MaineCare Benefits Manual, Section 45, Hospital 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 45, Hospital Services

NATURE OF PROPOSED CHANGES: 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 of service is on or after July 1, 2023. 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 prior to July 1, 2025. The methodology shall be as follows:

MS-DRG Adjusted Payment

The Department has adopted the Medicare MS-DRG and length of stay factors as specified in the distinct psychiatric unit and distinct SUD unit reimbursement schedule which is posted on the Department’s website. Per diem base rates were calculated to result in total reimbursement equal to one hundred percent (100%) of the costs of such discharges in the aggregate across all hospitals with distinct psychiatric units and distinct SUD units, utilizing 2022 data, when adjusted for MS-DRG relative weights and length of stay factor.

The Department will calculate reimbursement for covered inpatient stays in these distinct units using the following formula:  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.

Per diem base rates for psychiatric MS-DRGs differ for adults aged nineteen (19) and older and youth aged eighteen (18) and younger, reflecting the significant difference in average costs observed in hospitals’ 2021 and 2022 cost report data for these populations. The per diem base rate for SUD MS-DRGs will remain consistent regardless of member’s age.

Per diem base rates will be inflated annually.

Supplemental Payment for Certain Distinct Psychiatric Units

Effective through June 30, 2025, 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.

REASON FOR PROPOSED CHANGES: All changes are pursuant to P.L. 2021 Ch. 639, An Act to Codify MaineCare Rate System Reform and P.L. 2023 Ch. 3,  An Act to Make Supplemental