C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-45, subsec. 144-101-III-45.03
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, which include estimated capital costs, as described in Appendix A: DRG-Based Payment Methodology.
Effective July 1, 2023, the Department will pay distinct psychiatric unit and distinct substance use disorder (SUD) units as outlined below. This reimbursement methodology shall apply for members whose From Date is on or after July 1, 2023. The methodology shall be as follows:
Per diem base rate (determined by whether the MS-DRG is a psychiatric or SUD MS-DRG) multiplied by the applicable MS-DRG relative weight multiplied by the applicable Length of Stay factor
Hospitals that have distinct psychiatric units, are located in zip codes that CMS designates as "super rural," meaning they are in the bottom quartile of nonmetropolitan zip codes by population density, and also have a designation by the Health Resources and Services Administration (HRSA) as a High Needs Geographic Health Professional Shortage Area (HPSA) for mental health are eligible to receive a yearly supplemental payment in the amount of eight hundred and seventy-five thousand dollars $875,000. This supplemental payment will be distributed in equal payments in May and November. This supplemental payment is not subject to cost settlement. The supplemental payment will expire on June 30, 2025.
Claims paid under this methodology do not include graduate medical education costs, and will not be subject to cost settlement, with the exception of capital costs incurred prior to September 1, 2024.
Providers billing for distinct psychiatric units or distinct SUD units should ensure billing practices align with requirements outlined in the MaineCare UB-04 Billing Instructions Guide located on the HealthPAS website.
Effective July 1, 2024, the Department will reimburse Acute Care Non-Critical Access 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 rates, where the APC is applicable, unless otherwise specified in this rule. This percentage is determined by using utilization and cost data from hospital fiscal year 2022 As-Filed Medicare Cost Reports and is calculated to maximize reimbursement under the UPL with a small margin of error.
APC payments are made when the member receives services 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 patient 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 shall be paid only a DRG- based discharge rate and will not receive an APC payment.
An outlier payment adjustment is 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 three (3) calendar days 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 three (3) days immediately preceding the date of inpatient hospital admission.
Distinct rehabilitation, psychiatric, and substance use disorder units of a hospital are subject to only a one (1)-day payment window (the one (1) calendar 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 three (3) calendar days (or one (1) calendar day if applicable) 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 rates listed on the MaineCare Provider Fee Schedule.
Effective October 1, 2015, hospital payment for an emergency department visit (CPT codes 99281-99285 billed with revenue codes 0450-0459), with a primary diagnosis code included in Appendix B will be paid the outpatient physician's professional evaluation and management service fee schedule rate. This will be determined by using the current physician's payment rate listed in the MaineCare Provider Fee Schedule associated with the emergency department CPT code reported on the UB04 claim.
*Effective July 1, 2024, the former Public Hospitals section under 45.03 is repealed.
Effective August 9, 2024, items and/or services that are furnished by an off-campus hospital outpatient provider-based department (PBDs) will be reimbursed at a reduced MaineCare rate, proportionate to the reimbursement described in the annual CMS OPPS & ASC final rule. PBDs are required to bill using an institution claim (UB04) and report either the PO or PN modifier, as appropriate, on each claim line for applicable items and services. Physicians will be paid the professional claim and will be paid at the facility rate consistent with current policies for physicians practicing in an institutional setting for the technical component of all non-excepted items and services.
MaineCare will reimburse non-rural hospitals:
Ninety-three and three tenths percent (93.3%) of its share of inpatient hospital-based physician costs, Ninety-three and four tenths percent (93.4%) of its share of outpatient emergency room hospital-based physician costs, and Eighty-three and eight tenths percent (83.8%) of non-emergency room outpatient hospital-based physician costs.*MaineCare will reimburse rural hospitals and Acute Care Hospitals converting from Acute Care Critical Access Hospital reimbursement to Acute Care Non- Critical Access Hospital reimbursement:
One hundred percent (100%) of its share of inpatient hospital-based physician costs, One hundred percent (100%) of its share of outpatient emergency room hospital-based physician costs, and One hundred percent (100%) 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 cost settlement.
Effective July 1, 2024, all calculations are based on the hospital's As-Filed Medicare Cost Report (for interim settlement) or 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.
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 DRG- based system will include settlement of:
The DRG-based discharge rate as further described in the Appendix; Payments made for hospital-based physician services; and Outpatient prospective interim payments.MaineCare's interim cost settlement with a hospital operating under the DRG and APC based system will include settlement of:
The DRG-based discharge rate as further described in the Appendix; and Payments made for hospital-based physician services.MaineCare's interim cost settlement with a hospital operating under DRG and APC based systems will include settlement of:
Payments made for hospital-based physician services.APC payments will not be cost settled.
All settlement processes use charges included in MaineCare paid claims history for the relevant year, MaineCare supplemental data form and the hospital's Medicare Final Cost Report. No cap imposed on a PIP will limit or otherwise affect the determination of settlement amounts.
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 DRG-based system will include settlement of:
The DRG-based discharge rate as described in Appendix A; Payments made for hospital-based physician services; and Outpatient prospective interim payments.MaineCare's final cost settlement with a hospital operating under the DRG and APC based system will include settlement of:
The DRG-based discharge rate as further described in Appendix A; and Payments made for hospital-based physician servicesMaineCare's final cost settlement with a 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 made in relation to acute care critical access hospitals (CAH) must be made in accordance with the requirements for completion of the Medicare Cost Report and Generally Accepted Accounting Principles, except as stated below.
C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-45, subsec. 144-101-III-45.03