Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-45 - HOSPITAL SERVICES › Subsection 144-101-III-45.06 - REHABILITATION HOSPITALS

Current through 2024-29, July 17, 2024
45.06-1
Department's Total Obligation to the Hospital
The Department of Health and Human Services' total annual
						obligation to a hospital will be the sum of MaineCare's obligation for the
						following: inpatient services + outpatient services + inpatient capital costs +
						days awaiting placement in swing beds+ Disproportionate Share Payments (for
						eligible hospitals) + supplemental pool reimbursements - third party liability
						payments.
A.
Inpatient
					 Services
Effective July 10, 2018, the Department will reimburse
						$15,161.43 per discharge.
B.
Outpatient Services, including Laboratory and Imaging
1.
APC Payments
Effective July 1, 2013, the Department will reimburse
						rehabilitation hospitals eighty-three and seven tenths percent (83.7%) of the
						adjusted Medicare APC rate where the APC applies.
The APC payment does not include hospital-based physician
						services. The APC payment may include ancillary services such as imaging and
						laboratory test costs. If multiple procedures are performed, the Department
						will pay the hospital eighty-three and seven tenths percent (83.7%) of
						Medicare's single bundled APC rate.
APC payments will be made for services received in an
						emergency room, clinic or other outpatient setting, or, if the outpatient is
						transferred to another hospital or facility that is not affiliated with the
						initial hospital, where the member received the outpatient services. If the
						outpatient is admitted from a hospital's clinic or emergency department to the
						same hospital as an inpatient, the hospital will be paid only a discharge rate
						and will not receive an APC payment.
An outlier payment adjustment will be made to the rate
						when an unusually high level of resources has been used for a case. Effective
						July 1, 2013, calculations for outlier payments will follow Medicare rules and
						be paid at eighty-three and seven tenths percent (83.7%) of the Medicare
						payment.
2.
Payment
					 Window Rule
This rule institutes billing and payment procedures for
						outpatient services provided on either the date of a member's inpatient
						hospital admission or during the one (1) calendar day immediately preceding the
						date of a member's inpatient hospital admission. Hospitals (or an entity that
						is wholly owned or wholly operated by the hospital) must include on the claim
						for a member's inpatient stay, the diagnoses, procedures, and charges for all
						outpatient diagnostic services and admission-related outpatient non-diagnostic
						services that are furnished to the member during the one (1) day immediately
						preceding the date of inpatient hospital admission.
An entity is wholly owned by the hospital if the hospital
						is the sole owner of the entity. An entity is wholly operated by a hospital if
						the hospital has exclusive responsibility for conducting and overseeing the
						entity's routine operations, regardless of whether the hospital also has
						policymaking authority over the entity.
The technical component of all outpatient diagnostic and
						clinically related non-diagnostic services that are provided by the hospital,
						or by an entity wholly owned or wholly operated by the hospital, are to be
						billed with the claim for inpatient services when the outpatient services are
						provided in the one (1) calendar day preceding an inpatient admission.
All non-clinically related, non-diagnostic services
						provided before admission are not to be included on the inpatient claim. These
						outpatient services should be identified with the appropriate condition code.
						All non-diagnostic services, clinically related or not, provided on the date of
						inpatient admission are always deemed to be related to the admission and are to
						be included on the inpatient claim.
MaineCare will reimburse the technical portion of the
						outpatient services on the inpatient claim.
For physician services provided during the payment window
						and billed on the CMS 1500, the entity must append the appropriate modifier to
						all claim lines identified as connected to the inpatient stay. MaineCare will
						reimburse the professional component with payment rates that include a
						professional and technical split and at the facility rate for services that do
						not have a professional and technical split.
It is the responsibility of the admitting hospital to
						notify wholly-owned or wholly-operated entities of an inpatient admission which
						may impact the entities eligibility for payment.
The payment window rule does not apply to outpatient
						services included in the rural health clinic or federally qualified health
						center all-inclusive rate, nor does it apply to ambulance and maintenance renal
						dialysis services.
3.
Fee Schedule Payments
A limited number of Current Procedural Terminology (CPT)
						codes do not have associated Medicare APC rates, as listed in Addendum B.
						MaineCare covers certain services listed in Addendum B and pays for these
						services based on a fee schedule.
C.
Capital and Graduate Medical
					 Education Costs
MaineCare will reimburse its share of inpatient capital
						costs and all graduate medical education costs during the interim and final
						settlement processes.
D.
Hospital based Physicians
MaineCare will reimburse
Ninety-three and three tenths percent (93.3%) of
						  its share of inpatient hospital-based physician,
													Eighty-three and eight tenths percent (83.8%) of
						  outpatient hospital-based physician costs.
Hospitals will be reimbursed based on claim forms filed
						with the Department. The billing procedure is described in Chapter II, Section
						45. These payments are
						subject to cost settlement.