MaineCare Notice of Agency Rule-making Adoption, REPEAL of MaineCare Benefits Manual, MaineCare Benefits Manual, Chapter VI, Section 1, Primary Care Case Management (PCCM)

May 12, 2022

Notice of Agency Rule-making Adoption

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

CHAPTER NUMBERS AND TITLES: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter VI, Section 3, Primary Care Plus and 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter VI, Section 1, Primary Care Case Management (PCCM).

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 rulemaking repeals 10-144 CMR Ch. 101, MaineCare Benefits Manual (the “MBM”), Ch. VI, Sec. 1, Primary Care Case Management (PCCM), and replaces it with MBM, Ch. VI, Sec. 3, Primary Care Plus (PCPlus), a single integrated program for MaineCare’s current primary care programs. To complete the transition to PCPlus, the Maine Department of Health and Human Services (the “Department”) also repealed MBM, Ch. II, Sec. 90.09-4 (Primary Care Provider Incentive Payment) and significantly revised MBM, Ch. II, Sec. 91 (titled “Health Home Services – Community Care Teams”), which includes repealing Health Home Practices. All of these rulemakings relate to the PCPlus initiative and have the same effective date.

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.

As a result of comments, the Department determined that it would delay the effective date of the PCPlus rule until June 21, 2022. The removal of the Primary Care Provider Incentive Payment in Section 90 and the final adopted changes in Section 91 (described below and in separate MAPA documents) shall also be effective June 21, 2022.

Overview of the PCPlus Initiative

The Department and the Office of MaineCare Services (OMS) are committed to improving health care access and outcomes for MaineCare members, demonstrating cost-effective use of resources, and creating an environment where providers can innovate in delivering high-value care. PCPlus is part of OMS’ commitment to have 40% of MaineCare expenditures paid through Alternative Payment Models (APMs) by the end of 2022. APMs are health care payment methods that use financial incentives to promote or leverage greater value, indicated by higher quality care and/or lower costs.

PCPlus is considered an “Integrated Care Model” by CMS under State Medicaid Director Letter #12-002, aligns with the Center for Medicare and Medicaid Innovation’s (CMMI) Primary Care First Model (See also: https://innovation.cms.gov/innovation-models-options), and operates under the authority of Section 1905(t)(1) of the Social Security Act (SSA). The PCPlus program is intended to give primary care providers (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.

Participation in PCPlus is voluntary for PCPs. For PCPs that elect to participate, the Department will share quality and utilization data, offer a new value-based payment model, and provide technical assistance to assist practices to transform care delivery and achieve performance outcomes. The new payment model is risk-based, meaning reimbursement will increase or decrease depending on the PCPlus provider’s performance, as set forth in Section 3.08 of the rule. Providers may appeal Departmental actions, pursuant to Chapter I, Section 1.

Member participation in this model is based on which PCP the member visited for health care services or by the members’ identification of a PCP through calling MaineCare Member Services. Member participation is voluntary and does not interfere with MaineCare members’ freedom of choice to access other MaineCare providers. If a member identified their PCP for attribution through MaineCare Member Services but does not receive at least one primary care service from their selected PCP within one year, then DHHS will notify and reattribute the member in accordance with the primary care services-based attribution methodology. Members may change their PCP or opt out of PCPlus at any time.

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 Section 3.04. All covered services rendered by PCPlus providers must be documented in the member’s electronic health record. The Department will continue to reimburse other MaineCare covered services under the fee-for-service system.

Differences Between PCPlus and PCCM

CMS considers PCCM to be a form of managed care, which operates under Section 1905(a)(25) of the SSA and 42 CFR 438.6 with mandatory member participation for the majority of MaineCare members. PCPlus operates under 1905(t)(1) of the SSA and is not a managed care program. Since PCPlus is not a managed care program, it does not include many of the managed care requirements that PCCM follows. For example, except as set forth in the rule, member participation in PCPlus is based on members’ selection of a PCP, members may opt out of this program, and this program has no bearing on MaineCare members’ freedom of choice to access services from any qualified MaineCare provider. In addition, PCPlus, unlike PCCM, does not include the PCCM provisions on member participation or complaints, and PCP selection, change, and reassignment.

Under both PCCM and PCPlus, providers locate, coordinate, and monitor health care services. However, PCPlus expands service and practice requirements to support whole-person coordination and transitions of care; completing timely prior authorizations; providing, tracking, and following up on referrals; and closing care gaps, including a focus on preventive services.

PCCM providers who choose to participate in PCPlus will benefit from a new value-based payment model, which includes a risk-adjusted population-based payment tied to cost- and quality-related outcomes, rather than the flat per member per month management fee provided under PCCM. Given the additional requirements and support for providers, PCPlus should improve health outcomes for members. 

Section 90 and 91 Rulemakings for PCPlus Initiative

Regarding the related adopted rulemaking for Section 90, the Department eliminated the Primary Care Provider Incentive Payment because it would duplicate the reimbursement model of the new PCPlus program. Physicians who received the Incentive Payment may apply to be PCPs under the PCPlus program, and, if approved, will receive reimbursement based on the PCPlus service expectations and performance for members attributed to their practice. 

For Section 91, as it relates to the PCPlus initiative, the Department removed Health Home Practices (HHPs) because payment for these Health Home services would be duplicative of the reimbursement the PCPs will receive and the covered services they provide via PCPlus. HHPs that received reimbursement through Section 91 may apply to participate in the PCPlus program, and, if approved, PCPs will receive reimbursement based on the PCPlus service expectations and performance for members attributed to their practice.

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

STATUTORY AUTHORITY:              22 M.R.S. §§ 42, 3173; Social Security Act § 1905(t)(1) (42 U.S.C. § 1396d(t)(1))                  

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

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