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Effective January 1, 2025, MaineCare will implement its second phase of changes to our outlier payment methodology and update the hospital-specific Cost to Charge Ratios (CCRs).
Phase 2 changes to the methodology include:
In accordance with the Performance-Based Adjustments rule provision of the MaineMOM rate methodology, MaineCare is adjusting the Per Member Per Month (PMPM) reimbursement rates to reflect a 4% withhold.
Effective January 1, 2025, we will implement the new rates to align with the billing cycle for MaineMOM providers.
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.
In April 2024, the Centers for Medicare & Medicaid Services (CMS) introduced the Ensuring Access to Medicaid Services Rule, known as the Access Rule. This new rule is designed to make it easier for people to access HCBS and to improve the quality of these services. We are committed to the goals of the Access Rule and beginning to plan for how to meet these new requirements. Over the coming months, we will ask for your feedback about how we implement the requirements.
The Centers for Medicare & Medicaid Services (CMS) issued updated guidance on the use of 340B modifiers for providers and suppliers participating in the 340B Drug Pricing Program and who bill separately for payable Part B drugs and biologicals.
Effective January 1, 2025, providers must use the TB modifier on all 340B drugs provided to MaineCare members whether billing MaineCare for primary or secondary claims.
Acentra Health will end all Section 28 “School-Related SPT Exempt” authorizations after December 31, 2024.
Effective January 1, 2025, you will no longer be able to use the following procedure codes:
H2021HI School-Related, One-to-One (BHP), and SPT Exempt
H2021HK Specialized School-Related and One-to-One – SPT Exempt
Effective January 1, 2025, Section 103, RHC CY25 rate letters will be accessible on the secure Health PAS Online Portal. You can view them by logging into your Trading Partner Account and following this pathway: Exchange > Reports > Rate Setting Letters.
If you have questions about accessing the letters, please contact Provider Services at 1-866-690-5585.
The Department is in the process of updating reimbursement rates for Medicare covered codes and services for the sections of policy noted below, with an effective date of January 1, 2025. The new rates will reflect 72.4% of the most recent 2025 Medicare rates.
The Department is proposing to amend 10-144 CMR Chapter 708 concurrently with the rulemaking proposal to amend the related rule Chapter 707 to expand the age eligibility for the Maine Center for Disease Control and Prevention - Breast and Cervical Health Program (MBCHP) to qualifying participants who are 21 to 34 years old. The Department is proposing non-substantive changes to the rule format, including a revised title, and language for conformity with agency standards.
The Department is proposing to amend 10-144 CMR Chapter 707, Rules Relating to the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in Maine, to expand the age eligibility for the Maine CDC Breast and Cervical Health Program (MBCHP) to also include participants who are 21 to 34 years old. The Department is proposing changes to the order of prioritizing program expenditures that incorporate the additional age group in the event of financial exigency.