quality management unit ~ primary care provider network services 207-287-4827 ~ 866-796-2463...

Quality Management Unit ~ Primary Care Provider Network Services207-287-4827 ~ 866-796-2463 Extension 74827Revised March 2008

Introduction to MaineCare Managed Care

Prepared for Primary Care Provider Sites

Department of Health and Human ServicesMaineCare Services442 Civic Center Drive# 11 State House StationAugusta, Maine 04333-0011Primary Care Provider Network Services207-287-4827 ~ 866-796-2463 Extension 74827 ~ FAX 207-287-1864

March 2008


MaineCare managed care is a Primary Care Case Management (PCCM) Benefit for eligible (primarily the TANF population ~ Temporary Aid for Needy Families) MaineCare members. MaineCare 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 MaineCare Services, is continuously recruiting primary care providers (PCPs) to join MaineCare managed care. The purpose of this manual is to introduce MaineCare 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 MaineCare members’ access to care, and to enhance the State’s network of services.

Managed Care


The State of Maine currently enrolls eligible MaineCare members into managed care, a Primary Care Case Management (PCCM)

PCCM is the only MaineCare managed care plan

Operational in all 16 counties with member enrollment over 169,800+

20001994 1996 1997 1998 19991995

MaineCare managed care begins as a voluntary pilot program in Kennebec and Somerset counties

MaineCare managed care expands as a mandatory program in Aroostook, Piscataquis, & Washington counties

NYLCare Choice (HMO) begins as a voluntary program in 10 counties

Enrollment advisor is hired for MaineCare managed care.

MaineCare managed care expands as a mandatory program into Androscoggin, York, Cumberland and Somerset counties

MaineCare managed care completes expansion as a mandatory program Statewide

Introduction to MaineCare Managed Care

Aetna US Healthcare (HMO) withdraws

Aetna US Healthcare new HMO


The primary objectives of MaineCare managed care are to:

The Purpose and Success ofMaineCare Managed Care

Improve MaineCare members’ access to providers

Have MaineCare members establish a “medical home” Increase continuity of care

Strengthen the patient and provider relationship

Reduce unnecessary utilization and expenditures


The Member Enrollment Cycle

MaineCare managed care requires a member (TANF/TANF Related) to choose a PCP within twenty-eight calendar days of the mailing of the enrollment packet, or MaineCare will choose one for that member. Over 90% of members voluntarily choose a PCP site.

If the member does not enroll voluntarily within twenty-eight days, MaineCare autoassigns a PCP for the member using historical MaineCare paid claims data and assigning each member using an algorithm that recognizes both currency and frequency.

All enrollees are mailed a Confirmation Letter the business day after their enrollment is entered into the MaineCare managed care enrollment system.

New enrollments are effective on the 1st and the 15th of each month.

The following timeline displays the key events in the twenty-eight day enrollment cycle:Day 14 Day 21 Day 25/27 Day 28Day 1 Day 7

Enrollment Packet Mailed

Follow-Up Letter Mailed

Follow-Up Call Made

Follow-Up Call Made

(Or letter if no valid phone)

Follow- Up Call Made

Auto-Assign PCP & Confirmation Letter Mailed

Welcome Packet Mailed

Within 14 Days After Confirmation

Letter


Any existing MaineCare provider who provides comprehensive primary care and provides twenty-four hour/seven day per week coverage for their patients can enroll in MaineCare managed care.

Primary Care Providers can be any of the following MaineCare providers:

Providers may enroll as a solo provider, group, Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or clinic upon OMS approval.

PCPs are assigned a MaineCare managed care referral number for use with their MaineCare managed care patients.

Doctors of Medicine (MDs) Doctors of Osteopathy (DOs) Physician Assistants (PAs) Nurse Practioners (NPs)

Who Can Become a MaineCare Managed Care Provider?


There are several advantages to becoming a MaineCare managed care provider: PCP sites receive the regular MaineCare 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 MaineCare 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)

The PCP directs all patient care. OMS defers to PCPs, allowing them to make decisions regarding the care of their patients for MaineCare covered services by other MaineCare providers. The Department does not approve or disapprove PCP referrals.

About 45% (on average) of your MaineCare patients - and over 70% of your MaineCare patients under 18 - will be enrolled in MaineCare managed care. The only way to continue to see your patients for primary care without a referral is if you enroll as a MaineCare managed care PCP.

Providers who are eligible MaineCare managed care PCPs fare better with MaineCare’s Primary Care Incentive Payment Program (PCPIP) because these incentives are geared towards the goals of MaineCare managed care.

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 MaineCare member panel changes.

Why Should My Site Join MaineCare Managed Care ?


MaineCare managed care also holds many key advantages for members:

MaineCare managed care is a mandatory program through an approval by the CMS.

Members who often have difficulty finding a “medical home” are able to enter into stable relationships with providers.

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.

Members can be sure that their care is coordinated by their PCP.

Members know that their PCP has 24 hours a day/7 days a week coverage.

Members In Managed Care


Obtaining a referral (prior to obtaining services), for those services not provided by his/her PCP;

Calling his/her PCP for instructions prior to obtaining off-hours non-emergent care;

Following the after-hours coverage plan of his/her PCP; and

Following practice rules of his/her PCP.

Providing comprehensive primary care;

Authorizing medically necessary referrals; (Referral forms are free of charge through the Office of MaineCare Services)

Providing or arranging 24 hour coverage, 7 days a week; and

Educating patients about MaineCare managed care rules, seeking appropriate regular care and following practice rules.

Responsibilities

PCP responsibilities are:

Member responsibilities are:


MaineCare managed care PCPs are responsible for assuring a referral is authorized when their patients need to access services from another MaineCare provider. The lists of managed and non-managed services are on following pages. You may only refer MaineCare managed care members to MaineCare providers.

By authorizing the service via a referral the patient can access services immediately. (Please note that these services may require MaineCare Prior Authorization. For Prior Authorization, you must to call 800-321-5557 extension 72033. The referral form is not enough.)

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.

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.)

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 MaineCare Services.

If you fax a referral to us, do not mail in a copy also. Fax Number is 207-287-1864

MaineCare Managed Care Referral Process

*Automated referrals = Primary Care Provider site system generated version of the MaineCare referral form that must contain same information. OMS approved.


The MaineCare 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 MaineCare 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.

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.

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.

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.

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.

Things to Watch for With Referrals


Advanced Practice Registered Nursing Services Ambulatory Surgical Center Services Audiology Services Chiropractic Services Clinic:

Ambulatory Care Clinics Federally Qualified Health Centers Rural Health Clinics

Developmental and Behavioral Evaluation Clinic Early and Periodic Screening, Diagnosis, and Treatment

Services

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

The following services require a referral from MaineCare managed care PCP. PCPs are responsible for completing a referral form when patients need to access the following services:

MaineCare Managed Care Services

MaineCare managed care members are responsible for payment of copays as directed by the applicable policy.


Ambulance Services Annual Gynecological Examinations and

Limited follow-up for abnormal PAP Smears 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

for Adults with Disabilities Home and Community Based Waiver Services for

Persons with Mental Retardation Home and Community Based Waiver Services for

the Physically Disabled Hospice Services ICF-MR Services

The following services do not require a referral from the MaineCare managed care PCP

These services will remain under regular fee-for-service MaineCare

Non-Managed MaineCare Managed Care Services

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 MaineCare Benefits Manual, Chapter II Sections

MaineCare managed care members are responsible for payment of copays as directed by the applicable policy.


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 MaineCare managed care members to schedule these visits.

Offices must verify all member eligibility & enrollment. All MaineCare members must show their MaineCare ID card when they access services. Treating a MaineCare member without checking eligibility puts providers at risk for nonpayment of their claims.

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 MaineCare Interactive Voice Response at (800) 452-4694 or (207) 287-3081 - local Augusta Number.

Each MaineCare managed care enrollee is sent a Confirmation Letter that shows his/her PCP, and is asked to keep it with

his/her MaineCare card until the system reflects the correct PCP.

MaineCare managed care enrollment occurs on the 1st and 15th of each month. It is important to verify the current eligibility and enrollment status of all MaineCare members.

All PCP sites receive member Panel Reports monthly. Reports are called: Enrolled/Disenrolled Panel Report and Current Patient Panel Report. Reports may be used to verify site MaineCare managed care enrollment. Reports are run on or about the 1st and the 15th of every month and the information is date specific.

Identifying the MaineCareManaged Care Patients


Billing under the MaineCare managed care program is similar to billing for regular MaineCare.

MaineCare managed care claims ARE MaineCare claims

For provider visits, the CMS-1500 is completed as usual, except:

For hospital visits, the UB-92 will be completed as usual, except:

You must type referral numbers on paper claims, as these claims are scanned

MaineCare encourages electronic billing. You may contact 207-287-3704 for assistance

Billing Under MaineCare

Managed Care

Block 17 should contain the PCP Name Block 17a must contain the PCP MaineCare managed care referral number (which will be

unique to the site or the provider) Electronic: Record F, Field 8, left justified

Field Locator 63 Line A must contain the PCP MaineCare managed care referral number Electronic: Record 40, Position 28-45, PCCM#, Field 5, left justified


The State, Member Services, and MaineCare Managed Care

Department of Health and Human Services Regional Offices

Determines MaineCare Eligibility

MaineCare Services

• Recruits and maintains PCPs for MaineCare managed care members

• Enrolls members into MaineCare managed care • Provides ongoing services to members

Determines MaineCare Managed Care Eligibility

MaineCare Managed Care Members

MaineCare Managed Care PCPs

Bureau of Health (BOH)

Coordinates Access to EPSDT Services with Member Services

Primary Care Network Servicesand Member Services


Primary Care Provider Network Services is responsible for providing assistance to PCPs with the following:

Mailing practice site confirmation sheets to PCP Sites every six months;

Mailing PCP Sites semi-monthly MaineCare 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;

Monitoring 24-hour access coverage with the Office of MaineCare Services by calling each PCP site after hours at least once annually;

Updating and providing exempt procedure and diagnosis codes;

Assuring an Interactive Voice Response System to verify MaineCare and MaineCare managed care eligibility - if you choose not to verify eligibility, you are at risk for non-payment of services;

MaineCare Services andMaineCare Managed Care

Continued on next page


Sending Primary Care Provider Incentive Program (PCPIP)/Utilization reports;

Assisting with the patient or PCP Grievance Procedure;

Conducting periodic PCP and member surveys;

Sending PCP Sites special mailings;

Supplying MaineCare managed care PCP Sites with referral forms - at no cost;

Supplying MaineCare managed care PCP Sites with Member Education Request Forms that are used as an educational tool for follow-up with members; and,

Assisting PCP Sites with questions, research, education, follow-up, etc

MaineCare Managed Care

(Continued)


Member Education Request Form

Managed Care Member Education Request Form

(Please Print)

Date: __________________________

PCPS Name:

_______________________________________________

PCP Phone Number:

_________________________________ MaineCare Member’s Name:

_______________________________________________

Member’s MaineCare ID Number:

_________________________________

This MaineCare managed care member needs to be educated regarding: (Check all that apply, and please be specific in your explanation) When to access emergency Sservices Following managed care rules Obtaining referrals for Ccare No-showing for appointments Following practice rules Bringing MaineCare card to

appointments Other _________________________________________________________________________ Explanation: ______________________________________________________________________

___________________________________________________________ ___________________________________________________________

___________________________________________________________ ___________________________________________________________ ___________________________________________________________

___________________________________________________________

Please contact the Bureau of Medical Services ~ PCP Network Services at: 1-866 796-2463 or 207-287-7131, for a supply of these forms.

You may also FAX this form to 207-287-1864 (If mailing, please seal with the attached adhesive tape to preserve confidentiality.)

Thank you.


Below is the process for becoming a MaineCare managed care PCP. More specific instructions are included as

part of the MaineCare managed care rider:

1. Enroll as a MaineCare provider;

2. Follow Primary Care Case Management (PCCM) rules;

3. Agree to the MaineCare managed care rider terms and conditions;

4. Determine the eligible providers in your practice who provide primary care;

5. Complete the MaineCare Managed Care Rider and Primary Care Provider Site Fact Sheet and forward this information to Office of MaineCare Services;

6. Primary Care Provider Network Services will work with you in processing your paperwork.

To add an enrolled MaineCare provider(s) to an existing PCP site, call Primary Care Provider Network Services

at (866) 796-2463 Extension 74827 and request a MaineCare Primary Care Provider Site Fact Sheet.

How Do I BecomeA Managed Care PCP Site


Key Terms

Office of Integrated This state agency determines member eligibility for MaineCare, Food Access & Support (OIAS) Stamps, and other types of assistance.

MaineCare Services MaineCare managed care.

Prevention, Health Promotion, and A federally mandated program requiring the state to provide certain Optional Treatment Services services to MaineCare 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 MaineCare services to individuals, where the individual accesses services as needed and MaineCare pays for the services provided.

Member Services Member services is the entity that is responsible for educating MaineCare members about their health care options.


Key Terms (Continued)

MaineCare Managed Care Primary Care Case Management (PCCM) program for MaineCare managed care eligible members.

Member A person receiving MaineCare, who, in this case, is eligible to participate in the MaineCare managed care program.

Primary Care Case A MaineCare managed care model where patients are linked with Management (PCCM) 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 MaineCare provider that provides comprehensive primary care and provides twenty-four hour/seven day per week coverage for their

patients that has enrolled with MaineCare managed care.


Key Terms (Continued)

Public Consulting Group, Inc. Company that has been hired by the Office of MaineCare Services

(OMS) to provide member services for the MaineCare members.

Temporary Assistance The federal assistance program that replaced Aid to Families with Needy Families (TANF) Dependent Children (AFDC) as part of PRWORA Act

(“Welfare Reform”) passed in 1996.


Primary Care Case Management Rules from the MaineCare Benefits Manual

MaineCare Managed Care Exempt Codes

Point of Service (POS) Electronic Eligibility Verification – Member MaineCare ID Medifax-EDI MaineCare member eligibility verification system

Sample MaineCare Managed Care Referral Form Instructions on how to obtain a referral form supply

MaineCare managed care frequently asked questions

Contact Sheet

MaineCare Co-Payments

Attachments

quality management unit ~ primary care provider network services 207-287-4827 ~ 866-796-2463...

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