MaineCare Benefits Manual, Section 31, Federally Qualified Health Center Services

Notice of MaineCare Reimbursement Methodology Change

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

SERVICES INCLUDED:  Chapter 101, MaineCare Benefits Manual, Section 31, Federally Qualified Health Center Services

NATURE OF PROPOSED CHANGES: The Department plans to implement an Alternative Payment Methodology (APM) effective March 1, 2023. The APM is calculated using total eligible costs from the CMS-224 and total eligible visits provided by each FQHC on a supplemental cost report, for fiscal years 2018 and 2019, performed by each FQHC to develop a per-encounter reimbursement rate. 

All state plan services are reimbursable within an APM encounter except for the following, which will be reimbursed fee-for-service:

• Interpreter Services,
• Court Testimony,
• Intrauterine devices (IUDs) and long-acting contraceptives (LARC),
• Injectable drugs for treatment of Opioid Use Disorder (OUD),
• Administrative fee for Immunizations (flu and pneumonia only),
• Education Diabetes/Asthma (group only),
• Smoking/Tobacco Cessation & Preventative Counseling (group only), and
• Services for and associated with Dental Crowns and Dentures – must bill according to requirements within Section 25 – Dental Services

All services listed above are reimbursed according to otherwise approved sections of the Maine Medicaid State Plan.

The following services are not reimbursable to an FQHC. These services must be provided and billed through other applicable sections of the MaineCare Benefits Manual:

• Medical Supplies and Durable Medical Equipment (DME), including prosthetics – Section 60, Medical Supplies and Durable Medical Equipment,
• Laboratory Services (with the exception of incidentals) – Section 55, Laboratory Services,
• Radiology Services (including EKG/US and x-ray) – Section 101, Medical Imaging Services, and
• Ambulance Services – Section 5, Ambulance Services

REASON FOR PROPOSED CHANGES: All changes are pursuant to Maine P.L. 2021, Ch.747, An Act To Improve the Quality and Affordability of Primary Health Care Provided by Federally Qualified Health Centers and as a result of recently completed rate determination process performed by a vendor contracted by the Department and pursuant to P.L. 2021 Ch. 639, An Act to Codify MaineCare Rate System Reform.

ESTIMATE OF ANY EXPECTED INCREASE OR DECREASE IN ANNUAL AGGREGATE EXPENDITURES: The Department anticipates that this change will result in an increase of $13,053,283 in federal fiscal year 2023 which includes $9,621,438 in federal funds and $3,431,845 in state funds, and will cost $22,377,056 in federal fiscal year 2024 which includes $15,788,175 in federal funds and $6,588,881 in state funds.