MaineCare Update on Capping of MaineCare Payment Cycles

• By: Angela Westhoff
• On: 02/27/2025 16:15:15
• In: Legislative/Government Affairs

On February 10, 2025, we shared that, if the Legislature does not pass the Fiscal Year 2025 supplemental budget request to fill the MaineCare shortfall, the Department will not have sufficient funds to pay MaineCare providers in full through the end of the fiscal year and will need to temporarily withhold payments to MaineCare providers (also known as “capping weekly cycles”). 
 
On February 11, 2025 and February 25, 2025, the Legislature attempted but failed to pass the supplemental budget with sufficient votes to enact the bill immediately. In order for the Department to access the necessary funding immediately, the budget must have the support of two-thirds of the Legislature.
 
Accordingly, the Department will temporarily withhold certain provider payments beginning with the payment cycle that will run on March 12, 2025.This timeline will allow the Department to ensure some level of funding is available for the duration of the current fiscal year. This strategy is an attempt to avoid pausing all payments for providers who rely largely or entirely on Medicaid for their revenue for the last several weeks of the fiscal year.
 
As a reminder, the Department plans to take the following action:

• Pay hospital prospective interim payments (PIPs) at 70 percent the normal level;
• Hold payment for all hospital claims greater than $50,000;
• Hold payment for large retail pharmacies and large durable medical equipment suppliers; and;
• Hold payment for out-of-state providers of hospital, ambulance, pharmacy, and durable medical equipment services.

Beyond this, the Department plans to employ measures to protect, to the extent possible, providers who are most dependent on MaineCare revenue. For other provider and claim types, every week the Department will set a cap on payments based on available funding and will pay “first in first out” based on date and time of submission, up to the weekly cap.
In the next few days, as it is finalized, we will send more detail about how providers will know if they will receive payment in a given week.
 
Based on the complexity of this work, the continuing work of the Legislature, and our ongoing refinement of FY25 budget projections, the current capping plans, including which providers are impacted, are subject to change. The Department does not yet have information about when we can release held payments. The Department will share additional information when then have it.
 
Staff contact: awesthoff@mehca.org