December 19, 2011

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

Opposition Strong to Governor's Cuts to MaineCare, Raid of Fund for a Healthy Maine

Hundreds of Maine citizens joined MMA, the Maine Hospital Association, and many other groups in expressing opposition to the Governor's Supplemental Budget which was the subject of public hearings last Wednesday, Thursday, and Friday at the State House.  Other physician associations expressing strong opposition were the Maine Chapter of the American Academy of Pediatrics, the Maine Association of Psychiatric Physicians, and the Northern New England Chapter of the American Society of Addiction Medicine.  A work session on the proposal has been scheduled for tomorrow.

Less than two weeks ago, the LePage Administration released its proposed supplemental budget for the Department of Health & Human Services for State Fiscal Years 2012 and 2013.  According to the Administration, the DHHS budget gap is $120 million in FY 2012 and $101 million in FY 2013.  

In an unusual procedural move, the legislature's Appropriations Committee held public hearings on just this DHHS portion of the supplemental budget on Wednesday, Thursday, and Friday last week.   We understand that the Governor will release a supplemental budget for other state agencies in early January. 

Rather than simply balancing the state budget for the period ending June 30, 2012 (State Fiscal Year 2012), the Governor is proposing a major restructuring of the state's Medicaid program, a substantial shift in health policy that will have a negative impact on patients and health care practitioners and providers.  MMA's testimony offered on Friday can be found on the MMA website:  In its testimony, MMA suggested that the state look for increased revenue to make up some of the gap, rather then focusing on cuts to the DHHS budget where every dollar cut costs the state approximately $1.72 in federal matching funds.  In addition to the work session planned for tomorrow, the Appropriations Committee has planned another work session for Tuesday, January 3, 2012, the day before the legislature reconvenes on January 4th.

Here’s an overview of the budget proposal (all figures are General Fund only, so FMAP (federal match) would have to be factored in on a roughly 2-to-1 basis to judge real impact).

  • Sweep approximately half of the Fund for a Healthy Maine to fill the budget gap
  • Eliminates all PNMI coverage, both behavioral health & other ($47.6+ M in FY 13)
  • Eliminates targeted case management services
  • Eliminates optional coverage for 19/20 year olds < 150% of FPL
  • Reduces optional coverage for children “who are behaviorally challenged who are in a residential setting"
  • Reduces funding for contracts for residential services in children’s mental health ($1.25 M in FY 13)
  • “Limits” mental health crisis intervention services to people with severe & persistent mental illness ($2.1M in FY 13)
  • Eliminates low-cost drugs for the elderly program ($837k in FY 12; $4.5 M in FY 13)
  • Reduces coverage for brand name drugs from 4/month to 2/month ($1.2 M in FY 12; $5.8 M in FY13)
  • Some adjustment in Cub Care program for families >= 150% of FPL, but < 200% (shift to Dirigo)
  • $8 M in salary savings in DHHS ($5 M in FY 12; $3 M in FY 13)
  • Eliminates $1.1 M in FHM funds that went to vaccines
  • Eliminates Head Start funding ($800k in FY 12; $2.5 M in FY 13)
  • Eliminates MaineCare coverage for families above mandatory federal levels ($2.2 M in FY 12; $8.5 M in FY 13)
  • Eliminates adult family care as optional service
  • Eliminates ASC services as optional service ($17,200 in FY 12; $93,274 in FY 13)
  • Eliminates dental services as optional service ($411k in FY 12; $2.2 M in FY 13)
  • Eliminates OT as optional service ($79k in FY 12; $427k in FY 13)
  • Eliminates vision services as optional service ($152k in FY 12; $823k in FY 13)
  • Eliminates PT services as optional service ($98k in FY 12; $529k in FY 13)
  • Eliminates podiatry services as optional service ($68k in FY 12; $371k in FY 13)
  • Eliminates STD screening clinics as optional service ($40k in FY 12; $218k in FY 13)
  • Eliminates chiropractic services as optional service ($69k in FY 12; $375k in FY 13)
  • Reduces Critical Access Hospital reimbursement from 109%to 105% of cost ($291k in FY 12; $1.2 M in FY 13)
  • Limits coverage to 15 outpatient hospital visits per year ($278k in FY 12; $1.5 M in FY 13)
  • Limits coverage to 5 hospital admissions per member per year ($92k in FY 12; $490k in FY 13)
  • Limits use of suboxone for opioid dependency treatment to 2 years ($148k in FY 12)
  • Eliminates childless adult waiver program (the “non-categoricals”) ($22 M in FY 13)
  • Eliminates coverage of smoking cessation products ($80k in FY 12; $430k in FY 13)
  • Reduces reimbursement for outpatient services at acute care hospitals by 5% effective 7/1/12 ($3.2 M in FY 13)
  • Reduces reimbursement for hospital inpatient services by 10% ($768k in FY 12; $3.1 M in FY 13) 

You can find the DHHS budget materials, including the budget documents, on the web at:

 You can find the Appropriations Committee schedule for the week on the web at:

 You can find the Appropriations Committee members and their contact information on the web at:

Senate Passes Two-Month SGR Delay; AMA Expresses Alarm and DIsappointment

On Friday, December 16th, the United States Senate supported legislation to extend the date of the deep Medicare physician payment cut (31.4% in all but Cumberland and York counties, 28.4% in Cumberland and York) from January 1, 2012 to March 1, 2012.   For it to be effective, the legislation would need to be enacted by the House of Representatives which is expected to vote early this week.  Passage is not a given as many House Republicans are not supportive of a very short-term fix.  The American Medical Association, which had anticipated at least a one-year fix (and was hoping for a two-year deal or even a permanent fix), released a statement expressing disappointment with the short-term nature of the bill:

As noted in last week's Update, each physician in Maine should communicate with Maine's Congressional delegation as soon as possible and emphasize what this cut would mean to them and their patients.  Time is running out.  Find contact information and a sample letter at the AMA Advocacy website.

The AMA also has some helpful guidance on Medicare participation options for physicians here.  

CMS Medicare FFS Provider e-News

CMS Information for the Medicare Fee-For-Service Provider Community

CMS asks that you share the following important information with all of your association members and state and local chapters.  Thank you!

Robin Fritter, Director

Division of Provider Relations & Outreach

Provider Communications Group

Center for Medicare

Centers for Medicare & Medicaid Services


Attention Health Professionals:  Information Regarding the Holding of 2012 Date-of-Service Claims for Services Paid Under the 2012 Medicare Physician Fee Schedule

The negative update under current law for the 2012 Medicare Physician Fee Schedule is scheduled to take effect on Sun Jan 1, 2012, eight business days from today.  Consequently, as on numerous occasions in the past, CMS will instruct its Medicare claims administration contractors to hold claims containing 2012 services paid under the Medicare Physician Fee Schedule for the first 10 business days of January 2012 (i.e., Sun Jan 1 through Tue Jan 17).  The hold should have minimal impact on provider cash flow because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt. 

Medicare Physician Fee Schedule claims for services rendered on or before Sat Dec 31 are unaffected by the 2012 claims hold and will be processed and paid under normal procedures and time frames.

The Administration is disappointed that Congress has failed to pass a solution to eliminate the sustainable growth rate (SGR) formula-driven cuts, and has put payments for health care for Medicare beneficiaries at risk.  We continue to urge Congress to take action to ensure these cuts do not take effect.

CMS will notify you on or before Wed Jan 11, 2012, with more information about the status of Congressional action to avert the negative update and next steps regarding the claims hold.

[return to top]

125th Maine Legislature Reconvenes January 4, 2012; MMA Invites Physicians to Serve as "Doctor of the Day" & to Participate in Advocacy Efforts

The 186 members of the 125th Maine Legislature will reconvene for their Second Regular Session on Wednesday, January 4, 2012 for a "short" session that is expected to end in mid-April.  The supplemental budget mentioned in the lead article will be a substantial piece of business upon their return to the State House.  The legislature also will address bills carried over from the First Regular Session and some "emergency" bills admitted by vote of the Legislative Council, the 10 members comprising the legislative leadership.  

The MMA needs physicians to serve as "Doctor of the Day" for this session.  In particular, we are looking for physicians able to serve on January 10, 11, 17, 19, 24, 26, & 31, as well as February 2.  The session begins at 10:00 a.m. on each of these days and you would likely be finished by noon.  FMI, contact Maureen Elwell, Legislative Assistant, at 622-3374, ext. 219 or, or see the MMA web site at:

Also, please mark your calendars that the first weekly conference call of the MMA Legislative Committee will take place at 8:00 p.m. on Tuesday, January 10, 2012.  Look for more information on this call in the Maine Medicine Weekly Update of Monday, January 9, 2012.

[return to top]

L.D. 1501 Work Group Completes Final Recommendations on Reducing Prescription Drug Abuse and Addiction

The work group established  by L.D. 1501 completed its Report to the Legislature this past week and it was delivered to the Legislature on Thursday.   The Health & Human Services Committee is expected to review the report and its recommendations and schedule a presentation by the Commission in January.

There was a final consensus around a number of important issues, as follows:

  1. Participating in the state's Prescription Monitoring Program (PMP) will be strongly encouraged, but not mandated.
  2. Appropriate continuing education courses will be developed but any mandated education will likely come from  the federal level, not because of any state mandate.
  3. Prescribers will be encouraged to exercise universal precautions when starting a patient on opioid therapy for chronic pain.
  4. Prescribers will be provided with appropriate assessment, screening and risk reduction tools.
  5. The licensing boards for the various prescribers will be asked to review the current rule, Chapter 21, regarding guidelines for treatment of chronic pain and adopt any necessary changes. 
  6. A number of enhancements to the PMP are recommended, all aimed at making the program more valuable to physicians and other prescribers.  Additional access to the program by law enforcement is also being considered.  
  7. Local law enforcement agencies will be encouraged to provide diversion alerts to local health professionals.  These alerts would contain photos and names of individuals arrested for drug related offenses. 
  8. In order to decrease the number of deaths due to accidental overdose, a pilot project to provide naloxone kits will be recommended along with appropriate state legislation providing for protection of individuals who prescribe, dispense or otherwise intervene.

A copy of the final report will be placed on the MMA website,, later this week.  Any questions about the report should be addresses to Gordon Smith, Esq., MMA EVP who represented MMA on the Work Group, along with several physicians.

[return to top]

CMS Releases Proposed Rule on Physician "Sunshine" Part of ACA

On December 14, 2011, CMS released a proposed rule that would provide greater transparency in financial transactions between physicians and drug and device makers.  Senators Herb Kohl (D-WI) and Chuck Grassley (R-IA) have long championed this cause.  The proposed rule is the result of Section 6002 of the ACA, also known as the Physician Payments Sunshine Act.  Because this provision was included in the ACA, the Maine legislature repealed a state statute on drug and device manufacturer marketing disclosure.  You can find a CMS press release with links to the proposed rule on the web at:

The proposed rule appears in today's Federal Register.
[return to top]

AMA Comments to HHS on Key ACA Implementation Rules

On October 31st, the AMA submitted comments on six proposed rules and/or requests for information issued by the U.S. Department of Health & Human Services (HHS).  The HHS proposals dealt with numerous key Affordable Care Act (ACA) implementation issues at the state level, including health insurance exchanges, the Basic Health Program, Medicaid, and risk adjustment.  States have discretion on how/if some of these programs will be established, and the AMA has been advocating at both the federal and state levels to ensure that programs, such as exchanges, are established in an optimal fashion for both patients and physicians.  Some of the AMA's key recommendations to HHS include:

  • Exchanges should include physicians in their governance structures and increase competition in health insurance markets

  • Exchange and Basic Health Program plans should include robust provider networks and establish procedures to allow for fair compensation for providers taking part in such plans

  • Supporting a streamlined application and enrollment process among Medicaid, CHIP, state Basic Health Programs, and exchange plans

  • Quality measures in such programs should be true quality metrics and not just based on cost issues

  • Physicians will need access to real-time patient enrollment and coverage status in order to provide patients with needed information regarding their health care options

  • Risk adjustment mechanisms should promote access to health insurance markets for CO-OPs and other new market entrants

For more information on the AMA's continuing work on the ACA, please see the AMA web site at:

[return to top]

Update on January 1, 2012 HIPAA 5010 Compliance Deadline

January 1, 2012 marks the compliance deadline for use of the new version of the standard electronic Health Insurance Portability and Accountability (HIPAA) transactions.  Version 4010 has been in use since 2003 and the Centers for Medicare and Medicaid Services (CMS) is requiring all HIPAA "covered entities," which includes physicians who conduct any of the transactions named in HIPAA electronically (i.e. claims or remittance advice), to begin using Version 5010 starting on January 1, 2012. 

The AMA has been extremely proactive in educating physicians and continues to make a wealth of easy to understand resources available for free on our website at  Despite significant efforts by many in the health care industry, including physicians, there remains a considerable amount of work that needs to be done before everyone will be able to use the new standards.  For example, many practices have not had their practice management system (PMS) software upgraded by their vendor and have not been able to conduct testing with key trading partners. If your PMS vendor has not yet updated your system to accommodate the use of version 5010 you are strongly encouraged to contact them to obtain the necessary software upgrades.

CMS Announces Enforcement Flexibility

CMS is the federal agency charged with oversight of HIPAA standards.  AMA and others advocated to CMS that overall lack of industry readiness should not compromise physician cash flow following the January 1, 2012 compliance date. For this reason, CMS has indicated they will not levy any enforcement actions for the first three months of 2012 while HIPAA covered entities continue to work towards compliance.  What this means is that the HIPAA 5010 compliance date remains January 1, 2012 and all physicians and other HIPAA covered entities should continue to make every effort to comply with the use of the new standards, but that CMS will not take any enforcement action during this period.

Medicare’s Plans

Medicare, as the largest insurer that is required to comply with HIPAA requirements, has indicated that they are continuing to work with those who submit claims directly to them  (Submitters).  Submitters” include clearinghouses, third party billers, and physicians who submit claims directly (without the use of a third party or clearinghouse) to Medicare.  Every submitter is required to test with Medicare before claims can be processed using the 5010 format.  Medicare remains focused on ensuring all Submitters have tested successfully and that claims processing is not interrupted.  “What this means for physicians:

            Direct Submitters

If you are a physician who sends claims directly to Medicare (“Submitters”) without the use of a billing service or clearinghouse:

  • If you HAVE NOT tested by December  31, 2011: You are required to submit a "transition plan" to your Medicare contractor that details your plans for moving to 5010 and when you think you will be able to test with Medicare.  You will have 30 days to do this once you have been contacted by your Medicare contractor.
    • No prescribed format for transition plan:  It can be sent via letter, email, or fax and can be a brief explanation of your transition plans.   
    • Keep evidence plan was submitted: Submitters are strongly encouraged to retain evidence that a plan was sent (i.e. return receipt email, fax transmission confirmation, copy of an email).  
    • All submitters must test: Unless submitters have tested with their Medicare contractor, even if you submit compliant 5010 transactions, your claims will be rejected. 
  • If you HAVE tested successfully by December 31, 2011: You will be contacted by Medicare and told you have 30 days to move over to use of the 5010 standards.  Submitters that have not yet tested with Medicare prior to the compliance date will be contacted and asked to submit the transition plan described above. 

Physicians who use a clearinghouse or billing service to submit their claims

Physicians who rely on a billing service or clearinghouse to submit their claims to Medicare are NOT required to file a transition plan to Medicare.  The entity they use to submit their claims is the Submitter and is the one required to submit a transition plan.  These physicians should contact their billing services or clearinghouses to determine their ability to generate the physician’s claims and other transactions using the Version 5010 format.

For More information

For more information on 5010 please visit and

[return to top]

Downeast Association of Physician Assistants Winter CME Meeting in February at Sunday River is Open for Registration

22nd Annual Downeast Association of Physician Assistants

Winter CME Conference

February 1-4, 2012

Grand Summit Resort Hotel & Conference Center

Sunday River, Newry Maine

This conference offers a wide range of topics for all PAs!

                 Register before the Early Bird Special expires on 12/31/11


Visit for all hotel, skiing/winter activities and directions!

[return to top]

CMS Responds to Questions on Billing by Nonenrolled Physicians

Recently, the AMA provided updated information on Medicare participation options for physicians. The AMA Medicare participation kit describes three ways of relating to the Medicare program: participation, nonparticipation and opting out/private contracting.

The AMA asked the Centers for Medicare & Medicaid Services (CMS) whether there is a fourth option: to not enroll as a Medicare provider and have patients submit claims on their own using form CMS 1490s.  If legal, this option would have allowed a physician to be free from the Medicare limiting charges and other payment policies and rules just as a physician who has opted out and privately contracted with their patients would be, but, in addition, their patients could still be reimbursed by Medicare for services they receive from the nonenrolled physician.  CMS indicated, however, that the option of having physicians not enroll in Medicare and have beneficiaries submit claims on their own using the form CMS 1490s is not consistent with Medicare law and unenrolled physicians who engage in this type of practice are subject to penalties.  [return to top]

Change in Timeline For Providers Attesting to Meaningful Use

Providers and hospitals that attest to Stage 1 of the “meaningful use” incentive program in 2011 will not have to meet Stage 2 criteria until 2014, allowing extra time for early adopters of electronic health records (EHRs), Department of Health and Human Services Secretary Kathleen Sebelius announced November 30th.

By allowing more time for early adopters to reach Stage 2 of meaningful use, HHS hopes to make it easier to adopt health IT, and to encourage faster adoption, the agency said in a press release.

Under the current requirements, eligible doctors and hospitals that participate in the Medicare EHR incentive programs in 2011 would have to meet new criteria for the program in 2013. However, if they did not participate in the program until 2012, they could wait to meet these new criteria until 2014 and still be eligible for the same incentive payments.

Additional information on the EHR incentive programs is available here.

[return to top]

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