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 III - Allowances for Services › Section 144-101-III-92 - Behavioral Health Home Services

Current through 2024-29, July 17, 2024
Section 92 - Principles of
					 Reimbursement
So long as the requirements of Chapter II, Section 92
					 are met, reimbursement shall be as follows:
A.
Behavioral Health Home
				  Organizations
1.
Reimbursement
				  Rate:
Behavioral Health Home Organizations (BHHOs) will be reimbursed at
				  a rate of $394.40 per member per month (PMPM).
The Department shall seek and anticipates receiving
					 CMS approval for the following Sections.
Pending approval:
2.
Pay-for- Performance
				  Provisions:
One percent of total BHHO PMPM payments are subject to
				  recoupment based on performance on the performance measure below. BHHO
				  performance will be assessed every six (6) months, using twelve (12) months of
				  claims data. Of the twelve (12) months of data used to measure performance, at
				  least six (6) months of claims data will be drawn from a time period following
				  the implementation of a new or adjusted performance measure or threshold.
The Department will provide interim performance data
					 throughout the assessment period. Providers will have the opportunity to review
					 and refute Department findings on their performance score before recoupment.
					 Notice of recoupment and the right to appeal will be provided in accordance
					 with
					 22 M.R.S.
					 §1714-A and MBM, Section 1, Chapter 1,
					 General Administrative Policies and Procedures. Recoupment will be pursuant to
					 22 M.R.S.
					 §1714-A and recoupment shall not occur
					 until any appeals have been exhausted.
Providers will receive at least one-hundred and eighty
					 (180) days' notice prior to a change to pay-for-performance
					 stipulations.
Recoupment under the pay-for-performance provision of this
					 chapter shall not interfere with the ability of the Department to enforce
					 compliance with any other requirements of the
MaineCare Benefits
					 Manual
(MBM).
3.
Performance Measure:
Numerator
: MaineCare members
					 assigned to the BHH who had two (2) or more prescriptions filled for an
					 anti-psychotic medication (anti-psychotic medications are those included in the
					 most recently published HEDIS Listing which is available at
www.ncqa.org
) AND who had an HbA1c or blood
					 glucose test during the twelve (12)-month time period.
Denominator
: MaineCare members
					 assigned to the BHH who had two or more prescriptions filled for an
					 anti-psychotic medication during the twelve (12)-month period.
4.
Performance Threshold for
				  Recoupment:
The current threshold for the BHH pay-for-performance will
					 be listed on:
http://www.maine.gov/dhhs/oms/vbp
The Department will set a performance threshold based on
					 at least twelve (12) months of data from members in existing BHHOs. The
					 performance threshold will be set so that at least 70% of eligible BHHOs are
					 expected to be above the recoupment threshold thresholdbasedbased on the data
					 available at the time of the calculation. The Department cannot anticipate the
					 percent of providers that will, during the performance period, fail to meet the
					 performance threshold.
Eligible Behavioral Health Homes Organizations are those in
					 which at least ten percent (10%) of their member panel is clinically eligible
					 for inclusion in the performance measure.