DHHS Achieves Progress on MaineCare Rate Reform

March 30, 2023

Since the start of the Mills Administration, the Department of Health and Human Services (DHHS) has prioritized both expanding eligibility for MaineCare and improving how the program pays for services for its members. These efforts have culminated in significant achievements that the Department continues to build on to further promote quality, accessible services for the over 400,000 Maine residents currently served by the program.

By the end of 2022, about 50 percent of MaineCare payments were tied to purchasing initiatives that reward high-quality care for members. This exceeded the Department’s goal set in 2019 that 40 percent of MaineCare payments should be tied to value by the end of Governor Mills’ first term.

In tandem with value-based purchasing initiatives, the Office of MaineCare Services (OMS) has implemented payment reforms through its nationally recognized, new rate system reform process. These reforms now affect 55 percent of MaineCare’s claims-based spending, according to a recent presentation by OMS Director Michelle Probert. Current studies underway will reform rates for services representing another 39 percent of claims-based spending.

OMS launched the comprehensive evaluation of its rates and reimbursement system to guide efforts to improve payment policy, finding that reform was sorely needed. For example, the study found that 40 percent of rates had not been updated since prior to 2015; 30 percent of rates had no methodology; and rates benchmarked to Medicare used different percentages and years for MaineCare payments.

This solidified a commitment at DHHS to ensure adequate, equitable and data-driven reimbursement; reward quality, cost-effective care; promote accountability for cost and performance; and reduce administrative burden. DHHS began work with the Legislature to start reforms (e.g., PL21, Chapter 398, Part AAAA) as well as to codify a system for ongoing reforms (PL21, Chapter 639). This law (1) sets a schedule for regular rate reviews and adjustments; (2) ensures review of relevant state and national data to provide context and inform decisions; (3) formalizes a clear and transparent process for rate determinations; and (4) establishes a Technical Advisory Panel for input. OMS is well into implementing this law, with additional changes on the near-term horizon.

Results to date can be seen both in alternative payment models and rate changes. In 2022, OMS implemented Primary Care Plus (PCPlus), an aligned model with Medicare’s Primary Care First program, which moves primary care toward more flexible, population-based payments tied to risk and performance. OMS also broadened the total cost of care accountability within the Accountable Communities initiative and added performance metrics to the Opioid Health Home model. These efforts promote high-value care.

On rates, OMS implemented several major reforms using rate reform principals prior to enactment of the rate reform law. For example, OMS:

  • Aligned and increased MaineCare rates linked to Medicare rates from 70 percent of 2009 Medicare rates to 72.4 percent of current-year Medicare rates;
  • Through rebasing, Part AAAA, and other reforms, increased nursing facility rates by 20.8 percent on average from July 2021 to 2022, with another 0.9 percent increase in January 2023 to account for an increase in the minimum wage;
  • Implemented a 57 percent median rate increase for dental services based on benchmarking MaineCare rates to a percentage of Maine commercial payer rates for dental services, when available, or to rates from other state Medicaid agencies.

In the last year, OMS deployed the new rate reform law to set a schedule and start the process set forth in the law. The primary focus of this work was an overhaul of MaineCare’s behavioral health service rates, which comprise over 100 specific services, and even more billing codes. Behavioral rate increases on January 1, 2023 include (but are not limited to):

  • 22 percent median increase for behavioral health services (Section 65);
  • 43 percent median increase for behavioral health home services (Section 92); and a
  • 72 percent median increase in rehabilitation and community support services for children with cognitive impairments (Section 28).

Additionally, under the rate reform law process, OMS has increased targeted case management rates by 7 percent; day health services by 53 percent; and aligned durable medical equipment to 100 percent of Medicare rates and methodologies.

The process established by OMS was awarded the 2022 Spotlight Award from the National Association of Medicaid Directors. More is to come. A publicly posted schedule for rate reform describes studies underway, including for payments to hospitals and nursing homes. And DHHS is working on tracking the outcomes of these changes in terms of quality care and access.