C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-45, subsec. 144-101-III-45.12

Current through 2024-44, October 30, 2024

Subsection 144-101-III-45.12 - OUT-OF-STATE HOSPITALS

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.

C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-45, subsec. 144-101-III-45.12