Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter III - Allowances for Services
Section 144-101-III-97 - Private Non-Medical Institution Services
Appendix 144-101-III-97-C - MEDICAL AND REMEDIAL SERVICE FACILITIES
Section 144-101-III-97-C-8000 - CASE MIX PAYMENT SYSTEM

Universal Citation: 10 ME Code Rules ยง 144-101-III-97-C-8000

Current through 2024-38, September 18, 2024

8010 Industry-Specific DCP

The Department multiplies the industry-specific DCP for each peer group by the facility's average MaineCare case mix so that this payment system can take into consideration that some residents are more costly to care for than others. Thus, the system requires:

a) The assessment of residents on the Department's approved MDS-RCA form;

b) The classification of residents into groups that are similar in resource utilization by use of the case mix resident classification groups defined in Section 9020 of this Appendix; and

c) A weighting system that quantifies the relative cost of caring for different classes of residents by direct service staff to determine a resident's case mix index.

8020 Case Mix Resident Classification Groups and Weights

There are a total of 15 case mix resident classification groups, including one resident classification group used when residents cannot be classified into one of the 14 clinical classification groups.

The Department assigns each case mix classification group a specific case mix weight, as follows:

RESIDENT CLASSIFICIATION GROUP CASE MIX WEIGHT

Resident Group

Order

Short description

MaineCare Weight

IC1

1

IMPAIRED 15-28

2.25

IB1

2

IMPAIRED 12-14

1.568

IA1

3

IMPAIRED 0-11

1.144

CD1

4

COMPLEX 12+

1.944

CC1

5

COMPLEX 7-11

1.593

CB1

6

COMPLEX 2-6

1.205

CA1

7

COMPLEX 0-1

0.938

MC1

8

BEHAVIORAL HEALTH 16+

1.916

MB1

9

BEHAVIORAL HEALTH 5-15

1.377

MA1

10

BEHAVIORAL HEALTH 0-4

0.98

PD1

11

PHYSICAL 11+

1.418

PC1

12

PHYSICAL 8-10

1.019

PB1

13

PHYSICAL 4-7

1.004

PA1

14

PHYSICAL 0-3

0.731

BC1

15

NOT CLASSIFIED

0.731

8030. Rate Setting Case Mix

8030.1 The Department will calculate rates on January 1st and July 1st of each year, beginning on July 1, 2001.

8030.2 The Department will calculate each facility's rate setting case mix index using the number of MaineCare residents in each case mix classification group determined from the most recent MDS-RCA on all MaineCare residents in the facility as of the 1st of March for the July rate and the 1st of September for the January rate.

8030.3 The Department will compute the applicable rate setting case mix index by multiplying the number of residents in each case mix classification group, including those in the unclassified group, by the case mix weight for the relevant classification group. The sum of these products divided by the total number of MaineCare residents in the facility equals the rate setting case mix index.

8030.4 The Department will calculate the case mix rate by multiplying the rate setting case mix index by the DCP. The program allowance will be added to the case mix rate.

8030.5 The Department will send a roster of residents and source of payment as of March 1st and September 1st to facilities for verification prior to rate setting.

8030.6 The Department will utilize the roster in identifying MaineCare residents and their most recent assessment. It is the provider's responsibility to check the roster, make corrections and submit corrections to the Department or its designee within one week of receiving the roster.

8030.7 For purposes of this Appendix, the Department will not utilize assessments of residents for whom assessments are incomplete due to the death, discharge, or nursing facility or hospital admission of the resident during the time frame in which the assessment must be completed to compute payment.

8040 New Facilities

For new facilities opening after July 1, 2002, the Department will apply a case mix index of 1.000 to the price for new facilities for the first rate setting period. The Department will apply the actual case mix index to the first rate setting period after either a March 1st or September 1st roster is available, as applicable. The Department will not apply sanctions to new facilities until an actual case mix index is used in rate setting.

8050 Inflation Adjustment

Except when there is specific statutory direction, the Commissioner of the Department of Health and Human Services will determine if an inflation adjustment will be made, the amount of that adjustment, and any performance standards related to that adjustment.

For the state fiscal year ending June 30, 2020 and each year thereafter, the MaineCare payment rates attributable to wages and salaries for both the direct care cost component and the personal care cost component will be increased by an inflation factor in accordance with the United States Department of Labor, Bureau of Labor Statistics Consumer Price Index - medical care services index from the prior December for professional services, nursing home and adult day care services.

Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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