support Services for Adults with Intellectual Disabilities or Autistic Disorder (CMS control # 0467) - The waiver will be amended to reflect Work Support, Home Support and Assistive Technology changes. Staff: Ginger Roberts-ScottStatus: in draftSection 19, Home and Community-Based Benefits for the Elderly and for Adults with Disabilities (CMS control #0276) - This amendment will merge Sections 19 and 22 together. Staff: Ginger Roberts-ScottStatus: in draft

Section 18 Home and Community Based Services for Members with Brain Injury.New Brain Injury Waiver-1915 (c)Staff: Ginger Roberts-Scott

Staff telephone numbers Staff email addressesCari Bernier – 287-1856 [email protected] Michael Dostie - 287-6124 [email protected] Peter Kraut - 287-6131 [email protected] Roberts-Scott - 287-9365 [email protected] O’Brien - 287-5505 [email protected]

Pascale Desir – 287-2829 [email protected]

*PLEASE NOTE THAT ALL RULES ARE PROMULGATED IN COMPLIANCE WITH EXECUTIVE ORDER OF AUGUST 24, 2011 “AN ORDER TO IMPROVE REVIEW OF THE RULEMAKING PROCESS,” detailed at: http://www.maine.gov/tools/whatsnew/index.php?topic=Gov_Executive_Orders&id=182022&v=article2011.

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http://www.maine.gov/tools/whatsnew/index.php?topic=Gov_Executive_Orders&id=182022&v=article2011

http://www.maine.gov/tools/whatsnew/index.php?topic=Gov_Executive_Orders&id=182022&v=article2011

mailto:[email protected]







August, 2013**Please note: Public Hearings are no longer being held at 442 Civic Center Drive, Augusta. Please check the published rulemaking documents to find the location where the public hearing will be held for each individual rule.**

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Documents

bjbjt+t+ - Maine.gov Web viewThis rule is proposed to permanently adopt the provisions now in place by emergency rule that eliminate coverage of Medicare Part D copayments for members