September 14, 2021 MaineCare Updates

Upcoming Changes to Chapter II, Section 60, Medical Supplies and Durable Medical Equipment (DME) and CR 98710

Effective October 1, 2021, to comply with the Centers for Medicare and Medicaid Services’ (CMS) Upper Payment Limit (UPL) requirement and pursuant to P.L. 2021, Ch. 398, Sec. A-17, An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023, the Department will align the rate structures and fee schedule for purchased DME with those used by Medicare via rulemaking and a State Plan Amendment. For background, UPL requirements mandate states to carry full financial responsibility for any Medicaid expenditures that exceed what Medicare would have paid in the aggregate for such items and services. This amendment is intended to achieve compliance with the UPL requirements where applicable, while also establishing a clear and consistent reimbursement methodology for all DME and supplies, regardless of whether they are subject to UPL requirements. 

Specifically, the Department will change the reimbursement methodology for all DME and medical supplies, unless otherwise specified, to 88.2% of the current year Medicare rural and non-rural fee schedule amounts. This replaces the current methodology which reimburses DME and medical supplies at 85% of the 2011, or subsequent earliest available year’s, rural Medicare fee schedule amount and at 100% of the current year’s rural Medicare fee schedule amount for DME and medical supplies impacted by the 21st Century Cures Act. 

Claims will be paid at the appropriate rural or non-rural rate for a service based on the zip code of the physical address of the member receiving the DME. CMS determines which zip codes are rural versus non-rural and includes an updated table of rural zip codes with the most current DME Prosthetic, Orthotic, and Supplies Fee Schedule.

To review the new rates for each procedure code included within this change, please see the Medical Supplies and DME Fee Schedule (PDF) on the Codes and Rates webpage. 

Please contact Policy Writer, Henry Eckerson with questions about this change.

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COVID-19 Vaccine Third Dose Administration Code Additions, CR 104094 and ACS-5537

On August 12, 2021, the Food and Drug Administration (FDA) amended the Pfizer and Moderna COVID-19 vaccine Emergency Use Authorizations (EUAs) to allow for the administration of a third dose to individuals who have immunocompromised conditions. Administration of the COVID-19 vaccine third dose must be delivered in accordance with the following guidance:

• United States Centers for Disease Control (US CDC) guidelines on moderately and severely immunocompromised conditions recommended for a third dose
• Pfizer Comirnaty COVID-19 Vaccine EUA Factsheet for Healthcare Providers*
• Moderna COVID-19 Vaccine EUA Factsheet for Healthcare Providers 

Effective August 12, 2021, MaineCare has added the following COVID-19 vaccine administration codes to MaineCare Benefits Manual (MBM), Chapter II, Sections 3, 5, 7, 9, 14, 31, 40, 80, 90, and 103 services fee schedules and/or contracts as follows:   

Providers may now submit claims or resubmit denied claims for dates of service on or after August 12, 2021.

*On August 23, 2021, the FDA issued full approval for the first two doses of the Pfizer-BioNTech COVID-19 vaccine in individuals sixteen years and older. This vaccine is now called Comirnaty.

Claims Instructions Section 80: Pharmacy Services Providers

The Submission Clarification Code (420-DK) field should be used to differentiate which dose is being administered to allow proper reimbursement. Submission Clarification Code = 7 should be used for the booster dose. This guidance applies regardless if the same provider or different providers administered the initial 2-dose series.

Please refer to the NCPDP EMERGENCY PREPAREDNESS GUIDANCE V1.10 for additional information. In general, claims submitted for zero-cost vaccines should be submitted on a single B1/B3 billing transaction including the following data elements and values:

• Quantity Dispensed (442-E7)

• Moderna NDC Codes (value=0.5 mL):
• 80777027310
• 80777027315
• 80777027398
• 80777027399
• Pfizer-BioNTech NDC Codes (value= 0.3 mL):
• 59267100001
• 59267100002
• 59267100003

• Professional Service Code (440-E5)  “MA” (Medication Administered)

• Submission Clarification Codes (SCC, 420-DK)

• First Dose=2
• Second Dose=6
• Third Dose=7

• Incentive Amount (438-E3) is the administration fee of $37.29 for each dose 
• Basis of Cost (423-DN) “15” (free product or no associated cost)
• Ingredient Cost (409- D9) value of $0.00 or $0.01
• Gross Amount Due (430-DU) Include "Incentive Amount" submitted for the administration fee and zero cost of the vaccine

For pharmacy questions, please contact the Change Healthcare Pharmacy Help Desk at 1-888-420-9711. MaineCare providers can also send inquiries via email to PBA_helpdesk@changehealthcare.com. All other MaineCare providers, please contact your Provider Relations Specialist with questions.