C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-93, subsec. 144-101-II-93.08

Current through 2025-02, January 8, 2025

Subsection 144-101-II-93.08 - REIMBURSEMENT

OHHs are reimbursed a Per Member Per Month (PMPM) payment for each OHH member, based on the member's level of care at the end of the billing month. The PMPM payment amount for each level of care is based on the expected use of OHH covered services.

93.08-1Minimum Requirements for OHH Reimbursement

In order for the OHH to be eligible for the PMPM payments for each billing month, the OHH shall:

A. Provide the covered services described in and in accordance with 93.05, Covered Services;

B. Submit cost and utilization reports upon request by the Department, in a format determined by the Department;

C. Scan panel data, as identified by the Department, for its assigned population;

D. Attest to meeting the following requirements:

1. Members in the IOP, Induction, Maintenance, and Stabilization Levels of Care must be enrolled for a minimum of fifteen (15) days in a service month for the OHH to attest for each member.

2. Members in the Medication Plus or Methadone Levels of Care must be enrolled for a minimum of one (1) day in a service month for the OHH to attest for each member.

E. Document each service provided to each member, for each billing month, as required by these rules, in order to be eligible to receive the PMPM reimbursement.

F. For members in the Methadone Level of Care, have them sign a release of information allowing coordination of care between the OTP and the OHH.

93.08-2Reimbursement for Additional Provider Support

OHH members who have additional community support needs related to mental health, HIV, medical concerns and/or utilization, and/or homelessness, may receive Health Home Services, as described in 93.05-1, from providers in MBM Section 13, Targeted Case Management Services (excluding 13.03-4(B)); Section 17.04-1 and 17.04-2, Community Support Services; and Section 92, Behavioral Health Home Services. In these cases, the OHH will receive an increased PMPM payment based on the member's level of care that includes a $394.40 pass-through payment which the OHH must give to the additional support provider. Additional provider support provided to eligible members shall be approved by the Department or its authorized entity, requires the member to sign an authorization to release confidential information between the OHH and the additional support provider, and requires a contractual agreement between the OHH and additional support provider.

93.08-3Pay-for-Performance

Four (4) percent of total OHH PMPM payments is withheld from regular payments and reimbursed based on performance on three performance measures. Thresholds for minimum and excellent performance determine reimbursement amount and are based on a composite score of the performance measures and will be set so that no less than 70% of eligible OHHs are expected to be above the minimum performance threshold and no less than 20% of OHHs are expected to be above the excellent performance threshold. OHHs who meet the minimum performance threshold receive the full four (4) percent back. The four (4) percent withholds that are not distributed to OHHs due to the OHHs' failure to meet the minimum performance threshold will be distributed to the OHHs that meet the excellent performance threshold. Every six (6) months, OHHs will receive a report indicating whether they qualified for the four (4) percent withhold and the excellent performance threshold redistribution. For more information, see MBM, Chapter III, Opioid Health Homes.

93.08-4Duplicative Services Will Not Be Reimbursed

The Department will not reimburse OHH providers for a member receiving Section 93 services if the member receives:

A. Services through Section 13, Targeted Case Management Services, for adults with substance use disorder.

B. Services through Section 13, Targeted Case Management Services; Section 17, Community Support Services; or Section 92, Behavioral Health Homes, unless the Section 13, 17, or 92 provider has a contract with the OHH to provide Health Home Services, as described in 93.05-1.

C. Opioid dependency counseling provided through MBM, Section 65, Behavioral Health Services, unless the member is in the Medication Plus Level of Care.

D. MAT with Methadone provided through MBM, Section 65, Behavioral Health Services, unless the member is in the Methadone Level of Care.

E. Medication management for opioid dependency treatment through MBM, Section 65, Behavioral Health Services.

NOTE: Mental health counseling and medication management not related to opioid dependency treatment through Section 65, Behavioral Health Services, are not considered duplicative services.

F. Urine drug screening from the same service location under which a member is receiving OHH services.

G.Section 97, Private Non-Medical Institution Services, Appendix B.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-93, subsec. 144-101-II-93.08