C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-45, subsec. 144-101-III-45.02

Current through 2024-46, November 13, 2024

Subsection 144-101-III-45.02 - GENERAL PROVISIONS

45.02-1Inflation

*Annual inflation adjustments will be applied to components of inpatient DRG reimbursement. For Distinct Psychiatric Units, and Distinct Substance Use Disorder Units this includes the per diem base rate. For other Acute Care Non-Critical Access Hospitals this includes the Maine Base Rate, GME add-on rate, and DRG outlier threshold. During rebasing years, inflationary increases will not be applied to DRG reimbursement components, as inflation components are considered during rebasing. For purposes of determining inflation, unless otherwise specified, the economic trend factor from the most recent edition of the "Healthcare Cost Review" from IHS Markit is used.

45.02-2Third Party Liability (TPL)

When a member is admitted to a hospital, it is the hospital's responsibility to identify all coverage available and perform all procedural requirements of that identified coverage to assure proper reimbursement. The Department will remove claims data from the MaineCare paid claims history when the TPL reimbursement for that claim is equal to or exceeds MaineCare reimbursement. Please see Chapter I Section 1.07 of the MaineCare Benefits Manual for detailed definitions applicable to Third Party Liability. Providers must adhere to the procedures outlined in that Section. Any MaineCare claims data submitted by a hospital may only be withdrawn within one hundred twenty (120) days of the date of the remittance statement.

45.02-3Interim and Final Cost Settlements

At interim and final settlements, the hospital will reimburse the Department for any overpayments within thirty (30) days of receipt of the settlement report, or the Department will reimburse the amount of any underpayment to the hospital. Each Interim and Final Cost Settlement Report must be treated separately for purposes of remitting checks for overpayment and underpayment. If no payment is received within thirty (30) days, the Department may offset prospective interim payments, if permitted by federal and state law. Any caps imposed on Prospective Interim Payments (PIPs) are not applicable to the determination of settlement amounts.

The final settlement will not be performed until the Department receives the Medicare Final Cost Report. If the Medicare Final Cost Report has been received by the Department prior to the issuance of the Interim Cost Settlement Report, the Department will issue only a Final Cost Settlement Report.

Pursuant to PL 2007, P & S Law, Chapter 19, when carrying out final and interim settlements of payments, the Department shall pay all final settlements for hospital fiscal years 2003 and earlier prior to paying interim settlements for services for hospital fiscal years 2005 and later. This does not limit the Department's authority to:

1. Make ongoing MaineCare payments for services being rendered during the current fiscal year; or

2. Provide partial settlements for hospital fiscal years 2004 and later to certain hospitals in need of such relief in order to relieve financial hardship. Financial hardship is determined by the Department and includes consideration of such factors as a high settlement amount due as a percent of total patient revenue, significant negative operating margins and/or negative cash flow as reflected on audited financial statements.

The provider must submit a written request for a hardship waiver to the DHHS Commissioner sixty (60) days from the due date for the hospital's MaineCare cost report. All supporting documentation must be submitted with the request. The Department will not make a determination of financial hardship until resources are available to issue interim or final hospital audit settlements. The Department may request additional information to support the provider's claim of financial hardship before making a determination.

45.02-4Crossover Payments

MaineCare does not reimburse for Medicare crossover payments, except to the extent required by CMS (See 42 U.S.C. 1396a(a)(10)(E)(i) and 42 U.S.C. 1396d(p)(3)).

45.02-5Reporting and Payment Requirements

All Maine hospitals are required to submit an As-Filed Medicare Cost Report, MaineCare Supplemental Data Form and additional documents as described below, within five (5) months of the end of the provider's fiscal year, as defined above, to the State of Maine Department of Health and Human Services, Office of Audit, 11 State House Station, Augusta, ME, 04333. Non-Maine (out-of-state) hospitals are not required to submit any cost reports.

A.As-Filed Medicare Cost Report and MaineCare Supplemental Data Forms

Maine hospitals are required to utilize the Medicare Cost Report forms including both Title XVIII and Title XIX work sheets for their As-Filed Medicare Cost Reports. Title XIX worksheets must include all MaineCare charge data available at the time of filing. The MaineCare Supplemental Data Form must also be provided on a template provided by the Department. All sections relevant to Title XIX must be completed, whether or not required by CMS.

B.Required Certifications and Signatures

All documents must bear original signatures. The administrator of the hospital must certify the As-Filed Medicare Cost Report by signing it. If someone other than facility staff prepares the return, the preparer must also sign the report.

The hospital shall also submit a copy of the MaineCare Supplemental Data Form electronically.

C.As-Filed Medicare Cost Report and MaineCare Supplemental Data Form Time Period

The As-Filed Medicare Cost Report and the MaineCare Supplemental Data Form shall cover the twelve (12) month period of each provider's fiscal year unless:

1. A change in licensing category has become effective during a provider's fiscal year, (e.g., a hospital becomes designated as a critical access hospital) in which case the hospital must file two (2) versions of As-Filed Medicare Cost Report and the MaineCare Supplemental Data Form, one (1) for the part of the fiscal year under one licensing category and another for the part of the fiscal year under the second licensing category; or

2. Advance authorization to submit an As-Filed Medicare Cost Report and a MaineCare Supplemental Data Form for a lesser period has been granted in writing by the Director of the Office of Audit.

D.Documentation Required to Be Filed with the As-Filed Medicare Cost Report

The Department requires that the following supporting documentation be submitted with the As-Filed Medicare Cost Report:

[Note: Cents are omitted in the preparation of all schedules except when inclusion is required to properly reflect per diem costs or rates.]

1. Audited financial statements;

2. Worksheet reconciling financial statement revenue to the Worksheet C charges on the As-Filed Medicare Cost Report;

3. MaineCare Supplemental Data Form;

4. UB Mapping - mapping revenue codes to appropriate cost center; and

5. 1500 Mapping - mapping of 1500 claims to clinic/cost centers by service area, specialty, or physician.

E.Payment Requirements in the Event of an Overpayment to the Hospital

If a hospital determines from the As-Filed Medicare Cost Report that the hospital owes monies to the Department of Health and Human Services, a check equal to one hundred percent (100%) of the amount owed to the Department must accompany the As-Filed Medicare Cost Report.

If the Department does not receive a check with the As-Filed Medicare Cost Report, the Department may elect to suspend prospective payments, pursuant to State regulations and statutes.

F. *Upper Payment Limits (UPL)

Reimbursement is subject to applicable CMS Upper Payment Limits (UPL). Non-State Government Owned Hospitals are subject to a separate UPL.

If the Department determines MaineCare payments to a hospital exceed the UPL, the Department shall limit payments accordingly to ensure compliance with the applicable UPL, after providing written prior notice to the hospital.

G.Consequences of Failing to File Complete and Adequate As-Filed Medicare Cost Report and MaineCare Supplemental Data Form

The Department has determined that failing to file an adequate, complete As- Filed Medicare Cost Report and MaineCare Supplemental Data Form, as determined by the Department, in a timely manner as required above is grounds for the Department to impose sanctions pursuant to the MaineCare Benefits Manual Chapter I, Section I.

The Office of Audit may reject any reports that do not comply with these regulations. In such cases, the Department shall deem the report incomplete until re-filed and in compliance.

H.Extensions

Hospitals must file all requests for extension of time to file an As-Filed Medicare Cost Report and/or MaineCare Supplemental Data Form in writing, and the Office of Audit must receive the request no less than fifteen (15) days prior to the due date. The hospital must clearly explain the reason for the request and specify the date by which the Office of Audit will receive the report.

The Office of Audit will not grant automatic extensions. The Director of the Office of Audit has the sole discretion to determine whether the request is for good cause based on the merits of each request. A "good cause" is one that supplies a substantial basis for the delay or an intervening action beyond the provider's control. Ignorance of the rule, inconvenience, or a Cost Report preparer engaged in other work will not be considered "good cause."

45.02-6Data for PIP Calculation

To calculate the PIP for a given state fiscal year the Department will use the most recent As-Filed Medicare Cost Report, and the MaineCare Supplemental data form filed by the hospital, to the extent these reports contain complete information, including but not limited to, the Title XIX section of the Medicare Cost Report and the MaineCare paid claims history to the extent that it is available. If they are not complete, the Department will use the most recent Cost Settlement Report. The Department will also review any additional data submitted by the deadline regarding significant differences in costs that occurred after the year of the cost report. The Department's estimates of PIP will also reflect operational and/or policy revisions expected to result in substantive changes to services provided by hospitals.

The deadline for receipt of data related to the calculation of prospective interim payments, including estimated discharges, will be May 31 of the calendar year in which the state calculates the PIP.

*A Hospital approved by the Department for conversion to an Acute Care Critical Access Hospital must submit cost report data to determine the hospital's PIP estimate prior to the effective date of the facility's new status as an Acute Care Critical Access Hospital. The hospital must complete a Critical Access Hospital Cost Report, as published by the Division of Audit, for the fiscal year determined by the Department. This template (available at https://www.maine.gov/dhhs/about/financial-management/audit/mainecare-cost-report) must be submitted to: State of Maine Department of Health and Human Services, Office of MaineCare Services, Attn: Rate Setting, 11 State House Station, Augusta, ME, 04333.

45.02-7PIP Payment Floor

If CMS approves, the Department establishes a floor for PIP payments so that the total payment to all hospitals receiving a PIP is not less than seventy percent (70%) of the calculated amount of the total PIP for the state fiscal year.

45.02-8 *Days Awaiting Nursing Facility (NF) Placement

Effective July 1, 2024, in-state Acute Care Non-Critical Access Hospitals may bill for each day that a MaineCare eligible member is in the care of the hospital while awaiting placement in a NF. The Department will reimburse at seventy-five percent (75%) of the statewide average per diem rate per MaineCare member day for NF services. The statewide average rate will be computed based on the simple average NF rate per MaineCare member day for the applicable state fiscal year. The reimbursement fund for days awaiting placement pursuant to this section is capped at a maximum annual sum of $1,500,000 of combined state General Fund funds and federal funds for each State fiscal year. The Department will reimburse quarterly by order of claim date. In the event the cap is expected to be exceeded in any quarter, reimbursement for claims in that quarter will be paid out proportionately, and a notification of total funds expended for that year will be sent out to providers.

45.02-9 *Claims Billing

Hospitals must submit claims using required billing forms, as described in the Department's billing instructions.

The Department has provided additional Hospital Billing Guidance to supplement this rule; this guidance is updated regularly and is available at https://mainecare.maine.gov/Billing%20Instructions/Forms/Publication.aspx.

45.02-10 *Readmission Penalty

Effective August 9, 2024, clinically related readmissions for the member to the same hospital within thirty (30) days of an inpatient Discharge are not eligible for reimbursement. Examples of clinically related readmissions include, but are not limited to:

A. The readmission DRG is in the same DRG classification as the initial admission DRG;

B. The readmission is related to the same condition(s) treated or care provided in the initial admission; and

C. The readmission is a result of complications from the initial admission.

The following scenarios do not constitute readmissions:

A. Admissions to Rehabilitation Hospitals;

B. Admission following discharge from inpatient maintenance chemotherapy treatment;

C. Admission following discharge from obstetric or newborn related services;

D. Admission following Discharge from or transfer to a Distinct Rehabilitation Unit, Psychiatric Unit, or Substance Use Disorder Unit within the same hospital;

E. Admission following patient self-directed Discharge (discharged against medical advice);

F. Claims for which the member exclusively received Days Awaiting Nursing Facility (NF) Placement services (see Section 45.02-8);

G. Claims for which MaineCare is not the primary payer;

H. Linked admissions (leave of absence); and

I. Any inpatient service billed as outpatient.

Following claim redetermination, providers may submit a claims adjustment request to the Department as outlined in MBM Ch. I, Section 1: General Administrative Policies and Procedures.

Specific service codes and additional billing instructions can be found in the Hospital Billing Guidance.

C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-45, subsec. 144-101-III-45.02