C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-89, subsec. 144-101-II-89.09
Section 89 MaineMOM Providers are reimbursed a monthly Per Member Per Month (PMPM) payment for each Section 89 member receiving services from the provider, based on which
Model Service the member is utilizing at the end of the month. Providers may only receive a PMPM payment if they satisfy the minimum requirements set forth in this section.
To be eligible for PMPM payment, for each member for each billing month, the MaineMOM provider shall meet the following Minimum Requirements for all MaineMOM Providers:
There are three PMPM rates. The PMPM rates are determined by the model of service provided. The three models of service are:
Integrated Model Service Partnership Model Service Perinatal Navigation Model Service4% of the PMPM payments are withheld from regular payments and redistributed every six months in accordance with the Performance-Based Adjustment provision.
Effective July 1, 2024, the three (3) MaineMOM PMPM rates will receive an annual cost of living adjustment (COLA) equal to the percentage increase in the state minimum wage as set by the Department of Labor, pursuant to 26 M.R.S. §664(1).
The PMPM rates and the annual updates will be posted on the Department's website at: https://mainecare.maine.gov/Default.aspx.
Effective January 1, 2025, four (4) percent of total MaineMOM PMPM payments will be withheld from regular payments and reimbursed every six (6) months, based on a twelve- (12) month assessment period of the two performance measures described in 89.09-3(B). Beginning July 1, 2024, after the twelve- (12) month assessment period and a three- (3) month claims runout period, all MaineMOM providers, 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 MaineMOM providers satisfy the minimum or excellent performance thresholds. The report will contain instructions for the MaineMOM provider to rebut the report's data if the MaineMOM provider 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, MaineMOM providers will not be scored on a new or adjusted performance measure at least six (6) months after the change is implemented.
MaineMOM providers are eligible for the pay-for-performance provision if at least 10% of their member panel is eligible for inclusion in the performance measures. If the MaineMOM provider does not have the minimum number of required members, it will automatically receive the four (4) percent withhold.
Denominator: Members enrolled with the MaineMOM provider with a pregnancy end date resulting in a live birth 56 days prior to the end of the performance period.
Numerator: Members who meet the denominator criteria with a qualifying outpatient postpartum visit between 21 and 56 days after the end of pregnancy date. Postpartum services provided in an inpatient setting are not included in the numerator.
Denominator: Members who received at least one Covered Service (89.05) at least 30 days prior to their end of pregnancy date.
Numerator: Members who meet the denominator criteria and received screening for HCV infection prior to their end of pregnancy date.
Exclusions: Members who have a prior diagnosis of HCV.
The current thresholds for MaineMOM pay-for-performance will be listed on: https://www.maine.gov/dhhs/oms/providers/value-based-purchasing.
Minimum and excellent performance thresholds for MaineMOM providers will be established based on a composite score of the performance measures, above. Performance thresholds are set in advance of performance periods. If the performance threshold(s) change, MaineMOM providers will not be scored on an adjusted threshold until six (6) months after the change is implemented. Based upon the available data at the time of the performance thresholds calculations, the Department shall set the thresholds so that no less than 70% of eligible MaineMOM providers are expected to be above the minimum performance threshold and no less than 20% of MaineMOM providers are expected to be above the excellent performance threshold. To clarify, the Department expects no more than 30% of MaineMOM providers to be below the minimum performance threshold. The Department cannot anticipate the exact percent of MaineMOM providers that will, during the performance period, satisfy either or neither of the performance thresholds.
MaineMOM providers that meet the minimum performance threshold receive four (4) percent of the PMPM payments that were withheld. The four (4) percent withholds that are not distributed to MaineMOM providers that fail to meet the minimum performance threshold will be distributed to the MaineMOM providers that meet the excellent performance threshold, based on each MaineMOM provider's proportion of the total number of attributed members who meet all performance measure numerator criteria and are attributed to MaineMOM providers that meet the excellent performance threshold. Hence, the amount of funds available to distribute to MaineMOM providers that meet the excellent performance threshold depends on the number of MaineMOM providers that fail to meet the minimum performance threshold. If all MaineMOM providers meet the minimum performance threshold, then there will be no funds to distribute to MaineMOM providers that meet the excellent performance threshold.
Mental health counseling and medication management services not related to the treatment of OUD through MBM, Section 65, Behavioral Health Services, are not considered duplicative services.
Professional services for Prenatal and Postpartum Care and toxicology screening for SUD are billed separately and therefore not considered duplicative. All medications are also billed separately.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-89, subsec. 144-101-II-89.09