C.M.R. 10, 144, ch. 101, ch. VI, 144-101-VI-03, subsec. 144-101-VI-0303

Current through 2024-46, November 13, 2024

Subsection 144-101-VI-0303 - PROVIDER REQUIREMENTS

Each PCP shall:

A. Be approved by the Department through the PCPlus application process. The application process will open, at a minimum, annually, and providers must receive initial approval and subsequently recertify annually;

B. Be a provider or provider group (i.e. solo or group practice) that delivers primary care services, limited to the following:

1. A physician (including residents), nurse practitioner, certified nurse midwife, or physician assistant with a primary specialty designation of pediatrics, general practice, family practice/medicine, geriatrics, internal medicine, obstetrics, gynecology, or other specialties approved by the Department, where Primary Care Services account for fifty percent (50%) of the service location's collective billing;

2. A rural health clinic (as defined in MBM, Section 103);

3. A federally qualified health center (as defined in MBM, Section 31); or

4. A tribal health clinic (as defined in MBM, Section 9); and

C. Meet Tier One requirements (3.03-1). PCPs who meet Tier Two (3.03-2) or Tier Three (3.03-3) requirements are eligible for enhanced reimbursement.

3.03-1Tier One PCP Requirements

A. The PCP shall ensure twenty-four (24) hour availability of information for triage and referral to treatment for medical emergencies. This requirement may be fulfilled through an after-hours telephone number that connects the patient to:

1. The PCP or an authorized licensed medical practitioner providing coverage for the PCP;

2. A live voice call center system or answering service which directs the patient to the appropriate care site or connects the patient to the PCP/authorized covering medical practitioner; or 3. A hospital if the PCP has standing orders with the hospital to direct patients to the appropriate care site within the hospital.

The following are examples of what does not constitute adequate coverage:

A twenty-four (24) hour telephone number answered only by an answering machine without provision for arranging for interaction with the PCP or their covering provider; Referring to hospital Emergency Departments (EDs) that do not offer phone triage or assistance in reaching the PCP or their covering provider; or Emergency medical technicians who do not offer phone triage or assistance in reaching the PCP.

The PCP shall inform members of their normal office hours and explain to members the procedures that should be followed when seeking care outside of office hours. The PCP shall update its twenty-four (24)-hour availability information with the Department. The PCP 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 electronic health record during hours they are covering.

B. Annually, at least one representative from each PCP shall participate in designated Department-sponsored quality improvement initiatives and technical assistance activities. The Department will not require more than eight hours of PCP participation annually. The PCP's representative shall be involved in clinical care, population health, and/or quality improvement.

C. The PCP shall adopt and maintain, at a minimum, a CEHRT.

D. The PCP shall, annually with the PCPlus application/recertification, submit a completed assessment of the PCP's 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 will provide the assessment tool.

E. The PCP shall, as appropriate and at a minimum of once biennially, educate Members about the appropriate use of office visits, urgent care clinics, and the ED. PCPs may provide this education through methods including, but not limited to, pamphlets, signage, direct discussion, or Member letters.

3.03-2Tier Two PCP Requirements

Tier Two PCPs shall meet all Tier One (3.03-1) requirements and shall:

A. Hold active Patient-Centered Medical Home recognition from the National Committee for Quality Assurance, the Joint Commission, the Accreditation Association for Ambulatory Health Care, or another accreditation body as approved by the Department, OR be approved by the Centers for Medicare and Medicaid Innovation as a Primary Care First practice and participate in the Primary Care First alternative payment model;

B. Maintain a Participant Agreement for data sharing with Maine's statewide state-designated Health Information Exchange (HIE). The minimum clinical data set the practice shares must include: all patient demographic, encounter, and visit information (including diagnosis and procedure coding) and must be shared via a Health Level Seven (HL7) Admission, Discharge & Transfer (ADT) interface. Tribal health clinics may connect to the HIE as view-only participants;

C. Conduct a standard, routine assessment or screening to identify health-related social needs of Members and use the results to make necessary referrals. Assessment for health-related social needs involves using screening tools or questions that identify community and social service needs among Members;

D. Have a current documented relationship (e.g. Memorandum of Understanding or practice agreement) with at least one Behavioral Health Home Organization (as defined in MBM, Ch. II, Section 92) in the PCP's service area that describes procedures and protocols for regular communication and collaboration between the PCP and the Behavioral Health Home Organization to effectively serve shared members.

This must include the designation of the role(s) responsible for this coordination and the method for contacting the specific role(s). 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;

E. Maintain processes and procedures to initiate and coordinate care with a Community Care Team (CCT) as defined in MBM, Ch. II, Section 91, in the PCP service area, for Members who are high-risk and/or high-cost whose needs cannot be managed solely by the PCP and are eligible for Section 91 covered services;

F. Offer MAT services in alignment with American Society for Addiction Medicine guidelines for appropriate level of care, have a cooperative referral process with specialty behavioral health providers including a mechanism for co-management for the provision of MAT as needed, or be co-located with a MAT provider;

G. Offer telehealth as an alternative to traditional office visits in accordance with MBM, Ch. I, Sec. 4, Telehealth Services, and/or for non-office visit supports and outreach to increase access to the care team and clinicians in a way that best meets the needs of Members;

H. Include MaineCare members and/or their families in advisory activities to identify needs and solutions for practice improvement. Advisory activities may include, but are not limited to, having MaineCare members on an advisory board and/or holding focus groups with members. Solely collecting survey data, e.g., patient experience data, without inclusion of members/families in synchronous engagement activities to identify needs and solutions is insufficient;

I. Submit to the Department an environmental scan of which populations served by the PCP could benefit from CHW engagement. This scan shall include basic demographic information of the practice to identify population groups that may benefit from CHW services and the identification and description of any CHW services currently offered through the provider's practice or through partnerships with community-based organizations; and

J. Beginning April 1, 2024, ensure the provision of community-based CHW services that are aligned with best practices for the identified population(s) of Members at the practice through contracting with a community-based organization (preferred) or employing a CHW through the health system (e.g. the PCP, contracting CCT, and/or associated AC).

K.

3.03-3Tier Three PCP Requirements

Tier Three PCPs shall meet all Tier One (3.03-1) and Tier Two (3.03-2) requirements, unless otherwise noted, and shall:

A. Be included in the list of AC primary care sites for attribution purposes in the AC program;

B. Submit an aligned Joint Care Management and Population Health Strategy (Strategy) to the Department on or before July 31^st of every year. The Strategy shall include a high-level description of the process used to ensure that care is coordinated, efficient, and based on patient goals and needs. The Strategy includes:

1. An overview of how information is obtained from various data sources to risk stratify, identify, and target specific populations that may benefit from specified interventions. The summary shall include how health disparities and health related social needs will be assessed and addressed and how the participant providers ensure consistent collection and use of demographic information such as, but not limited to, race, ethnicity, and language data;

2. A discussion of the processes the practice uses to communicate internally and amongst external partners about changes in a member's medical, emotional and social status, risks, or needs, as they evolve;

3. An overview of current population health, wellness, or disease management initiatives deployed by the PCP, CCT (if applicable), AC, and their community-based partners (e.g. community-based organizations); and

4. An outline of the strategies (including PCPlus and CCT payments and AC shared savings payments, when applicable) the entities believe are necessary to support the Strategy, including how these resources support collaborations with community-based partners and the use of health information technology, including HIE and electronic health records; and

C. Maintain a Participant Agreement for data sharing with Maine's statewide, state-designated HIE for the purpose of submitting the required data elements to allow the HIE to produce specified clinical quality measures within PCPlus. This may include, but is not limited to, sharing data related to all patient demographic, encounter, and visit information (including diagnosis and procedure coding), vital signs, and laboratory test results and coding via HL7 ADT and/or Observation Result (ORU) interfaces. This requirement satisfies the requirements of 3.03-2(B).

C.M.R. 10, 144, ch. 101, ch. VI, 144-101-VI-03, subsec. 144-101-VI-0303