C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-89, subsec. 144-101-II-89.05

Current through 2024-51, December 18, 2024

Subsection 144-101-II-89.05 - COVERED SERVICES

MaineMOM Services are for the perinatal period. MaineMOM providers shall provide the following Covered Services in accordance with the requirements in their respective subsections. Providers of MaineMOM Integrated Model Services (Section 89.06-3) and MaineMOM Partnership Model Services (Section 89.06-4) shall deliver all covered services. Providers of MaineMOM Perinatal Navigation Model Services (Section 89.06-5) shall only deliver Health Home Services (Section 89.05-1) and Access to Medication (Section 89.05-4).

MaineMOM providers shall document in their EHR all covered services provided to members.

89.05-1Health Home Services

The MaineMOM provider shall provide at least one of the following Health Home Services to each member within the reporting month, pursuant to the member's Care Plan. Until such time as a Care Plan is in place, each month's services must include Care Plan development under Section 89.05-1(A).

Services may be delivered in any community location where confidentiality can be maintained, as clinically appropriate. Not all aspects of the covered services will require direct member involvement; however, all covered services require that MaineMOM provider activities be directly related to an individual member, are member-informed, and pursuant to the member's Care Plan.

A.Comprehensive Care Management

The MaineMOM provider shall complete a screening and comprehensive assessment and create Care Plans, Plans of Safe Care, and plans for labor and delivery based on the screening and comprehensive assessment with the member and family or other support system input if desired by the member.

MaineMOM providers shall use shared decision-making aids and consider members' health literacy levels and cultural identification in comprehensive assessments and care planning, in setting measurable goals as clinically appropriate.

MaineMOM providers shall facilitate access to prenatal, intrapartum, postpartum medical services in accordance with the MBM, Chapter II, Section 90, Physician Services.

1.Screening and Comprehensive Assessment

Qualified MaineMOM staff shall conduct a screening and comprehensive assessment to determine diagnosis, the level of care in which the member should be placed, and to identify treatment priorities for the Care Plan. The MaineMOM provider shall place and maintain in the medical record for each MaineMOM member a comprehensive assessment report and evidence of the member having had an annual physical exam. A comprehensive assessment shall be completed at the time of intake of a new member, updated no later than thirty (30) days after an end of pregnancy date and reviewed when a member's needs or circumstances change.

a. The comprehensive assessment shall include documentation of:

i. medications;

ii. allergies;

iii. family history;

iv. nutritional status;

v. education;

vi. military service (if applicable);

vii. legal issues;

viii. vocational background;

ix. spirituality and religious preferences;

x. leisure and recreational activities; and

xi. addiction-focused history, including patterns of use, durations or periods of sobriety, and successful recovery strategies used.

b. In conducting the screening and comprehensive assessment and development of the Care Plan, MaineMOM providers shall ensure the provision of the following screenings and assessments, facilitate access to needed services, and develop follow-up plans based on results of:

i.Health-Related Social Needs: Screen for Health-Related Social Needs, assessing for housing stability, financial strain, intimate partner violence, food insecurity, and social support network and make necessary referrals and connections. An additional screening for Health-Related Social Needs should be completed at least once during the first sixty (60) days postpartum.

ii.Co-Occurring Mental Health: Screen for co-occurring mental health and substance use conditions at intake and again, no later than six (6) weeks postpartum (e.g., for depression, Patient Health Questionnaire (PHQ-9), and anxiety, Generalized Anxiety Disorder (GAD-7)).

2.Care Plan

The multi-disciplinary MaineMOM care team, which must include the member, shall develop, and implement a goal-oriented Care Plan, which must be available for update and review by all MaineMOM care team members.

The Care Plan must:

a. Be consented to by the member, verbally or in writing, with documentation included in the member's record that the member has reviewed the Care Plan and understands and agrees with it, including the date of the review;

b. Include measurable goals that are developed following clinical assessment of the member;

c. Include the member's health goals and the services and supports necessary to achieve those goals (including prevention, wellness, specialty care, behavioral health, transitional care and coordination, and social and community services as needed);

d. Include measurable treatment objectives and activities designed to meet those objectives;

e. Be developed within a maximum of thirty (30) days following the member's enrollment and minimally updated no later than thirty (30) days postpartum;

f. Be reviewed when a member's needs or circumstances change;

g. Specify the services and supports that are to be furnished to meet the member's preferences, choices, abilities, and needs, which can include, but are not limited to, prevention, wellness, specialty care, behavioral health, transitional care and coordination, and social and community services;

h. Provide comprehensive and maximally effective OUD care, include a medication plan which is documented by the MaineMOM provider in the member's record and modified as medically indicated by the member's response to treatment;

i. Be revised to reflect changes in treatment recommendations including referrals and coordination for gaps in care and revisions are communicated with the MaineMOM care team; and

j. Meet the requirements of Section 89.08, "Documentation and Confidentiality."

3.Plan of Safe Care: Ensure a Plan of Safe Care is created prior to the pregnancy due date for a member who enrolls in MaineMOM services at least thirty (30) days prior to the pregnancy due date. For a member who enrolls after thirty (30) days prior to the pregnancy due date, a Plan of Safe Care should be developed as soon as possible and appropriate, conditional on birth outcome. A Plan of Safe Care is distinct from the Care Plan and identifies needed resources and services to ensure the member and infant's well-being and ongoing safety, and to guarantee the best possible short-term and long-term health and developmental outcomes for substance exposed infants. A Plan of Safe Care can also be developed for non-substance exposed infants. A Plan of Safe Care remains in effect for the first twelve (12) months of a child's life.

4.Plan for Labor and Delivery

MaineMOM providers shall maintain a documented plan for labor and delivery with the member, when applicable. MaineMOM providers shall communicate this plan with the Intrapartum Care team prior to delivery. This plan shall include, but not limited to:

a. Confirmation the member is informed of ESC;

b. Pain management guidance specific to the member's needs and choice; and

c. Current treatment and care coordination support available to the member, throughout the hospital stay.

B.Care Coordination

MaineMOM providers shall provide intensive and comprehensive Care Coordination to address the clinical and non-clinical needs of members as appropriate to the member's treatment needs and Care Plan. MaineMOM providers may provide care coordination services through outreach, referrals, and communication with clinical and non-clinical service providers. Forms of Care Coordination may include, but are not limited to, assistance in accessing the following:

1. Primary health care for member and infant;

2. Specialty health care as appropriate;

3. Peer support for recovery;

4. Home visiting programs for prenatal and family development;

5. Housing and providing assistance to access and maintain safe/affordable housing;

6. Food and nutrition and providing connection and coordination with Women, Infants and Children (WIC) services;

7. Financial resources and providing connection and coordination with services offered by the Office of Family Independence (OFI), such as Temporary Assistance for Needy Families (TANF);

8. Childcare support;

9. Employment and providing assistance to access and maintaining employment;

10. Connection to family and others to support connections to services and expand social networks;

11. Transportation services;

12. Legal services; and

13. Maintaining frequent communication with other team providers to monitor health status, medical conditions, medications, and medication side effects.

C.Health Promotion

MaineMOM providers shall offer Health Promotion services to encourage and support healthy behaviors and self-management of health. MaineMOM providers must provide and document efforts to connect each member to a primary care provider. MaineMOM health promotion activities may also include, but are not limited to:

1. Health education specific to opioid dependence and treatment;

2. Relapse prevention plans;

3. Education and referral support regarding the member's other chronic conditions or health-related risk factors (e.g., oral health, contraceptive counseling, age-appropriate preventative care);

4. Evaluate and provide education on skills to self-manage health and healthcare needs relevant to the individual's Care Plan;

5. Behavioral techniques to promote healthy lifestyles;

6. Managing chronic pain;

7. Smoking cessation and reduction in use of alcohol and other drugs;

8. Nutritional counseling;

9. Promotion of physical activity; and

10. Specific education for pregnant members in SUD treatment prior to Intrapartum Care:

a. Education on the ESC method of monitoring newborn infants for neonatal opioid withdrawal syndrome and the related extended newborn hospital stay;

b. Education on the mandatory notification to DHHS of all infants born substance exposed, pursuant to 22 M.R.S. § 4004-B; and

c. Education on the Plan of Safe Care for the substance exposed infant.

D.Comprehensive Transitional Care

MaineMOM providers shall ensure continuity and coordination of care for members transitioning between healthcare providers and settings, such as inpatient discharge planners, hospital Emergency Department (ED) staff, longterm care facilities, corrections, probation and parole staff, residential treatment programs, primary care, and specialty mental health and substance use treatment services, with an aim to ensure the appropriate care post transition and reduce ED use, morbidity, mortality, inpatient admissions, readmissions, and lengths of stay. Following the end of a member's pregnancy, MaineMOM providers shall:

1. Coordinate with hospital discharge planners on care instructions for the member and infant, when applicable; and

2. Within twelve (12) months following a member's end of pregnancy date, or upon the end of MaineMOM services if less than twelve (12) months, MaineMOM providers shall provide the following transitional care activities including, but not limited to:

a. Establish a long-term substance use treatment plan, including access to Medications for OUD (MOUD), as appropriate;

b. Coordinate care with an established primary care provider for the member; and

c. Coordinate and communicate relevant information with an established pediatric provider for the infant, such as Hepatitis C exposure, during birth for follow-up, as appropriate.

E.Individual and Family Support Services

Individual and family support services are a required service for all members. These services promote recovery by supporting participation in treatment. MaineMOM providers shall incorporate into the member's Care Plan individual and family strengths and needs, needed resources and services to support the member's goals, and assist in navigating the health and human services systems to obtain the services necessary to achieve the goals.

MaineMOM providers shall employ approaches which may include, but are not limited to, supports, support groups, and self-care programs.

These approaches shall be designed to increase member and family/support knowledge about an individual's health conditions, including pregnancy and postpartum health, promote member engagement and self-management capabilities, and help the member maintain their recovery.

MaineMOM providers shall ensure connection to social support and recovery services through a Recovery Coach and other relevant services, including home visiting for prenatal and family development, resources for partner violence, childcare, and child development support.

F.Referral to Community and Social Support Services

MaineMOM providers shall make referrals through telephone or in person contact and may transmit requested data electronically. MaineMOM providers shall follow through on referrals to encourage the member to connect with the services.

MaineMOM providers shall refer members to community, social support, and recovery services, including, but not limited to, resources and agencies that provide the following based on the member's needs identified through assessment and care planning:

1. Transportation;

2. Housing;

3. Career planning/employment;

4. Childcare support;

5. Home visiting programs for prenatal and family development;

6. Nutrition programs for pregnant individuals and families;

7. Support with issues relating to intimate partner violence;

8. Obstetric health care and follow-up care; and

9. Primary care and family planning postpartum.

89.05-2Office Visit with the MOUD Prescriber

The MaineMOM MOUD Prescriber shall meet with each member at least one (1) time per month. The visit shall focus on the treatment priorities identified in the current Care Plan for the member, including, but not limited to, the member's physical health, behavioral health, recovery-oriented goals, and the services and supports necessary to achieve those goals.

89.05-3SUD Counseling

MaineMOM providers shall provide individual or group counseling sessions to address SUD. MaineMOM providers shall engage members, at a minimum, in individual or group counseling for one (1) billable hour monthly. The expectation is that counseling will be, at a minimum, one (1) hour in duration for each required period, but this may be delivered in multiple member contacts, if clinically appropriate and documented in the member's record. Counseling must be provided by a professional who is licensed to provide counseling for individuals with SUD.

Group sessions shall include direct oversight by a professional who is licensed to provide counseling for individuals with SUD. Group counseling sessions shall be related to substance use treatment and recovery goals and may include, but are not limited to, psychoeducational groups, skills development groups, and/or cognitive behavioral therapy groups.

89.05-4Access to Medication

A. MaineMOM providers shall ensure members have access to MOUD services to assist in the member's recovery, as medically appropriate. Medications for treatment of OUD include buprenorphine, buprenorphine combination medications, naltrexone, and methadone. Medications can be provided either directly on site, by an outside pharmacy, or by an Opioid Treatment Program (OTP) (in accordance with the MBM, Chapter II, Section 65, Behavioral Health Services), when a member is receiving methadone.

B. All controlled substances (e.g., buprenorphine) prescribed by the MaineMOM MOUD Prescriber, must be reported to the Maine Prescription Monitoring Program (PMP) pursuant to 14-118 C.M.R. Chapter 11, Rules Governing the Controlled Substances Prescription Monitoring Program and Prescription of Opioid Medications, and other applicable state and federal laws. Please refer to MBM, Chapter II, Section 80, Pharmacy Services, and MaineCare's Preferred Drug List at www.mainecarepdl.org, for the most current and accurate prescribing procedures and criteria for these medications.

C. MaineMOM providers shall ensure that members at risk for an opioid overdose have access to naloxone through a prescription, dispensing in office, or a distribution site and are informed on how to administer it.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-89, subsec. 144-101-II-89.05