MaineCare Policy Adoption - Ch. II, Section 90 - July 20, 2016

The Division of Policy posts all proposed and recently adopted rules on MaineCare’s Policy and Rules webpage.  This website keeps the proposed rules on file until they are finalized and until the Secretary of State website is updated to reflect the changes.  The MaineCare Benefits Manual is available on-line at the Secretary of State’s website. 

Below, please find a Notice of Agency Rule-making Adoption.  You can access the complete rule at: http://www.maine.gov/dhhs/oms/rules/index.shtml

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 Notice of Agency Rule-making Adoption

AGENCY:  Department of Health and Human Services, MaineCare Services

CHAPTER NUMBER AND TITLE:  10-144 C.M.R. Chapter 101, MaineCare Benefits Manual (MBM), Chapter II, Section 90, Physician Services

ADOPTED RULE NUMBER:

CONCISE SUMMARY:  This rulemaking includes the following changes:

• Allows for coverage of comprehensive tobacco cessation treatment without limitations, including individual and group counseling and products for all members. These change are effective retroactive to August 1, 2014 for members who are eighteen (18) years and older or who are pregnant. Members under the age of eighteen (18) had already been receiving these benefits at no cost. The amended rule adoption language from the proposal reminds providers of existing legal requirements for the submission of any retroactive claims. 
• Adds coverage for Oral Evaluations by a medical provider for children under the age of three (3) and amends coverage of topical application of fluoride varnish to align with MBM, Ch. II and III, Section 25, Dental Services.
• Removes current limits for outpatient Psychiatric Services on the number of allowable services in any consecutive seven (7) day period and on the number of emergency therapy visits. This rulemaking also removes the requirement that providers delivering psychiatric services within their scope of licensure and state law must be under direct supervision of a board-eligible or certified psychiatrist.
• Amends the anesthesia time unit used for billing anesthesia services to one (1) minute intervals, rather than fifteen (15) minutes, in order to comply with HIPAA Version 5010. The rule adoption clarifies the start and end times of anesthesia services in line with Centers for Medicare and Medicaid Services (CMS) rules. This rulemaking also clarifies the components of anesthesiology services and more closely aligns MaineCare policy to CMS regulations regarding medically-directed and medically-supervised anesthesia services.
• The time periods indicated in surgical services for post-operative treatment have been amended to comply with the CMS standard fee schedule for durational global surgical periods of 0, 10, or 90 days. The rule adoption also clarifies what services are included in the global surgical package in accordance with CMS standards.
• Aligns with current MBM, Section 94, Early and Periodic Screening, Diagnosis, and Treatment Services (EPSDT) practice and reimbursement policies so that providers are no longer required to submit Well Child Visit (“Bright Futures”) forms in order to receive MaineCare reimbursement for services.
• Amends provider qualifications for obstetrical services to ensure that any appropriately licensed or certified, qualified professional working within their scope of licensure or certification may deliver obstetrical services to MaineCare members. Providers are expected to engage in collaborative management of individual members with appropriate consultation, referrals and transfers of care including, but not limited to, transfer of care for the purpose of specialized treatment and admission to an approved MaineCare hospital, with such treatment including maternity services.
• Updates the methods the Department uses to set rates in the MaineCare Fee Schedule to include an option to obtain an average from other state Medicaid agencies when a code is not priced by Medicare.
• The rulemaking also incorporates the Primary Care Increased Payment initiative, effective January 1, 2015. This initiative replaces expiring funds provided through the federal Affordable Care Act (ACA),
• L. 111-148 and Pub. L. 111-152, that have been extended through the State’s biennial budget, P.L. 2015, Ch. 267, Part A. Providers who were enrolled prior to January 1, 2015 have continued to receive the increased reimbursement and new providers have been eligible to enroll through completing a self-attestation form since January 1, 2015. Eligible providers are physicians practicing with a specialty designation of family medicine, internal medicine, or pediatric medicine or with a subspecialty within these three primary care categories that is recognized by the American Board of Medical Specialties, the American Board of Physician Specialties, or the American Osteopathic Association. Advanced Practice Registered Nurses and Physician Assistants who work under the direct supervision of an eligible physician are also eligible. Hospital-based physicians and physicians in Federally Qualified Health Centers or Rural Health Clinics remain ineligible.
• Clarifies Section 90.09-3, Reimbursement Rate for Drugs Administered By Other Than Oral Methods, without any change in coverage, reimbursement, or procedures.
• Deletes the separate Computerized Axial Tomography Scan subsection under Covered Services and includes the same information in Medical Imaging Services subsection.
• States that audiologists, physical therapists, and occupational therapists must follow the expectations and limitations in their applicable sections of policy when rendering services in a physician’s practice.
• Removes language referencing “provinces” and “provincial law” for consistency with MBM, Ch. 1, Section 1.03-2, which provides that MaineCare will not provide payment to any entity outside the United States, and as required by Section 6505 of the ACA, Pub. L. 111-148.
• Makes a number of non-substantive technical changes to the rule as a result of public comments and further review by the Department and the Office of the Attorney General.

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

EFFECTIVE DATE:                          July 20, 2016  

AGENCY CONTACT PERSON:      Olivia Alford, Social Services Program Manager

                                                            Olivia.Alford@maine.gov

AGENCY NAME:                              Division of Policy

ADDRESS:                                         242 State Street

                                                            11 State House Station

                                                              Augusta, Maine 04333-0011

TELEPHONE:                                  (207)-624-4059 FAX: (207) 287-1864

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