A new rule by the Maine Department of Health and Human Services (DHHS) to address service eligibility for adults and children with mental illness who receive Medicaid along with a review of provider rate adjustments has sounded the alarm for the entire mental health community who fear business closures and subsequent loss of services.

Hundreds of Maine consumers turned out March 25 during a public hearing to oppose Gov. Paul LePage’s administration’s eligibility changes to Section 17 of the MaineCare rules. The plan limits automatic eligibility to Mainers with schizophrenia or schizoaffective disorder, potentially leaving behind Mainers with post-traumatic stress disorder, major anxiety disorder and other diagnoses, according to a press release from Rep. Drew Gattine’s (D-Westbrook) office.

Maine lawmakers on April 6 voted to keep services in place to help Maine consumers with mental illness stay in their homes and avoid costly hospitalization and residential services. The committee’s bill provides at least a 120-day transition period for each individual affected by the DHHS’s plan, and if alternative services are not available, a 90-day extension through June 30, 2017.

The new rule regarding Section 17 took effect April 8. Meanwhile, the legislative proposal will need to be presented before the full legislature.

David Sorensen, an aide in Gov. LePage’s office, in a March 31 editorial to The Portland Press Herald, wrote that of the 17,000 people currently served by Section 17, the department estimates that about 8,000 have these less-severe diagnoses. Meanwhile, there are 350 people on waitlists for these services, many of them requiring the higher level of care that Section 17 was originally intended to provide, Sorensen wrote.

Provider rate adjustments

Proposed provider rate adjustments have also raised concern in the provider community. Samantha Edwards, DHHS spokesperson, said there are no “proposed cuts” but rather draft rate models prepared by Arizona-based Burns & Associates and the DHHS for provider review and comment, she said.

The rates are for services provided under various sections, including Section 17, of the MaineCare policy. “Before proposing new final rates, the department will review provider comments and respond to each in writing — either agreeing and adjusting rate models accordingly or disagreeing and explaining why — as has been the practice for each of the prior four rate studies that the department has conducted with Burns & Associates,” she noted.

Edwards added that the DHHS is committed to ensuring that MaineCare rates adequately support delivery of services authorized under the program. As noted earlier, the current rate study is the fifth the department has conducted over the past two years with Burns & Associates. We have found their work to be exceptional, and the rate studies they have produced have been well-received.

The DHHS is at the midpoint of the rate review process, and the department extended the comment period to May 16, giving providers and stakeholders two months to provide feedback on the draft models, Edwards said.

Once the comment period closes, the DHHS and Burns & Associates will review each submission and respond in writing, either accepting the comment and incorporating its recommended changes into the rate model(s) or explaining their disagreement with the comment, said Edwards. “Herein, our goals are transparency in our reasoning, granularity in our analysis and thorough engagement with providers and stakeholders,” she said.

Legislative action

As the DHHS prepares to move consumers from one Medicaid program to another, the legislative proposal is expected to move to the full legislature, said Rep. Gattine, co-chair of the legislature’s Health and Human Services Committee. “We’re telling the department to provide for a longer transition period,” Gattine told MHW.

“There are concerns that people aren’t ready to make the transition because behavioral health homes are a relatively new service in the state,” he said. There are capacity issues in geographic parts of the state, Gattine noted.

The department’s plans regarding provider reimbursement rates are technically a separate issue but are very much related, noted Gattine. The provider rate proposal reduction would range anywhere from about 25 to 50 percent, he said.

“Providers are telling us that if the department moves forward there would be thousands of adults and children [without services],” he said. The problem is the department proposed a rate cut last year during its budget session, which was rejected by legislators, he said.

The DHHS had until January of this year to release another proposal regarding the provider reimbursement rates; however, they never did, he said. It wasn’t until March when they presented the rate proposal, he said. “Providers will be in a very compromised position with the rate cuts,” said Gattine. At MHW press time, a meeting had been scheduled to address the proposed rate adjustments.

Gattine said he is hoping the department will delay its proposal until the legislative session resumes January 2017. The current session is expected to end April 20, he said. “We’re now at the end of the session and the department is proposing these cuts,” Gattine said. “We’re not in a budget crisis. We’re not trying to fill a budget hole.”

Gattine added, “This is a very hot topic and a topic of great concern to the people.” For the past 30 years, Maine has been pretty much operating under a consent decree, he said.  The consent decree plays a huge factor in how mental health services can be provided in the state, he said.

“The consent decree has a lot of bearing on how services can be developed for people in the community,” he said. “It’s been a real struggle for us to create a quality mental health system. We can’t afford to take a step backward. We’re looking very hard at building a mental health system we can be proud of.”

Advocacy, peer concerns

Aashley Malsbury, policy associate at the National Alliance on Mental Illness Maine, said the DHHS’s proposal would have a devastating impact, not just on consumers receiving MaineCare, but on the state’s entire mental health system as well. “Providers can’t keep their doors open with the suggested proposal,” she told MHW.

The proposed rule would impact about 8,000 consumers with mental health needs who aren’t currently receiving services under MaineCare, said Malsbury. New eligibility criteria would apply to individuals diagnosed with bipolar disorder or schizophrenia, and who might be at risk of homelessness, criminal justice involvement or hospitalization, she said.

NAMI Maine submitted written testimony highlighting their concerns and its impact on peers utilizing services, and the unnecessary anxiety caused by the notices consumers received, she said. The notices about the changes to Section 17 were sent to consumers before being sent to providers, Malsbury said. NAMI Maine raised concerns because the service eligibility under the new rule should be more specific to the need for that type of service, rather than the diagnosis, she said.

Under the rule, a person with schizophrenia would receive case management services. One-third of people diagnosed with schizophrenia would experience only one episode of psychosis in their lifetime, she said. They would automatically be eligible to receive those services. It would not be based on need, Malsbury said.

According to the Burns & Associates rate study, the reimbursement rate cut for providers of adult case management services would be reduced by 28.7 percent. The rate for a physician or nurse practitioner for medical management services would be reduced by 47.8 percent, she said. “The proposed rate cuts would have a devastating impact on the mental health system as a whole — not just on those receiving services through MaineCare. Providers can’t keep their doors open with the suggested proposal,” she said.

Although pleased with the momentary reprieve from lawmakers courtesy of legislation to extend the transition to services, peers are concerned that the department’s proposal could mean potentially closing four of the state’s 12 recovery centers, said Marge Grant, coordinator of Friends Together Peer Support and Recovery Center in Livermore Falls.

“We could lose our contract,” Grant told MHW. “They want to close four of the 12 recovery centers in the state of Maine,” said Grant. The recovery center receives the bulk of its funding from the DHHS, she added.

The center, in operation for 20 years, provides social, leisure, educational and recreational services to promote recovery among its members, along with nutritional and wellness support, Grant said.

Representatives from the Maine Association of Peer Support and Recovery Center participated in the state hearing on March 25 to air their concerns, she noted.

The legislative proposal introduced April 6 is a step in the right direction, said Grant. “Unfortunately, it’s not going to happen overnight,” she said. “We’re now waiting to see [what more] the legislature is doing going forward. We’re trying to get this all figured out.”

Bottom Line…

The DHHS plan that includes provider rate adjustments is still being addressed by lawmakers.