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-93 - Opioid Health Home Services

Current through 2024-29, July 17, 2024
1.
If the
				  requirements of Chapter II, Section 93, are met, reimbursement shall be as
				  follows:
Per Member Per Month (PMPM)
								rate
PMPM Rate with 4% Withheld
Intensive Outpatient Services
								(IOP) Level of Care
with no additional provider support (T2022)
$2,327.32
$2,234.23
with additional Section
								13,
								17, or
								92 provider support ((T1012),
								there is a $394.40 pass-through payment to the additional
								provider1
$2,474.33
$2,381.24
Induction and Stabilization
								Levels of Care
with no additional provider support (T2022))
$1,096.63
$1,052.77
with additional Section
								13,
								17, or
								92 provider support (T1012),
								there is a $394.40 pass-through payment to the additional
								provider2
$1,243.64
$1,199.78
Maintenance Level of
								Care
with no additional provider support (T2022)
$695.41
$667.60
with additional Section
								13,
								17, or
								92 provider support (T1012),
								there is a $394.40 pass-through payment to the additional
								provider3
$842.42
$814.61
Medication Plus Level of
								Care
with no additional provider support (T1041)
$670.36
$643.78
with additional Section
								13,
								17, or
								92 provider support (T1041 HH),
								there is a $394.40 pass-through payment to the additional
								provider4
$817.61
$790.79
Methadone Health Home Level of
								Care
with no additional provider support (T2022
								HF)
$413.88
$397.32
2.
Pay-for-Performance Provisions:
Four (4) percent of total OHH PMPM payments is withheld
					 from regular payments and reimbursed every six (6) months, based on a
					 twelve-(12) month assessment period of performance on the below three
					 performance measures. After the twelve-(12) month assessment period and a
					 three-(3) month claims runout period, all OHHs, regardless of performance, will
					 receive a quarterly report with the performance assessment, indicating whether
					 they qualify for receipt of the 4% withheld amount or the withheld amount and
					 an additional amount, based on whether OHHs satisfy the minimum or excellent
					 performance thresholds. The report will contain instructions for the OHH to
					 rebut the report's data if the OHH disagrees with the report and the
					 reimbursement they are set to receive. The Department will provide a
					 thirty-(30) day rebuttal period prior to issuing reimbursement.
If the performance measures change via rulemaking,
					 providers will not be scored on a new or adjusted performance measure until six
					 (6) months after the change is implemented.
OHHs are eligible for the pay-for-performance provision if
					 at least ten percent (10%) of their member panel is clinically eligible for
					 inclusion in the performance measures. If the OHH does not have the minimum
					 number of required members, it will automatically receive the four (4) percent
					 withhold.
3.
Performance Measures:
A.
				  Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)
Denominator:
MaineCare members assigned to the
					 OHH panel for a minimum of 60 days in the measurement period who are in the
					 Maintenance and Stabilization Levels of Care.
Numerator:
MaineCare members in the
					 denominator who have at least 180 days of continuous pharmacotherapy with a
					 medication prescribed for OUD without a gap of more than seven (7) days, based
					 on the measure 'Continuity of Pharmacotherapy for Opioid Use Disorder,' as
					 stewarded by the University of Southern California.
Medications:
Medications included in this
					 measure are Buprenorphine, Naltrexone, Buprenorphine-Naloxone, and
					 Methadone.
B. Community
				  Engagement
Denominator:
MaineCare members assigned to the
					 OHH panel for a minimum of 60 days in the measurement period who are in the
					 Maintenance and Stabilization Levels of Care.
Numerator:
MaineCare members who meet all
					 denominator criteria and on their most recent assessment by the Department's
					 designated contractor, gave a response other than "Not currently employed."
Other responses include, but are not limited to,
					 competitively employed, self-employed, student, and parent of a child under age
					 18.
C. Access to Preventive
				  and Ambulatory Care
Denominator:
MaineCare members assigned to the
					 OHH panel for a minimum of 60 days in the measurement period who are in the
					 Maintenance and Stabilization Levels of Care.
Numerator:
MaineCare members who meet the
					 denominator criteria and who had an ambulatory or preventive care visit during
					 the 12 months being assessed.