MaineCare’s Rate System Evaluation

Project Purpose

MaineCare reimburses health providers for care and treatment they provide to MaineCare members. This includes a wide range of providers, from hospitals and primary care clinics to therapists, behavioral health and substance use disorder treatment facilities, and nursing facilities, among many others. Over the years, MaineCare has used varying methods to determine reimbursement rates to providers, which has contributed to a rate system that is fragmented and outdated. Therefore, MaineCare is conducting an evaluation of its rates and rate setting system and developing a plan for the creation of a comprehensive, streamlined, and coherent system that will support MaineCare members' access to high value-services. The evaluation will include all MaineCare services with the exception of Pharmacy and Non-Emergency Transportation.

See the Rate System Evaluation Update for more information on this process, the schedule, and stakeholder engagement efforts.

Rate System Timeline and Deliverables (PDF)

Interim Report

The Comprehensive Rate System Evaluation Interim Report (PDF) which was updated on January 26, 2021 and includes a number of interim recommendations for how MaineCare can establish and maintain reimbursement rates that promote members’ access to high-quality care  and accurately account for Maine health care providers’ costs. The Department is currently reviewing the interim recommendations included in this report. A final report will be issued at the end of February that may include refinements to some individual recommendations and will include a more detailed implementation plan.   

Phase 1 Benchmarking Report

The Phase 1 Benchmarking Report focuses on the comparison of MaineCare rates to rates of other payers and is comprised of the Executive Summary (PDF) which was updated on January 26, 2021 and contains key findings across all section of MaineCare policy and the policy-specific workbooks that compare MaineCare’s rate to those of other payers. The workbooks can be found below. Additionally, this summary document (XLS) which was updated on January 26, 2021, includes the basis for each section of policy’s rates (when known), along with any update schedule and date of the last major rate update. 

As a reminder, the comparison of payment methodologies will be included in the findings and report (PDF) due in January and February, along with the stakeholder feedback regarding payment methodology from our meetings in October. 

Before reviewing the workbooks, please review these instructions (PDF).  

Behavioral Health Services (XLS) - Updated 1/15/2021

Behavioral Health Outpatient

Includes services from:

  • Sec. 65: Children's Outpatient Behavioral Health Services, includes services from Behavioral Health Services
  • Adult Outpatient Behavioral Health Services, includes services from:
    • Sec. 17: Community Support Services 
    • Sec. 65: Behavioral Health Services 
  • Sec. 65: Outpatient Mental Health Services - All Ages, includes services from Behavioral Health Services

Behavioral Health Community-Based

Includes services from:

  • Children's Community-Based Behavioral Health Services, includes services from:
    • Sec. 28: Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations 
    • Sec. 65: Behavioral Health Services 
  • Adult Community-Based Behavioral Health Services, includes services from:
    • Sec. 17: Community Support Services 
    • Sec. 65: Behavioral Health Services 
  • Sec. 92: Behavioral Health Home Services 

Children's Residential Behavioral Health Services

Includes services from:

  • Sec. 97, Appendix D: Private Non-Medical Institution Services 
  • Sec. 107: Psychiatric Residential Treatment Facility Services 

Adult Residential Behavioral Health Services:

Includes services from:

  • Sec. 65: Behavioral Health Services 
  • Sec. 97, Appendices E, F: Private Non-Medical Institution Services 

Substance Use Disorder Services:

Includes services from:

  • Sec. 65: Behavioral Health Services 
  • Sec. 93: Opioid Health Home Services 
  • Sec. 97, Appendix B: Private Non-Medical Institution Services 

Sec. 23: Developmental and Behavioral Clinic Services

Includes services from:

Dental Services

Includes services from:

Home and Community-Based Services (HCBS) Personal Care, Home Health, Nursing, and Clinical Services (XLS) - Updated 1/19/2021

Includes services from:

  • Sec. 12: Consumer Directed Attendant Services
  • Sec. 19: Home and Community Benefits for the Elderly and Adults with Disabilities
  • Sec. 20: Home and Community Based Services for Adults with Other Related Conditions
  • Sec. 21: Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder
  • Sec. 26: Day Health Services
  • Sec. 40: Home Health Services
  • Sec. 43: Hospice Services
  • Sec. 96: Private Duty Nursing and Personal Care Services
  • Sec. 102: Rehabilitative Services

Home and Community-Based Services (HCBS) - Residential and Day Habilitation and Supported Employment (XLS) - Updated 1/15/2021

Includes services from:

  • Sec. 18: Home and Community-Based Services for Adults with Brain Injury
  • Sec. 20: Home and Community Based Services for Adults with Other Related Conditions
  • Sec. 21: Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder
  • Sec. 29: Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder

Hospital Services (XLS) - Updated 1/15/2021

Includes services from:

  • Sec. 45: Hospital Services
  • Sec. 46: Psychiatric Hospital Services

Institutional Care Services (XLS) - Updated 1/15/2021

Includes services from:

  • Sec. 50: Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID)
  • Sec. 67: Nursing Facility Services

Miscellaneous Services

Includes services from:

Physician, APRN, Primary Care, Ambulatory Care/Clinics Services

Includes services from:

Primary Care Health Centers (XLS), including: - Updated 1/15/2021

  • Sec. 9: Indian Health Services
  • Sec. 31: Federally Qualified Health Center Services
  • Sec. 103: Rural Health Clinic Services

Residential Care

Assisted Living Services (XLS), including: - Updated 1/15/2021

  • Sec. 2: Adult Family Care Services
  • Sec. 97: PNMI Services, Appendix C

Behavioral Health Residential Services (XLS), including:

  • Sec. 97: PNMI Services, App B, D, E, and F
  • Sec. 107: Psychiatric Residential Treatment Facility Services

Specialty Services

Includes services from:

Targeted Case Management

Includes services from:
Stakeholder Engagement Meetings

Phase 2 Stakeholder Engagement Meetings

Phase 2 Stakeholder Engagement Meeting Recordings

Phase 1 Stakeholder Engagement Meetings

Phase 1 Stakeholder Engagement Meeting Recordings

Questions?

For have questions, comments, or notice errors in any of the reports and associated documents, please send an email to: RateSettingEval@maine.gov.