A provision in federal law designed to control costs – called the upper payment limit – is creating an obstacle.
By: Joe Lawlor, Staff Writer
A federal requirement in the Medicaid program is threatening to hamper the Mills administration’s effort to increase access to opioid treatment programs in Maine.
The Legislature shelved a bill this session that would have increased reimbursement rates, starting in July, by 8 percent for those offering medication-assisted treatment to Medicaid patients. The proposal stalled after the cost of the bill for Maine taxpayers increased by $12.5 million – from $5.2 million to $17.7 million, according to official state estimates.
A provision in federal law designed to control Medicaid costs – called the upper payment limit – is creating the roadblock that the Mills administration and lawmakers are working to resolve. When states cross the upper payment limit for certain Medicaid services, the federal government – which typically pays for two-thirds or more of the cost of Medicaid services – will not pay for costs above the payment limit. That means state taxpayers would be on the hook for costs above the limit.
The upper payment limit was also an issue in $1.4 million in extra funding for nursing homes, with Republicans in the Legislature and advocates for nursing homes sparring with the Mills administration over how to interpret the payment limit for nursing homes.
The obstacle comes at a time when Maine is in the throes of an opioid crisis, with 354 drug overdose deaths in 2018 and 417 in 2017. Gov. Janet Mills, a Democrat working with Democratic majorities in the House and the Senate, has made the opioid crisis one of her top priorities.
Medication-assisted treatment – a combination of Suboxone and therapy – is considered the “gold standard” of treatment options for those with opioid use disorder.
But access to the treatment has traditionally been a difficult, not only in Maine but across the country.
One of the barriers to treatment has been cost, especially for the uninsured or those with Medicaid, which is insurance for low-income and the disabled that covers more than 290,000 Mainers.
Medicaid expansion, which Mills implemented in January and will eventually add about 70,000 state residents to the Medicaid program, should help increase access to substance abuse treatment.
But advocates say better access will only happen if therapists can be reimbursed an amount that will let them treat patients without losing money.
Malory Shaughnessy, executive director of the Alliance for Addiction and Mental Health Services, Maine, which represents nonprofits that offer medication-assisted treatment to patients, said Medicaid patients are essentially a “loss leader” for treatment centers. Many have to limit their Medicaid patients to stay in business.
“You can’t keep adding new Medicaid patients if you are losing money on each one. As the demand goes up, the wait list will go up, too,” Shaughnessy said.
Eric Haram, owner of Bowdoinham-based Haram Consulting, which gives advice to treatment providers on a number of issues, including financial decisions, said the cost for outpatient medication-assisted treatment is about $4,000 to $7,500 per year. Medicaid will cover about 50 to 60 percent of the cost, so an 8 percent increase would help give treatment centers the ability to take on more Medicaid patients, he said.
“The rates haven’t changed in a very long time, and in fact they’ve gone down,” Haram said. “These rates need to improve to help cover the cost of rendering the service, or there is a disincentive to offering the service to Medicaid patients.”
Patients covered by private insurance can make up for the cost of taking on Medicaid and uninsured patients, but nonprofits have to carefully monitor their patient mix or risk losing money, Haram said.
Some treatment providers, such as Dr. Mark Publicker of Portland, don’t see any Medicaid patients because they can’t afford to do so.
The key to solving the reimbursement problem is figuring out how to avoid the upper payment limit, Shaughnessy said. If it’s resolved, the bill could come back to the legislature in January.
Jackie Farwell, spokeswoman for the Maine Department of Health and Human Services, said the agency is working on the issue.
“We are working with our consultant to assess the appropriateness of the current UPL calculations. Any changes to the UPL would require approval from the (federal) Centers for Medicare and Medicaid Services,” Farwell said.
The LePage administration hired Connecticut-based Myers and Stauffer consultants in 2018 on a $171,000 contract to work on upper payment limit issues in Medicaid. Mills started serving as governor in January.
Dr. Joe Parks, the medical director of the National Council for Behavioral Health and the former Missouri Medicaid director, said in a phone interview Tuesday that a consultant will need several months to work out problems with the upper payment limit.
But Parks said it can be done, although it takes a lot of time and effort by accountants to tackle the myriad of requirements in the UPL to maximize a state’s flexibility to charge the reimbursement rates it needs to.
“If I’m a Medicaid director, I can tell the consultants to find me room under the UPL,” Parks said. “Maine has an opportunity to get better on this.”
Meanwhile, the nonprofit agencies were expecting to get a reimbursement rate increase in July and now will have to wait for several more months or longer if the state can resolve the bureaucratic issues, Shaughnessy said.
The LePage administration did increase reimbursement rates under the Opioid Health Homes program in December, a separate program that covers some of the Medicaid population as well as the uninsured.
This article appears in Portland Press Herald.