Attention Specialty Providers: Primary Care Plus (PCPlus) Impact on Referrals  

Jul 15, 2022

Effective July 1, 2022, Primary Care Plus (PCPlus) is MaineCare’s new value-based approach to support the primary care system, improve healthcare quality, and reduce inefficient health care spending. PCPlus replaces MaineCare’s former primary care programs, including Primary Care Case Management (PCCM), Primary Care Provider Incentive Payment (PCPIP), and primary care Health Homes, with a single, integrated initiative. It gives primary care providers greater flexibility and incentives to effectively meet MaineCare members’ healthcare needs.    

How will this affect MaineCare (non-primary care) specialty providers?  

Primary care providers enrolled with PCPlus are required to manage their members’ care consistent with high-quality primary care principles. With the implementation of PCPlus, MaineCare has changed specific referral management processes previously defined through PCCM to general management guidelines:  

• MaineCare Services will no longer monitor processes such as referrals, unless otherwise specified in MaineCare policies.  

• Claims for specialty services will not be affected by the lack of a referral submitted to MaineCare from a primary care provider.  

• MIHMS is retaining functionality as an optional tool that providers may elect to use in  support of referral processes between primary care and specialty providers.  

• Through July 2022, Health PAS may continue to show PCCM eligibility for MaineCare members, but PCCM policy was repealed and replaced with PCPlus policy on June 21, 2022.     

For your reference, MaineCare Benefits Manual, Chapter VI, Section 3, Primary Care Plus can be found here. If you have any questions regarding PCPlus or how this will affect your organization, please feel free to reach out to PCP-Network-Services.DHHS@maine.gov