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-45.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
45.01-1
Accountable Communities
					 (AC)
is a MaineCare initiative established through a contract between
					 the Department and an Accountable Community Lead Entity that establishes a
					 financial relationship between the Department and the AC Lead Entity to both
					 provide a financial incentive and hold the AC accountable for the provision of
					 efficient, coordinated, and high-quality care. AC Lead Entities that achieve
					 savings relative to a benchmark Total Cost of Care (TCOC) amount are eligible
					 to receive a portion of these savings dependent on and proportional to their
					 performance on a number of quality measures.
45.01-2
Acute Care Critical Access
					 Hospital
is a hospital licensed by the Department of Health and Human
					 Services (DHHS or "the Department") as a critical access hospital that is being
					 reimbursed as a critical access hospital by Medicare.
45.01-3
Acute Care Non-Critical Access
					 Hospital
is a hospital licensed by the Department as an acute care
					 hospital that is not being reimbursed as a critical access hospital by
					 Medicare. There are two subsets of Private Acute Care Non-Critical Access
					 Hospitals: rural hospitals and non-rural hospitals.
45.01-4
Ambulatory Payment
					 Classifications (APC)
means the classification of hospital based
					 outpatient services for use in determining facility reimbursement as defined in
					 the Medicare APC system.
45.01-5
As-Filed Medicare Cost Report
means the cost report that the
					 hospital files with the Medicare fiscal intermediary and with MaineCare,
					 utilizing the CMS Medicare Cost Report form. In order for an As-Filed Medicare
					 Cost Report to be accepted by MaineCare, hospitals must complete all
					 information in the sections relevant to Title XIX, whether or not required by
					 CMS.
45.01-6
Diagnosis-Related Group
(DRG) means the classification of medical
					 diagnoses for use in determining reimbursement as defined in the Medicare DRG
					 system or as otherwise specified by the Department.
45.01-7
Discharge
occurs when a
					 member is formally released from the hospital, transferred from one hospital to
					 another, transferred to a distinct unit in the same hospital (distinct units
					 include distinct rehabilitation psychiatric, and substance use disorder units),
					 or dies in the hospital. For purposes of this Section for all hospitals except
					 critical access hospitals, a member is not considered discharged if he or she
					 is transferred to any different location or non-distinct unit) in the same
					 hospital, or is readmitted to the same hospital on the same day, or is
					 readmitted to the same hospital within fourteen (14) days of an inpatient
					 discharge for a diagnosis within the same DRG, regardless of complications or
					 co-morbidity.
There are exceptions to the fourteen (14) day readmission
						protocol. The exceptions are as follows:
a) Readmissions for individuals who are
					 diagnosed with a mental health diagnosis described in the most current version
					 of the American Psychiatric Association's
Diagnostic and Statistical
					 Manual
(DSM);
b)
					 Readmissions for individual whose symptoms meet the American Society of
					 Addiction Medicine (ASAM) Level 4 Criteria, as defined in the most recent
					 edition of the ASAM Criteria: Treatment Criteria for Addictive, Substance
					 -related, and Co-Occurring Conditions; and
c) Readmissions for individual receiving
					 inpatient maintenance chemotherapy treatment.
Effective July 1, 2011, for hospitals billing under DRG
						based methodology, transferring a member to a distinct rehabilitation unit
						within the same hospital for the same diagnosis will be considered a
						discharge.
Effective July 1, 2023, for Acute Care Non-Critical and
						Acute Care Critical Access Hospitals, transferring a member to a distinct
						psychiatric or substance use disorder unit from a non-distinct unit within the
						same hospital will be considered a discharge.