Notice of MaineCare Reimbursement Methodology Change, MaineCare Benefits Manual, Chapter III, Section 67

Date posted:

Attachment(s):

Notice of MaineCare Reimbursement Methodology Change

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

SERVICES INCLUDED:  Chapter 101, MaineCare Benefits Manual, Chapter III, Section 67

NATURE OF PROPOSED CHANGES: The Department plans to submit a state plan amendment to address changes in reimbursement methodologies for Nursing Facilities.

These changes include moving toward creating a methodology that incentivizes high quality care, incorporates acuity measures that capture the range of need associated with caring for all residents, and decreases administrative burden.

This new reimbursement model and structure will be accomplished through the following changes: 

  • Definitions:
    • Changes Allowable Costs so that it aligns with the Daily Rate.
    • Changes Ancillary Services from a charge made in addition to the per diem charge to a charge made in addition to the Daily Rate.
    • Changes the definition of Base Year so that it aligns with the new methodology.
    • Adds a definition of Capital Cost Rate, Daily Rate, Direct Care Rate, Hours Per Day, Maine Veterans’ Home 70% Program, Nursing Component of Patient-driven Payment Model, and Routine Care Price.
    • Removes the definition of Experience Modifier, Fixed Cost Component, Free Standing Facility, Hospital-affiliated Nursing Facility, Per Diem Rate, Prospective Case Mix Reimbursement System, Reasonable Costs, and Total Allowable Inflated Direct Care Rate Per Day.
  • Cost Allocation Plans and Changes in Accounting Methods:
    • Removes references to allowable costs that are no longer applicable.
  • Cost Related to Resident Care:
    • Removes reference to bonuses based on the availability of any anticipated savings in the MaineCare Direct Care Component.
    • Changes the date at which costs must be incurred to become consistent with the effective date of the rule.
  • Upper Payment Limit:
    • Removes reference to exceeding 112% of the State mean.
  • Financial Reporting:
    • Changes fiscal year to calendar year.
  • Reimbursement Method:
    • Changes when nursing facilities will be rebased to reference the applicable statute.
  • Cost Components:
    • Changes the prospective case mix system model of reimbursement from a cost settlement model to two established statewide prices for Direct Care and Routine, and specifies that capital costs will be based on facility-audited cost settlement.
  • Direct Care Cost Components:
    • Changes the title from Direct Care Cost Components to Direct Care Costs.
    • Updates Resident Assessments to reflect current CMS protocols and updates when the Admissions Assessment must be completed.
    • Updates the Assessment Review Process to remove reference to CMS documents that no longer exist.
    • Updates how sanctions will be applied.
    • Removes reference to how direct care cost components are determined.
  • Routine Cost Component:
    • Changes the title from Routine Costs Components to Routine Costs.
    • Removes reference to how routine care cost components are determined.
    • Adds workers compensation to the list of routine costs.
    • Adds a cost-of-living adjustment to the allowable cost of medical directors to comply with Maine statute.
  • Capital Cost Component:
    • Changes the title from Fixed Costs Components to Capital Costs.
    • Changes the definition of base year costs from the audited fiscal year to the as-filed MaineCare cost report.
    • Removes workers compensation insurance premiums, the costs of loss-prevention and safety services, and wages and fringes paid to workers engaged in formal return-to-work programs as components of capital costs.
    • Removes occupancy adjustments.
    • Removes payment for high MaineCare Utilization.
    • Removes aggregate hold harmless.
  • Establishment of Prospective Per Diem Rate:
    • Changes the title to Establishment of Daily Rate.
    • Creates a new rate methodology that includes a Direct Care Rate, Routine Care Rate, Capital Cost Rate, and Bariatric Add-ons.
    • Creates a new Value-Based Payment and withhold rate.
    • Removes portions of the prior methodology that are no longer applicable.
  • Interim, Subsequent, and Prospective Rates:
    • Changes the Interim Rate and Subsequent Year Rates to align with the new methodology.
  • Final Audit of First and Subsequent Prospective Years:
    • Removes references to direct care and routine costs.
    • Removes the section on transfers of cost centers.
    • Removes the section on final audit adjustments.
  • Bedbanking of Nursing Facility Beds:
    • Removes Routine and Direct Care Cost Components.
  • Inflation Adjustment:
    • Establishes a new method of calculating inflation adjustments consistent with State statute.
  • Adjustments:
    • Changes the title to Adjustments to Capital Costs.
    • Makes changes to the section so that it only applies to Capital Costs.

The Department is removing the following sections entirely:

  • Final Prospective Rate
  • Establishment of Peer Group
  • Regions
  • Remote Island Nursing Facilities

In addition to the above changes, the Department changed all references of “fixed” costs, charges, or rates to “capital” for consistency and clarity.

REASON FOR PROPOSED CHANGES: All changes are pursuant to Maine P.L. 2023, ch. 643, PART A, Sec. A-14.

ESTIMATE OF ANY EXPECTED INCREASE OR DECREASE IN ANNUAL AGGREGATE EXPENDITURES: The Department anticipates that this change will cost $74,394,902 in federal fiscal year 2025 which includes $46,169,476 in federal funds and $28,225,426 in state funds, and will cost $90,929,172 in federal fiscal year 2026 which includes $55,730,490 in federal funds and $35,198,683 in state funds.

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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