Maine sets rules for how MaineCare pays health care providers

The Maine Department of Health and Human Services adopts formal rules for how MaineCare pays providers. These requirements cover payments for MaineCare-covered services. Billing codes and payment amounts can be updated without adopting rules when the overall payment method stays the same and rates are posted as required. Changes to the percentage paid under a comparison rate or to the payment method require rulemaking. Advance notices go to people who request them. Notice comes at least 30 calendar days before cost-of-living updates and at least 7 calendar days before Medicare fee schedule updates or added service codes.

The Maine Department of Health and Human Services applies annual cost-of-living adjustments to eligible payments based on service cost studies. The annual adjustments cover eligible rates based on studies of service costs. The service must have received no rate adjustment in the preceding 12 months, and the department must find comparisons with other payers inappropriate or inadvisable. Adjustments paid from the MaineCare Stabilization Fund are not permanent until ongoing funding is provided. Federal emergency payment changes and legislative cuts for projected MaineCare budget shortfalls are exempt from this payment-setting system. Each service has a consistent annual adjustment date. Adjustments equal to a minimum wage increase apply between 6 and 12 months after that wage increase takes effect.

The Maine Department of Health and Human Services recalculates nursing facility payment rates. The schedule covers nursing homes and parts of hospitals or institutions operated as nursing homes when the State is responsible for paying for care. The recalculated rates take effect January 1, 2028.

The Maine Department of Health and Human Services reviews provider payments and invites public comment on payment decisions. Reviews cover MaineCare service groups or specific services. Rate comparisons include Medicare, at least five other states’ Medicaid programs, and appropriate Maine commercial payers. Federally required emergency payment changes and legislative cuts responding to projected MaineCare budget shortfalls are exempt. The department prepares a review schedule annually and presents payment recommendations for public comment before adopting rules.