Introduction to MaineCare Managed Care Prepared for Primary Care Provider Sites

1. Introduction to MaineCare Managed Care Prepared for Primary Care Provider Sites Department of Health and Human Services MaineCare 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 March 2008

2. Managed Care 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.

3. 1998 1994 2000 1999 1997 1996 1995 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 NYLCare Choice (HMO) begins as a voluntary program in 10 counties 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 Enrollment advisor is hired for MaineCare managed care. Introduction to MaineCare 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+ Aetna US Healthcare new HMO Aetna US Healthcare (HMO) withdraws

4. The Purpose and Success of MaineCare Managed Care • The primary objectives of MaineCare managed care are to: • 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

5. 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: Within 14 Days After Confirmation Letter Day 7 Day 21 Day 28 Day 1 Day 25/27 Day 14 Follow-Up Call Made (Or letter if no valid phone) Follow-Up Call Made Follow- Up Call Made Follow-Up Letter Mailed Enrollment Packet Mailed Auto-Assign PCP & Confirmation Letter Mailed Welcome Packet Mailed

6. Who Can Become a MaineCare Managed Care Provider? • 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)

7. Why Should My Site Join MaineCare Managed Care ? 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.

8. Members In 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.

9. Responsibilities Member responsibilities are: • Obtaining a referral (prior to obtaining services), for those services not providedby 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. PCP responsibilities are: • 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 followingpractice rules.

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

11. Things to Watch for With Referrals • 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.

12. 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 MaineCare Managed Care Services The following services require a referral from MaineCare managed carePCP. PCPs are responsible for completing a referral form when patients need to access the following services: MaineCare managed care members are responsible for payment of copays as directed by the applicable policy.

13. Non-Managed MaineCare Managed CareServices The following services do not require a referral from the MaineCare managed care PCP These services will remain under regular fee-for-service MaineCare • 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 • 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 MaineCare managed care members are responsible for payment of copays as directed by the applicable policy.

14. Identifying the MaineCareManaged Care Patients • 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.

15. Billing Under MaineCare Managed Care Billing under the MaineCare managed careprogram is similar to billing for regular MaineCare. MaineCare managed careclaims 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 • Block 17 should contain the PCP Name • Block 17a must contain the PCP MaineCare managed carereferral 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 carereferral number • Electronic: Record 40, Position 28-45, PCCM#, Field 5, left justified

16. Bureau of Health (BOH) Coordinates Access to EPSDT Services with Member Services The State, Member Services, and MaineCare Managed Care Department of Health and Human Services Regional Offices MaineCare Services Determines MaineCare Managed Care Eligibility Determines MaineCare Eligibility MaineCare Managed CareMembers Primary Care Network Services and Member Services MaineCare Managed Care PCPs • Recruits and maintains PCPs for MaineCare managed care members • Enrolls members into MaineCare managed care • Provides ongoing services to members

17. MaineCare Services andMaineCare Managed Care 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 CarePanel 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 careeligibility - if you choose not to verify eligibility, you are at risk for non-payment of services; Continued on next page

18. MaineCare Managed Care(Continued) • 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 carePCP Sites with referral forms - at no cost; • Supplying MaineCare managed carePCP 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

19. Member Education Request Form

20. How Do I Become A Managed Care PCP Site Below is the process for becoming a MaineCare managed carePCP. 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 carerider terms and conditions; 4. Determine the eligible providers in your practice who provide primary care; 5. Complete the MaineCare Managed CareRider and Primary CareProvider 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.

21. 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.

22. 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.

23. 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.

24. Attachments • 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