The MaineCare Accountable Communities (AC) Program

Date posted:

Attachment(s):

Notice of MaineCare Reimbursement Methodology Change

AGENCY:  Department of Health and Human Services, Office of MaineCare Services

SERVICES INCLUDED:  The MaineCare Accountable Communities (AC) Program

NATURE OF PROPOSED CHANGES: The Department is moving to a shared risk model for the Performance Year (PY) aligning with State Fiscal Year 2026 (SFY 26, July 1, 2025 – June 30, 2026). This change impacts the methodology under which an AC may qualify for a shared savings payment or be required to repay a shared loss payment. The Department is offering two shared risk models, described below.

Model I:

  1. Shared Savings Rate. Lead Entities under Model I may share in a maximum of 40 percent of savings, based on quality performance. If the AC Lead Entity does not complete at least one Department-Aligned Initiative, that Entity may share in a maximum of 35 percent of savings, based on quality performance. 
  1. Quality Measure Adjusted Rate. The product of the quality score times the applicable shared savings percentage or 1 minus the quality score for the quality-adjusted shared loss percentage.
  1. Shared Savings Payment Limit. The AC Lead Entity’s initial shared savings rate will be capped at 5% (i.e. the initial difference between benchmark and PY TCOC, as a percentage). The shared savings payment is capped at 1 percent of the AC’s core costs before claims cap of the PY.
  1. Shared Loss. Lead Entities under Model I are liable for up to 15 percent of shared losses, based on quality performance. If the AC Lead Entity does not complete at least one Department-Aligned Initiative, that Entity will be liable for up to 20 percent of the shared loss, based on quality performance. 
  1. Shared Loss Payment Limit: The AC Lead Entity’s shared loss payment is capped by the lower of: 
    1. The total aggregate difference between Tier 2 and Tier 3 PCPlus PMPM payments to PCPlus practices that are part of the AC, or 
    2. 0.25 percent of the AC’s core costs before claims cap of the PY.  

Model II:

  1. Shared Savings Rate. Lead Entities participating under Model II share in a maximum of 60 percent of savings, based on quality measure performance. If the AC Lead Entity does not complete at least one Department-Aligned Initiative, that Entity will be eligible for up to 55 percent of the shared loss, based on quality performance. 
  1. Quality Measure Adjusted Rate. The product of the quality score times the applicable shared savings percentage or 1 minus the quality score for the quality-adjusted shared loss percentage. The AC Lead Entity’s quality score is capped at 80 percent for the quality-adjusted shared loss percentage.  
  1. Shared Savings Payment Limit. The AC Lead Entity’s initial shared savings rate will be capped at 7 percent (i.e. the initial difference between benchmark and PY TCOC, as a percentage).  The shared savings payment is capped at 2 percent of the AC’s core costs before Claims Cap of the PY.
  1. Shared Loss Rate. Lead Entities under Model II are liable for up to 25 percent of shared losses, based on quality performance. If the AC Lead Entity does not complete at least one Department-Aligned Initiative, that Entity will be liable for up to 30 percent of the shared loss, based on quality performance.

      5. Shared Loss Payment Limit. The AC Lead Entity’s Shared Loss Payment is capped by the lower of:

  1. The total aggregate difference above Tier 1 (excluding performance-based payment components) PCPlus PMPM payments to PCPlus Practices that are part of the AC, or
  2. 1 percent of the AC’s core costs before claims cap of the PY. 

Initiative requirements for successful participation in Department-Aligned Initiatives are established here https://www.maine.gov/dhhs/oms/providers/value-based-purchasing/accountable-communities, effective for services on and after July 1, 2025. 

Additional changes:

  • Based on actuarial analysis, the Department will update the claims cap to $200,000 for ACs with 2,000-4,000 attributed members or $300,000 for ACs with greater than 5,000 attributed members. The claims cap for the Comparison group will update to $400,000.
  • The health care trend used in setting the AC benchmark total cost of care amount will be adjusted to include all MaineCare members that meet attribution criteria, instead of just those members eligible for attribution to primary care and hospital locations that are not part of an AC.

REASON FOR PROPOSED CHANGES: All changes are pursuant to Department discretion, including data analysis and review of other state and national accountable care models.

ESTIMATE OF ANY EXPECTED INCREASE OR DECREASE IN ANNUAL AGGREGATE EXPENDITURES: The Department anticipates that this change will be cost neutral in federal fiscal years 2025 and 2026.

ACCESS TO PROPOSED CHANGES AND COMMENTS TO PROPOSED CHANGES:  The public may review the proposed methodology changes and written comments at any Maine DHHS office in every Maine county. To find out where the Maine DHHS offices are located, call 1-800-452-1926. The Department will hold a hearing for the proposed rulemaking and will be publishing a notice which includes information on the hearing date and location.

CONTACT INFORMATION

FOR RECEIPT OF COMMENTS:                 Kristin Merrill  

                                                                       Kristin.Merrill@maine.gov

AGENCY NAME:                                          Office of MaineCare Services

ADDRESS:                                                      109 Capitol Street, 11 State House Station

                                                                          Augusta, Maine 04333-0011

TELEPHONE:                                                  (207) 624-4006 FAX: (207) 287-6106

                                                                        TTY: 711 Maine Relay (Deaf or Hard of Hearing)

See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.

Office: MaineCare Services

Comment deadline:

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