§3174-UU. Reimbursement for opioid drugs for the treatment of pain
This section applies to reimbursement under the MaineCare program for opioid drugs for the treatment of pain. [PL 2011, c. 657, Pt. O, §2 (NEW).]
1. Treatment of a new onset of acute pain. The department shall establish limits for MaineCare reimbursement of opioid drugs that are prescribed as medically necessary in response to a new onset of acute pain. After the initial 15-day prescription, the limits established may not exceed 42 days per year without prior authorization. In order to qualify for reimbursement under this subsection, the prior authorized prescription may not provide for more than 14 days of medication and requires a face-to-face visit between the prescriber and the MaineCare member. Notwithstanding the provisions of this subsection, the department shall limit to a period of 60 days following the surgical procedure MaineCare reimbursement for opioid drugs as treatment of post-operative care prescribed following a surgical procedure for which the medical standard of care includes the use of opioids. A MaineCare member who suffers from intractable pain and for whom opioid drugs are medically necessary beyond the limits set by this subsection may qualify for opioid drugs under subsection 2 as treatment for long-term chronic pain.
[PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]
2. Treatment of long-term chronic pain. Reimbursement for opioid drugs beyond the limit set in subsection 1 is allowed by prior authorization if the MaineCare member participates in one or more therapeutic treatment options established by the department through rulemaking.
In order to qualify for reimbursement for opioid drugs under this subsection, the MaineCare member must:
A. Have failed to have an adequate response to the prescribed therapeutic treatment options; [PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]
B. Have completed the prescribed therapeutic treatment options in accordance with the guidelines and show signs of regression; or [PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]
C. Have completed at least 50% of the prescribed therapeutic treatment options under this subsection, after which the prescriber recommends that adequate control of pain will not be obtained under the therapeutic treatment options. [PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]
The department shall limit reimbursement for opioids for a MaineCare member who fails to have an adequate response to the prescribed therapeutic treatment options, subject to exception based on medical necessity. The department may include in rulemaking the establishment of a daily dosing limit, subject to exception.
The department may waive the requirement of therapeutic treatment options through prior authorization when participation is not feasible and opioid treatment is medically necessary.
The department may allow a MaineCare member who is participating in a course of treatment recommended by a prescriber, including alternatives, in accordance with rules adopted by the department to obtain a prior authorization for physical therapy in excess of 2 visits to a maximum of 6 visits.
[PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]
3. Second opinion. In order for a prescription to qualify for reimbursement under this section, prior to prescribing an opioid drug for a medical diagnosis known typically to have a poor response to opioid drugs, a prescriber shall obtain an evaluation from a prescriber from outside the practice of the prescriber.
[PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]
4. Current use. The department may delay until January 1, 2013 the application of this section to the reimbursement for opioid drugs for MaineCare members who have been receiving such treatment consistently for 6 months or longer on the effective date of this section. The department may require the development of a protocol for proper, safe and effective tapering from opioid use when appropriate and may adopt exceptions to the requirements of this section based on diagnosis or condition or on the basis of daily doses.
[PL 2011, c. 657, Pt. O, §2 (NEW).]
5. Collaboration. The department shall seek input from pain specialists, addiction medicine specialists and members of the department's physician advisory committee in the development of rules governing this section.
[PL 2011, c. 657, Pt. O, §2 (NEW).]
6. Morphine equivalent dose. The department may establish and utilize a total daily morphine equivalent dose calculation when developing rules to implement this section.
[PL 2011, c. 657, Pt. O, §2 (NEW).]
7. Exceptions. This section does not apply to reimbursement for opioid drugs for the following MaineCare members as specified in rules adopted by the department or as established through the MaineCare preferred drug list:
A. A MaineCare member who is receiving opioid drugs for symptoms related to HIV, AIDS, cancer and certain other qualifying diseases and conditions, as established by department rule; [PL 2011, c. 657, Pt. O, §2 (NEW).]
B. A MaineCare member who is receiving opioid drugs during inpatient treatment in a hospital or during hospice care; [PL 2011, c. 657, Pt. O, §2 (NEW).]
C. A MaineCare member who is receiving opioid drugs at certain qualifying low doses, as established by department rule; [PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]
D. A MaineCare member for whom MaineCare reimbursement for opioid drugs for the treatment of addiction is restricted by limits applicable to methadone and buprenorphine and naloxone combination drugs; and [PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]
E. A MaineCare member who is residing in a nursing facility. [PL 2013, c. 368, Pt. AAAAA, §1 (NEW).]
[PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]
8. Rules. The department shall adopt rules to implement this section. Rules adopted under this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A.
[PL 2011, c. 657, Pt. O, §2 (NEW).]
Revisor's Note: §3174-UU. Methadone reimbursement limitations (As enacted by PL 2011, c. 657, Pt. S, §1 is REALLOCATED TO TITLE 22, SECTION 3174-VV)
SECTION HISTORY
RR 2011, c. 2, §27 (RAL). PL 2011, c. 657, Pt. O, §2 (NEW). PL 2011, c. 657, Pt. S, §1 (NEW). PL 2013, c. 368, Pt. AAAAA, §1 (AMD).
Structure Maine Revised Statutes
Subtitle 3: INCOME SUPPLEMENTATION
Chapter 855: AID TO NEEDY PERSONS
22 §3172-A. Mental Health and Mental Retardation Improvement Fund (REPEALED)
22 §3172-B. Moneys received; credit to General Fund; unencumbered balance (REPEALED)
22 §3173. Powers and duties of department
22 §3173-A. Reimbursement for therapy; intermediate care facilities and skilled nursing facilities
22 §3173-B. Medically needy program; certain individuals in intermediate care facilities
22 §3173-D. Reimbursement for substance use disorder treatment
22 §3173-E. Treatment of joint bank accounts in Medicaid eligibility determinations
22 §3173-F. Charging or increasing premiums
22 §3173-G. Medicaid coverage for reproductive health care and family planning services
22 §3173-H. Services delivered through telehealth
22 §3173-I. Maine Telehealth and Telemonitoring Advisory Group
22 §3174-A. Medical coverage program for certain boarding home residents
22 §3174-C. Coverage for inpatient hospital mental disease treatment services
22 §3174-E. Interim assistance agreement
22 §3174-F. Coverage for adult dental services
22 §3174-H. Availability of income between married couples in determination of eligibility
22 §3174-I. Medicaid eligibility determinations for applicants to nursing homes
22 §3174-J. Medicaid drug formulary (REPEALED)
22 §3174-K. Counseling for certain children
22 §3174-L. Parity among counselors
22 §3174-M. Medicaid drug formulary
22 §3174-N. Authorization to pursue federal waivers to develop Medicaid managed-care program
22 §3174-P. Prescription processing service fee (REPEALED)
22 §3174-Q. Medicaid stability
22 §3174-R. Medicaid drug rebate program
22 §3174-T. Cub Care program (REALLOCATED FROM TITLE 22, SECTION 3174-R)
22 §3174-U. Medicaid reimbursement for dental services
22 §3174-V. Federally qualified health center reimbursements
22 §3174-W. Procedure for home health care changes (REALLOCATED FROM TITLE 22, SECTION 3174-U)
22 §3174-X. Contracted ombudsman services
22 §3174-Y. Prior authorization in Medicaid program
22 §3174-Z. Private, nonmedical and board and care institutions
22 §3174-BB. Enrollment periods
22 §3174-CC. Medicaid eligibility during incarceration
22 §3174-DD. Dirigo health coverage
22 §3174-EE. Mail order drugs (REALLOCATED FROM TITLE 22, SECTION 3174-AA)
22 §3174-GG. Long-term Care Partnership Program
22 §3174-HH. Coordination of services
22 §3174-II. Relationship to federal Medicare program
22 §3174-KK. MaineCare Stabilization Fund (REALLOCATED FROM TITLE 22, SECTION 3174-II)
22 §3174-LL. Inpatient services reimbursement based on diagnosis-related groups
22 §3174-QQ. Care for children with life-threatening conditions
22 §3174-RR. Dental hygienist reimbursement (REALLOCATED FROM TITLE 22, SECTION 3174-QQ)
22 §3174-SS. Calculation of 24 months (REPEALED)
22 §3174-TT. Limitation on reimbursement for opioids (REPEALED)
22 §3174-UU. Reimbursement for opioid drugs for the treatment of pain
22 §3174-WW. Tobacco cessation
22 §3174-XX. Dental therapy reimbursement
22 §3174-YY. State educational Medicaid officer
22 §3174-ZZ. Reimbursement for hearing aids
22 §3174-CCC. Chiropractic services reimbursement (REALLOCATED FROM TITLE 22, SECTION 3174-AAA)
22 §3174-DDD. Coverage for conversion therapy (REALLOCATED FROM TITLE 22, SECTION 3174-BBB)
22 §3174-EEE. Prior authorization of treatment for opioid use disorder
22 §3174-FFF. State-funded medical program for noncitizens
22 §3174-GGG. Palliative care reimbursement (REALLOCATED FROM TITLE 22, SECTION 3174-FFF)
22 §3174-HHH. Ostomy equipment reimbursement (REALLOCATED FROM TITLE 22, SECTION 3174-FFF)
22 §3174-III. Reimbursement for donor breast milk
22 §3175. Acceptance of federal provisions
22 §3175-A. Delinquent nursing home taxes to be withheld from Medicaid payments
22 §3175-B. Delinquent residential treatment facility taxes to be withheld from Medicaid payments
22 §3175-C. Delinquent hospital taxes to be withheld from Medicaid payments
22 §3175-D. Nursing facility depreciation
22 §3176. Treasurer of State as agent
22 §3178. Payment to conservator or guardian
22 §3179. Change of circumstances
22 §3180. Inalienability of aid
22 §3182. Fraudulent representations; penalty
22 §3184. Recovery of illegal payments
22 §3185. Medical expenses for catastrophic illness
22 §3186. Medical and social services referral service
22 §3187. Principles of reimbursement; rules
22 §3188. Maine Managed Care Insurance Plan Demonstration for uninsured individuals
22 §3189. The Maine Health Program (REPEALED)
22 §3189-A. Advisory Board to Privatize the Maine Health Program (REPEALED)
22 §3190. Community Health Program grants (REPEALED)
22 §3192. Community Health Access Program
22 §3193. Affordable Health Care Fund (REALLOCATED FROM TITLE 22, SECTION 3192)
22 §3194. Report on cost of dispensing medication
22 §3195. Compensation for care provided to persons with intellectual disabilities or autism
22 §3196. Coverage for non-Medicaid services to MaineCare members