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Effective October 18, 2025, we completed the CMS quarterly updates for DRGs in MIHMS. Updates are as follows:
Effective December 22, 2025, we completed the CMS quarterly updates for APCs in MIHMS. The following CMS documents provide the details about the APC updates.
Referral Process
Beginning February 2, 2026, Single Assessment Referral will be the required statewide process for determining eligibility for children’s medium- and high-intensity behavioral health services, as required under Maine’s Children’s Behavioral Health Services Settlement Agreement.
The Single Assessment is a standardized approach to assessing a child’s behavioral health needs and identifying the appropriate level of care and clinically indicated services for children who require medium- to high-intensity behavioral health services.
The Department has initiated a Rate Determination Process* for Doula Services. This is a newly covered service with the section of the MaineCare Benefits Manual to be determined. Rates are being determined pursuant to LD 1523 “Resolve, to Develop MaineCare Coverage for Doula Services” and in alignment with Maine’s participation in the Transforming Maternal Health (TMaH) Model, led by the Centers for Medicare & Medicaid Services.
The Department initiated a Rate Determination Process* for MaineCare Benefits Manual (MBM), Section 43: Hospice Services.
Reimbursement rates are being determined pursuant to P.L. 2025, Ch. 388. Opportunities to further align Hospice Services with Medicare requirements and improve access to Hospice care will be explored during the rate determination process.
MaineCare updated the OTP (H0020) rate retroactively due to a rate update from the Centers for Medicare Services (CMS) in March 2025. This new rate was implemented for billing on December 17, 2025.
Referral Process
Beginning February 2, 2026, Single Assessment Referrals will be the required statewide process for determining eligibility for children’s medium- and high-intensity behavioral health services, under Maine’s Children’s Behavioral Health Services Settlement Agreement.
Single Assessment is a standardized approach to assessing behavioral health needs and identifying the appropriate level of care and clinically indicated services for children who require medium- to high-intensity services.
Training
Corrected for Calendar Year
Effective January 1, 2026, MaineCare will update reimbursement rates for Medicare covered codes and services for the sections of policy noted below. The new rates will reflect 72.4% of the most recent 2026 Medicare rates.
Effective January 1, 2026, MaineCare will update reimbursement rates for Medicare covered codes and services for the sections of policy noted below. The new rates will reflect 72.4% of the most recent 2026 Medicare rates.
Effective January 1, 2026, MaineCare is updating ASC rates to reflect 100% of current year Medicare rates.
Once new rates are implemented, MaineCare will provide adjustment billing guidance and post an updated fee schedule to the Rate Setting webpage of the Health PAS Online Portal.
Effective January 1, 2026, MaineCare will update ambulance service rates to reflect 100% of the most current Maine Medicare area 99 urban, rural, or super rural rates.