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Health Care Payments in Maine Version 2.0

- updated May 2026

At the request of the Governor’s Office, in January 2023, MHDO released its first interactive Tableau report on health care expenditures in Maine (based on claim payments) to serve as a baseline set of information to begin to inform the discussion on health care spending in the state. In 2025, in collaboration with the Office of Affordable Health Care, MHDO updated the underlying analysis with several methodological enhancements to create Health Care Payments in Maine version 2.0. The updated interactive Tableau report displayed below provides data on payments by payor for health care in Maine per capita, by demographic breakdowns, geography, and chronic conditions.

Data Source, Methodology and Definitions

The data source used for this report is the MHDO’s All-Payer Claims Database (APCD), consisting of medical claims and medical eligibility records submitted by payors to the MHDO per the requirements in Rule 90-590, Chapter 243, Uniform Reporting System for Health Care Claims Data Sets, for the time frame January 1, 2018 – December 31, 2024.

The detailed information about the methodology, including enhancements, used in the development of the report is available.

Definitions for terms used in the interactive Tableau report are available below.

Definitions for Terms Used in the Dashboard

  • Total Payments – The sum of payor payments and member liability amounts to be paid (see Cost Sharing Payments, below) for medical services and procedures.
  • Cost Sharing Payments – The out-of-pocket amounts to be paid by the insured member to health care providers (includes copay, coinsurance, and deductible amounts) for medical services and procedures; also referred to as member liability amounts.
  • Payments Per Capita – The total payments divided by the sum of member months (regardless of whether the member had any claims during the reporting year), multiplied by 12 – showing the annual per capita values across individuals assigned to the respective payor type.
  • Year-Over-Year (YOY) Percent Change – The YOY percent change represents the relative difference in values between two consecutive years. For example, 2018 and 2019, calculated as the 2019 value minus the 2018 value, divided by the 2018 value, then multiplying the result by 100. A negative percent change indicates that the 2019 value has decreased compared to 2018. A positive percent change indicates that the 2019 value has increased compared to 2018. If the value was the same in both 2018 and 2019, the YOY percent change is zero. If the value in 2018 is zero, the YOY percent change is not calculated.
  • Service Category – Dependent on whether the claim is classified as “institutional” (UB 04) or “non-institutional” (CMS-1500), and using the Type of Bill and Place of Service codes on the medical claim, services are classified as Inpatient, Outpatient, and Professional, and by whether services were delivered in a hospital setting. Categories displayed in the report are defined as follows:
    • Institutional (UB-04): Hospital Inpatient Services – Facility claims originating from a UB-04 claim form related to hospital stays, whether for the day, overnight, or an extended stay. May include Emergency Room services that resulted in hospital admission and other pre-admission services linked to admissions.
    • Institutional (UB-04): Hospital Outpatient Services – Facility claims originating from a UB-04 claim form related to hospital visits. Includes Emergency Room visits that did not result in hospital admission.
    • Institutional (UB-04): Other Services – Facility claims originating from a UB-04 claim form related to health care settings other than hospitals, for example clinics, ambulatory surgery centers, Federally Qualified Health Centers (FQHCs), skilled nursing, residential and hospice facilities. Includes long-term care services for MaineCare (Medicaid), which are not covered by commercial or Medicare insurance.
    • Professional (CMS-1500): Hospital Inpatient, Outpatient and Emergency Room Services – Non-institutional claims originating from a CMS-1500 claim form related to professional services provided by clinicians in the hospital inpatient or outpatient setting, or during Emergency Room visits.
    • Professional (CMS-1500): Other Services – Non-institutional claims originating from a CMS-1500 claim form related to professional services provided by clinicians outside of hospital settings, such as clinics, ambulatory surgery centers, Federally Qualified Health Centers (FQHCs), skilled nursing, residential and hospice facilities. Includes long-term care services for MaineCare (Medicaid), which are not covered by commercial or Medicare insurance.
  • Payor Type – Payors are grouped into mutually exclusive types that reflect the monthly medical coverage information available in the MHDO APCD eligibility files for distinct individuals: Commercial, MaineCare (Medicaid), Original Medicare, Medicare Advantage, Dual Eligible Medicare-MaineCare, and Commercial and Medicare. The report also displays a Medicare payor type, which aggregates the Original Medicare and Medicare Advantage payor types.
  • Insured Individual – Individual with health care insurance coverage for medical services, per insurance eligibility information submitted to the MHDO APCD.
  • Average Number of Insureds – The average number of insured individuals is equivalent to the number of insured years, calculated as the sum of member months divided by 12. The average number of insureds is available in the dashboard’s tooltip (hover text) information for selected charts.
  • MHDO Deidentified Person ID – De-identified identifier is assigned to unique individuals in MHDO datasets, which facilitates the linkage of records for the same individual across submitters and data submissions, and across time. This is a value-add data element developed after data submission to MHDO.
  • Age Group – Insured individual’s age on December 31st of the reporting year, grouped in one of the following age ranges: 0 to 17, 18 to 34, 35 to 49, 50 to 64, and 65 or older.
  • Sex – Insured individual’s sex based on the most recent insurance eligibility records available in the APCD for each individual.
  • Geography Type and Region – Insured individual’s location of residence based on the most recent member eligibility records available for the reporting year. Individuals that reside outside of Maine are excluded from analyses. Individuals with missing location of residence information in the APCD are assumed to be Maine residents, however they are excluded from the geographic type displays. The location of residence is grouped by geography type, as follows:
    • County – One of Maine’s sixteen counties (e.g. Aroostook, Cumberland, York), representing administrative divisions of the state.
    • Market Rating Area – One of Maine’s four Market Rating Areas that all health insurance issuers in the state must uniformly use as part of their rate setting (e.g. Rating Area 1); these geographic areas represent multiple counties combined.
    • Public Health District – One of Maine’s eight Public Health Districts (e.g. District 1: York; District 7: Downeast), established by the Maine Department of Health and Human Services (DHHS) using population size, county borders, and hospital service areas; these geographic areas represent single or multiple counties combined.
  • Chronic Conditions – One of 30 health care conditions, such as diabetes, hypertension, non-Alzheimer’s dementia, assigned to individuals at the reporting year level using MHDO APCD medical claims; the assignment is based on the Centers for Medicare & Medicaid Services (CMS) Chronic Conditions methodology.