Rate System Evaluation Update - Provider Relief Fund (PRF) Application Deadline Extension - Attention Acute Care Non-Critical Access Hospitals: Non-Emergent Services Claims - Incorrect Denials of Rebate-Ineligible Drugs with Prior Authorizations (PA)

Rate System Evaluation Update 

The Department of Health and Human Services (the Department) is conducting an evaluation of MaineCare’s rates and rate setting system and developing a plan for the creation of a comprehensive, streamlined, and coherent system. To complete this work, the Department has contracted with Myers and Stauffer, LLC, a national accounting firm. 

Consultants from Myers and Stauffer will conduct their work in two phases. In Phase 1, they will evaluate existing MaineCare reimbursement rates and payment models. This work will result in a report that catalogs existing payment methods; benchmarks payment rates to those used by other states, commercial health plans, and Medicare for comparable services; and recommends services as candidates for alternative payment models (APMs). 

Phase 2 will include the development of a plan for a comprehensive rate assessment process, including: 

• Recommendations for simplifying and streamlining rate methodologies, and for a process and structure for ongoing rate review and rebasing;
• A priority list and work plan for short- and longer-term rate reviews; and
• An estimate of the necessary investment to implement recommendations. 

The Department and Myers and Stauffer will be seeking opinions, ideas, and comments from many stakeholders across the state who participate in MaineCare, including providers, members, and other interested parties. 

In Phase 1, the consultants will conduct fact-finding meetings with “key informants” regarding the way MaineCare payment methodologies work now. These key informants will include MaineCare providers and representatives from the Offices of Aging and Disability Services, Child and Family Services, and Behavioral Health. The objective of these meetings is to confirm the consultants’ understanding of how the payment systems work and nuances of the design of the payment systems and the effects they have on service delivery. 

The consultants will schedule virtual meetings with provider organizations, grouped by service type, and will have prepared questions in advance of the meetings. While the key informants are providers, the meetings will be open to anyone interested in listening in. More information about these sessions will be forthcoming. 

Most of the key informant meetings will occur during September, and Phase 1 is expected to be complete at the end of October. 

In Phase 2, after the Phase 1 benchmarking and APM report is available, the Department and consultants will conduct a series of virtual town hall meetings to invite participants, grouped by service type, to provide feedback on the Phase 1 benchmarking report and comments to help inform Myers and Stauffer’s recommendations for rate setting system reform and the rate assessment work plan, which will be completed at the end of February. 

As part of this overall assessment, the consultants will also lead several virtual focus groups, depending on level of interest, with MaineCare members to assess their experiences with accessing MaineCare-covered services, including any barriers and challenges that currently exist. The Department will consult with the MaineCare Advisory Committee (MAC) and key advocacy organizations to identify MaineCare members to participate in the focus groups. 

These town hall meetings will be scheduled to accommodate providers and members separately, but they will be open to the public. 

The Department and Myers and Stauffer will update and engage the MAC and its Rates Subcommittee throughout the process and will keep the public informed through e-message updates and website postings.

Please contact Peter Kraut, MaineCare’s Rate Setting Manager, with questions or for more information.  

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Provider Relief Fund (PRF) Application Deadline Extension

The deadline to apply for Phase 2 General Distribution Funding has been extended to September 13, 2020.

As a reminder, the federal Department of Health and Human Services (HHS) announced that it will allow certain Medicare providers who experienced challenges in the Phase 1 Medicare General Distribution application period a second opportunity to receive funding from the Provider Relief Fund (PRF). Examples of eligible Medicare/Medicaid/CHIP/dental providers include:

• Providers who did not receive an initial payment that totals approximately two percent of their annual patient revenue
• Providers who did receive an initial payment, but missed the June 3^rd deadline to submit their revenue information
• Providers who were ineligible for prior General Distribution funds due to a change in ownership or because they did not have Medicare fee-for-service revenue in 2019
• Providers who previously received Phase 1 General Distribution payment(s), but rejected and returned the funds and are now interested in reapplying.

All eligible providers will only receive funding of up to 2 percent of their reported total revenue from patient care. Visit the HHS Provider Relief Fund website for more information. You can also access a tip sheet about the PRF application process on MaineCare’s website. 

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Attention Acute Care Non-Critical Access Hospitals: Non-Emergent Services Claims, CR 76243

 Emergency Services are only covered by MaineCare when the condition could be considered life threatening without medical intervention. We have updated MIHMS so that claims from Acute Care Non-Critical Access Hospitals for non-emergent services will no longer pay when a member is only eligible for emergency services. Affected claims will be reprocessed and no provider action is needed. Please see the MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services, Appendix B: Non-Emergent Use of the Emergency Department for more information. 

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Incorrect Denials of Rebate-Ineligible Drugs with Prior Authorizations (PA), CR 91101

The system will now correctly process drugs with PAs that are rebate ineligible. You may resubmit the claims that denied in error.

Please see the e-message from December 10, 2019 that originally described this issue:

Drugs Ineligible for Rebates with Prior Authorizations (PA) are Denying Incorrectly, CR 91101

Some rebate ineligible drugs with PAs in the system are denying for Edit 5021 (drug not rebate eligible) in error. We are working to update the system to pay these claims when appropriate. We will notify you when this issue is corrected, and you will be able to adjust or resubmit your claims at that time.