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 II - Specific Policies By Service › Section 144-101-II-90 - Physician Services › Subsection 144-101-II-90.09 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
90.09-1
Fee Schedule
MaineCare reimburses for physician services using a fee
						schedule known as the MaineCare rate of reimbursement (See Section 90.09-2 A.)
						The fees or cap associated with service codes are in the MaineCare claims
						processing database, and are available to any provider who requests a paper or
						electronic copy. The information is also available on the MaineCare Services
						website: https://mainecare.maine.gov/. Fees are subject to change, although the
						rate in effect as of the date of service applies for procedures performed on
						that date.
Providers who use electronic information from the website
						should note that they are still subject to all applicable MaineCare rules. The
						MaineCare Program will provide quarterly updates on the website.
Providers must bill using their usual and customary
						charges and reimbursement will be in accordance with the criteria cited below.
						Providers must bill medical supplies and therapeutic injections at their cost,
						using NDC codes where available. Providers should direct any questions to the
						Provider Relations Unit..
90.09
					 -2
MaineCare Reimbursement Rates
MaineCare will reimburse the lowest of the following
						(subparts A, B, or C) for covered services, except as otherwise outlined in
						this Section (MBM, Chapter II, Section 90.09):
A.
Effective through June 30,
					 2022
, the Fee Schedule rate, which is set based on:
(1) Seventy percent (70%) of the lowest level
					 in the 2009 Medicare fee schedule (or 70% of the rate in the year CMS assigned
					 a rate for that code) for Maine area "99" including appropriate Medicare fee
					 adjustments for place of service and modifiers in effect at that time;
					 or
(2) The lowest amount allowed by
					 Medicare Part B for Maine area "99" fee schedule including appropriate Medicare
					 fee adjustments for place of service and modifiers; or
(3) If the above two options are not
					 available, the Department will research other State Medicaid agencies that
					 cover the relevant service/code. The Department will base its rate on the
					 average cost of the relevant services/codes from those other agencies.
The Department shall submit to CMS and anticipates
						approval for a State Plan Amendment related to these provisions.
Effective July 1, 2022
, the Fee Schedule
						rate, which is set based on:
(1)
					 Seventy-two point four percent (72.4%) of the current year's Medicare rate per
					 code for Maine area "99," including appropriate Medicare fee adjustments for
					 place of service and modifiers in effect at that time; or
(2) If there is no Medicare rate available,
					 the Department will research other State Medicaid agencies that cover the
					 relevant service/code. The Department will base its rate on the average cost of
					 the relevant services/codes from those other agencies.
OR