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-2 - Adult Family Care Services › Subsection 144-101-II-2.08 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
A. The Department will reimburse a
					 resource-adjusted (case-mix) price for covered services. The unadjusted price
					 is listed in Chapter III, Section 2, "Allowances for Adult Family Care
					 Services." The Department will multiply this unadjusted price by the
					 member-specific MaineCare weight. That weight will calculate reimbursement by
					 taking into consideration by resource grouping that some members are more
					 costly to serve than others. Thus, the system requires:
1. Accurate assessment using the MDS-ALS form
					 of all residents;
2. Classification
					 of members into groups which are similar in resource utilization, as reflected
					 in the AFC services classification groups defined in section; and
3. A weighting system that quantifies the
					 relative cost of services for different subsets of members according to a time
					 study that translates into a resource-adjusted price.
There are eight (8) resource-adjusted (case mix) groups,
						including one classification group used when members cannot be classified into
						one of the other seven (7) classification groups. Each group has a specific
						resource adjusted weight, as follows:
Resident Group
Resource Classification Group
Short description
MaineCare Weight
ALS 7-9
1
ADL=7-28
1.657
2
ADL=0-6
1.210
ALS 5-6
3
ADL=3-28
1.360
4
ADL=0-1
1.027
ALS 2-4
5
IADLB=12-18
.924
6
IADLB=10-11
.804
ALS 0-1 or ALS 2-4 and IADL 0-9
7
ALS 0-1 or ALS 2-4 and IADL 0-9
.551
ALS 0-1
8
Unclassified
.551
4. The Department will calculate
					 resource-adjusted prices on assessments as of January
					 1st and July 1st of each
					 year, beginning on July 1, 2004. The Department will calculate the price for
					 each member based on the MaineCare weight for the period as follows:
a. The most recent MDS-ALS for each member in
					 the facility as of the 15th of March for the July
					 rate and the 15th of September for the January
					 rate.
b. The resource-adjusted
					 price will be calculated by multiplying the resource group by the MaineCare
					 weight.
c. A roster of all members
					 receiving AFC services and sources of payment as of March
					 15th and July 15th will
					 be sent to facilities for verification prior to rate setting.
d. The Department will utilize the roster
					 sent to the provider in identifying the MaineCare members and their most recent
					 assessment. It is the provider's responsibility to check the roster, make
					 corrections and submit corrections to the Department or its designee within one
					 week of receiving the roster.
For new facilities without a resource grouping already
						calculated, the Department will apply a MaineCare weight of .924 to the
						unadjusted price for the first rate setting period. The actual
						resource-adjusted price will be applied to the first rate setting period after
						either a March 15 or September 15 roster is available, as applicable. Sanctions
						pursuant to Section 2.07-1 will not be applied to new facilities until an
						actual resource-adjusted price is used in rate setting.