Subsection 144-101-II-25.06 - REIMBURSEMENT METHODOLOGYSpecific reimbursement rates are listed on the dental fee schedule, which is posted on the Department's website in accordance with 22 MRSA §3173-J(7). Reimbursement for covered services may be inclusive of, but is not limited to, local anesthesia, sutures, materials, supplies, and routine postoperative care.
Reimbursement rates are based on the following methodology:
A.BenchmarksThe Department calculates reimbursement rates for covered CDT codes using either the Commercial Median Benchmark or the All-States Medicaid Average Benchmark.
1. The Commercial Median Benchmark for each CDT code is the median of Maine commercial payer dental claim allowed amounts when the claim is paid as primary with an allowed amount greater than zero (0) based on data from the Maine Health Data Organization's All Payer Claims Database. The Commercial Median Benchmark rate for a CDT code must have equal to or greater than one-hundred (100) claims billed in the source data used to set the benchmarks in order for the Department to consider it reliable. Benchmarks are assessed every two (2) years utilizing claims from the most recent Maine state fiscal year.2. The Medicaid State Average Benchmark (Medicaid Benchmark) is the average of all other states' Medicaid rates for a CDT code, where rates are available and reliable. The Department excludes any rates as unreliable in the determination of the Medicaid Benchmark when they represent outliers in comparison to the other state rates, or when there is excessive variation across all state rates available. If a Medicaid agency uses different child and adult rates, the Department uses the average of the rates. Benchmarks are assessed every two (2) years utilizing the most current rates available as of the time of the rate schedule update.B.Determination of Benchmark and Percent of BenchmarkThe Department determines which Benchmark and percent of Benchmark to use in setting rates using the following methodology:
1. The Department sets rates for diagnostic, endodontic, periodontic, preventive, and limited orthodontic treatment services based on 67% of the Commercial Median Benchmark or 133% of the Medicaid State Average Benchmark, if the Commercial Median Benchmark rate is unavailable or unreliable as defined in Section 25.06(A)(1).2. The Department sets rates for adjunctive, oral and maxillofacial surgery, orthodontics (except for limited orthodontic treatment), prosthodontics, and restorative services based on 50% of the Commercial Median Benchmark, or 100% of the Medicaid State Average Benchmark if the Commercial Median Benchmark rate is unavailable or unreliable as defined in Section 25.06(A) (1).3. Temporary Exceptions: The following methodologies will be in effect through June 30, 2026.a. The methodology set forth in B.1 will also apply to codes for extraction of an erupted or exposed root; andb. The Department will default codes for medicament application to 133% of the Medicaid State Average Benchmark.C.Adaptation of Methodology for Related CodesIn alignment with common practice by commercial payers and other state Medicaid agencies, for codes in the same series and/or for the same service, differentiated only by time increment for the code or age of patient, etc., the methodology outlined above applies to the base service; other CDT codes are set in relation to the base service proportional to the amount of time or factor of difficulty of the related service.
1. Orthodontic Treatment: For limited and comprehensive orthodontic treatment, after calculation of the initial rates by code in alignment with the methodology above, the Department then sets the final MaineCare rates at the adolescent dentition rate for the codes in the same series (limited and orthodontic). In order to identify claims that reflect a bundled rate for orthodontic treatment, the Department only includes claims that are paid as primary and that have a rate greater than $300 and $1000 for limited and comprehensive orthodontic treatment codes, respectively. The Department excludes claims when the code was billed more than once per person.
2. Sedation: The Department sets rates for deep and intravenous moderate sedation service codes at 50% of the Commercial Median Benchmark for the CDT code that represents the first fifteen (15) minutes of deep sedation.D.Inflation AdjustmentThe Department applies an inflation adjustment to all rates based on the Consumer Price Index (CPI) for dental services in U.S. city average, all urban consumers, seasonally adjusted (CUSR0000SEMC02) to adjust rates to the current year.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-25, subsec. 144-101-II-25.06