Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter II - Specific Policies By Service
Section 144-101-II-92 - Behavioral Health Home Services
Subsection 144-101-II-92.05 - COVERED SERVICES
Universal Citation: 10 ME Code Rules § 144-101-II-92.05
Current through 2024-52, December 25, 2024
BHH services may be delivered face-to-face, via phone or other media, in any community location where confidentiality can be maintained. Not all aspects of BHH covered services require direct member involvement; however, all covered services require that provider activities are directly related to an individual member, are member-informed, and pursuant to the member's Plan of Care. BHH covered services are services provided by the BHHO and HHP as follows.
92.05-1 Comprehensive Care Management
Comprehensive Care Management are services provided to assure that members receive timely and coordinated services and supports that address physical and behavioral health needs, and promote community and home-based recovery.
A.
Comprehensive Care Management Services - BHHO :
(1)
Comprehensive Assessment.
Within the first thirty (30) days following a member's enrollment for BHH
services, the Health Home Coordinator, in consultation with other providers, as
necessary, shall provide each member with a face-to-face meeting and a
comprehensive assessment that identifies the medical, behavioral, mental
health, social, residential, educational, vocational, and other related needs,
strengths, and goals of the member (and the family/caretaker if the member is a
minor), including utilization of screening tools for co-occurring disorders.
The comprehensive review shall include a psychosocial assessment, including
history of trauma and abuse, substance use, general health and capabilities,
medication needs, member strengths and how they can be optimized to promote
goals, available support systems, living situation, employment and/or
educational status, and other relevant information. A reassessment must occur
as change in the member's needs warrants or at a minimum on an annual basis.
(2)
Plan of Care
.Based on the comprehensive assessment, within the first thirty (30) calendar
days following a member's enrollment, the Health Home Coordinator in
partnership with the member, shall draft a comprehensive, individualized, and
member-driven Plan of Care that shall identify and integrate behavioral and
physical health needs and goals. The BHHO shall be responsible for the
management, oversight, and implementation of the Plan of Care, including
ensuring active member participation and that measurable progress is being made
on the goals identified in the Plan of Care.
(a) The Plan of Care must be consented to by
the member, as reflected by the member's signature on the Plan of Care,
documented in the member's record, and accessible to the member, the BHHO, HHP
and other providers, as appropriate.
(b) The BHHO shall obtain written consent for
services and authorization for release and sharing of information from each
member.
(c) The Plan of Care may
include, but not be limited to, information on prevention, wellness, peer
supports, health promotion and education, crisis planning, and identifying
other social, residential, educational, vocational, and community services and
supports that enable a member to achieve physical and behavioral health
goals.
(d) The member (or
parent/guardian) plays a central and active role in the development and
maintenance of the Plan of Care, which shall clearly identify the goals and
timeframes for improving the member's health and health care status, and the
interventions that will produce this effect.
(e) If authorized by the member, the BHHO
shall document in the Plan of Care the member's family, guardian(s), or
caregiver support systems and preferences. If authorized by the member, the
Plan of Care shall be accessible to the member's family, guardian(s), or other
caregivers.
(f) The Plan of Care
shall identify member strengths and how these strengths can be optimized to
promote goals.
(g) The Plan of Care
shall clearly identify providers involved in the member's care, such as the
primary care physician/nurse practitioner, specialist(s), behavioral health
care provider(s), Health Home Coordinator, and other providers directly
involved in the member's care.
(h)
All identified clinical services indicated in the Plan of Care must be approved
by a medical or mental health professional working within the scope of his/her
license.
(i) The Plan of Care must
be reviewed and approved in writing by a medical or mental health professional
within the first thirty (30) calendar days following acceptance of the Plan by
the member, and every ninety (90) calendar days thereafter, or more frequently
if indicated in the Plan of Care. The Health Home Coordinator with other care
team members, as appropriate, shall review the Plan of Care as changes in the
member's needs occur, or at least every ninety (90) days, to determine the
efficacy of the services and supports, and formulate changes in the Plan as
necessary, with member consultation.
(j) The BHHO shall consult with care team
members and the member as necessary, and update the Plan accordingly to ensure
that it remains current.
(k) The
member may decline to receive services identified in the Plan of Care, in which
case the BHHO must document such declination in the member's record.
(3)
Integration with Primary
Care. During the first three (3) months after a member's enrollment, the
BHHO shall provide individualized outreach, education and support to the member
(and family, if the member is a minor) regarding BHHO services and benefits,
including information on sharing personal health information, and coordination
with primary care services. These services may be provided via in-person
meetings, follow up phone calls, development of written materials or
presentations, assistance from Peer Support providers, and other strategies to
ensure that the BHHO's members are fully educated and engaged with the needs
and goals set forth in the Plan of Care.
(4) The BHHO shall scan for gaps in each
member's care by reviewing, at a minimum, utilization reports for data across
the following domains, and work with the member and appropriate providers to
address any gaps in care:
(a) Hospitalizations
in the last quarter as well as the last year;
(b) ED visits in the last quarter as well as
the last year;
(c) Patients with
total paid claims greater than $10,000;
(d) Patients with eleven (11) or more
medications;
(e) Patients with no
PCP visits in the last year;
(f)
Patients with no HbA1c test (diabetes) in the last quarter;
(g) Patients with no LDL panel (diabetes) in
the last year; and
(h) Patients
with no LDL panel in the last year (CVD).
B.
Comprehensive Care Management
Services - HHP :
(1) The HHP shall
coordinate with the member and the BHHO in the development of the Plan of Care
and ensure that current medical information regarding all physical health
conditions, including lab tests/results, and medications, are shared and
incorporated in the Plan of Care.
(2) The HHP shall conduct clinical
assessment, monitoring and follow up of physical and behavioral health care
needs, conduct medication review and reconciliation, monitor chronic
conditions, weight/BMI, tobacco and other substance use, and communicate
regularly with the BHHO and other treatment providers, as necessary, to
identify and coordinate a member's emerging care management needs.
Specifically, HHPs shall have processes in place to conduct the following screenings and assessments for all of their assigned BHH members:
(a) Measurement of BMI in all
adult patients at baseline and at least every two years, and BMI
percent-for-age at least annually in all children.
(b) During the second year of MaineCare
participation as a Health Home practice and annually thereafter:
(c) Depression and substance use screening
(PHQ9 and AUDIT, DAST) for all adults with chronic illness, and substance use
screening (CRAFFT) for adolescents.
(d) ASQ or PEDS developmental screening for
all children age one to three, and the MCHAT 1 for at least one screening
between ages 16-30 months with a follow-up MCHAT 2 if a child does not pass the
screening test.
(3) The
HHP shall scan for gaps in each member's care by, at a minimum, reviewing
utilization reports for data across the following domains, and work with the
BHHO and the member to address any gaps in care:
(a) Hospitalizations in the last quarter as
well as the last year;
(b) ED
visits in the last quarter as well as the last year;
(c) Patients with total paid claims greater
than $10,000;
(d) Patients with
eleven (11) or more medications;
(e) Patients with no PCP visits in the last
year;
(f) Patients with no HbA1c
test (diabetes) in the last quarter;
(g) Patients with no LDL panel (diabetes) in
the last year; and
(h) Patients
with no LDL panel in the last year (CVD).
92.05-2 Care Coordination
Care Coordination is a set of services designed to support the member (and family/guardian if the member is a minor) in the implementation of the Plan of Care.
A.
Care Coordination Services - BHHO
(1) For each member, the BHHO shall identify
specific resources and the amount, duration, and scope of services necessary to
achieve the goals identified in the Plan of Care. The BHHO shall provide
referrals to other services and supports, as identified in each member's Plan
of Care, and shall follow up with each member to ensure that the member takes
action in regard to each referral.
(2) The BHHO shall have an organizational
understanding and provide systematic identification of local medical,
community, and social services and resources that may be needed by the
member.
(3) The BHHO shall assign
to each member a Health Home Coordinator, who shall be responsible for overall
management of the Plan of Care, and coordinate and provide access to other
providers, including the HHP, as set forth in the Plan of Care.
(4) The BHHO shall ensure that members have
access to crisis intervention and resolution services, coordinate follow up
services to ensure that a crisis is resolved, and assist in the development and
implementation of crisis management plans. Unless other resources are preferred
by the member, crisis services are DHHS-funded crisis providers in the
community.
(5) The BHHO shall
coordinate and facilitate access to psychiatric consultation and/or medication
management.
B.
Care
Coordination Services - HHP: For each member, the HHP shall coordinate
and provide access to high quality physical health and treatment services
identified in the Plan of Care, including the identification and referral to
physical health care specialty providers. The HHP shall consult and coordinate
with the BHHO to facilitate successful referral to all necessary services and
supports identified in the Plan of Care.
92.05-3 Health Promotion
Health Promotion is a set of services that emphasize self-management of physical and behavioral health conditions, in an effort to assist the member in the implementation of the Plan of Care.
A.
Health Promotion Services -
BHHO
(1) The BHHO shall provide
education, information, training and assistance to members in developing
self-monitoring and management skills.
(2) The BHHO shall promote healthy lifestyle
and wellness strategies, including but not limited to: substance use
prevention, smoking prevention and cessation, nutritional counseling, obesity
reduction and prevention, and increasing physical activities.
(3) The BHHO shall coordinate and provide
access to self-help/self-management and advocacy groups, and shall implement
population-based strategies that engage members about services necessary for
both preventative and chronic care. For members who are minors, the BHHO shall
provide training to the member's parent/guardian in regard to behavioral
management and guidance on at-risk behavior.
B.
Health Promotion Services -
HHP
(1) The HHP shall coordinate with
the member and the BHHO to identify and provide access to necessary Health
Promotion Services, based on each member's needs, as set forth in the Plan of
Care, including providing education about the management of chronic physical
conditions.
(2) The HHP shall
review all discharge plans, monitor and review medication and lab results, and
regularly communicate about these efforts with the BHHO.
92.05-4 Comprehensive Transitional Care
Comprehensive Transitional Care services are designed to ensure continuity and coordination of care, and prevent the unnecessary use of the ED, hospitals, and/or out of the home placement of members.
A.
Comprehensive Transitional Care
Services - BHHO
(1) The BHHO shall
collaborate with facility discharge planners, the member and the member's
family or other support system, as appropriate, to ensure a coordinated, safe
transition to the home/community setting, and to prevent avoidable
readmission after discharge.
(2)
The BHHO shall assist the member with the discharge process, including outreach
in order to assist the member with returning to the home/community.
(3) The BHHO shall follow up with each member
following a hospitalization, use of crisis service, or out of home placement.
(4) The BHHO shall collaborate
with members, their families, and facilities to ensure a coordinated, safe
transition between different sites of care, or transfer from the home/community
setting into a facility.
(5) The
BHHO shall assist the member in exploration of less restrictive alternatives to
hospitalization/institutionalization.
(6) The BHHO shall provide timely and
appropriate follow up communications on behalf of transitioning members, which
includes a clinical hand off, timely transmission and receipt of the
transition/discharge plan, review of the discharge records, and coordination of
medication reconciliation.
(7) The
BHHO shall facilitate, coordinate, and plan for the transition of members from
children's services to the adult system.
B.
Comprehensive Transitional Care
Services - HHP
(1) The HHP shall
review any and all discharge plans and timely follow up with the member
regarding physical health needs, including medication reconciliation, consult
with the BHHO regarding same, and update the member's Plan of Care
accordingly.
92.05-5 Individual and Family Support Services
Individual and family support services include assistance and support to the member and/or the member's family in implementing the Plan of Care.
A.
Individual and
Family Support Services - BHHO
(1) The
BHHO shall provide assistance with health-system navigation, and training on
self-advocacy techniques.
(2) In
accordance with the members Plan of Care, the BHHO shall provide information,
consultation, and problem-solving supports, if desired by a member, to the
member, and his or her family or other support system, in order to assist the
member in managing symptoms or impairments of his or her illness.
(3) The CIPSS shall coordinate and provide
access to Peer Support Services, Peer advocacy groups, and other Peer-run or
Peer-centered services, and shall assist the member with identifying and
developing natural support systems.
(4) The BHHO shall discuss advance directives
with members and their family, guardian(s), or caregivers, as
appropriate.
(5) The BHHO shall
assist the member in developing communication skills necessary to request
assistance or clarification from supervisors and co-workers when needed and in
developing skills to enable the individual to maintain employment.
B.
Individual and Family
Support Services - HHP : The HHP shall assist the member with medication
and treatment management and adherence, and shall document such efforts in the
member's EHR.
92.05-6 Referral to Community and Social Support Services
Referral to Community and Social Support Services involves providing assistance to members to obtain and maintain diverse services and supports as identified in their Plan of Care. Referral to community and social services involves an organizational understanding and systematic identification of area resources, services and supports
A.
Referral to Community and Social
Support Services - BHHO
(1) Services
may include outreach and coordination by providers, as needed to ensure a
successful referral, and may include reminders and scheduling appointments.
(2) The BHHO will also provide
linkages to services, including linkages to long-term care services and home
and community supports.
B.
Referral to Community and Social
Support Services - HHP. Clinical staff at the HHP may provide referrals
to community and social supports.
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