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Effective January 1, 2026, MaineCare retroactively updated the Physician Drug Rates to align with the Centers for Medicare & Medicaid Services’ (CMS) quarterly update. We implemented these rates on March 4, 2026.
You can find the updated rates on the Rate Setting webpage of the Health PAS Online Portal.
Adjustment Billing Guidance
Please note that Maine DHHS will be hosting informational webinars for clinician and community partners that will provide an overview and updates on Maine’s recent federal award of $190 million for Year 1 funding of the RHTP. To accommodate varying schedules, the webinar will be offered on two different dates (same content each time):
Effective January 1, 2026, MaineCare revised the following reimbursement rates for section 109, in alignment with Medicare. The new rates reflect 72.4% of the Maine Medicare rate and were implemented for billing on March 11, 2025.
|
Code |
Modifier |
New Rate Effective 1/1/2026 |
|
92524 |
GN |
$76.47 |
|
92545 |
Public Review & Comment
On March 30, 2026, we will host a public forum with our vendor, Milliman, to present the recommended draft rate and model along with rationale for MDFT - a new service under Section 65. Interested parties will have the opportunity to provide public comments.
Some MaineCare members may be required to participate in cost-sharing for covered services they receive. Consistent with federal requirements, cost-sharing incurred by all individuals in a MaineCare household may not exceed an aggregate limit of 5% of the household’s monthly income.
The Office of MaineCare Services (OMS) tracks cost-sharing expenditures to identify when a household has reached the monthly maximum. OMS will send letters to notify members when they have reached their cost-sharing maximum.
Impact on MaineCare Enrolled Providers
Emergency Services, or Defined Emergency Services (DES), is a limited benefit that covers only the medical services necessary to stabilize an emergency condition. To receive proper reimbursement, providers must mark Admission Type “1” on the UB04 claim form or the Emergency Indicator “Y” on the CMS 1500 claim form and include a qualifying emergency diagnosis code.
Emergency Services, also known as Emergency MaineCare, is a limited benefit that covers emergency medical services to stabilize the emergency condition only. For proper reimbursement, providers must use Admission Type “1” on the UB04 claim form or the Emergency Indicator “Y” on the CMS 1500 claim form.
For questions related to billing for Emergency Services or any other Limited Benefit Package offered by MaineCare, please contact your Provider Relations Specialist.
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Effective February 21, 2026, MaineCare completed the following Centers for Medicare and Medicaid Services (CMS) quarterly updates for APCs in MIHMS.
Claims Adjustment
Payments for the 2025 Quality Bonus Pool will be released in the March 11, 2026 payment cycle. The Office of MaineCare Services received federal approval to release these payments on February 25, 2026. As previously noticed, payment amounts vary by facility.
The Department issued a notice on February 25, 2026, of additional MaineCare Public Hearings for MaineCare Benefits Manuals (MBM): Chapters II and III, Section 13,