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 VI › Section 144-101-VI-03 - Primary Care Plus › Subsection 144-101-VI-0302 - DEFINITIONS

Current through 2024-29, July 17, 2024
3.02-1
Accountable Community (AC)
is an entity participating in a MaineCare program established through a
					 contract between the Department and an AC Lead Entity that establishes a
					 financial relationship between the Department and the AC Lead Entity to both
					 provide a financial incentive and hold the AC accountable for the provision of
					 efficient, coordinated, and high-quality care. AC Lead Entities that achieve
					 savings relative to a benchmark Total Cost of Care (TCOC) amount are eligible
					 to receive a portion of these savings dependent on and proportional to their
					 performance on a number of quality measures.
3.02-2
Attribution Assessment
					 Period
is the twenty-four- (24) month "lookback" period used for member
					 attribution.
3.02-3
Behavioral and Physical Health Integration
is the care a member
					 experiences as a result of a team of primary care and behavioral health
					 providers, working together with members and families, using a systematic and
					 cost-effective approach to provide patient-centered care for a defined
					 population (based on the definition of "Integrated Behavioral Health Care" from
					 the Agency for Healthcare Research and Quality).
3.02-4
Care Plans
are developed
					 and updated by the PCP in collaboration with the Member and their families and
					 contain a problem list, expected outcome/prognosis, treatment goals, and
					 medication management.
3.02-5
Certified Electronic Health Record Technology (CEHRT)
is
					 Electronic Health Record (EHR) technology (which could include multiple
					 technologies) certified under the Office of National Coordinator for Health IT
					 Certification Program that meets the criteria listed in
					 42
					 CFR §
												414.1305.
3.02-6
Community Health Worker
					 (CHW)
is a trained health worker who applies their unique understanding
					 of the community's experience, socio-economic needs, language and/or culture to
					 advocate for individual and community needs and acts as a bridge between
					 providers and individuals to promote health, reduce disparities, and improve
					 service delivery. CHWs are distinguished from other health professionals in
					 that they are hired primarily for their understanding of the populations and
					 communities they serve, conduct outreach a significant portion of the time, and
					 have experience providing services in community settings (adapted from the
					 Maine State Innovation Model).
CHW training shall include CHW core competencies defined
						by The Community Health Worker Core Consensus Project (see
https://www.c3project.org/roles-competencies
)
						or be evidenced by a Maine CHW certification or registration (effective the
						date such a designation becomes active in the State of Maine).
3.02-7
Joint Care Management and
					 Population Health Strategy
is a written three-year plan, updated
					 annually, which describes operational and financial coordination across the
					 PCPlus practice, the AC, and any Community Care Team (as described in Section
					 91 of the MaineCare Benefits Manual) that is contracted with the AC and/or the
					 PCPlus practice.
3.02-8
MaineCare Peer Group
is a group of PCPs, determined by the
					 Department, based on Risk Scores and influenced by Tier level, practice size,
					 practice type, and rurality, as needed. MaineCare Peer Group assignment will be
					 determined upon acceptance into PC Plus and reassessed at least annually or
					 when a PCP undergoes a significant change, which may include a relocation or
					 inclusion of new populations.
3.02-9
Medication for Addiction
					 Treatment (MAT)
is the use of medications for the treatment of substance
					 use disorders.
3.02-10
Members
are MaineCare members attributed to a PCP for the purposes
					 of reimbursement.
3.02-11
Performance-Based Adjustments (PBA)
are quarterly adjustments made
					 to participating PCPs' PBPs based on PCP performance on PCPlus performance
					 measures.
3.02-12
Performance-Based Adjustment Assessment Period
is the twelve
					 (12)-month "lookback" period used for assessing PBAs.
3.02-13
Population-Based Payments
					 (PBP)
are monthly payments that the Department calculates quarterly by
					 adding the Tier per member per month (PMPM) rate and the population group and
					 risk category PMPM rate and multiplying the sum by the PCP's total number of
					 Members. These payments are for a flexible array of care delivery approaches,
					 including those that are not dependent on office-based, face-to-face care, such
					 as care management, access to additional care team members, and targeted
					 patient supports that best meet the needs of the Members.
3.02-14
Primary Care Services
are evaluation and management, preventive, and wellness services.
3.02-15
Risk Score
is a metric
					 from a patient classification model that evaluates and forecasts individual
					 healthcare utilization and costs for each individual Member using demographic
					 and heath care data from a rolling twelve-(12) month period with a two-month
					 claims run out period.