An Act To Establish a MaineCare Reimbursement Rate Review Process and the MaineCare Independent Rate Commission
Maine Legislature, Session 129, LD 1288
Committee: Health and Human Services
Sponsors: FARNSWORTH, CRAVEN, HANDY, HICKMAN, HYMANSON, MADIGAN, RECKITT, WARREN
Amends: 5 MRSA §12004-J, 22 MRSA §19-A

Legislative Document
No. 1288
H.P. 930
House of Representatives, March 14, 2019
An Act To Establish a MaineCare Reimbursement Rate Review 
Process and the MaineCare Independent Rate Commission
Reference to the Committee on Health and Human Services suggested and ordered printed.
ROBERT B. HUNT
Clerk
Presented by Representative FARNSWORTH of Portland.
Cosponsored by Representatives: CRAVEN of Lewiston, HANDY of Lewiston, HICKMAN of 
Winthrop, HYMANSON of York, MADIGAN of Waterville, McCREIGHT of Harpswell, 
RECKITT of South Portland, WARREN of Hallowell.
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  5 MRSA §12004-J, sub-§18 is enacted to read:
18.  
Sec. 2.  22 MRSA §19-A is enacted to read:
§19-A.  Review of reimbursement rates for providers under MaineCare program
1.  Definitions.  As used in this section, unless the context otherwise indicates, the 
following terms have the following meanings.
A.  "Alternative health care practices" means health care practices not considered to 
be part of conventional medicine, including alternative medical systems, mind-body 
interventions, biologically based treatments, manipulative and body-based methods 
and energy therapies.
B.  "Commission" means the MaineCare Independent Rate Commission.
C.  "Committee" means the joint standing committee of the Legislature having 
jurisdiction over appropriations and financial affairs.
D.  "Facility-based physician" means an anesthesiologist, emergency room physician, 
neonatologist, pathologist or radiologist practicing medicine primarily in a health care 
facility.
E.  "Initial contact agency" means an agency or private organization that a recipient 
or potential recipient contacts initially to determine MaineCare program eligibility or 
for a referral for specific MaineCare program services.
F.  "Provider" means a provider of MaineCare program services.
G.  "Recipient" means a recipient of MaineCare program services.
2.  Schedule of review of reimbursement rates for providers under the 
MaineCare program.  On or before September 1st of each calendar year, the department 
shall establish a 5-year schedule for annual reviews of reimbursement rates under the 
MaineCare program so that each provider rate is reviewed at least every 5 years and 
provide the schedule to the committee.  If the department receives a petition or proposal 
for a reimbursement rate to be reviewed or adjusted, the department shall provide a copy 
of the petition or proposal to the commission.  The department may exclude a 
reimbursement rate from the schedule under this subsection if that rate is adjusted on a 
periodic basis as a result of state law or federal law or regulation.  The department shall 
include the list of excluded rates with the schedule of reimbursement rates required by 
this subsection.  By December 1st of the year prior to a scheduled year, the committee or 
the commission may direct the department to review any reimbursement rate that is not 
scheduled during or that is excluded from the scheduled year.  The department shall 
Health and 
Human Services
MaineCare 
Independent Rate 
Commission
Not Authorized
MRSA §19-A
review each reimbursement rate pursuant to subsection 3 scheduled for review and any 
unscheduled or excluded reimbursement rate the commission or the committee directs the 
department to review. 
3.  Review process.  The department shall review a reimbursement rate under 
subsection 2 pursuant to this subsection.
A.  The department shall conduct an analysis of the access, service, quality and use of 
each service subject to reimbursement rate review.  The department shall compare the 
rate reimbursed with available benchmarks, including Medicare rates and usual and 
customary rates paid by private parties, and use qualitative tools to assess whether 
reimbursements are sufficient to allow for provider retention and recipient access and 
to support appropriate reimbursement of high-value services. On or before May 1st of 
the scheduled review year the department shall provide a report on the analysis 
required by this subsection to the committee, the commission and any stakeholder 
and stakeholder group affected by the reimbursement rate review as identified by the 
department.
B.  Subsequent to the provision of a report under paragraph A, the department shall 
work with the commission and any stakeholder and stakeholder group identified by 
the department under paragraph A to review the report and develop strategies for 
responding to the findings, including any nonfiscal approaches or rebalancing of 
rates.
C.  Subsequent to the review under paragraph B, the department shall work with the 
Department of Administrative and Financial Services, Bureau of the Budget to 
determine achievable goals and executive branch priorities within the state budget.
D.  On or before November 1st of the scheduled rate year, the department shall 
submit a written report to the committee and the commission containing the 
department's recommendations on all of the reimbursement rates reviewed for that 
year pursuant to this subsection and all of the data relied upon by the department in 
making its recommendations. The committee shall consider the recommendations 
submitted pursuant to this subsection in formulating the budget for the department.
4.  MaineCare Independent Rate Commission.  The MaineCare Independent Rate 
Commission, established by Title 5, section 12004-J, subsection 18, is established as an 
independent commission within the department that provides review and oversight over 
the MaineCare program reimbursement rate process.
5.  Membership; meetings; bylaws; administrative support.  The commission 
consists of 24 members, appointed as follows:
A.  A recipient with a disability or a person who represents recipients with a 
disability, appointed by the President of the Senate;
B.  A representative of hospitals providing MaineCare program services 
recommended by a statewide association of hospitals, appointed by the President of 
the Senate;
C.  A representative of providers of transportation to recipients, appointed by the 
President of the Senate;
D.  A representative of rural health care centers, appointed by the President of the 
Senate;
E.  A representative of home health care providers recommended by a statewide 
organization of home health care providers, appointed by the President of the Senate;
F.  A representative of providers of durable medical equipment recommended by a 
statewide association of durable medical equipment providers, appointed by the 
President of the Senate;
G.  A representative of providers of behavioral health care services, appointed by the 
President of the Senate;
H.  A representative of primary care physicians who provide services to recipients 
recommended by a statewide association of primary care physicians, appointed by the 
President of the Senate;
I.  A representative of dentists who provide services to recipients recommended by a 
statewide association of dentists, appointed by the President of the Senate;
J.  A representative of federally qualified health centers, appointed by the President of 
the Senate;
K.  A representative of private nonmedical institutions and community-based service 
providers, appointed by the President of the Senate;
L.  A representative of providers serving recipients with intellectual and 
developmental disabilities, appointed by the President of the Senate;
M.  A representative of child recipients with a disability, appointed by the Speaker of 
the House of Representatives;
N.  A representative of physicians who specialize in an area of health care and are not 
employed by a hospital who see recipients, recommended by a statewide association 
whose members include at least 1/3 of the doctors of medicine and osteopathy 
licensed by the State, appointed by the Speaker of the House of Representatives;
O.  A representative of providers of alternative health care practices recommended by 
a statewide association of alternative health care practices, appointed by the Speaker 
of the House of Representatives;
P.  A representative of initial contact agencies, appointed by the Speaker of the House 
of Representatives;
Q.  A representative of ambulatory surgery centers, appointed by the Speaker of the 
House of Representatives;
R.  A representative of hospice providers recommended by a statewide association of 
hospice and palliative care providers, appointed by the Speaker of the House of 
Representatives;
S.  A representative of substance use disorder treatment providers recommended by a 
statewide association of substance use disorder treatment providers, appointed by the 
Speaker of the House of Representatives;
T.  A representative of facility-based physicians who see recipients, appointed by the 
Speaker of the House of Representatives;
U.  A representative of pharmacists providing services to recipients, appointed by the 
Speaker of the House of Representatives;
V.  A representative of managed care plans, appointed by the Speaker of the House of 
Representatives;
W.  A representative of advanced practice registered nurses recommended by a 
statewide association of nurses, appointed by the Speaker of the House of 
Representatives; and
X.  A representative of physical therapists or occupational therapists recommended 
by a statewide association of physical or occupational therapists, appointed by the 
Speaker of the House of Representatives.
A member serves a 4-year term and may be reappointed.  The appointing authorities shall 
make a concerted effort to include members of diverse political, racial, cultural, income 
and ability groups from urban and rural areas. Members shall elect a chair and a vice-
chair from among the membership.  A member serves without compensation or 
reimbursement for expenses.  The commission shall meet at least once every quarter, and 
the chair may call additional meetings determined necessary for the commission to 
complete its duties.  The commission shall enact bylaws and procedures to govern its 
operations.  The department shall provide administrative support to the commission.
6.  Commission duties.  The commission shall:
A.  Review the schedule of reimbursement rates under subsection 2 and recommend 
any changes to the schedule;
B.  Review a report prepared by the department under subsection 3, paragraph A and 
provide to the department comments and feedback on the report;
C.  With the department, conduct a public meeting to allow providers, recipients, 
stakeholders, stakeholder groups and other interested parties an opportunity to 
comment on a report prepared by the department under subsection 3, paragraph A;
D.  Review a proposal or petition for a reimbursement rate to be reviewed or adjusted 
that is received by the commission;
E.  Determine whether a reimbursement rate not scheduled for or excluded from 
review should be reviewed during that calendar year;
F.  Recommend to the department and the committee any changes to the process of 
reviewing reimbursement rates including measures to increase access to the process 
such as providing for electronic comments by providers and the public; and
G.  Provide other assistance to the department as requested by the department and the 
committee.
SUMMARY
This bill establishes a process by which the Department of Health and Human 
Services maintains a schedule of MaineCare program reimbursement rate reviews in 
which each rate is reviewed at least every 5 years.  Under this process, the department 
reviews a rate for access, service, quality and use of service and compares the rate 
reimbursed with available benchmarks, including Medicare rates and usual and 
customary rates paid by private parties, and uses qualitative tools to assess whether 
reimbursements are sufficient to allow for provider retention and recipient access and to 
support appropriate reimbursement of high-value services.  The department is required to 
provide a report of its review to the joint standing committee of the Legislature having 
jurisdiction over appropriations and financial affairs, the MaineCare Independent Rate 
Commission, a 24-member group of interested parties providing oversight of the rate 
review process, and stakeholders.  After holding public meetings and consulting 
stakeholders and stakeholder groups and consultation with the Department of 
Administrative and Financial Services, Bureau of the Budget, the department makes 
recommendations on the MaineCare reimbursement rates to the joint standing committee 
of the Legislature having jurisdiction over appropriations and financial affairs to assist in 
developing the department's budget.