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-45.03 - ACUTE CARE NON-CRITICAL ACCESS HOSPITALS

Current through 2024-29, July 17, 2024
45.03-1
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 +
						hospital-based physician costs + graduate medical education costs +
						Disproportionate Share Payments (for eligible hospitals) + supplemental pool
						reimbursements - third party liability payments.
A.
Inpatient Services
(not
					 including distinct psychiatric or, if CMS approves, substance use disorder unit
					 discharges)
Effective for reimbursement for admissions on or after
						July 1, 2011, the Department will pay using DRG-based discharge rates, which
						include estimated capital and medical education costs (see Appendix for full
						description). The Department will reimburse hospitals based on required billing
						forms, as described in the Department's billing instructions. As explained in
						the Appendix, the payment is comprised of three components: the capital expense
						and graduate medical education components will be subject to interim and final
						cost settlement, and the DRG direct rate component will not be cost
						settled.
B.
Distinct
					 Psychiatric Units and Distinct Substance Use Disorder Units
Effective July 1, 2023, the Department will pay distinct
						psychiatric unit and distinct substance use disorder (SUD) units as outlined
						below. This reimbursement methodology shall apply for members whose From Date
						is on or after July 1, 2023. The methodology shall be as follows:
1.
Payment Rate for Distinct
					 Psychiatric Units and Distinct Substance Use Disorder Units
a. The Department has adopted the Medicare
					 MS-DRG and Length of Stay factors as specified in the distinct psychiatric unit
					 and distinct SUD unit reimbursement schedule which is posted on the
					 Department's website. Per diem base rates were calculated to result in total
					 reimbursement equal to one hundred percent (100%) of the costs of such
					 discharges in the aggregate across all hospitals with distinct psychiatric
					 units and distinct SUD units, utilizing 2022 data, when adjusted for MS-DRG
					 relative weights and Length of Stay factor. The Medicare Length of Stay factor
					 is a cumulative factor that takes into account how many days the patient stays
					 in the distinct unit.
b. The
					 Department will calculate reimbursement for covered inpatient stays in these
					 distinct units using the following formula:
Per diem base rate (determined by whether the MS-DRG is a
						psychiatric or SUD MS-DRG) multiplied by the applicable MS-DRG relative weight
						multiplied by the applicable Length of Stay factor
c. Per diem base rates for psychiatric
					 MS-DRGs differ for adults aged nineteen (19) and older and youth aged eighteen
					 (18) and younger, reflecting the significant difference in average costs
					 observed in hospitals' 2021 and 2022 cost report data for these populations.
					 The per diem base rate for SUD MS-DRGs will remain consistent regardless of
					 member's age.
d. Per diem base
					 rates will be updated annually based on the inflation provision in this rule
					 and are posted on the MaineCare Provider Fee Schedule, in accordance with
					 22 MRSA
					 Section3173-J.
e. DRG and outlier methodology as described
					 in the Appendix does not apply to claims from these distinct
					 units.
2.
Supplemental Payment for Certain Distinct Psychiatric Units
Hospitals that have distinct psychiatric units, are
						located in zip codes that CMS designates as "super rural," meaning they are in
						the bottom quartile of nonmetropolitan zip codes by population density, and
						also have a designation by the Health Resources and Services Administration
						(HRSA) as a High Needs Geographic Health Professional Shortage Area (HPSA) for
						mental health are eligible to receive a yearly supplemental payment in the
						amount of eight hundred and seventy-five thousand dollars $875,000. This
						supplemental payment will be distributed in equal payments in May and November.
						This supplemental payment is not subject to cost settlement. The supplemental
						payment will expire on June 30, 2025.
3.
Cost Settlement
Claims paid under this methodology do not include
						graduate medical education costs, and will not be subject to cost settlement,
						with the exception of capital costs incurred prior to July 1, 2025.
4.
Billing Practices
Providers billing for distinct psychiatric units or
						distinct SUD units should ensure billing practices align with requirements
						outlined in the MaineCare UB-04 Billing Instructions Guide located on the
						HealthPAS website.
C.
Outpatient Services, Including
					 Laboratory and Imaging
1.
Private
					 Hospitals
a.
APC Payment
Effective July 1, 2013, the Department will reimburse
						hospitals eighty-three and seven tenths percent (83.7%) of the adjusted
						Medicare APC rates, where the APC is applicable, unless otherwise specified in
						this rule.
The APC payment does not include hospital-based physician
						services. The APC payment may include ancillary services such as imaging and
						laboratory test costs.
APC payments are made when the member receives services
						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 patient 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 shall
						be paid only a DRG-based discharge rate and will not receive an APC
						payment.
An outlier payment adjustment is 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.
b.
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 three (3) calendar days 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
						nondiagnostic services that are furnished to the member during the three (3)
						days immediately preceding the date of inpatient hospital admission. Distinct
						rehabilitation, psychiatric, and substance use disorder units of a hospital are
						subject to only a one (1)-day payment window (the one (1) calendar 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 three (3) calendar days (or one (1) calendar day if applicable)
						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.
c.
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 rates listed on the MaineCare Provider Fee Schedule.
d.
Payment for Non-emergency
					 use of the Emergency Department
Effective October 1, 2015, hospital payment for an
						emergency department visit (CPT codes 99281-99285 billed with revenue codes
						0450-0459), with a primary diagnosis code included in Appendix B will be paid
						the outpatient physician's professional evaluation and management service fee
						schedule rate. This will be determined by using the current physician's payment
						rate listed in the MaineCare Provider Fee Schedule associated with the
						emergency department CPT code reported on the UB04 claim.
2.
Public Hospitals
a.
APC Payment
Effective July 1, 2009, the Department's total annual
						obligation to a hospital for outpatient services equals the lower of
						eighty-three and eight tenths' percent (83.8%) of MaineCare outpatient costs or
						charges.
MaineCare's share of clinical laboratory and imaging
						costs are added to this amount. The procedure codes and terminology of the
						Healthcare Common Procedure Coding System (HCPCS) are used to establish
						MaineCare allowances for clinical laboratory and imaging services.
Hospitals must use APC billing for all outpatient
						services. The APC billing does not include hospital-based physician services.
						The APC billing may include ancillary services such as imaging and laboratory
						test costs.
APC billing is required when the member receives services
						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 patient 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 shall
						not report this under APC billing requirements.
b.
Payment for Non-emergency use of the
					 Emergency Department
Effective October 1, 2015, hospital payment for an
						emergency department visit (CPT codes 99281-99285 billed with revenue codes
						0450-0459), with a primary diagnosis code included in Appendix B will be the
						outpatient physician's professional evaluation and management service fee
						schedule rate. This will be determined by using the current physician's payment
						rate listed in the MaineCare Provider Fee Schedule associated with the
						emergency department CPT code reported on the UB04 claim.
3.
Hospital Outpatient
					 Provider-Based Departments (PBDs)
Effective November 14, 2017, items and/or services that
						are furnished by an off-campus hospital outpatient provider-based department
						(PBDs) will be reimbursed as follows:
*MaineCare requires hospitals to use a PN modifier to
						identify nonexcepted items and services provided by PBDs. These services are
						paid at a reduced MaineCare rate, proportionate to the reimbursement described
						in the annual CMS OPPS/ASC final rule. PBDs are required to bill nonexcepted
						items and services on an institution claim (UB04) and report the PN modifier on
						each claim line for non-excepted items and services. Physicians will be paid
						the professional claim and will be paid at the facility rate consistent with
						current policies for physicians practicing in an institutional setting for the
						technical component of all non-excepted items and services.
The non-excepted items and services PN modifier
						requirement does not apply to items and services furnished by:
1. A dedicated emergency
					 department;
2. Remote locations of
					 a hospital (where inpatient services are furnished) and locations that are
					 within two hundred fifty (250) yards of a remote location of a hospital;
					 and
3. A location that was billing
					 as an outpatient department of a hospital prior to November 2, 2015 (known as
					 "excepted" locations).
*MaineCare does not require providers to bill using the
						Centers for Medicare & Medicaid Services (CMS) created HCPCS "PO" modifier
						for hospital claims for outpatient hospital excepted items and services
						furnished in an excepted off-campus provider-based (PBD) department of a
						hospital. Providers must follow guidelines set by the primary insurance
						carriers.
*Relocation of an off campus PBD from the hospital's
						recorded address of November 1, 2015, will be considered "new" and ineligible
						for continued excepted status. Any expansion of an excepted PBD (to include new
						or additional services) will be considered "new" and ineligible for excepted
						status for those new or additional services.
* The Department shall submit to CMS and
						anticipates approval for a State Plan Amendment related to these
						provisions.
D.
Capital and Graduate Medical
					 Education Costs
MaineCare will reimburse its share of inpatient capital
						costs. Effective January 1, 2020, Maine will reimburse one hundred percent
						(100%) of all graduate medical education costs for both rural and non-rural
						hospitals.
Estimates of these costs will be included in the
						DRG-based discharge rate as described in the Appendix. This reimbursement is
						subject to cost settlement.
E.
Hospital-based Physician, Effective
					 January 1, 2020:
MaineCare will reimburse non-rural hospitals
Ninety-three and three tenths percent (93.3%) of
						  its share of inpatient hospital-based physician costs,
													Ninety-three and four tenths percent (93.4%) of its
						  share of outpatient emergency room hospital-based physician costs,
						  and
													Eighty-three and eight tenths percent (83.8%) of
						  non-emergency room outpatient hospital-based physician costs.
MaineCare will reimburse rural hospitals
One hundred percent (100%) of its share of
						  inpatient hospital-based physician costs,
													One hundred percent
(
100%) of its
						  share of outpatient emergency room hospital-based physician costs,
						  and
													One hundred percent (100%) of non-emergency room
						  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.