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-103 - Rural Health Clinic Services › Subsection 144-101-II-103.07 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
103.07-1
General Reimbursement
RHCs are reimbursed in accordance with the requirements
						of section 702 of the
Benefits Improvement and Protection Act (BIPA) of
						2000
, including requirements for a Prospective Payment System.
Reimbursement is generally limited to one core service
						visit, and/or one ambulatory service visit per day. Reimbursement for a second
						core visit is also covered if the member has both an encounter with a
						physician, physician assistant, nurse practitioner or visiting nurse, and in
						addition to that encounter, is seen by a licensed clinical psychologist,
						clinical social worker, clinical professional counselor, clinical nurse
						specialist, or a registered nurse certified in the specialized field of mental
						health, on the same day. An additional visit of any kind will only be
						reimbursed for unforeseen circumstances as documented in the member's
						record.
Additional clinic visits required in the member's
						treatment plan that do not qualify as clinic visits for reimbursement purposes,
						such as a visit for venipuncture only, are non-billable and are included in the
						RHC's cost based reimbursement.
103.07-2
PPS Reimbursement
					 Methodology
A.
Initial PPS Rates
					 and Annual Adjustments
Effective January 1, 2020, Rural Health Clinics can
						choose to be reimbursed on the basis of 100% of the average of their reasonable
						costs of providing MaineCare-covered services during:
(a) calendar years 1999 and 2000 with
					 historical Medicare Economic Index (MEI) adjustments; or
(b) calendar years 2016 and 2017. The
					 resulting average will be adjusted to take into account any increase or
					 decrease in the approved scope of services furnished during the provider's
					 fiscal year 2001 (for choice (a)), or 2018 (for choice (b)), respectively
					 (calculating the amount of payment on a per visit basis).*
At the start of each subsequent year, beginning in CY
						2002 (for choice (a)) or CY 2021 (for choice (b)), each RHC is entitled to the
						payment amount (on a per visit basis) to which the clinic was entitled under
						the Act in the previous fiscal year, inflated by the percentage increase in the
						MEI for primary care services, and adjusted to take into account any increase
						or decrease for a MaineCare approved "change in scope of services."*
* The Department submitted to CMS and anticipates
						approval of a State Plan Amendment (SPA) related to these
						provisions.
Newly qualified RHCs after state fiscal year 2017 will
						have initial payments (calculated on a per visit basis) established either by
						reference to payments to other RHCs in the same or adjacent areas with similar
						caseload, or in the absence of such other RHCs, through cost reporting methods.
						Cost reports must accurately reflect the costs of the individual RHC (i.e. may
						not be a consolidated report of multiple sites or organizations that is not
						able to distinguish RHC costs.) For each fiscal year following the initial
						year, payment shall bead justed for MEI and approved "change in scope of
						services." This applies to each new RHC site or location with a separate
						National Provider Identifier that is opening for the first time, regardless of
						affiliation to an existing organization, and regardless of previous service
						delivery.