Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-92 - Behavioral Health Home Services › Subsection 144-101-II-92.05 - COVERED SERVICES

Current through 2024-29, July 17, 2024
BHH services may be delivered face-to-face, via phone or
						other media, in any community location where confidentiality can be maintained.
						Not all aspects of BHH covered services require direct member involvement;
						however, all covered services require that provider activities are directly
						related to an individual member, are member-informed, and pursuant to the
						member's Plan of Care. BHH covered services are services provided by the BHHO
						and HHP as follows.
92.05-1
Comprehensive Care Management
Comprehensive Care Management are services provided to
						assure that members receive timely and coordinated services and supports that
						address physical and behavioral health needs, and promote community and
						home-based recovery.
A.
Comprehensive Care Management Services - BHHO
:
(1)
Comprehensive Assessment
.
					 Within the first thirty (30) days following a member's enrollment for BHH
					 services, the Health Home Coordinator, in consultation with other providers, as
					 necessary, shall provide each member with a face-to-face meeting and a
					 comprehensive assessment that identifies the medical, behavioral, mental
					 health, social, residential, educational, vocational, and other related needs,
					 strengths, and goals of the member (and the family/caretaker if the member is a
					 minor), including utilization of screening tools for co-occurring disorders.
					 The comprehensive review shall include a psychosocial assessment, including
					 history of trauma and abuse, substance use, general health and capabilities,
					 medication needs, member strengths and how they can be optimized to promote
					 goals, available support systems, living situation, employment and/or
					 educational status, and other relevant information. A reassessment must occur
					 as change in the member's needs warrants or at a minimum on an annual basis.
(2)
Plan of Care
.Based on the comprehensive assessment, within the first thirty (30) calendar
					 days following a member's enrollment, the Health Home Coordinator in
					 partnership with the member, shall draft a comprehensive, individualized, and
					 member-driven Plan of Care that shall identify and integrate behavioral and
					 physical health needs and goals. The BHHO shall be responsible for the
					 management, oversight, and implementation of the Plan of Care, including
					 ensuring active member participation and that measurable progress is being made
					 on the goals identified in the Plan of Care.
(a) The Plan of Care must be consented to by
					 the member, as reflected by the member's signature on the Plan of Care,
					 documented in the member's record, and accessible to the member, the BHHO, HHP
					 and other providers, as appropriate.
(b) The BHHO shall obtain written consent for
					 services and authorization for release and sharing of information from each
					 member.
(c) The Plan of Care may
					 include, but not be limited to, information on prevention, wellness, peer
					 supports, health promotion and education, crisis planning, and identifying
					 other social, residential, educational, vocational, and community services and
					 supports that enable a member to achieve physical and behavioral health
					 goals.
(d) The member (or
					 parent/guardian) plays a central and active role in the development and
					 maintenance of the Plan of Care, which shall clearly identify the goals and
					 timeframes for improving the member's health and health care status, and the
					 interventions that will produce this effect.
(e) If authorized by the member, the BHHO
					 shall document in the Plan of Care the member's family, guardian(s), or
					 caregiver support systems and preferences. If authorized by the member, the
					 Plan of Care shall be accessible to the member's family, guardian(s), or other
					 caregivers.
(f) The Plan of Care
					 shall identify member strengths and how these strengths can be optimized to
					 promote goals.
(g) The Plan of Care
					 shall clearly identify providers involved in the member's care, such as the
					 primary care physician/nurse practitioner, specialist(s), behavioral health
					 care provider(s), Health Home Coordinator, and other providers directly
					 involved in the member's care.
(h)
					 All identified clinical services indicated in the Plan of Care must be approved
					 by a medical or mental health professional working within the scope of his/her
					 license.
(i) The Plan of Care must
					 be reviewed and approved in writing by a medical or mental health professional
					 within the first thirty (30) calendar days following acceptance of the Plan by
					 the member, and every ninety (90) calendar days thereafter, or more frequently
					 if indicated in the Plan of Care. The Health Home Coordinator with other care
					 team members, as appropriate, shall review the Plan of Care as changes in the
					 member's needs occur, or at least every ninety (90) days, to determine the
					 efficacy of the services and supports, and formulate changes in the Plan as
					 necessary, with member consultation.
(j) The BHHO shall consult with care team
					 members and the member as necessary, and update the Plan accordingly to ensure
					 that it remains current.
(k) The
					 member may decline to receive services identified in the Plan of Care, in which
					 case the BHHO must document such declination in the member's record.
(3)
Integration with Primary
					 Care.
During the first three (3) months after a member's enrollment, the
					 BHHO shall provide individualized outreach, education and support to the member
					 (and family, if the member is a minor) regarding BHHO services and benefits,
					 including information on sharing personal health information, and coordination
					 with primary care services. These services may be provided via in-person
					 meetings, follow up phone calls, development of written materials or
					 presentations, assistance from Peer Support providers, and other strategies to
					 ensure that the BHHO's members are fully educated and engaged with the needs
					 and goals set forth in the Plan of Care.
(4) The BHHO shall scan for gaps in each
					 member's care by reviewing, at a minimum, utilization reports for data across
					 the following domains, and work with the member and appropriate providers to
					 address any gaps in care:
(a) Hospitalizations
					 in the last quarter as well as the last year;
(b) ED visits in the last quarter as well as
					 the last year;
(c) Patients with
					 total paid claims greater than $10,000;
(d) Patients with eleven (11) or more
					 medications;
(e) Patients with no
					 PCP visits in the last year;
(f)
					 Patients with no HbA1c test (diabetes) in the last quarter;
(g) Patients with no LDL panel (diabetes) in
					 the last year; and
(h) Patients
					 with no LDL panel in the last year (CVD).