C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-45, subsec. 144-101-III-45.06
Effective July 1, 2024, the Department will reimburse Rehabilitation Hospitals as follows:
Effective for reimbursement for inpatient claims with a From Date on or after July 1, 2024, the Department will pay using DRG-based discharge rates, as described in Appendix A: DRG Based Payment Methodology.
The Department will reimburse Rehabilitation Hospitals for covered outpatient services, including ancillary services such as laboratory and imaging services, but not hospital-based physician services, at one hundred and nine percent (109%) of the adjusted Medicare APC rate, where the APC is applicable, unless otherwise specified in this rule.
APC payments will be made for services received in an emergency room, clinic or other outpatient setting, or, if the outpatient is transferred to another hospital or facility that is not affiliated with the initial hospital, where the member received the outpatient services. If the outpatient is admitted from a hospital's clinic or emergency department to the same hospital as an inpatient, the hospital will be paid only a discharge rate and will not receive an APC payment.
An outlier payment adjustment will be made to the rate when an unusually high level of resources has been used for a case. Effective July 1, 2024, calculations for outlier payments will follow Medicare rules and be paid at one hundred and nine percent (109%) of the Medicare payment.
This rule institutes billing and payment procedures for outpatient services provided on either the date of a member's inpatient hospital admission or during the one (1) calendar day immediately preceding the date of a member's inpatient hospital admission. Hospitals (or an entity that is wholly owned or wholly operated by the hospital) must include on the claim for a member's inpatient stay, the diagnoses, procedures, and charges for all outpatient diagnostic services and admission-related outpatient non-diagnostic services that are furnished to the member during the one (1) day immediately preceding the date of inpatient hospital admission.
An entity is wholly owned by the hospital if the hospital is the sole owner of the entity. An entity is wholly operated by a hospital if the hospital has exclusive responsibility for conducting and overseeing the entity's routine operations, regardless of whether the hospital also has policymaking authority over the entity.
The technical component of all outpatient diagnostic and clinically related non-diagnostic services that are provided by the hospital, or by an entity wholly owned or wholly operated by the hospital, are to be billed with the claim for inpatient services when the outpatient services are provided in the one (1) calendar day preceding an inpatient admission.
All non-clinically related, non-diagnostic services provided before admission are not to be included on the inpatient claim. These outpatient services should be identified with the appropriate condition code. All non-diagnostic services, clinically related or not, provided on the date of inpatient admission are always deemed to be related to the admission and are to be included on the inpatient claim.
MaineCare will reimburse the technical portion of the outpatient services on the inpatient claim.
For physician services provided during the payment window and billed on the CMS 1500, the entity must append the appropriate modifier to all claim lines identified as connected to the inpatient stay. MaineCare will reimburse the professional component with payment rates that include a professional and technical split and at the facility rate for services that do not have a professional and technical split.
It is the responsibility of the admitting hospital to notify wholly-owned or wholly-operated entities of an inpatient admission which may impact the entities eligibility for payment.
The payment window rule does not apply to outpatient services included in the rural health clinic or federally qualified health center all-inclusive rate, nor does it apply to ambulance and maintenance renal dialysis services.
A limited number of Current Procedural Terminology (CPT) codes do not have associated Medicare APC rates, as listed in Addendum B. MaineCare covers certain services listed in Addendum B and pays for these services based on a fee schedule.
MaineCare will reimburse
Ninety-three and three tenths percent (93.3%) of its share of inpatient hospital-based physician costs; Eighty-three and eight tenths percent (83.8%) of non-emergency room outpatient hospital-based physician costs.Hospitals will be reimbursed based on claim forms filed with the Department. The billing procedure is described in Chapter II, Section 45. These payments are subject to interim and final cost settlement.
Effective July 1, 2024, all calculations will be based on the hospital's As-Filed Medicare Cost Report (for interim settlement), Final Medicare Cost Report (for final settlement), MaineCare Supplemental Data Form and MaineCare paid claims history for the year for which the interim or final settlement is being performed. No cap imposed on a PIP will limit or otherwise affect the determination of settlement amounts.
DRG and APC payments are not cost settled.
To the extent applicable, MaineCare's interim cost settlement with a hospital will include settlement of:
Prospective interim payments; and Payments made for hospital-based physician services provided on or after the date MIHMS went live.MaineCare's interim cost settlement with a hospital operating under the discharge rate-based system will include settlement of:
Capital and medical education costs based on Medicare and GAAP principles Payments made for hospital-based physician services Outpatient prospective interim payments.MaineCare's interim cost settlement with a rehabilitation hospital operating under the discharge rate and APC based system will include settlement of:
Capital and medical education costs based on Medicare and GAAP principles Payments made for hospital-based physician servicesMaineCare's interim cost settlement with a rehabilitation hospital operating under DRG and APC based systems will include settlement of:
Payments made for hospital-based physician servicesAPC payments will not be cost settled
All calculations are based on the hospital's Final Medicare Cost Report, MaineCare Supplemental Data Form and MaineCare paid claims history for the year for which interim settlement is being performed. No cap imposed on a PIP will limit or otherwise affect the determination of settlement amounts.
To the extent applicable, MaineCare's final cost settlement with a hospital will include settlement of:
Prospective interim payments; and Payments made for hospital-based physician services provided on or after the date MIHMS went live.MaineCare's final cost settlement with a hospital operating under the discharge rate-based system will include settlement of:
Capital and medical education costs based on Medicare and GAAP principles Payments made for hospital-based physician servicesMaineCare's final cost settlement with a rehabilitation hospital operating under the discharge rate and APC based system will include settlement of:
Capital and medical education costs based on Medicare and GAAP principles Payments made for hospital-based physician servicesMaineCare's final cost settlement with a rehabilitation hospital operating under DRG and APC based systems will include settlement of:
Payments made for hospital-based physician servicesAPC payments will not be cost settled.
* The Department shall submit to CMS and anticipates approval for a State Plan Amendment related to these provisions
C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-45, subsec. 144-101-III-45.06