MaineCare Update #2


Joint Update from Maine Department of Education Commissioner Stephen L. Bowen and Maine Department of Health and Human Services Commissioner Mary Mayhew, providing information to school administrators of recent changes to MaineCare policy and reimbursement procedures.

View ongoing series of MaineCare updates

For FY 2011, what should school administrative units  expect to receive for reimbursement from MaineCare?

The Department of Health and Human Services repealed the Section 104 MaineCare policy for School based Rehabilitation. These changes were made to make MaineCare compliant in configuration of its new MMIS claims system. All services formerly covered under Section 104 are covered under other sections of MaineCare policy, including: Section 28, Habilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations; Section 65, Behavioral Health Services; Section 68, Occupational Therapy; Section 85, Physical Therapy; and Section 109, Speech and Hearing Services.   School administrative units (SAUs) should not expect to receive what they received in the past, as services must be billed as a fee for service, school based providers must meet MaineCare provider qualifications, and students must meet medical eligibility criteria for  services.

Moving forward, which services will be eligible for MaineCare reimbursement?

There is a distinction between educational services and medical services, and MaineCare services are only reimbursable when the services are  provided by qualified  providers. Federal guidelines require that school based providers meet the same provider qualifications as other providers of the same service.

MaineCare school based services are being audited for the 2006-2008 school year by the US Office of Inspector General (OIG). The audits will be conducted in randomly selected SAUs, and will include review of records for children for whom MaineCare services were reimbursed. The Department of Health and Human Services is also working with the Centers for Medicare and Medicaid Services (CMMS) to ensure federal compliance for all school based services. As a result, MaineCare will be issuing several proposed rules soon that will be in effect for the beginning of next school year. The rule changes will require schools to meet all of the same requirements that other community based providers must meet, ensure that children meet all medical necessity and prior authorization requirements, and clarify that school based providers must maintain all necessary records for MaineCare billed services in the same manner as other providers.

Federal law prohibits the reimbursement of providers that are not licensed providers practicing within the scope of their license. (42 CFR § 440.60) Federal law also requires that Medicaid provide comparable services across various Medicaid groups. (Social Security Act, § 1902(a)(10)(B)) This has been interpreted by CMMS and OIG to require that practitioners within the schools meet the same standards of licensure as those who serve outside the schools. (Medicaid and School Health: A Technical Assistance Guide (1997)) Against this interpretation, recent audits by OIG have found Medicaid programs in other states in violation of federal law. As a result, those states, providers and school systems are liable for substantial Medicaid overpayments – a result that the Department seeks to avoid here in Maine. Maine DOE and DHHS will conduct additional trainings over the summer months to review and explain these requirements.

Will SAU staff be able to provide MaineCare eligible services to students in school facilities?

If the provider is qualified, whether the service is provided in a school or not is irrelevant.

To become qualified to provide MaineCare services, what will school personnel  need to do ?

There have been questions raised with regard to two sections of MaineCare policies and whether the actual provider of the service needs to have his/her NPI number on the claim form. The following chart has been developed by MaineCare staff to clarify when renderings are required.

Policy Section Provider Type and Specialty Renderings Required
Section 65 (Day Treatment) Public Schools/ Community Support No
Section 65 (Therapy Services) Public Schools/Therapy Services Yes
Section 68, 85, 109 (Therapy Services) Public Schools/Therapy Services Yes
Section 28 Public Schools/ Children’s Community Rehabilitation No

What is the status of training with regard to MaineCare’s new MIHMS system?

DHHS staff have been working with representatives of the Maine Association of Directors of Special Education (MADSEC) and the Maine School Management Association (MSMA) to develop regional trainings to provide technical support in finalizing enrollment, proper billing of claims, and developing and maintaining appropriate documentation within individual client records. These trainings are being conducted in the superintendent regions during May and early June. Four have already taken place; three more are scheduled for June:

  • June 2, Augusta, 442 Civic Center Drive
  • June 6, Augusta, 442 Civic Center Drive
  • June 8, Biddeford, 208 Graham Street

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Looking ahead to next school year, how should SAUs budget for MaineCare spending?

  • Planning Budgets for FY 2012 and MaineCare Reimbursement – There is significant work underway in Congress on federal funding and/or proposed reductions of programs. While Medicaid is not specifically addressed in the current Continuing Resolution (CR), there are some proposals that would refine the Medicaid program. Given this climate, we would advise school administrative units to be very conservative in budgeting for MaineCare reimbursement for FY 2012.
  • Memos of Clarification from the Department of Health and Human Services – Two clarification memos (March 3, 2011; March 17, 2011) have been posted on the Maine Department of Education Medicaid web page which address: Early Intervention Services, School Based Services, and MaineCare Reimbursement; and Billing Concerns for School Based MaineCare Services for Physical Therapy, Occupational Therapy, and Speech Language Pathology Services Provided by Hospitals.

If you have questions, please contact Jaci Holmes, Federal State Legislative Liaison, Maine Department of Education, by phone at 624-6669 or email at or Patricia Dushuttle, MaineCare Policy Director, Department of Health and Human Services, by phone at 287-9368 or email at

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