10-144-101 Me. Code R. § III-93
Per Member Per Month (PMPM) rate | PMPM Rate with 4% Withheld | |
Intensive Outpatient Services (IOP) Level of Care | ||
with no additional provider support (T2022) | $2,327.32 | $2,234.23 |
with additional Section 13, 17, or 92 provider support ((T1012), there is a $394.40 pass-through payment to the additional provider1 | $2,474.33 | $2,381.24 |
Induction and Stabilization Levels of Care | ||
with no additional provider support (T2022)) | $1,096.63 | $1,052.77 |
with additional Section 13, 17, or 92 provider support (T1012), there is a $394.40 pass-through payment to the additional provider2 | $1,243.64 | $1,199.78 |
Maintenance Level of Care | ||
with no additional provider support (T2022) | $695.41 | $667.60 |
with additional Section 13, 17, or 92 provider support (T1012), there is a $394.40 pass-through payment to the additional provider3 | $842.42 | $814.61 |
Medication Plus Level of Care | ||
with no additional provider support (T1041) | $670.36 | $643.78 |
with additional Section 13, 17, or 92 provider support (T1041 HH), there is a $394.40 pass-through payment to the additional provider4 | $817.61 | $790.79 |
Methadone Health Home Level of Care | ||
with no additional provider support (T2022 HF) | $413.88 | $397.32 |
Four (4) percent of total OHH PMPM payments is withheld from regular payments and reimbursed every six (6) months, based on a twelve-(12) month assessment period of performance on the below three performance measures. After the twelve-(12) month assessment period and a three-(3) month claims runout period, all OHHs, regardless of performance, will receive a quarterly report with the performance assessment, indicating whether they qualify for receipt of the 4% withheld amount or the withheld amount and an additional amount, based on whether OHHs satisfy the minimum or excellent performance thresholds. The report will contain instructions for the OHH to rebut the report's data if the OHH disagrees with the report and the reimbursement they are set to receive. The Department will provide a thirty-(30) day rebuttal period prior to issuing reimbursement.
If the performance measures change via rulemaking, providers will not be scored on a new or adjusted performance measure until six (6) months after the change is implemented.
OHHs are eligible for the pay-for-performance provision if at least ten percent (10%) of their member panel is clinically eligible for inclusion in the performance measures. If the OHH does not have the minimum number of required members, it will automatically receive the four (4) percent withhold.
Denominator: MaineCare members assigned to the OHH panel for a minimum of 60 days in the measurement period who are in the Maintenance and Stabilization Levels of Care.
Numerator: MaineCare members in the denominator who have at least 180 days of continuous pharmacotherapy with a medication prescribed for OUD without a gap of more than seven (7) days, based on the measure 'Continuity of Pharmacotherapy for Opioid Use Disorder,' as stewarded by the University of Southern California.
Medications: Medications included in this measure are Buprenorphine, Naltrexone, Buprenorphine-Naloxone, and Methadone.
Denominator: MaineCare members assigned to the OHH panel for a minimum of 60 days in the measurement period who are in the Maintenance and Stabilization Levels of Care.
Numerator: MaineCare members who meet all denominator criteria and on their most recent assessment by the Department's designated contractor, gave a response other than "Not currently employed."
Other responses include, but are not limited to, competitively employed, self-employed, student, and parent of a child under age 18.
Denominator: MaineCare members assigned to the OHH panel for a minimum of 60 days in the measurement period who are in the Maintenance and Stabilization Levels of Care.
Numerator: MaineCare members who meet the denominator criteria and who had an ambulatory or preventive care visit during the 12 months being assessed.
The current thresholds for the OHH pay-for-performance will be listed on: http://www.maine.gov/dhhs/oms/vbp.
The minimum and excellent performance thresholds will be composite scores of all three performance measures, above. Performance thresholds are set in advance of performance periods. If the performance threshold(s) change, providers will not be scored on an adjusted threshold until six (6) months after the change is implemented. Based upon the available data at the time of the performance thresholds calculations, the Department shall set the thresholds 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. To clarify, the Department expects no more than 30% of OHHs to be below the minimum performance threshold. The Department cannot anticipate the exact percent of OHHs that will, during the performance period, satisfy either or neither of the performance thresholds.
OHHs that meet the minimum performance threshold will receive the full four (4) percent of the PMPM payments that was withheld. The four (4) percent withholds that are not distributed to OHHs that fail to meet the minimum performance threshold will be distributed to the OHHs that meet the excellent performance threshold, based on each OHH's proportion of the total number of attributed members who meet all three performance measure numerator criteria and are attributed to OHHs that meet the excellent performance threshold. Hence, the amount of funds available to distribute to OHHs that meet the excellent performance threshold depends on the number of OHHs that fail to meet the minimum performance threshold. If all OHHs meet the minimum performance threshold then there will be no funds to distribute to OHHs that meet the excellent performance threshold.
1 For Section 13, Opioid Health Home (OHH) providers will use the following codes with modifiers for their authorization: T1017 HG-TCM HIV, T1017 U5 HG-TCM Homeless, T1017 UC HG-TCM Children. For Section 92, OHH providers will use the following codes with modifiers for their authorization: T2022 HA HG-BHH Children, T2022 HB HG-BHH Adult. For Section 17, OHH providers will use the following codes with modifiers for their authorization: H2015 HG-Community Integration.
2 See footnote 1
3 See footnote 1
4 See footnote 1
10-144 C.M.R. ch. 101, § III-93
3/16/2019 - filing 2019-052
8/21/2022 - filing 2022- 147