MaineCare Notice of Agency Rule-making Adoption, MaineCare Benefits Manual, Chapters II and III, Section 91, Health Home Services

May 11, 2022

Notice of Agency Rule-making Adoption

AGENCY:  Department of Health and Human Services, MaineCare Services, Division of Policy

CHAPTER NUMBER AND TITLE: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapters II and III, Section 91, Health Home Services

ADOPTED RULE NUMBER:

CONCISE SUMMARY: This adopted rule will have a future effective date of June 21, 2022, and will not be effective five days after filing the adopted rule with the Secretary of State’s Office, as is typical.

This adopted rule eliminates Health Home Practices (HHP) from the Section 91 rule, makes various changes to Community Care Teams (CCTs), establishes the Housing Outreach and Member Engagement Provider (HOME Provider) as a provider of specialized CCT services and adds affiliated reimbursement rates to Chapter III, Section 91, and changes the names of the Chapters II and III, Section 91, rules to Health Home Services – Community Care Team.

Health Home Practices and the PCPlus Initiative

HHPs are primary care practices that have been approved by MaineCare to provide Health Home Services. In this adopted rule, the Department eliminates HHPs as providers because it would be duplicative of the covered services and reimbursement which the members and primary care providers (PCPs), respectively, will receive via the new Primary Care Plus (PCPlus) program. To complete the transition to PCPlus, the Department repealed Primary Care Case Management (Ch. VI, Sec. 1) and the Primary Care Provider Incentive Payment within Ch. II, Sec. 90 (Physician Services).

The PCPlus program is intended to give PCPs greater flexibility and incentives to effectively meet MaineCare members’ health care needs by transitioning away from a volume-based (fee-for-service) payment system with little connection to value, toward an approach that provides risk-adjusted Population-Based Payments tied to cost- and quality-related outcomes. To receive reimbursement under PCPlus, providers are required to locate, coordinate, and monitor health care services for members who are attributed to them, as set forth in the PCPlus rule, Section 3.04. The Department will continue to reimburse other MaineCare-covered services under the fee-for-service system. PCPs who were HHPs may apply to participate in the soon-to-be-implemented PCPlus program and, if approved, will receive reimbursement based on their practice level characteristics and performance for members attributed to their practice. Interested parties should refer to the new PCPlus rule (MBM, Ch. VI, Sec. 3) for more details.  

On April 21, 2022, the Department received approval from the Centers for Medicare and Medicaid Services (CMS) for the state plan amendment (SPA) to implement the PCPlus program. The Department shall seek approval from CMS for SPAs to repeal and revise any other programs necessary to implement the PCPlus program. The Department will publish notice of changes in reimbursement methodology pursuant to 42 CFR 447.205.

Members who were attributed to an HHP panel will not experience any direct impacts. Members will keep their PCPs, but those PCPs that were HHPs are no longer held to the HPP provider and covered service requirements. Members will be notified of the HHP repeal if their PCP was an HHP and if their PCP becomes a PCPlus provider.

Community Care Teams

Under the adopted rule, CCTs support PCPs, rather than HHPs, by providing services to members who are high-risk and/or high-cost and whose health care needs are more intense than can be managed by a PCP. The rule expands, simplifies, clarifies, and removes redundancies from the covered service requirements.

Under the adopted rule, CCTs are subject to new provider requirements. CCTs must implement an electronic health record, participate in Department-required technical assistance and educational opportunities, maintain a Participant Agreement for data sharing with Maine’s Health Information Exchange, follow ten core standards originally designed for and applied to HHPs, have a documented relationship with one or more PCPs, and have a multidisciplinary team of at least three health care professionals whose roles have been clarified.

The adopted rule also changes member eligibility requirements for CCT services to be more inclusive by decreasing the number of chronic medications, hospital admissions, and emergency department visits that are needed to qualify a member. Members are also now eligible if they are transitioning from an institutional setting and if members are identified by risk-stratification as at risk for deteriorating health; high-risk or high-cost due to severity of illness or high social needs; or higher health care needs than is expected for their clinical risk group. To receive CCT services Members must still have two or more chronic conditions or have one chronic condition and be at risk for another. The adopted rule also adds new risk factors that make a member at risk for a chronic condition.

Housing Outreach and Member Engagement Providers

Via Resolve, To Increase Access to Housing-related Support Services, LD 1318 (129th Legislature 2019), the Legislature directed the Department to examine federal opportunities to provide housing-related services to persons experiencing chronic homelessness who have mental health conditions or substance use disorder and other vulnerable populations. In addition, the Office of MaineCare Services, Maine State Housing Authority (MSHA), and various housing and homeless services providers applied for and were accepted into a Medicaid Innovation Accelerator Program (IAP) for State Medicaid-Housing Agency Partnerships with technical assistance from the Corporation for Supportive Housing (CSH) and the Center for Health Care Strategies (CHCS). The collaborative group focused on improving outcomes for MaineCare members with disabilities and chronic health conditions, including Substance Use Disorder (SUD), who are experiencing homelessness and developing a Medicaid benefit to support housing sustainability, improved health outcomes, and reduced overall costs of care. The group proposed to use Section 2703 of the Affordable Care Act to develop a new type of CCT, a “HOME Provider,” that would provide comprehensive care management and medical and behavioral health care coordination with intensive levels of transitional care and individual supports to meet the needs of MaineCare members with long-term homelessness.

HOME Providers shall conduct outreach to underserved populations in need of intensive HOME services due to high emergency services utilization, chronic conditions, complex care coordination needs, and long-term homelessness. The HOME Provider shall be comprised of a manager, clinical leader, case manager, peer support staff, and housing navigator. HOME Providers shall receive and review referrals for HOME service eligibility and enrollment from any point of care, including but not limited to hospitals, medical and behavioral health providers, and community service organizations. HOME Providers shall provide comprehensive care management, care coordination, health promotion, comprehensive transitional care, individual and family support services, and referral to community and social support services. There are three HOME service tiers in which members can be enrolled. Members must first meet the Intensive Tier criteria before entering the Stabilization and Maintenance Tiers. Each tier represents an intensity level of covered services and has a different per member per billing month reimbursement amount. Eligible members who are children may receive covered HOME services, as long as the HOME Provider obtains written consent from a parent or legal guardian.

Lastly, the adopted rule requires both CCTs and HOME Providers to submit data necessary to compile and report on performance measures, as identified by the Department. This will aid in the development of value-based metrics to include in future iterations of rulemaking and to ensure that the services provided are high-quality. The rulemaking also defines “billing month” as the period from the 21st of a month to the 20th of the following month and, when appropriate, replaces “month” and “calendar month” with “billing month” to clarify the reimbursement period for providers.

See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.

EFFECTIVE DATE:                           June 21, 2022

AGENCY CONTACT PERSON:       Henry Eckerson, Comprehensive Health Planner II

AGENCY NAME:                              MaineCare Services

ADDRESS:                                       109 Capitol Street, 11 State House Station, Augusta, Maine  04333-0011

EMAIL:                                              Henry.Eckerson@maine.gov

TELEPHONE:                                    207-624-4085 FAX: (207) 287-6106

                                                            TTY: 711 (Deaf or Hard of Hearing)