Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 590 - MAINE HEALTH DATA ORGANIZATION › Chapter 247 - UNIFORM REPORTING SYSTEM FOR NON-CLAIMS-BASED PAYMENTS AND OTHER SUPPLEMENTAL HEALTH CARE DATA SETS › Section 590-247-1 - Definitions

Current through 2024-29, July 17, 2024
Unless the context indicates otherwise, the following words
				  and phrases shall have the following meanings:
A.
Behavioral Health Care
.
				"Behavioral health care (BH)" means services to address mental health and
				substance use conditions. 24-A MRSA §
									6903, sub-§
									1- A.
B.
Capitation Payments
.
				"Capitation payments" means per capita payments to providers to provide
				services needed by designated patients over a defined period.
C.
Care Management/Care
				Coordination/Population Health Payments
. "Care management/ care
				coordination/population health payments" means payments to fund a care manager,
				care coordinator, or other traditionally non-billing practice team members
				(e.g., practice coaches, patient educators, patient navigators, or nurse care
				managers) who help providers organize clinics to function better and help
				patients take charge of their health.
D.
Carrier
. "Carrier" means an
				insurance company licensed in accordance with 24-A M.R.S., including a health
				maintenance organization, a multiple employer welfare arrangement licensed
				pursuant to 24-A M.R.S., chapter 81, a preferred provider organization, a
				fraternal benefit society, or a nonprofit hospital or medical service
				organization or health plan licensed pursuant to 24 M.R.S. An employer exempted
				from the applicability of 24-A M.R.S., chapter 56-A under the federal
Employee Retirement Income Security Act of 1974
, 29
United States Code
, Sections
				1001 to
				1461(1988)
				("ERISA") is not considered a carrier.
E.
Designee
. "Designee" means an
				entity with which the MHDO has entered into an agreement under which the entity
				performs data collection, validation and management functions for the MHDO and
				is strictly prohibited from releasing information obtained in such a
				capacity.
F.
Electronic
				Health Records/Health Information Technology Infrastructure/Other Data
				Analytics Payments
. "Electronic health records/health information
				technology infrastructure and other data analytics payments" means payments to
				help providers adopt and utilize health information technology, such as
				electronic medical records and health information exchanges, software that
				enables practices to analyze quality and/or costs outside of the electronic
				health records and/or the cost of a data analyst to support
				practices.
G.
Global Budget
				Payments
. "Global budget payments" means payments made to providers for
				either a comprehensive set of services for a designated patient population or a
				more narrowly defined set of services where certain services such as behavioral
				health or pharmacy are carved out. Services typically include primary care
				clinician services, specialty care physician services, inpatient hospital
				services, and outpatient hospital services, at a minimum. Hospitals and health
				systems are typically the provider types that would operate under a global
				budget, though this is not widespread.
H.
Medicare Health Plan Sponsor
.
				"Medicare health plan sponsor" means a health insurance carrier or other
				private company authorized by the United States Department of Health and Human
				Services, Centers for Medicare and Medicaid Services to administer Medicare
				Part C and Part D benefits under a health plan or prescription drug
				plan.
I.
Medication
				Reconciliation
. "Medication reconciliation" means payments to fund the
				cost of a pharmacist to help practices with medication reconciliation for
				poly-pharmacy patients.
J.
MHDO
. "MHDO" means the Maine Health Data Organization.
K.
M.R.S.
"M.R.S." means
Maine Revised Statutes
.
L.
Non-Claims Based Payments.
"Non-claims-based" means payments that are for something other than a
				fee-for-service claim. These payments include but are not limited to Capitation
				Payments, Care Management/Care Coordination/Population Health Payments,
				Electronic Health Records/Health Information Technology Infrastructure/Other
				Data Analytics Payments, Global Budget Payments, Patient-centered Medical Home
				Payments, Pay-for-performance Payments, Pay-for-reporting Payments, Primary
				Care and Behavioral Health Integration Payments, Prospective Case Rate
				Payments, Prospective Episode-based Payments, Provider Salary Payments,
				Retrospective/Prospective Incentive Payments, Risk-based Payments, Shared-risk
				Recoupments, Shared-savings Distributions.
M.
Patient-centered Medical Home
				Payments
. "Patient-centered medical home payments" means Practice-level
				payments such as payments to Patient-Centered Medical Homes (PCMH), Health
				Homes for provision of comprehensive services; payments based upon PCMH
				recognition; or payments for participation in proprietary or other multi-payor
				medical -home or specialty care practice initiative.
N.
Pay-for-performance Payments
.
				"Pay-for-performance payments" means payments to reward providers for achieving
				a set target (absolute, relative, or improvement-based) for quality or
				efficiency metrics. Payments could include the return of a withhold if not
				attached to a claim payment.
O.
Pay-for-reporting Payments
. "Pay-for-reporting payments" means
				payments to providers for reporting on a set of quality or efficiency metrics,
				usually to build capacity for future pay-for-performance incentives.
P.
Payor.
"Payor" means a
				carrier, third-party payor, third-party administrator, Medicare health plan
				sponsor or Medicaid.
Q.
Primary Care
. "Primary care" means regular check-ups, wellness and
				general health care provided by a provider (see Appendix A) with whom a patient
				has initial contact for a health issue, not including an urgent care or
				emergency health issue, and by whom the patient may be referred to a
				specialist.
R.
Primary Care
				and Behavioral Health Integration Payments
: "Primary care and behavioral
				health integration payments" means payments that promote the appropriate
				integration of primary care and behavioral health care that are not
				reimbursable through claims (e.g., funding behavioral health services not
				traditionally covered with a discrete payment when provided in a primary care
				setting), such as:
a) substance abuse or
				depression screening;
b) performing
				assessment, referral, and warm hand-off to a behavioral health clinician;
				and/or
c) supporting health behavior
				change, such as diet and exercise for managing prediabetes risk). This excludes
				payments for mental health or substance use counseling.