MaineCare Notice of Agency Rule-making Adoption, MaineCare Benefits Manual Chapter II, Section 23, Developmental and Behavioral Health Services and Chapter III, Section 23, Allowances for Developmental and Behavioral Evaluation Services

The Division of Policy posts all proposed and recently adopted rules on MaineCare’s Policy and Rules webpage. This website keeps the 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 MaineCare Notice of Agency Rulemaking Proposal. 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. Ch. 101 MaineCare Benefits Manual, Chapter II, Section 23, Developmental and Behavioral Health Services and Chapter III, Section 23, Allowances for Developmental and Behavioral Evaluation Services

ADOPTED RULE NUMBER:

CONCISE SUMMARY:

The Department of Health and Human Services finally adopts these rule changes in 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapter II, Section 23, Developmental and Behavioral Health Services, and Chapter III, Section 23, Developmental and Behavioral Evaluation Clinic Services.

MaineCare Benefits Manual, Chapter III, Section 23, Developmental and Behavioral Evaluation Clinic Services

The Department repeals this regulation.

MaineCare Benefits Manual, Chapter II, Section 23, Developmental and Behavioral Evaluation Clinic Services

Sec. 23.02-2 (Eligibility for Care). This rule lists out two separate categories of children, defining which Sec. 23 services the children are eligible for:

(1) Members from birth through age 20 are eligible for the Developmental and Behavioral Evaluations and also Child Abuse Evaluations; and

(2) Children in the care and custody of the Department are eligible for Developmental and Behavioral Evaluations, Child Abuse Evaluations, and a Foster Care Comprehensive Health Assessment (CHA).

Sec. 23.04-2 (Child Abuse Evaluation). The rule eliminates the limit of eleven units per evaluation.

Sec. 23.04-3 (Foster Care Comprehensive Health Assessment). The rule adds CHAs as a new covered service in accordance with 22 MRSA §4063-A(3). The new service will provide timely, comprehensive evaluations for children in foster care that align with the Child Welfare League of America (CWLA) and the American Academy of Pediatrics Standards for Health Care Services for Children in Out of Home Care.

This service includes an initial comprehensive assessment that includes a medical exam, a psychosocial evaluation, and a final report that is submitted to the Department. The service also includes a six (6) to eight (8) month follow-up comprised of another medical evaluation and a psychosocial evaluation. Providers who meet the criteria to provide the CHA do not have to hold a Developmental and Behavioral Evaluation Clinic contract with the Department.

Sec. 23.07 (Reimbursement). The now-repealed Ch. III rate table has been moved to Ch. II. Changes to the rate table include adding two new covered services for the CHA assessment/evaluation. In a change from the proposed rule, the rate table in the adopted rule includes the July 3, 2024, effective date for the rates. The rule also adds a cost-of-living-adjustment (COLA) provision in accordance with 22 MRSA §3137-J (2)(D)(3). The Department will apply a COLA to the rates annually every July 1, unless the rate has been adjusted during the previous twelve months. The Department will not do rulemaking to reflect the new rates every year, but, rather, new rates will be listed on the MaineCare Provider Fee Schedule, posted on the Department’s website, in accordance with 22 M.R.S. Sec. 3173-J(7). 

The 7/3/24 rate for the Developmental and Behavioral Evaluation services was increased from the proposed rate, reflecting the 7/1/24 COLA adjustment. The Child Abuse Evaluation services rate does not reflect a 7/1/24 COLA adjustment as this rate was adjusted in the past twelve months.

23.08(B) (Billing Instructions). This rule adds three provisions – the CHA Initial Assessment Bundled Payment; the CHA Follow-Up Evaluation Bundled Payment and the CHA Psychosocial Evaluation Component Reimbursement. Each provision details what services are reimbursed. 

Note that for the CHA Psychosocial Evaluation Component Reimbursement, CHA providers deliver and bill for the services that make up the psychosocial component of the CHA in accordance with the applicable section of the MaineCare Benefits Manual.

This rulemaking complies with 22 M.R.S. §3173-J. For the CHA, the Department issued a Rate Determination Initiation Notice on October 14, 2022. The Department held a public rate forum on November 23, 2022, to collect stakeholder input and comments to inform the Rate Determination process and accepted written comments through December 2, 2022.

Other Changes Made to the Adopted rule:

As described in the List of Changes to the Final Rule at the end of the Summary of Comments and Responses document, the Department made the following changes in the adopted rule:

  1. As a result of comment 1, the Department clarified in Section 23.04-3(B)(1)(b) that the appointment must occur within fourteen (14) “calendar” days of the referral “unless there are unforeseen and uncontrollable circumstances, such as inclement weather or illness, that prevent the appointment from occurring. If the appointment occurs after fourteen calendar days from the referral, the provider must document the justification for the delay in the member’s record.”
  1. As a result of comment 2, the Department has added to Section 23.04-3(B)(3)(a)(i) that “The provider may conduct the psychosocial evaluation virtually if it is for the benefit of the child, and providers must document the justification in the member’s record. Providers cannot conduct a virtual psychosocial evaluation for their own benefit or convenience.”
  1. As a result of comment 2, the Department added to Section 23.04-3(B)(5) that “the follow-up medical examination may only be conducted virtually if the findings from the initial examination indicate that a virtual follow-up is appropriate.”
  1. As a result of comment 2, the Department has removed “face-to-face” from Section 23.04-3(B)(5)(a).
  1. As a result of comments 6 and 8, the Department corrected the final rate for the CHA to $1,462.48 in Section 23.07.
  1. As a result of comment 9, the Department increased the rate for child abuse evaluations in Section 23.07; removed the larger, inaccurate list of providers who may conduct child abuse evaluations and replaced it with the team of three providers that conduct the evaluations together in Section 23.04-2: child abuse pediatricians, nurse practitioners, and licensed clinical social workers; expanded the list of components included in the evaluation in Section 23.04-2; and removed the unnecessary 11-hour service limit in Section 23.04-2.
  1. As a result of comment 10, the Department clarified the CHA provider must submit the final report no later than 21 “calendar” days after CHA is complete.
  1. As a result of the OAG legal review, the Department deleted the definition of trauma-informed care in Section 23.01-3 because the Sec. 23 services are evaluation services, and not medical services.
  1. As a result of the OAG legal review, the Department removed Section 23.04-3(B)(3)(b)(iv) (which stated that the psychosocial evaluation may include “other services as medically necessary”) because the psychosocial evaluation is an evaluation service.  Other MaineCare services that are identified as medically necessary for a child are delivered and billed in accordance with the applicable section of the MaineCare Benefits Manual.
  1. As a result of the OAG legal review, the Department removed “Providers that determine that additional services are required to complete the services described in this Section must deliver or coordinate the additional services with appropriately licensed providers acting within the scope of their licensure or qualifications, as appropriate” in Section 23.06-2 because it is duplicative of another provision and is not particularly clear in this provision. The Department revised the provision to its original intent to clarify that “Developmental and Behavioral Evaluation, Child Abuse Evaluation, and CHAs are reimbursable services when provided by appropriately licensed providers acting within the scope of their licensure.”
  1. As a result of the OAG legal review, the Department deleted Section 23.06-3 CHA Providers because the provision was duplicative of the CHA requirements set forth in Section 23.04-3(B).
  1. As a result of the OAG legal review, the Department added the effective date of the rates to the rate table in Section 23.07(A).
  1. With the approval of the OAG legal review, the Department updated the cost-of-living-adjustment language in Section 23.07(B).
  1.  As a result of the OAG legal review, the Department edited the headers and language in Section 23.08(B) to clarify precisely what the three different types of CHA payments are. 
  1. As a result of the OAG legal review, the Department removed “Other services delivered as part of the CHA, but not included in the bundled payments, must be delivered and billed in accordance with the applicable Section of the MBM” in Section 23.08(B)(3) because the first sentence states clearly that services which make up the psychosocial component of the CHA are delivered and billed in accordance with the applicable section of the MaineCare Benefits Manual.

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

EFFECTIVE DATE:                         July 3, 2024

STATUTORY AUTHORITY:         22 M.R.S. §§42, 4063-A, 3137-J, 4063-A(3)

AGENCY CONTACT PERSON:   Laurel Noddin

AGENCY NAME:                          Division of Policy

ADDRESS:                                    109 Capitol Street, 11 State House Station

                                                       Augusta, Maine 04333-0011

                                                       Email: laurel.noddin@maine.gov

TELEPHONE:   (207)-624- FAX: (207)-624-4019

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