Subsection 144-101-VI-0304 - COVERED SERVICESThe Department reimburses PCPlus PCPs for locating, coordinating, and monitoring health care services to provide Members with high-quality and cost-effective care.
This includes locating MaineCare providers who can provide timely access to patient centered, culturally and linguistically appropriate, medically necessary MaineCare covered services. This also includes supporting whole-person coordination and transitions of care; completing timely prior authorizations; providing referrals and clinician orders; tracking and following up on referrals; and closing care gaps.
PCPs shall document all covered services provided to Members in their EHR. PCPs shall:
A.Care Plans. Partner with Members and other care team members to create care plans that support members' needs. Use shared-decision aids and consider Members' health literacy levels in assessment and care planning. Include both clinician and patient action plans in the care plan as clinically appropriate;B.Care Coordination. Engage in coordination with any external care coordinator, case manager, discharge planners, or care team of the Member, as determined appropriate by the needs of the Member, in accordance with all applicable state and federal privacy laws and best practices to support the Member's care goals. This may include but is not limited to coordinating covered services with providers of: Section 13, Targeted Case Management; Section 17, Community Support Services; Section 91, Health Home Services Community Care Teams; Section 92, Behavioral Health Homes; and Section 93, Opioid Health Homes. When coordinating and partnering with other providers, PCPs shall not duplicate efforts;C.Assessments. Connect Members to clinically appropriate assessments including, but not limited to, Medical Eligibility Determination (MED) assessments for long-term care needs;D.Care Transition Services. Provide care transition services between healthcare providers and settings to ensure continuity of care and reduce emergency department (ED) use, morbidity, mortality, inpatient admissions, readmissions, and lengths of stay. Pediatric-to-adult health care transition services shall include but are not limited to the following:
1. Preparing a current medical summary and plan of care;2. Identifying an adult primary care provider;3. Scheduling and ensuring that initial and follow-up appointments with the adult primary care provider are kept; and4. Facilitating linkages to other adult care providers (e.g., reproductive, behavioral, medical specialties);E.Screenings. Ensure the provision of the following screenings, deliver screening-related services, and develop follow-up plans based on results: 1.Developmental Screenings. Provide the American Academy of Pediatrics/Bright Futures recommended screenings. This includes, but is not limited to: a. For all children by ages one (1), two (2), and three (3): Ages and Stages Questionnaire (ASQ), Parents' Evaluation of Development Status (PEDS), or the Survey of Well Being of Young Children (SWYC) developmental screening; andb. The M-CHAT-R (Modified Checklist for Autism in Toddlers, Revised) screening tool to assess the risk for autism at eighteen (18) and twenty-four (24) months and the M-CHAT-F (Follow-up) screening if a child does not pass the initial M-CHAT-R screening test;2.Lead Testing. Provide required blood lead level testing for all children at one year of age and two years of age per Maine Public Law, Chapter 479, An Act to Strengthen the Lead Poisoning Control Act and develop follow-up plans based on results;3.Other Screenings. Provide the following screenings: a. Measurement of Body Mass Index (BMI) in all adult patients at baseline and at least every two years, and BMI percent-for-age at least annually in all children;b. Depression, anxiety, and substance use screenings as clinically appropriate (e.g. Patient Health Questionnaire (PHQ-9), Alcohol Use Disorder Identification Test (AUDIT), Drug Abuse Screening Test (DAST), CRAFFT for adolescents);c. Postpartum screening for depression (e.g. Edinburgh Postpartum Depression Scale (EPDS)) at least once in the first six (6) weeks postpartum; andd. Beginning one (1) year after the PCPlus effective date, implement a documented process to routinely perform Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Members;F.EPSDT. Afford children enrolled in MaineCare and CHIP Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefits through written member acknowledgement of MBM, Chapter II, Section 94. States must provide all medically necessary section 1905(a) services coverable under the Medicaid program to eligible children and youth under age twenty-one (21) in order to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Maine Medicaid State Plan. PCPlus providers shall apply this understanding of EPSDT rights and demonstrate an ability to appropriately request prior authorizations for EPSDT services;G.Oral Health1.Oral Health Risk Assessment. Offer oral health risk assessments for Members in accordance with Section 90.04-31;2.Fluoride. Offer topical fluoride varnish for Members under age 21 in accordance with Section 90.04-30.H.Immunizations. Offer all appropriate immunizations to each Member in accordance with the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices immunization schedule;J.Advanced Care Planning and Palliative Care. Offer or refer Members who may benefit to advanced care planning and palliative care consultation. C.M.R. 10, 144, ch. 101, ch. VI, 144-101-VI-03, subsec. 144-101-VI-0304