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-45.04 - ACUTE CARE CRITICAL ACCESS HOSPITALS

Current through 2024-29, July 17, 2024
45.04-1
Department's Total Obligation
					 to the Hospital
The Department of Health and Human Services' total annual
						obligation to the hospitals will be the sum of MaineCare's obligation of the
						following: inpatient services + outpatient services + days awaiting placement
						and in swing beds + hospital based physician + Disproportionate Share Hospital
						(for eligible hospitals) + supplemental pool reimbursements (for eligible
						hospitals) - third party liability payments.
A. *
Inpatient Services
MaineCare will reimburse one hundred and nine percent
						(109%) of allowable costs.
B.
Outpatient Services
MaineCare will reimburse one hundred and nine percent
						(109%) of allowable costs.
C. *
Distinct Psychiatric and Substance
					 Use Disorder Units
MaineCare will reimburse stays on these units as outlined
						in Section
						45.03(B)
						of this rule. Reimbursement for services provided on these units will not be
						cost settled.
* The Department shall submit the CMS and anticipates
						approval for a State Plan Amendment related to these provisions.
D.
Supplemental Pool
The Department will allocate the supplemental pool amount
						for each state fiscal year among the privately owned and operated acute care
						critical access hospitals based on their relative share of total MaineCare
						payment as compared to other critical access hospitals.
Total annual supplemental pool amounts are available on
						the MaineCare Services website; or, interested parties may request a paper copy
						by calling (207) 624-4050 or Maine Relay number 711.
The relative share is defined as the critical access
						hospital's MaineCare payment in the applicable state fiscal year divided by
						MaineCare payments made to all CAH hospitals in that year; multiplied by the
						total supplemental pool. This amount will not be adjusted at the time of
						audit.
For state fiscal year beginning on or after July 1, 2019,
						but before July 1, 2021, the hospital's applicable year is the hospital's
						fiscal year that ended during calendar year 2016.
Each hospital in the pool will receive its relative share
						of this supplemental payment. Supplemental payments will be distributed
						semiannually in November and May.
D.
MaineCare Member Days Awaiting
					 Placement at a Nursing Facility
The Department will reimburse prospectively at the
						estimated statewide average rate per member day for NF services. The Department
						will reimburse at the prospective statewide average rates per member day for NF
						services that are specified in the "Principles of Reimbursement for Nursing
						Facilities",
MaineCare Benefits Manual
Chapter III, Section
						67. The Department
						shall compute the average statewide rate per member day based on the simple
						average of the NF rate per member day for the applicable State fiscal year(s)
						and prorated for a hospital's fiscal year.
E.
Other Components
MaineCare will reimburse its share of inpatient
						hospital-based physician costs, outpatient emergency room hospital-based
						physician costs, outpatient nonemergency room hospital-based physician costs,
						and all graduate medical education costs.
Effective January 1, 2020, MaineCare's share of
						hospital-based physician costs is reimbursed at one hundred percent (100%) of
						costs.
July 1, 2009, through December 31, 2019, MaineCare will
						reimburse ninety-three and three tenths percent (93.3%) of its share of
						inpatient hospital-based physician, ninety-three and four tenths percent
						(93.4%) of its share of outpatient emergency room hospital-based physician, and
						eighty-three and eight tenths percent (83.8%) of outpatient non-emergency room
						hospital-based physician costs.