May 1, 2006

Subscribe to Maine Medicine eNewsletters
Manage Your Subscriptions
Email our Editor...
Maine Medical Association Home Page
. Search back issues
. Plain Text Version
Printer Friendly

Legislature Recesses until May 22; Dirigo "SOP" Compromise Appears
The 122nd Maine Legislature recessed early Saturday morning until May 22. Late in the week, the Insurance & Financial Services Committee supported, on a party-line vote of 7 to 6, an amendment to L.D. 1935 that represents a significant compromise on a number of the controversial issues regarding funding for the Dirigo Health Program.
The amendment to L.D. 1935, An Act to Protect Health Insurance Consumers, presented by committee co-chairs Sen. Nancy Sullivan (D-Biddeford) and Rep. Anne Perry (D-Calais),  removes from the original bill the language that would have prohibited health insurers from passing the controversial "savings offset payment" ("SOP") on to premium payers.  Instead, the amendment:

  • Reduces the SOP for the current year from $43.7 million to $23 million;
  • Requires health insurers to certify that the insurer has not included profit from any savings that may have been the result of Dirigo Health or MaineCare expansion;
  • Requires health insurers to use their "best efforts" to limit the impact of the SOP on health insurance rates;
  • Requires the Dirigo Health Agency and Anthem to amend the current contract in order to reduce the 2006 experience modification payment by $11 million;
  • Requires the Dirigo Health Agency to save $1.9 million in administrative costs in 2006-2007;
  • Establishes a Blue Ribbon Commission on Long-Term Funding of the Dirigo Health Program.

The 15-member Blue Ribbon Commission is charged to "study the Dirigo Health Program and make recommendations on a long-term funding mechanism in an effort to ensure its sustainability over time."  In its study, the Commission shall:

  • Review and make recommendations for alternatives for funding the Dirigo Health Program and subsidies under the program in a fair, equitable and broadly distributed manner.  The recommendations must include a number of funding sources and may include the savings offset payment in some manner.
  • Evaluate the MaineCare expansion in the Dirigo Health reform law, including its funding source, enrollment of the uninsured, and the potential impact on private payors and providers.
  • Review and make recommendations for reforms that may improve the affordability of health insurance in the individual market.
  • Review and make recommendations on cost containment methods proven effective in reducing and controlling health care costs and health care spending or creating savings in Maine's health care market.
  • Review alternatives for funding sources within existing resources to maximize federal Medicaid matching funds for the purpose of reimbursing medical providers for unpaid claims or to adjust rates.

A representative on the Commission is "to be recommended by the statewide association of physicians."  MMA is expected to be represented on the Commission as a result of this provision, included at our request.  The Commission membership and appointing authority follows:

Gubernatorial appointments:

  • a representative of the Governor's Office of Health Policy & Finance
  • a representative of the Dirigo Health Board of Directors
  • a representative of organized labor
  • a representative of a statewide health care advocacy organization
  • a representative of a statewide consumer advocacy organization

Senate President's appointments:

  • 2 members of the Senate
  • a representative of employers recommended by a statewide organization of business and employer members
  • a representative of hospitals recommended by the statewide hospital association
  • a representative of insurance producers

House Speaker's appointments:

  • 2 members of the House
  • a representative of health insurance carriers recommended by a statewide association of health plans
  • a representative of physicians recommended by the statewide medical association
  • a representative of the MaineCare Advisory Committee

The Commission must report its recommendations and potential legislation to the Insurance & Financial Services Committee and the Appropriations & Financial Affairs Committee by November 1, 2006. 

The majority "ought to pass as amended" report from the IFS Committee passed in a 19-16 party-line vote in the Senate on Friday, April 28, 2006.  You can review the legislative history of the bill and see the amendments on the web at:

New Medicare Rule Guarantees Against Loss of Drug Coverage

The government has issued a new policy that protects Medicare beneficiaries against the sudden loss of coverage for medications they are taking under the prescription drug program, reports The New York Times. Under the policy, insurers can still change their formularies of covered drugs, but if they drop any drugs or impose new restrictions, they must exempt beneficiaries who are already taking the drugs. The policy addresses one of the chief criticisms of the Medicare drug benefit which was that drug plans could change their formularies at will while most beneficiaries were locked into a drug plan for the full year. The new policy specifies, "No beneficiaries will be subject to a discontinuation or reduction in coverage of the drugs they are currently using," with a few exceptions. For example, an insurer could remove a drug from its formulary if new research showed that the drug was unsafe for some patients, or if a new lower-cost generic version became available. To read more:

[return to top]

Standardized Codes and Exceptions Form for Medicare Prescription Drug Benefit
CMS in collaboration with our partners has been working to simplify administrative processes and create common procedures throughout the Medicare Part D program.  To that end, America's Health Insurance Plans (AHIP), the National Association of Chain Drug Stores (NACDS), and the National Community Pharmacists Association (NCPA) met with CMS Administrator Mark B. McClellan, MD, PhD, to announce standardized coding messaging designed to assist pharmacists and better serve beneficiaries when they fill prescriptions at pharmacies.

Specifically, these standardized electronic messages will help pharmacists quickly determine the appropriate course of action for filling beneficiaries’ prescriptions under four different circumstances: (1) when a particular drug is not covered; (2) when prior authorization is required; (3) when plan quantity or other coverage limitations have been exceeded; and (4) when the pharmacy is not part of the Part D plan's network.  These organizations' agreement on this messaging will result in the consistent use of key terms by Part D plans and thus allow pharmacists to more quickly address issues at the pharmacy counter.

In addition, Dr. McClellan announced the formation of the Pharmacy Quality Alliance (PQA).  PQA will aim to improve pharmacy care and outcomes through a collaboration of the pharmacy community, health plans, government, employers, physicians, and consumers.  The goal of PQA will be to agree on a strategy for measuring and reporting data that will help consumers make informed choices and appropriate healthcare decisions.

"Pharmacists and pharmacies have demonstrated how important they are to the implementation of the Medicare drug benefit, and we're pleased to support these collaborative efforts,” said Dr. McClellan. “The PQA is an important next step in supporting pharmacists’ efforts to improve quality and reduce costs in our health care system,” he said.

To further the goal of simplifying procedures in the new drug benefit, last week the American Medical Association (AMA) and America's Health Insurance Plans (AHIP), in conjunction with CMS, released a standardized exceptions form designed to assist physicians in applying for exceptions and prior authorizations on behalf of Medicare beneficiaries enrolled in Medicare drug plans.  This form allows for a simplified process for physicians to apply for coverage determinations on behalf of all of their Medicare patients, regardless of which Part D plan the beneficiary is enrolled in.

The Exceptions Form has been modified to include the standard HIPAA disclaimer. The most up to date form can be downloaded by visiting:
[return to top]

Governor Writes to DHHS Secretary Leavitt Citing Part D Problems
The Governor's Medicare Part D Stakeholders' Group directed by state pharmacy manager Jude Walsh has drafted the following letter to DHHS Secretary Michael Leavitt requesting action to address a variety of problems Maine is experiencing with transition to the new Medicare Part D drug benefit.

Michael O. Leavitt, Secretary

U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201


Dear Secretary Leavitt:


I am once again writing to you to request your assistance.  When you came to Maine in January of this year I felt we had a productive meeting to address our concerns.  We have followed your advice and have tried to move as many of our members as possible to Part D.  We do however continue to have the following problems:


Enrollment and LIS Issues:


Ø      There are 3,287 Dual eligible and DEL members that are not assigned into Part D Plans.

§         We are working with pharmacies trying to “message” them to bill the unassigned Dual eligibles to Wellpoint.

§         Many pharmacists express concerns regarding using the Wellpoint system and not getting reimbursement.

Ø      Between 1,500 and 2,000 member still are missing Low Income Subsidy indicators.

Ø      There are 5,777 DEL members that have been auto enrolled by the State into PDP’s in February but CMS has not confirmed their eligibility for Part D.  (These same people were confirmed eligible by CMS in January on a “Finder File” and then submitted to PDP’s in February but still have not received their Part D benefit.)




We would like a commitment from CMS to honor all the enrollments that the State of Maine has tried to process since January 1, 2006.  We would also like a guarantee that if members are still not confirmed on the April or May files that the state will not be responsible for premium penalties.  In addition, we would like some commitment from CMS as to when LIS and enrollment validation processes will be fixed and timely.


Overrides -since 3/31/06:


§         The state has spent $344,762 through 4/19/06.

§         Due in large part to the end of transitional assistance





We would like a commitment from you to assist the state for repayment of these overrides as we are still having difficulties with the enrollment and LIS issues mentioned above.



Mass Disenrollment:


We are extremely concerned that CMS intends to “mass disenroll” many Part D members that are open in more than 1 Prescription Drug Plan (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. We conservatively estimate that over 20,000 of our members are open in 2 PDP’s.   If the override is taken away the outcome may be that duals and potentially some DELs leave the pharmacy without their medically necessary medications.





We would like financial assistance for the use of our safety net should we experience problems resulting from the mass disenrollment during the month of May.



Ongoing Enrollment of Duals:


We have concerns about on-going issues we are experiencing with getting CMS to timely enroll our Dual eligibles into Part D plans.  We have over a thousand of members each month that have not been enrolled into Part D plans.




We are requesting that Maine be allowed to intelligently assign both our new dual eligibles and our LIS eligible DEL members on an on-going basis.  This will assure that:

Ø      Enrollment will occur on a timely basis

Ø      Members will be matched to plans where 90% or more of their drugs are available

Ø      Decrease the likelihood on enrollment into more than 1 plan


Thank you very much for your consideration of this request.  I look forward to hearing from you.




John E. Baldacci, Governor

State of Maine


Cc:       Stephen Rowe, Attorney General, State of Maine

            Mark McClellan, M.D.

            Dennis Smith

            Charlotte Yeah, M.D.

            Senator Olympia Snowe

            Senator Susan Collins

            Congressman Thomas Allen

            Congressman Michael Michaud

  [return to top]

May 1-7 is Cover the Uninsured Week; Let's Get America Covered
On Friday, April 28, 2006, Cover the Uninsured Week released a new report that confirms there is a significant gap in the amount of health care accessed by people who do and do not have health care coverage in every state and the District of Columbia.  Nationally, uninsured adults are nearly four times more likely not to see a physician when they need to compared to people who have health coverage.

The Coverage Gap:  A State-by-State Report on Access to Care identifies the extent of disparities in access to health care between insured and uninsured Americans.  The findings confirm that not receiving needed medical care is taking a toll on the millions of Americans who do not have coverage.  Across the nation, a far greater percentage of uninsured adults report being in "poor" or "fair" health, compared to adults who have insurance.

You can still get involved in Cover the Uninsured Week!  During the Week, May 1-7, individuals and organizations across the country will join together to tell Congress that health care coverage must be their top priority.

This year, Cover the Uninsured Week is highlighting ways everyone can help get America covered.  Go to to see how you can help. 

New materials related to the campaign are available at www.Cover [return to top]

MaineCare MECMS Update
The Governor's MaineCare Providers' Advisory Group met this past Thursday for its bi-weekly meeting.  The weekly metrics showed that just over 90% of fresh claims were processed, with 73.64% paid.  Total claims in suspension are 180,215 which is the lowest amount yet.

Other important information presented included the following:

  • The Office of MaineCare Services (OMS) will be closed on Friday, May 5, 2006 for all-day planning and progress meetings.  The automated system will be available by calling 1-800-321-5557 Option 2.  You can also choose Option 9 for billing questions.  Additionally, you can access information through the OMS website at  All OMS offices will reopen as usual on Monday morning, May 8, 2006.
  • On the interim payment recovery front, total recaptures and returns are now over $149 million with another $122 million promised in agreements in place.
  • Timely filing requirements have been changed to allow a 19 month filing window.  This will be announced to providers soon. 
  • Electronic processing of Part B crossover claims remains delayed, but the current paper billing option is working well and many physicians are exercising this option.  Unfortunately, the federal government is changing, effective July 1, 2006, the way it handles the crossover claims, moving to a national claims crossover contractor, aptly named the Coordination of Benefits Contractor (COBC).  For Maine, crossover claims from July 1, 2006 forward will be in the new COBA (Coordination of Benefits Agreement) Program, but no COBA changes can be implemented prior to completing the processing of the current backlog of crossover claims.  Given that the electronic processing is not expected to begin before September, this federal change would appear to signal a further significant delay in the processing of Part B claims.

The Advisory Group will meet again on May 11. [return to top]

State Senate Confirms Brenda Harvey as HHS Commissioner
The state Senate unanimously accepted the nomination Wednesday of acting Commissioner Brenda Harvey as commissioner of the Health and Human Services Department.  The Health and Human Services Committee had recommended confirmation of Ms. Harvey in a 10-3 vote the previous day.

At the public hearing on the nominee, MMA Executive Vice President  Gordon Smith testified in favor of the nominee, noting that in his experience, the Commissioner was honest, fair and a good listener.  Mr. Smith did, however, use the occasion to remind committee members of the serious situation at the Office of MaineCare Services which has not had a permanent director since the Baldacci Administration took office.  "The disastrous MEMES experience has been extremely painful for providers and enrollees the last 15 months, and the Commissioner needs to find permanent and capable leadership for the Office immediately, " said Smith. 

Commissioner Harvey, who resides in Gardiner, served previously as acting commissioner of the Department of Behavioral and Developmental Services, prior to it being merged into the Health And Human Services Department.  Her background is in the area of mental health.

You can read the Governor's brief press release regarding the swearing in of Commissioner Harvey on the web at: [return to top]

NHIC and Medicare to Present Medicare Part B Fair in Manchester, N.H. May 15 and 16.
Maine's Part B Medicare Carrier, National Heritage Insurance Company, and CMS will present a Medicare "Fair" in Manchester, New Hampshire on May 15 and 16.  The program will be at the Radisson Hotel in Manchester and there is a registration fee of $110 (does not include hotel charge) .

The program will include presentations on error rate testing, appeals,and specialty sessions on:

  • non physician practitioners: incident to and consults
  • provider enrollment
  • modifiers
  • evaluation & management services
  • navigating the web                         

On the second day, sessions will be held on mental health, ambulance claims, physical & occupational therapy and preventive services.

Registration is through Teri Gagnon at NHIC in Hingham, MA. [return to top]

New England AMA Delegation Meets in Maine
Perfect spring weather greeted 58 members of the New England delegation to the American Medical Association as they met in Scarborough at the Black Point Inn over this past weekend.  David Simmons, M.D. chairs the New England delegation, while Richard Evans, M.D. chairs the Council of New England Medical Societies which meets as part of the delegation meeting.

At the meeting, delegates reviewed resolutions to be presented by the delegation to the AMA at the Annual Session in June, including a resolution presented by MMA which calls for the government to put science over politics in the decisions of the FDA and other science-related bodies.  The delegation voted, nearly unanimously, to support the Maine resolution. The text of the resolution appears below:

Title: The Primacy of Science in FDA Decision Making
Sponsor: ME AMA Delegation

Whereas it has been reported that potential appointees to important federal health advisory panels have been asked, prior to nomination, their position on abortion, their voting habits and political affiliation, and

Whereas the FDA refused non-prescription status for emergency contraception (EC) despite the fact that the FDA’s own scientific advisory committee voted overwhelmingly to make EC available without a doctor’s prescription, and

Whereas a recent editorial in the New England Journal of Medicine stated:

 “The recent actions of the FDA have made a mockery of the process of evaluating scientific evidence, disillusioned many of the participating scientists both inside and outside the agency, squandered the public trust, and tarnished the agency’s image”, and

Whereas despite 10,000 American women contracting cervical cancer each year leading to 4,000 deaths annually and two drug companies being on the verge of marketing a vaccine that appears to be 100% effective in preventing cervical cancer, young women may not have access to these vaccines due to government imposed restrictions, and

Whereas the CDC website, until recently and not in accordance with scientific opinion, downplayed the effectiveness of condoms in preventing STD’s and HIV, and

Whereas the government appears to be using not science, but politics as a basis for making public health decisions, to an extent not seen previously.

Therefore, be it resolved, our AMA hereby urges this administration and all future administrations to:

  1. Consider our best and brightest scientists for positions on advisory committees and councils regardless of their political affiliation and voting history, and
  2. Urge the FDA, when they consider the new vaccine to prevent HPV, to apply science in this and all other deliberations.
[return to top]

A Few Places Available at May 5 "First Friday's" Program on Release of Physician-Specific Data
A limited number of spots are left for this Friday's four hour CME program at MMA featuring information on the release of physician specific data from the state's all-payor claims database.  The program runs from 9:00am to 1:00pm at MMA's offices in Manchester.

The faculty for the program includes Alan Prysunka from the Maine Health Data Organization, Dennis Shubert, M.D. from the Maine Quality Forum, Ted Rooney, R.N. from Pathways to Excellence, Maureen Kenney from Bath Iron Works and Gordon Smith, Esq., from MMA.

There is a $60 fee which includes breakfast and all course materials.  Call the MMA office right now to reserve your slot as there are less than ten spots available:  622-3374 and press 0 and ask for Jess. [return to top]

Update on U.S. Senate "Health Week"
In last week's Weekly Update, the MMA noted that the U.S. Senate was planning to debate several current health policy issues, including medical liability reform and small business health plans.  Media events and floor action on these issues still are planned for this week, but action may be delayed by consideration of a supplemental spending bill.

Last week, Senator John Ensign (R-NV) announced that he would introduce medical liability legislation (S. 22) that will include a $750,000 cap on non-economic damages, equally divided among physicians, hospitals, and any other health care provider, but will not include limitations of liability for pharmaceutical manufacturers or medical device companies.  Senate Republican leaders also said that they would submit a medical liability reform bill targeted at OB/GYNs (S. 23).  In response to this action, opponents of medical liability reform, including the American Trial Lawyers Association, made the usual arguments - that medical liability costs are less than 2% of total health care spending and that rising liability insurance costs are a result of professional liability carriers "ripping off" physicians.

As in the recent past, medical liability legislation in the Senate likely will not advance because the Republicans' 55 votes are insufficient to break a Democratic filibuster and to reach the 60 votes needed for cloture on the issue.  Still, it provides you an opportunity to contact Senators Snowe and Collins to remind them of physician interest in this issue and to thank them for their past support.

Senator Olympia J. Snowe:  202-224-5344;

Senator Susan Collins:  202-224-2523; [return to top]

Study: More Americans Without Health Insurance

The percentage of working Americans with moderate to middle incomes who lacked health insurance for at least part of the year rose to 41 percent in 2005, a significant increase from the 28 percent in 2001 without coverage, according to the Associated Press. Further, more than half of the uninsured adults said they were having problems paying their medical bills or had incurred debt to cover their health care expenses, according to a report by the Commonwealth Fund, a New York-based private, health care policy foundation. The study of 4,350 adults also found that people without insurance were more likely to forgo recommended health screenings such as mammograms than those with coverage. They were also less likely to have a regular doctor. In addition, the study illustrates how more employers are dropping coverage or are offering plans that are just too expensive for many people. The study also found that 59 percent of the uninsured with chronic conditions such as diabetes or asthma either skipped a dose of their medicine or went without it because it cost too much.  For more information:,2933,193215,00.html [return to top]

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