Notice of Agency Rule-making Proposal: Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 93, Opioid Health Home Services
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 & III, Section 93, Opioid Health Home Services
PROPOSED RULE NUMBER:
CONCISE SUMMARY: The Department of Health and Human Services (the “Department”) proposes this rule change in 10-144 C.M.R. Ch. 101, MaineCare Benefits Manual, Chapters II & III, Section 93, Opioid Health Home Services, to improve access to treatment, reduce administrative barriers to providing Medication Assisted Treatment (MAT), promote evidence-based treatment standards, and reinforce the importance of Opioid Health Home (OHH) integration with primary care. The Department will submit a State plan amendment (SPA) to the Center for Medicare and Medicaid Services (CMS) for some of these changes and expects it to be approved. The proposed rule and the SPA will have the same effective date.
This rulemaking consists of the following changes in Chapters II and III, Section 93, Opioid Health Home Services:
The proposed rule makes various changes to the MAT prescriber position. It allows practitioners licensed under state and federal law to order, administer, or dispense opioid agonist treatment medications to be MAT prescribers for members in the Methadone Level of Care who receive OHH services from an Opioid Treatment Program (OTP). It requires the MAT prescriber to coordinate with the OTP OHH when members in the Methadone Level of Care receive OHH services from a non-OTP OHH. It also requires MAT prescribers to be involved in providing the services described under 93.05-1, Health Home Services.
The proposed rule makes various changes to the nurse care manager position on the OHH team. In response to requests from providers, the proposed rule allows licensed practical nurses to be nurse care managers. It requires any person serving as the nurse care manager to complete the eight-hour training for buprenorphine prescribing by physicians within six months of initiating service delivery for OHH members, unless the individual is an Advanced Practice Registered Nurse with a X-Drug Enforcement Administration (DEA) license. It no longer requires the nurse care manager to oversee and/or participate in all aspects of OHH services because the nurse care manager would not oversee opioid use disorder (OUD) counselling. It specifies that the nurse care manager position may be filled by another appropriate licensed medical professional on the OHH team, as long as the individual completes training for an X-DEA license within six months of initiating service delivery for OHH members.
The proposed rule adds methadone to the medications included in the OHH model and allows an OTP to provide methadone to members. The rule also adds a statement encouraging the co-prescribing of naloxone for OHH members, as appropriate, in alignment with best practice guidelines.
The proposed rule makes a number of changes to the counseling requirement. It clarifies that counseling is not required for the Medication Plus Level of Care and is not part of the OHH bundle for the Methadone Level of Care. It changes the counseling requirement to be assessed on a monthly instead of weekly basis, which is in response to feedback that weekly requirements are too stringent for this service and are challenged by normal life events. It clarifies that counseling requirements for each clinical phase are based on a “billable” month (in alignment with standard billing practice), which does not always equate to a full 60 minutes of counseling. It requires OHH members in Intensive Outpatient (IOP) and Induction Levels of Care to engage in individual or group counseling for four billable hours per month; members in the Stabilization Level of Care for two hours; and members in the Maintenance Level of Care for one hour.
The proposed rule makes various changes to the reimbursement section. This rulemaking allows providers to bill the new Medication Plus and Methadone Levels of Care if the member is enrolled for at least one day during the billing month. It adds that OHH providers will not be reimbursed for an OHH member if that member also receives Section 97, Private Non-Medical Institution Services; Section 13, Targeted Case Management Services; Section 17, Community Support Services; or Section 92, Behavioral Health Homes, unless the Section 13, 17, or 92 provider has a contract with the OHH to provide Health Home Services. The rule also adds an Additional Provider Support provision for OHH members with additional community support needs related to mental health, HIV, medical concerns and/or utilization, and/or homelessness. The Department or its authorized entity must approve additional supports provided to eligible members and reimbursed through the pass-through payment described in Chapter III, Section 93, Opioid Health Home Services, including an active release of information and a contractual agreement between the OHH and additional support provider.
The rule also adds a pay-for-performance provision which withholds four percent of total OHH PMPM payments. This amount shall be paid to providers every six months if they satisfy the minimum performance threshold, and providers who meet the excellent performance threshold are eligible to receive any additional available amount. The Department shall set the performance thresholds so that no less than 70% of eligible OHHs are expected to be above the minimum performance threshold and no less than 20% of OHHs are expected to be above the excellent performance threshold. This means that 30% of eligible OHHs are not expected to meet the minimum performance threshold and thus will not receive the four percent payment. Those four percent amounts will be combined and distributed to OHH providers that meet the excellent performance threshold. If all OHH providers satisfy the minimum performance threshold, then no amounts would be distributed to OHH providers who satisfy the excellent performance threshold. Performance calculations shall be based on the composite score of three performance measures, as set forth in the rule. Providers shall receive reports quarterly to inform them about whether they satisfied the minimum or excellent performance threshold standards, what their reimbursement shall be, as well as instructions for appeal if they disagree with the Department’s determinations.
This rulemaking also makes the following changes:
- Clarifies that the clinical counselor provides behavioral health expertise and contributes to care planning, assessment of individual care needs, and identification of and connection to behavioral health services, as part of the services described in 93.05-1.
- Allows community health workers to be patient navigators, in response to requests from providers. A definition and certification/training requirements for community health workers is also added.
- Requires Connecticut Community for Addiction Recovery (CCAR) or other Department approved recovery coach training for recovery coaches. OHHs will have six months from rule adoption to train existing staff, and each new recovery coach will have six months to complete the applicable training upon start of delivery OHH services.
- Encourages people with lived experience to serve as recovery coaches but also allows recovery allies to serve as recovery coaches.
- Requires the OHH to adopt processes to identify and classify patients across their population served who are missing critical preventive services and/or other health screenings.
- Adds that members must be assessed for appropriateness of OHH services in alignment with American Society of Addiction Medicine guidelines. Requires OHHs to retain a signed consent form for all OHH members in the member record. The documentation must indicate that the individual has received information in writing, and verbally as appropriate, that explains the OHH purpose and the services provided and indicates that the individual has consented to receive the OHH services and understands their right to choose, change, or disenroll from their OHH provider at any time.
- Requires OHH providers to provide and document efforts to connect each OHH member to a primary care provider.
- Adds that health promotion activities may include health education and referral support for health-related risk factors (e.g. oral health, contraceptive counseling, preventive screenings).
- Removes language that referred to “coordinated case management” to align with language for the approved MaineCare SPA for these services, which instead utilizes an expanded team-based approach for the provision of additional supports, reimbursed through pass-through payments.
- Requires OHHs to conduct a comprehensive biopsychosocial assessment annually.
This rulemaking also consists of the following changes in Chapter III, Section 93, Opioid Health Home Services:
The proposed rule introduces the Medication Plus and Methadone Levels of Care. The Medication Plus Level of Care reimburses for all OHH covered services except for OUD counseling, which allows members to receive OUD medication without electing to participate in OUD counseling. The Methadone Level of Care allows members who receive Methadone Medication Assisted Treatment (MAT) from Chapter II, Section 65, Behavioral Health Services, providers to receive Health Home services from the team-based care delivery model of the OHH.
Under the current rule, when members receiving OHH services elect to receive comprehensive care management and comprehensive transitional care from an additional support provider, the Department reimburses both providers separately. CMS advised that the OHH should reimburse the additional support provider via a pass-through payment. Hence, this rulemaking increases the reimbursement amount to the OHH provider to include a pass-through payment of $394.40 for the IOP, Induction, Stabilization, and Maintenance Levels of Care when members elect to receive services from an additional support provider.
In alignment with the Department’s goal to implement value-based payment models tied to quality, the proposed rule adds a pay-for-performance provision that will withhold four (4) percent of OHH payments, pending the OHH’s performance on three measures of OHH quality and effectiveness of service. The measures include assessing whether members in Maintenance and Stabilization Levels of Care have attended an annual primary care visit, had continuous pharmacotherapy as part of their MAT, and are involved in regular employment or other forms of community engagement. While the methodology for this pay-for-performance provision is detailed in rule, MaineCare will evaluate the need for adjustments to ensure OHH providers are not inappropriately penalized for the costs or changes in quality/utilization that result from COVID-19. Performance measure thresholds and the performance of other providers will determine if OHHs receive the full four percent and if they are eligible for a pay-for-performance surplus payment.
The proposed rules also make minor technical corrections.
See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.
STATUTORY AUTHORITY: 22 M.R.S. §§ 42, 3173
DATE, TIME AND PLACE OF PUBLIC HEARING: 1:00pm; Monday, April 4, 2022
Due to the ongoing threat posed by COVID-19, DHHS has determined that its public hearing will be conducted solely remotely, via Zoom. This is in accordance with the DHHS Remote Rulemaking Hearings Policy issued September 10th, 2021.
Remote Hearings Policy link: https://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/9%209%2021%20Remote%20Rulemaking%20Hearings%20Policy.pdf
Zoom Meeting link: https://mainestate.zoom.us/j/82913607531
Meeting ID: 829 1360 7531
Some devices may require downloading a free app from Zoom prior to joining the public hearing event. The Department requests that any individual requiring special arrangements to participate in the hearing contact the person listed for this filing 5 days in advance of the hearing.
DEADLINE FOR COMMENTS: Comments must be received by 11:59 PM on April 14th, 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)
IMPACT ON MUNICIPALITIES OR COUNTIES (if any): The Department anticipates that this rulemaking will not have any impact on municipalities or counties.
CONTACT PERSON FOR SMALL BUSINESS INFORMATION (if different): N/A
Check out our new MaineCare logo! Learn more about this logo on the About Us page of our website.
