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An Act To Establish a MaineCare Reimbursement Rate Review Process and the MaineCare Independent Rate Commission
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  5 MRSA §12004-J, sub-§18  is enacted to read:
 
18.   
Sec. 2.  22 MRSA §19-A  is enacted to read:
§ 19-A. Review of reimbursement rates for providers under MaineCare program
 
1.  Definitions.     As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
 
A.  "Alternative health care practices" means health care practices not considered to be part of conventional medicine, including alternative medical systems, mind-body interventions, biologically based treatments, manipulative and body-based methods and energy therapies.
 
B.  "Commission" means the MaineCare Independent Rate Commission.
 
C.  "Committee" means the joint standing committee of the Legislature having jurisdiction over appropriations and financial affairs.
 
D.  "Facility-based physician" means an anesthesiologist, emergency room physician, neonatologist, pathologist or radiologist practicing medicine primarily in a health care facility.
 
E.  "Initial contact agency" means an agency or private organization that a recipient or potential recipient contacts initially to determine MaineCare program eligibility or for a referral for specific MaineCare program services.
 
F.  "Provider" means a provider of MaineCare program services.
 
G.  "Recipient" means a recipient of MaineCare program services.
 
2.  Schedule of review of reimbursement rates for providers under the MaineCare program.     On or before September 1st of each calendar year, the department shall establish a 5-year schedule for annual reviews of reimbursement rates under the MaineCare program so that each provider rate is reviewed at least every 5 years and provide the schedule to the committee. If the department receives a petition or proposal for a reimbursement rate to be reviewed or adjusted, the department shall provide a copy of the petition or proposal to the commission. The department may exclude a reimbursement rate from the schedule under this subsection if that rate is adjusted on a periodic basis as a result of state law or federal law or regulation. The department shall include the list of excluded rates with the schedule of reimbursement rates required by this subsection. By December 1st of the year prior to a scheduled year, the committee or the commission may direct the department to review any reimbursement rate that is not scheduled during or that is excluded from the scheduled year. The department shall review each reimbursement rate pursuant to subsection 3 scheduled for review and any unscheduled or excluded reimbursement rate the commission or the committee directs the department to review.
 
3.  Review process.     The department shall review a reimbursement rate under subsection 2 pursuant to this subsection.
 
A.  The department shall conduct an analysis of the access, service, quality and use of each service subject to reimbursement rate review. The department shall compare the rate reimbursed with available benchmarks, including Medicare rates and usual and customary rates paid by private parties, and use qualitative tools to assess whether reimbursements are sufficient to allow for provider retention and recipient access and to support appropriate reimbursement of high-value services. On or before May 1st of the scheduled review year the department shall provide a report on the analysis required by this subsection to the committee, the commission and any stakeholder and stakeholder group affected by the reimbursement rate review as identified by the department.
 
B.  Subsequent to the provision of a report under paragraph A, the department shall work with the commission and any stakeholder and stakeholder group identified by the department under paragraph A to review the report and develop strategies for responding to the findings, including any nonfiscal approaches or rebalancing of rates.
 
C.  Subsequent to the review under paragraph B, the department shall work with the Department of Administrative and Financial Services, Bureau of the Budget to determine achievable goals and executive branch priorities within the state budget.
 
D.  On or before November 1st of the scheduled rate year, the department shall submit a written report to the committee and the commission containing the department's recommendations on all of the reimbursement rates reviewed for that year pursuant to this subsection and all of the data relied upon by the department in making its recommendations. The committee shall consider the recommendations submitted pursuant to this subsection in formulating the budget for the department.
 
4.  MaineCare Independent Rate Commission.     The MaineCare Independent Rate Commission, established by Title 5, section 12004-J, subsection 18, is established as an independent commission within the department that provides review and oversight over the MaineCare program reimbursement rate process.
 
5.  Membership; meetings; bylaws; administrative support.     The commission consists of 24 members, appointed as follows:
 
A.  A recipient with a disability or a person who represents recipients with a disability, appointed by the President of the Senate;
 
B.  A representative of hospitals providing MaineCare program services recommended by a statewide association of hospitals, appointed by the President of the Senate;
 
C.  A representative of providers of transportation to recipients, appointed by the President of the Senate;
 
D.  A representative of rural health care centers, appointed by the President of the Senate;
 
E.  A representative of home health care providers recommended by a statewide organization of home health care providers, appointed by the President of the Senate;
 
F.  A representative of providers of durable medical equipment recommended by a statewide association of durable medical equipment providers, appointed by the President of the Senate;
 
G.  A representative of providers of behavioral health care services, appointed by the President of the Senate;
 
H.  A representative of primary care physicians who provide services to recipients recommended by a statewide association of primary care physicians, appointed by the President of the Senate;
 
I.  A representative of dentists who provide services to recipients recommended by a statewide association of dentists, appointed by the President of the Senate;
 
J.  A representative of federally qualified health centers, appointed by the President of the Senate;
 
K.  A representative of private nonmedical institutions and community-based service providers, appointed by the President of the Senate;
 
L.  A representative of providers serving recipients with intellectual and developmental disabilities, appointed by the President of the Senate;
 
M.  A representative of child recipients with a disability, appointed by the Speaker of the House of Representatives;
 
N.  A representative of physicians who specialize in an area of health care and are not employed by a hospital who see recipients, recommended by a statewide association whose members include at least 1/3 of the doctors of medicine and osteopathy licensed by the State, appointed by the Speaker of the House of Representatives;
 
O.  A representative of providers of alternative health care practices recommended by a statewide association of alternative health care practices, appointed by the Speaker of the House of Representatives;
 
P.  A representative of initial contact agencies, appointed by the Speaker of the House of Representatives;
 
Q.  A representative of ambulatory surgery centers, appointed by the Speaker of the House of Representatives;
 
R.  A representative of hospice providers recommended by a statewide association of hospice and palliative care providers, appointed by the Speaker of the House of Representatives;
 
S.  A representative of substance use disorder treatment providers recommended by a statewide association of substance use disorder treatment providers, appointed by the Speaker of the House of Representatives;
 
T.  A representative of facility-based physicians who see recipients, appointed by the Speaker of the House of Representatives;
 
U.  A representative of pharmacists providing services to recipients, appointed by the Speaker of the House of Representatives;
 
V.  A representative of managed care plans, appointed by the Speaker of the House of Representatives;
 
W.  A representative of advanced practice registered nurses recommended by a statewide association of nurses, appointed by the Speaker of the House of Representatives; and
 
X.  A representative of physical therapists or occupational therapists recommended by a statewide association of physical or occupational therapists, appointed by the Speaker of the House of Representatives.
 
A member serves a 4-year term and may be reappointed. The appointing authorities shall make a concerted effort to include members of diverse political, racial, cultural, income and ability groups from urban and rural areas. Members shall elect a chair and a vice-chair from among the membership. A member serves without compensation or reimbursement for expenses. The commission shall meet at least once every quarter, and the chair may call additional meetings determined necessary for the commission to complete its duties. The commission shall enact bylaws and procedures to govern its operations. The department shall provide administrative support to the commission.
 
6.  Commission duties.     The commission shall:
 
A.  Review the schedule of reimbursement rates under subsection 2 and recommend any changes to the schedule;
 
B.  Review a report prepared by the department under subsection 3, paragraph A and provide to the department comments and feedback on the report;
 
C.  With the department, conduct a public meeting to allow providers, recipients, stakeholders, stakeholder groups and other interested parties an opportunity to comment on a report prepared by the department under subsection 3, paragraph A;
 
D.  Review a proposal or petition for a reimbursement rate to be reviewed or adjusted that is received by the commission;
 
E.  Determine whether a reimbursement rate not scheduled for or excluded from review should be reviewed during that calendar year;
 
F.  Recommend to the department and the committee any changes to the process of reviewing reimbursement rates including measures to increase access to the process such as providing for electronic comments by providers and the public; and
 
G.  Provide other assistance to the department as requested by the department and the committee.
 
SUMMARY
This bill establishes a process by which the Department of Health and Human Services maintains a schedule of MaineCare program reimbursement rate reviews in which each rate is reviewed at least every 5 years. Under this process, the department reviews a rate for access, service, quality and use of service and compares the rate reimbursed with available benchmarks, including Medicare rates and usual and customary rates paid by private parties, and uses qualitative tools to assess whether reimbursements are sufficient to allow for provider retention and recipient access and to support appropriate reimbursement of high-value services. The department is required to provide a report of its review to the joint standing committee of the Legislature having jurisdiction over appropriations and financial affairs, the MaineCare Independent Rate Commission, a 24-member group of interested parties providing oversight of the rate review process, and stakeholders. After holding public meetings and consulting stakeholders and stakeholder groups and consultation with the Department of Administrative and Financial Services, Bureau of the Budget, the department makes recommendations on the MaineCare reimbursement rates to the joint standing committee of the Legislature having jurisdiction over appropriations and financial affairs to assist in developing the department's budget.