reglab/statecodes huggingface dataset:
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-71 - National Diabetes Prevention Program Service › Subsection 144-101-II-71.01 - INTRODUCTION AND INCORPORATION BY REFERENCE

Current through 2024-29, July 17, 2024
This section establishes standards for covering services
						delivered to MaineCare members under the United States Centers for Disease
						Control and Prevention's (CDC) National Diabetes Prevention Program Lifestyle
						Change Program (National DPP LCP).
All providers delivering services to MaineCare members
						under this section must adhere to the "Centers for Disease Control and
						Prevention Diabetes Prevention Recognition Program Standards and Operating
						Procedures," published by the CDC on May 1, 2021 (OMB No. 0920-0909, Exp. Date:
						04/30/2024), hereinafter "DPRP Standards," and available on the CDC's National
						DPP webpage at:
https://www.cdc.gov/diabetes/prevention/requirements-recognition.htm
.
						The DPRP Standards are hereby adopted and incorporated by
						reference.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-71 - National Diabetes Prevention Program Service › Subsection 144-101-II-71.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
71.02-1
CDC Diabetes Prevention
					 Recognition Program Standards and Operating Procedures (DPRP Standards)
is the CDC publication, incorporated above, that describes the requirements for
					 operating and delivering the National DPP LCP and explains how an organization
					 may apply for, earn, and maintain CDC recognition to deliver National DPP LCP
					 services.
71.02-2
Diabetes
					 Prevention Recognition Program (DPRP)
is the quality assurance arm of
					 the National DPP, which identifies organizations that have demonstrated the
					 ability to deliver the National DPP LCP to prevent type 2 diabetes.
71.02-3
Lifestyle Coach
is an
					 individual trained by a CDC-authorized entity to implement a CDC-approved
					 curriculum designed to effect lifestyle change for preventing or delaying type
					 2 diabetes and provide support and guidance to participants in the National DPP
					 LCP. The DPRP Standards contains a Lifestyle Coach position
					 description.
71.02-4
Medicare
					 Diabetes Prevention Program (MDPP)
is the same underlying program as the
					 National DPP LCP, but Medicare holds MDPP providers to additional requirements
					 beyond those included in the DPRP Standards.
71.02-5
National Diabetes Prevention
					 Program (National DPP)
is a program within the CDC and established
					 pursuant to 42 USCA §
												240g-14 that works to prevent or delay type 2
					 diabetes.
71.02-6
National
					 Diabetes Prevention Program Lifestyle Change Program (National DPP LCP)
is an evidence-based, year-long, lifestyle behavior change program designed and
					 overseen by the CDC that teaches participants the skills to change and maintain
					 physical activity levels and dietary habits to prevent or delay type 2
					 diabetes.
71.02-7
National
					 DPP LCP Provider (Provider)
is an entity that the DPRP has awarded
					 pending, preliminary, or full recognition to deliver the National DPP LCP and
					 that has enrolled with MaineCare to deliver services under this
					 section.
71.02-8
Program
					 Coordinator
is an individual employed by a National DPP LCP Provider to
					 serve as an organizational expert for implementing the National DPP LCP
					 consistent with the DPRP Standards. They supervise daily operations related to
					 the National DPP LCP and provide guidance and support to Lifestyle Coaches. The
					 DPRP Standards contains a Program Coordinator position description.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-71 - National Diabetes Prevention Program Service › Subsection 144-101-II-71.03 - MEMBER ELIGIBILITY

Current through 2024-29, July 17, 2024
71.03-1
General Eligibility
Individuals must meet the eligibility and residency
						requirements set forth in the MaineCare Eligibility Manual, 10-144 CMR Ch. 332.
						Some members may have restrictions on the type and amount of services they are
						eligible to receive. MaineCare Providers must verify an individual's
						eligibility for MaineCare prior to providing services, pursuant to Chapter I,
						Section 1, of the
MaineCare Benefits Manual
(MBM), 10-144 CMR Ch. 101.
71.03-2
Program
					 Eligibility
Providers may receive reimbursement for members
						participating in the National DPP LCP who meet the following criteria:
A. The member meets the participant
					 eligibility requirements in the current DPRP Standards (see the Appendix);
					 and
B. The member received a
					 referral to enroll in the National DPP LCP from a physician or other qualified
					 provider acting within his or her scope of practice.
Providers shall retain qualifying eligibility criteria
						and the referral in the member's record.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-71 - National Diabetes Prevention Program Service › Subsection 144-101-II-71.04 - PROVIDER REQUIREMENTS

Current through 2024-29, July 17, 2024
Providers shall meet all MaineCare-specific requirements
						and all requirements outlined in the DPRP Standards, including, but not limited
						to, the following criteria:
A. Have
					 and maintain pending, preliminary, or full recognition awarded by the
					 DPRP;
B. Have a Lifestyle Coach
					 lead all National DPP LCP sessions. Lifestyle Coaches shall meet all DPRP
					 qualifications and training standards and fulfill all responsibilities outlined
					 in the DPRP Standards. For MaineCare auditing purposes, Providers shall retain
					 proof of Lifestyle Coaches' approved and ongoing training for auditing
					 purposes;
C. Have a Program
					 Coordinator who meets all DPRP qualifications, training, and eligibility
					 standards. Program Coordinators shall serve both as the primary external
					 champions of the program and as the organizational experts for program
					 implementation consistent with the DPRP Standards;
D. Document each MaineCare participant's
					 primary care provider (PCP) in the member's record and report each member's
					 National DPP LCP participation and outcomes to their PCP no more than 60 days
					 after the final session of the program;
E. Deliver all National DPP LCP sessions in
					 accordance with DPRP location and delivery standards. Providers may only
					 deliver sessions through the delivery modes for which the CDC has authorized
					 them;
F. Comply with all DPRP
					 safety and data privacy standards; and
G. Submit evaluation data to the DPRP in
					 accordance with DPRP Standards. To collect and track evaluation data, providers
					 may use any type of spreadsheet or data tracking tool or any other system that
					 meets DPRP data privacy standards.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-71 - National Diabetes Prevention Program Service › Subsection 144-101-II-71.05 - COVERED SERVICES

Current through 2024-29, July 17, 2024
The National DPP LCP is comprised of a minimum of
						twenty-two (22) sessions delivered over the course of one (1) rolling year. In
						accordance with the DPRP Standards, Providers shall use the CDC's PreventT2
						Curriculum or another CDC-approved curriculum that meets DPRP curriculum
						requirements. The first sixteen (16) core sessions occur during the first six
						(6) months and the final six (6) core maintenance sessions occur monthly during
						the last six (6) months. Sessions include, but are not limited to, education on
						becoming physically active, tracking physical activity, healthy eating,
						tracking food, caloric balance, how to buy and cook healthy food, heart health,
						how to start losing weight, and how to cope with triggers of unhealthy
						behaviors.
Providers may deliver more than twenty-two (22) sessions
						in one (1) rolling year if consistent with the curriculum content in the DPRP
						Standards, but the Department will not reimburse for any additional sessions
						beyond the required twenty-two (22) sessions. Members shall not participate in
						more than one National DPP LCP at a time, but there is no limit to the number
						of times members may reenroll in a National DPP LCP. Providers shall deliver
						the minimum number of required sessions in accordance with any relevant updates
						the DPRP makes to the DPRP Standards.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-71 - National Diabetes Prevention Program Service › Subsection 144-101-II-71.06 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
A.
Enrollment.
Providers shall enroll as MaineCare providers at the
					 organizational level. Organizations that do not have a National Provider
					 Identification (NPI) number must obtain one through the National Plan &
					 Provider Enumeration System to enroll.
B.
Unenrolled Locations.
Providers that deliver sessions at one or more service locations that are not
					 enrolled with MaineCare (unenrolled locations), such as a community center,
					 shall retain a list of these locations that includes the dates of the first and
					 last day, as applicable, that the Provider delivered a session at each
					 location. Providers shall send the list to MaineCare's Section
					 71 provider relations specialist
					 and shall update and resend the list prior to delivering sessions at a new
					 unenrolled location and immediately after discontinuing delivering sessions at
					 an unenrolled location. Providers billing for National DPP LCP sessions
					 delivered at an unenrolled location shall use place of service code "99" on the
					 claim.
C.
Family Member,
					 Support Person, or Guardian Participation.
Providers shall allow a
					 family member, guardian, or support person to join sessions if a member
					 requires assistance in order to participate. Providers shall not bill for a
					 family member, guardian, or support person who accompanies a member during
					 sessions unless that person is also enrolled in the program and is also a
					 MaineCare member.
D.
Cohorts.
National DPP LCP cohorts, described in the DPRP
					 Standards, may include nonMaineCare enrolled participants. Providers cannot
					 bill MaineCare for delivering sessions to nonMaineCare enrolled
					 participants.
E.
Scales.
Providers shall provide and deliver a scale to measure
					 weight to any participating member who reports they do not have access to and
					 cannot obtain a scale.
F.
Third Party Liability.
Providers enrolled with Medicare or any
					 other primary payer to deliver the MDPP or the National DPP LCP shall bill the
					 primary payer before billing MaineCare for National DPP LCP sessions, unless
					 the participant has already reached their lifetime MDPP or National DPP LCP
					 benefit maximum.
G.
Make-up
					 Sessions.
Providers may offer make-up sessions in accordance with DPRP
					 Standards.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-71 - National Diabetes Prevention Program Service › Subsection 144-101-II-71.07 - REIMBURSEMENT AND BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
71.07-1
Reimbursement Methodologies
The following reimbursement methodologies set the rates
						for each session and performance payment:
A.
Session Rate.
The allowed
					 amount for each National DPP LCP session is 100% of Medicare's current total
					 reimbursement for all sessions without weight loss included in the MDPP divided
					 by the total number of sessions required by the most current version of the
					 DPRP Standards.
B.
Performance Payment.
The allowed amount for each performance
					 payment is 100% of Medicare's current maximum reimbursement for additional
					 payments related to weight loss in the MDPP divided by two (2).
Specific reimbursement rates for each session and
						performance payment are listed on a fee schedule, which is posted on the
						MaineCare Health PAS Online Portal in accordance with
						22 MRS
						§
														3173-J(7).
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-75 - Vision Services › Subsection 144-101-II-75.01 - VISION SERVICE PROVIDERS

Current through 2024-29, July 17, 2024
The provider of vision services may be an
						ophthalmologist, optometrist or optician. Providers of vision services
						reimbursed under Section 90, Physician Services, must also provide services
						following the requirements and standards set forth in this Section.
All providers must function within the scope of their
						current license to practice in the state or province in which services are
						provided.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-75 - Vision Services › Subsection 144-101-II-75.02 - MEMBER ELIGIBILITY FOR COVERED SERVICES

Current through 2024-29, July 17, 2024
MaineCare members are eligible for medically necessary
						vision services as long as they are enrolled in MaineCare.
If a member loses his/her MaineCare eligibility,
						MaineCare will pay for eyeglasses if the provider requested and received
						approval for eyeglasses and laboratory services while the member was enrolled
						in MaineCare. Providers must indicate on the claim the date the eyeglasses were
						ordered. The Vision Care Volume Purchase Contractor ("Contractor") will bill
						the provider at the Contractor's usual and customary charge for any orders
						submitted for an ineligible individual.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-75 - Vision Services › Subsection 144-101-II-75.03 - COVERED SERVICES

Current through 2024-29, July 17, 2024
MaineCare reimburses for some services differently for
						members based on age or residence in an ICF-MR. Only an ophthalmologist or
						optometrist may provide services described in Section 75.03-1.
75.03-1
Services That May be Provided
					 Only by an Ophthalmologist or Optometrist
Only an ophthalmologist or optometrist may provide the
						following services:
A.
Eye
					 Exams
For members who are under age twenty-one (21) or who
						reside in an ICF-MR, MaineCare will pay for one annual routine eye exam. For
						members ages twenty-one (21) and over, MaineCare will pay for only one routine
						eye exam every three (3) rolling calendar years, except that routine eye exams
						indicated as standard of care for specific medical diagnoses (ex. diabetes) or
						medication use (ex. Plaquenil) will be covered as medically indicated.
1.
Eye Examination, Brief - Limited -
					 Minimal
A brief eye examination is a limited or minimal level of
						service for which evaluation and detection require only a brief history and
						examination.
Example: A patient visit of 5 to 15 minutes required to
						evaluate a problem, to re-evaluate a prior problem or abnormality, or for
						further testing and evaluation of an existing chronic concern.
2.
Eye Examination,
					 Intermediate - Extended
An intermediate eye examination is a level of service
						more extensive than that of a follow-up, substantiated by documentation noting
						change and/or complication necessitating evaluation and detection of an
						otherwise stable condition.
3.
Eye Examination -
					 Comprehensive
A comprehensive eye examination is a level of service
						involving an in-depth evaluation of a member with a new or existing problem
						requiring the development or complete re-evaluation of data.
Example: The examination of the eye and related
						structures to ascertain defects or abnormalities, to detect the presence of eye
						diseases, to determine the refractive and accommodative states of the eyes, and
						to evaluate the visual functions. The eye examination includes a diagnostic
						history, visual acuity determination, testing for refraction, muscle balance
						and accommodative function, ophthalmoscopy and biomicroscopy. Tonometry and
						gross visual field testing should be included when indicated. Other tests may
						be included as required as long as they fall within the scope of licensure for
						optometry.
4.
Exam
					 Referral Restrictions
An ophthalmologist or optometrist who has provided an eye
						exam for a member may not refer that member to another vision service provider
						for the sole purpose of obtaining eyeglasses through the Vision Care Volume
						Purchase Contractor.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-75 - Vision Services › Subsection 144-101-II-75.05 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
MaineCare will not reimburse providers for the
						following:
A. Contact lenses for
					 members' ages twenty-one (21) and over.
B. Cosmetic contact lenses such as colored or
					 tinted contact lenses and/or contact lenses for cosmetic reasons
					 alone.
C. Eyeglasses for members
					 ages twenty-one (21) and over, except for one pair per lifetime and only for
					 eyeglasses of power equal to or greater than 10.00 diopters.
D. Provision and repair of oversize lenses,
					 fashion frames, fashion tints or other ophthalmic supplies that serve only a
					 cosmetic purpose.
E. Tinted lenses,
					 ultraviolet or photochromatic lenses for members ages twenty-one (21) and over
					 whose prescription is less than 10.00 diopters.
F. Covered eyeglasses or replacement parts
					 obtained through any lab other than the Vision Care Volume Purchase Contractor
					 except as noted in Section 75.04-4(D).
G. New examinations where a MaineCare member
					 is merely requesting that a current eyewear prescription be filled through the
					 Vision Care Volume Purchase Contractor.
H. Sample kits available to providers through
					 the Vision Care Volume Purchase Contractor.
I. MaineCare reimburses ophthalmologists
					 performing cataract surgery a rate including both surgery and follow-up care
					 following the surgery. If follow-up care is provided by an optometrist, that
					 visit may not be billed additionally to MaineCare.
J. MaineCare does not reimburse for UVA or
					 UVB for polycarbonate lenses.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-75 - Vision Services › Subsection 144-101-II-75.06 - CO-PAYMENT

Current through 2024-29, July 17, 2024
Co-payment exemptions and procedures for dispute
						resolution are described in Chapter I, Section 1, General Administrative
						Policies and Procedures, of the MaineCare Benefits Manual.
75.06-1
Co-payment Amount
MaineCare members are responsible for paying co-payments
						for vision services. The co-payment amount is based on the amount MaineCare
						pays for the services as indicated in the chart below.
MaineCare Payment for Services
Member
								Co-payment (Optometrist)
Member Co-payment (Optician)
$10.00 or less
$ .50
$ .50
$10.01 - 25.00
$1.00
$1.00
$25.01 - 50.00
$2.00
$2.00
$50.01 or more
$3.00
$2.00
75.06-2
Member Responsibility
Co-payment for members may not exceed $2.00 per day or
						$20.00 per month for services provided by an optician or $3.00 per day or
						$30.00 per month for services provided by an optometrist. After the cap has
						been reached, the member will not be required to make additional co-payments
						and the provider will receive full MaineCare reimbursement for covered
						services.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-75 - Vision Services › Subsection 144-101-II-75.07 - REIMBURSEMENT & BILLING

Current through 2024-29, July 17, 2024
75.07-1
Reimbursement
The provider must accept as payment in full the amounts
						established by MaineCare for covered services. Therefore, in accordance with
						State and federal laws, providers cannot charge a member an amount in addition
						to the payment received, or to be received, from MaineCare for a covered
						service. The MaineCare rates of reimbursement are posted in the fee schedule on
						the MaineCare website. Rates other than drug prices for new or changed codes
						(any CPT or HCPCS code) are determined based on the following lowest
						benchmark:
A. The fee for service rate
					 is set at fifty-three percent (53%) of the lowest level in the current Medicare
					 fee schedule for Maine in effect at that time; or
B. The lowest amount allowed by Medicare Part
					 B for Maine area "99" non-facility fee schedule; or
C. The amount allowed under Section 90
					 Physician Services; or
D. The
					 provider's usual and customary charge.
If a MaineCare member has coverage for eyeglasses from
						Medicare or any other third party, the provider must follow his/her customary
						practice for the acquisition of these items rather than the above rules
						relating to acquisition from the Vision Care Volume Purchase Contractor. If
						these items are to be covered by MaineCare only, however, then they must be
						acquired in accordance with the above rules relating to acquisitions from the
						Contractor.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-80 - Pharmacy Services › Subsection 144-101-II-80.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Individuals must meet the eligibility criteria as set
						forth in the
MaineCare Eligibility Manual
. Some members may
						have restrictions on the type and amount of services they are eligible to
						receive. It is the responsibility of the provider to verify eligibility and
						benefit level. The following members are eligible for some or all of the
						covered services set forth in this Section:
MaineCare members who receive full MaineCare benefits and
						certain members who receive special benefits are eligible to receive pharmacy
						benefits as described in this Section.
Members who are eligible for Medicare Part D are not
						eligible for MaineCare coverage of drugs covered by Medicare Part D. The
						Department may automatically enroll such eligible MaineCare members without
						creditable coverage into Medicare Part D and act as an authorized agent on
						their behalf. The Department will reimburse Medicare Part D Excluded Drugs for
						members dually eligible for Medicare Part D when those drugs are otherwise
						covered by MaineCare for members not eligible for Medicare Part
						D.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-80 - Pharmacy Services › Subsection 144-101-II-80.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each MaineCare member is eligible for as many covered
						services as are medically necessary within the limits of this Section. The
						Department reserves the right to request additional information to evaluate
						medical necessity.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-80 - Pharmacy Services › Subsection 144-101-II-80.05 - COVERED SERVICES

Current through 2024-29, July 17, 2024
80.05-1
Drug
					 Benefits
Reimbursement is available for the following drugs when
						medically necessary.
A.
Legend
					 drugs
. All legend drugs found on the MaineCare program State drug file,
					 except those drugs set forth in Section 80.05-3, which must meet the
					 requirements of prior authorization, and those drugs set forth in Section
					 80.05-4, which are covered for certain diagnoses only as set forth in that
					 Section. In addition, those legend drugs described as a non-covered service in
					 Section
					 80.06 are not
					 reimbursable.
B.
Over-the-Counter drugs
. Some over-the-counter drugs and supplies
					 are covered when filled pursuant to a prescription. Over-the-counter drugs will
					 be eligible for reimbursement, by prescription only, if such coverage is
					 efficacious, safe, has a lower net cost, the drug has an NDC, and coverage is
					 recommended by the Drug Utilization Review Committee and approved by the
					 Department. A list of covered over-the-counter drugs will be posted and updated
					 on the Department's designated website.
C.
Medicare Part D Excluded
					 Drugs
The Department will post a complete list on its
						designated website of Medicare Part D Excluded Drugs that are covered drugs
						under this Section to the extent that they are covered for MaineCare non-dual
						eligible members.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-80 - Pharmacy Services › Subsection 144-101-II-80.07 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
80.07-1
Regulation of Pricing
A. Drugs
					 added and deleted and price changes with regard to drugs that fall within the
					 parameters of the Federal Upper Limits will be updated upon notification from
					 the United States Government Centers for Medicare and Medicaid Services
					 (CMS).
B. Price changes with regard
					 to drugs that fall within the MMAC guidelines and all other MaineCare drugs
					 will be updated according to periodic review by the Department of fluctuations
					 in the average wholesale price list maintained by the Department of Health and
					 Human Services, OMS under the guidelines of OBRA 90, as amended. The Department
					 is under no obligation to apply these changes retroactively.
C. Designation of an effective date for all
					 MMAC changes will be determined together with allowance for mailing
					 requirements in order to afford a minimum five (5) day notice to the provider.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-80 - Pharmacy Services › Subsection 144-101-II-80.08 - CO-PAYMENT

Current through 2024-29, July 17, 2024
A co-payment is to be charged by the pharmacy to each
						MaineCare member for each prescription filled or refilled, with the exception
						of prescriptions filled by the Department's mail order pharmacy providers and
						tobacco cessation products. Members shall not pay a co-payment for drugs
						obtained from the Department's mail order pharmacy providers and tobacco
						cessation products. Co-payment dispute resolution procedures are described in
						Chapter I of the
MaineCare Benefits Manual
. No pharmacy may
						discount the co-payment for promotional purposes.
80.08-1
Pharmacy Benefits Provided By
					 Retail and Specialty Pharmacy Providers
A. The amount of the co-payment shall be
					 three dollars ($3.00) per prescription, except for tobacco cessation products
					 (see Section 80.08-4 ), not to exceed thirty dollars ($30.00) per member per
					 month, except as otherwise described below. The co-payment is the same for
					 Medicare Part D Excluded Drugs.
B.
					 The pharmacy shall not deny pharmacy services to a MaineCare member on account
					 of the member's inability to pay a co-payment. Providers must rely upon the
					 member's representation that he or she does not have the cash available to pay
					 the co-payment. However, the individual's inability to pay does not eliminate
					 his or her liability for the co-payment.
C. If a member is dispensed a drug in a
					 quantity specifically intended by the prescriber or pharmacist to last less
					 than one month for the member's health and welfare, only one co-payment for
					 that drug that month is required.
D. Co-payment exemptions are described in
					 Chapter I of the
MaineCare Benefits Manual
.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-80 - Pharmacy Services › Subsection 144-101-II-80.09 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
80.09-1
Reimbursement Rates
MaineCare reimbursement for drugs covered under this
						Section will only be made for drugs of any manufacturer that has entered into
						and complies with a rebate agreement, except as noted in Section
						80.09, and specific
						reporting requirements as defined by Title XIX of the
Social Security
						Act
Section 1927 described in OBRA 90 as amended.
A.
Reimbursement for Retail Pharmacy
					 Providers
1.
Generic
					 Drugs
The reimbursement rate for covered generic drugs shall be
						the lowest of the following:
a. The
					 usual and customary charge; or
b.
					 The Average Wholesale Price minus sixteen point six seven percent (16.67%) plus
					 eleven dollars and eighty-nine cents ($11.89) dispensing fee except as
					 otherwise noted below; or
c The
					 Federal Upper Limit (FUL) unless the Department meets the FUL in aggregate;
					 or
d. The Maine maximum allowable
					 cost plus eleven dollars and eighty-nine cents ($11.89) dispensing fee except
					 as otherwise noted below; or
e. The
					 Wholesale Acquisition Cost (WAC) plus eleven dollars and eighty-nine cents
					 ($11.89) dispensing fee; or
f. The
					 Submitted Ingredient Cost plus eleven dollars and eighty-nine cents ($11.89)
					 dispensing fee; or
g. Gross Amount
					 Due (GAD); or
h. National Average
					 Drug Acquisition Cost (NADAC) plus eleven dollars and eighty-nine cents
					 ($11.89) dispensing fee.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-80 - Pharmacy Services › Subsection 144-101-II-80.10 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
A. Billing using
					 paper claims must be accomplished in accordance with the Department's billing
					 requirements, "Billing Instructions for Pharmacy Services."
B. Electronic billing must be accomplished in
					 accordance with the Department's billing requirements as described in the
					 Electronic Media Claims rider to the Provider Agreement.
C. Mail order pharmacy providers must comply
					 with the Department's billing requirements and submit claims through the
					 Department's claims system.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-85 - MaineMOM Services and Reimbursement › Subsection 144-101-II-85.01 - Purpose

Current through 2024-29, July 17, 2024
The purpose of this rule is to provide medically
						necessary physical therapy services to MaineCare members who are adults (age
						twenty-one (21) and over), who are not residing in a Nursing Facility (NF) or
						Intermediate Care Facility for Individuals with Intellectual Disabilities
						(ICF-IID), and who have rehabilitation potential; and to provide medically
						necessary physical therapy services to MaineCare members who are under age
						twenty-one (21).
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-85 - MaineMOM Services and Reimbursement › Subsection 144-101-II-85.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
85.02-1
Functionally Significant
					 Improvement
: demonstrable, measurable increase in the member's ability
					 to perform specific tasks or motions that contributes to independence outside
					 the therapeutic environment.
85.02-2
Long-Term Chronic Pain:
any pain that has lasted or is expected to last more than sixty (60) days and
					 impacts and is expected to impact a member's level of function for more than 60
					 days.
85.02-3
Maintenance
					 Care
: physical therapy services provided to a member whose condition is
					 stabilized after a period of treatment or for whom no further functionally
					 significant improvement is expected.
85.02-4
Pain Management Care
					 Plan
: a plan of care ordered by a rendering provider or consulting
					 provider including the use of at least one therapeutic treatment
					 option.
85.02-5
Physical
					 Therapy Practitioner
: an individual who is licensed as a Physical
					 Therapist or licensed as a Physical Therapy Assistant working under the
					 supervision of a licensed Physical Therapist.
85.02-6 Physical Therapy Services: the
					 evaluation, treatment and instruction of human beings to detect, assess,
					 prevent, correct, alleviate and limit physical disability, bodily malfunction
					 and pain from injury, disease and any other bodily condition; the
					 administration, interpretation and evaluation of tests and measurements of
					 bodily functions and structures for the purpose of treatment planning includes
					 the planning, administration, evaluation and modification of treatment and
					 instruction; and the use of physical agents and procedures, activities and
					 devices for preventive and therapeutic purposes; and the provision of
					 consultative, educational and other advisory services for the purpose of
					 reducing the incidence and severity of physical disability, bodily malfunction
					 and pain.
85.02-7
Practitioner of the Healing Arts
: Physicians and all others
					 registered or licensed in the healing arts, including, but not limited to,
					 nurse practitioners, podiatrists, optometrists, chiropractors, physical
					 therapists, occupational therapists, speech therapists, dentists, psychologists
					 and physicians' assistants.
85.02-8
Rehabilitation Potential
: documented expectation of measurable
					 functionally significant improvement in the member's condition in a reasonable,
					 predictable period of time as the result of the prescribed treatment plan.
85.02-9
Terminal
					 Illness
: is a medical condition resulting in a prognosis that a member
					 has a life expectancy of six (6) months or less if the illness runs its normal
					 course.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-85 - MaineMOM Services and Reimbursement › Subsection 144-101-II-85.03 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Members must meet the financial eligibility criteria as
						set forth in the MaineCare Eligibility Manual. Some members may have
						restrictions on the type and amount of services they are eligible to receive.
						It is the responsibility of the provider to verify a member's eligibility for
						MaineCare prior to providing services, as described in Chapter
						I.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-85 - MaineMOM Services and Reimbursement › Subsection 144-101-II-85.04 - SPECIFIC ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Services for members of all ages must be medically
						necessary. The Department or its authorized agent has the right to perform
						eligibility determination, prior authorization and/or utilization review to
						determine if services provided are medically necessary.
Adult members age twenty-one (21) and over in an
						outpatient setting must have rehabilitation potential documented by a physician
						or primary care provider (PCP). Adult members are specifically eligible only
						for:
1. Treatment following an acute
					 hospital stay for a condition affecting range of motion, muscle strength and
					 physical functional abilities. If CMS approves, the treatment must start within
					 six months of the hospital discharge and be specific to the diagnosed
					 condition;
2. Treatment after a
					 surgical procedure performed for the purpose of improving physical function. If
					 CMS approves, the treatment must start within six months of discharge after
					 surgery and be specific to the diagnosed condition;
3. Treatment for which a physician or PCP has
					 documented that the patient has at some time during the preceding thirty (30)
					 days, required extensive assistance in the performance of one or more of the
					 following activities of daily living: eating, toileting, locomotion, transfer
					 or bed mobility;
4. Medically
					 necessary treatment for other conditions including maintenance, subject to the
					 limitations in Section 85.07;
5.
					 Maintenance care required to prevent deterioration in functions that would
					 result in an extended length of stay or placement in an institutional or
					 hospital setting, as documented by a physician or PCP;
6. If CMS approves, rehabilitative services
					 ordered by a physician or other licensed practitioner of the healing arts for
					 the maximum reduction of physical disability and restoration of a member to
					 his/her best possible functional level;
7. If CMS approves, medically necessary
					 treatment when diagnosed with a terminal illness; or
8. Treatment used for pain management in
					 conjunction with a prescribed pain management care plan subject to section
					 85.07.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-85 - MaineMOM Services and Reimbursement › Subsection 144-101-II-85.05 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Covered services must be medically necessary and must not
						exceed the limitations set in Section 85.07. The Department or its authorized
						agent reserves the right to request additional information to evaluate medical
						necessity.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-85 - MaineMOM Services and Reimbursement › Subsection 144-101-II-85.06 - COVERED SERVICES

Current through 2024-29, July 17, 2024
MaineCare will reimburse for covered medically necessary
						services in all outpatient settings. If CMS approves, covered services
						requiring a Prior Authorization are limited to one (1) evaluation and one (1)
						treatment per each condition or per each event unless specified under 85.07.
						Services must be of such a level, complexity, and sophistication that the
						judgment, knowledge, and skills of a qualified professional staffare required
						as defined in 85.09-1.All services must be in accordance with acceptable
						standards of medical practice and be a specific and effective treatment for the
						member's condition. Services related to activities for the general good and
						welfare of members are not MaineCare covered physical therapy services.
Pursuant to
						42
						CFR §440.110, MaineCare physical therapy
						services must be prescribed by a physician or other licensed practitioner of
						the healing arts within the scope of practice under Maine law and must be
						provided by or under the direction of a qualified professional staff as defined
						in 85.09-1.
MaineCare reimburses providers for the following physical
						therapy services:
85.06-1
Evaluations or re-evaluations
: For adults, one evaluation or
					 re-evaluation per member per condition or event is a covered service. For
					 children, additional evaluations or reevaluations are allowed as medically
					 necessary.
85.06-2
Modalities
: Modalities are any physical agents applied to produce
					 therapeutic changes to biologic tissues; including but not limited to thermal,
					 acoustic, light, mechanical, or electric energy. Except when performing
					 supervised modalities, the therapist is required to have direct (one-on-one)
					 continuous patient contact.
85.06-3.
Therapeutic Procedures
:
					 Therapeutic procedures effect change through the application of clinical skills
					 and/or services that attempt to improve function.
85.06-4
Tests and measurements
:
					 The therapist is required to have direct (one-on-one) continuous patient
					 contact in performing testing and measurement.
85.06-5
Splinting
: Providers may
					 bill for splinting supplies necessary for the provision of physical therapy
					 services. Covered supplies under this Section must be billed and reimbursed at
					 the lesser of acquisition cost or the maximum allowed cost set by the
					 Department. The acquisition cost must be documented by an invoice in the
					 member's file. Please visit
http://www.maine.gov/dhhs/audit/rate-setting/documents/S85PhysicalTherapyServices.pdf
to access maximum allowed cost.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-85 - MaineMOM Services and Reimbursement › Subsection 144-101-II-85.07 - LIMITED SERVICES

Current through 2024-29, July 17, 2024
85.07-1
All
					 ages
1. MaineCare will not reimburse
					 for more than two (2) hours of physical therapy services per day.
2. Supervised modalities (those without
					 direct one-to-one continuous contact) that are provided on the same day as
					 modalities requiring constant attendance or on the same day as any other
					 therapeutic procedure are not billable. Billing for supervised modalities as
					 stand-alone treatment is limited to one (1) unit per modality per
					 day.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-85 - MaineMOM Services and Reimbursement › Subsection 144-101-II-85.08 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
Refer to Chapter I of the MaineCare Benefits Manual for
						additional non-covered services, including academic, vocational, socialization
						or recreational services.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-85 - MaineMOM Services and Reimbursement › Subsection 144-101-II-85.10 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
The amount of payment for services rendered shall be the
						lowest of the following:
1. The amount
					 for services is listed in Chapter III, Section 85, and "Allowances for Physical
					 Therapy Services" of the MaineCare Benefits Manual.
2. The lowest amount allowed by the Medicare
					 carrier.
3. The provider's usual
					 and customary charge.
See section 85.06-5 for reimbursement for splinting
						supplies.
In accordance with Chapter I of the MaineCare Benefits
						Manual, it is the responsibility of the provider to seek payment from any other
						resources that are available for payment of a rendered service prior to billing
						MaineCare.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-85 - MaineMOM Services and Reimbursement › Subsection 144-101-II-85.11 - COPAYMENTS

Current through 2024-29, July 17, 2024
Note
: Requirements regarding copayment
						disputes and exemptions are contained in Chapter I of the MaineCare Benefits
						Manual.
1. A copayment will be charged
					 to each MaineCare member receiving services, with the exception of those
					 exempt, as specified in the MaineCare Eligibility Manual, such as children. The
					 amount of the copayment shall not exceed $2.00 per day for services provided,
					 according to the following schedule:
MaineCare Payment for
								  Service
Member Copayment
$10.00 or less
$ .50
$10.01 - 25.00
$1.00
$25.01 or more
$2.00
2. The member is responsible for copayments
					 up to $20.00 per month whether theco-payment has been paid or not. After the
					 $20.00 cap has been reached, the member will not be required to make additional
					 copayments and the provider will receive full MaineCare reimbursement for
					 covered services.