reglab/statecodes huggingface dataset:
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-40 - Home Health Services

Current through 2024-29, July 17, 2024
REV CODE/PROC. CODE
DESCRIPTION
MAXIMUM ALLOWANCE PER UNIT EFFECTIVE THROUGH
								DECEMBER 31, 2018
MAXIMUM ALLOWANCE PER UNIT EFFECTIVE AS OF
								JANUARY 1, 2019*
UNIT
0551/ G0299
Services of skilled nurse in home health
								setting(RN)
$28.32
$33.46
15 minutes
0559/ G0300
Services of skilled nurse in home health
								setting(LPN/LVN)
$19.82
$23.42
15 minutes
0571/ G0156
Services of home health aide in home health
								setting
$13.28
$15.16
15 minutes
0431/ G0152
Services of occupational therapist, in home health
								setting
$33.25
$36.83
15 minutes
0431/ G0152TF
Services of occupational therapist, in home health
								setting (occupational therapy assistant)
$23.28
$25.79
15 minutes
0421/ G0151
Services of physical therapist in home health
								setting
$31.29
$36.58
15 minutes
0421/ G0151TF
Services of physical therapist in home health
								setting (physical therapy assistant)
$21.91
$25.61
15 minutes
0441/ G0153
Services of a speech and language pathologist in
								home health setting
$32.78
$39.75
15 minutes
0441/ G0153TF
Services of speech and language pathologist in home
								health setting (speech and language pathologist assistant)
$22.95
$27.83
15 minutes
0561/ G0155
Services of clinical social worker in home health
								setting
$28.32
$36.82
15 minutes
0551/ T1502
Administration of oral, intramuscular and/or
								subcutaneous medication by health care agency/professional
$84.95
$84.95
Per visit
Code on web/ 0290
Non Routine Medical Supplies - General - To be
								billed with appropriate, allowable supplies code designated by MaineCare
								Services on the Internet At
https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx?RootFolder=%2FProvider%20Fee%20Schedules%2FCustom%20Fee%20Schedules&FolderCTID=0x012000264D1FBA0C2BB247BF40A2C571600E81&View=%7B69CEE1D4-A5CC-4DAE-93B6-72A66DE366E0%7D
Lower of either Acquisition Cost or DME
								price
Lower of either Acquisition Cost or DME
								price
Per Item
S9110
Telemonitoring of Patient in their Home
$84.55
$84.55
Per Month
* The Department is seeking, and anticipates receiving
					 approval, from CMS for these reimbursement rates. Pending approval, the rates
					 will be effective 1/1/19.
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-43 - ALLOWANCES FOR HOSPICE SERVICES (REPEALED)

Current through 2024-29, July 17, 2024
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-45.05 - HOSPITALS RECLASSIFIED TO A WAGE AREA OUTSIDE MAINE BY THE MEDICARE GEOGRAPHIC CLASSIFICATION REVIEW BOARD (MGCRB) PRIOR TO OCTOBER 1, 2008

Current through 2024-29, July 17, 2024
The reimbursement methodology for these hospitals is
						identical to that used for critical access hospitals, except that these
						hospitals are not eligible for payments from the supplemental pool described in
						Section 45.04.
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-45.09 - PRIVATE PSYCHIATRIC HOSPITALS

Current through 2024-29, July 17, 2024
45.09-1
Department's Total Annual Obligation to the Hospital
The Department of Health and Human Services' total annual
						obligation to the hospitals is the sum of MaineCare's obligation of the
						following: inpatient services + outpatient services + Disproportionate Share
						Hospital (for eligible hospitals) - third party liability payments.
A.
Inpatient Services
The rate will be negotiated and becomes effective at the
						beginning of a hospital's fiscal year. The Department's total annual obligation
						shall be computed based on the hospital's negotiated rate.
The negotiated rate shall be between eighty-five percent
						(85%) and one hundred percent (100%) of the hospital's estimated inpatient
						charges, less third party liability. The hospital must notify the Department
						sixty (60) days prior to any increase in its charges.
If the hospital increases charges subsequent to the
						annual adjustment, the hospital and the Department will meet to consider the
						extent that the increase in charges will affect the amount paid by MaineCare
						and to negotiate the amount by which the previously negotiated percentage of
						charges must be adjusted to account for the impact. If the hospital commences
						any new MaineCare inpatient covered service, whether or not subject to
						Certificate of Need review, the parties will separately negotiate the
						percentage of charges to be paid by MaineCare for that service.
Special circumstances may arise during the course of a
						year that may warrant reconsideration and adjustment of the negotiated rate.
						These circumstances could include changes in psychiatric bed capacity or
						patient populations within the State that materially impact MaineCare or
						uncompensated care volume, extraordinary increases in charges, legislative
						deappropriation, MaineCare deficits that may result in decreased State funding,
						as well as other special circumstances that the parties cannot now
						foresee.
B.
Outpatient
					 Services
The Department's total annual obligation to the hospital
						will be one hundred and seventeen percent (117%) of allowable outpatient costs,
						determined from the most recent Interim Cost Settlement Report, inflated
						forward to the current State fiscal year.
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-45.10 - STATE OWNED PSYCHIATRIC HOSPITALS

Current through 2024-29, July 17, 2024
State owned psychiatric hospitals will be reimbursed as
						follows:
45.10-1
Total
					 Obligation to the Hospital
The MaineCare total annual obligation to the hospitals
						will be the sum of: MaineCare's obligation of the following: inpatient services
						+ outpatient services + days awaiting placement + hospital-based physician +
						direct graduate medical education costs + estimated DSH obligation - third
						party liability payments. Amounts are calculated as described below:
A.
Inpatient Services
The total MaineCare inpatient operating costs from the
						most recent Interim Cost Settlement Report inflated forward as described in
						Section 45.02-1 to the
						current State fiscal year.
B.
Outpatient Services
MaineCare outpatient costs inflated to the current State
						fiscal year using the most recent Interim Cost Settlement
						Report
.
C.
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
						shall adopt 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 will
						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.
D.
Other Components
MaineCare's share of hospital-based physician + graduate
						medical education costs are taken from the most recent hospital Interim Cost
						Settlement Report inflated to the current year.
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-45.11 - OUT-OF-STATE HOSPITALS

Current through 2024-29, July 17, 2024
The Department will reimburse out-of-state hospitals for
						inpatient and outpatient services based on
1. The MaineCare rate if
					 applicable;
2. The lowest
					 negotiated rate with a payor whose rate the hospital provider currently
					 accepts;
3. The hospital provider's
					 in-State Medicaid rate;
4. A
					 percentage of charges; or
5. A rate
					 specified in MaineCare's contract with the hospital provider.
Except as otherwise specifically provided in the
						agreement between MaineCare and the out-of-state hospital providers,
						out-of-state hospital providers must accept MaineCare reimbursement for
						inpatient services as payment in full for all services necessary to address the
						illness, injury or condition that led to the admission. Reimbursement for
						out-of-state hospital outpatient laboratory and imaging services shall not
						exceed the one-hundred percent (100%) of the Medicare reimbursement rate for
						the Maine area ("99 locality"). Out-of-state hospitals are required to report
						and are subject to all applicable pricing modifiers.
Out-of-State hospital providers must meet all
						requirements outlined in Chapter I of the
MaineCare Benefits
						Manual
(MBM) including signing a provider/supplier agreement and
						obtaining prior authorization.
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-45.12 - CLINICAL LABORATORY AND IMAGING SERVICES

Current through 2024-29, July 17, 2024
Hospital laboratory, imaging, and physician services
						provided to a member not currently a patient of the hospital are considered
						outpatient hospital services. These services are covered in accordance with
						requirements, and utilization limitations (including prior authorizations)
						described in the following sections of the
MaineCare Benefits
						Manual
and are reimbursable in accordance with MBM Chapter II, Section
						55, Laboratory Services, Chapter
						II, Section
						90, Physician Services, or
						Chapter II, Section
						101, Medical Imaging Services.
						Rates for those services are posted on the Department's website.
In the case of tissues, blood samples or specimens taken
						by personnel that are not employed by the hospital but are sent to a hospital
						for performance of tests, the tests are not considered outpatient hospital
						services since the member does not receive services directly from the
						hospital.
Certain clinical diagnostic laboratory tests must be
						performed by a physician and are, therefore, exempt from the fee schedule.
						Medicare periodically sends updated lists of exempted tests to hospitals.
						Laboratory services must comply with the rules implementing the Clinical
						Laboratory Improvement Amendments (CLIA 88) and any applicable
						amendments.
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-45.13 - PROVIDER PREVENTABLE CONDITIONS

Current through 2024-29, July 17, 2024
In accordance with the
Affordable Care
						Act
, MaineCare will not reimburse providers for Provider Preventable
						Conditions (PPCs) as defined in the federal Medicaid regulation,
						42 CFR
						447.26.
All hospitals must identify and report to the Department
						all PPCs, but Hospital providers are prohibited from submitting claims for
						payment of these conditions except as permitted in
						42 CFR
						447.26, when the PPC for a particular patient
						existed prior to the initiation of treatment for that patient by that hospital
						provider.
The DRG payment calculations automatically ensure that
						providers will not be compensated for these conditions. Hospital providers who
						are not reimbursed using DRGs must report all PPCs on claims and bill zero
						charges for these PPCs, except as provided above.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-1000 - PURPOSE

Current through 2024-29, July 17, 2024
The purpose of these Principles is to comply with Section
						1902(a)(13)(A) of the Social Security Act and the Rules and Regulations
						published thereunder ( 42 CFR Part 447 ) namely to provide for payment to
						Intermediate Care Facilities for the Mentally Retarded (ICFs-MR) through the
						use of rates that are reasonable and adequate to meet the costs incurred by
						efficiently and economically operated facilities in order to provide care and
						services in conformity with applicable State and Federal laws, regulations, and
						quality and safety standards.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-1010 - AUTHORITY

Current through 2024-29, July 17, 2024
The authority of the Department of Health and Human
						Services to accept and administer any funds that may be available from private,
						local, State, or Federal sources for the provision of the services set forth in
						these Principles of Reimbursement is established in Title 22 of the Maine
						Revised Statutes Annotated, § 10 and § 12. These regulations are
						issued pursuant to authority granted to the Department of Health and Human
						Services by Title 22 of the Maine Revised Statutes Annotated §
						42(l).
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-1020 - DEFINITONS

Current through 2024-29, July 17, 2024
1021
Department
as used
					 throughout these Principles is the State of Maine Department of Health and
					 Human Services.
1022
Designated Planning Agency
as used throughout these Principles is
					 the State of Maine Department of Health and Human Services functioning as the
					 Designated Planning Agency under Section 1122 of Public Law 92-603, the Social
					 Security Amendments of 1972.
1023
State Licensing and Federal Certification
as used throughout these
					 principles are the "Regulations Governing the Licensing and Functioning of
					 Intermediate Care Facilities for the Mentally Retarded" and the Federal
					 Certification requirements for Intermediate Care Facilities for the Mentally
					 Retarded that are in effect at the time the expense is incurred.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-1030 - REIMBURSEMENT METHOD

Current through 2024-29, July 17, 2024
The Department will reimburse an ICF-MR on the basis of a
						prospectively determined rate on cost reporting forms provided by the
						Department (See Section 7000 P rospective Method of Payment for details of the
						Prospective Reimbursement System).
All long-term care facilities are required to submit
						annual cost reports as prescribed herein to the State of Maine Department of
						Health and Human Services, Office of Audit, 11 State House Station, Augusta,
						Maine 04333-0011. Such cost reports shall be based on the fiscal year of the
						facility.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-1040 - ALLOWABLITY OF COSTS

Current through 2024-29, July 17, 2024
A determination of whether or not a cost is allowable and
						interpretations of definitions, not specifically detailed in these Principles,
						will be based on; first the Medicare Provider Reimbursement Manual (CMS Pub 15)
						guidelines and then on Internal Revenue Service guidelines in effect at the
						time of such determination.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-1050 - EFFECTIVE DATE

Current through 2024-29, July 17, 2024
These Principles apply to reimbursement for all
						Intermediate Care Facilities for Mental Retarded. The effective date of this
						rule is September 1, 2007.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-1055 - APPLICABLE DATE

Current through 2024-29, July 17, 2024
These Principles are applicable for the facility's fiscal
						period beginning on or after the effective date.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-1060 - PUBLIC HEARINGS

Current through 2024-29, July 17, 2024
The State of Maine will provide for public hearings as
						necessary in the State Plan, according to State procedures.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-1070 - WAIVER

Current through 2024-29, July 17, 2024
The failure of the Department to insist, in any one (1)
						or more instances, upon the performance of any of the terms or conditions of
						these Principles, or to exercise any right under these Principles, or to
						disapprove of any practice, accounting procedure or item of account in any
						audit, shall not be construed as a waiver of future performance of the right.
						The obligation of the provider with respect to future performance shall
						continue, and the Department shall not be estopped to require such future
						performance.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-1080 - LIMITATIONS ON REOPENING AUDITS

Current through 2024-29, July 17, 2024
No final audit shall be reopened, nor shall any hearing
						be allowed concerning any matter contained in any final audit, after three (3)
						years following the date of the final audit settlement. This limitation does
						not apply in the event of fraud or misrepresentation, or reviews by Program
						Integrity for medical necessity or non-covered services.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-2000 - COST FINDING AND COST REPORTING

Current through 2024-29, July 17, 2024
2010
Cost Report Periods
. All long-term care facilities are required to
					 submit annual cost reports as prescribed herein to the State of Maine,
					 Department of Health and Human Services, Office of Audit, 11 State House
					 Station, Augusta, Maine 04333-0011. Such cost reports shall be based on the
					 fiscal year of the facility.
2020
Accounting Principles
.The allowable costs shown in all cost
					 reports described herein shall be on the basis of generally accepted accounting
					 principles and the accrual method of accounting except that, for governmental
					 institutions operated on a cash method of accounting, data based on such a
					 method of accounting will be accepted. Any other providers who maintain their
					 records on a cash basis should record such accruals as adjustments.
2021 Generally accepted accounting principles
					 means accounting principles approved by the American Institute of Certified
					 Public Accountants.
2022 Accrual
					 method of accounting means that revenue is reported in the period when it is
					 earned, regardless of when it is collected, and expenses are reported in the
					 period in which they are incurred, regardless of when they are paid.
2022.1 All year end accruals must be paid by
					 the facility within six (6) months after the end of the fiscal year in which
					 the amounts are accrued. If the accruals are not paid within such time, these
					 amounts will be deducted from allowable costs incurred in the subsequent fiscal
					 year.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-3000 - FIXED COST COMPONENT

Current through 2024-29, July 17, 2024
3005 The fixed cost
					 per diem rate is determined from the sum of the following costs:
3005.1 depreciation on land improvements,
					 buildings, fixed and movable equipment, vehicles, and amortization of leasehold
					 improvements;
3005.2 amortization
					 of finance costs for new construction and/or renovations;
3005.3 amortization of start-up
					 costs;
3005.4 real estate and
					 personal property taxes;
3005.5
					 liability insurance, (not including insurance for directors and officers), fire
					 insurance, bond, and vehicle insurance. Reasonable and necessary costs of
					 insurance involved in operating a facility are considered allowable costs.
					 Premiums paid on property not used for patient care are not allowed;
3005.6 interest on long term debt;
3005.7 rental expenses;
3005.8 8medical supplies that are supplied as
					 part of the regular rate of reimbursement. These supplies are listed in the
					 MaineCare Benefits Manual, Chapter II, Section 60. Excluded are costs that are
					 an integral part of another cost center.
3005.9
ICF-MR Health Care Provider
					 Tax
. ICFs-MR subject to the Health Care Provider Tax defined in State
					 law 36 M.R.S.A., Chapter 373, will have the tax treated as an allowable fixed
					 cost. If CMS approves, effective January 1, 2012, the tax imposed is six
					 percent (6%) of the facility's annual gross patient services revenue. This
					 expense is allowed based on a cash basis instead of accrual basis.
3005.10 mandated direct care staff training
					 program costs as required by State and Federal regulations.
3005.11 mandated accreditation
					 costs.
3005.12 approved
					 administrator in training expense.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-4000 - VARIABLE COST COMPONENT

Current through 2024-29, July 17, 2024
Variable Costs include all allowable costs that are not
						defined as fixed costs, staff wages, salaries, or authorized staff benefits,
						and that are incurred in the efficient and economical operation of the
						facility.
4010
Principle
.
					 All reasonable variable costs that providers mustincur to meet State Licensing
					 and Federal Certification standards are allowable.
4011 Allowable variable costs shall also
					 include all items of expense that efficient and economical providers incur for
					 the provision of routine services.
4011.1
Allowable costs for routine services
shall include but not be
					 limited to:
a. Supplies for activities,
					 social services, maintenance, housekeeping, laundry, dietary, and
					 office;
b. food, plant operations,
					 and plant repairs;
c. help-wanted
					 advertising;
d. dues (net of
					 lobbying);
e.
					 subscriptions;
f. legal fees
					 (related to resident care, see Sections 4160 & 4165);
g. accounting fees;
h. short-term working capital
					 interest;
i. in-state travel
					 expenses;
j. seminars;
k. central office administrative and
					 bookkeeping costs;
l. auto expenses
					 (see Section 4140);
m. pharmacy,
					 dietary, and social services consultants.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-5000 - SPECIAL SERVICE ALLOWANCE

Current through 2024-29, July 17, 2024
5010
Principle
. A special service is to be distinguished from a routine
					 service.
5010.1 A special service is that of
					 an individual nature required in the case of a specific member. This service is
					 limited to professional services such as physical therapy, occupational
					 therapy, and speech and hearing services. Special services of this nature must
					 be billed monthly to the Department as separate items required for the care of
					 individual members.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-6000 - LABOR COST COMPONENT

Current through 2024-29, July 17, 2024
6010
Wages
: Reasonable costs incurred for personnel wages will be
					 reimbursed at actual cost.
6011
All Facility Staff
6011.1 The
					 reasonable allowable cost of wages for personnel employed on site at the
					 facility shall be determined based on the lesser of actual hours worked, or
					 hours approved by the Department.
6011.2 Direct care staff hours related to
					 mandatory programs, as specified in Section 3005.10, above, will be considered
					 allowable and will be reimbursed at the actual hourly wage for the relevant
					 category of direct care staff.
6011.3 Contract labor costs for RNs, LPNs,
					 and CNAs working on-site are an allowable labor cost. Contract labor hours must
					 be included with the direct care worked hours for the comparison to approved
					 hours.
6011.4 Bonuses that are part
					 of a written policy of the provider and that require some measurable and
					 attainable job performance expectation from the employee are
					 allowable.
6011.5 Orientation, on
					 the job training, in-service education, and similar work learning programs are
					 recognized as normal operating costs for labor cost. The hours associated with
					 orientation are not used to determine approved hours (staffing pattern) for the
					 facility.
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-7000 - PROSPECTIVE METHOD OF PAYMENT

Current through 2024-29, July 17, 2024
7010
Prospective Per Diem Rate
7011 Intermediate Care Facilities for
					 Mentally Retarded will be reimbursed for services provided to a member under
					 MaineCare based on a rate that the Department establishes on a prospective
					 basis. In establishing the prospective rate, the Department will determine what
					 costs are reasonable and necessary to provide the services.
7012
Definitions
7012.1 Per Diem Rate means total allowable
					 costs divided by days of care. The prospective per diem rate, multiplied by
					 days of care for MaineCare members, will determine reimbursement.
7012.2 Days of Care means total number of
					 actual days of care provided whether or not payment is received, and the number
					 of any other days for which payment is made. (Note: Bed hold days and discharge
					 days are included only if payment is received for these days.)
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-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded › Subsection 144-101-III-50-8000 - APPEAL PROCEDURES - DEFICIENCY RATE - RATE LIMITATION

Current through 2024-29, July 17, 2024
8010
Procedures
8010.1 A facility may administratively appeal
					 any of the following types of Office of Audit determinations:
8010.11. Audit Adjustment; or
8010.12. Calculation of final
					 settlement.
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-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-2 - REQUIREMENTS FOR PARTICIPATION IN MAINECARE PROGRAM

Current through 2024-29, July 17, 2024
2.1
Nursing facilities
must
					 satisfy all of the following prerequisites in order to be reimbursed for care
					 provided to MaineCare members:
2.1.1 be
					 licensed and certified by the Maine Department of Health and Human Services,
					 pursuant to
					 Title 22,
					 Section1811 and
					 42 CFR, Part 442 , Subpart C,
					 and
2.1.2 have a Provider/Supplier
					 Agreement with the Department of Health and Human Services, as required by 42
					 CFR, Part 442 , Subpart B.
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-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-3 - RESPONSIBILITIES OF OWNERS OR OPERATORS

Current through 2024-29, July 17, 2024
3.1 The owners
					 or operators of a nursing facility shall prudently manage and operate
					 residential health care services of adequate quality to meet its residents'
					 needs. Neither the issuance of a per diem rate, nor final orders made by the
					 Commissioner or a duly authorized representative shall in any way relieve the
					 owner or operator of a nursing facility from full responsibility for compliance
					 with the requirements and standards of the Department of Health and Human
					 Services or Federal requirements and standards.
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-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-4 - DUTIES OF THE OWNER OR OPERATOR

Current through 2024-29, July 17, 2024
In order to qualify for MaineCare reimbursement the owner
						or operator of a nursing facility, or a duly authorized representative
						shall:
4.1 Comply with the provisions
					 of Principles 3 and 4 setting forth the requirements for participation in the
					 MaineCare Program.
4.2 Submit
					 master file documents and cost reports in accordance with the provisions of
					 Principles 13.1 and 13.2 of these Principles.
4.3 Maintain adequate financial and
					 statistical records and make them available when requested for inspection by an
					 authorized representative of the Department of Health and Human Services, the
					 state, or the Federal government.
4.4 Assure that annual records are prepared
					 in conformance with Generally Accepted Accounting Principles (GAAP), except
					 where otherwise required.
4.5
					 Assure that the construction of buildings and the maintenance and operation of
					 premises and services comply with all applicable health and safety
					 standards.
4.6 Submit such data,
					 statistics, schedules or other information that the Department requires in
					 order to carry out its functions. Failure to supply the required documentation
					 may result in the Department imposing the deficiency per diem rate described in
					 Principle 37 of these Principles.
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-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-5 - ACCOUNTING REQUIREMENTS

Current through 2024-29, July 17, 2024
5.1 ACCOUNTING
					 PRINCIPLES
5.1.1 All financial and statistical
					 reports shall be prepared in accordance with Generally Accepted Accounting
					 Principles (GAAP), consistently applied, unless these rules require specific
					 variations in such principles and Medicare Provider Reimbursement Regulations
					 HIM-15.
5.1.2 The provider shall
					 establish and maintain a financial management system that provides for adequate
					 internal control assuring the accuracy of financial data, safeguarding of
					 assets and operation efficiency.
5.1.3 The provider shall report on an accrual
					 basis, unless it is a state or municipal institution that operates on a cash
					 basis. The provider whose records are not maintained on an accrual basis shall
					 develop accrual data for reports on the basis of an analysis of the available
					 documentation. The provider shall retain all such documentation for audit
					 purposes.
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-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-6 - PROCUREMENT STANDARDS

Current through 2024-29, July 17, 2024
6.1 Providers shall
					 establish and maintain a code of standards to govern the performance of its
					 employees engaged in purchasing Capital Assets. Such standards shall provide,
					 and providers shall implement to the maximum extent practical, open and free
					 competition among vendors. Providers are encouraged to participate in group
					 purchasing plans when feasible.
6.2
					 If a provider does not accept the lowest bid for a Capital Asset, the amount
					 over the lower bid that cannot be demonstrated to be a reasonable and necessary
					 expenditure is an unallowable cost. In situations not competitively bid,
					 providers must act as a prudent buyer as referenced in Principle 9.2 in these
					 Principles. See cost to related organizations Principle 9.8.
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-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-7 - COST ALLOCATION PLANS AND CHANGES IN ACCOUNTING METHODS

Current through 2024-29, July 17, 2024
With respect to the allocation of costs to the nursing
						facility and within the nursing facility, the following rules shall
						apply:
7.1 Providers that have costs
					 allocated from related entities included in their cost reports shall include as
					 a part of their cost report submission, a summary of the allocated costs,
					 including a reconciliation of the allocated costs to the entity's financial
					 statements which must also be submitted with the MaineCare cost report. In the
					 case of a home office, related management company, or real estate management
					 company, this would include a completed Home Office Cost Statement that shows
					 the costs that are removed which are unallowable. The provider shall submit
					 this reconciliation with the MaineCare cost report. If the nursing facility is
					 a Medicare provider, the Medicare Home Office Cost report may be used to
					 identify the unallowable costs that are removed, if the Medicare Home Office
					 Cost report is completed in sufficient detail to allow the Department to make
					 its findings.
7.2 No change in
					 accounting methods or basis of cost allocation may be made without prior
					 written approval of the Office of MaineCare Services.
7.3 Any application for a change in
					 accounting method or basis of cost allocation, which has an effect on the
					 amount of allowable costs or computation of the per diem rate of payment, shall
					 be made within the first ninety (90) days of the reporting year. The
					 application shall specify
7.3.1 the nature of
					 the change;
7.3.2 the reason for
					 the change;
7.3.3 the effect of the
					 change on the per diem rate of payment; and
7.3.4 the likely effect of the change on
					 future rates of payment.
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-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-8 - ALLOWABILITY OF COST

Current through 2024-29, July 17, 2024
8.1 If these
					 principles do not set forth a determination of whether or not a cost is
					 allowable or sufficiently define a term used, reference will be made first, to
					 the
Medicare Provider Reimbursement Manual
(HIM-15)
					 guidelines, followed by the Internal Revenue Service Guidelines in effect at
					 the time of such determination if the HIM-15 is silent on the issues.
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-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-10 - UPPER PAYMENT LIMITS

Current through 2024-29, July 17, 2024
10.1 Aggregate
					 payments to nursing facilities pursuant to these rules may not exceed the
					 limits established for such payments in 42 CFR. §
											447.272, using
					 Medicare principles of reimbursement.
10.2 If the Division of Audit projects that
					 MaineCare payments to nursing facilities in the aggregate will exceed the
					 Medicare upper limit, the Division of Audit shall limit some or all of the
					 payments to providers to the level that would reduce the aggregate payments to
					 the Medicare upper limit as set forth in Principle 10.3.
10.3 In computing the projections that
					 MaineCare payments in the aggregate are within the Medicare Upper Limit, any
					 facility exceeding one hundred-twelve percent (112%) of the State mean
					 allowable routine service costs may be notified that additional information is
					 required to determine allowable costs under the Medicare Principles of
					 Reimbursement, including any exceptions as stated in
					 42 CFR
					 413.30(f). This information
					 may be requested within thirty (30) days of the effective date of these
					 regulations, and thereafter, at the time the interim rates are set.
10.4 Facility Rate Limitations if Aggregate
					 Limit is exceeded. If the Department projects that the MaineCare payments to
					 nursing homes in the aggregate exceed the Medicare upper limit, the Department
					 shall limit payments to those facilities whose projected MaineCare payments
					 exceed what would have been paid using Medicare Principles of Reimbursement.
					 The Department will notify the facilities when the Department projects that the
					 MaineCare payments to nursing homes in the aggregate exceed the Medicare upper
					 limit and that the Department must limit payments to those facilities to the
					 level that would reduce the aggregate payments to the Medicare upper
					 limit.
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-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-11 - SUBSTANCE OVER FORM

Current through 2024-29, July 17, 2024
11.1 The cost
					 effect of transactions that have the effect of circumventing these rules may be
					 adjusted by the Department on the principle that the substance of the
					 transaction shall prevail over the form.
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-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-13 - FINANCIAL REPORTING

Current through 2024-29, July 17, 2024
13.1
MASTER
					 FILE
The following documents concerning the provider or, where
						relevant, any entity related to the Provider, will be submitted to the
						Department at the time that the cost report is filed. Such documents will be
						updated to reflect any changes on a yearly basis with the filing of a cost
						report. Such documents shall be used to establish a Master file for each
						facility in the MaineCare Program:
13.1.1 Copies of the articles of
					 incorporation and bylaws, of partnership agreements of any provider or any
					 entity related to the provider;
13.1.2 Chart of accounts and procedures
					 manual, including procurement standards established pursuant to Principle
					 6;
13.1.3 Plant layout;
13.1.4 Terms of capital stock and bond
					 issues;
13.1.5 Copies of long-term
					 contracts, including but not limited to leases, pension plans, profit sharing
					 and bonus agreements;
13.1.6
					 Schedules for amortization of long-term debt and depreciation of plant
					 assets;
13.1.7 Summary of
					 accounting principles, cost allocation plans, and step-down statistics used by
					 the provider;
13.1.8 Related party
					 information on affiliations, and contractual arrangements;
13.1.9 Tax returns of the nursing facility;
					 and
13.1.10 Any other documentation
					 requested by the Department for purposes of establishing a rate or conducting
					 an audit.
If any of the items listed in Principle 13.1.1 - 13.1.10
						are not submitted in a timely fashion the Department may impose the deficiency
						per diem rate described in Principle 37 of these Principles.
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-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-14 - REIMBURSEMENT METHOD

Current through 2024-29, July 17, 2024
14.1
Principle
. Nursing care facilities will be reimbursed for services
					 provided to members based on a rate which the Department establishes on a
					 prospective basis and determines is reasonable and adequate to meet the costs
					 which must be incurred by an efficiently and economically operated facility in
					 order to provide care and services in conformity with applicable State and
					 Federal laws, regulations and quality and safety standards.
14.2 Nursing facilities costs will be rebased
					 by the Department every two years beginning July 1, 2014.