Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-19 - Patient-Centered Medical Homes
Section 5160-19-03 - Comprehensive maternal care program
Universal Citation: OH Admin Code 5160-19-03
Current through all regulations passed and filed through September 16, 2024
The "comprehensive maternal care (CMC) program" is a maternal and infant support program that utilizes a comprehensive care coordination and service model incorporating supportive services for expectant and postpartum medicaid eligible individuals to reduce adverse birth and infant outcomes.
(A) For purposes of Chapter 5160-19 of the Administrative Code, the following definitions apply:
(1)
"Attribution" is
the process through which the Ohio department of medicaid (ODM) or its designee
assigns eligible individuals to a specific CMC entity.
(2)
"CMC attributed
medicaid individuals" are the eligible pregnant and postpartum Ohio medicaid
recipients for whom an entity eligible under this rule has accountability for
coordinating and ensuring the delivery of CMC program activities. All eligible
individuals will be attributed except for:
(a)
Individuals who
are currently receiving another care coordination service that substantially
duplicates those activities provided under this program.
(b)
Individuals with
a limited medicaid benefit plan other than presumptive eligibility for pregnant
individuals.
(c)
Individuals dually enrolled in Ohio medicaid and
medicare.
(d)
Individuals with third party benefits as defined in
rule 5160-1-08 of the Administrative
Code except for those with exclusively dental or vision
coverage.
(3)
"Comprehensive maternal care entity" (CMC entity) is
the primary entity which meets the criteria described in this rule and is
responsible for meeting CMC program activities for attributed medicaid
individuals. The following medicaid providers are eligible to participate and
receive payment under this rule:
(a)
Professional medical groups as defined in Chapter
5160-1 of the Administrative Code.
(b)
Federally
qualified health centers (FQHC) and rural health clinics (RHC) as defined in
Chapter 5160-28 of the Administrative Code.
(c)
Clinics as
defined in Chapter 5160-13 of the Administrative Code.
(d)
Professional
medical groups billing under hospital provider types.
(4)
"Electronic pregnancy risk assessment form" (e-PRAF) is the
electronic version of ODM form 10207 "pregnancy risk assessment form" (PRAF)
that is submitted through the web portal designated by ODM.
(5)
"Electronic
report of pregnancy" (e-ROP) is the electronic version of ODM form 10257,
"report of pregnancy" (ROP) that is submitted through the web portal designated
by ODM.
(6)
"Eligible provider" is as defined in rule
5160-1-17 of the Administrative
Code.
(B) To be eligible and remain eligible for enrollment and participation as a CMC entity for payment in each program year, the CMC entity will:
(1)
Have
an active Ohio medicaid provider agreement in accordance with rule
5160-1-17.2 of the
Administrative Code;
(2)
Have provided prenatal and perinatal services to at
least one hundred fifty pregnant and postpartum individuals under the same tax
identification number, as identified through ODM data sources;
and
(3)
Apply to become a CMC entity. ODM reserves the right to
deny any enrollment application it determines is not in compliance with the
activities in this rule. An applicant may seek reconsideration pursuant to rule
5160-70-02 of the Administrative
Code if ODM has denied a CMC program enrollment
application.
(C) At the time of enrollment, the applicant attests that for the duration of its participation, it will do all of the following:
(1)
Perform the
activities identified in this rule.
(2)
Have at least one
practitioner from each of the following categories on staff or contracted with
the entity:
(a)
A practitioner with prescribing authority in the state of
Ohio;
(b)
A registered nurse (RN) or licensed practical nurse
(LPN); and
(c)
A case manager to lead the care coordination
relationship and serve as the primary point of contact for the attributed
medicaid individual.
(3)
Demonstrate
organizational commitment to integration of physical and behavioral health care
by meeting one of the following:
(a)
Employ or have under contract one or more licensed
behavioral health care clinicians;
(b)
Have an
integrated care agreement such as a contract or memorandum of understanding
with a behavioral health care entity;
(c)
Have an ownership
or membership interest in a provider organization where primary and behavioral
health care services are integrated within the facility structure or entity,
and are readily available to attributed medicaid individuals;
or
(d)
Have accreditation by a national accrediting entity as
an integrated primary care-behavioral health provider.
(4)
Integrate services of community resources and other
practitioners including nonphysician licensed or certified behavioral health
practitioners described in rule
5160-8-05 of the Administrative
Code.
(5)
Conduct the following cultural competency activities to
advance health equity:
(a)
Ensure all clinical and professional staff who provide
direct care to or interact with patients complete cultural competency training,
meeting criteria established by ODM within six months of program enrollment and
annually thereafter and for new employees within thirty calendar days of start
date; and
(b)
At least annually, assess the demographics of patients
served, including race, ethnicity, and language, and adapt training needs for
staff based on the results of the assessment.
(6)
In the delivery
of the CMC program activities, ensure appropriate measures are taken to protect
the safety and confidentiality of attributed medicaid individuals in accordance
with all state and federal regulations.
(7)
Establish or
adapt a patient and family advisory council to include members who reflect the
demographics of the attributed medicaid individuals served.
(8)
Participate in
learning activities as determined by ODM or its designee and share data with
ODM and contracted managed care organizations (MCOs).
(9)
Review quarterly
and annual reports as specified by ODM.
(10)
Actively use an
electronic health record (EHR) in clinical services.
(11)
Have the ability
to share, receive, and use electronic data from a variety of sources with other
health care providers, ODM, and the MCOs.
(12)
Have the ability
to submit prescriptions electronically.
(13)
Ensure than an
e-PRAF is submitted for every pregnant individual.
(D) Attribution.
(1)
The following hierarchy will be used in attributing
individuals to a CMC entity:
(a)
The eligible individual's choice of provider identified
through the completion of the PRAF or e-PRAF.
(b)
Pregnancy or
postpartum related claims data concerning the eligible
individual.
(c)
Primary care provider relationship.
(d)
Other data
concerning the eligible individual such as geographic location.
(2)
All
pregnant and postpartum medicaid individuals will be assigned to either of the
following risk tiers:
(a)
Pregnant or postpartum individuals who:
(i)
Are determined to
be progesterone eligible as evidenced on the PRAF;
(ii)
Are at risk of
pre-term birth based on having had a prior pre-term birth or a shortened cervix
as evidenced by vital statistics data or claims history;
(iii)
Live in an area
determined to have the least access to critical services according to the most
recent Ohio opportunity index (OOI); or
(iv)
Are considered
medically complex as evidenced by claim history indicating substance use
disorder, asthma, diabetes, lupus, chronic kidney disease, advanced maternal
age (individuals over forty years of age), or cardiovascular
disease.
(b)
Pregnant or postpartum individuals up to three months
postpartum who do not qualify under the previous tier.
(3)
At any
time, the eligible individual may choose a specific CMC entity or request to be
re-attributed to a different CMC entity by submitting a request to the MCO, ODM
or its designee.
(4)
Eligible individuals may opt-out of the CMC program and
may opt-in at any time by making a request to the MCO, ODM, or its
designee.
(E) It is the responsibility of the CMC entity, upon enrollment and on an annual basis, to attest that it will meet the following provisions:
(1)
Risk stratification. It is the responsibility of the CMC
entity to:
(a)
Use risk stratification information from multiple sources
(including payers, e-PRAF, screenings tools, electronic health records, and
patient history) to risk stratify patients and integrate this information into
clinical records and care plans; and
(b)
Perform maternal
depression screens and use screening tools such as social determinants of
health, screenings, brief intervention, and referral to treatment (SBIRT) at
routine intervals to identify patients in need of, and connect them to,
community services and supports.
(2)
Enhanced access.
It is the responsibility of the CMC entity to:
(a)
Expedite the
first prenatal visit by:
(i)
Offering appointments within seven calendar days of the
patient's initial request; and
(ii)
Establishing a
process to reduce the gestational age at the first prenatal appointment with
the overall goal of achieving the first appointment by the ninth week of
gestation.
(b)
Offer at least one alternative to traditional office
visits to increase access to the patient care team and clinicians in ways that
best meet the needs of the population. This may include e-visits, telehealth,
phone visits, group visits, home visits, alternate location visits, or expanded
hours in the early mornings, evenings, or weekends;
(c)
Within one
business day of initial request, provide access to a maternal care provider
with access to the patient's medical record; and
(d)
Make patient
clinical information available through paper or electronic records, or
telephone consultation to on-call staff, external facilities, and other
clinicians outside the entity when the office is closed.
(3)
Patient engagement. It is the responsibility of the CMC
entity to:
(a)
Implement strategies to engage patients early in their care
and encourage them to be active participants in their care
delivery;
(b)
Implement specialized outreach strategies for pregnant
individuals who are attributed to, but have not been seen by, the
CMC;
(c)
Deliver services in a manner that addresses the social,
cultural, and linguistic needs of patients with specific attention to
populations with high rates of infant and maternal mortality;
(d)
Implement
procedures that acknowledge patient consent and choice regarding referrals for
needed treatment, community, and other supports;
(e)
Assure patient
consents are obtained to support exchange of information in compliance with
state and federal regulations; and
(f)
Establish
partnerships with primary care practitioners and payers in order to strengthen
the referral process of the CMC entity.
(4)
Team based care
delivery. It is the responsibility of the CMC entity to:
(a)
Define care team
members, roles, and qualifications with specific input from the patient
regarding team composition (e.g., obstetricians, primary care, behavioral
health, pediatricians, doulas, midwives, community workers, care managers,
payers and community partners, as applicable);
(b)
Establish care
team meetings and planned, formal communication (including sharing of care plan
documentation) among team members for highest risk patients;
(c)
Have a process
during the individual's prenatal period to assemble a team of providers who
will care for the individual and baby during the postpartum
period;
(d)
Have active relationships with providers and community
resources based on patient population needs; and
(e)
Provide various
care management strategies in partnership with payers, ODM and other providers,
as applicable.
(5)
Care management plan. It is the responsibility of the
CMC entity to:
(a)
Create, maintain, and update care plans and clinical
documentation such as progress notes for the highest risk pregnant individuals
which includes necessary key elements including integrated behavioral health
elements, as applicable; and
(b)
Identify key
activities that need action or follow up by care team members.
(6)
Patient experience. It is the responsibility of the CMC
entity to:
(a)
Have a process to ensure continuity in relationships and
care throughout the entire care process including:
(i)
A plan to
transition patients to appropriate providers and resources as they move through
the care continuum; and
(ii)
A process to complete a transfer of care (in person or
by telephone) with the CMC entity, the patient and members of the care team,
specifically the individual's primary care practitioner, pediatric primary care
for the baby, behavioral health provider, and community partners as
appropriate.
(b)
Assess its approach to improving the patient experience
at least once annually through quantitative and qualitative means, including
the patient and family advisory council, covering such topics as access to
care, cultural competence, holistic care, and effective
communication;
(c)
Use the collected information to identify and act on
opportunities to improve patient experience and reduce disparities;
and
(d)
Report findings and opportunities for improvement to
patients, patient and family advisory council, payers, and ODM.
(7)
Follow-up after hospital discharge. It is the responsibility
of the CMC entity to:
(a)
Establish relationships with emergency departments
(EDs) and hospitals from which it frequently sends and receives referrals and
has an established process to ensure a reliable flow of
information;
(b)
Proactively and consistently obtain patient discharge
summaries from hospitals and other facilities, and connect information from
discharge summaries to broader entity systems for highest risk tier patients;
and
(c)
Track patients receiving care at hospitals and EDs,
proactively contact patients for appropriate follow-up care given the cause of
admission within an appropriate period following a hospital admission or
emergency department visit.
(8)
Community
integration. It is the responsibility of the CMC entity to:
(a)
Identify local
entities that can help address social and emotional needs of patients and
integrate them into activities described in paragraph (F) of this rule, as
appropriate;
(b)
Participate directly or indirectly in state and local
infant and maternal mortality efforts; and
(c)
Integrate
community services and supports into broader entity systems, including risk
stratification, care management plan, and population health
management.
(9)
Population health management. It is the responsibility
of the CMC entity to:
(a)
Identify individuals in need of medical, behavioral, or
community support services to drive best-evidence care using multifaceted
outreach efforts;
(b)
Track and follow up on referrals to medical, behavioral
health, and community service providers and ensure no gaps in
care;
(c)
Actively review maternal and infant health outcome
measures for the CMC entity, affiliated health system, etc.;
and
(d)
Have a planned strategy to improve maternal and infant
health outcomes segmented by high risk subpopulations, including a planned
strategy to reduce disparities in outcomes.
(F) It is the responsibility of the CMC entity to pass at least fifty percent of the following clinical quality measures, to be evaluated annually at the end of each performance period. Further details regarding these metrics can be found on the ODM website, www.medicaid.ohio.gov.
(1)
Hepatitis B screening.
(2)
Maternal primary
care visit.
(3)
HIV screening.
(4)
TDAP
vaccine.
(5)
Tobacco cessation.
(6)
Postpartum
care.
(G) The CMC entity may qualify to access the following payments:
(1)
The CMC per-member-per-month (PMPM) is a payment to support
the CMC entity. Payment is in the form of a prospective PMPM payment that will
be calculated for each attributed medicaid individual using ODM's risk tier
file to categorize individuals in one of the two risk tiers. Specific
information about this payment can be found on the ODM website,
www.medicaid.ohio.gov.
(2)
The CMC quality add-on payment is made to the CMC
entities who meet quality outcomes. Specific information about this payment can
be found on the ODM website,
www.medicaid.ohio.gov.
(H) Penalties.
(1)
It is the
responsibility of the CMC entity to continue meeting all provisions as defined
in this rule, including those contained in the described attestations. If these
provisions are not met, payment under this rule is subject to
termination.
(2)
It is the responsibility of the CMC entity to continue
meeting clinical quality measures defined in this rule. If any of these
provisions are not met, a warning will be issued. After two consecutive
warnings, payment under this rule will be terminated.
(3)
A CMC entity may
seek reconsideration pursuant to rule
5160-70-02 of the Administrative
Code to challenge decisions by ODM to terminate payment described in this
rule.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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