Subsection 144-101-II-2.08 - REIMBURSEMENTA. The Department will reimburse a resource-adjusted (case-mix) price for covered services. The unadjusted price is listed in Chapter III, Section 2, "Allowances for Adult Family Care Services." The Department will multiply this unadjusted price by the member-specific MaineCare weight. That weight will calculate reimbursement by taking into consideration by resource grouping that some members are more costly to serve than others. Thus, the system requires: 1. Accurate assessment using the MDS-ALS form of all residents;2. Classification of members into groups which are similar in resource utilization, as reflected in the AFC services classification groups defined in section; and 3. A weighting system that quantifies the relative cost of services for different subsets of members according to a time study that translates into a resource-adjusted price. There are eight (8) resource-adjusted (case mix) groups, including one classification group used when members cannot be classified into one of the other seven (7) classification groups. Each group has a specific resource adjusted weight, as follows:
Resident Group | Resource Classification Group | Short description | MaineCare Weight |
ALS 7-9 | 1 | ADL=7-28 | 1.657 |
2 | ADL=0-6 | 1.210 |
ALS 5-6 | 3 | ADL=3-28 | 1.360 |
4 | ADL=0-1 | 1.027 |
ALS 2-4 | 5 | IADLB=12-18 | .924 |
6 | IADLB=10-11 | .804 |
ALS 0-1 or ALS 2-4 and IADL 0-9 | 7 | ALS 0-1 or ALS 2-4 and IADL 0-9 | .551 |
ALS 0-1 | 8 | Unclassified | .551 |
4. The Department will calculate resource-adjusted prices on assessments as of January 1st and July 1st of each year, beginning on July 1, 2004. The Department will calculate the price for each member based on the MaineCare weight for the period as follows: a. The most recent MDS-ALS for each member in the facility as of the 15th of March for the July rate and the 15th of September for the January rate.b. The resource-adjusted price will be calculated by multiplying the resource group by the MaineCare weight.c. A roster of all members receiving AFC services and sources of payment as of March 15th and July 15th will be sent to facilities for verification prior to rate setting.d. The Department will utilize the roster sent to the provider in identifying the MaineCare members and their most recent assessment. It is the provider's responsibility to check the roster, make corrections and submit corrections to the Department or its designee within one week of receiving the roster. For new facilities without a resource grouping already calculated, the Department will apply a MaineCare weight of .924 to the unadjusted price for the first rate setting period. The actual resource-adjusted price will be applied to the first rate setting period after either a March 15 or September 15 roster is available, as applicable. Sanctions pursuant to Section 2.07-1 will not be applied to new facilities until an actual resource-adjusted price is used in rate setting.
B.Inflation AdjustmentThe Commissioner will determine by July 1st of each year whether the price will be adjusted for inflation, using standard industry economic trend factors.
C. In accordance with Chapter I, of the MaineCare Benefits Manual , it is the responsibility of the provider to seek payment from any other sources that are available for the rendered covered service prior to billing the MaineCare Program.D. AFC providers may not accept or receive payment for MaineCare covered services in addition to the MaineCare payment.E.Remote Island Facility Supplemental PaymentIf CMS approves, effective October 1, 2015, Remote Island Facilities are entitled to a supplemental payment of fifteen (15) percent in addition to the standard MaineCare reimbursement rate, as set forth in Chapter III. Eligible facilities are allowed to retain this supplemental payment in addition to the total allowable rate under these rules.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-2, subsec. 144-101-II-2.08