C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-89, subsec. 144-101-II-89.06

Current through 2024-44, October 30, 2024

Subsection 144-101-II-89.06 - PROVIDER REQUIREMENTS

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.

89.06-1Requirements 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.

89.06-2MaineMOM 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).

89.06-3Additional 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.

89.06-4Additional 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.

89.06-5Additional 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.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-89, subsec. 144-101-II-89.06