Notice of MaineCare Reimbursement Methodology Change: MaineCare Benefits Manual, Section 67, Nursing Facility Services

Notice of MaineCare Reimbursement Methodology Change

AGENCY:  Department of Health and Human Services, Office of MaineCare Services

SERVICES INCLUDED:  Chapter 101, MaineCare Benefits Manual, Section 67, Nursing Facility Services

NATURE OF PROPOSED CHANGES: The Department plans to submit a State Plan Amendment in the near future identifying the following:

Establishment of a one-time payment adjustment for fiscal year 2024 and an ongoing annual payment adjustment beginning fiscal year 2024. These payment adjustments are established to ensure access to nursing facilities that provide comprehensive care to MaineCare veterans to meet their unique needs. In order to receive payment, a nursing facility must meet the following criteria:

1. The facility provides critical access to veteran-focused care, including specialized training and care of war-related injuries and conditions, such as Post Traumatic Stress Disorder (PTSD) and service-connected disabilities;

2. The nursing facility is subject to Department of Veterans Affairs (VA) regulations, oversight, and reporting requirements;

3. The nursing facility board of directors is appointed by the governor; and

4. The nursing facility participates in the Maine Public Employees Retirement System.

Principle. A nursing facility that qualifies under this section will be reimbursed annually for services provided to residents covered under Title XIX of the United States Social Security Act based on audited cost reports.

Rate Setting. These payment adjustments will be calculated using the uniform cost reports filed by the facilities in November of each year, using the following methodology:

1. The difference between the MaineCare payments and actual allowed MaineCare costs as reported on the most recent and filed cost reports for all eligible nursing facility services delivered by eligible nursing facilities as defined above;

• a)  For fiscal year 2024, the total of the one-time and ongoing payment adjustments across all eligible facilities shall not exceed the lesser of $11,054,322 (equal to $8,612,122 for the one-time payment and $2,442,200 for the ongoing payment), or the difference as calculated under Step 1; and

• b)  Beginning fiscal year 2025 and ongoing each year thereafter the payment adjustment across all eligible facilities shall not exceed the lesser of $2,442,200, or the difference as calculated under Step 1.

3. Each facility’s annual payment adjustment shall be proportionate to its overall share of the amount calculated under Step 1 and limited to the aggregate amount across all facilities available under Step 2; and

4. For each facility, if the amount calculated under Step 1 is greater than or equal to zero, the facility is not eligible for the temporary adjustment.