Subsection 144-101-III-45.01 - DEFINITIONS45.01-1Accountable Communities (AC) is a MaineCare initiative established through a contract between the Department and an Accountable Community Lead Entity that establishes a financial relationship between the Department and the AC Lead Entity to both provide a financial incentive and hold the AC accountable for the provision of efficient, coordinated, and high-quality care. AC Lead Entities that achieve savings relative to a benchmark Total Cost of Care (TCOC) amount are eligible to receive a portion of these savings dependent on and proportional to their performance on a number of quality measures.45.01-2Acute Care Critical Access Hospital is a hospital licensed by the Department of Health and Human Services (DHHS or "the Department") as a critical access hospital that is being reimbursed as a critical access hospital by Medicare.45.01-3Acute Care Non-Critical Access Hospital is a hospital licensed by the Department as an acute care hospital that is not being reimbursed as a critical access hospital by Medicare. There are three subsets of Acute Care Non-Critical Access Hospitals: rural hospitals, non-rural hospitals, and Acute Care Hospitals converting from Acute Care Critical Access Hospital reimbursement to Acute Care Non-Critical Access Hospital reimbursement.45.01-4 *Acute Care Hospitals Converting from Acute Care Critical Access Hospital Reimbursement to Acute Care Non-Critical Access Hospital Reimbursement means a hospital that was, as of January 1, 2024, reimbursed for inpatient and outpatient services by Medicare as a Non-Critical Access Hospital and was reimbursed by MaineCare like a Critical Access Hospital, and effective July 1, 2024 will be reimbursed by MaineCare as an Acute Care Non-Critical Access Hospital.45.01-5 *Ambulatory Payment Classifications (APC) means the classification of hospital-based outpatient services for use in determining facility reimbursement as defined in the Medicare Outpatient Prospective Payment System (OPPS). Codes CMS defines as "primary" may include ancillary services (e.g. drugs, supplies) in the APC rate amount.45.01-6As-Filed Medicare Cost Report means the cost report that the hospital files with the Medicare fiscal intermediary and with MaineCare, utilizing the CMS Medicare Cost Report form. In order for an As-Filed Medicare Cost Report to be accepted by MaineCare, hospitals must complete all information in the sections relevant to Title XIX, whether or not required by CMS.45.01-7Diagnosis-Related Group (DRG) means the classification of medical diagnoses for use in determining reimbursement as defined in the Medicare DRG system or as otherwise specified by the Department.45.01-8 *Discharge occurs when the hospital formally releases a member from hospital care, or when a member dies in the hospital. Acute Care Non-Critical Access Hospitals, Non-State Government Owned Hospitals and Rehabilitation Hospitals are subject to readmission penalties as set forth in section 45.02-10 of this rule.45.01-9Distinct Rehabilitation Unit is a unit within an acute care non-critical access hospital that specializes in the delivery of inpatient rehabilitation services. The unit must be reimbursed as a distinct rehabilitation unit as a sub provider on the Medicare cost report.45.01-10 *Distinct Psychiatric Unit is a unit within an acute care non-critical access hospital or within an acute care critical access hospital that specializes in the delivery of inpatient psychiatric services. The unit must be reimbursed as a distinct psychiatric unit as a sub provider on the Medicare cost report, or must be comprised of beds reserved for use for involuntary commitments under the terms of a contract with the Department. The claim must also be distinguishable as representing a discharge from a distinct psychiatric unit in the MaineCare claims processing system. *The Department shall submit and anticipates approval for a State Plan Amendment related to this provision
45.01-11Distinct Substance Use Disorder Unit is a unit that combines the medical management of withdrawal with a structured inpatient rehabilitation program. Services include coordinated group education and psychotherapy, and individual psychotherapy and family counseling as needed. Licensed Alcohol and Drug Abuse Counselors (LADCs) assist medical staff in developing an interdisciplinary plan of care. Evidence-based best practices such as motivational interviewing are used by staff who are trained in substance use disorder treatment. The claim must also be distinguishable as representing a discharge from a distinct substance use disorder unit in the MaineCare claims processing system. This label is not a Medicare designation.45.01-12Final Cost Settlement Report is the report issued by the DHHS Office of Audit that contains the final settlement calculation and settlement amount due to or due from the hospital. This Report utilizes the hospital cost data from the Medicare Final Cost Report.45.01-13From Date is the earliest date the hospital provides care to the member during an inpatient stay including up to one (1) day preceding, a member's admission to a distinct unit, or three (3) days preceding, a member's admission to a medical unit. This date is indicated on the UB-04 Claim Form in Field Locator 6 under statement covers period.45.01-14Institution for Mental Disease (IMD) means an institution primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases. This includes medical attention, nursing care, and related services.45.01-15Interim Cost Settlement Report is the report issued by the DHHS Office of Audit that contains the settlement calculation and amount due to or due from the hospital. This report utilizes the hospital cost data from the As-Filed Medicare Cost Report.45.01-16Low Income Utilization Rate for a hospital means the sum of: 1) the fraction (expressed as a percentage) a) the numerator of which is the sum (for a period) of (i) the total revenues paid the hospital for patient services under a State Plan, and (ii) the amount of the cash subsidies for patient services received directly from State and local governments, andb) the denominator of which is the total amount of revenues of the hospital for patient services (including the amount of such cash subsidies) in the period; and2) the fraction (expressed as a percentage) a) the numerator of which is the total amount of the hospital's charges for inpatient hospital services which are attributable to charity care in a period, less the portion of any cash subsidies described in clause a) (ii) of subparagraph 1) above in the period reasonably attributable to inpatient hospital services, this numerator shall not include contractual allowances and discounts (other than for indigent patients not eligible for MaineCare), andb) the denominator of which is the total amount of the hospital's charges for inpatient hospital services in the hospital in the period.45.01-17MaineCare Supplemental Data Form, also known as the As-Filed MaineCare Report, is a form submitted by hospitals on a template provided by the department which contains information supplemental to the Medicare Cost Report necessary for computing the Prospective Interim Payment, including, but not limited to, data pertaining to hospital-based physicians, lab and radiology claims and third-party payments.45.01-18MaineCare Paid Claims History is a summary of all claims billed by the hospital to MaineCare for MaineCare eligible members that have been processed and accepted for payment by MaineCare.45.01-19MaineCare Utilization Rate (MUR) means, for a hospital, a fraction (expressed as a percentage), the numerator of which is the hospital's number of inpatient days attributable to patients who (for such days) were eligible for MaineCare and the denominator of which is the total number of the hospital's inpatient days in that period. In this paragraph, the term "inpatient days" includes each day in which an individual (including a newborn) is an inpatient in the hospital, whether or not the individual is in a specialized ward and whether or not the individual remains in the hospital for lack of suitable placement elsewhere. The period used to determine the MUR is the Payment Year, as defined below.
45.01-20Medicare Final Cost Report means the Report issued by the Medicare fiscal intermediary and issued to the hospital and to MaineCare.45.01-21Medicare Severity Diagnosis-Related Group (MS-DRG) means the classification of medical diagnoses which adds patient's severity of illness and risk of mortality for use in determining reimbursement as defined in the Medicare DRG system or as otherwise specified by the Department.45.01-22Non-rural Hospital is a acute care non-critical access hospital that does not meet the definition of a "Rural Hospital" as defined in this regulation.45.01-23 *Non-State Government Owned Hospital is an Acute Care Non-Critical Access Hospital licensed by the Department that is neither privately owned nor operated by the State of Maine.45.01-24Payment Year, for purposes of Disproportionate Share (DSH) eligibility calculations, means a year commencing on or after October 1 However, if a hospital has a fiscal year that commences between September 20 and September 30, then its fiscal year shall be deemed to be a fiscal year commencing October 1 of the same calendar year. For example, if a hospital's fiscal year ends September 25, its fiscal year shall be deemed to be a fiscal year commencing October 1 of that calendar year.45.01-25Private Psychiatric Hospital is a hospital that is primarily engaged in providing psychiatric services for the diagnosis, treatment, and care of persons with mental illness and is privately owned. The facility must be licensed as a psychiatric hospital by the Department of Health and Human Services. A psychiatric hospital may also be known as an institution for mental disease.45.01-26 *Provider-Based Department (PBD) is a "Department of a Provider" as defined by Medicare in 42 C.F.R. Sec. 413.65, and as reported on the hospital's Medicare cost report. Rural Health Clinics, as described in MBM Chapter II, Section 103: Rural Health Clinic Services, are not PBDs.45.01-27Prospective Interim Payment (PIP) is the prospective periodic payment made to hospitals. State owned hospitals receive quarterly prospective interim payments. All other hospitals that receive PIP payments will receive them on a weekly basis. These payments may represent only a portion of the amount due the hospital; other lump sum payments made to hospitals throughout the year are not Prospective Interim Payment unless designated.45.01-28Provider's Fiscal Year is the twelve (12) month period used by a hospital as an accounting period.45.01-29Rehabilitation Hospital is a hospital that provides an intensive rehabilitation program and is recognized as an Inpatient Rehabilitation Facility by Medicare.45.01-30Rural Hospital is a acute care non-critical access hospital that meets one of the following criteria:1. Is a "Sole Community Hospital" as designated by Medicare, and as reported on the hospital's Medicare cost report; or2. Is a "Medicare-Dependent Hospital" as designated by Medicare, and as reported on the hospital's Medicare cost report; or3. Is a participating hospital on the Medicare "Rural Community Hospital Demonstration", as reported in the hospital's Medicare cost report.45.01-31State Fiscal Year is the twelve (12) month period used by the State of Maine as an accounting period which begins July 1 and ends June 30 (e. g., SFY 2001 begins July 1, 2000, and ends June 30, 2001).45.01-32State Owned Psychiatric Hospital is a hospital that is primarily engaged in providing psychiatric services for the diagnosis, treatment, and care of persons with mental illness and is owned and operated by the State of Maine. The facility must be licensed as a psychiatric hospital by the Department of Health and Human Services. A psychiatric hospital may also be known as an institution for mental disease.45.01-33Transfer means a member is moved from one hospital to the care of another hospital. MaineCare will not reimburse for more than two discharges for each episode of care for a member transferring between multiple hospitals. * The Department shall submit to CMS and anticipates approval for a State Plan Amendment related to these provisions.
C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-45, subsec. 144-101-III-45.01