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 VI
Section 144-101-VI-03 - Primary Care Plus
Subsection 144-101-VI-0304 - COVERED SERVICES
Current through 2024-38, September 18, 2024
The Department reimburses PCPlus PCPs for locating, coordinating, and monitoring health care services to provide Members with high-quality and cost-effective care.
This includes locating MaineCare providers who can provide timely access to patient centered, culturally and linguistically appropriate, medically necessary MaineCare covered services. This also includes supporting whole-person coordination and transitions of care; completing timely prior authorizations; providing referrals and clinician orders; tracking and following up on referrals; and closing care gaps.
PCPs shall document all covered services provided to Members in their EHR. PCPs shall:
A. Care Plans. Partner with Members and other care team members to create care plans that support members' needs. Use shared-decision aids and consider Members' health literacy levels in assessment and care planning. Include both clinician and patient action plans in the care plan as clinically appropriate;
B. Care Coordination. Engage in coordination with any external care coordinator, case manager, discharge planners, or care team of the Member, as determined appropriate by the needs of the Member, in accordance with all applicable state and federal privacy laws and best practices to support the Member's care goals. This may include but is not limited to coordinating covered services with providers of: Section 13, Targeted Case Management; Section 17, Community Support Services; Section 91, Health Home Services Community Care Teams; Section 92, Behavioral Health Homes; and Section 93, Opioid Health Homes. When coordinating and partnering with other providers, PCPs shall not duplicate efforts;
C. Assessments. Connect Members to clinically appropriate assessments including, but not limited to, Medical Eligibility Determination (MED) assessments for long-term care needs;
D. Care Transition Services. Provide care transition services between healthcare providers and settings to ensure continuity of care and reduce emergency department (ED) use, morbidity, mortality, inpatient admissions, readmissions, and lengths of stay.
Pediatric-to-adult health care transition services shall include but are not limited to the following:
E. Screenings. Ensure the provision of the following screenings, deliver screening-related services, and develop follow-up plans based on results:
F. EPSDT. Afford children enrolled in MaineCare and CHIP Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefits through written member acknowledgement of MBM, Chapter II, Section 94. States must provide all medically necessary section 1905(a) services coverable under the Medicaid program to eligible children and youth under age twenty-one (21) in order to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Maine Medicaid State Plan. PCPlus providers shall apply this understanding of EPSDT rights and demonstrate an ability to appropriately request prior authorizations for EPSDT services;
G. Oral Health
H. Immunizations. Offer all appropriate immunizations to each Member in accordance with the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices immunization schedule;
I. United States Preventive Services Task Force (USPSTF) Recommendations. Provide or provide referrals for all USPSTF recommendations with a Grade of A or B, as outlined on https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations; and
J. Advanced Care Planning and Palliative Care. Offer or refer Members who may benefit to advanced care planning and palliative care consultation.