Adopted Rulemaking

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

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

Clarifications regarding adopted rules are also posted here.

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Chapter II, Section 21, Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorder. WORD  PDF 
Concise Summary: The Department added three new services: Assistive Technology, Career Planning and Home Support-Remote Support. The Department split the existing Home Support service into four separate services: Home Support-Agency Per Diem, Home Support-Family Centered Support, Home Support-Quarter Hour, and Shared Living. Additionally, the Department split Work Support into two separate services: Work Support-Individual and Work Support-Group. The Department added performance measures. The primary goal of performance measurement is to use data to determine the level of success a service is achieving in improving the health and wellbeing of members. Performance goals and performance measures have been established to monitor quality, inform, and guide reimbursement decisions and conditions of provider participation across MaineCare services. This focus on performance measurement is anticipated to enhance the overall quality of services provided and raise the level of public accountability for both the Department and MaineCare providers. Other changes to the rule included: • The addition of Licensed Audiologists and Assistive Technology Professionals as qualified providers for the Communication Aids service. • The addition of Certified Occupational Therapy Assistants (COTA) under the supervision of an Occupational Therapist Registered (OTR) as qualified providers for the Occupational Therapy (Maintenance) service. • The addition of six (6) new definitions: Activities of Daily Living, Administrative Oversight Agency, Independent Contractor, Instrumental Activities of Daily Living, Prior Authorization and Utilization Review. • The removal of the definition of Summary of Authorized Services. • The addition of a reserved capacity category to meet the needs of members under 21 in out-of-state residential placements funded by MaineCare or State funds. • The phase-out of the Home Support-Family Centered Support services. • New procedures for filling vacancies in two-person agency-operated homes. • A requirement for Section 21 applicants and their planning teams to estimate the annual budget for services in the course of applying for waiver services. • A requirement that the Personal Plan for members electing the Home Support-Remote Support service incorporate a safety/risk plan. • The addition of limits on Community Support services, Counseling services, Consultation services, and Employment Specialist Services. • The addition of new provider qualifications for those Direct Support staff that provide Work Support-Individual services, Work Support-Group services, Employment Specialist Services and Career Planning services. Other technical language changes were also adopted. The reason for the rule changes are to comply with the budget bill P.L. 2013, chapter 368 directing the Department to add Assistive Technology. The Department is complying also with a CMS directive to separate Home Support into separate services. The work support and career planning changes are to comply with LD 8, Resolve, Directing the Department of Health and Human Services to provide coverage under the MaineCare program for Home Support Services for Adults with Intellectual Disabilities or Autistic Disorder. A public hearing was held on April 14, 2014. The comment deadline was April 14, 2014. This change is not expected to have an adverse effect on the administrative burdens of small businesses. The Department made numerous changes to the Final Rule from the Proposed Rule, in response to comments, and also on the advice of the Office of the Attorney General. A list of the changes and the reasons for the changes can be found in the MAPA document, “Summary of Comments and Responses”. These rule changes are not anticipated to impose any burden on small businesses or any costs on counties or municipalities. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: 09-01-2014
View Comments: Comments  Posted: August 25, 2014
 
MaineCare Benefits Manual, Chapter II, Section 29, Support Services For Adults With Intellectual Disabilities or Autistic Disorder WORD  PDF 
Concise Summary: The Department is adopting four new services: Assistive Technology, Career Planning, Home Support-Quarter Hour and Home Support-Remote Support. Additionally, the Department split Work Support into two separate services: Work Support-Individual and Work Support-Group. The Department is also adopting performance measures. The primary goal of performance measurement is to use data to determine the level of success a service is achieving in improving the health and well-being of members. Performance goals and performance measures have been established to monitor quality, inform, and guide reimbursement decisions and conditions of provider participation across MaineCare services. The focus on performance measurement is anticipated to enhance the overall quality of services provided and raise the level of public accountability for both the Department and MaineCare providers. Other changes to the rule include: • The addition of seven (7) new definitions: Activities of Daily Living, Agency Home Support, Independent Contractor, Instrumental Activities of Daily Living, Medical Add On, Prior Authorization and Utilization Review. • Removal of the definition of Summary of Authorized Services. • A requirement for Section 29 applicants and their planning teams to estimate the annual budget of services in the course of applying for waiver services. • A requirement that the Personal Plan for members electing the Home Support-Remote Support Service incorporate a safety/risk plan. • The addition of limits on Community Support Services, Assistive Technology Services, Career Planning Services, Counseling Services, Consultation Services, Employment Specialist Services and Home Support-Remote Support Services. • The addition of new provider qualifications for those Direct Support staff that provide Home Support Services, Work Support-Individual Services, Work Support-Group Services, Employment Specialist Services and Career Planning Services. Other technical language changes are also being adopted. The reason for the rule changes are to comply with the budget bill P.L. 2013, chapter 368 directing the Department to add Assistive Technology to this waiver. The Department is complying with Resolve, Chapter 24, LD 8, Resolve, Directing the Department of Health and Human Services to Provide Coverage under the MaineCare Program for Home Support Services for Adults with Intellectual Disabilities or Autistic Disorder. This Resolve directs the Department to add Home Support as a covered Service to this waiver. The Department is also complying with a CMS directive to separate Home Support into separate services. The Work Support and Career Planning changes are to comply with LD 8, Resolve, Directing the Department of Health and Human Services to provide coverage under the MaineCare program for Home Support Services for Adults with Intellectual Disabilities or Autistic Disorder. This rule change is not anticipated to have any adverse impact on small businesses or impose any additional costs on counties or municipalities. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: 09-01-2014
View Comments: Comments  Posted: August 25, 2014
 
MaineCare Benefits Manual, Chapter II, Section 67, Nursing Facility Services WORD  PDF 
Concise Summary: The Department recently received CMS approval for a new Home and Community Based Services waiver for individuals with brain injury, aged 18 and over. In conjunction with same, the Department is developing a new section of the MaineCare Benefits Manual, Section 18. The purpose of the new waiver and Section 18 is to provide more non-institutional services and options for individuals with Acquired Brain Injury. The changes to Section 67 are being adopted in order to make brain injury eligibility and the providers’ requirements for Section 67: Nursing Facility Services consistent with the new Section 18: Home and Community Based Services for Members with Brain Injury. Individuals with Acquired Brain Injury will be eligible for Nursing Facility services if they score three or higher in two items on the Mayo-Portland Adaptability Inventory and score a 0.1 or higher on the Brain Injury Health and Safety Assessment. The changes also require, for Nursing Facilities receiving an enhanced rate for their work with individuals with acquired brain injury, that all direct care staff have expertise in brain injury rehabilitation as demonstrated by achieving the Certified Brain Injury Specialist (CBIS) designation from the Academy of Certified Brain Injury Specialists, or through a Department-approved equivalent training program. This rulemaking also: a) Updates the Brain Injury definition in Section 67.01-22 to be consistent with the definition developed in 22 MRS 3086 and the definition used in the new Section 18; b) Adds the word “Acquired” to “Brain Injury” in various places where the term is used, to be consistent with 22 MRS 3086; c) Changes “Brain Injury” to “Acquired Brain Injury,” and “BI” to “ABI” in the table of contents and on pages 4, 14, 27, 28, 45, 46, 47, 51; d) Reorganizes Section 67.02-5; e) Corrects a numbering error in Section 67.05-13. In response to comments, the Department has clarified that all ‘direct care’ staff, rather than all nursing facility staff are expected to be CBIS compliant. Additionally, the Department is making the following technical change in the adopted rule by correcting the term “Mentally Retarded” to “Intellectually Disabled” as required by P.L. 2012, ch. 542, B(5), removing “If CMS approves” language for changes that have been approved in sections 67.05-11(C), 67.05-12 and 67.05-14(B); and changing the formatting of the Acquired Brain Injury definition from that of the proposed to more closely match 22 MRS 3086.. The Department held a public hearing on Monday, April 7, 2014, and accepted comments until Thursday April 17, 2014.
Effective Date: August 3, 2014
View Comments: Comments  Posted: August 3, 2014
 
MaineCare Benefits Manual, Chapter 101, Chapters II & III, Section 35, Hearing Aids & Services WORD  PDF 
Concise Summary: The Department is adopting changes to this rule to add digital hearing aids as a covered service for eligible members through MaineCare. A public hearing on the proposed rule was held on June 2, 2014. There were no attendees. The comment deadline was June 12, 2014. One comment was received. No changes were made to the rule based on comments. These changes reflect current industry standards and ensure compliance with the federal requirements for Early and Periodic Screening, Diagnostic and Treatment Services, pursuant to 42 U.S.C. 1396a(a)(43) and 1396d(r), and 42 CFR 440.110 and 441.56. This rule requires that providers use the State of Maine Division of Purchases’ vendors that are contracted through the Hearing Aid Procurement Program as the sole suppliers of all digital hearing aids for MaineCare members under the age of 21. Contracted hearing aid vendors and pricing information can be found at: http://www.maine.gov/purchases/contracts/hearingaids.shtml. The Department is also adopting the following changes: a) Adding digital hearing aid codes V5246, V5252, V5253, V5256, V5257, V5260, and V5261; b) Allowing current dispensing fee codes V5090, V5110, V5160, V5200, V5240, and V5241 to be billed for digital hearing aids; and c) Adding a definition for Prior Authorization.
Effective Date: July 27, 2014
View Comments: Comments  Posted: July 27, 2014
 
MaineCare Benefits Manual, Chapter III, Section 109, Speech & Hearing Services WORD  PDF 
Concise Summary: The Department is adopting changes to implement new rates and codes for Section 109, Speech & Hearing Services, subject to approval by the Centers for Medicare and Medicaid Services. The Department utilizes federal Medicare rates as the basis for its rates of reimbursement for Medicaid services. In addition, pursuant to 45 C.F.R. 162.1000 and 162.1002, the Department uses the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) code sets for the coding of its Medicaid services. The code sets and Medicare rates are periodically updated by the American Medical Association CPT Editorial Panel and the federal Department of Health and Human Services, respectively. Pursuant to 45 C.F.R. 162.1001, each code set is valid within the dates specified by the organization responsible for maintaining that code set. The codes utilized for Speech and Hearing Services were recently updated by the American Medical Association CPT Editorial Panel, in October of 2013, with a generally intended effective date of January 1, 2014. In addition, the Medicare rates for Speech and Hearing Services also changed, and the Department received notice of those rates from CMS on or about January 6, 2014. The adopted changes made to this rule align with current 2014 CPT codes and current Medicare rates for Speech and Hearing Services. These changes include the elimination of code 92506 with the addition of codes 92521, 92522, 92523, and 92524.
Effective Date: July 6, 2014
View Comments: Comments  Posted: July 6, 2014
 
Chapter 104, Maine State Services Manual, Section 6, Independent Practice Dental Hygienist (IPDH) Services WORD  PDF 
Concise Summary: This rule implements a state-only funded program to provide reimbursement for Independent Practice Dental Hygienists (IPDHs) services and to Federally Qualified Health Centers (FQHCs) employing IPDHs for certain services, provided to MaineCare Members during the period October 1, 2012 through September 30, 2013. This state-only funded service reimburses IPDHs and FQHCs who employed IPDHs providing such services, during the period October 1, 2012 through September 30, 2013, for the following services provided to individuals who were eligible MaineCare members at the time of service: prophylaxis performed on a person who was 21 years of age or younger; topical application of fluoride performed on a person who was 21 years of age or younger; provision of oral hygiene instructions; the application of sealants; temporary fillings; and processing and exposing radiographs (X-rays). To be reimbursed, IPDHs and FQHCs must be enrolled as MaineCare providers on the date they submit claims. Additionally, FQHC’s must have been enrolled as MaineCare providers on the date of the service. If the FQHC had been reimbursed by MaineCare for an ambulatory clinic visit for the MaineCare Member, on the same date as the IPDH service, the FQHC is ineligible for IPDH reimbursement under this rule. Providers must submit claims on or before December 31, 2014, in order to be reimbursed. The Department made numerous changes to the Final Rule from the Proposed Rule, in response to comments, and also on the advice of the Office of the Attorney General. A list of the changes and the reasons for the changes can be found in the MAPA document, “Summary of Comments and Responses.”
Effective Date: July 1, 2014
View Comments: Comments  Posted: July 1, 2014
 
MaineCare Benefits Manual, Chapter II, Section 31, Federally Qualified Health Center Services WORD  PDF 
Concise Summary: This rulemaking makes the following changes to Chapter II Section 31, Federally Qualified Health Center Services: 1. The addition of three dental provider types: o Independent Practice Dental Hygienists (IPDHs), as required by per P.L. 2011, Chap. 457 “An Act To Include Independent Practice Dental Hygienists in MaineCare.” o Dental Externs. Adding this provider type will increase access to dental services by MaineCare beneficiaries. o Dental Residents. Adding this provider type will increase access to dental services across the state. IPDHs are added effective October 1, 2013, subject to approval by CMS. Dental Externs are added as a MaineCare provider, effective July 1, 2013. The July 1, 2013 effective date for Dental Externs is consistent with the proposed rule, which proposed adding this provider type “effective 365 days before date of adoption”. The adopted rule clarifies precisely what the effective date is of this change. Dental Residents are added as a MaineCare provider effective July 1, 2013, although the proposed rule added them as a provider type effective September 1, 2011. As a result of advice from the Office of the Attorney General, the Department changed the effective date to July 1, 2013. Federal Medicaid law requires state Medicaid agencies like MaineCare to “require [Medicaid] providers to submit all claims no later than 12 months from the date of service.” 42 CFR 447.45(d)(Timely processing of claims). Accordingly, MaineCare cannot add a provider type retroactively beyond the 12 months, since claims from an earlier period could not legally be processed as MaineCare claims. 2. Tobacco cessation codes were updated to reflect the upcoming national change from ICD-9 to ICD-10. 45 CFR Sec 162.1000 requires covered entities such as the Maine Office of MaineCare Services, to utilize the Medical data code sets as specified in the federal regulation that are valid at the time the health care is provided. As of the date this rule became effective, CMS, and the Office of MaineCare Services, utilized the International Classification of Diseases, 9th Edition, Clinical Modification, (ICD-9-CM), and Volume 3 Procedures, (including The Official ICD-9-CM Guidelines for Coding and Reporting). CMS has notified states that it intends to switch to the ICD-10 Manual at some time in the future. 3. The Department added a sentence: “Dental services rendered under this policy must be performed in accordance with the Maine Board of Dental Examiners requirements” to clarify that this is a legal requirement. 4. Per Public Law 2014, Chapter 444, eliminates the three times per year limit on tobacco counseling and specifies that Smoking cessation counseling is exempt from the copayments required by 31.08 (A). This change was not in the proposed rule because the Legislature enacted the change after the rule was proposed. The Department has determined that it is appropriate to include this change in the adopted rule due to the fact that: (1) the changes required by statute should be effective by August 1, 2014 (90 days upon the Legislature’s adjournment), and it would not be possible to meet that deadline without including it in this adopted rule; (2) the public had an opportunity to comment on this change during the legislative process; and (3) the changes have a positive impact on both members and providers. This rule has retroactive application effective dates for adding the three new provider types. The Department is authorized to adopt rules with retroactive application, pursuant to 22 MRSA 42(8), when necessary to conform to the State plan and to maximize federal Medicaid funding, and where there is no adverse financial impact on any MaineCare provider or Member. Here, because there is a positive impact on MaineCare providers and Members, since the Department is adding new provider types, and access to dental services should be improved, the retroactive application of those provider types is appropriate.
Effective Date: July 1, 2014
View Comments: Comments  Posted: July 1, 2014
 
MaineCare Benefits Manual, Chapters II & III, Section 25, Dental Services WORD  PDF 
Concise Summary: The rulemaking makes the following changes: (1) adds three dental provider types: Independent Practice Dental Hygienists (effective October 1, 2013 subject to approval from CMS), Dental Externs (effective July 1, 2013), and Dental Residents (effective July 1, 2013); (2) eliminates the limit on tobacco counseling; (3) adds partial dentures to services reimbursable to denturists; (4) updates policy to conform to changes in the American Dental Association’s 2014 CDT Dental Procedure Codes (this includes addition, deletion, and renaming of codes, as appropriate); and (5) changes limitations for a number of specific procedures. The Department made numerous changes to the Final Rule from the Proposed Rule, in response to comments, and also on the advice of the Office of the Attorney General. A list of the changes and the reasons for the changes can be found in the MAPA document, “Summary of Comments and Responses.”
Effective Date: July 1, 2014
View Comments: Comments  Posted: July 1, 2014
 
MaineCare Benefits Manual, Chapters II and III, Section 20, Home and Community-Based Services for Adults with Other Related Conditions WORD  PDF 
Concise Summary: The rules have been amended to make a number of clarifications and technical changes, as follows: • Clarification of the prioritization categories for members on the waitlist for Section 20 services; • Clarification that the rate for the Community Support service includes the cost of transportation, i.e., that transportation costs are a component of the rate paid for the service; • Clarification that a member may receive some 1:1 direct care under the Home Support service, and that the need for 1:1 support must be specified in the care plan; and, • Clarification that Assistive Technology devices and Communication Aids will be reviewed based on medical necessity, efficiency and compatibility with safety needs. Additionally, the Department made changes to comply with amendments to the Section 20 waiver program that were approved by the Centers for Medicare and Medicaid (CMS) on May 5, 2014. These include the following: • An increase in the limit for the Community Support and Work Support services from 64 units each to allowing the member a combination of 128 units of either service, subject to an annual limit of 6,656 units on the total combined expenditures for both services; • An increase in the limit for the Home Support –Remote Support service from 44 units per day to 64 units per day; • An increase in the limit for the Home Support-Quarter Hour service from 44 units per day to 64 units per day; • An increase in the limit for Communication Aids from $2,000.00 to $6,000.00 per year; • An increase in the limit for the Care Coordination service from 144 units to 400 units per year; • Clarification that the Consultation service is limited to 64 units per each type of consultation annually; • Clarification that Remote Support-Interactive Support and Remote Support-Monitor are two separate components of Remote Support and are reimbursed separately; and, • The addition of Licensed Speech Language Pathologists (SLP) as qualified providers of Communication Aids. The Department made numerous changes to the Final Rule from the Proposed Rule, in response to comments, and also on the advice of the Office of the Attorney General. A list of the changes and the reasons for the changes can be found in the document, “Summary of Comments and Responses.” A public hearing was held on April 15, 2014. The comment deadline was April 25, 2014. This change is not expected to have an adverse effect on the administrative burdens of small businesses.
Effective Date: July 1, 2014
View Comments: Comments  Posted: July 1, 2014
 
MaineCare Benefits Manual, Chapter III, Section 97, Private Non-Medical Institution Services Word  PDF 
Concise Summary: This final adopted major substantive rule eliminates Private Non-Medical Institution Services (PNMI), Appendix D (Child Care Facilities), Model 3 (Intensive Mental Health Services for Infants and/or Toddlers) reimbursement rate. In a separate rulemaking, the Department permanently adopted the elimination of PNMI, Appendix D, Child Care Facilities, Model 3, Intensive Mental Health Services for Infants and/or Toddlers, effective October 11, 2013. Although eligible infants and toddlers no longer have access to PNMI Appendix D, Model 3, Intensive Mental Health Services, they remain eligible for medically necessary Behavioral Health Services through Chapter II, Section 65, Behavioral Health Services. Additionally, the rule corrects prior rules and amends the reimbursement rates for PNMI, Appendix D, Child Care Facilities to agree with the correct rates configured in the MaineCare claims system. The rates in the prior rules were lower than the correct rates.
Effective Date: June 30, 2014
View Comments: Comments  Posted: June 30, 2014
 
MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities Word  PDF 
Concise Summary: This rule permanently adopts changes already made on an emergency basis. In this rulemaking, the Department adopts the changes required by Resolve 2013, ch. 72, to clarify the timeframe during which nursing facilities must demonstrate their compliance with the October 1, 2011, 2% Cost-Of-Living Adjustment (COLA) for front-line staff. If CMS approves, the following applies for the 2%, October 2011, COLA that the Department gave to nursing facilities: nursing facilities must demonstrate, to the satisfaction of the Department, a 2% increase in the average wage and benefit rate per hour for front-line employees for their first fiscal years ending after July 1, 2013, from the average wage and benefit rate per hour for front-line employees that was in effect for their fiscal years ending 2008. If the nursing facilities cannot demonstrate that 2% increase to the satisfaction of the Department, then the Department will recoup, at time of audit, the difference between what the average wage and benefit rate per hour for front line employees for the first fiscal years ending after July 1, 2013, should have been if it had been increased by 2% from what it was. This rulemaking also: (1) Removes the word “Care” from “Routine Care Cost Component” (2) Removes obsolete language – from Section 41.2.3(D), regarding how sanctions were calculated in the period of time leading up to MIHMS implementation and language referring to MIHMS in the future tense. MIHMS went live on 9/1/2010. (3) Removes obsolete language – from Section 80.3.4, regarding how the “Direct Care Component” was calculated in the period of time leading up to MIHMS implementation and language referring to MHIMS in the future tense. MIHMS went live on 9/1/2010. (4) Changes ‘Brain Injury’ to Acquired Brain Injury and ‘BI’ to ‘ABI’ to use the same definitions set forth in 22 M.R.S. 3086 and to be consistent with terminology utilized in Chapter II, Sec. 67.
Effective Date: May 29, 2014
  Posted: May 28, 2014
 
MaineCare Benefits Manual Chapter III, Section 32, Allowances for Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders Word  PDF 
Concise Summary: This rule adopts changes in the reimbursement of services to members with Intellectual Disabilities and Autistic Disorders by deleting the reimbursement of transportation services, since transportation services are provided under the MaineCare Benefits Manual, Section 113 Non-Emergency Medical Transportation waiver transportation services. An emergency rule took effect 8/1/13; this is the final adoption of a permanent rule. A public hearing was held on June 3, 2013. The comment deadline was June 13, 2013. This change is not expected to have any adverse impact on small businesses or impose any additional costs on municipalities or counties. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: May 1, 2014
  Posted: April 3, 2014
 
MaineCare Benefits Manual, Chapter III, Section 29, Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorder Word  PDF 
Concise Summary: This major substantive rule changes the reimbursement of services to members with Intellectual Disabilities and Autistic Disorders by deleting the reimbursement of transportation services, as transportation services are provided under the MaineCare Benefits Manual, Section 113 Non-Emergency Transportation Services (NET) Waiver transportation services. An emergency rule took effect 8/1/13; this is the final adoption of a permanent rule. A public hearing was held on June 3, 2013. The comment deadline was June 13, 2013. This change is not expected to have any adverse impact on small businesses or impose any additional costs on municipalities or counties. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: May 1, 2014
  Posted: April 3, 2014
 
MaineCare Benefits Manual, Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder Word  PDF 
Concise Summary: The Department has adopted changes to this major substantive rule to provide services for members with Intellectual Disabilities and Autistic Disorders (Section 21) concurrently with the operation of a 1915 (b) Non-Emergency Transportation Waiver. Members who receive services under this policy are provided Non-Emergency Transportation under Section 113 of the MaineCare Benefits Manual. The Department contracts with Brokers to establish, manage, authorize, coordinate and reimburse the provision of Non-Emergency Transportation services for eligible MaineCare members. The Brokers are responsible for establishing a network of Non-Emergency Transportation drivers to deliver Non-Emergency Transportation services to eligible members who live in their assigned region. The Chapter III change includes removal of the procedure code, as the reimbursement will be handled by the broker. Additionally, the Department added a HCPCS procedure code for Behavioral Consultation, G9007 HI, which is $14.85 per fifteen-minute unit. The Department added HI to the modifier table based on comments. An emergency rule took effect 8/1/13; this is the final adoption of a permanent rule. A public hearing was held on June 3, 2013. The comment deadline was June 13, 2013. This change is not expected to have any adverse impact on small businesses or impose any additional costs on municipalities or counties. HTTP://WWW.MAINE.GOV/DHHS/OMS/RULES/INDEX.SHTML for rules and related rulemaking documents.
Effective Date: May 1, 2014
  Posted: April 3, 2014
 
MaineCare Benefits Manual, Chapters II & III, Section 92, Behavioral Health Home Services Word  PDF 
Concise Summary: This rulemaking creates Behavioral Health Homes, effective April 1, 2014, (conditional upon Centers of Medicare and Medicaid Services approval of a state plan amendment) which will provide a comprehensive system of care coordination for members with Serious Emotional Disorders (SED), and Serious and Persistent Mental Illness (SPMI). Members eligible for Section 92 services may also be eligible for services under Section 13 (Targeted Case Management), Section 17 (Community Integration Services) and/or Section 91 (Health Home Services); such members may not receive those services at the same time that they receive Section 92 services, and must choose among the different types of services for which they are eligible. Section 92 services shall be provided to eligible members by a Behavioral Health Home Organization (BHHO) that partners with one or more Health Home Practices (HHPs). BHHOs and HHPs shall integrate and coordinate all primary, acute, behavioral health and long term services and supports for eligible members. BHHOs shall develop and implement a comprehensive Plan of Care for each member. Section 92 services are expected to result in improved physical and behavioral health outcomes for members, reduced hospital admissions and emergency room use, better transitional care, improved communication between health care providers, and the increased use of preventive services, community supports, and self-management tools. Section 92 Behavioral Health Homes are implemented pursuant to section 2703 of the Affordable Care Act, 42 U.S.C. 1396w-4. The Department is seeking approval of a State Plan Amendment from the Centers for Medicare and Medicaid Services. Section 2703 provides an enhanced federal matching rate of 90% for the first eight (8) quarters following the effective date of the program. The rule has been amended to reflect public comments received, including the following: • 92.01 Definitions: o 92.01-3 Electronic Health Record (EHR): Additional language has been added to this section to clarify the EHR definition. o 92.01-7 Plan of Care: deleted language that required all clinical data to be in the Plan of Care. • 92.02-1 Provider Requirements (BHHO): o Clarified the role of the Psychiatric Consultant o Added additional language regarding the type of nurse that can provide the service o Added language that permitted the use of Licensed Master Social Worker Conditional II licensure o Amended Certified Intentional Peer Support Specialist language to clarify certification requirements o Added language to clarify that an individual who provides peer support services for children will be called a “Family or Youth Support Specialist,” rather than a CIPSS, and added language clarifying such individuals’ certification requirements o Amended language regarding the role of the HH Coordinator to specify that the HH Coordinator “supports and encourages” o Removed language regarding “SPMI member” o Added Physician’s Assistant to list of professionals that can serve as Medical Consultant o Clarified that the Medical Consultant role may be pro-rated o Amended language regarding co-occurring capability o Amended language to align with/reference licensing standards o Specified that the HHP and BHHO may have an executed contract or a Memorandum of Agreement (MOA), and provided detail regarding the required contents of the contract or MOA o Deleted language requiring that EHRs be used to share information o Deleted language requiring that BHHO protocols with hospitals must require prompt notification to the BHHO of a member’s admission and discharge o Clarified language regarding team-based approach to care o Clarified language on enhanced access o Included language on recovery o Deleted language that BHHO would be held accountable for savings resulting from reductions in wasteful spending o Clarified that member and family participation in leadership and/or advisory activities includes, but is not limited to, serving on agency’s Board of Directors, involvement in internal advisory committees that solicit and support the engagement of consumers and families in identifying needs and solutions, etc. • 92.02-2 Provider Requirements (HHP): o Deleted language requiring that EHRs be used to share information o Specified that the HHP and BHHO may have an executed contract or a Memorandum of Agreement (MOA), and provided detail regarding the required contents of the contract or MOA o Deleted language requiring that HHP protocols with hospitals must require prompt notification to the HHP of a member’s admission and discharge o Clarified language on site assessment o Clarified that open access scheduling means that the organization leaves some percentage of its appointment hours open for same-day/next day appointments o Replaced the term “behavioralist” with a “behavioral health professional” • 92.03 Member Eligibility o Made changes to this section to reflect that information on the member shall be stored only in the member’s record and not the member’s record and the Plan of Care o Updated (Diagnostic and Statistical Manual of Mental Disorders) DSM title • 92.04 Policies And Procedures For Member Identification And Enrollment o Clarified that members will be identified based on current prior authorizations and not via a 12-month look back period o Clarified that the time period to identify an HHP is six months and not 180 days o Amended to use “enrollment” and not “assignment” throughout o Amended to refer to “members’ clinical documentation,” as opposed to “medical documentation” • 92.05 Covered Services o Amended that BHH services may be delivered “in any community location where confidentiality can be maintained” as opposed to “in any appropriate location” o Amended to include additional language about member strengths o Deleted requirement that all clinical data would need to be contained in the member’s Plan of Care o Amended to reflect documentation required in member record and not Plan of Care o Clarified the meaning of “crisis provider” o Clarified that the BHHO shall facilitate access to psychiatric services, not provide access o Clarified that the BHHO shall facilitate access to referral services, not ensure successful referral o Added language – consistent with Section 91 – to clarify that as part of care management, HHPs shall conduct certain screenings and assessments for all of their assigned BHH members • 92.06 Non-Covered Services and Limitations o Deleted language that referenced direct delivery of underlying services o Amended language to reflect that the member may only have one BHHP Team • 92.07 Reporting Requirements o Deleted the list of quality measures • 92.08 Documentation and Confidentiality o Amended language to reference current licensing standards o Deleted 92.08 (B) “Record Retention,” because it is redundant with the requirements of MaineCare Benefit Manual Chapter 1, Section 1 o Deleted “The disclosure of information regarding members receiving services herein is strictly limited to purposes directly connected with the administration of the MaineCare program” because it would preclude any other sharing of information permitted by state and federal law • 92.09 Minimum Requirements for Reimbursement o Amended language to reflect provider requirement to submit cost and utilization reports upon request by the Department, in a format determined by the Department See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: April 1, 2014
View Comments: Comments  Posted: April 1, 2014
 
MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services Word  PDF 
Concise Summary: This rule permanently adopts an emergency rule adopted on November 15, 2013. This rulemaking permanently updates the amount available for reimbursement in the hospital pool for the privately owned and operated Acute Care Non-Critical Access hospitals, hospitals reclassified to a wage area outside Maine by the Medicare Geographic Classification Review Board and rehabilitation hospitals, from fifty-one million six hundred-forty-two thousand thirty five dollars ($51,642,035) to sixty-five million three hundred-twenty-one thousand three hundred and one dollars ($65,321,301) for the 2013-2014 fiscal year. This change was submitted in the fourth-quarter 2013 State Plan Amendment and is awaiting CMS Approval. This rulemaking will not impose any costs on municipal or county governments, or have any adverse impact on small businesses employing twenty or fewer employees. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents. EFFECTIVE DATE: February 13, 2014 AGENCY CONTACT PERSON: Rachel Thomas, Health Planner AGENCY NAME: Division of Policy ADDRESS: 242 State Street 11 State House Station Augusta, Maine 04333-0011 TELEPHONE 207) 624-4001 FAX: (207) 287-1864 TTY: 711 (Deaf/Hard of Hearing)
Effective Date: February 13, 2014
View Comments: Comments  Posted: February 12, 2014
 
MaineCare Benefits Manual Chapter 101, Chapter X, Non Categorical Adults Word   
Concise Summary: The MaineCare Childless Adults section 1115 demonstration waiver that provided health care coverage to childless adults and non-custodial parents with incomes at or below 100% of the Federal Poverty Level (FPL), expires on December 31, 2013. Therefore, the Department is repealing Chapter X, Section 2, Non-Categorical Adults. This population of adults will no longer be eligible for MaineCare benefits as of December 31, 2013. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: January 1, 2014
View Comments: Comments  Posted: January 3, 2014
 
MaineCare Benefits Manual, Chapter II, Section 85 Physical Therapy Services Word  Comments 
Concise Summary: The Department is adopting changes to this rule to require prior authorization for all Physical Therapy Services for persons age 21 and older. The Department is also adopting the following changes: a. Adding a definition for Long-Term Chronic Pain and Terminal Illness; b. Adding new covered services and clarifying covered services and their limits; c. Limiting supplies to splinting only and adding the link to the Department’s Rate Setting website; and, d. Adding language and clerical changes to clarify the policy. Additionally, changes to the final rule include: a. Language regarding the intent of requiring prior authorization on all services before payment was removed from section 85.07-3 for clarification, as recommended by the Attorney General’s office; and b. Due to comments 1-2, 4-6, and 8-9, section 85.07-2 was changed to remove language requiring services to be ordered by a physician. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: January 1, 2014
  Posted: January 3, 2014
 
MaineCare Benefits Manual, Chapter II, Section 68 Occupational Therapy Services Word  Comments 
Concise Summary: The Department is adopting changes to this rule to require prior authorization for all Occupational Therapy Services for persons age 21 and older. The Department is also adopting the following changes: a. Adding a definition for Long-Term Chronic Pain and Terminal Illness; b. Adding new covered services and clarifying covered services and their limits; c. Limiting supplies to splinting only and adding the link to the Department’s Rate Setting website; and, d. Adding language and clerical changes to clarify the policy. Additionally, changes to the final rule include: a. Language regarding the intent of requiring prior authorization on all services before payment was removed from section 68.07-3 for clarification, as recommended by the Attorney General’s office; and, b. Due to comments 1-2, and 4-10, section 68.07-2 was changed to remove language requiring services to be ordered by a physician. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: January 1, 2014
  Posted: January 3, 2014
 
MaineCare Benefits Manual, Chapter I, Section 1 General Administrative Policies and Procedures Word   
Concise Summary: The adopted rule amends several sections of Chapter 101, MaineCare Benefits Manual, Chapter 1, Section 1, General Administrative Policies and Procedures. The Department is adopting the following changes to the rule, for the following reasons: 1. Removed references to DirigoChoice, since the Maine Legislature dissolved the Dirigo Health Agency (P.L. 2013, ch. 368, Sec. A-19). 2. As required by 45 C.F.R. 162. 410, any MaineCare provider that is a “covered health care provider” must obtain a National Provider Identifier (NPI). 3. Requires that MaineCare providers must include their NPI on their MaineCare Provider Agreements and MaineCare enrollment applications, and requires updates for new or changed NPIs. 4. Requires that all MaineCare providers must include their NPI on all MaineCare claims, pursuant to the Affordable Care Act, Section 6402(a), as codified in 42 CFR 431.107, or those claims will be denied. 5. Pursuant to 42 CFR 455.410, specifies that, in order for MaineCare to reimburse for services or medical supplies or prescriptions resulting from a provider’s order, prescription or referral, the ordering, prescribing or referring (OPR) provider must be enrolled in MaineCare, and the OPR provider’s NPI must be on the claim. This change will be effective when the Maine Medicaid Management Information System (MMIS) is able to process this change, and the Department will notify all providers via the listserve, and also serve notice to the Secretary of State’s office, as required by 5 MRSA 8052(6). 6. Pursuant to P.L. 2013, c. 368, Part A-34, effective January 1, 2014, if approved by CMS, the Department will limit cost sharing payments for the Qualified Medicare Beneficiary without other Medicaid (QMB only) population to hospital and nursing facility providers, to the amountnecessary to provide a total payment equal to the amount MaineCare would pay for these services under the State Plan. The Department is seeking CMS approval to amend its State Plan for this change. The Department will serve notice to all providers via the listserve, and also notify the Secretary of State’s office upon CMS approval, pursuant to 5 MRSA 8052(6). 7. The Department makes some additional changes to Section 1.07-5 (Medicare provision), all to comport with the current State Plan, and these changes also reflect the Department’s current practice: (a) adding hospitals and nursing facilities to the list of MaineCare providers who may bill MaineCare for cost sharing (however, the cost sharing is limited in that it cannot exceed the lowest rate that Medicare determines to be the allowed amount); (b) deleting references to “Medicare Part B” in provisions where the provisions related both to Medicare A and B, pursuant to the State Plan; (c) deleting a provision regarding claims received from January 1, 1997 to February 29, 2000, since that time period has long passed. 8. As a result of public comments regarding the proposed rule, and pursuant to 42 U.S.C. 1396a(n)(3), added subpart (E) to Section 1.07-5, which strictly prohibits providers from seeking to collect any amount from a QMB for Medicare deductibles or coinsurance, even if the MaineCare payment is less than the total amount of the Medicare deductible and coinsurance. Providers are, however, allowed to collect from the QMB Member any MaineCare copayment for the service. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: January 1, 2014
View Comments: Comments  Posted: January 3, 2014
 
MaineCare Benefits Manual, Chapter 101, Section 2, Chapter VI MaineCare DirigoChoice Initiatives PDF   
Concise Summary: CONCISE SUMMARY: The Department of Health and Human Services is permanently adopting a repeal of MaineCare Benefits Manual, Chapter VI, Section 2, MaineCare DirigoChoice Initiatives, in accordance with Public Law 2013, Chapter 368, Section A-19. The Department anticipates that this rule adoption will have no impact on MaineCare enrolled providers. This rulemaking will not yield new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. No changes were made from the proposed rule to this rule adoption.
Effective Date: December 31, 2013
View Comments: Word  Posted: December 16, 2013
 
MaineCare Benefits Manual, Ch 101 Sec 45, Ch II, Hospital Services PDF   
Concise Summary: CONCISE SUMMARY: This rulemaking permanently adopts changes made on an emergency basis to implement a provision in the 2014-15 budget law (P.L. 2013 Chap. 368), as amended by P.L. 2013 Chap. 423. Specifically, this rulemaking, retroactive to April 1, 2013, increases the number of days that MaineCare will reimburse a hospital for therapeutic Leave of Absence-During Days Awaiting Nursing Facility Placement from one (1) day to twenty (20) days per state fiscal year. The rulemaking also makes clerical clarifications and corrections in several places: on pages 8 and 10 changing “days waiting” to “days awaiting” to be consistent with language elsewhere in the rule; and inserting the words “Therapeutic Leave of Absence During Days Awaiting Nursing Facility Placement” on page 7 and changing that entry in the Table of Contents so that it conforms to the language on page 7. The Department is seeking approval from the Centers for Medicare and Medicaid Services for a state plan amendment for this change.
Effective Date: November 25, 2013
View Comments: Word  Posted: December 2, 2013
 
MaineCare Benefits Manual, Ch 101, Sec 67, Ch II, Nursing Facility Services PDF   
Concise Summary: CONCISE SUMMARY: This rulemaking permanently adopts changes made on an emergency basis to implement a provision in the 2014-15 budget law (P.L. 2013, Chap. 368), as amended by P.L. 2013, Chap. 423. Specifically, this rulemaking, retroactive to April 1, 2013, increases the number of days that MaineCare will reimburse a nursing facility for: (a) Therapeutic Leave of Absence from one (1) day to twenty (20) days per state fiscal year, and (b) Bed Hold Days from four (4) per year to seven (7) per inpatient hospitalization. The rulemaking also makes the following clerical changes: (1) inserts the word “Therapeutic” before “Leave Days for a MaineCare Member” on page 39, (2) changes that entry in the Table of Contents so that it conforms to the language on page 39. The Department is seeking approval from the Centers for Medicare and Medicaid Services for a state plan amendment for this change.
Effective Date: November 25, 2013
View Comments: Word  Posted: December 2, 2013
 
MaineCare Benefits Manual, Ch 101, Ch II, Sec 32, Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders PDF   
Concise Summary: CONCISE SUMMARY: The Department made changes to the rule to comply with the concurrent operation of a 1915(b) Non-Emergency Transportation Waiver. The changes to Section 32 included referencing the regional, risk-based, Pre-Paid Ambulatory Health Plan (PAHP) Brokerages operating under a 1915(b) waiver (see 42 U.S.C. 1396n) approved by the Centers for Medicare and Medicaid Services (CMS). Under risk-based contractual agreements, the Department contracted with Broker(s) to establish, manage, authorize, coordinate and reimburse the provision of Non-Emergency Transportation (NET) services for eligible MaineCare members. The Broker(s) are responsible for establishing a network of NET drivers to deliver NET transportation services to eligible members within assigned region. The Department has also made a number of other changes: 1. The Department made changes to the definitions of “seclusion” and “restraint” to conform to the definitions employed in the Department of Education’s regulations (5-71 C.M.R. ch. 33). The Department of Health and Human Services was directed by the Legislature’s Committee on Health and Human Services to amend Chapter II to mirror the definitions of seclusion and restraint in the Department of Education’s regulations. 2. The Department replaced the term “aggression” throughout the rule with “self-injurious behavior and/or aggression.” 3. The Department added language that clarified, for purposes of initial and continuing eligibility, that the annual cost of a member’s services under Section 32 may not exceed the statewide average annual cost of care for an individual in either (a) an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or (b) an Inpatient Psychiatric Facility for individuals age 21 and under, depending upon the level of care at which the individual qualified for the waiver. This is not a new limit; the Department made the changes to clarify that these limits are not fixed numbers, but instead change each year based upon the prior year’s statewide average annual cost of care for the respective facility type. 4. The Department added a number of definitions (including Authorized Agent, Intellectual Disability, and Pervasive Developmental Disorders), and changed the term “Mentally Retarded” to “Intellectual Disabilities,” as required by P.L. 2012, ch. 542, B(5), An Act To Implement the Recommendations of the Department of Health and Human Services and the Maine Developmental Disabilities Council Regarding Respectful Language. 5. The Department clarified the requirements for providers of Section 32 services. These changes included clarification of the circumstances under which Behavioral Health Professionals may assist with administration of medication, requirements for Respite Service providers, and a requirement that providers put in place a Department-approved informed consent policy. 6. Performance Measures were adopted in Section 32.11. The primary goal of Performance Measurement is to use data to determine the level of success a service is achieving in improving the health and wellbeing of members. Performance Goals and Performance Measures have been established to monitor quality, inform and guide reimbursement decisions and conditions of provider participation across MaineCare services. This focus on Performance Measurement is anticipated to enhance the overall quality of services provided and raise the level of public accountability for both the Department and MaineCare providers. Additionally, changes to the final rule were made based on the recommendation of the Attorney General’s office. 1. 32.02-1, “means” was inserted into the definition. 2. 32.03-2(B), there was an incorrect citation; 34-B MRSA 6001 has been changed to 5001. 3. In 32.05-1, a comma was added after the reference to the MaineCare Benefits Manual and a reference to (14 472 CMR 1) was inserted. 4. In 32.05-1(C), a typographical error “has an change” was changed to “has any change.” 5. In 32.-05-1(F), a hyphen was inserted in DHHS-sponsored. 6. In 32.05-1(N), the reference to SAMHSA‘s system of care principles was modified to refer to an appendix added containing a copy of the principles and called APPENDIX I- Federal Substance Abuse and Mental Health Services Administration’s (SAMHSA) System of Care Principles.
Effective Date: November 17, 2013
View Comments: Word  Posted: November 12, 2013
 
10-144 C.M.R. Chapter 115, Principles of Reimbursement for Residential Care Facilities Room and Board Costs PDF   
Concise Summary: CONCISE SUMMARY: This final rule permanently adopts rule changes mandated by Resolves 2011, Ch. 106. In the proposed rule, Chapter 115, Section 20.21(e)(4) continued to impose a prior approval requirement for energy efficiency improvements which exceeded $35,000 in cost. As a result of public comments and upon reviewing L.D. 790, the bill that became Resolve 2011, Chapter 106, the Department determined that retaining the prior approval for energy efficiency improvements was contrary to the Legislature’s intent. Therefore, in response to the public comment and to conform with Resolve 2011, Chapter 106, the Department has eliminated the prior approval requirements for energy efficiency improvements as follows: (1) Effective November 13, 2013, in order for an energy efficient improvement to be reimbursable, the energy efficiency improvement must be recommended as a cost- effective energy efficiency improvement in an energy audit conducted by an independent energy audit firm, as evidenced in a written document, or must be determined to be cost- effective by the Efficiency Maine Trust, established in 35-A MRSA Sec. 10103, as evidenced in a written document; and (2) Effective July 8, 2011, the rule retroactively raises the threshold beyond which providers must seek prior approval of capital expenditures for new construction, acquisitions, or renovations from $35,000 to $350,000. The rule also excludes costs for energy efficiency improvements, replacement equipment, information systems, communications systems, parking lots and garages from the cost of the project for the purpose of determining whether prior approval is required. However, all such costs will continue to be reviewed and audited for allowable costs, in compliance with Chapter 115 regulations. Providers should also note that the Department is engaged in discussions with the Centers for Medicare and Medicaid Services (CMS) concerning for Private Non-Medical Institutions (PNMI) funding. If the MaineCare PNMI regulations change, that may impact the reimbursement of room and board for PNMIs under this Chapter 115, which is a solely state-funded program. The Department advised providers to consider these factors in making their investment decisions. Note that the $350,000 prior approval provision is retroactive to July 8, 2011 – the date the Governor signed the resolve into law. The retroactive application of this provision is lawful under the Maine Administrative Procedures Act since: (a) it provides a benefit to providers and (b) it was the intent of the Legislature that it take effect immediately. The energy efficiency project provision, however, cannot be applied retroactively since it places a burden on providers to obtain written documentation of cost-effectiveness. The Department does not anticipate that this rulemaking will cause any actual or potential public controversy. This rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments.
Effective Date: November 13, 2013
View Comments: Word  Posted: November 12, 2013
 
MaineCare Benefits Manual, Ch 104, Sec 4, Maine Part D Wrap Benefits PDF  Word 
Concise Summary: CONCISE SUMMARY: This rule will permanently adopt the provisions now in place by the emergency rule that eliminated coverage of Medicare Part D copayments for members of the Medicare Savings Program who are not eligible for, or receiving the full MaineCare benefit. This change is being made pursuant to PL 2013, Chapter 368, Part A, Section A-34, the Maine Biennial Budget.
Effective Date: November 06, 2013
View Comments: Word  Posted: November 4, 2013
 
MaineCare Benefits Manual, Ch101, Sec 45, Ch III Hospital Services    
Concise Summary: CONCISE SUMMARY: This rulemaking permanently adopts changes made on an emergency basis, effective July 1, 2013, to implement provisions in the 2014-15 budget law (LD 1509, P.L. 2013, ch. 368). Specifically, this rulemaking: a) Increases the reimbursement rate per psychiatric discharge for members under 18 years of age from hospitals in the Lewiston/Auburn area to $9,128.31; b) Reduces the outpatient Ambulatory Payment Classification (APC) rate for Acute Care Non-Critical Acess Hospitals and Rehabilitation Hospitals from 93% to 83.7% of the adjusted Medicare APC rate for outpatient services; if multiple procedures are performed, the Department will pay 83.7%, rather than 93%, of Medicare’s single bundled APC rate; calculations for outlier payments will follow Medicare rules and also be paid at 83.7%, rather than 93%, of the Medicare payment. The rulemaking also corrects two clerical errors: (1) on page 15, the proper heading should be “Section 45.04 Acute Care Critical Access Hospitals;” and, (2) on pages 11 and 18, removes “un” from “unadjusted” so the proper word is “adjusted.” The Department is seeking approval from the Centers for Medicare and Medicaid Services for a State Plan Amendment for this change.
Effective Date: October 11, 2013
View Comments: Word  Posted: October 17, 2013
 
MaineCare Benefits Manual, Ch 101 Sec 97 Ch II Private Non-Medical Institution Services PDF   
Concise Summary: CONCISE SUMMARY: This final adopted rule eliminates Private Non-Medical Institution Services (PNMI), Appendix D (Child Care Facilities), Model 3 (Intensive Mental Health Services for Infants and/or Toddlers). The reimbursement rate is being eliminated in a separate provisionally adopted rulemaking for Chapter III, Section 97. Although eligible infants and toddlers will no longer be able to access PNMI Appendix D, Model 3 intensive mental health services, they will be eligible for medically necessary behavioral health services through Section 65, Behavioral Health Services.
Effective Date: 06-26-2013
View Comments: Word  Posted: October 15, 2013
 
MaineCare Benefits Manual, Ch 101, Sec 65, III, Behavioral Health Services-Restorative PDF   
Concise Summary: CONCISE SUMMARY: This rule is permanently adopting the emergency rule that restores the reimbursement rates for Licensed Clinical Professional Counselors (LCPCs) and Licensed Marriage and Family Therapists (LMFTs) to levels in place prior to March 1, 2013 for MaineCare Benefits Manual, Chapter III, Section 65, Behavioral Health Services beginning July 1, 2013. The Legislature mandated this rule in P.L. 2013, Ch. 368 WWWW-1 and authorized the Department to do emergency rulemaking. This change in rates requires a State Plan Amendment to be approved by the Centers for Medicare and Medicaid Services (CMS). The Department will request approval of a State Plan Amendment.
Effective Date: 09-28-2013
View Comments: Word  Posted: September 26, 2013
 
MaineCare Benefits Manual, Chapter II, Section 65, Behavioral Health Services PDF   
Concise Summary: CONCISE SUMMARY: The Department seeks to adopt this rule in accordance with P.L. 2011, ch. 657, (L.D. 1746), Part A, S, S-1 (125th Legis.) effective January 1, 2013 that limits MaineCare reimbursement for methadone for the treatment of addiction to opioids to a maximum of twenty-four (24) months per lifetime, except as permitted with prior authorization beyond twenty-four (24) months. Only treatment after January 1, 2013 will count toward the limit.
Effective Date: 08-31-2013
View Comments: Word  Posted: August 27, 2013
 
MaineCare Benefits Manual, Ch 101, Sec 65, III, Behavioral Health Services PDF   
Concise Summary: CONCISE SUMMARY: This proposed rule seeks to permanently adopt a 5% reduction to reimbursement rates for Licensed Clinical Professional Counselors (LCPC) and Licensed Marriage and Family Therapists (LMFT), as directed by the Maine State Legislature in P.L. 2013, Ch. 1, A-23 (“An Act To Make Supplemental Appropriations and Allocations for the Expenditures of State Government and To Change Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Year Ending June 30, 2013”). This change in rates requires a State Plan Amendment to be approved by the Centers for Medicare and Medicaid Services (CMS); the Department will request approval of a State Plan Amendment retroactive to March 5, 2013.
Effective Date: June 3, 2013
View Comments: Word  Posted: August 16, 2013
 
CHAPTER III, SEC 29, SUPPORT SERVICES FOR ADULTS WITH INTELLECTUAL DISABILITIES AND AUTISTIC DISORDER word  pdf 
Concise Summary: This provisionally adopted rule proposes to provide that Section 29 MaineCare members access transportation for their Section 29 services through Section 113 Non-Emergency Transportation Services. On October 2, 2012, CMS approved an amendment to the Section 29 Waiver to waive the Section 1902(a) (32) freedom of choice provision, to limit the Section 29 Member’s choice of provider of transportation services, in order that this waiver will be consistent with the requirements of the Section 113 Waiver. The April 23, 2013, Centers for Medicare & Medicaid Services (CMS) approval of the Maine Non-Emergency Medical Transportation Waiver (MaineCare Benefits Manual, Section 113) expressly required that this Maine 1915(c) home- and community-based services (HCBS) Waiver use the Section 113 Waiver for all transportation needs for its members. This rule has been provisionally adopted and submitted to the Maine State Legislature for final approval. The Department will adopt an emergency major substantive rule so that this change can be effective upon implementation of the Section 113 Non-Emergency Transportation (NET) program, as required by CMS. This rule change is not anticipated to have any adverse impact on small businesses or impose any additional costs on municipalities or counties.
Effective Date: To be determined; provisional adoption
View Comments: word  Posted: August 8, 2013
 
MaineCare Benefits Manual, Ch III, Sec. 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder WORD  PDF 
Concise Summary: The Department is adopting a major substantive final rule, Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autistic Disorder, adopting a 5% reduction in Agency Home Support. The change in reimbursement was directed by the Maine Legislature in P.L.2011, Chapter 477, M-1. This final rule was approved by the Legislature in Resolves 2012, Chapter 15. This rule will be effective 30 days after the final filing with the Secretary of State.
Effective Date: August 1, 2013
  Posted: July 22, 2013
 
MaineCare Benefits Manual, Chapter II, Section 85, Physical Therapy WORD  PDF 
Concise Summary: The adopted rules will increase the limits for Physical Therapy Services to allow for up to five (5) treatment visits and one (1) evaluation within twelve (12) months, when provided pursuant to a pain management care plan. The adopted rule includes one change which is made in response to the Assistant Attorney General’s review for form and legality. This technical change includes the prior authorization criterion in the legally promulgated rule, instead of on the Department’s website.
Effective Date: July 20, 2013
View Comments: WORD  Posted: July 19, 2013
 
Adoption final rule - MaineCare Benefits Manual, Chapter III, Section 65, Behavioral Health Services Word  PDF 
Concise Summary: CONCISE SUMMARY: This proposed rule seeks to permanently adopt a 5% reduction to reimbursement rates for Licensed Clinical Professional Counselors (LCPC) and Licensed Marriage and Family Therapists (LMFT), as directed by the Maine State Legislature in P.L. 2013, Ch. 1, A-23 (“An Act To Make Supplemental Appropriations and Allocations for the Expenditures of State Government and To Change Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Year Ending June 30, 2013”). This change in rates requires a State Plan Amendment to be approved by the Centers for Medicare and Medicaid Services (CMS); the Department will request approval of a State Plan Amendment retroactive to March 5, 2013.
Effective Date: 06-03-2013
  Posted: June 19, 2013
 
MaineCare Benefits Manual, Ch. VI, Sec. 1, Primary Care Case Management WORD  PDF 
Concise Summary: The Department is repealing the Patient Centered Medical Home (PCMH) provision of the Primary Care Case Management (PCCM) rule, MaineCare Benefits Manual, Ch. VI, Sec. 1, effective January 1, 2013, because the PCMH program is being replaced by the new “Health Home” program being promulgated as MaineCare Benefits Manual, Ch. II, Sec. 91 and Ch. III, Sec. 91. This rule change is not anticipated to impose any cost upon municipalities or counties or have any adverse impact upon small businesses.
Effective Date: April 1, 2013
View Comments: PDF  Posted: April 2, 2013
 
MaineCare Benefits Manual, Chapters II & III Section 91, Health Home Services WORD  PDF 
Concise Summary: Effective January 1, 2013, the Department began offering and reimbursing Health Home Services under a new section of policy, Chapters II and III, Section 91. Health Homes Services are for MaineCare beneficiaries who suffer from certain chronic health conditions (including a mental health condition; a substance use disorder; tobacco use; diabetes; heart disease; overweight or obese as evidenced by a Body Mass Index over 25; Chronic Obstructive Pulmonary Disease; hypertension; hyperlipidemia; developmental and intellectual disorders; circulatory congenital abnormalities; asthma; acquired brain injury; and seizure disorders). MaineCare beneficiaries who suffer from Serious and Persistent Mental Illness and Serious Emotional disturbance are not eligible for Section 91 services. Congress enacted the Affordable Care Act which, in part, authorized States to offer Medicaid Health Home Services as a way to improve health care through coordinated care and at a reduced cost. For the first two years that a state offers Medicaid Health Home Services, the federal matching rate equals 90%. Under Maine’s Health Home program, members eligible for Health Home services will be assigned to a “Health Home Practice”(HHP). The HHP is responsible for providing acute and preventive care, managing chronic illnesses, coordinating specialty care and referrals to social, community, and long-term care supports, providing comprehensive care management, and providing access to 24/7 coverage. The HHP is required to work with a Community Care Team (CCT) to identify members with the most intense health care needs and to provide more intense Health Home services for such members. The number of members receiving CCT services at any point in time is capped at 5% of each HHP’s members. This rule change is not anticipated to impose any cost upon municipalities or counties or have any adverse impact upon small businesses.
Effective Date: April 1, 2013
View Comments: PDF  Posted: April 2, 2013
 
MaineCare Benefits Manual, Chapters II, Section 4, Ambulatory Surgical Center Services PDF  Word 
Concise Summary: CONCISE SUMMARY: The Department of Health and Human Services (DHHS) is adopting this rule to repeal Chapter 101, MaineCare Benefits Manual, Chapter II, Section 4, Ambulatory Surgical Center Services, in accordance with Public Law 2011, c. 657, Part A, the Maine State Supplemental Budget.
Effective Date: August 30, 2012
  Posted: August 29, 2012
 
MaineCare Benefits Manual, Section 15, Chapter II, Chiropractic Services Word   PDF  
Concise Summary: With this rule, the Department of Health and Human Services (DHHS) is permanently adopting the April 1, 2012, emergency changes to Chapter 101, MaineCare Benefits Manual, Section 15, Chapter II, Chiropractic Services, pursuant to Public Law 2011, Chapter 477, the Maine Supplemental Budget. The change limits reimbursement for Section 15, Chiropractic Services to twelve (12) visits per rolling calendar year for adult members. The Department is also clarifying Section 15.04, Specific Eligibility for Care, to align with the definition of rehabilitation potential earlier in the Section.
Effective Date: June 26, 2012
View Comments: Word  Posted: June 26, 2012
 
MaineCare Benefits Manual, Chapter III, Section 50, Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded (ICF-MR) Services WORD  PDF 
Concise Summary: This is a major substantive rule and will be final thirty days after it is filed. The legislature approved the rule for final adoption in 2011-Resolve chapter 161. In 2011, the Legislature amended 36 M.R.S.A. 2872 by increasing the tax on ICF-MRs from 5.5% to 6% via P. L. 2011, ch 411. This provisionally adopted rule permits an ICF-MR to obtain reimbursement of the full 6% tax, subject to CMS approval. The rule has a retroactive application with an effective date of January 1, 2012 (authorized under 22 MRSA 42(8) because this rule will benefit providers by increasing their reimbursement). This change is not expected to have an adverse economic impact on small businesses or municipalities and counties.
Effective Date: Retroactive to January 1, 2012
View Comments: WORD  Posted: June 7, 2012
 
MaineCare Benefits Manual Chapters II & III, Section 3, Ambulatory Care Clinic Services WORD  PDF 
Concise Summary: The adopted rules will consolidate and update all rules pertaining to the reimbursement of Indian Health Service (IHS) clinic services to one new section of MaineCare Benefits Manual (MBM) policy. Services provided by IHS providers are subject to different federal guidelines. Separation of these rules will clarify specific rules for IHS providers. The Department will also add guidelines for co-payment exemptions and tribal consultation to be in compliance with Section 5006(a) of the American Recovery and Reinvestment Act of 2009 (Recovery Act), Public Law 111-5. Currently IHS services are included in MBM Section 3, Ambulatory Care Clinic Services. The Ambulatory Care Clinic Services section of the MBM will be amended at the same time as this rule-making in order to delete those portions that will now be part of Section 9, Indian Health Services.
Effective Date: March 21, 2012
View Comments: WORD  Posted: March 19, 2012
 
MaineCare Benefits Manual, Chapter II, Section 9, Indian Health Services WORD  PDF 
Concise Summary: The adopted rules will consolidate and update all rules pertaining to the reimbursement of Indian Health Service (IHS) clinic services to one new section of MaineCare Benefits Manual (MBM) policy. Services provided by IHS providers are subject to different federal guidelines. Separation of these rules will clarify specific rules for IHS providers. The Department will also add guidelines for co-payment exemptions and tribal consultation to be in compliance with Section 5006(a) of the American Recovery and Reinvestment Act of 2009 (Recovery Act), Public Law111-5. Currently IHS services are included in MBM Section 3, Ambulatory Care Clinic Services. The Ambulatory Care Clinic Services section of the MBM will be amended at the same time as this rule-making in order to delete those portions that will now be part of Section 9, Indian Health Services.
Effective Date: March 21, 2012
View Comments: WORD  Posted: March 19, 2012
 
MaineCare Benefits Manual, Chapter III, Section 67, Principles of Reimbursement for Nursing Facilities WORD  PDF 
Concise Summary: This adopted rulemaking, if CMS approves, raises the Cost of Living Adjustment (COLA) for Nursing Facilities to 2% beginning on October 1, 2011. This is prompted by changes to P.L. 2011, ch. 411. The retroactive application of this rule is permitted under 22 MRSA 42(8).
Effective Date: March 3, 2012
View Comments: WORD  Posted: March 2, 2012
 
MaineCare Benefits Manual, Chapters II and III Section 13, Targeted Case Management Services WORD  PDF 
Concise Summary: The adopted rules eliminate two target groups currently being reimbursed under Chapter 13, Targeted Case Management (TCM): “Case Management Services for Children Involved with Protective Services”, and “Case Management Services for Adults Involved with Protective Services”. Additionally the rulemaking adds medical eligibility criteria for the target group “Members Experiencing Homelessness”. Chapter II is also changed to delete obsolete language concerning the 2009 transition to one Comprehensive Case Manager and add a requirement for documentation that members have had choice of providers. Chapter III is changed to align the standard units of service and maximum allowance for two categories of TCM services with the other TCM categories. These rule changes will not impose any cost on municipalities or counties or have any adverse impact on small businesses.
View Comments: WORD  Posted: October 31, 2011
 
MaineCare Benefits Manual, Chapter II, Section 13, Targeted Case Management Services Word  PDF 
Concise Summary: This rule will permanently adopt the emergency rule effective December 20, 2013, that updates the Targeted Case Management (TCM) policy to include the Child and Adolescent Needs and Strengths (CANS) assessment as an approved TCM eligibility tool. See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
Effective Date: March 20, 2014
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