C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-90, subsec. 144-101-II-90.09

Current through 2024-51, December 18, 2024

Subsection 144-101-II-90.09 - REIMBURSEMENT

90.09-1Fee Schedule

MaineCare reimburses for physician services using a fee schedule known as the MaineCare rate of reimbursement (See Section 90.09-2 A.) The fees or cap associated with service codes are in the MaineCare claims processing database, and are available to any provider who requests a paper or electronic copy. The information is also available on the MaineCare Services website: https://mainecare.maine.gov/. Fees are subject to change, although the rate in effect as of the date of service applies for procedures performed on that date.

Providers who use electronic information from the website should note that they are still subject to all applicable MaineCare rules. The MaineCare Program will provide quarterly updates on the website.

Providers must bill using their usual and customary charges and reimbursement will be in accordance with the criteria cited below. Providers must bill medical supplies and therapeutic injections at their cost, using NDC codes where available. Providers should direct any questions to the Provider Relations Unit..

90.09 -2MaineCare Reimbursement Rates

MaineCare will reimburse the lowest of the following (subparts A, B, or C) for covered services, except as otherwise outlined in this Section (MBM, Chapter II, Section 90.09):

A.Effective through June 30, 2022, the Fee Schedule rate, which is set based on:

(1) Seventy percent (70%) of the lowest level in the 2009 Medicare fee schedule (or 70% of the rate in the year CMS assigned a rate for that code) for Maine area "99" including appropriate Medicare fee adjustments for place of service and modifiers in effect at that time; or

(2) The lowest amount allowed by Medicare Part B for Maine area "99" fee schedule including appropriate Medicare fee adjustments for place of service and modifiers; or

(3) If the above two options are not available, the Department will research other State Medicaid agencies that cover the relevant service/code. The Department will base its rate on the average cost of the relevant services/codes from those other agencies.

The Department shall submit to CMS and anticipates approval for a State Plan Amendment related to these provisions.

Effective July 1, 2022, the Fee Schedule rate, which is set based on:

(1) Seventy-two point four percent (72.4%) of the current year's Medicare rate per code for Maine area "99," including appropriate Medicare fee adjustments for place of service and modifiers in effect at that time; or

(2) If there is no Medicare rate available, the Department will research other State Medicaid agencies that cover the relevant service/code. The Department will base its rate on the average cost of the relevant services/codes from those other agencies.

B. The provider's usual and customary charges.

C. The amount, if any, by which the MaineCare rate of reimbursement for services billed exceeds the amount of the third party payment as set in MBM, Chapter I. MaineCare considers a claim paid in full if the insurance amount received exceeds the MaineCare rate of reimbursement.

When a member is covered by insurance with a service benefit principle, the insurance payment is considered payment in full in accordance with the service

benefit agreement between the provider and the insurance company. MaineCare should not be billed in such instances.

90.09-3Reimbursement Rate for Drugs Administered By Other than Oral Methods

MaineCare will not reimburse claims without both a valid J code and NDC.

MaineCare will not reimburse for provider-administered drugs that are not rebateable under Section 1927 of the Social Security Act ( 42 U.S.C.A. § 1396r-8(a) ) and implementing CMS regulations ( 42 C.F.R. § 447.500et seq.) unless the provider obtains PA. PA procedures can be found in MBM, Chapter 1, Section 1.14. PA will not be granted for non-rebateable, provider-administered drugs for which there are therapeutically equivalent alternatives that are rebateable. Instructions for billing, a crosswalk of J codes, and a list of rebateable NDC codes are available on the MaineCare Services website at: https://mainecare.maine.gov.

MaineCare determines drug fee schedules for drugs payable under this section as Average Sales Price (ASP) plus six percent (6%) as set by Medicare Part B for Maine area "99." MaineCare will reimburse the lower of:

1) The fee schedule rate (when the ASP is available), or

2) The provider's acquisition cost only, excluding shipping and handling.

90.09-4 Primary Care Provider Incentive Payment

The Department shall submit to CMS and anticipates approval for a State Plan Amendment removing 90.09-4, Primary Care Provider Incentive Payment, effective June 21, 2022.

Effective through June 20, 2022, the Primary Care Physician Incentive Payment (PCPIP) rewards physicians who have provided quality primary care to MaineCare members. Physicians receive scores in various categories such as the number of MaineCare patients, emergency room utilization and prevention/quality. Each physician's practices are compared to other physicians in his/her primary care specialty and then are given an overall ranking. Physicians ranking above the twentieth percentile will receive a monetary share of their specialty pool, based on percentile. The twentieth percentile and below do not receive a monetary share of their specialty pool. The following describes how the incentives are calculated:

1.Access - Forty Percent (40%)

a. Total number of unduplicated MaineCare members served per quarter.

b. Total number of health care providers accepting new MaineCare members.

2.Utilization - Thirty Percent (30%)

Emergency visit and/or hospitalization rate per quarter for physicians unduplicated MaineCare members per quarter.

3.Quality - Thirty Percent (30%)

a. Preventive measures score higher.

b. Comparison of quality indicators (QI) among specialty groups.

Examples:

Childhood immunization - percentage of children in the practice immunized by age two (2) against DPT, polio, measles/ mumps/rubella, type B influenza, and hepatitis B.

Adolescent immunization - percentage of adolescents in practice's children who have had following immunizations by age thirteen (13): second dose of measles/mumps/rubella, hepatitis B, tetanus/ diphtheria booster, and chicken pox.

Prenatal Care - percentage of women in practice who delivered a baby in previous year and received prenatal care in the first trimester.

Post-delivery checkup - percentage of pregnant persons in practice who had a checkup within six (6) weeks after delivery.

Mammography - percentage of women in practice ages fifty-two (52) to sixty-nine (69) who had a mammogram in previous year.

Pap test - percentage of women in practice ages twenty-one (21) to sixty-four (64) who had a pap test for cervical cancer in previous year.

Board certification - percentage of practice board certified in appropriate discipline.

The specific indicators utilized will be selected quarterly as necessary to obtain targeted quality of care evaluations. The same criteria shall be used among similar groups of physicians, i.e., family practitioners/general practitioners, internal medicine, pediatrics, etc.

Determination of Physician Incentive Payments

The elements described above will be the basis for placing each participating MaineCare physician in an octal grouping as follows:

Group 1 Percentile-Sixty Percent (60%) Of Total Payment

Octal 1	90 - 100	Thirty percent (30%) of Group 1 payment
Octal 2	80 - 89	Twenty percent (20%) of Group 1 payment
Octal 3	70 - 79	Ten percent (10%) of Group 1 payment

Group 2 Percentile-Twenty-Five Percent (25%) Of Total Payment

Octal 4	60 - 69	Ten percent (10%) of Group 2 payment
Octal 5	50 - 59	Eight percent (8%) of Group 2 payment
Octal 6	40 - 49	Seven percent (7%) of Group 2 payment

Group 3 Percentile-Fifteen Percent (15%) Of Total Payment

Octal 7	30 - 39	Ten percent (10%) of Group 3 payment
Octal 8	20 - 29	Five percent (5%) of Group 3 payment

90.09-5Primary Care Provider Enhanced Reimbursement

The Department shall submit to CMS and anticipates approval for a State Plan Amendment related to these provisions.

Effective July 1, 2022, enhanced reimbursement rates for select primary care services are set at 100% of current year Medicare rates for eligible primary care providers. Federally Qualified Health Centers, Rural Health Centers, and hospital-based physicians are not eligible providers. For a full list of eligible codes and their rates, see the MaineCare Rate Setting website: https://mainecare.maine.gov/. The following providers are eligible to receive primary care provider enhanced reimbursement:

(A) physicians who attest on a MaineCare self-attestation form that they practice with a specialty designation of Family Medicine, Internal Medicine, or Pediatric Medicine or a subspecialty within these primary care categories recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS) or the American Osteopathic Association (AOA).

(B) APRNs or PAs for whom an eligible physician (defined in 90.09-5(A)) has attested that he or she accepts direct professional responsibility.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-90, subsec. 144-101-II-90.09