C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-45, app 144-101-III-45-A
*Effective for claims with a From Date on or after July 1, 2024, the Department will use the process described below to determine reimbursement for hospitals to which a DRG-based payment methodology applies.
*The Department recognizes three distinct hospital peer groups with similar delivery systems and cost structures which observe DRG-based reimbursement methodology. These three distinct hospital peer groups are: Acute Care Non-Critical Access, Non-State Government Owned, and Rehabilitation. Each peer group has a distinct Maine Base Rate. The payment calculation further varies for acute care non critical access hospitals based on whether they are a teaching or non-teaching hospital.
*The Department calculates a hospital's DRG payment for a covered inpatient service using the following formula:
(Maine Base Rate + GME) x Medicare DRG Relative Weight + applicable outlier adjustment
45.A - 1 *Maine Base Rate
The Maine Base Rate is determined by the Department and includes MaineCare's estimated share of inpatient operating and capital costs. Rates are determined by using utilization (Discharges) and cost data from hospital fiscal year 2022 As- Filed Medicare Cost Reports and are calculated to maximize reimbursement under the UPL with a small margin of error. Maine Base Rates are available in the Hospital Billing Guidance.
45.A - 2 *Graduate Medical Education (GME) Add-on Rate
The Department assigns each teaching hospital a custom GME add-on rate inclusive of direct and indirect medical education costs. This adjustment is determined by using utilization (Discharges) and cost data from hospital fiscal year 2022 As-Filed Medicare Cost Reports.
Adjustments equal to one hundred percent (100%) of MaineCare's share of GME costs are applied as an add-on to the Maine Base Rate. Non-teaching hospitals will have a GME adjustment of zero (0). Each hospital's GME adjustment is available in Hospital Billing Guidance.
45.A * 3 *Medicare DRG Relative Weight Calculation
The Medicare Severity Diagnosis-Related Groups (MS-DRG) relative weight is assigned by CMS to represent the time and resources associated with providing services for that diagnosis related group. Relative weights are available at
https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/ms-drg-classifications-and-software. The Department will align with prevailing weights on July 1, 2024 and may update annually at its sole discretion.
45.A - 4 *Outlier Adjustment
An outlier payment adjustment is made to the inpatient service rate when an unusually high level of resources has been used for a case. An outlier adjustment will be made only when the outlier determination is greater than zero.
Effective July 1, 2024 through December 31, 2024, the outlier determination will be figured using the following formula:
Hospital-specific cost-to-charge ratio x (charges - fixed charge threshold - hospital DRG payment)
The outlier adjustment is equal to the outlier determination multiplied by ninety percent (90%) for the period in which the case has been Discharged. The fixed charge threshold and hospital-specific cost-to-charge ratios are available in the Hospital Billing Guidance.
*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, app 144-101-III-45-A