Introduction to Maine Care Managed Care Prepared for

Introduction to Maine. Care Managed Care Prepared for Primary Care Provider Sites Department of Health and Human Services Maine. Care Services 442 Civic Center Drive # 11 State House Station Augusta, Maine 04333 -0011 Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 ~ FAX 207 -287 -1864 Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

Managed Care Maine. Care managed care is a Primary Care Case Management (PCCM) Benefit for eligible (primarily the TANF population ~ Temporary Aid for Needy Families) Maine. Care members. Maine. Care managed care is a mandatory program through an approval by the Center for Medicare and Medicaid Services (CMS), previously known as Health Care Financing Administration (HCFA). The State of Maine Department of Human Services, Office of Maine. Care Services, is continuously recruiting primary care providers (PCPs) to join Maine. Care managed care. The purpose of this manual is to introduce Maine. Care managed care benefit, outline the benefits of joining, explain how to join, and offer this manual as a useful tool to PCP staff. We hope to increase participation, continue to increase Maine. Care members’ access to care, and to enhance the State’s network of services. Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

Introduction to Maine. Care Managed Care z The State of Maine currently enrolls eligible Maine. Care members into managed care, a Primary Care Case Management (PCCM) z PCCM is the only Maine. Care managed care plan z Operational in all 16 counties with member enrollment over 169, 800+ NYLCare Choice (HMO) begins as a voluntary program in 10 counties Maine. Care managed care begins as a voluntary pilot program in Kennebec and Somerset counties 1994 1995 1996 Maine. Care managed care expands as a mandatory program in Aroostook, Piscataquis, & Washington counties Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008 1997 Aetna US Healthcare new HMO 1998 Enrollment advisor is hired for Maine. Care managed care expands as a mandatory program into Androscoggin, York, Cumberland Somerset counties Maine. Care managed care completes expansion as a mandatory program Statewide 1999 Aetna US Healthcare (HMO) withdraws 2000

The Purpose and Success of Maine. Care Managed Care z The primary objectives of Maine. Care managed care to: w Improve Maine. Care members’ access to providers w Have Maine. Care members establish a “medical home” w Increase continuity of care w Strengthen the patient and provider relationship w Reduce unnecessary utilization and expenditures Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

The Member Enrollment Cycle z Maine. Care managed care requires a member (TANF/TANF Related) to choose a PCP within twentyeight calendar days of the mailing of the enrollment packet, or Maine. Care will choose one for that member. Over 90% of members voluntarily choose a PCP site. z If the member does not enroll voluntarily within twenty-eight days, Maine. Care autoassigns a PCP for the member using historical Maine. Care paid claims data and assigning each member using an algorithm that recognizes both currency and frequency. z All enrollees are mailed a Confirmation Letter the business day after their enrollment is entered into the Maine. Care managed care enrollment system. z New enrollments are effective on the 1 st and the 15 th of each month. z The following timeline displays the key events in the twenty-eight day enrollment cycle: Day 1 Enrollment Packet Mailed Day 7 Follow-Up Letter Mailed Day 14 Follow-Up Call Made Day 21 Follow-Up Call Made (Or letter if no valid phone) Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008 Day 25/27 Follow- Up Call Made Day 28 Auto-Assign PCP & Confirmation Letter Mailed Within 14 Days After Confirmation Letter Welcome Packet Mailed

Who Can Become a Maine. Care Managed Care Provider? z Any existing Maine. Care provider who provides comprehensive primary care and provides twenty-four hour/seven day per week coverage for their patients can enroll in Maine. Care managed care. z Primary Care Providers can be any of the following Maine. Care providers: w w Doctors of Medicine (MDs) Doctors of Osteopathy (DOs) Physician Assistants (PAs) Nurse Practioners (NPs) z Providers may enroll as a solo provider, group, Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or clinic upon OMS approval. z PCPs are assigned a Maine. Care managed care referral number for use with their Maine. Care managed care patients. Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

Why Should My Site Join Maine. Care Managed Care ? There are several advantages to becoming a Maine. Care managed care provider: z PCP sites receive the regular Maine. Care Fee For Service (FFS) payment for each service provided; and a $2. 50 management fee per patient per month, even if they do not see the patient during that particular month. For Example: 100 Maine. Care member panel X $2. 50/month = $250. 00 per month. (NOTE: Primary Care Provider sites that are Hospital Base Sites, billing under a hospital billing number are not eligible to receive PCCM Management Fee) z The PCP directs all patient care. OMS defers to PCPs, allowing them to make decisions regarding the care of their patients for Maine. Care covered services by other Maine. Care providers. The Department does not approve or disapprove PCP referrals. z About 45% (on average) of your Maine. Care patients - and over 70% of your Maine. Care patients under 18 will be enrolled in Maine. Care managed care. The only way to continue to see your patients for primary care without a referral is if you enroll as a Maine. Care managed care PCP. z Providers who are eligible Maine. Care managed care PCPs fare better with Maine. Care’s Primary Care Incentive Payment Program (PCPIP) because these incentives are geared towards the goals of Maine. Care managed care. z Through PCP Network Services, Member Services will work to help you educate your patients about seeking appropriate and regular care and following practice rules, as well as to assist in appropriate Maine. Care member panel changes. Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

Members In Managed Care Maine. Care managed care also holds many key advantages for members: z Maine. Care managed care is a mandatory program through an approval by the CMS. z Members who often have difficulty finding a “medical home” are able to enter into stable relationships with providers. z Members receive continuity of care rather than random emergency department care or multiple primary care by different providers. As a result, there is a greater emphasis placed on preventive care. z Members can be sure that their care is coordinated by their PCP. z Members know that their PCP has 24 hours a day/7 days a week coverage. Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

Responsibilities Member responsibilities are: w Obtaining a referral (prior to obtaining services), for those services not provided by his/her PCP; w Calling his/her PCP for instructions prior to obtaining off-hours non-emergent care; w Following the after-hours coverage plan of his/her PCP; and w Following practice rules of his/her PCP responsibilities are: w Providing comprehensive primary care; w Authorizing medically necessary referrals; (Referral forms are free of charge through the Office of Maine. Care Services) w Providing or arranging 24 hour coverage, 7 days a week; and w Educating patients about Maine. Care managed care rules, seeking appropriate regular care and following practice rules. Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

Maine. Care Managed Care Referral Process z Maine. Care managed care PCPs are responsible for assuring a referral is authorized when their patients need to access services from another Maine. Care provider. The lists of managed and non-managed services are on following pages. You may only refer Maine. Care managed care members to Maine. Care providers. z By authorizing the service via a referral the patient can access services immediately. (Please note that these services may require Maine. Care Prior Authorization. For Prior Authorization, you must to call 800 -3215557 extension 72033. The referral form is not enough. ) z Providers can refer a patient for more than one visit (e. g. , six months). This referral is good as long as the member is enrolled with the same PCP. z When staff fill out referral forms, they are required to list the presenting symptoms in Box 4 - Clinical Information. (These symptoms may not be part of the final diagnosis. ) z When referral forms are completed or *automated referrals are done, one copy stays with the provider, one copy may be given to the patient, one copy is sent to the referred provider, and a copy is mailed or faxed to the Office of Maine. Care Services. z If you fax a referral to us, do not mail in a copy also. Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008 Fax Number is 207 -287 -1864 *Automated referrals = Primary Care Provider site system generated version of the Maine. Care referral form that must contain same information. OMS approved.

Things to Watch for With Referrals z The Maine. Care managed care referral number always follows the patient. If a patient is seen in a covering PCP office and referred on to another provider for treatment, the Maine. Care managed care referral number on the referral form must be from the actual PCP site from where the patient is enrolled (not where the patient was seen) in order for that provider to be paid. z You may make a referral for several types of care on one form, e. g. consult and surgery. But if you only check consult, then you must prepare an additional referral for surgery. z Specialists may use a PCP’s referral to authorize any diagnostic testing they feel is needed to carry out your referral, unless PCP specifically checks the “No Lab X-Ray” or “No Diagnostic Procedure” box on the referral form. z If you make a referral for surgery that takes place in a hospital, the form should indicate Surgery/Admit, and Hospital. The surgeon may give referral information to the hospital for billing purposes. z Referrals from a PCP are only effective for dates of service while a member is enrolled with that PCP. When patients transfer to your office, find out if they are currently receiving care that would require a referral from your office. Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

Maine. Care Managed Care Services The following services require a referral from Maine. Care managed care PCPs are responsible for completing a referral form when patients need to access the following services: z z z z Advanced Practice Registered Nursing Services Ambulatory Surgical Center Services Audiology Services Chiropractic Services Clinic: y Ambulatory Care Clinics y Federally Qualified Health Centers y Rural Health Clinics Developmental and Behavioral Evaluation Clinic Early and Periodic Screening, Diagnosis, and Treatment Services Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008 z z z Hearing Aids and Services Home Health Services Hospital Services (Except lab and medical imaging) Medical Supplies and Durable Medical Equipment Occupational Therapy Services Ophthalmology and Optometry Services Physical Therapy Services Physician Services Podiatry Services Speech and Hearing Agencies Speech/Language Pathology Services Maine. Care managed care members are responsible for payment of copays as directed by the applicable policy.

Non-Managed Maine. Care Managed Care Services The following services do not require a referral from the Maine. Care managed care PCP These services will remain under regular fee-for-service Maine. Care z z Ambulance Services Annual Gynecological Examinations and Limited follow-up for abnormal PAP Smears z z z z Annual Routine Eye Exams Community Support Services Consumer Directed Attendant Services Day Habilitation Services for Persons with Mental Retardation Day Health Services Day Treatment Services Dental Services Early Intervention Services Hospital’s Emergency Department Services Family Planning Agency Services Genetic Testing and Clinical Genetic Services Home Based Mental Health Services Home and Community Benefits for the Elderly and z z Home and Community Based Waiver Services for Persons with Mental Retardation Home and Community Based Waiver Services for z z Hospice Services ICF-MR Services for Adults with Disabilities the Physically Disabled Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008 z z z z z z Laboratory Services Licensed Clinical Social Worker Services Medical Imaging Services Mental Health Clinic Services Mental Health and Substance Abuse Services Nursing Facility Services Obstetrical Services Optician Services Organ Transplant Services Pharmacy Services Private Duty Nursing and Personal Care Services Private Non-Medical Institution Services Psychiatric Facility Services Psychological Services Rehabilitative Services School-Based Clinics and Well Child Clinics School-Based Rehabilitation Services Substance Abuse Treatment Services Targeted Case Management Services Transportation Services V. D. Screening Clinic Services New Maine. Care Benefits Manual, Chapter II Sections Maine. Care managed care members are responsible for payment of copays as directed by the applicable policy.

Identifying the Maine. Care Managed Care Patients z PCP sites have found that it helps to contact new patients for a “get acquainted” visit, so that they get to know their patients before they get sick. We encourage Maine. Care managed care members to schedule these visits. z Offices must verify all member eligibility & enrollment. All Maine. Care members must show their Maine. Care ID card when they access services. Treating a Maine. Care member without checking eligibility puts providers at risk for nonpayment of their claims. z For the most current eligibility and enrollment status of members, you can use the swipe card technology if available in your office or call the Maine. Care Interactive Voice Response at (800) 452 -4694 or (207) 287 -3081 - local Augusta Number. z Each Maine. Care managed care enrollee is sent a Confirmation Letter that shows his/her PCP, and is asked to keep it with his/her Maine. Care card until the system reflects the correct PCP. z Maine. Care managed care enrollment occurs on the 1 st and 15 th of each month. It is important to verify the current eligibility and enrollment status of all Maine. Care members. z All PCP sites receive member Panel Reports monthly. Reports are called: Enrolled/Disenrolled Panel Report and Current Patient Panel Reports may be used to verify site Maine. Care m anaged care enrollment. Reports are run on or about the 1 st and the 15 th of every month and the information is date specific. Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

Billing Under Maine. Care Managed Care Billing under the Maine. Care managed care program is similar to billing for regular Maine. Care managed care claims ARE Maine. Care claims z For provider visits, the CMS-1500 is completed as usual, except: w Block 17 should contain the PCP Name w Block 17 a must contain the PCP Maine. Care managed care referral number (which will be unique to the site or the provider) w Electronic: Record F, Field 8, left justified z For hospital visits, the UB-92 will be completed as usual, except: w Field Locator 63 Line A must contain the PCP Maine. Care managed care referral number w Electronic: Record 40, Position 28 -45, PCCM#, Field 5, left justified z You must type referral numbers on paper claims, as these claims are scanned z Maine. Care encourages electronic billing. You may contact 207 -287 -3704 for assistance Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

The State, Member Services, and Maine. Care Managed Care Department of Health and Human Services Regional Offices Maine. Care Services Determines Maine. Care Managed Care Eligibility Determines Maine. Care Eligibility Bureau of Health (BOH) Coordinates Access to EPSDT Services with Member Services Maine. Care Managed Care Members Primary Care Network Services and Member Services • • • Recruits and maintains PCPs for Maine. Care managed care members Enrolls members into Maine. Care managed care Provides ongoing services to members Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008 Maine. Care Managed Care PCPs

Maine. Care Services and Maine. Care Managed Care Primary Care Provider Network Services is responsible for providing assistance to PCPs with the following: z Mailing practice site confirmation sheets to PCP Sites every six months; z Mailing PCP Sites semi-monthly Maine. Care Managed Care Panel Reports (including enrollments and disenrollments) and monthly reports complete panel report. These reports are very helpful in determining managed care enrollment for: Referrals, claims that require the 9 -digit PCP Site Referral Number and identifying new patients who have not established with the office. Reports are sent to each PCP Site location. We encourage PCP Sites to make contact with new patients or identifying enrollment errors; z Monitoring 24 -hour access coverage with the Office of Maine. Care Services by calling each PCP site after hours at least once annually; z Updating and providing exempt procedure and diagnosis codes; z Assuring an Interactive Voice Response System to verify Maine. Care and Maine. Care managed care eligibility - if you choose not to verify eligibility, you are at risk for non-payment of services; Continued on next page Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

Maine. Care Managed Care (Continued) z Sending Primary Care Provider Incentive Program (PCPIP)/Utilization reports; z Assisting with the patient or PCP Grievance Procedure; z Conducting periodic PCP and member surveys; z Sending PCP Sites special mailings; z Supplying Maine. Care managed care PCP Sites with referral forms - at no cost; z Supplying Maine. Care managed care PCP Sites with Member Education Request Forms that are used as an educational tool for follow-up with members; and, z Assisting PCP Sites with questions, research, education, follow-up, etc Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

Member Education Request Form Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

How Do I Become A Managed Care PCP Site Below is the process for becoming a Maine. Care managed care PCP. More specific instructions are included as part of the Maine. Care managed care rider: 1. Enroll as a Maine. Care provider; 2. Follow Primary Care Case Management (PCCM) rules; 3. Agree to the Maine. Care managed care rider terms and conditions; 4. Determine the eligible providers in your practice who provide primary care; 5. Complete the Maine. Care Managed Care Rider and Primary Care Provider Site Fact Sheet and forward this information to Office of Maine. Care Services; 6. Primary Care Provider Network Services will work with you in processing your paperwork. To add an enrolled Maine. Care provider(s) to an existing PCP site, call Primary Care Provider Network Services at (866) 796 -2463 Extension 74827 and request a Maine. Care Primary Care Provider Site Fact Sheet. Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

Key Terms Office of Integrated Access & Support (OIAS) This state agency determines member eligibility for Maine. Care, Food Stamps, and other types of assistance. Maine. Care Services Maine. Care managed care. Prevention, Health Promotion, and A federally mandated program requiring the state to provide certain Optional Treatment Services services to Maine. Care eligible children under the age of 21. These include services to identify and address health & development issues at an early age, in addition to assisting a child to gain access to the appropriate health care. Fee-For-Service (FFS) A method for providing Maine. Care services to individuals, where the individual accesses services as needed and Maine. Care pays for the services provided. Member Services Member services is the entity that is responsible for educating Maine. Care members about their health care options. Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

Key Terms (Continued) Maine. Care Managed Care Primary Care Case Management (PCCM) program for Maine. Care managed care eligible members. Member A person receiving Maine. Care, who, in this case, is eligible to participate in the Maine. Care managed care program. Primary Care Case Management (PCCM) A Maine. Care managed care model where patients are linked with individual providers who manage their care. (Chapter VI, Section 1, Primary Care Case Management http: //www. maine. gov/OMS/rulemaking/) Primary Care Provider (PCP) A Maine. Care provider that provides comprehensive primary care and provides twenty-four hour/seven day per week coverage for their patients that has enrolled with Maine. Care managed care. Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

Key Terms (Continued) Public Consulting Group, Inc. Company that has been hired by the Office of Maine. Care Services (OMS) to provide member services for the Maine. Care members. Temporary Assistance Needy Families (TANF) The federal assistance program that replaced Aid to Families with Dependent Children (AFDC) as part of PRWORA Act (“Welfare Reform”) passed in 1996. Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008

Attachments z Primary Care Case Management Rules from the Maine. Care Benefits Manual z Maine. Care Managed Care Exempt Codes z Point of Service (POS) Electronic Eligibility Verification – Member Maine. Care ID y Medifax-EDI Maine. Care member eligibility verification system z Sample Maine. Care Managed Care Referral Form y Instructions on how to obtain a referral form supply z Maine. Care managed care frequently asked questions z Contact Sheet z Maine. Care Co-Payments Quality Management Unit ~ Primary Care Provider Network Services 207 -287 -4827 ~ 866 -796 -2463 Extension 74827 Revised March 2008