C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-45, subsec. 144-101-III-45.04
The Department of Health and Human Services' total annual obligation to the hospitals will be the sum of MaineCare's obligation of the following: inpatient services + outpatient services + days awaiting placement and in swing beds + hospital based physician + Disproportionate Share Hospital (for eligible hospitals) + supplemental pool reimbursements (for eligible hospitals) - third party liability payments.
MaineCare will reimburse one hundred and nine percent (109%) of allowable costs.
MaineCare will reimburse one hundred and nine percent (109%) of allowable costs.
MaineCare will reimburse stays on these units as outlined in Section 45.03(B) of this rule. Reimbursement for services provided on these units will not be cost settled.
The Department will allocate the supplemental pool amount for each state fiscal year among the privately owned and operated acute care critical access hospitals based on their relative share of total MaineCare payment as compared to other critical access hospitals.
Total annual supplemental pool amounts are available on the MaineCare Services website; or, interested parties may request a paper copy by calling (207) 624-4050 or Maine Relay number 711.
The relative share is defined as the critical access hospital's MaineCare payment in the applicable state fiscal year divided by MaineCare payments made to all CAH hospitals in that year; multiplied by the total supplemental pool. This amount will not be adjusted at the time of audit.
For state fiscal year beginning on or after July 1, 2019, but before July 1, 2021, the hospital's applicable year is the hospital's fiscal year that ended during calendar year 2016.
Each hospital in the pool will receive its relative share of this supplemental payment. Supplemental payments will be distributed semiannually in November and May.
The Department will reimburse prospectively at the estimated statewide average rate per member day for NF services. The Department will reimburse at the prospective statewide average rates per member day for NF services that are specified in the "Principles of Reimbursement for Nursing Facilities", MaineCare Benefits Manual Chapter III, Section 67. The Department shall compute the average statewide rate per member day based on the simple average of the NF rate per member day for the applicable State fiscal year(s) and prorated for a hospital's fiscal year.
MaineCare will reimburse its share of inpatient hospital-based physician costs, outpatient emergency room hospital-based physician costs, outpatient non- emergency room hospital-based physician costs, and all graduate medical education costs.
Effective January 1, 2020, MaineCare's share of hospital-based physician costs is reimbursed at one hundred percent (100%) of costs.
July 1, 2009, through December 31, 2019, MaineCare will reimburse ninety-three and three tenths percent (93.3%) of its share of inpatient hospital-based physician, ninety-three and four tenths percent (93.4%) of its share of outpatient emergency room hospital-based physician, and eighty-three and eight tenths percent (83.8%) of outpatient non-emergency room hospital-based physician costs.
The estimated departmental annual inpatient/outpatient obligation, described above, will be calculated using the most recent MaineCare Supplemental Data Form increased by the rate of inflation to the beginning of the current state fiscal year. Third party liability payments are subtracted from the PIP obligation.
PIPs will be reduced by the anticipated amount of reimbursement for Medicare approved provider based primary care physician services as required to be billed on the CMS 1500 under Chapter II, Section 45, all inpatient hospital-based physician payments and those outpatient services the hospital has elected to bill on the CMS 1500. The PIP payment does not include DSH payments or the hospital's share of the supplemental pool payments.
The Department initiates an interim PIP adjustment under very limited circumstances, including but not limited to, restructuring payment methodology as reflected in a state plan amendment; when a hospital "changes" categories (e.g., becomes designated critical access); or a hospital opens or closes resulting in a redistribution of patients among facilities.
The Department calculates the Interim Cost Settlement with a hospital using the same methodology as is used when calculating the PIP, except that the data sources used are the hospital's As-Filed Medicare Cost Report, MaineCare Supplemental Data Form and MaineCare paid claims history for the year for which interim settlement is being performed.
The Department of Health and Human Services calculates the final settlement with a hospital using the same methodology as is used when calculating the PIP, except that the data sources used are the Medicare Final Cost Report, MaineCare Supplemental Data Form and MaineCare paid claims history for the year for which settlement is being performed.
C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-45, subsec. 144-101-III-45.04