MaineCare Notice of Agency Rule-making Adoption, MaineCare Benefits Manual, Chapter II, Section 90, Physician Services

Nov 18, 2021

Notice of Agency Rule-making Adoption

AGENCY:  Department of Health and Human Services, MaineCare Services, Division of Policy

CHAPTER NUMBER AND TITLE: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter II, Section 90, Physician Services

ADOPTED RULE NUMBER:

CONCISE SUMMARY: This final rule makes the following changes:

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 “Budget”), and in alignment with the recommendations from the comprehensive rate setting evaluation conducted by Myers and Stauffer at the request of the Department, this final rule increases the reimbursement rate from 70% of the lowest level in the 2009 Medicare fee schedule to 72.4% of the current year’s Medicare rate per code. In addition, the final rule sets the reimbursement rates for select primary care services at 100% of current Medicare rates, from 100% of 2014 Medicare rates, for eligible primary care providers, which is an additional reimbursement increase. These reimbursement changes shall be effective July 1, 2022, as authorized and required by the Budget.

Also per the Budget, the final rule adds a new provision, Section 90.04-7(B), Physician-Administered Drugs that have Biosimilar Equivalents and/or Prior Authorization (PA) Criteria. This provision implements a Biosimilar Preferred Drug List which establishes preferred and non-preferred drug statuses based on cost and biosimilar equivalency for physician-administered drugs. Physician-administered drugs are those that satisfy the criteria in 90.04-7(A), but they also may be drugs administered orally. For drugs that are not administered orally, the adopted changes require providers not only to go through the steps set forth in 90.04-7(A), but also to use physician-administered biosimilar drugs when a physician-administered drug has a Food and Drug Administration- (FDA) approved, biosimilar equivalent that the Department identifies as more affordable. Annually, the Department shall identify drugs that have a more affordable FDA-approved biosimilar equivalent on the Biosimilar Preferred Drug List on the MaineCare Health PAS Online Portal. Physicians shall submit a PA request to administer the original drug. For physician-administered drugs that are administered orally, providers must satisfy the requirements in 90.04-7(B).

Section 90.04-7 also requires that some physician-administered drugs may require PA to ensure members meet age, clinical, or other requirements for MaineCare to provide payment and that the MaineCare Health PAS Online Portal contains a complete list of physician-administered drugs that require PA and corresponding PA criteria sheets. Providers must make requests for PA on the Department’s approved form and get approval prior to the date of service. This new PA process is in addition to the requirements for PA in 90.04-7(A).

The final rule (Sec. 90.04-30) allows members under the age of 21 to receive the application of topical fluoride varnish up to four times per calendar year from eligible providers, rather than two times per calendar year or three times for members with a high caries rate or new restorations placed in the last 18 months. This change aligns with other states’ Medicaid program limitations on fluoride treatment and the current American Academy of Pediatrics recommendation on fluoride treatment. The final rule also removes the list of allowable providers who may provide topical fluoride varnish and has replaced “eligible providers” and “providers” with “qualified providers.” The adopted rule (Sec. 90.04-31) also allows all members to receive an oral health risk assessment if they do not have a dental home and/or have not seen a dentist in the past year, rather than restricting the service to members under three years of age. In addition, the final rule adds dental hygienists to the list of providers in association with physician services in Section 90.04-15.

The final rule (Sec. 90.05-2(A)) clarifies that medication abortions are covered and shall be performed in compliance with applicable Food and Drug Administration law and guidelines.

The 130th Maine Legislature enacted P.L. 2021, Ch. 348, An Act to Discontinue the Use of the Terms "Handicap," "Handicapped" and "Hearing Impaired" in State Laws, Rules and Official Documents. The final rule replaces the term ‘handicapped’ with ‘person with disabilities’ pursuant to P.L. 2021, Ch. 348.

Effective June 21, 2022, this Section 90 rulemaking also eliminates Sec. 90.09-4, Primary Care Provider Incentive Payment (PCPIP), as part of the new Primary Care Plus (PCPlus) initiative. PCPIP authorizes an incentive payment to primary care practices (PCP) based on their performance on several access, utilization, and quality measures. Retaining this payment after PCPlus takes effect would be duplicative of the reimbursement PCPs will receive under the new PCPlus rule. PCPs who currently receive the Incentive Payment may instead apply to participate in PCPlus and, if approved as part of the program, will receive reimbursement based on their performance for members attributed to their practice.

To complete the transition to PCPlus, the Department also significantly revises MBM, Ch. II, Sec. 91 (adopted to be titled “Health Home Services – Community Care Teams), which includes repealing Health Home Practices. All of these rulemakings make up the PCPlus initiative, will be adopted simultaneously, and will have the same effective date.

The PCPlus program is intended to give primary care providers (PCPs) greater flexibility and incentives to effectively meet MaineCare members’ health care needs by transitioning away from a volume-based (fee-for-service) payment system with little connection to value, toward an approach that provides risk-adjusted Population-Based Payments tied to cost- and quality-related outcomes. To receive reimbursement under PCPlus, providers are required to locate, coordinate, and monitor health care services for members who are attributed to them. The Department will continue to reimburse other MaineCare covered services under the fee-for-service system. Interested parties should refer to the new PCPlus rule (MBM, Ch. VI, Sec. 3) for more details. 

On April 21, 2022, the Department received approval from the Centers for Medicare and Medicaid Services (CMS) for the state plan amendment (SPA) to implement the PCPlus program. The Department shall seek approval from CMS for SPAs to repeal and revise any other programs necessary to implement the PCPlus program. The Department will publish notice of changes in reimbursement methodology pursuant to 42 CFR 447.205.

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

EFFECTIVE DATE:                           May 14, 2022

AGENCY CONTACT PERSON:       Henry Eckerson, Comprehensive Health Planner II

AGENCY NAME:                              MaineCare Services

ADDRESS:                                       109 Capitol Street, 11 State House Station, Augusta, Maine  04333-0011

EMAIL:                                              henry.eckerson@maine.gov

TELEPHONE:                                   207-624-4085 FAX: (207) 287-6106

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