August 27, 2021 MaineCare Updates

In this message:

• Private Non-Medical Institution (PNMI) Appendix B Update 
• Attention MaineCareProviders of Emergency Department (ED) Services: Coverage Added for Code G2213, CR 103993
• Claim Line Denials Corrected for CPT/GT Modifier Combinations, CR 103814
• Rate Update for Drug codes, CR 102903
• Rate Updates for Section 90, CR 102883
• Opportunity for Kepro Review of IEP Documentation for School-Health Related Services under MaineCare Sections 28 and 65

Private Non-Medical Institution (PNMI) Appendix B Update  

The Office of MaineCare Services (OMS), in collaboration with the Office of Behavioral Health (OBH), the Office of Child and Family Services (OCFS), and the Centers for Medicare & Medicaid Services (CMS), has recently completed a rate study of Section 97 Appendix B Substance Use Disorder (SUD) Treatment facilities as part of the Department’s grant-funded SUPPORT for ME initiative, which assesses gaps, barriers, and opportunities of Maine’s SUD delivery system.  

Through a parallel but related effort, in December 2020, MaineCare received federal approval of its 1115 demonstration waiver application, known as Maine’s Substance Use Disorder Care Initiative, which allows for the expansion of SUD residential treatment programs above sixteen beds. To correspond with the expansion of beds, MaineCare took action through the PNMI B rate study to further support member access to quality treatment through ensuring adequate reimbursement for these programs. This work also aligns with MaineCare’s Rate Reform initiative, which aims to ensure adequate reimbursement across MaineCare’s continuum of services, and to progressively tie reimbursement to the delivery of high value care. The new rates, shown in the table below, along with expanded capacity through the 1115 waiver, will help increase member access to quality care. 

The rate changes in the table below are anticipated to be effective on November 1, 2021. These rates are the result of the rate study conducted by Burns and Associates on behalf of the Department and in partnership with providers, and are revised to reflect public comments received on draft rates presented to providers on March 26, 2021. Click here for (1) details of the models used to develop the rates, and (2) responses to public comments about the draft rates.   

This rate study is supported by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $2,144,225 with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.  

Attention MaineCare Providers of Emergency Department (ED) Services: Coverage Added for Code G2213, CR 103993 

Effective January 1, 2021, the Office of MaineCare Services (OMS) has added coverage for Healthcare Common Procedure Coding System (HCPCS) code G2213 to MaineCare Benefits Manual (MBM), Sections 45: Hospital Services and 90: Physician Services contracts as follows:  

G2213: Initiation of medication for the treatment of opioid use disorder in the Emergency Department setting, including assessment, referral to ongoing care, and arranging access to supportive services   

Providers may now submit claims or adjust previously submitted claims for these services.  

Please contact your Provider Relations Specialist with any questions.   

Claim Line Denials Corrected for CPT/GT Modifier Combinations, CR 103814 

The issue where some claims submitted with GT modifier were denying inappropriately has been corrected. The issue affected some claims submitted with GT modifier between July 7, 2021 until August 25, 2021.    

No provider action is needed and claims that denied in error will be reprocessed.  

Rate Update for Drug codes, CR 102903  

Twelve drug code rates were revised in MIHMS due to a Centers for Medicare & Medicaid Services (CMS) rate update. See the table below for details.  

Rate Updates for Section 90, CR 102883  

Effective January 1, 2021, the following codes have been updated:    

92651    $54.98 

92652    $72.81 

92653    $53.52 

93242    $9.11 

93244    $15.30 

93246    $9.11 

93248    $16.79 

Please contact your Provider Relations Specialist with questions. 

Opportunity for Kepro Review of IEP Documentation for School-Health Related Services under MaineCare Sections 28 and 65  

The Office of MaineCare Services (OMS) and the Maine Department of Education  (MDOE) are pleased to announce that, effective September 1, 2021, Kepro will be able to review MaineCare members’ Individualized Education Program (IEP) documentation at the time providers submit a Prior Authorization (PA) request for services, pursuant to the MaineCare Benefits Manual (MBM). This review will help providers ensure that there is alignment between the member’s IEP and the services being requested, prior to delivery of the services. 

Providers may voluntarily take advantage of this opportunity for review from September 1, 2021 through December 31, 2021; beginning in January 2022, the current plan is for Kepro to conduct this IEP review as a regular, mandatory component of their general prior authorization request process.  

As a reminder, as communicated in recent joint guidance from the Maine Department of Health and Human Services (MDHHS) and MDOE, Section 1903(c) of the federal Social Security Act permits Medicaid payments for medical services provided to children under the Individuals with Disabilities Education Act (IDEA) through a child’s IEP. Documentation that health-related services are being provided as part of a member’s IEP is required under federal law to ensure the services are Medicaid reimbursable. 

During this voluntary “soft launch” period, providers who take advantage of Kepro’s new review process will be asked to indicate if the requested service is being provided pursuant to IDEA regulations. If the answer is yes, the provider will be asked if they would like to have the IEP reviewed for compliance with OMS/MDOE guidance. If so, providers will then be able to submit the IEP cover page, along with Sections 6 and 7 of a member’s IEP.  

Kepro will review the submitted IEP documents to ensure services are documented in accordance with the DHHS/MDOE joint guidance. Providers will be notified if documentation is not in compliance; they will then have the opportunity to correct and update the member’s IEP. Service authorizations will be placed on hold until providers upload the updated IEP. The Kepro IEP review process will help providers ensure their documents are aligned with IDEA and federal requirements prior to the provision of services. As reminder, IEP services must be a determination of the IEP team and cannot be altered or added solely for the purpose of MaineCare authorization of payment. 

Whether or not providers participate in this voluntary review process starting in September, federal law requires that providers keep IEP documents on file that are aligned with services provided. All providers will be required to submit IEP documents via the Atrezzo portal once the final process becomes mandatory in January 2022. 

Additional information regarding the provision of MaineCare-covered services in schools is available on the MaineCare in Education website.  Providers will also find a recording of the joint OMS/MDOE presentation from June 2, 2021. To access the recording, please use Passcode:  %r^KpD51. 

For technical assistance with the IEP process, please contact Colette.Sullivan@maine.gov or Roberta.Lucas@maine.gov.

For technical assistance regarding the billing and processing of MaineCare claims, please email MaineCareinEducation.DHHS@maine.gov or Rebecca.A.Maranda@maine.gov.