September 13, 2021 MaineCare Updates

In this message:

• Interim Coverage for Use of Palivizumab Prophylaxis to Prevent Hospitalization from Severe Respiratory Syncytial Virus (RSV) Infection During the Current Atypical Inter-seasonal RSV Spread
• Critical Access Hospitals and Nursing Facilities Rate Updates, CR 104143 and 104145
• Rate Update for Drug Codes, CR 103279
• Provider Trainings

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Interim Coverage for Use of Palivizumab Prophylaxis to Prevent Hospitalization from Severe Respiratory Syncytial Virus (RSV) Infection During the Current Atypical Inter-seasonal RSV Spread

The Office of MaineCare Services (OMS), in coordination with our pharmacy benefits manager, Change Healthcare, reviews data from the National Respiratory and Enteric Virus Surveillance System (NREVSS) and the Maine Centers for Disease Control and Prevention (ME CDC) to track the epidemic season for RSV.

Peak RSV activity typically occurs between November and March. As recently reported by the ME CDC in a Public Health Advisory, RSV activity is on the rise. NREVSS is reporting a 33% positivity rate in Maine from a total of 97 PCR RSV tests through week ending August 28, 2021. 

In response to the national atypical inter-seasonal rise in RSV activity, the American Academy of Pediatrics (AAP) is supporting the consideration of the use of palivizumab in patients who would be candidates per current eligibility recommendations as outlined in our prior authorization form. Palivizumab is indicated for the prevention of serious lower respiratory tract disease caused by RSV in infants who are considered high risk for severe disease. The clinical benefit of palivizumab therapy is best realized by timing the administration to coincide with the peak of RSV activity. 

MaineCare is accepting PA requests for palivizumab prescriptions. OMS and CHC will continue to monitor RSV activity and may end the atypical inter-seasonal palivizumab approvals when the percent positives on antigen tests is ≤ 10% for two consecutive weeks or the percent positives on PCR tests is ≤ 3% for two consecutive weeks.

For questions, please contact the Change Healthcare Pharmacy Help Desk at 1-888-420-9711.  Maine providers can also send inquiries via email to PBA_Helpdesk@changehealthcare.com

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Critical Access Hospitals and Nursing Facilities Rate Updates, CR 104143 and 104145

Effective July 1, 2021, the Critical Access Hospital (CAH) swing bed rate and nursing facility days waiting placement rate have been recalculated for State Fiscal Year 2022.

• The new rate of $273.64 per day can be billed by CAHs for swing bed days on or after July 1, 2021 through June 30, 2022.
• The new rate of $112.83 per day can be billed by nursing facilities for days waiting placement on or after July 1, 2021 through June 30, 2022.

Providers must adjust all claims that were paid before the system was updated on August 18, 2021.

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Rate Update for Drug Codes, CR 103279

Effective July 1, 2021, drug code rates have been updated in MIHMS for MaineCare Benefits Manual (MBM), Chapter II, Sections:

• 25: Dental Services
• 30: Family Planning Agency Services
• 45: Hospital Services
• 55: Laboratory Services
• 60: Medical Supplies and Durable Equipment
• 75: Vision Services
• 90: Physician Services
• 95: Podiatric Services
• 101: Medical Imaging Services

The updated rates can be found on the Codes and Rates webpage.

Claims billed at the previous rate for dates of service between July 1, 2021 and July 14, 2021 will be reprocessed and no provider action is needed.

Please contact your Provider Relations Specialist with questions.

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Provider Trainings

The Office of MaineCare Services is hosting virtual provider trainings about multiple sections of MaineCare policy. Each session will include information regarding provider enrollment and MaineCare policy. The trainings will be held via Zoom and registration is required for each session. Please be advised, the registration link will be emailed directly to you on the morning of the scheduled training. Please be sure to key in your correct email address when registering.

You can register online, and the Zoom link will be provided after registration.

Training Schedule

• Section 45, All Maine Hospitals: September 28, 2021
• Section 50, ICF-MR Services: September 30, 2021
• Sections 21 & 29, Home/Community Benefits for Members w/Intellectual Disabilities or Autistic Disorder and Support Services for Adults w/ Intellectual Disabilities or Autistic Disorder: October 5, 2021
• Section 55, Laboratory Services: October 7, 2021
• Sections 18 & 20, Home/Comm Based Services for Adults w/ Brain Injury and Home/Comm Benefits for Adults w/ Other Related Conditions: October 12, 2021
• Sections 14 & 90, Advanced Practice Registered Nursing Services and Physician Services: October 14, 2021
• Sections 40 & 43, Home Health Services and Hospice Services: October 19, 2021
• Section 97-Appendix B, Principles of Reimbursement for Substance Abuse Treatment Facilities: October 21, 2021
• Section 97-Appendix C & F, Principles of Reimbursement for Medical and Remedial Service Facilities and Principles of Reimbursement for Non-Case Mixed Medical and Remedial Facilities: October 26, 2021
• Section 5, Ambulance Services: October 28, 2021
• Section 2, Adult Family Care Services: November 2, 2021
• Section 68, 85, & 109, Occupational Therapy Services, Physical Therapy Services, and Speech and Hearing Services: November 4, 2021
• Section 25, Dental Services: November 9, 2021
• Section 67, Nursing Facility Services: November 16, 2021
• Section 31 & 103, FQHC and RHC: November 18, 2021
• Section 102, Rehabilitative Services: November 30, 2021
• Section 15 Chiropractic Services: December 2, 2021 FROM 9:00 to 10:00
• Section 75, Chiropractic Services: December 2, 2021 FROM 10:00 to 11:00
• Section 9, Indian Health Services: December 7, 2021
• Section 19 & 96, Home/Comm Based Benefits for the Elderly and/or Adults w/ Disabilities and Private Duty Nursing and Personal Care Services: December 9, 2021
• Section 30, Family Planning Agency Services: December 14, 2021