Adopted Rulemaking Archives

NOTICE OF REDUCTION: Community Support Services For Adults with Intellectual Disabilities or Autistic Disorder WORD   
Concise Summary: This is a Notice of Reduction in Hours of MaineCare’s Community Support Services For Adults with Intellectual Disabilities or Autistic Disorder. The adopted rule is expected to be effective July 1 and will be posted on this site shortly after it has been adopted.
Effective Date: July 1, 2011
  Posted: June 1, 2011
 
MaineCare Benefits Manual, Chapter II & III, Section 97, Private Non-Medical Institution Services, Appendix B: Principles of Reimbursement for Substance Abuse Treatment Services WORD  WORD 
Concise Summary: The amendments to Chapter III, Section 97 change the method of reimbursing PNMI substance abuse treatment facilities from an interim rate/cost-settlement basis to fixed per diem rates depending on the type of service. The new standardized rates are set forth in the regulation, and appropriate, HIPAA compliant billing codes are provided. Chapter II, Section 97 is amended to coordinate with changes to Chapter III regarding the method of reimbursement for these services. Minor revisions are made to the names of some services. The changes are necessary to meet budget reduction targets. The Legislature ordered various reductions in expenditures in the MaineCare program to counteract predicted deficits and balance the budget. P.L. 2009, ch. §571. The reduction in reimbursements for PNMI substance abuse treatment facilities was selected by the Legislature after careful consideration, and it will be implemented in a fair and equitable manner. It is anticipated that the proposed changes will result in savings of $264,744 in State fiscal year 2011. These changes were first adopted by emergency rule effective November 15, 2010.
Effective Date: February 13, 2011
View Comments: WORD  Posted: February 16, 2011
 
MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures. WORD  PDF 
Concise Summary: The Department is adopting numerous changes to the MaineCare Benefits Manual (MBM), Chapter 101, Chapter 1, Section 1, General Administrative Policies and Procedures to assure that provider requirements align with the Department’s new claims system and to up-date other aspects of the rule. The methods of claims submission reflect various updates in moving from the Maine Claims Management System (MECMS) to the Maine Integrated Health Management Solution (MIHMS) claims system. Chapter I retains the one (1) year deadlines from dates of services for the correct filing of claims, but adds the proviso that if the service was provided before September 1, 2010, then the claim must be filed within one (1) year or by January 31, 2011, whichever is sooner. Various other changes are made, including requiring that provider license renewals must be received within 30 days prior to the date of expiration or change, that providers must update ownership information on an annual basis and that out-of-state providers treating MaineCare members on an emergency basis must contact the Department within 24 hours. The Department also adopts federally required changes to copayments, including an exemption from copayments for Native Americans (42 C.F.R. § 447.57) and a limit on total copayments to 5% of income (42 C.F.R. § 447.78). The Department adds information regarding filing and managing claims in MIHMS, recognizes nurse licensure to include current, unencumbered compact licenses from another compact state, strengthens the Department’s ability to collect overpayments determined by providers (P.L. 111-148, §6506) eliminates obsolete billing codes and pursuant to federal law, eliminates payments to entities outside the United States (P.L. 111-148, §6505). Various grammatical and structural changes are also made to the rule.
Effective Date: February 13, 2011
View Comments: COMMENTS  Posted: February 10, 2011
 
MaineCare Benefits Manual, Chapter III, Section 21, Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder - PROVISIONAL ADOPTION WORD  PDF 
Concise Summary: THIS RULE IS A MAJOR SUBSTANTIVE RULE AND HAS BEEN PROVISIONALLY ADOPTED. THIS RULE MUST HAVE THE APPROVAL OF THE LEGISLATURE BEFORE IT CAN BE ADOPTED AS A FINAL RULE. THIS RULE WAS ADOPTED AS AN EMERGENCY AND WAS EFFECTIVE OCTOBER 1, 2010. THE EMERGENCY RULE WILL REMAIN IN EFFECT UNTIL THE FINAL RULE IS APPROVED AND ADOPTED. ANOTHER NOTICE WILL BE PUBLISHED WHEN THE FINAL RULE IS ADOPTED AND THAT NOTICE WILL INDICATE THE EFFECTIVE DATE. The Department is provisionally adopting rates for Shared Living Providers pursuant to PL 2009, Ch 571 §§ A-25, A-26, and CCCC-3 that were effective 10/1/10 via emergency rule. The Department also made technical changes to the rule to remove procedure codes that were effective for MECMS, the payment system that was effective prior to 9/1/10.
Effective Date: AFTER LEGISLATIVE APPROVAL
View Comments: PDF  Posted: January 7, 2011
 
MaineCare Benefits Manual, Chapter III, Section 96, Private Duty Nursing and Personal Care Services WORD  PDF 
Concise Summary: The Department adopts this final rule with the following changes: the 15 minute rate for RN services is $10.58, (an increase to the proposed rate of $9.25), due to comments received during rulemaking. Some providers and recipients were concerned that the proposed rate of $9.25 for RN services was too low and therefore some providers would refuse to provide services at this rate. The Department believes that this higher rate can be achieved while maintaining cost neutrality. The rule also makes changes to the titles of some services, in order to comply with the National Correct Coding Initiative (NCCI).
Effective Date: January 9, 2011
View Comments: WORD  Posted: January 6, 2011
 
MaineCare Benefits Manual, Chapters II & III, Section 43, Hospice Services WORD  PDF 
Concise Summary: These rules permanently adopt previously filed emergency rules reflecting the codes necessary when billing through Maine Integrated Health Management Solution (MIHMS), therefore, allowing providers to bill correctly in the new system. In addition, these rules permanently adopt the previously filed emergency rule permitting terminally ill MaineCare members under the age of 21 to receive hospice services without requiring them to forgo other treatments covered by MaineCare. This implements Section 2302 of the Affordable Care Act (Pub. L. No. 111-148 as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. No. 111-152)).
Effective Date: January 4, 2011
View Comments: WORD  Posted: January 6, 2011
 
MaineCare Benefits Manual, Chapters II & III, Section 31, Federally Qualified Health Center Services Word   
Concise Summary: The adopted rules amended billing instructions and Chapter III coding requirements to ensure that FQHC providers could bill for covered services for MaineCare members upon implementation of MIHMS. Also, the rule amended Chapter II, Section 31.06-1 to recognize the licensure of advanced practice and registered nurses who hold a current, unencumbered compact license from another compact state they claim as their legal residence. The rule allowed providers sufficient time to make necessary software changes and billing changes to meet the Department’s reporting requirements.
Effective Date: 2010-11-29
View Comments: Word  Posted: December 7, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section # 103, Rural Health Clinic Services Word   
Concise Summary: The adopted rules amend billing instructions and Chapter III coding requirements to ensure that FQHC providers are able to bill for covered services for MaineCare members upon implementation of MIHMS. The rule also requires providers to report all encounter data on the UB 04 form. Also, the rule recognizes licensure of advanced practice and registered nurses who hold a current, unencumbered compact license from another compact state they claim as their legal residence.
Effective Date: 2010-11-29
View Comments: Word  Posted: December 7, 2010
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services WORD   
Concise Summary: This adopted rule changes the definition of “discharge”. Public Law 2009, ch. 571, Part A, Sec. A-26 directs the Department to reduce funding to hospitals by “limiting reimbursement to hospitals when a MaineCare patient is subsequently readmitted to the hospital within three days following an inpatient admission for the same diagnosis”. This rulemaking makes that change. The Department will reimburse for only one discharge if a patient is readmitted to the same hospital within 72 hours for the same diagnosis. Additionally, this adopted rule makes changes, effective November 1, 2010, to allow hospitals reclassified to a wage area outside Maine by the Medicare Geographic Classification Review Board to become eligible for supplemental pool payments under the Acute Care Non-Critical Access Hospitals provision of this rule. This rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. This rulemaking has no adverse impact on small businesses employing twenty or fewer employees.
Effective Date: September 28, 2010
View Comments: WORD  Posted: November 9, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 29, Community Support Benefits for Members with Mental Retardation or Autistic Disorder WORD   
Concise Summary: The Department is adopting changes to Ch. III Section 29, Community Support Benefits for Members with Mental Retardation or Autistic Disorder. These changes have been in place as an Emergency Rule since July 1, 2010. Specifically, this rule enacts a reduction in reimbursement rates by 2% for day habilitation and work support services; all other services are reduced by 10%. This complies with Legislative budget initiatives designed to balance the State budget. In addition, the Department is adopting minor changes in the billing codes to be employed with the adoption of the Maine Integrated Health Management Solution. This change is not expected to have an adverse effect on the administrative burdens of small businesses.
Effective Date: September 28, 2010
View Comments: WORD  Posted: October 15, 2010
 
Me State Services Manual, Ch 104, Sec 5, Health Insurance Purchase Option & REPEAL OF CH VIII, SEC. 2 WORD   
Concise Summary: The Department of Health and Human Services, MaineCare Services, is deleting a section of the MaineCare Benefits Manual, Chapter VIII, Section 2, and creating a new section of the Maine State Services Manual. Concurrent to this rulemaking, the Office of Integrated Access and Support is adding the eligibility portion of this program and publishing the information in a manual maintained by that Office. The benefits of this State administered program have not changed.
Effective Date: September 15, 2010
View Comments: WORD  Posted: October 14, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities WORD   
Concise Summary: The Department permanently adopts amendments to Chapter 101, MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities, in order to comply with the State Supplemental Budget initiative to balance the State budget and to address changes related to the implementation of the Maine Integrated Health Information Management System (MIHMS). The following are changes in the rule: application of an additional inflation of 12.37% to the routine cost component for SFY 11; calculation of the upper limit on the base year cost per day based on the median multiplied by 88.73 % for direct care and routine cost components; clarification of the rate determination schedule under Principle 81 and removal of reimbursement Principle 101, Staff Enhancement Payments (SEP), from the rules. This rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. This rulemaking has no adverse impact on small businesses employing twenty or fewer employees.
Effective Date: September 29, 2010
View Comments: WORD  Posted: October 13, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 28, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations WORD   
Concise Summary: The adopted rule specifies a new category of children who are eligible for Section 28 services: those children between the ages of birth and five years who have been diagnosed with a specific congenital or acquired condition, with a written assessment by a physician that they will meet the functional impairment criteria if services and supports are not provided to these children. The Department also added schools, as defined in the regulation, as a new provider of Section 28 services. Additionally, the final rule clarifies that all staff working in the capacity of a BHP must obtain BHP certification by July 1, 2011. The final rule permanently adopts a 2% rate reduction that took effect 7/1/10 for all covered services. Other routine technical changes were also made to the final rule. This rule change is not expected to have an adverse effect on municipalities or counties in the delivery of medically necessary services. An economic impact statement regarding businesses of 20 or fewer employees is on file with the Department.
Effective Date: September 28, 2010
View Comments: WORD  Posted: September 27, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 23, Developmental and Behavioral Evaluation Clinic Services WORD   
Concise Summary: The final rule permanently adopts emergency rules that took effect 7/1/10, the rule adopted a 10% decrease in rates for Developmental and Behavioral Evaluation Clinic Services. This change is not expected to have an adverse effect on the administrative burden of small businesses.
Effective Date: September 28, 2010
View Comments: WORD  Posted: September 27, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 65, Behavioral Health Services WORD   
Concise Summary: The adopted rules specify rate reductions that took effect via emergency rule, 7/1/10. The adopted rules also specify criteria for members who need services beyond 72 quarter hour units for Outpatient Services. Both of these actions were pursuant to PL 2009, ch 571. Additionally, as a technical correction, the final rule details the provisional approval of BHP’s for Children’s Behavioral Health Day Treatment. This process is identical to the provisional approval process for Children’s Home and Community Based Treatment. This change is not expected to have an adverse effect on the administrative burdens of small businesses.
Effective Date: September 28, 2010
View Comments: WORD  Posted: September 27, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 113, Allowances for Transportation Services WORD   
Concise Summary: This final rule permanently adopts the cost savings measures mandated by Maine’s June 2010 Supplemental Budget resulting in a 6.5% decrease to all Allowances for Transportation Services reimbursement rates. These were in effect by emergency rule on August 1, 2010. Rate standardization had already been in progress for many months to prepare for the implementation of Maine Integrated Health Management Solution (MIHMS), the CMS certified billing system; therefore the Department completed rate standardization prior to addressing the 6.5% budgeted rate decrease.
Effective Date: September 28, 2010
View Comments: WORD  Posted: September 23, 2010
 
Chapters II and III, Section 13, Targeted Case Management Services WORD   
Concise Summary: The Department adopted changes to Chapter II and III, Section 13, Targeted Case Management Services. The changes eliminate the target group “Members With Long Term Care Needs” from the eligibility portion of the rule, as those members can receive comparable Case Management Services under several Home and Community Based Waivers. The Department also converted some billing units to weekly billing for the following target groups: “Children Involved with Protective Services (State Agencies),” and “Adults Involved with Protective Services.” The Department combined “Targeted Case Management Services For Adults with Developmental Disabilities (Provided by State Employees)” and “Targeted Case Management Services For Adults With Developmental Disabilities,” and the service will be billed in a weekly service unit as “Targeted Case Management Services For Adults with Developmental Disabilities.” The Department also changed the unit of service for billing Targeted Case Management Services for Adults With HIV to 15 minutes increments. The Department withdrew one proposed change in Section 13 that would have eliminated Section 13 TCM services for members who receive care coordination under the HIV waiver. Upon further analysis and receipt of compelling comments, the Department determined that the care coordination under the HIV waiver is not comparable to TCM provided under Section 13, and will continue to make this crucial services available to eligible members under Section 13. All of these changes are implemented with the Department’s new claims system.
Effective Date: September 1, 2010
View Comments: WORD  Posted: September 1, 2010
 
Chapter 101 MaineCare Benefits Manual, Chapter II, Section 109, Speech and Hearing Services WORD   
Concise Summary: This adopted rule achieves a number of goals to facilitate the delivery of Speech and Hearing services in school settings, specifically: 1. allow services to be ordered by a practitioner of the healing arts, 2. establish schools as an approved setting for the delivery of services, 3. authorize speech and language clinicians holding a Certificate 293 to deliver services, and 4. other minor, technical corrections.
Effective Date: September 1, 2010
View Comments: WORD  Posted: September 1, 2010
 
MaineCare Benefits Manual, Chapter II, Section 85, Physical Therapy Services WORD   
Concise Summary: This adopted rule achieves a number of goals to facilitate the delivery of physical therapy services in school settings, specifically: • allow services to be ordered by a practitioner of the healing arts, • remove the maximum limit of two (2) visits per year for sensory integration for members under age twenty-one (21), • establish schools as an eligible provider, and • remove the requirement that a physician or primary care provider sign a member’s plan of care every three (3) months for members under age twenty-one (21).
Effective Date: September 1, 2010
View Comments: WORD  Posted: September 1, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 90, Physician Services WORD   
Concise Summary: The final rule change incorporates new prior authorization language in Chapter II of this policy. The new language will allow the Department to use evidence based medical criteria based on nationally accepted criteria when determining medical necessity for certain services. Adopting these criteria will ensure that medical services are delivered to members in an appropriate way consistent with national standards of care. Services requiring prior authorization and their criteria can be found at: http://www.maine.gov/dhhs/oms/provider_index.html. In cases where the criteria are not met, the Provider/Member may submit additional supporting evidence such as medical documentation, to demonstrate that the requested service is medically necessary. The Department has amended the Transplant criteria, which can be found in Appendix A of this policy. The Department’s new criteria will require members to be free of alcohol and drug use for 6 months prior to transplants. This change was made to be consistent with industry wide standards of care. The Department is modifying Section 90.09-2 MaineCare Reimbursement to allow for MaineCare to reimburse and make adjustments according to Medicare place of service rates and modifiers. Furthermore, upon implementation of Maine’s Integrated Health Management System (MIHMS), the Department will repeal Chapter III, Section 90 of this policy as this Section has become unnecessary. No services are being reduced because of this change. The Department also made other structural, administrative, grammatical and clarifying changes within this rulemaking. This rule change is not anticipated to have any adverse impact on small business or create any new compliance burdens for municipalities and counties.
Effective Date: August 9, 2010
View Comments: WORD  Posted: August 19, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 25, Dental Services WORD   
Concise Summary: In Chapter II of Section 25, Dental Services, the final rule change requires, for Temporomandibular Joint Treatment (TMJ), that providers access prior authorization criteria that are industry recognized criteria utilized by a national company under contract, in addition to prior authorization criteria set forth in the rule itself. Providers can access these prior authorization criteria by accessing the OMS website at: http://www.maine.gov/dhhs/oms/provider_index.html, which will have a link to the PA portal. In cases where the criteria are not met, the Provider/Member may submit additional supporting evidence such as medical documentation, to demonstrate that the requested service is medically necessary. In Chapter III of Section 25, the Department is clarifying that PA is not required for code D4341, if a member has a diagnosis code 101- acute necrotizing ulcerative gingivitis (ANUG). To the extent that payment for code D4341 has been denied and the member has a diagnosis of 101-acute necrotizing ulcerative gingivitis (ANUG), the Department may approve reimbursement retroactively. The Department also made other structural, administrative, grammatical and clarifying changes within this rulemaking. This rule change is not anticipated to have any adverse impact on small business or create any new compliance burdens for municipalities and counties.
Effective Date: August 9, 2010
View Comments: Word  Posted: August 19, 2010
 
Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 5, Ambulance Services word   
Concise Summary: This rulemaking is adopting language in Chapter II to lift prior authorization requirements for all four air ambulance transportation services when performed within state borders. Out of state air ambulance services continue to require prior authorization following the guidelines set forth in Section 1.14-2 of the Maine Care Benefits Manual. Reflecting the 2010-2011 Supplemental Budget (P.L. 2009, c. 571, Part A, Section 26) allowance, Chapter III rates change to 70% of Medicare-allowed rates. These set-rate fees are in response to the CMS requirements of 42 CFR 414.601 et seq., as well as serve to replace the supplemental payments used in previous rulemakings under this Section. These rules will become effective on August 1, 2010, prior to the implementation of Maine Integrated Health Management Solution (MIHMS).
Effective Date: August 1, 2010
View Comments: word  Posted: July 23, 2010
 
MaineCare Benefits Manual, Chapter III, Section 7, Free Standing Dialysis Services word   
Concise Summary: This final rule requires that providers bill using HCPCS codes along with Revenue codes when billing for Free-Standing Dialysis Services. This will be effective upon implementation of the new claims system, MIHMS, with a 30 day notice to providers. This is necessary in order to be consistent with Medicare guidelines, satisfy correct coding, and to remain HIPAA compliant.
Effective Date: July 26, 2010
View Comments: word  Posted: July 23, 2010
 
MaineCare Benefits Manual, Chapter II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorder Word   
Concise Summary: The Department adopts the term “intellectual disabilities” where appropriate, to conform to more modern terminology. This is consistent with the newest revision to the Diagnostic and Statistical Manual and the Department’s focus on respectful language. Also in this adopted rule, the Department renames the initial classification process to “Determination of Eligibility.” Provisions regarding owned-operated businesses in the employment setting are clarified. Furthermore, the Department adopts rules that reduce the maximum allowance for community support service hours and work support service hours. The Department also clarifies language around work support services provided by a Direct Support Professional (DSP) to one member at a time. Additionally, the Department establishes two additional grounds for involuntary termination of services to a member in this rule-making. Qualifications for DSPs and Employment Specialists are amended in this final rule-making. These adopted rules also specify the use of the appeals process for members outlined in Chapter I of the MaineCare Benefits Manual. Finally, the adopted rule includes a new Appendix IV, which outlines the various combinations of community support and work support hours available.
Effective Date: July 1, 2010
View Comments: Word  Posted: July 8, 2010
 
Chapter 101, Chapters II & III, Section 65, Behavioral Health Services and repeal of Chapters II & III, Section 41, Day Treatment Services word   
Concise Summary: The adopted rule repeals Chapters II & III, Section 41, Day Treatment Services and incorporates Children’s Behavioral Health Day Treatment Services in to Chapters II & III, Section 65, Behavioral Health Services. The rule adoption was necessary to utilize HIPAA compliant codes and assure medically necessary services were being delivered by qualified staff. Schools were also added as a qualified provider. Other routine technical changes to the rule were also made
Effective Date: July 1, 2010
View Comments: Word  Posted: July 8, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 22, Home and Community Benefits for the Physically Disabled word   
Concise Summary: The changes adopted in this rulemaking involve expanding covered services to include those services that are bundled under the current case management service. These services are skills training, financial management services, and supports brokerage and will now be billed separately. The Department also adopts language that outlines the allowed maximum number of billable hours for each service. Also adopted in this final rule is language surrounding waiting list and cost of care practices. In Chapter III, the Department adopts three HIPAA-compliant service codes needed to bill for skills training, financial management services and supports brokerage. The Department also adopts an installation code for the Personal Emergency Response System (PERS), which is consistent with other Home and Community Based waiver programs. Finally, the Department adopts a new attendant care rate. All adopted changes will be implemented upon MIHMS go-live. Providers should follow current rules and protocols until that time. Providers will be notified at least thirty (30) days in advance of MIHMS implementation.
Effective Date: MIHMS implementation
View Comments: word  Posted: July 8, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 19, Home and Community Benefits for the Elderly and Adults with Disabilities word   
Concise Summary: The Department is adopting these final changes to Chapter II, Section 19: Services that were previously included under Comprehensive Care Management services have been broken out and clarified as Skills Training Services, Financial Management Services, and Care Coordination Services. The Home Care Coordination Agency (HCCA) has been deleted, and replaced with Service Coordination Agencies (SCA), which will coordinate services. However, the SCA providing care coordination services to a member may not be a provider of direct care services. A Limits provision limits the number of allowable hours for Skills Training Services and Care Coordination/Supports Brokerage Training Services. Additionally, this adopted rule requires the Office of Elder Services to maintain Member waiting lists, and it requires the Department to collect the Cost of Care from the Member. The adopted rule also adds a new type of provider: the Care Coordinator. This rule also allows Section 19 services to be suspended for up to 60 days without a Member losing eligibility for Section 19 services
Effective Date: MIHMS implementation
View Comments: word  Posted: July 7, 2010
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services Word   
Concise Summary: These adopted rules establish Medicare DRG and APC billing methodology for hospitals. Inpatient discharges will be reimbursed on a Medicare DRG-based system, and include a direct care DRG rate, as well as estimated capital and medical education costs. This reimbursement will be subject to interim and final settlements. Billing for outpatient discharges will also be required to begin capturing the data required to transition to paying outpatient claims with APC methodology. This final rule also makes a technical correction in the supplemental pool amount the Department allocates. These proposed changes are subject to CMS approval. Hospitals will receive at least a 30 day notice of “go live” date for MIHMS.
Effective Date: 2010-06-28
View Comments: word  Posted: June 29, 2010
 
Final Rule: MaineCare Benefits Manual, Chapters II & III, Section 96, Private Duty Nursing and Personal Care Services Word   
Concise Summary: The Department is adopting these changes to Chapter II: Care coordination and skills training services are covered under this Section. These services must be approved by Centers for Medicare and Medicaid Services (CMS) before they become effective. The Home Care Coordination Agency (HCCA) has been deleted, and replaced with Service Coordination Agencies (SCA), which will coordinate services. However, the SCA providing care coordination services to a member may not be a provider of direct care services. A limits provision limits the number of allowable hours for Skills Training Services and Care Coordination/Supports Brokerage Training Services. These rules also extend the ability to suspend services from 30 days to 60 days without a Member losing eligibility under this Section. Personal Support Specialist (PSS) training requirements are modified to allow job shadowing and on-the-job training to count toward the required number of training hours for PSSs. The Department also adopts the following changes to Chapter III: HIPAA-compliant service codes are included in Chapter III. The final rule clarifies billing by including the addition of two codes: T1019, Personal Support Services (PSS), and S5125TF, PCA Supervisit. These codes are necessary in order for Personal Support Agencies to bill for these services. In addition, the Department removed the 0589 revenue code from the S5125 HCPCs code as originally proposed. The revenue code is not required in order to bill for these particular PSS services.
Effective Date: IMPLEMENTATION OF MIHMS
View Comments: word  Posted: June 23, 2010
 
MaineCare Benefits Manual, Chapter 101, Ch II, Section 90, Physician’s Services Word   
Concise Summary: The Department gives notice of a final rulemaking: MaineCare Benefits Manual, Chapter 101, Section 90, Physician’s Services Ch II. This rulemaking formally adopts an Emergency rule effective March 1, 2010. The Department has increased the MaineCare reimbursement rate for non-hospital based physician services from 56.94% to 70% retroactive to March 1, 2010. This increase will not include reimbursement for procedures performed by radiologists, radiation oncologists, and pathologists, who currently receive a higher rate of reimbursement. No procedure codes are decreased as a result of this rulemaking. Furthermore, this increase does not apply to other sections of policy within the MaineCare Benefits Manual, Chapter 101. Providers can visit the Office of MaineCare’s website for the current fee schedule. The fee schedule can be found at http://portalxw.bisoex.state.me.us/oms/proc/pub_proc.asp?cf=mm.
Effective Date: 2010-06-01
View Comments: Word  Posted: May 27, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 12, Consumer Directed Attendant Services. Word   
Concise Summary: The Department adopts these rules in order to comply with the new Maine Integrated Health Management System (MIHMS) that requires fee for service reimbursement methodology and HIPAA-compliant codes. The Department expands covered services under this Section to include care coordination and skills training. This is a result of eliminating long-term care targeted case management as a covered service from Section 13, Targeted Case Management Services. These services have formerly been billed as a per member/per month fee. Additionally, the Department adopts limits for billable hours for each service. Chapter III contains three HIPAA-compliant codes for billing care coordination, skills training, and attendant care services. The Department made the following changes to the final rule as a result of public comment to these rules or comments to other sections: elimination of the requirement for an assessment at 6 months, clarification of conflict of interest language in the Service Coordination Agency definition, clarification that initial skills training must occur within 30 days of receipt of the MED assessment. The Department also finds that, as of the date of adoption of this rule, MIHMS has not yet been implemented. This finding requires an adjustment in the effective date, as set forth below.
Effective Date: MIHMS IMPLEMENTATION
View Comments: Word  Posted: May 24, 2010
 
MaineCare Benefits Manual, Chapter 101, Chapter II, Section 4, Ambulatory Surgical Center Services Word   
Concise Summary: The adopted rule clarifies and updates language. Section 4.04-A states that payment for implanted presbyopia-correcting intraocular lens and astigmatism-correcting intraocular lens will be at the rate of payment for a conventional intraocular lens. In section 4.04-B, the Department is eliminating website information that is stated in 4.04 Covered Services. It is also adding language that states that ASC covered services may be billed in addition to the surgical procedure. In section 4.05 Non-Covered Services, the Department is deleting the 3rd and 4th paragraph “Payment for” Presbyopia-Correcting Intraocular Lens, etc., as this is clarified in Section 4.04-A. In section 4.07-2 the Department is changing the language to clarify that when there are multiple procedures in the same operative session, MIHMS will pay only for the procedure that has the highest payment amount.
Effective Date: 2010-06-01
View Comments: Word  Posted: May 20, 2010
 
MaineCare Benefits Manual, Chapter II, Section 45, Hospital Services Word   
Concise Summary: These adopted rules add admission eligibility and continuing eligibility criteria for hospital detoxification services. These rules also remove specific billing instructions and reporting of rebatable drugs in favor of listing those specifics on the DHHS website. These changes consolidate those instructions to one location. These changes will assure the efficient operation of the MaineCare program. Further, the administrative burden of utilization review will be lessened if the admission and continuing eligibility criteria are clear from the beginning. This rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. This rulemaking has no adverse impact on small businesses employing twenty or fewer employees.
Effective Date: 2010-05-22
View Comments: Word  Posted: May 7, 2010
 
MaineCare Benefits Manual, Chapter(s) II & III, Section 31, Federally Qualified Health Center Services Word   
Concise Summary: The adopted rules add a new provision under “reimbursement” which sets forth the Department’s legal obligations for individuals who are eligible for Medicare, some of whom are also eligible for Medicaid (QMB only, QMB plus and non QMBs). This section complies with federal regulations on Medicare cost sharing. Also, the Department intends to transition to a new information system, MIHMS in 2010, with 30 days notice to providers. Upon implementation of MIHMS, the Department will delete the current local billing codes in Chapter III, Table 1, and replace them with the codes in Chapter III, Table 2 to become compliant with Federal HIPAA regulations. Further, the Department will require providers to bill services, including documenting the type of visit, diagnoses and procedures on the UB04 claims form, which will replace the CMS 12500 form. This adopted rule should not adversely impact those facilities with staff of 20 or fewer employees. In addition, this proposed rule-making is not expected to create any new compliance burdens for counties or municipalities.
Effective Date: 2010-05-01
View Comments: Word  Posted: May 3, 2010
 
Ch III Section 21 Home and Community Benefits for Members with Mental Retardation or Autistic Disorder Word   
Concise Summary: The final adopted rules specify rates. Additionally, the final rules specify changes to billing codes necessary to comply with federal coding requirements. The coding changes will take effect when the Department’s new claims processing system (MIMHS) becomes operational, which is expected to occur in August, 2010. Providers will receive 30 days notice of the effective date of the coding changes.
Effective Date: 2010-06-01
  Posted: April 27, 2010
 
MaineCare Benefits Manual, Section 94, Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) [formally known as Prevention, Health Promotion, and Optional Treatment Services] Word   
Concise Summary: The adopted rule updates terminology, clarifies certain sections, and makes technical corrections to prepare for the Maine Integrated Health Management Solution (MIHMS). Additionally, the rule is being renamed. This rule is not expected to have an adverse impact on municipalities, counties, or small businesses.
Effective Date: 2010-05-01
View Comments: Word  Posted: April 23, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 67, Nursing Facility Services and Principles of Reimbursement for Nursing Facilities Word   
Concise Summary: The Department is adopting Chapters II and III, Section 67, Nursing Facility Services and Principles of Reimbursement for Nursing Facilities. Specifically, the Department adopts language describing the practice of continued stay in a NF when a resident is no longer medically eligible for NF services and is awaiting placement for a residential care setting. The amended rules also expand eligibility for specialized services for members with MR or “other related condition”. Furthermore, the amended rules allow residents to receive maintenance-level speech therapy when it has been determined the services are medically necessary in order to avoid a significant deterioration in ability to communicate orally, safely swallow or masticate. The Department adopts changes to Chapter III, Principles of Reimbursement for Nursing Facilities, by changing the methodology establishing the direct care cost components and consequently the prospective per diem rates for facilities. Additionally, methodology is adopted under principal 70 to support facilities billing for community support services. The Department also adopts language regarding depreciation recapture. These changes do not impose negative fiscal impact on small businesses with twenty (20) or fewer employees or create any new compliance burdens for municipalities and counties.
Effective Date: 2010-04-01
View Comments: WORD  Posted: April 23, 2010
 
MaineCare Benefits Manual, Chapter III, Section 97, Private Non-Medical Institutions, and Chapter III, Appendices D and E Word   
Concise Summary: In this major substantive rulemaking, the Department is finally adopting the August 1, 2009 Emergency Substantive PNMI, Ch. III Rule, currently in effect as well as other additional clarifications. These rules were provisionally adopted by the Department and have now been finally approved by the Maine State Legislature in Resolve 2009, chapter 166. The Department amends Appendix D (Child Care PNMI Facilities) by deleting the cost settlement requirement. Instead, the Department adopted a standardized capitated rate for five (5) levels of child services based on a child’s diagnosis and level of acuity. These rates were established by analyzing data from claims and time studies and unbundling service components to establish an Upper Payment Limit. The Department added new billing codes for children’s services. The capitated rate includes reimbursement for all PNMI services required by a child for his/her category of level of care including all staffing required both by Maine licensing guidelines, and as identified in the child’s individual service plan. The Legislature mandated the 5 levels of child services in its budget initiative enacted into law (P.L. 2009, ch. 213, Part CC). The Department amended Appendix E (Community Residences for Persons with Mental Illness) by deleting “scattered site” PNMI services. Other changes in Chapter III update billing codes for the Department’s new claims system for all other PNMI services, and clarify in Chapter III where language pertaining to auditing cost reports no longer applies to Appendix D PNMI services.
Effective Date: 2010-05-15
View Comments: Word   Posted: April 15, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 104, School Based Rehabilitative Services Word   
Concise Summary: The adopted rules repeal Section 104, School Based Rehabilitation Services. Because this rule change is a repeal, there is no cost of implementation or compliance imposed by this rule on municipalities, counties or small businesses.
Effective Date: 2010-03-10
View Comments: Word  Posted: March 11, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 27, Early Intervention Word   
Concise Summary: The adopted rules repeal Section 27, Early Intervention Services. Because this rule change is a repeal, there is no cost of implementation or compliance imposed by this rule on municipalities, counties or small businesses.
Effective Date: 2010-03-10
View Comments: Word  Posted: March 11, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 23, Developmental and Behavioral Evaluation Clinic Service Word   
Concise Summary: The adopted rules specify new service descriptions accompanied by HIPPA compliant coding with new hourly rates.
Effective Date: 2010-04-01
View Comments: Word  Posted: March 10, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 85, Physical Therapy Services Word   
Concise Summary: These adopted rules: 1. change the definition of “maintenance therapy” to allow medically necessary physical therapy services if the services prevent a member from suffering a significant decline in function that would result in an extended length of stay or placement in an institutional hospital setting; 2. replace local billing codes with HIPAA compliant code; 3. adjust rates in a budget neutral fashion to match new billing codes; 4. remove “Collateral Contacts” as a billable service upon MIHMS go live; and 5. adopt other structural, administrative and grammatical changes.
Effective Date: 2010-03-10
View Comments: Word  Posted: March 9, 2010
 
Chapters II & III, Section 68, Occupational Therapy Services Word    
Concise Summary: These adopted rules: 1. change the definition of “maintenance therapy” to allow medically necessary occupational therapy services if the services prevent a member from suffering a significant decline in function that would result in an extended length of stay or placement in an institutional hospital setting; 2. replace local billing codes with HIPAA compliant code; 3. adjust rates in a budget neutral fashion to match new billing codes; 4. remove “Collateral Contacts” as a billable service upon MIHMS go live; and 5. adopt other structural, administrative and grammatical changes.
Effective Date: 2010-03-10
View Comments: Word  Posted: March 5, 2010
 
Chapters II & III, Section 28, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations Final rule  Member notice  
Concise Summary: The adopted rules establish a new service: Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations.
Effective Date: 2010-04-01
View Comments: Public comments   Posted: March 4, 2010
 
MaineCare Benefits Manual, Chapter II & III, Section 109, Speech and Hearing Services Word   
Concise Summary: These final rules achieve a number of goals: 1. Establishes HIPAA compliant coding for the delivery of services with implementation of MaineCare’s new claims system, MIHMS; 2. Establishes increased agency rates for services effective July 1, 2010 to comply with FY 2010 budget requirements; and 3. Fulfills the Legislature’s directive, as expressed in PL 2007, ch. 71, which allows for speech therapy benefits for members who, without a maintenance level of speech therapy services, may reasonably suffer a significant decline in their ability to communicate orally, safely swallow or masticate. This change is expected to decrease extended stays or placements in institutional settings. This rulemaking has no adverse impact on small businesses employing fewer than twenty employees.
Effective Date: 2010-03-01
View Comments: Word  Posted: March 2, 2010
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services Word   
Concise Summary: The Department is adopting changes to MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services. The adopted rules are necessary to avoid a threat to public health, safety, or general welfare. The threat to public health is due to the expected escalation of H1N1 (swine flu) this year. MaineCare is adopting the increase in reimbursement for administration of seasonal flu vaccines (H1N1) and other immunizations allowed under 32 MRSA § 13831 for licensed Maine pharmacists. MaineCare will reimburse $5 per vaccination for administration of these vaccines. Furthermore, MaineCare pharmacies who compound the drug Tamiflu for MaineCare children and other MaineCare members where there is a medical need and when the pharmacy is unable to provide Tamiflu Suspension will receive a $10.00 compounding fee. This is so that MaineCare children are not denied access to a medically necessary antiviral during this flu season.
Effective Date: 2010-02-16
View Comments: Word  Posted: February 23, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 102, Rehabilitative Services Word   
Concise Summary: The adopted rules specify renamed and defined services to clarify and reorganize services for better applicability and to allow for flexible patient centered care in Chapter II. Additionally, Chapter III has been recoded in a manner consistent with HIPAA compliant coding. Services have been realigned from a level system to a concurrent provision system. The final rule redesign allows a member to receive one of four services concurrently up to 18 hours a week, allowing for a more effective and efficient service delivery. The new services are Clinical Assessment and Reassessment, which was formerly Clinical Evaluation. Level I Intensive Rehabilitative Services was replaced by Intensive Integrated Neurorehabilitation. Group services will no longer be reimbursed. Level II Post Acute Rehabilitative Services was replaced by Neurobehavioral Rehabilitation, with one-on-one (1:1), group and family services. And lastly, Level III Day Health Rehabilitative Services were replaced by Self Care/Home Management and Community/Work reintegration, with group services. Other routine and technical changes have been made to the proposed rule.
Effective Date: 2010-04-01
View Comments: Word  Posted: February 23, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 29, Community Support Benefits for Members with Mental Retardation and Autistic Disorder Word   
Concise Summary: The adopted rules eliminate the Behavioral Add-on rate enhancement for providers of Community Support, Employment Specialist and Work Support Services. Additionally, the rates for Community Support, Employment Support Specialist and Work Support Services were reduced by eight cents ($0.08) per unit. This change is to conform with the current rates for these services under § 21, Chapter III, Home and Community Benefits for Members with Mental Retardation of Autistic Disorder.
Effective Date: 2010-03-01
View Comments: Word  Posted: February 18, 2010
 
MaineCare Benefits Manual, Chapter IV, Restriction Plans Word   
Concise Summary: The adopted rules restructure the restriction plans from two to four plans to improve the health care of MaineCare members and to integrate Member Lock-In plans with the new MaineCare claims system, Maine Integrated Health Management System (MIHMS). Lock-In type 1 requires a member to be restricted to a designated Primary Care Physician, a Hospital, a Prescriber, a Pharmacy and any other applicable health care professional. Lock-In type 2 restricts the member to one or multiple types of health care providers. Lock-In type 3 restricts the member to one or multiple specific prescriber(s) for their prescriptions. Lock-In type 4 restricts the member from being able to obtain a specific drug category (class). Additionally, the rule was renamed and technical corrections were done.
Effective Date: 2010-03-01
View Comments: Word  Posted: February 18, 2010
 
MaineCare Benefits Manual, Chapter III, Section 26, Day Health Services Word   
Concise Summary: The Department adopts changes Chapter III of Section 26, Day Health Services. Specifically, the TF and TG modifiers attached to the S5100 code for Day Care Services are removed. These modifiers are no longer necessary to distinguish the three levels of care upon MIHMS implementation. As a result, providers will only need to bill the S5100 to receive reimbursement for members at any level of care. These changes do not impose any cost municipalities or counties and do not impose any administrative burden on small businesses with twenty (20) or fewer employees. Although these rules are effective on March 1, 2010, these rules will not be implemented until MIHMS. Until MIHMS implementation, providers should continue to bill MECMS with the current three codes. Providers will be notified at least 30-days in advance of implementing the new claims system.
Effective Date: 2010-03-01
View Comments: Word  Posted: February 11, 2010
 
MaineCare Benefits Manual, Chapter VII, Section 5, Estate Recovery Word   
Concise Summary: This rulemaking is being adopted to ensure that the Estate Recovery rules fully comply with the terms of Maine’s State Medicaid Plan, as approved by the federal Centers for Medicare and Medicaid Services (CMS), and to incorporate programmatic changes mandated by the Legislature. The Department is adopting language that will implement an Estate Recovery Exemption with Qualified Long Term Care policies. These changes will allow the Department to disregard the amount of benefits covered by a qualified long term care policy. The amount of the disregard will be equal to the amount of the insurance benefits made to or on behalf of the decedent. Furthermore, the adopted rules remove language under Section 5.07, Care Given Exemption, and replace it with Section 5.08,Hardship Waiver Based on Care Given Exemption. This adopted change allows the Department to consider a care given exemption from estate recovery for a person requesting the waiver if their income is less than two hundred percent (200%) of federal poverty and if health maintenance activities and personal care services were performed for the member during part or all of the two (2) years immediately prior to the member’s death. All care given exemptions will not exceed the value of any MaineCare benefits paid on behalf of the member.
Effective Date: 2010-01-01
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 13, Targeted Case Management Services Word   
Concise Summary: This rulemaking adopts the following changes for Targeted Case Management Services: Target groups are consolidated and redefined. Several target groups are deleted, including Pregnant and Postpartum women, Adults with Diabetes and Asthma and Members who are receiving Healthy Futures Services. There is new language detailing eligibility criteria for Children and Adults applicable to Case Management Services for Children with Developmental Disabilities and Behavioral Health Disorders as well as Case Management Services for Adults with Developmental Disabilities, Behavioral Health Disorders, Substance Abuse Disorders, HIV, Long Term Care Needs and Members Experiencing Homelessness. This rule adds a prior authorization requirement for children’s targeted case management services. This rule also reduces funding for children’s targeted case management by limiting services to two (2) months for children with scores between fifty (50) and seventy (70) on the Child and Adolescent Functional Assessment Scale. The assessment tool score may not be the sole criterion for determining medical necessity, needs and/or eligibility. This rule also clarifies that MaineCare will not cover multiple TCM services; and it sets forth the eligibility process, and the requirement of transitioning to one comprehensive case manager for children and adult members. Chapter III adds new billing procedure codes based on HIPAA-compliant HCPCS coding. Chapter III also implements a change in reimbursement to some Providers/Case Management Agencies through the requirement of billing in 15- minute increments, while other TCM services require monthly or weekly billing. Record-keeping requirements, per the federal Medicaid requirement, have been adopted in this rule. This rule also provides TCM coverage for individuals receiving protective services, and this rule changes eligibility for homeless individuals so that these individuals are not required to have resided in a homeless shelter either currently or in the past 90 days. The Department made some minor corrections and edits in the final rule as a result of comments, which are summarized in the Department’s Response to Comments.
Effective Date: 2009-11-30
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter II & III, Section 3, Ambulatory Care Clinic Services Word   
Concise Summary: These final rules achieve a number of goals: - permanently adopt emergency rules currently in place which allow for the administration of H1N1 and seasonal flu vaccines by Ambulatory Care Clinic providers, schools and Home Health Agencies; - adopt new, HIPAA compliant billing codes to take effect when MaineCare’s new claims system, MIHMS, goes live; - remove reference to 2 sub-specialties that no longer have enrolled providers; - and other, minor grammatical changes. This rulemaking has no adverse impact on small businesses employing fewer than twenty employees.
Effective Date: 2009-12-21
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II and III, Section 25, Dental Services Word   
Concise Summary: The Department of Health and Human Services is adopting changes to the MaineCare Benefits Manual, Chapters II and III, Section 25, Dental Services. The Department amended language in sub-section 25.03-2 (G) for Tobacco Cessation Counseling to be consistent with the language in Chapter III, Section 90, Physician’s Services. The Department is also adopting new language in sub-section 25.04-1 For Adult Dental Care Requirements. The language clarifies criteria for imminent tooth loss. Furthermore, the Department is removing Appendix III-Supplemental Payment to General Dentists. Instead, the Department is increasing the reimbursement for selected dental codes in Chapter III of this Policy. The rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. The rulemaking has no adverse impact on small business, as all providers impacted by these rules employ more than twenty employees.
Effective Date: 2010-01-01
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures Word   
Concise Summary: The Department adopts changes to the MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures. These rules define billing and rendering (servicing) provider; set forth additional requirements for emergency services; clarify that providers must supply requested information to the Department, and that there is a continuing duty to update provider information; clarify the types of financial information that may be requested; set forth additional requirements for termination procedures; simplify provider requirements related to e-signatures and facsimiles obtained for member files; add the coverage of a new eligibility group (presumptive eligibility for pregnant women); require that providers of managed care services must have a referral from the member’s PCP; outline the requirements for the PA process; delete PA requirements for alcohol treatment services reimbursed by the Indian Health Service; provide that national standards may be used as criteria for defining “medically necessary”; and set forth procedures following a provider suspension. As a result of public comment, the following four changes were made to the final rule; removal of Section 1.03-7, Provider Debt; replacing “and” with “or” under Section 1.06-4 to clarify that coverage of services for medically necessary treatment under presumptive eligibility is for the pregnant woman or the fetus; clarifying under Section 1.06-5(C) that certain services do not require a referral as outlined under Chapter VI, Primary Care Case Management; adding language under Section 1.14-2(B)(1) to allow for an extension of the one-day requirement for out of state providers who cannot verify MaineCare membership; and deleting language under Section 1.14-2(C)(2) that outlined requirements for behavioral health emergency services for children. The adopted changes do not create any additional compliance burdens or adversely impact counties or municipalities, or businesses with twenty (20) or fewer employees.
Effective Date: 2010-01-11
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment Word   
Concise Summary: The Department is adopting changes to its reimbursement methodology so that it will reimburse for DME/Medical Supplies as follows: (1) For DME/medical supplies that are not “miscellaneous DME/medical supplies” or made available through an exclusive contract with the Department, providers will be reimbursed at the lower of: the Medicare rate, the provider’s usual and customary charge or a MaineCare fee schedule published on the Department’s website. (2) For DME/medical supplies, which contains the phrase “miscellaneous,” “accessories,” "not otherwise specified" or "not otherwise classified" in its description, MaineCare will reimburse at either the Manufacturers’ Suggested Retail Price (MSRP) minus twenty percent (20%) or in cases where there is no listed MSRP, providers will be paid their Usual and Customary Charges minus thirty percent (30%). (3) Where the Department has entered into a contract with a supplier, the Department will reimburse based on the priced contained in the contract. In addition, the Department (1) will no longer provide coverage for non-sterile wipes for all MaineCare members; (2) is placing limits on pressure mattress pads, commodes, walkers, pneumonic compressor devices, apnea monitors, etc., (3) is defining criteria for reclining wheelchairs; (4) is clarifying standards for phototherapy for the treatment of seasonal affective disorder; and (5) is reducing the amount of allowable incontinence supplies.
Effective Date: 2010-01-04
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapters II & III, Section 30, Family Planning Agency Services and Allowances for Family Planning Agency Services Word   
Concise Summary: The adopted rules will update the policy language, unbundle services, replace local codes with HIPAA compliant codes and standardize rates. Also contained within this rulemaking is the elimination of coverage for infertility treatment, elimination of coverage for cervical caps, and expansion of coverage to include blood testing and counseling related to HIV and Hepatitis. These changes will become effective upon implementation of MIHMS. Providers will be notified at least thirty (30) days prior to the effective date.
View Comments: Word  Posted: February 5, 2010
 
MaineCare Benefits Manual, Chapter III, Section 15, Chiropractic Services Word  PDF 
Concise Summary: These final rules allow for HIPAA compliant billing of chiropractic services under MaineCare’s new claims system, MIHMS. This rulemaking has no adverse impact on small businesses employing fewer than twenty employees.
Effective Date: 2009-11-23
View Comments: Word  Posted: November 17, 2009
 
MaineCare Benefits Manual, Chapter II, Section 4, Ambulatory Surgical Centers Word  PDF 
Concise Summary: These final rules update the definition of Ambulatory Surgical Center, per CMS Conditions for Care; update the conditions of care; clarify non-covered services; add documentation for assessments and informed consents; and make minor grammatical changes. This rulemaking has no adverse impact on small businesses employing fewer than twenty employees.
Effective Date: 2009-11-18
View Comments: Word  Posted: November 13, 2009
 
Chapter 275-Reporting Requirements for Pharmaceutical Manufacturers and Labelers; Office of the Attorney General, 26-239, Chapter 111, Reporting Requirements for Pharmaceutical Manufacturers and Labelers. Word  PDF 
Concise Summary: This letter gives notice of a final rule: Department of Health and Human Services, 10-144, Chapter 275-Reporting Requirements for Pharmaceutical Manufacturers and labelers; Office of the Attorney General, 26-239, Chapter 111, Reporting Requirements for Pharmaceutical Manufacturers and Labelers. This final rulemaking clarifies Maine requirements for clinical trial registration and results reporting, compatible with current and anticipated Federal reporting requirements and with the capabilities of the publicly funded website, www.ClinicalTrials.gov. The rule modifies the scope of the trials required to be registered and reported. It includes requirements to report on observational studies and clarifies the requirements of reporting post hoc analysis of trial results. This rulemaking provides contact information and clarifies the application of penalty for violations. This rule change does not require reposting of previously posted trials. Other minor technical, grammatical and structural changes are included within this rulemaking. This rule change is not anticipated to have any adverse impact on small business.
Effective Date: 2009-11-02
View Comments: Word  Posted: November 2, 2009
 
MaineCare Benefits Manual, Chapter II, Section 97, Private Non-Medical Institutions Word  PDF 
Concise Summary: This rule will adopt an expiring emergency rule which added language detailing eligibility criteria, requiring prior authorization for children’s and adult’s behavioral health PNMI services, and defining models of children’s PNMI services for which standard rates are being set in separate major substantive rulemaking this month pursuant to Chapter III of Section 97. In addition, this rule will adopt additional definitions subsequently proposed which will facilitate eligibility and prior authorization determinations, including additional criteria for some services. These changes are necessary to assure that PNMI services are medically necessary and that more cost effective community based services are used to the fullest extent possible. The Department expects to achieve significant cost savings as a result of these changes as directed by the Legislature, while still providing services deemed medically necessary. The rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. The rulemaking has no adverse impact on small business, as all providers impacted by these rules employ more than twenty employees.
Effective Date: 2009-10-30
View Comments: Word  Posted: October 30, 2009
 
Chapters III, Section 22, Home and Community Benefits for the Physically Disabled Word  PDF 
Concise Summary: The Department adopts Chapter III, Section 22, Home and Community Benefits for the Physically Disabled for purposes of increasing the attendant care services rate. This rate increase results from funds that were formerly reimbursed with all State dollars and will now receive Federal match. This rate change is retroactive to July 1, 2009.
Effective Date: 2009-11-01
View Comments: Word  Posted: October 27, 2009
 
MaineCare Benefits Manual, Chapter VI, Primary Care Case Management Word  PDF 
Concise Summary: The Department of Health and Human Services is adopting changes to Chapter VI, Primary Care Case Management (PCCM) to add a new level of services, Patient Center Medical Home. Patient Centered Medical Home services will assure effective, efficient and accessible health care services for eligible MaineCare members. Provider requirements are included in the adopted rule. Providers who are approved to deliver this service will receive $3.50 per member per month to deliver patient centered medical home services. This management fee is in addition to the $3.50 they receive for providing PCCM services for a total of $7.00 per member per month. Providers will be required to deliver additional integration of patient services, and participate in on-going educational and evaluation activities. The Department also added language to clarify what groups may not be required to participate in PCCM or PCMH services to be in compliance with federal guidelines and updated sections that have been revised or consolidated in the MaineCare Benefits Manual. The rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. The rulemaking has no adverse impact on small business.
Effective Date: 2009-11-01
View Comments: Word  Posted: October 25, 2009
 
MaineCare Benefits Manual, Chapters II & III, Section 62, Genetic Testing and Clinical Genetic Services Word  PDF 
Concise Summary: The Department gives notice of a final repeal of a rule: MaineCare Benefits Manual, Chapters II & III, Section 62, Genetic Testing and Clinical Genetic Services. The Department is repealing this section of the MaineCare Benefits Manual to simplify the billing for this service and to repeal outdated clinical provisions currently in Section 62, Genetic Testing and Clinical Genetic Services. Currently the majority of genetic services are being billed under Sections 90 and 55 of the MaineCare Benefits Manual. Providers who were currently billing under Section 62 will now bill under Sections 90, Physicians Services and 55, Laboratory Services, as appropriate. No services are being reduced as a result of this rulemaking.
Effective Date: 2009-10-01
View Comments: Word  Posted: October 1, 2009
 
Chapters II & III, Section 7, Free-Standing Dialysis Services Word  PDF 
Concise Summary: The adopted rule is a new Section of MaineCare Benefits Manual. Currently, providers of dialysis services are billing MaineCare under Section 90, Physician Services. The Physician Services rule does not contain any policy pertaining to dialysis services. This new rule is a stand-alone policy for dialysis providers with its own definitions; covered services, including renal dialysis, prescribed drugs, and training for home dialysis; eligibility requirements; reimbursement; limitations; and billing instructions.
Effective Date: 2009-10-01
View Comments: Word  Posted: October 1, 2009
 
MaineCare Benefits Manual, Chapter III, Section 29, Community Support Benefits for Members with Mental Retardation and Autistic Disorder Word  PDF 
Concise Summary: The adopted rules specify modifiers that providers will use when the new payment system, MIMHS is implemented. Providers will receive a notice thirty days in advance of the code implementation. Other than providers of these specific services, this rule is not expected to fiscally impact or create new recording burdens for other small businesses and is not expected to yield new costs for municipal or county governments.
Effective Date: 2009-11-01
View Comments: Word  Posted: September 28, 2009
 
MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facility Services Word  PDF 
Concise Summary: These rules adopt methodology for the case mix index, the direct care cost component, and the routine cost component in order for the nursing facilities to be properly reimbursed. As a result of public comment, two changes were made to the methodology used to calculate upper limits for the direct care and routine cost components. Specifically, the peer group upper limit for the direct care and routine cost components are now based on the median base year cost per day multiplied by 89.185% as opposed to the 87.122% in the proposed rule. This change will be made retroactive to July 1, 2009. In addition, the Department is adopting a new reimbursement methodology for remote island nursing facilities. These rules are necessary to ensure continued MaineCare funding for nursing facility services provided to the medically fragile residents of Maine.
Effective Date: 2009-09-28
View Comments: Word  Posted: September 28, 2009
 
Chapters II & III, Section 17, Community Support Services Word  PDF 
Concise Summary: The final rules permanently adopt emergency rules were in effect 7/1/09. A new service was established called Community Rehabilitation Services that took the place of Section 97, Private Non Medical Institution rules, scattered site PNMIs for persons with severe and persistent mental illness. This service is billed on a per diem basis using a HIPAA compliant code to comply with certification requirements for the new payment system, Maine Integrated Health Management System (MIMHS). Additionally, the final rule removed the Global Assessment of Functioning Score (GAF) and replaced it with Level of Care Utilization System (LOCUS) used to determine eligibility for Section 17 services. This was part of a budget initiative estimated to save $ 1,683,730.00 SFY 10 and $ 1,910,941.00 SFY11 in the general fund. The enhanced FMAP may alter the actual final savings. The final rule also defined requirements for Assertive Community Treatment (ACT), including a HIPAA compliant per diem code (H0040) that will be effective when the new MaineCare claims payments system, Maine Integrated Health Management System (MIMHS) begins processing claims. Providers will be notified thirty (30) days in advance of the change. The code for Intensive Case Management (ICM) was changed to a HIPAA compliant code (H0023) that is currently being used in Section 65, Behavioral Health Services ( but being phased out) that will be effective when the new MaineCare claims payments system, Maine Integrated Health Management System (MIMHS) begins processing claims. Providers will be notified thirty (30) days in advance of the change. Other routine technical changes in response to comments were also made in the final rule. Other than providers of these specific services, this rule is not expected to fiscally impact or create new recording burdens for other small businesses and is not expected to yield new costs for municipal or county governments.
Effective Date: 2009-10-01
View Comments: Word  Posted: September 25, 2009
 
MaineCare Benefits Manual, Section 46, Psychiatric Hospital Services, Chapter II Word  PDF 
Concise Summary: These final rules establish admission eligibility and continuing eligibility criteria for psychiatric hospitals within psychiatric hospitals. These changes assure the efficient operation of the MaineCare program by ensuring that only individuals who are eligible receive the service. Further, the administrative burden of utilization review is lessened when the admission and continuing eligibility criteria are clear from the beginning.
Effective Date: 2009-09-28
View Comments: Word  Posted: September 22, 2009
 
Section 109, Speech and Hearing Services, Chapter III Word  PDF 
Concise Summary: These adopted rules permanently adopt emergency rules currently in place which increase reimbursement rates for speech and hearing agencies as directed in the FY 2010 budget.
Effective Date: 2009-09-28
View Comments: Word  Posted: September 22, 2009
 
Section 45, Hospital Services, Chapter III Word  PDF 
Concise Summary: The Department is permanently adopting emergency rules currently in place that reduce hospital reimbursement. As mandated by the Legislature, in P.L. 2009, ch. 213, Part CC, effective July 1, 2009 the Department reduced hospital reimbursement. For acute care non-critical access hospitals, inpatient discharge rates (except for those from psychiatric units) were reduced 6.7% and reimbursement for outpatient services was decreased to 83.8% of costs. For critical access hospitals and hospitals reclassified to a wage area outside Maine, reimbursement for inpatient and outpatient services was reduced to 109% of costs. For all acute care hospitals, including critical access, hospital based physician reimbursement was decreased from 100% to 93.3% of allowable costs for inpatient non-emergency physicians, to 93.4% of costs for inpatient emergency physicians and to 83.8% of costs for outpatient non-emergency physicians. In addition, these rules eliminate the COLA adjustment for SFY’s 2010 and 2011 for non critical access acute care hospitals for inpatient discharge rate and for psychiatric unit discharge rates. Th e Department capped the PIP payment so that the total payment to all hospitals is not less than 80%. All of the above mentioned changes are contingent upon approval from CMS.
Effective Date: 2009-09-28
View Comments: Word  Posted: September 22, 2009
 
Section 45, Hospital Services, Chapter II Word  PDF 
Concise Summary: These adopted rules establish admission eligibility and continuing eligibility criteria for hospital psychiatric unit services. These changes will assure the efficient operation of the MaineCare program by ensuring that only individuals who are eligible receive the service. Further, the administrative burden of utilization review will be lessened if the admission and continuing eligibility criteria are clear from the beginning. These rules also require reporting of additional physician administered rebatable drugs.
Effective Date: 2009-09-28
View Comments: Word  Posted: September 22, 2009
 
Ch. 101, MaineCare Benefits Manual, Chapter II and III, Section 96, Private Duty Nursing and Personal Care Services Word  PDF 
Concise Summary: These rules permanently adopt the emergency and proposed rules that establish a new Level IX eligibility level for Section 96 services. These criteria are based on eligible members’ medication administration needs and assistance with ADLs and IADLs. Furthermore, the Department adopts Chapter III, which provides three codes to providers that will be billing for Level IX services. Other minor technical and grammatical changes are also adopted.
Effective Date: 2009-09-28
  Posted: September 22, 2009
 
MaineCare Benefits Manual, Chapter’s II and III, Section 103, Rural Health Services Word  PDF 
Concise Summary: The Department intends to transition to a new information system, MIHMS in 2010, with 30 days notice to providers. Upon implementation of MIHMS, the Department will delete the current local billing codes in Chapter III, Table 1, and replace them with the codes in Chapter III, Table 2, to become compliant with Federal HIPAA regulations. Furthermore, the Department is requiring providers to bill services, including documenting the type of visit, diagnoses and procedures on the UB04 claim form, which will replace the CMS 1500 form.
Effective Date: 2009-09-21
  Posted: September 16, 2009
 
MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy Services Word  PDF 
Concise Summary: The Department of Health and Human Services is adopting MaineCare Benefits Manual, Ch II, Section 80, Pharmacy Services. The adopted rules edit the definition of the Maine Maximum Allowable Cost as a result of savings initiatives. This rule also removes language in 80.05-3 (b), which allowed reimbursement for B-12 for documented pernicious anemia or megaloblastic anemia drugs for the conditions described and when the prescriber has written the diagnosis on the prescription. Finally, the Department is adding section 80.04-3, Academic Detailing Committee, to comply with 22 M.R.S.A § 2685. The Committee will provide evidence based education and outreach, improve quality measures and encourage better communication between the Department and health care professionals to reduce health complications and unnecessary cost associated with inappropriate drug prescribing. The Department also made other structural, administrative, grammatical and clarifying changes within this rulemaking.
Effective Date: 2009-10-01
View Comments: Word  Posted: September 16, 2009
 
Ch. 101, MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment Word  PDF 
Concise Summary: The adopted rules reflect changes to repeal and replace Section 60 in order to clarify the policy and to achieve legislatively mandated cost savings. Proposed changes include new language under Limitations, additional prior authorization requirements, and new language to clarify that items procured under a contract with the Department must be purchased, billed and reimbursed according to the terms of the contract. This Section has been totally replaced due to extensive formatting changes, including a thorough restructuring of the Appendix. Changes made to the Section 60 proposed rule based on the State budget include: increasing the markup of the acquisition cost of DME to 40% from 30%, and DME providers must deduct any prompt payment discounts when determining the acquisition cost of DME. Several additional changes were made to clarify the Section 60 proposed rule due to comments received and legal review, such as; sleep studies for CPAP and Bi-Pap done within the last three (3) years will be accepted; limits for incontinent supplies for members under 21 were removed; and the time to obtain a written prescription for a Power Mobility Device was changed to 45 days. The adopted rule does not impose an economic burden on municipalities or counties. The adopted rules are not expected to increase reporting, record keeping, or other administrative costs or skills necessary for reporting or recording for small businesses.
Effective Date: 2009-07-01
View Comments: Word  Posted: June 24, 2009
 
Chapters II and III, Section 6, Assisted Living Services Word  PDF 
Concise Summary: In this rulemaking, the Department eliminated services provided under MaineCare Benefits Manual, Chapters II and III, Section 6, Assisted Living Services. The Department has determined that it is necessary to repeal these rules because these services were never approved as MaineCare services by CMS. Section 6 Assisted Living Services will no longer be provided under MaineCare as of July 1, 2009. The Members currently receiving Assisted Living services will receive required notification of the discontinuation of these services and will receive an eligibility determination to assess what benefits and services they remain eligible for. Most will be eligible for MaineCare services under Section 96, Private Duty Nursing and Personal Care Services.
Effective Date: 2009-07-01
View Comments: Word  Posted: June 16, 2009
 
MaineCare Benefits Manual, Chapter X, Section 2 (Non-Categorical Adults) Word  PDF 
Concise Summary: The final rule repeals MaineCare Benefits Manual, Chapter X, Section 2, Benefits for Childless Adults, because most of the sub-sections duplicate rules in the MaineCare Eligibility Manual, Section 11000, and promulgates a new Chapter X, Section 2, now called Non-Categorical Adults, listing the covered services for this coverage group. In July 2008, the Department repealed sections 58, 100, and 111, and incorporated those services into Section 65 services. The covered services have not changed but the list of covered services has been revised to reflect the changes made in the consolidated MaineCare Benefits Manual, Chapter II, Section 65, Behavioral Health Services rules, adopted as final rules on October 29, 2008. This rule will not have any adverse impact on the administration of small businesses.
Effective Date: 2009-06-30
View Comments: Word  Posted: June 15, 2009
 
Final Rule: Ch. 101 MaineCare Benefits Manual Chapters II and III Section 45 Hospital Services Word  PDF 
Concise Summary: This adopted rule adjusts hospital reimbursement methodology. Chapter III, Section 45 clarifies and revises reporting requirements and defines the MaineCare Supplemental Data Form, and clarifies that cross-over payments are made to the extent required by CMS. Chapter III also increases the supplemental pool to be distributed among non-critical access hospitals from approximately $36 to $45 million and counts 50% of the psychiatric discharges when distributing the pool; increases the pool for the critical access hospital from $2 to 3.5 million; increases the PIP cap to approximately 81%; creates a separate section for Hospitals Reclassified to a Wage Area Outside Maine by the Medicare Geographic Classification Review Board and limits reimbursement under that section to hospitals reclassified prior to the effective date of the rule; revises sections 45.03, 45.04, 45.05 and 45.06 to separate the calculation of the PIP from the calculation of the Department’s obligation at settlement; establishes base discharge rates for acute care non-critical access hospitals (Franklin Memorial hospital services rate was changed due to a revision made to the base year report); and removes outdated material. Several provisions have a retroactive effective date of 10/1/08. Pursuant to 22 M.R.S.A. §42(8), the Department is authorized to adopt rules with retroactive application when, as here, it is necessary to maximize available revenue sources, and there is no adverse financial impact on any MaineCare provider or member. These rules permanently adopt emergency rules, effective February 21, 2009, that reduce hospital-based physician reimbursement to 46.21% of costs, which is the closest to 70% of the Medicare fee schedule that the Department could fund with the resources used for physician reimbursement, as adjusted by the Supplemental Budget, which reduced reimbursement by $1,947,490 of state dollars. A percentage of costs is being used to calculate 70% of the Medicare fee schedule absent claims—based data. Prospective Interim Payments (PIP) will be lowered in an amount corresponding to the anticipated hospital-based physician payment reimbursement, which are paid separately and not paid as part of PIP. Permanent adoption of this methodology change will be contingent upon approval by the U.S. Center for Medicare and Medicaid Services (CMS). Two proposed changes were withdrawn as a result of comments and legislative action. The provision for hospitals to report professional services on a CMS 1500 form separate from facility fees was withdrawn due to a moratorium enacted by Congress. Also, the reimbursement of non-emergency room hospital-based physicians at 70% of the Medicare fee schedule was withdrawn due to contrary pending legislation in the 1 st session of the 124 th Legislature. Two links were updated in Chapter II, Section 45.11 and Section 45.12. This rulemaking does not adversely impact counties or municipalities, and it does not adversely impact small businesses of twenty (20) or fewer employees because the service affected by the rate reduction is not provided by small businesses.
Effective Date: 2009-05-23
View Comments: Word  Posted: June 5, 2009
 
Final Rule: Ch. 101 MaineCare Benefits Manual Chapter III Section 21 Home and Community Benefits for Members with Mental Retardation or Autistic Disorder Word  PDF 
Concise Summary: This rule permanently adopts major substantive rules approved by the Maine State Legislature and currently in effect by emergency rule.
Effective Date: 2009-06-28
View Comments: Word  Posted: June 5, 2009
 
Chapter III, Section 97, and Appendices B, D, E, and F, Private Non-Medical Institution Services Word  PDF 
Concise Summary: These rules permanently adopt emergency rules already in place that have recently been approved by the Maine State Legislature in LR 1883(03). The rules eliminate bedhold day reimbursement for PNMI services. Specific changes in these rules include that bedhold day codes are eliminated from Chapter III, including BQL, BRL, MRPL, RHL RHL9, RML RML2, RTSL, and PL. Some language regarding occupancy rates was also eliminated from Appendices B, D, E, and F. The Department also replaced some local codes with HIPAA-compliant standard codes that will not be implemented until further notice when the new claims system is operating. Providers will be given prior notice of the change for these billing codes.
Effective Date: 2009-07-02
View Comments: Word  Posted: June 2, 2009
 
Final Rule: Ch. 101, MaineCare Benefits Manual, Chapters II & III, Section 5, Ambulance Services Word  PDF 
Concise Summary: The adopted rules reflect changes to this section to increase Ambulance Services base rates that will include ancillary services. Ancillary Services, which include oxygen, oxygen administration supplies such as disposable oxygen masks, intravenous therapy, EKG, endotracheal intubation, pulse oximetry, telemetry and defibrillation, will no longer be billed separately. RN services will also no longer be billed separately as the base rate for Specialty Care Transport has been increased. A definition of Specialty Care Transport has been added. These changes are being made so only HIPAA compliant codes will be utilized. Other changes to this section were made to update policy language. The proposed rule does not impose an economic burden on small business, municipalities or counties. EFFECTIVE DATE: May 21, 2009
Effective Date: 2009-05-21
View Comments: Word  Posted: April 22, 2009
 
Chapter III, Section 19, Home and Community Benefits for the Elderly and Adults with Disabilities Word  PDF 
Concise Summary: The adopted rules establish different reimbursement rates for comprehensive care management services and mileage reimbursement for health care attendants. Specifically, comprehensive care management rates are reduced from $139.00 to $126.50 as directed by the emergency and supplemental budgets. The comprehensive care management rate reduction produces $62,000 in savings to the General fund for SFY 09. The mileage rates for health care attendants (specifically HHAs, CNAs, PCAs) are increased from $.32 per mile to $.44 per mile. This mileage rate change has a minimal budgetary impact to the General fund.
Effective Date: 2009-03-30
View Comments: Word  Posted: March 29, 2009
 
Chapters II of Section 90- Physician Services, Section 55-Laboratory Services, Section 75-Vision Services, Section 95-Podiatry Services, Section 101-Medical Imaging and Ch III of Section 90 Physician's Services Word  PDF 
Concise Summary: This letter gives notice of a final rule: MaineCare Benefits Manual 10-144, Chapters II of Section 90- Physician Services and Section 55-Laboratory Services, Section 75-Vision Services, Section 95-Podiatry Services, Section 101-Medical Imaging and Ch III of Section 90 Physician's Services. The Department adopts the increase to the MaineCare reimbursement rate for non-hospital based physician services from 53% to 56.94% as of July 1, 2008. Furthermore, the Department is proposing to remove some prior authorization requirements for services including but not limited to hyperbaric oxygen therapy, cochlear implants, circumcision, septoplasty, and skin tag removal. Finally the Department is adopting changes to Chapter II Section 55-Laboratory Services, Section 75-Vision Services, Section 95-Podiatry Services, Section 101-Medical Imaging. The Department has amended the language under the "reimbursement" sections to these areas of policy to clarify that the increase mentioned above does not apply to these services. MaineCare will reimburse the lowest of 53% of 2005 Medicare rates, the provider's usual and customary or the allowed amount of the Medicare Part B carrier for these services. Providers can visit the Office of MaineCare's website for a list of MaineCare covered services and rates. This rule change clarifies what the current rate is; the rate is not being decreased.
Effective Date: 2009-03-29
View Comments: Word  Posted: March 24, 2009
 
Chapter II, Section 21, Home and Community Benefits for members with Mental Retardation or Autistic Disorder Word  PDF 
Concise Summary: The adopted rule eliminates Behavioral Add On. Additionally, the rule creates an added level of support for Home Support Shared Living and Home Support Family Centered Support. Lastly, Intensive Family Centered Support was eliminated as a type of Home Support. This rule is not anticipated to impose on small businesses any additional administrative cost required for compliance.
Effective Date: 2009-03-29
View Comments: Word  Posted: March 13, 2009
 
Chapters II & III, Section 29, Community Support Benefits for members with Mental Retardation and Autistic Disorder Word  PDF 
Concise Summary: The final rule adopts emergency rules that were put in to place on 1/1/09. The final rule reduces reimbursement for Community Support, Employment Specialist Services and Work Support with Medical Add On. The final rule also eliminates Behavioral Add On. This rule is not anticipated to impose on small businesses any additional administrative cost required for compliance.
Effective Date: 2009-03-29
View Comments: Word  Posted: March 13, 2009
 
Chapter 101, MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities Word  PDF 
Concise Summary: The Department has permanently adopted rule changes for Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities, in order to comply with budget appropriations for nursing facility reimbursement and State statute for conversion of nursing facility beds and medical director costs. Specifically, the new rate methodology changes the base year from 1998 to 2005 to calculate direct care and routine care costs; the rule clarifies the impact of conversion of nursing facility beds to residential care beds; and the base year cost for medical director is increased from $1,200 to $10,000. The Department also adopts changes that establish a new prospective per diem rate by adding a direct care regional cost component, hold harmless provision, and direct care add-on to the rule. In addition, all providers will receive a one time payment for the time period between July 1, 2008 and December 15, 2008, which equitably distributes a portion of the money appropriated in the budget. Other changes made in this rulemaking include the ability for the Department to waive administrator costs that are included under the management ceiling for smaller nursing facilities of forty (40) or fewer beds. Other minor technical, format and grammatical changes were adopted.
Effective Date: 2009-03-15
View Comments: Word  Posted: March 11, 2009
 
Chapter III, Section 12, Consumer Directed Attendant Services Word  PDF 
Concise Summary: The Department permanently adopts these rules to comply with Federal HIPAA guidelines for coding for attendant care services. Until now, these services have been billed using local codes. After research and testing, the Department has determined that the HIPAA compliant codes can be implemented in the current system. The provider (s) billing under this section will only need to make minor billing changes as a result of this change. There are no adverse impacts on small business or municipalities as a result of this change.
Effective Date: 2009-02-01
View Comments: Word  Posted: February 1, 2009
 
10-144 MaineCare Benefits Manual, Chapter II, Section 2, Adult Family Care Services Word  PDF 
Concise Summary: The adopted rules permanently adopt emergency rules currently in place. This rule increases the limit of reimbursable beds in an Adult Family Care Home from six to eight beds. This rule also adds an additional type of licensure that Adult Family Care Homes may have in order to be reimbursed appropriately when the facility has more than six beds. Previously, Adult Family Care Homes must be licensed as an Assisted Living Program: Level III Residential Care Facility. Those facilities with more than six beds will require licensure as an Assisted Living Program: Level IV Residential Care Facility. This rule is not anticipated to have any negative economic impact on small businesses.
Effective Date: 2008-09-30
View Comments: Word  Posted: September 22, 2008
 
Chapter II and III, Section 35, Hearing Aids and Services Word  PDF 
Concise Summary: The adopted rules reflect the current practice of only allowing members under age 21 to receive this service. Prior Authorization has been eliminated for all but one code. Updated criteria for medical evaluation and testing were added. Audiologists were added as hearing aid dispensers to conform to a change in their scope of practice. Terminology, such as using MaineCare instead of Medicaid and member instead of recipient, is also updated. Chapter III establishes new billing codes based on HIPAA compliant coding.
Effective Date: 2008-12-01
View Comments: Word  Posted: June 11, 2008
 

 

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