Renew Your Membership

Full Member – FY 2026 Membership Renewal Form

This form is for provider organizations that were Full Members of MACSP in FY 2025 and are renewing their membership for FY 2026 (July 1, 2025 – June 30, 2026).

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FY26 Membership Renewal Form Available July 7, 2025
Please complete and submit your MACSP Membership Renewal Form. Required fields are marked with an asterisk (*). When complete, use the submit button at the bottom of the page. Once submitted, you will receive a confirmation email. Within seven business days, an invoice will be emailed from accounts@meacsp.org to your agency’s designated billing contact, with a copy sent to the voting representative listed on the form. If you have any questions, please contact: Becca Emmons, Membership Coordinator: e: membercoord@meacsp.org o: 207.563.1883
Agency Name:*
Address*
Street Address Address Line 2 City State ZIP Code
Website:*
Telephone:*
Fax Number:
Corporate Status:*
- For Profit – Corporation
- For Profit – Individual
- For Profit – Partnership
- Non Profit – Corporation
- Non Profit – Other
If For Profit – list all owners and partners (first and last name) below:
Is your organization a subsidiary of, or affiliated with, another organization? If yes, list here.
Agency Provider ID (NPI):*
NPI +3 locations numbers NOT needed.
Year Agency Established Services in Maine:
Year Agency Started Providing Direct Support Services in Maine:
Designated Voting Representative Name:*
Please provide the full name of the individual in your organization who is authorized to vote on behalf of your agency in MACSP matters.
Title:*
Designated Voting Member Email:*
Designated Voting Member Telephone:*
Proxy Voting Representative Name:*
Please provide the name of the individual who is authorized to vote on behalf of your organization when the designated voting representative is unavailable. A proxy may only vote with the express consent of the designated voting representative.
Title:*
Proxy Voting Member Email:*
Please complete the following information for the person who is responsible for billing and financial management in your organization.
Name of Contact Person for Invoicing:*
Please provide the name and contact information for the individual responsible for billing and financial matters within your organization. This person will receive the membership invoice and any related communications.
Title:*
Contact for Invoicing Email:*
Contact for Invoicing Telephone:*
Address:
Street Address Address Line 2 City State ZIP Code
Name of individual(s) listed as Administrators on the Agency’s Provider Agreement and any licenses held by the organization.*
Does the agency hold any of the following licenses? (check all that apply)*
- Agency does not hold any of these licenses
- ICF-ID
- Assisted Housing
- Behavioral Health Section 65
- Children’s Services Section 28
- Childcare
- Other
Has anyone in the management of this organization been involved in a license revocation or forced to close any other organization delivering similar services?*
- Yes
- No
If yes, please describe:
Select the counties your agency provides services in:*
- Select All
- Androscoggin
- Aroostook
- Cumberland
- Franklin
- Hancock
- Kennebec
- Knox
- Lincoln
- Oxford
- Penobscot
- Piscataquis
- Sagadahoc
- Somerset
- Waldo
- Washington
- York
Agency Provided Covered Services
Please select the covered services provided by your agency, including number of individuals served and number of employees.
Please select the Covered Services under Section #13 provided by agency:
- Adult Case Management
- Children’s Case Management
- Adult and Child Case Management
Number of ADULTS served under Section #13:
Number of CHILDREN served under Section #13:
Number of employees performing covered services under Section #13:
Please select the Covered Services under Section #18 provided by your agency:
- Select All
- Assistive Technology Device and Services
- Care Coordination Services
- Career Planning
- Community/Work Reintegration
- Employment Specialist Services
- Home Support Services
- Non-Medical Transportation Services
- Self-Care/Home Management Reintegration
- Work Ordered Day Club House
- Work Support Services
Number of individuals served under Section #18:
Number of employees performing covered services under Section #18:
Please select the Covered Services under Section #19 provided by your agency:
- Select All
- Assistive Technology Device and Services
- Assistive Technology-Remote Monitoring
- Assistive Technology-Transmission
- Care Coordination Services
- Environmental Modifications
- Financial Management Services
- Home Delivered Meals
- Home Health Services
- Personal Care Services
- Attendant Services
- Living Well for Better Health
- Matter of Balance
- Per Diem Residential Services
- Transportation Services
- Respite Services
- Skills Training
Number of individuals served under Section #19:
Number of employees performing covered services under Section #19:
Please select the Covered Services under Section #20 provided by your agency:
- Select All
- Assistive Technology Device and Services
- Assistive Technology-Remote Monitoring
- Assistive Technology-Transmission
- Care Coordination Services
- Environmental Modifications
- Financial Management Services
- Home Delivered Meals
- Home Health Services
- Personal Care Services
- Attendant Services
- Living Well for Better Health
- Matter of Balance
- Per Diem Home Support Services
- Personal Emergency Response System Services
- Transportation Services
- Respite Services
- Skills Training
Number of individuals served under Section #20:
Number of employees performing covered services under Section #20:
Please select the Covered Services under Section #21 provided by your agency:
- Select All
- Assistive Technology
- Career Planning
- Community Support – Individual
- Community Support – Group (1:2, 1:3)
- Consultation Services
- Crisis Assessment
- Crisis Intervention Services
- Home Accessibility Adaptations
- Home Support-Agency Per Diem (group home)
- Home Support-Family-Centered Support
- Home Support-Quarter Hour
- Home Support-Remote Support
- Non-Traditional Communication Assessments
- Non-Traditional Communication Consultation
- Occupational Therapy (Maintenance)
- Physical Therapy (Maintenance)
- Shared Living
- Speech Therapy (Maintenance)
- Work Support-Group
- Work Support-Individual
Number of individuals served under Section #21:
Number of employees performing covered services under Section #21:
Number of employees working in Agency Group Homes:
Number of Agency Group Home locations (as of July 1, 2025):
# of agency group home locations that are open and actively providing Section 18 or Section 21 services as of July 1, 2025.
Number of Individuals/Residents living in Agency Group Home locations (as of July 1, 2025):
# of individuals/residents living in agency group home locations that are open and actively providing Section 18 or Section 21 services as of July 1, 2025.
Number of Shared Living Individuals Supported (as of July 1, 2025):
# of individuals supported by Section 21 Shared Living Services as of July 1, 2025.
Number of Shared Living Providers-unrelated as of July 1, 2025:
# of contracted Shared Living Providers that are NOT related to the individual supported.
Number of Shared Living Providers-related as of July 1, 2025:
# of contracted Shared Living Providers that are related to the individual supported.
Please select the Covered Services under Section #28 provided by your agency:
- Select All
- Treatment Services
- Specialized Services
- BCBA Services
Number of children served under Section #28:
Number of employees performing covered services under Section #28:
Please select the Covered Services under Section #29 provided by your agency:
- Select All
- Assistive Technology
- Career Planning
- Community Support – Group
- Community Support – Comm Membership
- Home Accessibility Adaptations
- Home Support-Family-Centered Support
- Home Support-Quarter Hour
- Respite Services
- Shared Living
- Transportation
- Work Support-Group
- Work Support-Individual
Number of individuals served under Section #29:
Number of employees performing covered services under Section #29:
Number of Shared Living Individuals Supported (as of July 1, 2025):
# of individuals supported by Section 21 Shared Living Services as of July 1, 2025.
Number of Shared Living Providers-unrelated as of July 1, 2025:
# of contracted Shared Living Providers that are NOT related to the individual supported.
Number of Shared Living Providers-related as of July 1, 2025::
# of contracted Shared Living Providers that are related to the individual supported.
Please select the Covered Services under Section #50 provided by your agency:
- Select All
- ICF-MR Development Training (Community Supports/Day) Program
- Per Diem Residential Services
- Pharmacy Services
- Physical Therapy and Occupational Therapy
- Speech and Hearing Services
- Supplies and Equipment Billed by Supplier or Pharmacy
- Other Services
Number of individuals served under Section #50:
Number of employees performing covered services under Section #50:
Please select the Covered Services under Section #65 provided by your agency:
- Select All
- Children’s Home and Community Based Treatment
- Children’s Behavioral Health Day Treatment
Number of individuals served under Section #65:
Number of employees performing covered services under Section #65:
Please select the Covered Services under Section #92 (Behavioral Health Home) provided by your agency:
- Select All
- Children’s Behavioral Health Home
Number of children served under Section #92:
Number of employees performing covered children's services under Section #92:
Please select the Covered Services under Section #97 – Appendix F provided by your agency:
- Select All
- Per Diem Residential Services
- Pharmacy Consultation
- RN Consultation
- Dietary Consultation
Number of individuals served under Section #97 – Appendix F:
Number of employees performing covered services under Section #97 – Appendix F:
Number of per diem residential locations under Section #97 – Appendix F:
Please select the Covered Services under Section #102 provided by your agency:
- Select All
- Clinical Assessment and Reassessment
- Intensive Integrated Neuro-rehabilitation
- Neuro-behavioral Rehabilitation
- Home and Community Reintegration
- Self-Care/Home Management
Number of individuals served under Section #102:
Number of employees performing covered services under Section #102:
Special Purpose Schools / Pre-Schools
- Yes
- No
Does your organization provide DOE-supported Special Purpose School Programs?
Number of students in your K-5 program?
# of students receiving K-5 programming as of July 1, 2025.
Select the DOE-supported programs your organization provides:
- Select All
- PreK
- K-5
- K-12
Number of students in your PreK program?
# of students receiving special purpose pre-school programming as of July 1, 2025.
Number of students in your K-12 program?
# of students receiving K-12 programming as of July 1, 2025.
Number of employees in your PreK program?
# of staff working in special purpose pre-school programming as of July 1, 2025.
Number of employees in your K-5 program?
# of staff working in K-5 programming as of July 1, 2025.
Number of employees in your K-12 program?
# of staff working in K-12 programming as of July 1, 2025.
Other IDD Services:
Please list the Mainecare Section # and service type for other IDD services agency provides.
Number of individuals served under other IDD services:
Number of employees performing covered services under other IDD services:
Membership Dues
Please provide all applicable information regarding the total revenue your organization receives for delivering services to children and adults with intellectual disabilities, autism, and brain injuries in the State of Maine. For the purposes of determining dues, MACSP defines qualifying revenue as any revenue your agency generates from services listed in the MaineCare Benefits Manual (MBM), Chapters II and III, including: Sections 13, 18, 19, 20, 21, 28, 29, 50, and 97 (Appendix F) Section 92 (Behavioral Health Homes for Children) Section 102 Revenue from Department of Education-funded Special Purpose Pre-School (SPPS) programs Please include all revenue from these sources when completing the dues calculation.
What is your total MACSP qualifying revenue from FY '25, FY25 or calendar year-end 2024, or your last completed audited financial statement?**
Numbers Only – No special characters, commas or decimal points. For the purposes of determining dues, MACSP defines qualifying revenue as any revenue your agency generates from services listed in the MaineCare Benefits Manual (MBM), Chapters II and III, including: Sections 13, 18, 19, 20, 21, 28, 29, 50, and 97 (Appendix F) Section 92 (Behavioral Health Homes for Children) Section 102 Revenue from Department of Education-funded Special Purpose Pre-School (SPPS) programs Please include all revenue from these sources when completing the dues calculation.
Dues Level*
Select the corresponding dues level for your agency. An invoice for this amount will be sent to the invoicing contact listed on this renewal form, with a cc to the designated voting member for your organization. Payment – Payment is due within 30 days of invoice receipt or no later than September 15, 2025. Details will be provided in the invoice sent within seven business days of submitting this renewal form.
Dues Level FY 2026*
- Level I 0-$999,999 Dues: $1,500
- Level II $1M to $1,999,999 Dues: $3,000
- Level III $2M – $6,999,999 Dues: $4,100
- Level IV $7M – $11,999,999 Dues: $5,250
- Level V $12M – $17,999,999 Dues: $6,500
- Level VI $18M – $29,999,999 Dues: $7,500
- Level VII $30M+ Dues: $8,750
MACSP Dues Structure Description (FY26 & FY27)
The dues structure is organized into seven levels based on qualifying MaineCare revenue ranges, starting at $1,500 for providers under $1M and scaling up to $12,000 for providers with $30M+ in revenue. A two-year phase-in for this model is planned: Dues Levels I & II: pay full membership fee in FY 26 Dues Levels III – VII: pay partial membership fee in FY 26. All levels pay the full membership fee in FY27. Details by level – Level I dues FY26 & 27 = $1,500 Level II dues FY26 & 27 = $3,000 Level III dues FY26= $4,100, FY27 = $4,500 Level IV dues FY26 = $5,250, FY27 = $6,500 Level V dues FY26 = $6,500, FY27 = $8,500 Level VI dues FY26 = $7,500, FY27 = $10,000 Level VII dues FY26 = $8,750, FY27 = $12,000
MACSP Members commit to the following prescribed standards and principles of quality, which apply to the supports provided in the professional relationship with persons served, parents and guardians of persons served, colleagues, related agencies and professions, and the community at large.

AS A MEMBER OF MACSP, THIS ORGANIZATION PLEDGES TO:
- Provide supports and services in a manner which exemplifies integrity, compassion, and respect for individual differences and choice;
- Provide supports and services designed to meet the needs of the individual supported with emphasis on promoting choice, self-determination, inclusion, growth, and development;
- Respect the privacy of the individual supported and protect the rights of confidentiality;
- Give preference to professional responsibility over any personal interest;
- Advocate for standards that promote outcomes of quality;
- Advocate for and provide supports and services that best assure the health and safety of the individual supported;
- Encourage and advocate for the protection of the individual supported and the community at-large against unethical and/or illegal practices or actions by other individuals or organizations engaged in providing supports;
- Not discriminate because of race, color, religion, age, sex, sexual orientation, disability, or national ancestry and work to eliminate or prevent such discrimination;
- Promote inclusion and equitable treatment of all people including those receiving supports, staff, friends, families, and the community at-large;
- Serve as a responsible steward for public and private funds;
- Contribute to MACSP Membership ideas, findings, concepts, understanding, knowledge, and practice which further develop education and expanded knowledge of leading practices in providing high quality supports and services to individuals with disabilities;
- Keep MACSP information and materials confidential without further dissemination or distribution to employees without a need or to any third parties without the express written permission of MACSP; and
- Be accountable for statements made with respect to individuals with disabilities and distinguish clearly statements and actions made as an individual and, when authorized by the MACSP Board of Directors, those made as a representative of MACSP.
CERTIFICATION SIGNATURE (sign in the box below)*
I certify that the information provided in this application is accurate and complete to the best of my knowledge. The undersigned hereby agrees that it will in all respects conform to and abide by MACSP’s Quality Pledge and Bylaws, and all amendments hereafter made thereto.
Date:*
MM slash DD slash YYYY
Name:*
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Renew Your Membership

Full Member – FY 2026 Membership Renewal Form

FY26 Membership Renewal Form Available July 7, 2025

Agency Provided Covered Services

Membership Dues

MACSP Dues Structure Description (FY26 & FY27)