Subsection 144-101-II-92.09 - MINIMUM REQUIREMENTS FOR REIMBURSEMENTReimbursement for Section 92 services shall be as follows:
A.Minimum Requirements for BHHO Reimbursement. The Department shall seek and anticipates receiving CMS approval for this Section. Pending approval, in order for the BHHO to be eligible for the per member per month (PMPM) payment, for each member for each calendar month, the BHHO shall:(1) In collaboration with the member and other appropriate providers, including but not limited to the primary care practice, and in accordance with 92.05-1(A)( 2) develop and/or update the Plan of Care with pertinent information from monthly activities or developments;(2) Submit cost and utilization reports upon request by the Department, in a format determined by the Department;(3) Scan the utilization data, as identified by MaineCare, for its assigned population;(4) Deliver at least one (1) Section 92.05 Covered Service to an enrolled member within the reporting month, pursuant to the member's Plan of Care. At least one (1) of the services must include a member encounter (including encounters with a member's family, guardian(s), or caregiver, if appropriate and pursuant to the Plan of Care) except that the BHH may attest to a member for a single month if a Section 92 service was delivered and a member encounter was attempted, but not achieved. This exception is allowable only for one month during a twelve-month period.(5) Make payment to affiliated HHPs for their members enrolled as a BHH member in those affiliated practices. The BHHO must document each service provided to each member, for each calendar month, in order to be eligible to receive the PMPM reimbursement.
B.Minimum Requirements for HHP Reimbursement. In order for the HHP to be eligible for a PMPM, for each member for each calendar month, the HHP shall, at a minimum: (1) Scan the utilization data, as identified by MaineCare, for its assigned population. AND
(2) Monitor and respond to treatment gaps on the individual level and/or provide patient engagement, outreach or other 92.05 Covered Services and in coordination with the Plan of Care and appropriate members of the care team. The HHP must attest to meeting this requirement in order to be eligible to receive the PMPM reimbursement. The HHP shall be reimbursed for services from the affiliated BHHO with whom that member is enrolled.
C.Duplication of Services Will Not Be Reimbursed. Payment for BHHO services must not duplicate payments made by public agencies or private agencies under other program authorities for health home, case management, or service coordination services. The Department shall not reimburse BHH providers for members receiving Section 92 services if: (1)For adults: The member is also receiving Sections 17.04-1 (Community Integration Services), 17.04-2 (Community Rehabilitation Services), 17.04-3 (Assertive Community Treatment, Section 13 (Targeted Case Management), Section 91 (Health Home Services) or Section 93 (Opioid Health Home Services) of the MaineCare Benefits Manual.(2)For children :The member is also receiving services pursuant to Section 13 (Targeted Case Management), Section 91 (Health Home Services), or Section 93 (Opioid Health Home Services) of the MaineCare Benefits Manual.(3) Similar services provided through the home and community-based waiver services authorized by Section 1915(c) of the Social Security Act that are described elsewhere in the MaineCare Benefits Manual. It is the duty and obligation of the BHHO and the HHP to review the entirety of each member's services and ensure that the Section 92 services do not duplicate similar services that may be provided.
D.Failure to Meet Program Requirements. The Department may terminate a provider from the BHH program based on failure to meet program requirements. Termination from the BHH program will be in accordance with the provisions of Ch. I, Sec. 1.03-4. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-92, subsec. 144-101-II-92.09