Current through 2024-38, September 18, 2024
1.07-1
Members Who Are Required to
Participate
A MaineCare member must participate in Primary Care Case
Management if he/she is in one of the following categories:
a. Receiving Temporary Assistance for Needy
Families (TANF) - Adults and Children;
b. Children under the age of twenty-one (21); parents of children
under age eighteen (18) who receive MaineCare; pregnant women; and those
members eligible for transitional MaineCare; except as referenced in
1.07-4.
c. Women who have been
screened for breast or cervical cancer under the Centers for Disease Control
and Prevention Title XV Program and are found to need treatment for breast or
cervical cancer, including pre-cancerous conditions, as defined in Section
2150.03 of the MaineCare Eligibility Manual.
d. Adults, ages twenty-one (2 1) through sixty-four (64), who
do not have children or do not have children under age eighteen (18) living
with them and are at or below one-hundred percent (100%) of the federal
poverty level. Those receiving benefits under the Non-Categorical Waiver will
receive benefits limited to those listed under Chapter X, Section 2, Benefit
for Childless Adults in the MaineCare Benefits Manual.
1.07-2
Exclusions from
Participation
The following MaineCare members are excluded from
participation in Primary Care Case Management:
a. Members who are eligible for both
MaineCare and Medicare;
b. Members
with other forms of comprehensive health insurance;
c. Members under age nineteen (19) with
special health care needs who meet the eligibility criteria for the MaineCare
Katie Beckett eligibility option, as described in Section 1902(e)(3) of the
Social Security Act;
d. Members
residing in a nursing facility or intermediate care facility for the mentally
retarded (ICF-MR);
e. Alaskan
Natives or Native Americans who are members of federally recognized tribes and
who have requested to be excluded from program participation; and
f. Members receiving Home and Community
Benefits.
1.07-3
Exemptions from Participation
Certain MaineCare members may request an exemption from
participation in Primary Care Case Management on the basis of individual
conditions. Exemptions may also occur when the Office of MaineCare Services
determines enrollment is not in the best interest of the State. The Office of
MaineCare Services will retain final responsibility for all exemption
decisions. Conditions supporting an exemption are listed below. A member is
eligible to request an exemption if she/he:
a.
Administrative Exemptions
i. has to travel more than thirty (30)
minutes to a participating PCP (if not in an established relationship with a
participating PCP);
ii. is
homeless;
iii. is a migrant or a
family member accompanying a migrant;
iv. has specific language barriers or
cultural needs that may not be addressed by an available PCP. Culturally
appropriate care is care that is provided with sensitivity, understanding and
respect for the member's culture. Each of these cases will be reviewed by the
OMS for cultural sensitivity/medical necessity for exemption;
v. is required to follow member restriction
provisions;
vi. is residing out of
state;
vii. does not have an
updated address;
viii. is residing
in a jail or State or private mental institution; or ix. is an inpatient of a
hospital on the date of enrollment. Such individuals will have an automatic
enrollment after the hospital discharge.
b.
Clinical Exemptions
i. has a terminal illness and has an
established relationship with a qualified health care provider who is not a
qualified MaineCare Primary Care Case Management PCP. Each of these cases will
be reviewed by the MaineCare Medical Director for medical necessity for
exemption;
ii. has a chronic and
debilitating condition which requires managed services from a qualified primary
care health provider who is not a MaineCare Primary Care Case Management PCP.
Each of these cases will be reviewed by the MaineCare Medical Director for
medical necessity for exemption; or iii. is receiving hospice care.
MaineCare members identified as exempt, but otherwise
eligible for participation in Primary Care Case Management, may voluntarily
choose to participate in Primary Care Case Management.
1.07-4
Voluntary
Participation
The following members may not be required to participate
in PCCM, but may voluntarily choose to participate in Primary Care Case
Management:
a. Children under age
nineteen (19):
i. with Adoption Assistance;
or
ii. under the age of nineteen
(19) with special health care needs who meet all other eligibility criteria; or
iii. in DHHS foster care; or other
out-of home placement;
iv. under
age nineteen (19) years of age and eligible for SSI who do not otherwise meet
exclusion criteria under Section 1.07-2;
b. Members who are Alaskan native or Native
American or part of a federally recognized tribe;
c. Non-English speaking members who had been
granted exemptions; or
d. Eligible
for Supplemental Security Income (SSI) who do not meet exclusion criteria under
Section 1.07-2.
1.07-5
Enrollment
MaineCare members who must participate in Primary Care
Case Management will be notified by mail within three (3) business days of the
date they appear in MECAPS.
Opportunities for face-to-face sessions to enroll in the
benefit will be provided on the basis of, among other things, the following:
(1) a specific request by a
member;
(2) a determination by
MaineCare Member Services that there is a significant probability that the
member will not complete and return the enrollment application and make an
informed choice without face-to-face intervention; or
(3) a meeting arranged by MaineCare Member
Services, in conjunction with, and at the request of a member, advocacy group
or community service agency. Upon request, MaineCare Member Services will
provide interpreter services for face-to-face sessions for members who are
non-English and limited English speaking and/or deaf/hard of hearing, provided
the request is received by MaineCare Member Services in advance of the session.
The member will have twenty-eight (28) calendar days to complete the enrollment
process. Prior to the end of the twenty-eight (28) calendar days, the member
must complete and return the provider choice form by mail or call MaineCare
Member Services to enroll by phone. The member must also, as a part of the
enrollment process, provide the names of three providers (in order of
preference) as choices for a PCP. In the event a member does not elect a
provider, a Primary Care Case Management PCP will be selected for the
member.
1.07-6
Selection of a Primary Care Provider (PCP) and/or a PCP Site
In order to assist members in selecting a PCP, MaineCare
Member Services will have available a list of participating PCPs within thirty
(30) minutes travel time of the member's town of residence. The member may
choose to enroll with a PCP who is further than a travel distance of thirty
(30) minutes. Members may request a PCP not on the list or not currently
enrolled as a PCP. If the member has requested a PCP who does not want to
enroll in Primary Care Case Management, the member must select another Primary
Care Case Management PCP.
In cases where a PCP has more than one PCP site, the
member must choose one PCP site where the member will get PCCM services. If the
member does not choose, the Department will choose for the member. A member can
receive PCCM services at only one PCP site.
1.07-7
Assignment
When a member is unable or unwilling to select a
MaineCare Primary Care Case Management PCP within twenty-eight (28) calendar
days of the date in which the enrollment packet was mailed, the member will be
assigned to a PCP who has an opening on his/her PCP panel. Members will be
assigned to a PCP based on age and gender-appropriateness and in accordance
with the travel time standard established in Section 1.07-3. To the extent
possible, members will be assigned in consideration of the following:
(a) members (including members within family
units) will be assigned to their existing participating PCPs; (b) family units
will be assigned to the same participating PCP or to a PCP the enrolled member
has selected, if that PCP is appropriate based on age and gender
parameters.
1.07 -8
Effective Date of Primary Care Case Management Enrollment and PCP
Selection
Enrollment in Primary Care Case Management will be
prospective only. The PCP selection or assignment is effective on the
1stor 15th of the month
following the date the assignment is entered into MECAPS.
1.07 -9
Member Initiated PCP Change or
PCP Site Change Emergency Change
Members enrolled in Primary Care Case Management
may change their PCP or PCP site within ninety (90) calendar days
of a PCP selection without cause and at any time for good cause. Good cause
means a documented situation where there is an inability, after making a
reasonable effort, to establish or maintain a satisfactory member/PCP
relationship.
a.
Member
Initiated PCP Change: Members enrolled in Primary Care Case Management
must contact MaineCare Member Services if they want to change from their
current PCP to a different PCP or a different PCP site.
If approved, selection of a different PCP will take place
on the first day of the following month or five (5) calendar days from the date
of the request for the PCP change, whichever comes later or as determined by
the OMS The OMS notifies PCP sites of changes with Enroll/Disenroll patient
panel reports. These reports are sent to the PCP sites on a monthly
basis.
Members are notified through a letter by MaineCare Member
Services with the PCP site change information.
b. Emergency reassignments will be made
within five (5) business days. Emergency means a situation where an expedited
change in the PCP is necessary to prevent serious and irreparable harm to the
member, PCP and/or staff. If the emergency reassignment cannot be implemented
within the five (5) day time frame, MaineCare Member Services must provide the
member with written notification that s/he may see any participating MaineCare
provider for the provision of all Managed Primary Care Case Management Services
until the reassignment process is completed.
1.07-10
Department Initiated PCP
Reassignment
In addition to member or PCP requests, the OMS will
disenroll a member from a PCP or a PCP site for the following reasons:
a. the contract with the PCP is
terminated;
b. a PCP dies, retires,
closes his/her practice or leaves the area;
c. the member loses MaineCare
eligibility;
d. the member moves to
an area where Primary Care Case Management is not operational;
e. the member's eligibility changes to a
category of assistance that is excluded from participation;
f. the member's status changes such that he
or she meets the criteria for exclusion in Section 1.07; or
g. other situations as determined appropriate
by the OMS.
h. Emergency
reassignments will be made within five (5) business days. Emergency means a
situation where an expedited reassignment in the PCP is necessary to prevent
serious and irreparable harm to the member, PCP and/or staff. If the emergency
reassignments cannot be implemented within the five (5) day time frame,
MaineCare Member Services must provide the member with written notification
that s/he may see any participating MaineCare provider for the provision of all
Managed Primary Care Case Management Services until the reassignment process is
completed.
1.07-11
Re-Enrollment Provisions
A member enrolled in Primary Care Case Management whose
MaineCare eligibility ends and who is again determined eligible for MaineCare
within sixty (60) calendar days of the termination date will be assigned to
his/her last PCP. Members who have been ineligible for MaineCare for more than
sixty (60) calendar days and are subsequently determined to be eligible for
MaineCare will be contacted, as set forth in Section 1.07, to select a
PCP.
When a PCP or a PCP site has been, or will be, closed
(because of termination of contract or if a PCP dies, retires, closes his/her
practice or leaves the area, or is otherwise unable or unwilling to continue
the PCP practice), the Department will immediately notify the PCP's members, in
writing, of the closing. OMS must complete the reassignment process within
sixty (60) calendar days from the date of the written notice.
1.07-12
Member Restriction
Provisions
A member enrolled in Primary Care Case Management may be
required to follow member restriction provisions in order to receive care (as
defined in the MaineCare Benefits Manual, Chapter IV) if a pattern of abuse or
non-compliance is identified. Members who are required to follow restriction
provisions will be disenrolled from Primary Care Case
Management.
