Rule Adoption: MaineCare Benefits Manual, Chapters II & III, Section 45, Hospital Services

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, Office of MaineCare Services

 

CHAPTER NUMBER AND TITLE:  10-144 C.M.R., Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 45, Hospital Services   

 

ADOPTED RULE NUMBER:

 

CONCISE SUMMARY: These rules are adopted to comply with P.L. 2017, ch. 454, An Act to Require Reimbursement to Hospitals for Patients Awaiting Placement in Nursing Facilities.

 

The Department adopts these rules with the following changes:

Chapter II: In Section 45.07-3(2), the Department updated a reference so that referrals are made to the Office for Family Independence, instead of the Office of Integrated Access and Support, which is outdated.

Chapter III: Section 45.02-8 is added and adopted to comply with P.L. 2017, ch. 454, An Act to Require Reimbursement to Hospitals for Patients Awaiting Placement in Nursing Facilities. The Act requires the Department to reimburse hospitals other than critical access hospitals, beginning January 1, 2019, for each day after the 10th day that a MaineCare eligible member is in the care of the hospital while awaiting placement in a nursing facility. The Department will reimburse at the statewide average rate per MaineCare member day for nursing facility services. The statewide average rate will be computed based on the simple average nursing facility rate per MaineCare member day for the applicable state fiscal year or years prorated for the hospital’s fiscal year. Reimbursement for days awaiting placement pursuant to this section is limited to a maximum of $500,000 of combined state General Fund funds and federal funds for each year. The Department will reimburse quarterly by order of claim date. In the event the cap is expected to be exceeded in any quarter, reimbursement in that quarter will be paid out proportionately, and a notification of total funds expended for that year will be sent out to providers. The Act further requires this law be repealed on December 31, 2023. Note that the proposed rule provided that this reimbursement be provided to acute care non-critical access hospitals only. The final rule comports with P.L. 2017, ch. 454, and ensures that this reimbursement be provided to “hospitals other than critical access hospitals.”

The Department is seeking and anticipates receiving CMS approval for this change effective January 1, 2019. Pending approval, the change will be effective retroactive January 1, 2019.

Additionally, Section 45.03-1(D)(3) identifies the modifier used when identifying non-excepted items and services provided by PBDs as the “PN” modifier. The identification was made to distinguish the “PN” modifier from the new “PO” modifier.

Changes to the ICD-10 codes that had been proposed in Ch. III, Appendix B, have been removed from the adopted rule. The Department is delaying this change to allow providers the one-year billing grace period outlined in Ch. I, Section 1, of the MaineCare Benefits Manual to help prevent any billing issues in association with these changes. The changes that were proposed will be addressed in a future rulemaking.

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

 

EFFECTIVE DATE:                         October 28, 2019

 

AGENCY CONTACT PERSON:     Anne E. Labonte, Comprehensive Health Planner II

AGENCY NAME:                              Division of Policy

ADDRESS:                                          109 Capitol Street, 11 State House Station

                                                              Augusta, Maine 04333-0011

EMAIL:                                               Anne.Labonte@Maine.gov

TELEPHONE:                                   (207)-624-4082 FAX: (207) 287-1864

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