DHHS Announces MaineCare Rate System Improvements

September 30, 2021

The Maine Department of Health and Human Services (DHHS) is marking another milestone in its effort to further Governor Janet Mills’ goal to strengthen MaineCare by releasing the timelines and details for implementing the first phase of MaineCare’s Rate System Reform plan (PDF), a strategy to improve members’ health and the program’s sustainability by comprehensively evaluating rates and promoting high-value services. The proposed timeline reflects DHHS’s efforts to implement changes in alignment with legislative schedules and available resources, including reimbursement-related laws and recently enacted budget initiatives, while also allowing sufficient time to seek Federal approvals, conduct State rulemaking, and make necessary system and policy changes.

The table below includes the Department’s plans for reimbursement changes and rate studies planned for fiscal years 2022 and 2023, resulting from the recommendations following MaineCare’s Comprehensive Rate System Evaluation and other related legislation. This table does not include DHHS’s proposed Home and Community-Based Services (HCBS) enhanced federal match (FMAP) spending plan under Section 9817 of the American Rescue Plan. That plan is currently under review by the Centers for Medicare & Medicaid Services (CMS). The Department will provide an update on its HCBS plan at a later date.

Overall, these changes reflect DHHS’ commitment to creating a comprehensive, streamlined, and coherent reimbursement system that will support providers and help ensure MaineCare members' access to high-value services.

Service

Rate Action

Planned Effective Date

Related Initiative/Citation

Behavioral Health: Medication Management (Section 65)

Provides funding for a 25% increase to medication management rates that were in place on January 1, 2019

10/1/21

LD 221 - An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 (page 241)

Behavioral Health: Mental Health IOP (Section 65)

Provides funding for new intensive outpatient program services in accordance with rate study.

4/1/22

LD 221 - An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 (page 114)

Behavioral Health: Substance Use Disorder IOP (Section 65)

Provides funding to increase rates in accordance with rate study.

1/1/22

LD 221 - An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 (page 104)

Behavioral Health: Psychiatric Inpatient (Section 45)

Provides funding to amend Section 45, Hospital Services, to provide reimbursement for patients discharged from Southern Maine Health Care's psychiatric inpatient unit in the amount of $10,166 per distinct discharge.

10/1/21

LD 1470 – Resolve, Regarding Reimbursement for Providing Inpatient Care to Individuals with Acute Mental Health Care Needs

Behavioral Health (Sections 17, 26, 28, 65)

Provides temporary monthly supplemental “ramp” payments for calendar year 2022, only.

Provides funding to enable rate adjustments necessary to ensure that rates are sufficient to support an average wage for direct service workers equal to at least 125% of minimum wage.

1/1/22

1/1/23

LD 221 - An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 (page 239)

Behavioral Health: Residential Substance Use Disorder Treatment (Section 97, Appendix B)

Provides funding to increase rates for Section 97, Private Non-Medical Institution Services, Appendix B, Substance Use Disorder Facilities in accordance with rate study.

11/1/21

LD 221 - An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 (page 103)

Behavioral Health: Children’s Residential Treatment (Section 97, Appendix D)

Provides funding to increase rates to meet the requirements of the federal Family First Prevention Services Act, in accordance with rate study.

11/1/21

LD 221 - An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 (page 111)

Long Term Care: Adult Family Care Homes (Section 2)

Provides temporary monthly supplemental “ramp” payments for calendar year 2022, only.

Provides funding to enable rate adjustments necessary to ensure that rates are sufficient to support an average wage for direct service workers equal to at least 125% of minimum wage.

1/1/22

1/1/23

LD 221 - An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 (pages 237-241)

Long Term Care: Nursing Facility Services (Section 67), Residential Care Facilities (Private Non-Medical Institution, Section 97, Appendix C)

Increases cost caps to ensure facilities receive adequate reimbursement to support an average wage for direct service workers equal to at least 125% of minimum wage.

7/1/22

LD 221 - An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 (page 240)

Ambulance Services (Section 5)

Differentiate payment rates for super rural, rural, and urban locations, in alignment with Medicare reimbursement methodology.

4/1/22

LD 1469 – Resolve, To Provide Add-on Payments for Ambulance Services Reimbursed by the MaineCare Program and To Increase Reimbursement Rates for Physical Therapy under the MaineCare Program

Chiropractic Services (Section 15)

Standardize the percent Medicare benchmark to the current year Medicare rate across a number of services, including Chiropractic. The percent amount was last estimated at 71.4%; this percentage may be updated based on current analysis underway to incorporate the most recent Medicare rates available.

7/1/22

LD 376 – Resolve, To Increase Certain Chiropractic Reimbursement Rates under the MaineCare Program

LD 221 - An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 ((page 103)page 103)

Personal Support Services (Section 12, 96) and 1915(c) waiver Home and Community Based Services (Sections 18, 19, 20, 21, 29)

Provides funding to enable rate adjustments necessary to ensure that rates are sufficient to support an average wage for direct service workers equal to at least 125% of minimum wage.

1/1/22

LD 221 - An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 (page 239)

Dental Services

(Section 25)

Provides funding to benchmark rates for dental services to median Maine commercial rates: 67% of commercial median for Preventive, Diagnostic and Endodontic; 50% of commercial median for other services

7/1/22

LD 221 - An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 (page 100, 106)

Durable Medical Equipment

(Section 60)

Initiative to establish consistent reimbursement methodology aligned with Medicare, and rates benchmarked to current year

Medicare reimbursement rate.

Fall ‘21 (see e-message)

LD 590 – An Act To Require MaineCare Coverage for Ostomy Equipment

LD 221, An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 (page 97)

Physical Therapy (Section 85)

Standardize the percent Medicare benchmark to the current year Medicare rate across a number of services, including Physical Therapy. The percent amount was last estimated at 71.4%; this percentage may be updated based on current analysis underway to incorporate the most recent Medicare rates available.

7/1/22

LD 1469 – Resolve, To Provide Add-on Payments for Ambulance Services Reimbursed by the MaineCare Program and To Increase Reimbursement Rates for Physical Therapy under the MaineCare Program

LD 221 - An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 (page 103)

Various: Sections that are not otherwise receiving a rate adjustment on or within 12 months prior to 7/1/22.

Provides funding for annual Cost of Living (COLA) Increases

7/1/22

LD 221 - An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 (page 91)

Various: Sections 14, 15, 68, 75, 85, 90, 95, 101,109.

Section 90 adjustments will also apply to aligned codes under Family Planning (Section 30).

Standardize the percent Medicare benchmark to the current year Medicare rate across these services. The percent amount was last estimated at 71.4%; this percentage may be updated based on current analysis underway to incorporate the most recent Medicare rates available. Section 90 enhanced Primary Care reimbursement will be the exception and remain benchmarked at 100% of Medicare.

7/1/22

LD 221 - An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022 and June 30, 2023 (page 103)

Planned rate studies: The Department currently plans to initiate the following rate studies in this biennium as part of its MaineCare Rate System Reform plan.

Service/ Section of Policy

Year of Rate/ Methodology Study Initiation

  • Behavioral Health: Sections 17, 26, 28, 65, 46, 107, CCBHC (new service model)

  • Long Term Care: Adult Family Care Homes (Section 2)

  • Hospital Services: Sections 45, 46

FY22

  • Long Term Care: Residential Care Facilities (Section 97, PNMI Appendices C, F); Nursing Facilities (Section 67)

  • Primary Care Payment Reform (new payment model, Primary Care Plus)

FY23

The MaineCare Rate System Reform plan is a multi-year effort that will include scheduling of additional rates for review and updating, as well as advancing value-based purchasing and alternative payment model initiatives.