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-89 - MaineMOM Services and Reimbursement › Subsection 144-101-II-89.06 - PROVIDER REQUIREMENTS

Current through 2024-29, July 17, 2024
All MaineMOM providers must meet the requirements of
						Section 89.06-1 and Section
						89.06-2.
There are three separate types of MaineMOM provider
						service models of care, offering different types and intensities of services:
						MaineMOM Integrated Model Services; MaineMOM Partnership Model Services; and
						MaineMOM Perinatal Navigation Model Services. The Integrated Model Service is
						for members who are receiving their prenatal and postpartum medical services at
						the same service location as OUD services, the Partnership Model Service is for
						members who are receiving OUD services onsite from the MaineMOM provider and
						prenatal and postpartum medical services from a different provider and service
						location, and the Perinatal Navigation Model Service is for members who receive
						only prenatal and postpartum medical services from the MaineMOM provider and/or
						are receiving their OUD treatment from a different non-MaineMOM provider and
						service location.
In addition to the requirements in Sections
						89.06-1 and
						89.06-2, a provider
						using the Integrated Model Services must also meet the requirements of Section
						89.06-3; a provider
						using the Partnership Model Services must also meet the requirements of Section
						89.06-4; and a
						provider using the Perinatal Navigation Model Services must also meet the
						requirements of Section
						89.065.
89.06-1
Requirements for all MaineMOM
					 Providers
A. The MaineMOM provider
					 must execute a MaineCare Provider Agreement. The MaineMOM provider is subject
					 to applicable state and federal Medicaid law, including but not limited to the
					 Chapter I, Section
					 1 of the
MaineCare Benefits
					 Manual
(MBM).
B. The
					 MaineMOM provider must be approved by the Department, or its Authorized Entity,
					 through the MaineMOM application process.
C. At the time of its application, lack of an
					 EHR system will not be a determining factor in approving a MaineMOM provider
					 application. However, prior to the delivery of any covered Section
					 89 services, a MaineMOM provider
					 must utilize an EHR and create an EHR for each member served.
D. The MaineMOM provider must be a
					 Co-occurring Capable Provider.
E.
					 The MaineMOM provider must adhere to applicable licensing standards regarding
					 documentation of all provider qualifications in their personnel files. The
					 MaineMOM provider must have a review process to ensure that employees providing
					 MaineMOM services possess the minimum qualifications.
F. The MaineMOM care team must consist of
					 employed or contracted personnel and minimally must include the personnel
					 identified in this sub-section. All MaineMOM care team members shall contribute
					 to delivery of integrated, coordinated, and person-centered care through a
					 team-based approach.
Unless otherwise specified, each MaineMOM care team
						member role must be filled by a different individual
. The Department
						reserves the right to waive this requirement based on team member professional
						experience and training.
1. The
					 MaineMOM care team members must include:
a.
Clinical Team Lead:
A licensed clinical professional who is
					 responsible for ensuring that the MaineMOM care team is complete and adheres to
					 provider requirements (Section
					 89.06). The Clinical
					 Team Lead shall coordinate the Care Plan for members served. The Clinical Team
					 Lead shall have significant experience caring for pregnant and postpartum
					 individuals with SUD.
The Clinical Team Lead must be a:
i. Physician (Doctor of Medicine (MD) or
					 Doctor of Osteopathic Medicine (DO));
ii. Physician Assistant (PA);
iii. Advanced Practice Registered Nurse
					 (APRN);
iv. Psychologist,
v. Registered Nurse (RN);
vi. Licensed Clinical Social Worker
					 (LCSW);
vii. Licensed Clinical
					 Professional Counselor (LCPC); or
viii. Licensed Alcohol and Drug Counselor -
					 Certified Clinical Supervisor (LADC-CCS).
The Clinical Team Lead role may be filled by an
						individual also serving in one of the other roles below, as long as the
						individual meets the qualifications of a Clinical Team
						Lead.
b.
MOUD Prescriber:
A licensed health care professional providing
					 services for treatment of OUD, including medications for SUD as appropriate.
The MOUD Prescriber shall coordinate with and provide
						guidance to the MaineMOM care team, to ensure physical and behavioral health
						goals are appropriate to the member's Care Plan, including guidance on pain
						management protocols, medication contraindications, and other support. The MOUD
						Provider shall interpret toxicology screens and discuss results with
						members.
The MOUD Prescriber must be a:
i. licensed health care professional with any
					 federally and state required training to prescribe medications for SUD,
					 including but not limited to buprenorphine, buprenorphine combination
					 medications, and naltrexone; or
ii.
					 practitioner licensed under state and federal law to order, administer, or
					 dispense opioid agonist treatment medications.
For members who receive MOUD covered services under MBM,
						Ch. II, Sec.
						65, from an OTP, the MaineMOM MOUD
						Prescriber must coordinate with the prescriber at the OTP.
The MOUD Prescriber role may be filled by an individual
						also serving as a Perinatal Provider and/or Clinical Team Lead as long as the
						individual meets the requirements of a MOUD Prescriber.
c.
Perinatal Provider:
A licensed health care professional coordinating with and providing guidance to
					 the MaineMOM care team, to ensure physical and behavioral health goals are
					 appropriate to the member's Care Plan. The Perinatal Provider shall have
					 significant experience caring for women during the Prenatal, Intrapartum, and
					 Postpartum periods.
The Perinatal Provider must be a:
i. Physician (Doctor of Medicine (MD) or
					 Doctor of Osteopathic Medicine (DO));
ii. PA; or
iii. APRN, including but not limited to a
					 Certified Nurse-Midwife, who practices obstetrics-gynecology or family
					 medicine.
If the Perinatal Provider does not provide Intrapartum
						Care, the MaineMOM Provider must establish an additional partnership with a
						care provider that does offer Intrapartum Care.
The Perinatal Provider role may be filled by an
						individual also serving as a MOUD Prescriber and/or Clinical Team Lead as long
						as the individual meets the requirements of a Perinatal
						Provider.
d.
Nurse Care Manager:
A licensed health care professional
					 contributing to implementation, coordination, and oversight of each member's
					 Care Plan, assisting in the coordination of care with outside providers, and
					 communicating barriers to adherence as appropriate to the team, including the
					 Clinical Team Lead. The Nurse Care Manager shall be involved in overseeing
					 and/or participating in all aspects of MaineMOM services.
The Nurse Care Manager must be a(n):
i. RN;
ii. APRN;
iii. Psychiatric and Mental Health Nurse
					 (PMHN) certified by the American Nurses Credentialing Center (ANCC);
					 or
iv. Licensed Practical Nurse
					 (LPN).
The Nurse Care Manager position may be filled by another
						appropriate licensed medical professional on the MaineMOM care team, as long as
						the individual also meets the qualifications described of a Nurse Case
						Manager.
e.
Clinical Counselor:
A licensed clinical professional providing
					 individual or group SUD outpatient therapy for members receiving counseling.
					 The Clinical Counselor provides behavioral health expertise in the coordination
					 of the member's Care Plan and identifies and connects members to behavioral
					 health services.
The Clinical Counselor must be a:
i. Psychologist;
ii. LCSW;
iii. LCPC;
iv. Licensed Master Social Worker-
					 Conditional Clinical (LMSW-CC);
v.
					 Licensed Clinical Professional Counselor-Conditional (LCPC-C);
vi. Licensed Marriage and Family Therapist
					 (LMFT);
vii. Licensed Marriage and
					 Family Therapist-Conditional (LMFT-C);
viii. Licensed Alcohol and Drug Counselor
					 (LADC); or
ix. Certified Alcohol
					 and Drug Counselor (CADC).
f.
Patient Navigator:
A
					 certified and/or qualified direct care worker coordinating health care, mental
					 health, and social services and supporting the member in their recovery during
					 the perinatal period. The Patient Navigator may be the primary provider of care
					 coordination, health promotion, individual and family support services, and
					 referral services.
The Patient Navigator must be a(n):
i. Mental Health Rehabilitation
					 Technician/Community (MHRT/C);
ii.
					 RN
iii. LPN
iv. Medical Assistant (MA);
v. Community Health Worker (CHW);
vi. Certified birth or postpartum doula who
					 has completed a doula training program with relevant perinatal core
					 competencies; or
vii. Individual
					 who has at least one (1) year of job experience in health/social services
					 setting supporting families affected by SUD.
The Patient Navigator role may be filled by an individual
						also serving as the Nurse Care Manager or Clinical Counselor, if that person
						only shares those two roles, and if the individual also meets the
						qualifications of a Patient Navigator.
g.
Recovery Coach:
A care team
					 member providing recovery support. The Department encourages and prefers that
					 those in this role are themselves in recovery, as their life and recovery
					 experiences allow them to provide recovery support in such a way that others
					 can benefit from their experiences. This may include contacting the member to
					 answer any questions and provide any support in navigating services.
The Recovery Coach must:
i. Be an individual in recovery from SUD and
					 who is willing to self-identify on this basis with members, or be a recovery
					 ally*; and
ii. Have completed the
					 thirty (30) hour Connecticut Community for Addiction Recovery (CCAR) training,
					 or other Department-approved Recovery Coach training or certification, within
					 six (6) months of the rule adoption date or within six (6) months of beginning
					 to deliver MaineMOM Services, whichever is later; and
iii. Be employed by the MaineMOM provider or
					 engaged through a formal contract with a community-based organization that
					 identifies referral processes and access to services.
*The Department shall submit to CMS and anticipates
						approval for a State Plan Amendment related to this
						provision.
2. Regardless of qualifications, a single
					 person may not fill the roles of Nurse Care Manager, Perinatal Provider, MOUD
					 Provider and Clinical Team Lead on the care team.
3. If MaineMOM care team member role(s) are
					 vacant for more than thirty (30) continuous days, the MaineMOM provider shall
					 notify the Department, or its Authorized Entity, in writing and maintain
					 records of active recruitment efforts to fill the position(s).
G. The MaineMOM provider shall
					 ensure twenty-four (24) hour
					 availability of information for triage and referral to treatment for medical
					 emergencies.
1. This requirement may be
					 fulfilled through an after-hours telephone number that connects the patient to:
a. The MaineMOM provider or an authorized
					 licensed medical practitioner providing coverage for the MaineMOM
					 provider;
b. A live voice call
					 center system or answering service which directs the patient to the appropriate
					 care site or connects the patient to the MaineMOM provider/authorized covering
					 medical practitioner; or
c. A
					 hospital, if the MaineMOM provider has standing orders with the hospital to
					 direct patients to the appropriate care site within the
					 hospital.
2. The
					 following do
not
constitute adequate coverage:
a. A twenty-four (24) hour telephone number
					 answered only by an answering machine without the ability to arrange for
					 interaction with the MaineMOM provider or their covering provider;
b. A resource or service that refers patients
					 to hospital EDs but does not offer phone triage or assistance in reaching the
					 MaineMOM provider or their covering provider.
3. The MaineMOM provider shall inform members
					 of their normal office hours and explain to members the procedures they should
					 follow when seeking care outside of office hours. The MaineMOM provider 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 EHR during hours
					 they are covering.
H.
					 The MaineMOM provider shall screen for SUD in pregnant individuals to identify
					 eligible members using a validated SUD screening tool (e.g., 4Ps, CRAFFT,
					 T-ACE). If the member screens positive for a SUD, the MaineMOM provider shall
					 schedule an appointment for the member for SUD evaluation/initiation of
					 treatment. That appointment shall occur within seven (7) days of the member
					 screening positive for a SUD.
I.
					 The MaineMOM provider shall ensure members are informed and educated on family
					 planning options, with assistance to access postpartum contraception as
					 desired, including the use of Long-Acting Reversible Contraceptives
					 (LARCs).
J. The MaineMOM provider
					 shall have systems in place to reduce barriers to accessing treatment for
					 parents with young children (e.g., allowing young children to attend
					 appointments, especially group sessions, and support in accessing childcare for
					 older children).
K. The MaineMOM
					 provider shall offer telehealth as an alternative to traditional office visits
					 in accordance with the MBM, Chapter I, Section 4, and/or for nonoffice visit
					 supports and outreach to increase access to the care team and clinicians in a
					 way that best meets the needs of members.
L. The MaineMOM provider shall have at least
					 one (1) representative from the MaineMOM care team participate in designated
					 Department-sponsored quality improvement initiatives and technical assistance
					 activities on an annual basis. The Department will not require more than eight
					 (8) hours of participation annually. The MaineMOM care team representative
					 shall be a person whose role involves clinical care, population health, and/or
					 quality improvement.
M. If a
					 MaineMOM member has a primary care provider, the MaineMOM provider must
					 establish and maintain a relationship with a primary care provider, authorized
					 and evidenced by a signed medical release for each MaineMOM member served. Such
					 a release is not required when the member's primary care provider is also the
					 member's provider within the MaineMOM provider.