MaineCare Rate System Reform

Our Goal

To provide a clear and transparent process for MaineCare rate determinations, with opportunities for robust participation from all interested stakeholders.

Please go here for information on how you can participate and to view our monthly Rate System Reform updates. 

We continue to update this page with important dates and progress made on past, current, and future rate determination work. Please check in often, as this site is a work in progress.

 

What is Rate Determination?

Rate Determination is a process conducted by the department to establish the reimbursement rate methodology, base rate amount or payment model for a MaineCare section of policy or for a specific covered service. Rate Determination is done through adoption or adaptation of a benchmark rate or methodology from another payer (e.g., private insurance, Medicare, another Medicaid agency) or developed through a rate study. Determinations may also lead to a rate study.

There are five phases in a Rate Determination:

  •  

    Phase 1
    Project Kickoff

  •  

    Phase 2
    Provider Data Survey

  •  

    Phase 3
    Rate Model Development

  •  

    Phase 4
    Public Comment

  •  

    Phase 5
    Finalize Proposed Rates

Typical Rate Determination Process Flowchart (PDF)

Typical Rate Determination Proces Ordered List (PDF)

CY 2024 Rate Determinations - in Progress

Public Notices

Presented Materials and Other Documents

Other Information

65 Mobile Crisis Response Teams

Initiation 9/01/2022

Kickoff and survey overview 3/11/2022

Draft Service Model and Survey Invite 2/21/2023

Draft Service Model and Rate Forum Invite 1/2/2024

Kickoff recording - 5/12/2022

Draft Service Model Presentation (PDF) 2/24/2023

Draft Service Model and Survey Tool Recording - 2/24/2023

Draft Service Model and Rates, Public Forum HMA-Burns Presentation, DHHS PresentationDraft Rate Models and Recording

Rationale: The American Rescue Plan Act of 2021 (ARP) amended Title XIX of the Social Security Act by adding after section 1946 (42 U.S.C. 1396w–5) the following new section: SEC. 1947. "State Option to Provide Qualifying Community-Based Mobile Crisis Intervention Services.” DHHS is reforming mobile crisis services to improve the service and align with this new federal opportunity.

Services: Mobile Crisis/Resolution

Effective Date: Pending Service Redesign 

Next Rate Adjustment: Pending Service Redesign

Further Section Change Needed: None

107 Psychiatric Residential Treatment Facility

Initiation

Draft Rate Model Public Review and Comment 5/26/2023

Public Forum Presented Materials and Comment Deadline - 6/16/2023

    (Please see CORRECTION to the         above notice) 

    

 

 

Draft Rate/Public Forum Presentation Recording - 6/15/2023

Draft Rate/Public Forum Presentation (PDF) - 6/15/2023

Rationale:  P.L. 2021, Ch. 635

Services: All

Effective Date: Pending Rate Determination 

Next Rate Adjustment: Pending Rate Determination

Further Section Change Needed: None

45, Specific to Acute Inpatient Distinct Psychiatric & SUD Units (for medically supervised withdrawal) 

Initiation 10/7/2022

Hospital Informational Forum 12/5/2022

Public Forum Presented Materials and Comment Deadline 1/26/2023

Rate Determination Update 6/16/2023

Final Draft Rates Notice - 7/14/2023

 

Hospital Informational Forum Presentation (PDF) 12/19/2022

Hospital Informational Forum Recording  12/19/2022

Draft Public Forum Presentation (PDF) - 1/12/2023

Draft Rate Determination Forum Recording - 1/12/2023

Comment Summary with Department Response (PDF) - 5/8/2024

Final Rates & Methodology (PDF) - 5/8/2024

Rationale: P.L. 2021, Ch. 635

Services: Inpatient Distinct Psychiatric and Substance Use Disorder Units

Effective Date: TBD

Next Rate Adjustment: TBD, pending rate determination

Further Section Change Needed: None

46, Institutions for Mental Disease (IMD)

Initiation 10/7/2022

 

 

 

 

 

 

Rationale: P.L. 2021, Ch. 635

Services: All

Effective Date: TBD

Next Rate Adjustment: TBD, pending rate determination

Further Section Change Needed: TBD

45 Hospitals

Initiation 6/23/2023

Draft Rate Model Public Forum Invite 11/29/2023

Draft Reimbursement Methods Public Forum Invite - 2/12/2024

Draft Rates & Methodologies Public Review and Comment Invite - 3/22/2024

Public Review Rescheduled - 4/2/2024

Public Review Postponed - 5/1/2024

 

Draft Rate Methodology Public Review: Inpatient Presentation (PDF) and Recording - 12/11/2023

Draft Reimbursement Methodology Public Review: Outpatient Presentation (PDF) and Recording - 2/26/2024

Public Review and Comment: Forum Recording and PPT Presentation - June 11, 2024

Rationale: Public Commitment. Outdated reimbursement methodology, incent quality/cost effectiveness

Services: All

Effective Date: TBD

Next Rate Adjustment: TBD, pending rate determination

Further Section Change Needed: TBD

30 Family Planning (New Alternative Payment Model)

Initiation 11/17/2022

Kickoff 1/26/2023

Public Forum 10/20/2023

Presented Materials and Comment Deadline  11/28/2023

 

Kickoff Meeting Presentation (PDF) - 1/26/2023

Kickoff Meeting Recording - 1/26/2023

APM Draft Rate & Service Model Public Review & Comment Version 2 (PDF) & (Corrected) Version 3 (PDF) & Recording - 11/20/2023

 

 

Rationale: Public Commitment. Current reimbursement does not reflect team-based, patient centered approach to integrated care

Services: All

Effective Date: TBD

Next Rate Adjustment: TBD, pending rate determination

Further Section Change Needed: None

67, 97 C - Nursing Homes and Private Non-Medical Institutions - Appendix C Residential Care

Initiation 1/12/2023

Kickoff 2/1/2023

Provider Rate Method Workgroup #1 Presented Materials Notice 3/28/2023

Provider Rate Method Workgroup #2 Presented Materials Notice 4/24/2023

Provider Rate Method Workgroup #3 Presented Materials Notice - 5/22/2023

Provider Rate Method Workgroup #4 Presented Materials Notice - 6/9/2023

Provider Rate Method Workgroup #5 Presented Materials Notice - 6/30/2023

Draft Rate Methodology Public Review and Comment for NF's - 2/23/2024

Comment Deadline Extended - 3/25/2024

Comment Deadline Extended - 4/17/2024

Kickoff Meeting Presentation (PDF) and Recording - 2/1/2023

Rates Workgroup Meeting #1 Introduction & Rate Discussion Presentation (PDF) and Recording – 3/13/2023

Rates Workgroup Meeting #2 Direct/Indirect & Capital Costs Presentation (PDF) and Recording - 4/12/2023

Rates Workgroup Meeting #3 Trend Discussion Presentation (PDF) and Recording - 5/17/2023

Rates Workgroup Meeting #4 Risk Adjustment Discussion Presentation (PDF) and Recording - 6/5/2023

Rates Workgroup Meeting #5 VBP and APM Discussion Presentation (PDF) and Recording - 6/26/2023

Draft Rate Methodology Public Review and Comment for Section 67, Nursing Facilities Part I, Presentation and Recording - 3/7/2024

Draft Rate Methodology Public Review & Comment for Section 67 Nursing Facilities Part II, Presentation and Recording - 3-8-2024

Questions & Answers on Draft Rate Model - 4/5/2024

 

Rationale: Public Commitment. Cost settlement system is administratively burdensome and does not incent quality of care or reward cost effectiveness.

Services: All

Effective Date: TBD, pending rate determination

Next Rate Adjustment:

  • COLA. Annually in July
  • Pending Rate Determination

Further Section Change Needed: None

 

97 - Appendix D Private Non-Medical Institution (Specific to Children’s Therapeutic Foster Care)

Initiation - 6/9/2023

Draft Rate Model, Public Comment - 11/17/2023

Draft Rate Model Presented Materials & Comment Deadline - 12/8/2023

Comment Deadline Extended - 12/22/2023

Draft Rate Model Public Review & Comment (PPT) and Recording - 12/6/2023

Rationale: Address U.S. Dept. of Justice June 2022 findings that state there is a lack of support for foster parents and address barriers to access children’s behavioral health needs in the community and be less reliant on residential facilities/institutions

Services: Therapeutic Foster Care

Effective Date: TBD

Next Rate Adjustment: TBD, pending rate determination

Further Section Change Needed: TBD, pending rate determination

Demonstration - Certified Community Behavioral Health Clinics (CCBHC)

Initiation - 6/20/2023

Kickoff - 9/11/2023

Prospective Payment System Cost Report Training Session Presented Materials - 11/6/2023

Deadline for Cost Report Submissions Extended to December 15, 2023 - 11/17/2023

 

 

Kickoff Meeting Recording - 9/25/2023

Kickoff Meeting Presentation (PDF) - 9/25/2023

Prospective Payment System Cost Report Training Session: Recording and Presentation (PDF)- 10/31/23

 

Rationale: Department goal to increase access to high-quality, comprehensive behavioral health services

Services: Behavioral Health 

Effective Date: TBD

Next Rate Adjustment: TBD, pending rate determination

Further Section Change Needed: TBD, pending rate determination

18, 20, 21, 29, HCBS for Individuals with Intellectual & Developmental Disabilities or Autism & Proposed Lifespan Waiver

Initiation and Kickoff Notice - 9/8/2023

Amendment to Inititation and Kickoff Presented Materials Notice - 9/26/2023

Cost Survey Tool 12/15/2023

Deadline Extended: Cost Survey Tool - 12/26/2023

 

 

 

Kickoff Meeting Presentation (PDF) - 9/15/2023

Kickoff Meeting Recording - 9/15/2023

 

Rationale: P.L. 2023, Ch.412, Part LLLLL. Authorizes the new Lifespan program and directs the Department to facilitate federal approval of the new program and adopt rules implementing it. Because many Lifespan services will be similar to current Section 21 and Section 29 services, development of Lifespan rates requires existing Sections 18, 20, 21 and 29 rates to be reviewed.

Services: Lifespan, HCBS and Support services for Members with Intellectual Disabilities or Autism Spectrum Disorder  

Effective Date: TBD

Next Rate Adjustment: TBD, pending rate determination

Further Section Change Needed: TBD, pending rate determination

TBD - Palliative Care

Initiation - 10/13/2023

Kickoff - 3/11/2024

Kickoff Meeting Presentation and Recording - 3/27/2024

Rationale: LD/BI (LD 1064, 9817 HCBS plan) 

Services: New Section/Service

Effective Date: TBD

Next Rate Adjustment: TBD, pending rate determination

Further Section Change Needed: TBD, pending rate determination

25 - Dental (Rebasing of benchmarks) 

Initiation - 10/13/2023

Kickoff - 10/26/2023

Benchmark Results and Draft Rates: Public Review & Comment - 3/14/2024

Public Review Rescheduled - 3/26/2024

Public Review Presented Materials and Comment Deadline - 4/16/2024

Comment Deadline Extended - 4/23/2024

 Kickoff Presentation (PDF) and Recording - 11/29/2023

Benchmarking Results and Draft Rates, Forum Recording and Presentation (PPT) - 4/12/2024

Rationale: Public Law Ch.639 requirement for services benchmarked to alternate payor source, update rates to most current year every 2 years

Services: All

Effective Date: 7/1/2024

Next Rate Adjustment: 7/1/2024 Rebasing of Benchmarks. COLA, Bi-Annually in July

Ch. VI, Section 3 Primary Care Plus (PCPlus)
Initiation - 12/4/2023  

Rationale: Establish a more advanced alternative payment model for primary care services and supports, including the incorporation of Community Health Worker (CHW) team members and social risk adjustment

Services: All

Effective Date: TBD

Next Rate Adjustment: TBD, Pending Rate Determination

93 - Opioid Health Home, Includes New Model for Other SUDs

Initiation - 11/8/2023

Kickoff Meeting Invite - 4/23/2024

Kickoff Presentation (PDF) and Recording - 5/7/2024

Rationale: P.L. 2021, Ch. 635, Part JJJ

Services: All

Effective Date: TBD

Next Rate Adjustment: TBD, Pending Rate Determination 

TBD - Community Paramedicine (New Service)

Initiation - 11/8/2023

 

Rationale: MaineCare coverage for community paramedicine services to improve health outcomes, improve access to care, and reduce unavoidable costs, especially for rural residents

Services: New Service (tentatively planned to be incorporated into Section 5 of the MaineCare Benefits Manual)

Effective Date: TBD

Next Rate Adjustment: TBD, Pending Rate Determination

 

23, Developmental and Behavioral Clinic Serivces: Child Abuse Evaluation Service 

Initiation and Public Forum Invite - 5/13/2024

Comment Deadline - 5/17/2024

Draft Rate Public Forum Draft Rate Model (PDF) and Recording - 5/17/2024

Comment Summary with Department Response (PDF) and Final Draft Rate (PDF) - 5/30/2024

Rationale: The Department is conducting this rate determination to improve member access to this service. 

Services: Child Abuse Evaluation Service 

Effective Date: TBD

Next Rate Adjustment: TBD

14, 30, 31, 45, 90, 103, Certain Medicare Covered Family Planning Services & Long-Acting Reversible Contraception (LARCs)
Initiation - 5/28/2024  

Rationale: The Department is conducting this rate determination to maintain member access to Family Planning Services. 

Services: Certain Medicare Covered Family Planning Services and Long-Acting Reversible Contraception (LARCs)

Effective Date: TBD

Next Rate Adjustment: TBD

12, 18, 19, 20, 21, 29, 40, 96, and 102, Home & Community Based Services (HCBS) Clinical, Therapy, Care Coordination, Supportive Skills Building, and Assistive Technology Services
Initiation - 6/4/2024  

Rationale: Align rates of similar services across sections and Department goal to address severe state labor shortages for nurses which has contributed to a decline in utilization of services, despite increased need. 

Services: Clinical, Therapy, Care Coordination, Supportive Skills Building, and Assistive Technology Services. 

Effective Date: TBD

Next Rate Adjustment: TBD

 

CY 2024 Rate Determinations - Upcoming

Section of Policy

Status

Other Information

Section TBD, Coordinated Specialty Care Internal Planning

Rationale: P.L. 2021, Ch. 398, Part A, provides funding to implement a coordinated specialty care model, to treat MaineCare members for a first episode of psychosis. 

Services

Section 106, School-Based Health Center Services & 65, Multi-Dimensional Family Therapy (MDFT) Internal Planning 

Rationale: P.L. 2021, Ch. 227, to address health-related services that are required for children ages 0-5 years, to access their education. This must be a major substantive rule. Additionally, the Children's Behavioral Health Services plan calls for MDFT services to be implemented under section 65. Finally, P.L. 2023, Ch. 412, Part A, provides funding for implementation. 

Services

Ch. I, Section 1, Interpreter Services Internal Planning 

Rationale: With Maine's growing population and expansion of MaineCare, a review is necessary to ensure quality of care and to ensure access to this critical service, especially during times of trauma and urgency.

Services: Interpreter Services

Prior Rate Reform Actions To Date

Public Notices

Presented Materials and Other Documents

Other Information

Section 23, Developmental and Behavioral Clinic Services, New Service - Foster Care Comprehensive Assessments

Initiation 10/14/2022

Draft Rate, public comment  11/23/2022

Draft Rates Posted and Comment Deadline 12/2/2022

Final Draft Rates and Comment Summary  1/11/2024

Foster Care Comprehensive Health Assessment Forum Presentation (PDF) 11/30/2022

Section 23 Forum Recording 11/30/2022

Final Draft Rate Model (PDF) 1/11/2024

Comment Summary 1/11/2024

Rationale: New service to conform with 22 MRSA Section 4063-A (3) requirement that the comprehensive assessment at the time a child enters state custody be reimbursed under MaineCare

Services: Foster Care Comprehensive Health Assessment 

Effective Date: TBD, pending adoption

Next Rate Adjustment: Pending Rulemaking

Further Section Change Needed: Other services in Section will need review. 

Section 71, National Diabetes Prevention Program

Initiation 12/16/2022

Draft Rate/Public Comment Invite - 12/29/2022

Posting of Final Draft Rate and Comment Summary 4/28/2023

UPDATED Proposed Rates - 9/1/2023

Notice of Agency Rulemaking Adoption 11/8/2023

Draft Rate/Public Comment (PDF) - 2/6/2023

Draft Rate/Public Comment Recording - 2/6/2023

Comment Summary with Department Response (PDF) - 4/25/2023

Final Draft Rates (PDF) - 4/25/2023

 

Rationale: P.L. 2021, Ch. 398, Sec. A-17

Services: All

Effective Date: November 8, 2023

Next Rate Adjustment: In coordination with Medicare

Further Section Change Needed: None

 

Section 2, Adult Family Care Homes

Initiation 8/11/2022

Kickoff and survey overview (direct email) 8/11/2022

Survey results (direct email) 10/24/2022

Draft Rate Public Review and Comment 11/22/2022

Comment Summary with Department Response and Final Draft Rates 4/18/2023

Implementation of January 1, 2023 Rate Study Increases 4/20/2023

 

Kickoff Recording - 9/1/2022

Survey Results (PDF) - 10/22/2022

Draft Rate/Public Comment Recording - 1/12/2023

Draft Rate Models (PDF) - 1/12/2023

Comment Summary (PDF) - 4/14/2023

Final Draft Rate Model (PDF) - 4/14/2023

 

Rationale: P.L. 2021 Ch.398, Part AAAA

Services: All

Effective Date: 1/1/2023 implementation of AAAA rate

Next Rate Adjustment:  COLA Annually in January

Further Section Change Needed: None

 

Section 13, Targeted Case Management

Initiation 9/01/2022

Kickoff and survey overview 3/11/2022

Survey distributed 4/22/2022

Draft Rate, public comment 9/01/2022

Draft Rate Presentation Posted and Comment Deadline Reminder - September 27, 2022

Final Draft Rates Posted - December 30, 2022

 

Kickoff Recording (included all BH sections) - May, 2022

Survey Results (PDF) - 10/5/2022

9/20/2022:

Comment Summary with Department Response (PDF) - 5/22/2023

Final Rate Model (PDF) - 5/22/2023

 

Rationale: Department priority (appropriation in P.L. 2021, Ch. 635)

Services: All

Effective Date: 1/1/2023

Next Rate Adjustment: COLA Annually in January

Further Section Change Needed: None

 

Section 17, Community Support

Initiation 9/1/2022

Kickoff and survey overview 3/11/2022

Survey distributed 4/22/2022

Draft Rate,public comment invite 9/1/2022

Draft Rate Presentation Posted and Comment Deadline Reminder - September 27, 2022

Final Draft Rates Posted - December 30, 2022

 

Kickoff Recording (included all BH sections) - May, 2022

Survey Results (PDF) - 10/5/2022

(13, 17, & 92) 9/20/2022:

(17, 28 & 92 Community-Based MH & SUD) 9/23/2022:

Comment Summary with Department Response (PDF) - 5/22/2023

Final Rate Model (PDF) - 5/22/2023

 

Rationale: P.L. 2021, Ch. 398, Part AAAA; P.L. 2021, Ch. 635

Services: All

Effective Date: 1/1/2023

Next Rate Adjustment: COLA Annually in January

Further Section Change Needed: None

 

Section 26, Day Health Services

Initiation 8/11/2022

Kickoff and survey overview (direct email) 8/11/2022

Survey results (direct email) 10/24/2022

Draft Rate Public Review and Comment 11/2/2022

Comment Summary with Department Response 4/3/2023

 

Kickoff Recording - 8/31/2022

Survey Results (PDF) - 10/24/2022

Draft Rate/Public Comment Recording - 11/17/2022

Draft Rate Model (PDF) - 11/17/2022

Comment Summary - 3/16/2023

Final Draft Rates - 12/27/2022

Rationale: P.L. 2021 Ch.398, Part AAAA

Services: All

Effective Date: 1/1/2023

Next Rate Adjustment: COLA Annually in January

Further Section Change Needed: None

 

Section 28,

Initiation 9/01/2022

Kickoff and survey overview 3/11/2022

Survey distributed 4/22/2022

Draft Rate, public comment 9/01/2022

Draft Rate Presentation Posted and Comment Deadline Reminder - September 27, 2022

Final Draft Rates Posted - December 30, 2022

Kickoff Recording (included all BH sections) - May, 2022

Survey Results (PDF) - 10/5/2022

17, 28 & 92 Community-Based MH & SUD 9/23/2022:

Comment Summary with Department Response (PDF) - 5/22/2023

Final Rate Model (PDF) - 5/22/2023

Rationale: P.L. 2021, Ch. 398, Part AAAA; P.L. 2021, Ch. 635

Services: All

Effective Date: 1/1/2023

Next Rate Adjustment: COLA Annually in January

Further Section Change Needed: None

 

Section 60 DME (Phase I)

Initiation - 9/27/2022

Draft Rate, public comment - 11/22/2022

Draft fee schedule and methodology - 11/23/2022

Summary of Comments with Department Response - 2/06/2023

Billing Guidance and Corrections - 3/23/2023

 

Public Forum Presentation (PDF) 12/01/2022

Public Forum Recording 12/01/2022

Draft Rate Methodology (PDF) 12/01/2022

Draft Fee Schedule (PDF) 12/01/2022

Rate Forum Comments and Responses (PDF) 2/6/2023

Final Draft Fee Schedule (1/5/2023)

 

Rationale: Department priority (appropriation in P.L. 2021, Ch. 635)

Services: 100% of Medicare, rural/non-rural, and DME index COLA for non Medicare

Effective Date: 1/1/2023

Next Rate Adjustment: annually, in coordination with Medicare.

Further Section Change Needed: Non-Medicare covered codes

 

Section 65, Behavioral Health

Initiation 9/01/2022

Kickoff and survey overview 3/11/2022

Survey distributed 4/22/2022

Draft rate, public comment 9/01/2022

Draft Rate Presentation Posted and Comment Deadline Reminder - September 27, 2022

Final Draft Rates Posted - December 30, 2022

 

Kickoff Recording (included all BH sections) - May, 2022

Survey Results (PDF) - 10/5/2022

65 Adult and Children Outpatient & School Health Related Services 9/21/2022:

17, 28 & 65 Community Based Mental Health & SUD Services 9/23/2022:

Comment Summary with Department Response (PDF) - 5/22/2023

Final Rate Model (PDF) - 5/22/2023

Rationale: P.L. 2021, Ch. 398, Part AAAA; P.L. 2021, Ch. 635

Services: All

Effective Date: 1/1/2023

Next Rate Adjustment: COLA Annually in January

Further Section Change Needed: None

 

Section 65, Crisis Residential and Resolution

Initiation 9/01/2022

Kickoff and survey overview 3/11/2022

Survey distributed 4/22/2022

Draft rate public review, written comment 11/16/2022

Draft Rate Presentation Posted and Comment Deadline Reminder - September 27, 2022

Final Draft Rates Posted - December 30, 2022

 

Kickoff Recording (included all BH sections) - May, 2022

Crisis Survey Analysis 11/7/2022

Draft Rate Model (PDF) - 11/22/2022

Draft Rate Public Review Recording - 11/22/2022

Comment Summary with Department Response (PDF) - 5/22/2023

Final Rate Model - 5/22/2023

 

Rationale: P.L. 2021, Ch. 398, Part AAAA; P.L. 2021, Ch. 635

Services: Crisis Services

Effective Date: Crisis Residential only 1/1/2023

Next Rate Adjustment: TBD

Further Section Change Needed: Work on Crisis Resolution is ongoing into 2023

 

Section 92, Behavioral Health Homes

Initiation 9/01/2022

Kickoff and survey overview 3/11/2022

Survey Distributed 4/22/2022

Draft Rate, public comment 9/01/2022

Draft Rate Presentation Posted and Comment Deadline Reminder - September 27, 2022

Final Draft Rates Posted - December 30, 2022

 

 

Kickoff Recording (included all BH sections) - May, 2022

Survey Results (PDF) - 10/5/2022

(13, 17, & 92) 9/20/2022:

(17, 28 & 92 Community-Based MH & SUD) 9/23/2022:

Comment Summary with Department Response (PDF) - 5/22/2023

Final Rate Model (PDF) - 5/22/2023

 

Rationale: Ensure equitable rates across behavioral health sections and help address DOJ findings.

Services: All

Effective Date: 1/1/2023

Next Rate Adjustment: COLA Annually in January

Further Section Change Needed: None

 

31 Federally Qualified Health Centers (Rebasing)

Initiation 9/27/2022

Provider Kickoff (direct invite to MPCA) 10/17/22

Draft Rates/Public Comment Invite 3/27/2023

Billing Guidance & Implementation Timing for Updated Payment Methodology 5/01/2023

Implementation of 3/01/2023 rates 5/12/2023

Kickoff Meeting Recording - 10/17/2022

LD 1787 Presentation (PDF) - 1/18/ 2023

LD 1787 Meeting Recording - 1/18/2023

Stakeholder Infomational Recording - 2/1/2023

Stakeholder Informational Presentation (PDF) - 2/1/2023

Stakeholder Informational Recording - 2/21/2023

Draft Public Forum Presentation (PDF) - 3/30/2023

Draft Public Forum Presentation Recording - 3/30/2023

Comment Summary with Department Response (PDF) - April 23, 2024

Rationale: P.L. 2021 Ch. 747

Services: All

Effective Date: 3/1/2023

Next Rate Adjustment: Annually in July

Further Section Change Needed: None

Section 5 Ambulance Services

Ambulance Reimbursement Effective 4/1/2022 and Billing Guidance 3/16/2022

(This update occurred prior to P.L. 2022 Ch. 639 becoming effective)

Rationale: Legislation, 2021 Resolve, Ch. 118 Resolve to provide add on payments for ambulance services reimbursed by MaineCare.

Services: Medicare Covered Services

Effective Date: 4/01/2022

Next Rate Adjustment:  Updated annually in January in Coordination with Medicare

Further Section Change Needed: Non-Medicare Codes/Services

 

Sections 13, 17, 23, 28, 30, 40, 65, 91, 92, 93, 97-App D Therapeutic Foster Care, 102

MaineCare Cost of Living Adjustments and Medicare Standardization Effective July 1, 2022 – 6/03/2022

(This update occurred prior to P.L. 2022 Ch. 639 becoming effective)

Rationale: Legislation, PL. 2021, Ch 635, Part A.


Services: COLA Rate Adjustments (4.94% equal to the percentage increase in the state minimum wage for January 1, 2022)


Effective Date: July 1, 2022


Next Rate Adjustment:

Annual COLA in January (sections 13, 17, 28, 65, 92.)

Annual COLA in July (sections 23, 30, 40, 91, 93, 97 B&D & 102)

Further Section Change Needed: All behavioral health sections have been addressed in a recently closed 2022 Rate Study. Other sections are currently in progress or upcoming for rate determinations in CY 2023 (except for section 91 Health Home Services).

 

Sections 14, 15, 68, 75, 85, 90, 95, 101, 109

MaineCare Cost of Living Adjustments and Medicare Standardization Effective July 1, 2022 – 6/03/2022

(This update occurred prior to P.L. 2022 Ch. 639 becoming effective)

Rationale: Comprehensive Rate Study Evaluation: areas of greatest need, Inconsistent, inequitable reimbursement across sections, and Standardized percentage of Medicare (72.4%) and use of current year’s rates

Services: Medicare covered services

Effective Date: July 1, 2022

Next Rate Adjustment: Annually in January in Coordination with Medicare

Further Section Change Needed: Non-Medicare codes need to be addressed

 

Section 25, Dental

Notice of Dental Rate Reform

Notice of Dental Policy Forum

Draft Dental Reform Methodology (PDF)

Draft Dental Rates (PDF)

Dental Provider Forum Presentation (PDF)

Dental Rate Forum Presentation (PDF) and Recording

 

Dental Policy Forum Presentation (PDF) and Recording

 

Rationale: Comprehensive Rate Study Evaluation: areas of greatest need

Services: Comprehensive adult and children’s dental

Effective Date: July 1,2022

Next Rate Adjustment: July rebasing or COLA (bi-annually).  

Further Section Change Needed: None needed. Rates will be updated to rebased benchmarks for July 2024

 

Section 67, Nursing Facility Services

NF/RCF Rate Letters and 125% Minimum Wage Adjustments - 6/30/2022

(This update occurred prior to P.L. 2022 Ch. 639 becoming effective)

Rationale: Legislation: Section AAAA-5, 2021 P.L. Ch. 398

Services: 125% min wage adjustment

Effective Date: July 1, 2022

Next Rate Adjustment: Annually in January (AAAA adjustment), Annually in July, (COLA)

Further Section Change Needed: Upcoming Rate Study to address the current administratively burdensome cost settlement system and to address lack of incentive for quality of care and to reward cost effectiveness.

 

Section 97, Appendix C, Medical Remedial (RCF)

NF/RCF Rate Letters and 125% Minimum Wage Adjustments6/30/2022

(This update occurred prior to P.L. 2022 Ch. 639 becoming effective)

Rationale: Legislation

Services: RCF 125% min wage adjustment

Effective Date: July 1, 2022

Next Rate Adjustment: January 1, 2023 (AAAA adjustment-not inflation)

Further Section Change Needed: Upcoming Rate Study to address the current administratively burdensome cost settlement system and to address lack of incentive for quality of care and to reward cost effectiveness.

 

Section 97, Appendix D, Children’s Residential Care Facilities

PNMI D Proposed Changes and Final Draft Rate Notice 8/13/2021

(This update occurred prior to P.L. 2022 Ch. 639 becoming effective)

 

Survey Analysis

Cost Report Analysis

Response to Public Comments

Final Rate Models

Rationale: Outdated legacy rate models and new federal quality standards

Services: Residential Care

Effective Date: November 1, 2021

Next Rate Adjustment: Annual COLA in July

Further Section Change Needed: Therapeutic Foster Care. (Planned study 2023)

 

Section 89, MaineMOM (New Service)

Informational Session on Proposed MaineMOM Services and Reimbursement 3/18/2022

(This service developed prior to P.L. 2022 Ch. 639 becoming effective)

MaineMOM Advisory Group Presentation (PDF) 9/15/2020

 

Rationale: New service

Services: Integrated opioid tx and perinatal care for pregnant/ postpartum people/ their infants

Effective Date: Rulemaking in progress

Next Rate Adjustment: To Be Determined

Further Section Change Needed: None needed

 

Cost-of-Living Adjustments (COLA) and Medicare Standardization

A schedule of COLA/Medicare Standardization updates per section of policy is coming soon!

Background

In 2019, DHHS and MaineCare launched a Comprehensive Rate System Evaluation (CRSE) to serve as the basis to inform policy making and improve members’ health and the program’s sustainability by comprehensively evaluating rates and promoting high-value services.

Evaluation

The evaluation found that many rates were outdated and inconsistent, some with no known basis or methodology. It also found significant inconsistencies in methodology and timelines for rate adjustments between services.

The evaluation made a number of recommendations that were ultimately codified in law in P.L. 2021 Ch. 639, which was enacted in 2022. Specifically, Ch. 639:

  1. Sets a schedule for regular rate review and adjustment.
  2. Establishes the MaineCare Rate Reform Expert Technical Advisory Panel (TAP) for consultative purposes.
  3. Establishes a rate system sub-committee to the MaineCare Advisory Committee (MAC).
  4. Formalizes a clear and transparent process for rate determination via public notice, presentation, and comments (as well as public response to comments) on proposed rates.
  5. Ensures review of relevant state and national data to inform rate amounts and payment models, with emphasis on models that promote high value services by connecting reimbursement to performance.

Annual Rate Determination Schedule Process

As mandated, the Department must annually develop a schedule of rate determination in consultation with the Technical Advisory Panel (TAP). The Department must then post the proposed rate determination schedule on its publicly accessible website, provide an opportunity for the public to review and comment on the rate determination schedule, and make available a summary of these comments on its publicly accessible website. The Department then posts the final rate determination schedule. 

Annual Rate Determination Schedules: Presented Materials and Associated Notices

Interested parties are encouraged to review presented materials for additional context and rationale pertaining to the proposed schedule.

CY 2024

CY 2023

Past Announcements

Frequently Asked Questions (FAQs)

Sections 17, 28, and 65 Rate Adjustment FAQ (PDF) - Updated February 8, 2024