Current through 2024-38, September 18, 2024
All MaineMOM providers must meet the requirements of
Section 89.06-1 and Section
89.06-2.
There are three separate types of MaineMOM provider
service models of care, offering different types and intensities of services:
MaineMOM Integrated Model Services; MaineMOM Partnership Model Services; and
MaineMOM Perinatal Navigation Model Services. The Integrated Model Service is
for members who are receiving their prenatal and postpartum medical services at
the same service location as OUD services, the Partnership Model Service is for
members who are receiving OUD services onsite from the MaineMOM provider and
prenatal and postpartum medical services from a different provider and service
location, and the Perinatal Navigation Model Service is for members who receive
only prenatal and postpartum medical services from the MaineMOM provider and/or
are receiving their OUD treatment from a different non-MaineMOM provider and
service location.
In addition to the requirements in Sections
89.06-1 and
89.06-2, a provider
using the Integrated Model Services must also meet the requirements of Section
89.06-3; a provider
using the Partnership Model Services must also meet the requirements of Section
89.06-4; and a
provider using the Perinatal Navigation Model Services must also meet the
requirements of Section
89.065.
89.06-1
Requirements for all MaineMOM
Providers
A. The MaineMOM provider
must execute a MaineCare Provider Agreement. The MaineMOM provider is subject
to applicable state and federal Medicaid law, including but not limited to the
Chapter I, Section
1 of the MaineCare Benefits
Manual (MBM).
B. The
MaineMOM provider must be approved by the Department, or its Authorized Entity,
through the MaineMOM application process.
C. At the time of its application, lack of an
EHR system will not be a determining factor in approving a MaineMOM provider
application. However, prior to the delivery of any covered Section
89 services, a MaineMOM provider
must utilize an EHR and create an EHR for each member served.
D. The MaineMOM provider must be a
Co-occurring Capable Provider.
E.
The MaineMOM provider must adhere to applicable licensing standards regarding
documentation of all provider qualifications in their personnel files. The
MaineMOM provider must have a review process to ensure that employees providing
MaineMOM services possess the minimum qualifications.
F. The MaineMOM care team must consist of
employed or contracted personnel and minimally must include the personnel
identified in this sub-section. All MaineMOM care team members shall contribute
to delivery of integrated, coordinated, and person-centered care through a
team-based approach.
Unless otherwise specified, each MaineMOM care team
member role must be filled by a different individual. The Department
reserves the right to waive this requirement based on team member professional
experience and training.
1. The
MaineMOM care team members must include:
a.
Clinical Team Lead: A licensed clinical professional who is
responsible for ensuring that the MaineMOM care team is complete and adheres to
provider requirements (Section
89.06). The Clinical
Team Lead shall coordinate the Care Plan for members served. The Clinical Team
Lead shall have significant experience caring for pregnant and postpartum
individuals with SUD.
The Clinical Team Lead must be a:
i. Physician (Doctor of Medicine (MD) or
Doctor of Osteopathic Medicine (DO));
ii. Physician Assistant (PA);
iii. Advanced Practice Registered Nurse
(APRN);
iv. Psychologist,
v. Registered Nurse (RN);
vi. Licensed Clinical Social Worker
(LCSW);
vii. Licensed Clinical
Professional Counselor (LCPC); or
viii. Licensed Alcohol and Drug Counselor -
Certified Clinical Supervisor (LADC-CCS).
The Clinical Team Lead role may be filled by an
individual also serving in one of the other roles below, as long as the
individual meets the qualifications of a Clinical Team
Lead.
b.
MOUD Prescriber: A licensed health care professional providing
services for treatment of OUD, including medications for SUD as appropriate.
The MOUD Prescriber shall coordinate with and provide
guidance to the MaineMOM care team, to ensure physical and behavioral health
goals are appropriate to the member's Care Plan, including guidance on pain
management protocols, medication contraindications, and other support. The MOUD
Provider shall interpret toxicology screens and discuss results with
members.
The MOUD Prescriber must be a:
i. licensed health care professional with any
federally and state required training to prescribe medications for SUD,
including but not limited to buprenorphine, buprenorphine combination
medications, and naltrexone; or
ii.
practitioner licensed under state and federal law to order, administer, or
dispense opioid agonist treatment medications.
For members who receive MOUD covered services under MBM,
Ch. II, Sec.
65, from an OTP, the MaineMOM MOUD
Prescriber must coordinate with the prescriber at the OTP.
The MOUD Prescriber role may be filled by an individual
also serving as a Perinatal Provider and/or Clinical Team Lead as long as the
individual meets the requirements of a MOUD Prescriber.
c.
Perinatal Provider:
A licensed health care professional coordinating with and providing guidance to
the MaineMOM care team, to ensure physical and behavioral health goals are
appropriate to the member's Care Plan. The Perinatal Provider shall have
significant experience caring for women during the Prenatal, Intrapartum, and
Postpartum periods.
The Perinatal Provider must be a:
i. Physician (Doctor of Medicine (MD) or
Doctor of Osteopathic Medicine (DO));
ii. PA; or
iii. APRN, including but not limited to a
Certified Nurse-Midwife, who practices obstetrics-gynecology or family
medicine.
If the Perinatal Provider does not provide Intrapartum
Care, the MaineMOM Provider must establish an additional partnership with a
care provider that does offer Intrapartum Care.
The Perinatal Provider role may be filled by an
individual also serving as a MOUD Prescriber and/or Clinical Team Lead as long
as the individual meets the requirements of a Perinatal
Provider.
d.
Nurse Care Manager: A licensed health care professional
contributing to implementation, coordination, and oversight of each member's
Care Plan, assisting in the coordination of care with outside providers, and
communicating barriers to adherence as appropriate to the team, including the
Clinical Team Lead. The Nurse Care Manager shall be involved in overseeing
and/or participating in all aspects of MaineMOM services.
The Nurse Care Manager must be a(n):
i. RN;
ii. APRN;
iii. Psychiatric and Mental Health Nurse
(PMHN) certified by the American Nurses Credentialing Center (ANCC);
or
iv. Licensed Practical Nurse
(LPN).
The Nurse Care Manager position may be filled by another
appropriate licensed medical professional on the MaineMOM care team, as long as
the individual also meets the qualifications described of a Nurse Case
Manager.
e.
Clinical Counselor: A licensed clinical professional providing
individual or group SUD outpatient therapy for members receiving counseling.
The Clinical Counselor provides behavioral health expertise in the coordination
of the member's Care Plan and identifies and connects members to behavioral
health services.
The Clinical Counselor must be a:
i. Psychologist;
ii. LCSW;
iii. LCPC;
iv. Licensed Master Social Worker-
Conditional Clinical (LMSW-CC);
v.
Licensed Clinical Professional Counselor-Conditional (LCPC-C);
vi. Licensed Marriage and Family Therapist
(LMFT);
vii. Licensed Marriage and
Family Therapist-Conditional (LMFT-C);
viii. Licensed Alcohol and Drug Counselor
(LADC); or
ix. Certified Alcohol
and Drug Counselor (CADC).
f.
Patient Navigator: A
certified and/or qualified direct care worker coordinating health care, mental
health, and social services and supporting the member in their recovery during
the perinatal period. The Patient Navigator may be the primary provider of care
coordination, health promotion, individual and family support services, and
referral services.
The Patient Navigator must be a(n):
i. Mental Health Rehabilitation
Technician/Community (MHRT/C);
ii.
RN
iii. LPN
iv. Medical Assistant (MA);
v. Community Health Worker (CHW);
vi. Certified birth or postpartum doula who
has completed a doula training program with relevant perinatal core
competencies; or
vii. Individual
who has at least one (1) year of job experience in health/social services
setting supporting families affected by SUD.
The Patient Navigator role may be filled by an individual
also serving as the Nurse Care Manager or Clinical Counselor, if that person
only shares those two roles, and if the individual also meets the
qualifications of a Patient Navigator.
g.
Recovery Coach: A care team
member providing recovery support. The Department encourages and prefers that
those in this role are themselves in recovery, as their life and recovery
experiences allow them to provide recovery support in such a way that others
can benefit from their experiences. This may include contacting the member to
answer any questions and provide any support in navigating services.
The Recovery Coach must:
i. Be an individual in recovery from SUD and
who is willing to self-identify on this basis with members, or be a recovery
ally*; and
ii. Have completed the
thirty (30) hour Connecticut Community for Addiction Recovery (CCAR) training,
or other Department-approved Recovery Coach training or certification, within
six (6) months of the rule adoption date or within six (6) months of beginning
to deliver MaineMOM Services, whichever is later; and
iii. Be employed by the MaineMOM provider or
engaged through a formal contract with a community-based organization that
identifies referral processes and access to services.
*The Department shall submit to CMS and anticipates
approval for a State Plan Amendment related to this
provision.
2. Regardless of qualifications, a single
person may not fill the roles of Nurse Care Manager, Perinatal Provider, MOUD
Provider and Clinical Team Lead on the care team.
3. If MaineMOM care team member role(s) are
vacant for more than thirty (30) continuous days, the MaineMOM provider shall
notify the Department, or its Authorized Entity, in writing and maintain
records of active recruitment efforts to fill the position(s).
G. The MaineMOM provider shall
ensure twenty-four (24) hour
availability of information for triage and referral to treatment for medical
emergencies.
1. This requirement may be
fulfilled through an after-hours telephone number that connects the patient to:
a. The MaineMOM provider or an authorized
licensed medical practitioner providing coverage for the MaineMOM
provider;
b. A live voice call
center system or answering service which directs the patient to the appropriate
care site or connects the patient to the MaineMOM provider/authorized covering
medical practitioner; or
c. A
hospital, if the MaineMOM provider has standing orders with the hospital to
direct patients to the appropriate care site within the
hospital.
2. The
following do
not constitute adequate coverage:
a. A twenty-four (24) hour telephone number
answered only by an answering machine without the ability to arrange for
interaction with the MaineMOM provider or their covering provider;
b. A resource or service that refers patients
to hospital EDs but does not offer phone triage or assistance in reaching the
MaineMOM provider or their covering provider.
3. The MaineMOM provider shall inform members
of their normal office hours and explain to members the procedures they should
follow when seeking care outside of office hours. The MaineMOM provider shall
ensure that their covering provider(s) is/are authorized to provide all
necessary referrals for services for members while providing coverage. The
covering provider shall be a participating MaineCare provider and shall have
real-time access to current, up-to-date medical records in the EHR during hours
they are covering.
H.
The MaineMOM provider shall screen for SUD in pregnant individuals to identify
eligible members using a validated SUD screening tool (e.g., 4Ps, CRAFFT,
T-ACE). If the member screens positive for a SUD, the MaineMOM provider shall
schedule an appointment for the member for SUD evaluation/initiation of
treatment. That appointment shall occur within seven (7) days of the member
screening positive for a SUD.
I.
The MaineMOM provider shall ensure members are informed and educated on family
planning options, with assistance to access postpartum contraception as
desired, including the use of Long-Acting Reversible Contraceptives
(LARCs).
J. The MaineMOM provider
shall have systems in place to reduce barriers to accessing treatment for
parents with young children (e.g., allowing young children to attend
appointments, especially group sessions, and support in accessing childcare for
older children).
K. The MaineMOM
provider shall offer telehealth as an alternative to traditional office visits
in accordance with the MBM, Chapter I, Section 4, and/or for nonoffice visit
supports and outreach to increase access to the care team and clinicians in a
way that best meets the needs of members.
L. The MaineMOM provider shall have at least
one (1) representative from the MaineMOM care team participate in designated
Department-sponsored quality improvement initiatives and technical assistance
activities on an annual basis. The Department will not require more than eight
(8) hours of participation annually. The MaineMOM care team representative
shall be a person whose role involves clinical care, population health, and/or
quality improvement.
M. If a
MaineMOM member has a primary care provider, the MaineMOM provider must
establish and maintain a relationship with a primary care provider, authorized
and evidenced by a signed medical release for each MaineMOM member served. Such
a release is not required when the member's primary care provider is also the
member's provider within the MaineMOM provider.
89.06-2
MaineMOM Core Standards
Prior to approval to provide services, the MaineMOM
provider must demonstrate how it will meet the following Core Standards. Within
the first three (3) months following the start of the MaineMOM provider's
participation, the MaineMOM provider shall participate in an on-site assessment
initiated by the Department, or its Authorized Agent, to establish a baseline
in meeting the Core Standards and identify the MaineMOM provider's training and
educational needs. For the remainder of the first year of participation, the
MaineMOM provider must submit quarterly reports on sustained implementation of
the Core Standards. After the first year, the MaineMOM provider may request the
Department's approval to submit the Core Standards progress report annually
instead of quarterly.
The MaineMOM Core Standards are:
A.
Demonstrated Leadership: The
Clinical Team Lead implements and oversees the Core Standards.
The Clinical Team Lead shall work with other providers
and staff to build a team-based approach to care, continually examine processes
and structures to improve care, and assist with the review of data on the
quality performance of the practice.
B.
Team-Based Approach to Care:
The MaineMOM provider shall implement a team-based approach to care delivery
that includes expanding the roles of nonphysician providers (e.g., APRNs, PAs,
nurses, MAs) and non-licensed staff (e.g., recovery coaches, patient
navigators) to improve clinical workflows.
The MaineMOM provider utilizes non-physician and
non-licensed staff to improve access and efficiency of the practice team in
specific ways, including one or more of the following:
1. Clearly identifying roles and
responsibilities;
2. Integrating
care management into clinical practice;
3. Expanding patient education; and
4. Providing support to enhance the quality
and cost-effectiveness of services provided.
C.
Population Risk Stratification and
Management: The MaineMOM provider shall adopt processes across its
population to identify and stratify patients who are at risk for adverse
outcomes or are missing critical preventive services and/or other health
screenings. The MaineMOM provider shall also adopt procedures that direct
resources or care processes to reduce those risks.
"Adverse outcomes," for purposes of this provision, means
a negative clinical outcome, fragmented care/becoming lost to follow-up, and/or
avoidable use of healthcare services such as hospital admissions, ED visits, or
non-evidence-based use of diagnostic testing or procedures.
D.
Enhanced Access: The MaineMOM
provider shall enhance access to services for its population of members,
including:
1. The MaineMOM provider shall
ensure same-day, medication-first substance use treatment is available to
members. Same day access can be provided by an external partner (e.g., a
buprenorphine induction program at a local hospital), with a documented process
to communicate and transition care with the MaineMOM MOUD Prescriber.
2. The MaineMOM provider shall have a system
that facilitates same-day access for a MaineMOM member to a MaineMOM care team
member using a form of care that meets the member's needs (e.g.,
open-availability for same day access to a care team member, telephonic
support, and/or secure messaging).
E.
Practice Integrated Care
Management:1.
Evidence-Based
Practices: The MaineMOM provider shall have processes in place to
identify the evolving evidence-based practices for the eligible member
population and to train care team members as appropriate.
2.
Person-Centered Care:
MaineMOM providers shall have processes in place to adapt services, so they are
inclusive and sensitive to culture, ethnicity, sexual orientation, and gender
identity. MaineMOM provider care teams shall be trained in Trauma-Informed Care
and stigma-reduction for people living with SUDs.
3.
Trauma-Informed Care:
Trauma-Informed Care is the provision of behavioral health services that
include:
a. An understanding of psychological
trauma, symptoms, feelings, and responses associated with trauma and
traumatizing relationships, and the development over time of the perception of
psychological trauma as a potential cause and/or complicating factor in medical
or psychiatric illnesses;
b.
Familiarity with current research on the prevalence of psychological (childhood
and adult) trauma in the lives of members with serious mental health and SUDs
and possible sequelae of trauma (e.g., Post-Traumatic Stress Disorder (PTSD),
depression, generalized anxiety, self-injury, substance use, flashbacks,
dissociation, eating disorder, revictimization, physical illness, suicide,
aggression toward others);
c.
Providing physical and emotional safety; maximizing member choice and control;
maintaining clarity of tasks and boundaries; ensuring collaboration in the
sharing of power; maximizing empowerment and skill building;
d. Consideration of all members as
potentially having a trauma history, understanding as to how such members can
experience retraumatization and ability to interact with members in ways that
avoid re-traumatization;
e. An
ability to maintain personal and professional boundaries in ways that are
informed and sensitive to the unique needs of a member with a history of
trauma; and
f. An understanding of
unusual or difficult behaviors as potential attempts to cope with trauma and
respect for member's coping attempts and avoiding a rush to negative
judgments.
F.
Behavioral and Physical Health Integration: MaineMOM providers
shall annually complete and submit an assessment of Behavioral and Physical
Health Integration progress and identify an area of focus for the following
twelve (12) month period to improve Behavioral and Physical Health Integration.
The Department, or its Authorized Entity, will provide the assessment
tool.
G.
Inclusion of
Patients and Families: The MaineMOM provider shall include as regular
participants in advisory activities representative MaineCare and/or MaineMOM
members, and family members where appropriate. MaineMOM providers shall have
member informed advisory processes to identify patientcentered needs and
solutions for improving care in the practice. These processes shall:
1. Identify opportunities to support members
and families to participate in leadership and/or advisory activities.
2. Gather member input, and family input when
beneficial, at least annually (e.g., via mail survey, phone survey, point of
care questionnaires, focus groups, etc.).
3. Design and implement changes that address
organizational needs and gaps in care identified via member and family
input.
H.
Connection to Community Resources and Social Support Services:
MaineMOM providers shall have processes in place to identify local community
resources and social support services. MaineMOM providers shall have processes
in place to routinely refer patients and families to local community resources
and social support services, including those that provide self-management
support to assist members in overcoming barriers to care and meeting health
goals.
I.
Commitment to
Reducing Waste, Unnecessary Healthcare Spending, and Improving Cost-Effective
Use of Healthcare Services: MaineMOM providers shall have processes in
place to reduce wasteful spending of healthcare resources and improve the
cost-effective use of healthcare services as evidenced by at least one
improvement initiative that targets waste reduction, including one or more of
the following:
1. Reducing avoidable
hospitalizations;
2. Reducing
avoidable ED visits; or
3. Working
with the team to develop new processes and procedures that improve patient
experience and quality of care, while reducing inappropriate use of
services.
J.
Integration of Health Information Technology: MaineMOM providers
shall use an electronic data system that includes identifiers and utilization
data about members. Member data is used for monitoring, tracking, and
indicating levels of care complexity for the purpose of improving member care.
The system must be used to support member care, including
one or more of the following:
1. The
documentation of need and monitoring clinical care;
2. Supporting implementation and use of
Evidence-Based Practice guidelines;
3. Developing Care Plans and related
coordination; or
4. Determining
outcomes (e.g., clinical, functional, recovery, satisfaction, and cost
outcomes) or risk levels (e.g., predictive analytics).
89.06-3
Additional Provider
Requirements for MaineMOM Integrated Model Services
The MaineMOM Integrated Model Service is for members who
are receiving their prenatal and postpartum medical services at the same
service location as MOUD services.
MaineMOM providers billing for MaineMOM Integrated Model
Services shall:
A. Provide MaineMOM
Covered Services (Section
89.05-1 through
Section 89.054) at a single
service location.
B. Provide
prenatal and postpartum medical services in accordance with the MBM, Chapter
II, Section
90, Physician Services.
C. Provide MOUD services informed by the ASAM
level of care criteria.
D. Conduct
toxicology screening during MOUD focused visits, as clinically appropriate, in
accordance with the MBM, Chapter II, Section
55, Laboratory Services.
89.06-4
Additional Provider
Requirements for MaineMOM Partnership Model Services
The MaineMOM Partnership Model is for members who receive
OUD treatment directly through the MaineMOM provider, but who are receiving
their prenatal and postpartum medical services from different provider(s) at a
separate service location. MaineMOM providers billing for MaineMOM Partnership
Model Services shall:
A. Provide
MaineMOM Covered Services (Section
89.06-1 through
Section 89.054) at a single
location or through partner locations with shared access to a single medical
record.
B. Provide MOUD services
informed by the ASAM level of care criteria.
C. Conduct toxicology screening during MOUD
focused visits, as clinically appropriate, in accordance with the MBM, Chapter
II, Section
55, Laboratory Services.
D. Facilitate access to prenatal and
postpartum medical services (in accordance with the MBM, Chapter II, Section
90, Physician Services) through a
current documented relationship (e.g., Memorandum of Understanding or practice
agreement) with at least one perinatal provider in the MaineMOM provider's
service area. The documented relationship must describe the procedures and
protocols for regular communication and collaboration. This may also include,
but is not limited to, acceptable mode(s) of electronic communication to ensure
effective and privacy-protected exchange of health information, frequency of
communication, procedures to access shared members' plans of care and other
health information, referral protocols for new members, and expectations for
collaboration on treatment planning. The agreement must include names, contact
information, and roles of key staff at each site. For members who receive
prenatal and postpartum medical services (in accordance with the MBM, Chapter
II, Section
90) from a perinatal provider
without a documented relationship with the MaineMOM provider, the MaineMOM
provider must obtain a documented release between the MaineMOM provider and the
perinatal provider.
89.06-5
Additional Provider
Requirements for MaineMOM Perinatal Navigation Model Services
The MaineMOM Perinatal Navigation Model Service is for
members who receive from the MaineMOM provider only the services described
below in the given billing month, including onsite prenatal and postpartum
care, but who are receiving their OUD treatment from a different provider at a
separate service location. MaineMOM providers billing for MaineMOM Perinatal
Navigation Model Services shall:
A.
Provide prenatal and postpartum medical services in accordance with the MBM,
Chapter II, Section
90, Physician Services.
B. Provide Health Home Services (Section
89.05-1) and Access
to Medication (Section
89.05-4) at a
single location.
C. Conduct
toxicology screening, as clinically appropriate, in accordance with the MBM,
Chapter II, Section
55, Laboratory Services.
D. Have processes and procedures to
coordinate access to a MOUD Prescriber (Section
89.05-2) and SUD
Counseling (Section
89.05-3), to
include proactive outreach and follow up to facilitate communicate with
providers delivering these services to ensure the co-management of the member's
Care Plan.
