90-590-247 Me. Code R. § 1

Current through 2024-51, December 18, 2024

Section 590-247-1 - Definitions

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.

S.Prospective Case Rate Payments. "Prospective case rate payments" means payments received by providers in a given provider organization for a patient receiving a defined set of services for a specific period.

T.Prospective Episode-based Payments. "Prospective episode-based payments" means payments received by providers (which can span multiple provider organizations) for a patient receiving a defined set of services for a specific condition across a continuum of care by multiple providers, including providers, or care for a specific condition over a specific time.

U.Provider. "Provider" means a health care facility, health care practitioner, health product manufacturer or health product vendor but does not include a retail pharmacy.

V.Provider Salary Payments. "Provider salary payments" means payments for salaries of providers who provide care. This category may only be applicable for closed health systems.

W.Recoveries. "Recoveries" means payments received by a provider from a payor and then later recouped due to a review, audit, or investigation. Recoveries not reported in claims payments should be netted out of the total non-claims-based payments reported.

X.Retrospective/Prospective Incentive Payments. "Retrospective/prospective incentive payments" means payments to reward providers for achieving quality and/or efficiency goals. The two main subcategories of incentive payments are pay-for-performance and pay-for-reporting.

Y.Redacted Payments. "Redacted payments" mean payments in which an entire claim or some portion of a claim that would normally be part of the payor's medical or pharmacy claims submission to the MHDO was removed or altered prior to submission to conform to the requirements of 42 CFR Part 2.

Z.Risk-based Payments. "Risk-based payments" means payments received by providers (or recouped from providers) based on performance relative to a defined spending target. Risk-based payment methodologies can be applied to different types of budgets, including but not limited to episode of care and total cost of care. The two main subcategories of risk-based payments are shared savings and shared risk.

AA.Shared-risk Recoupments. "Shared-risk recoupments" means payments payors recoup from providers if costs of services are above a predetermined, risk-adjusted target. Shared-risk arrangements are typically calculated on a total cost of care basis and typically exclude high-cost outliers. Recoupment should be netted out of the total non-claims-based payments reported.

BB.Shared-savings Distributions. "Shared-savings distributions" means payments received by providers if costs of services are below a predetermined and risk-adjusted target. The amount of savings the provider can receive is often linked to performance on quality measures.

CC.Supplemental Health Care Data Sets. "Supplemental health care data sets" means data files specific to payments for primary care, behavioral health or other health care services. Supplemental health care data sets may include aggregated, non-claims-based payment information, or aggregated or non-aggregated, redacted claims-based payment information.

DD.Third-party Administrator. "Third-party administrator" means any person licensed by the Maine Bureau of Insurance under 24-A M.R.S., chapter 18 who, on behalf of a plan sponsor, health care service plan, nonprofit hospital or medical service organization, health maintenance organization or insurer, receives or collects charges, contributions or premiums for, or adjusts or settles claims on residents of this State.

EE.Third-party Payor. "Third-party payor" means a state agency that pays for health care services or a health insurer, carrier, including a carrier that provides only administrative services for plan sponsors, nonprofit hospital, medical services organization, or managed care organization licensed in the State.

90-590 C.M.R. ch. 247, § 1