April 10, 2006

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2006-2007 State Health Plan Available Online
The long-awaited State Health Plan was released last week by the Baldacci administration, accompanied by a press release emphasizing prevention and individual responsibility. Each Maine citizen is encouraged in the plan to execute a personal contract to "Be Fit for Maine." The 146-page plan also calls for the establishment of a number of work groups - many of which MMA will be represented on - that are charged with carrying out many of the initiatives identified in the plan.
The new State Health Plan, Roadmap to Better Health:  Maine's State Health Plan 2006/2007, is now available online. 

Last week, the Governor issued a press release highlighting the following points in the Plan:

  • Creation of a more organized system to deliver prevention and public health building on strong bonds with community coalitions operating across the state, neighborhoods and towns.
  • Seeks innovations in telemedicine to assure our most rural citizens have access to a full array of health care choices and that the system of care reaches every part of Maine and strengthens rural health capacity.  A rural health workgroup will be appointed to assure this goal is met.
  • Seeks a culture of health in the state asking each citizen to sign a "Be Fit for Maine" contract taking appropriate steps to move closer to better health.
  • Establishes a "Wellness Star" program through the Maine Quality Forum to recognize business innovation in keeping employees healthy and assure that best practices are shared with other businesses.
  • The Maine Quality Forum will launch a new initiative statewide to improve the treatment of heart attacks.
  • Improve services to people with mental illness by better integrating primary care and behavioral health services and by establishing policies for depression screening to assure early detection and treatment.
  • Creation of a Health Policy Leadership Forum representing business, insurers, providers, consumers, and government to assure an ongoing dialogue about how best to make Maine the healthiest state and achieve universal access.

You can read the entire press release on the web at:  http://www.maine.gov/governor/baldacci/healthpolicy/news/4_3_06.htm.  The press release includes a link to the PDF version of the Plan which is 146 pages long.

ALERT: Without Waiver, Practices Must Bill Health Claims Electronically
Because the MMA has heard that a number of physician practices still are unaware of an electronic billing requirement enacted as part of the Dirigo health plan legislation in 2003 and fully implemented through a Bureau of Insurance rule that became effective in September 2005.  These laws require all health care practitioners to submit claims electronically after October 16, 2005 while permitting practitioners to apply for a "hardship" exemption to the requirement until January 30, 2006, an extension of the original December 16, 2005 deadline. 

ALTHOUGH THE DEADLINE FOR SEEKING THE HARDSHIP EXEMPTION HAS PASSED, IF YOU DO NOT BELIEVE YOU REASONABLY CAN COMPLY WITH THE REQUIREMENT, YOU SHOULD APPLY FOR THE EXEMPTION IMMEDIATELY.  If the Bureau denies the application as not timely, you should appeal and state as "good cause," that you were not aware of the requirement or the possibility of an exemption until this notice.



            Some time prior to October 16, 2003, CMS stated that after that date all health care practitioners billing the Medicare program would have to do so electronically.  The federal requirement includes an exemption for practices with fewer than 10 FTE employees.  As part of its cost containment provisions, Governor Baldacci’s Dirigo health legislation incorporated a stricter version of this federal requirement.  P.L. 2003, Chapter 469, Part D, 24 M.R.S.A. §2985.  It included the exemption for practices with fewer than 10 FTE employees between October 16, 2003 and October 16, 2005 and then provided for a hardship exemption from the requirement after that date.  The legislation directed the Superintendent of Insurance to adopt rules governing the standards and process for obtaining a hardship exemption.  Bureau of Insurance Rule Chapter 825, Procedures and Standards for Obtaining a Hardship Exemption from Submitting Electronic Health Claims.

            During the Dirigo legislative debate, the Baldacci Administration placed great emphasis on pushing the adoption of health care information technology as a means of containing costs and improving efficiency in our health care system.  The hardship exemption was one of a handful of changes the MMA succeeded in negotiating on behalf of the physician community.

            You may find these laws on the web as follows:


o       P.L. 2003, Chapter 469, Part D:  http://janus.state.me.us/legis/ros/lom/LOM121st/10Pub451-500/Pub451-500-112.htm#P8275_918195.  See Sec. D-2.

o       BOI Rule Chapter 825:  http://www.maine.gov/sos/cec/rules/02/031/031c825.doc.


The Bureau of Insurance has a FAQ document on the electronic billing requirement on its web site at:  http://www.state.me.us/pfr/ins/Rule825_faq.htm.


You may submit your hardship exemption request in letter format or using the form on the Bureau’s web site to:  Joanne Rawlings-Sekunda, Bureau of Insurance, State House Station 34, Augusta, Maine 04333-0034.  You may contact Joanne at 624-8472 or by email at Joanne.Rawlings-Sekunda@maine.gov.  [return to top]

Update on MaineCare MECMS
The Governor's Provider Advisory Committee on MECMS met on Thursday, March 30 and will meet again this coming Thursday (April 13).  As of March 26, suspended claims inventory was at 186,202 and continues to decline.  Processing of paid and denied fresh claims was at 92.25% for the week.

The Primary Care Case Management fee for January, 2006 was successfully generated and the checks have been mailed.  The February checks are being processed currently.  The backlog of fees owed for 2005 will be processed thereafter.

The expedited process for submitting Part B cross-over claims on paper, without the necessity of including the Medicare EOMB material, appears to be working.

An update on the issue was presented to the Legislature's Appropriations and Financial Affairs Committee on April 6th.  Last week's claim throughput was 88.5%, with 75% paid within the timeframe anticipated. As the % of claims put through the system is now remaining stable, staff can focus on the remaining backlog, with suspended claims remaining in the 180,000 to 200,000 range.

Relative to the issue of recovery of interim payments, $202,385,490 of the $225,000,000 goal has been collected or agreements reached for payment.   Broken down by provider type, physicians still have about $14 million in interim payments outstanding with over $23 million in suspended claims left.  Most physicians will therefor be part of the Phase III recovery which will not begin until after the state's fiscal year changes (July 1).

Deputy Commissioner J. Michael Hall and MaineCare Medical Director Laureen Biczak, D.O. have agreed to present at the MMA 15th Annual Physician Practice Management Seminar in Bangor on Wednesday, June 21.  Their presentation will be at 11:00am at the Spectacular Event Center in Bangor.  Watch for an insert in your March/April issue of Maine Medicine, being mailed this week, for a brochure and registration materials on the seminar. [return to top]

Governor Convenes Task Force on Medicare Part D Drug Benefit
On Friday, April 6, 2006, Governor Baldacci convened a task force of stakeholders to address a variety of issues relating to the new Medicare Part D drug benefit.  Chaired by the Governor's chief pharmacy advisor, Jude Walsh, the initial task force meeting included representatives of the MMA, the area agencies on aging, AARP, Legal Services for the Elderly, Inc., the Long Term Care Ombudsman Office, pharmacists, pharmacies, and consumer advocates.  The Governor has asked the group for help in determining how the State can assist seniors with transition to the new Part D benefit now that federal transitional assistance has ended effective March 31, 2006.

The most significant decision made at the first meeting was that the Administration would send a letter to CMS outlining the issues identified with the Part D transition, including the lack of uniformity of the PA standards and process among the PDPs, and requesting federal intervention.

REMEMBER, Legal Services for the Elderly has Part D information on its web site, http://www.mainelse.org/.

Jude Walsh presented meeting participants with the following memo:

Overview of Part D issues

  • On March 23, 2006, the Governor sent a letter to Secretary Leavitt requesting an extension of Maine's safety net through 4/30/06;
  • On April 2, 2006, the Governor's office received a verbal response from CMS that the request was denied;
  • On April 3, 2006, Governor Baldacci announced that the safety net would continue and this Task Force be convened to make recommendations on Medicare Part D.


  • There are 3287 dual eligible and DEL members that are not assigned to Part D Plans;
  • Between 1500 and 2000 members still are missing Low Income Subsidy indicators;
  • There are 5777 DEL members that have been auto enrolled by the State into PDPs in February, but CMS has not confirmed their eligibility for Part D.

Overrides since 3/30/06

  • 4978 claims
  • 2967 members
  • $101,894
  • increases due in part to end of transitional assistance

Wrap payments since 3/30/06

  • 13,683 claims
  • 8691 members
  • $61,693

Mass disenrollment

The Governor's office is very concerned that CMS intends to "mass disenroll" many Part D members that are open in more than 1 PDP on April 15th.  This could significantly impact Maine because we intelligently reassigned more than 15,000 duals into plans that would provide better prescription drug coverage.  If duals are dropped from the plan we assigned them to, they could once again be in a plan where less than 60% of their drugs are covered.  The State conservatively estimates that more than 20,000 of its members are open in 2 PDPs.  If the override is taken away, the outcome may be that duals and potentially some DELs leave the pharmacy without their medically necessary medications.

Facilitated enrollment

The Governor's office also is concerned that on April 15th CMS will randomly enroll members on DEL that are receiving the Low Income Subsidies.  The potential then exists for CMS' assignment to override the State's intellient assignment and members will once again be in 2 plans with the potential for disenrollment from the plan that provides the best drug coverage and no safety net available.

Legal Services for the Elderly presented the following information to meeting participants:

Overview of the Establishment of the LSE Appeals Unit

On 1/11/06, the Governor's office asked LSE to take immediate steps to develop a Medicare Part D Appeals Unit to assist Maine residents that had been receiving their prescription drugs through the MaineCare or Low Cost Drugs for the Elderly & Disabled programs in obtaining needed drugs through Medicare Part D.

The LSE Medicare Part D Appeals Unit began taking calls on February 27th.  The Unit includes 4 Appeals Specialists that are supervised by a staff attorney, and calls are accepted Monday through Friday from 9 to noon and 1 to 4 p.m. at 1-877-774-7772.

Initial calls with clients typically take 45 minutes to 1 hour.  In many cases, it has taken several days and multiple phone calls to the physician, pharmacy, and Plan, to even initiate the exceptions and appeals process.  This is not a process that most individuals could pursue without assistance.

With the recent expiration of the extended federal transitional drug benefit, which served to mask many of the coverage issues that will eventually need to be resolved through the exceptions and appeals process, call volumes at the Unit are expected to begin to climb quite dramatically.

Types of Exceptions & Appeals

The majority of the clients served by the Medicare Part D Unit have been DELs.  The most frequent call types are as follows:

  • Calls involving copayments that the caller states he or she can't afford.  Resolution of these calls is coordinated with the State Help Desk if it appears enrollment in another Plan should be pursued.  Options for resolving these issues include having the physician prescribe a generic, requesting a Tiering Exception from the Plan (which results in a lower copayment), or having the individual change Plans.  Many of these cases do not have an easily identifiable or satisfactory solution.
  • Calls involving drugs that are not on the applicable Plan's formulary.  These have all been resolved by either 1) having the physician changing the medication to a covered drug, 2) having the individual switch to a Plan that covers the drug, or 3) pursuing a successful appeal.
  • Calls involving a Plan requirement that the individual try a different drug before the desired drug will be covered (step therapy).  These have been addressed by assisting the physician to resolve the issue with the Plan, or pursuing an appeal.
  • Calls involving a Plan limitation on the quantity of the drug that is provided.  These have been addressed by having the individual switch to a Plan that does not include the limitation, or pursuing an appeal.
  • Calls involving a prior authorization requirement.  These have been addressed by assisting the physician in requesting the required authorization, or appealing the denial of a request.

Experiences of the Unit in Working with the Plans

  • Of the 10 plans that hold contracts with the State, 8 have made their general appeals process information available on their websites.  CIGNA and Pacificare have either not provided information or provided it in a way that is very unlikely to be successfully addressed by a consumer.
  • No plan has made available their written policies regarding their internal criteria for granting or denying exceptions.  Plans are required under applicable federal regulations to have written policies in place that include this information.
  • All of the Plans that require the use of specific forms in making a request for exception or filing an appeal have made the forms available on their website.
  • While the Plans consistently answer calls to their call centers, the individuals answering the phones at Wellcare, CIGNA, and AARP have provided the Unit with incorrect and inconsistent information.  Silverscript, on the other hand, has consistently provided the Unit with accurate information.
  • In the case of those Plans that require Step Therapy, the Plans do not provide any information on their websites regarding the drugs that patients are first required to use, and that information usually is not available upon request at the Plans' call centers.
  • Wellcare and RxAmerica have each failed on one occasion to provide a timely response to a request for exception.

Benefit Design Issues

  • If a Plan places a high cost or unique drug in its Specialty Drug Tier, which many have, the Plan is then permitted under federal regulations to refuse to grant a Tiering Exception that would reduce the cost of the drug.  The result is that while a needed drug may technically be covered by a Plan, the expense of actually obtaining the drug makes it unavailable from a practical perspective.  This is having a severe impact on individuals with health conditions such as multiple sclerosis.
  • Plans are permitted under federal regulations to place all generics in a separate Tier, and to then refuse to grant a Tiering Exception that would lower the cost of drugs that are included in other Tiers to the same cost as the generic Tier.  Wellcare has taken this approach in designing its formulary.  The result is that brand name drugs that would otherwise appear to be covered by a Plan are unavailable from a practical perspective, because of the inability of the individual to pay for the needed brand name drug.
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MMA Quality Committee Meets Tomorrow and Payor Liaison Committee on Thursday, April 13.
The MMA Committee on Quality Improvement and Peer Review will meet tomorrow, April 11, at 4:00pm at the Association offices in Manchester, Maine.  The Committee will hear a presentation from Maine Hospital Association Quality Council Chair Deborah Johnson, CEO of Eastern Maine Medical Center and Sandra Parker, Esq., Counsel to MHA.  The Committee will also review a final draft of the proposed contract with the Maine Quality Forum involving MMA and the Maine Osteopathic Association conducting confidential and voluntary practice assessments of primary care practices.

The Association's Payor Liaison Committee will meet Thursday evening, April 13, with dinner available beginning at 6:15pm.  Guests will include the new provider network manager for Anthem, Amy Cheslock and Jeffrey Holmstrom, D.O., Medical Director for Anthem.

All MMA committee meetings are open to any interested MMA member.  We do ask that you let us know if you do plan to attend in order to ensure sufficient food.  You may always access MMA staff by calling 622-3374 and pressing "O" for assistance. [return to top]

The Coding Center's Coding Tip of the Week
Helpful websites:

National Heritage Insurance Co. (local Medicare carrier) – http://www.medicarenhic.com/ne_prov/index.shtml

NHIC on-line provider education - http://www.medicarenhic.com/ne_prov/education_online.shtml

Centers for Medicare/Medicaid services (CMS) - http://www.cms.hhs.gov/

Medicare fee schedules - http://www.medicarenhic.com/ne_prov/fee_sched.shtml#60

CCI edits (Medicare) - http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage

CMS listservs - http://www.cms.hhs.gov/apps/mailinglists/

CMS-National Coverage Determinations/Local Medical Review Policies -

Questions? Call the Coding Center: 1-888-889-6597
Relative Value Units (RVU)—

ICD9 guidelines (effective December 1, 2005) –
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REMINDER: Half-Day Program on HIPAA Compliance at MMA on 4/14/06
As part of our First Fridays seminar series, the MMA will present a yearly update on the HIPAA Privacy and Security Rules at the MMA office in Manchester on the morning of Friday, April 14, 2006.  Whether you have new staff or simply want to accomplish some of your annual HIPAA training, this program is for you!  You can register on the MMA web site, www.mainemed.com (under Seminars/First Fridays), or by contacting Gail Begin at gbegin@mainemed.com.

Faculty for the program will be Gordon Smith, Esq., (privacy) and Bryan Michaud, PhD. (security).


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MGS Presents "Topics in Gastroenterology For Primary Care"
The Maine Gastroenterology Society is pleased to announce its May 6, 2006 conference at the Harraseeket Inn in Freeport, Maine.  The conference is entitled "Topics in Gastroenterology for Primary Care" and includes two featured speakers.  Brian Lacy, Ph.D., M.D. received his Ph.D. from Georgetown University and his medical degree from the University of Maryland School of Medicine.  He is Director of the GI Motility Laboratory at Dartmouth Hitchcock Medical Center in Hanover, New Hampshire.  Also speaking will be Lynn Butterly, MD., a gastroenterologist who is passionate about colon cancer screening and is working with health care providers throughout New Hampshire to provide free colon cancer education and screening fairs in local communities.  Dr. Butterly also works at Dartmouth Hitchcock Medical Center.  The Maine Medical Education Trust designates this activity for 6 credits of Category 1 CME, which can be applied toward the AMA Physicians Recognition Award.  Each physician should only claim those credits that he/she actually spent in the activity.  If you would like further information on this event, please contact Gail Begin at 622-3374, ext. 210 or by email at gbegin@mainemed.com to receive a brochure on this conference. [return to top]

RxSecurity Offers Spring Promotion on Tamper-Resistent Prescription Forms to MMA Members

Thank you MMA Members!!!

In appreciation of your overwhelming response, we are pleased to offer a Spring Promotion exclusive to MMA members.
Order Rx Security counterfeit- resistant prescription forms before June 21st and your office can enjoy Coffee On Us!

We’ll include a $20 Starbucks gift card with your next order.

Offer valid until June 21, 2006.

“Our secure forms can’t be duplicated, Neither can our prices”

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For more information or to contact us directly, please visit www.mainemed.com l ©2003, Maine Medical Association