• Read more about MaineCare Benefits Manual, January 1, 2026 Cost-of-Living Adjustment

Notice of MaineCare Reimbursement Methodology Change

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

SERVICES INCLUDED: Chapter 101, MaineCare Benefits Manual, January 1, 2026 Cost-of-Living Adjustment

NATURE OF PROPOSED CHANGES: The Department plans to submit a state plan amendment to increase reimbursement rates for the following sections by a 1% cost-of-living adjustment (COLA) which was appropriated by the Maine State Legislature.

• Read more about Section 103: Rural Health Center (RHC) Calendar Year 2026 (CY26) Rate Update

As previously noticed, MaineCare is increasing RHC reimbursement rates to reflect a 1.0% COLA. We will implement these new rates by January 7, 2026, and adjust all affected claims. No provider action is required.

• Read more about Section 97, Appendix C, Residential Care Facilities (RCFs) Cost-of-Living Adjustments (COLAs) & Rate Letters

As previously noticed, MaineCare will update RCF direct care rates to reflect a 1.0% COLA. We will implement these new rates by February 1, 2026.

Effective January 1, 2026, updated rate letters are accessible on the secure Health PAS Online Portal.

For questions on these rates, please contact the individual listed on the rate letters.

• Read more about Section 67, Nursing Facilities (NFs) Cost-of-Living Adjustments (COLAs) & Rate Letters

As previously noticed, MaineCare will update NF direct care and routine rates to reflect a 1.0% COLA. We will implement these new rates by February 1, 2026.

Effective January 1, 2026, updated rate letters are accessible on the secure Health PAS Online Portal.

For questions on these rates, please contact the individual listed on the rate letters.

• Read more about Microdyn Update for Ambulatory Payment Classification (APC) and Diagnostic Related Groups (DRG) – CRs 135015, 135189, 135705, 135712

Effective October 18, 2025, we completed the CMS quarterly updates for DRGs in MIHMS. Updates are as follows:

• Update DRG License
• Add new DRGs (402, 426, 427, 428, 429, 430, 447, 448, 450, 451)

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.

• Read more about Children’s Single Assessment Referral Training for Pediatricians, Family Medicine Providers, and Emergency Department (ED) Providers

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.

• Read more about Rate Determination Initiation Notice for Doula 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.

• Read more about Rate Determination Initiation Notice for Section 43, Hospice 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.

• Read more about Retroactive Rate Update: Section 65, Opioid Treatment Program (OTP) Services, CR 136636

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.

• Read more about Children’s Single Assessment Referral Training for Behavioral Health Home (BHH) and Targeted Case Management (TCM) Care Coordinators

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