C.M.R. 10, 144, ch. 101, ch. VI, 144-101-VI-01, subsec. 144-101-VI-01.07

Current through 2024-46, November 13, 2024

Subsection 144-101-VI-01.07 - MEMBER PARTICIPATION IN PRIMARY CARE CASE MANAGEMENT

1.07-1Members Who Are Required to Participate

A MaineCare member must participate in Primary Care Case Management if he/she is in one of the following categories:

a. Receiving Temporary Assistance for Needy Families (TANF) - Adults and Children;

b. Children under the age of twenty-one (21); parents of children under age eighteen (18) who receive MaineCare; pregnant women; and those members eligible for transitional MaineCare; except as referenced in 1.07-4.

c. Women who have been screened for breast or cervical cancer under the Centers for Disease Control and Prevention Title XV Program and are found to need treatment for breast or cervical cancer, including pre-cancerous conditions, as defined in Section 2150.03 of the MaineCare Eligibility Manual.

d. Adults, ages twenty-one (2 1) through sixty-four (64), who do not have children or do not have children under age eighteen (18) living with them and are at or below one-hundred percent (100%) of the federal poverty level. Those receiving benefits under the Non-Categorical Waiver will receive benefits limited to those listed under Chapter X, Section 2, Benefit for Childless Adults in the MaineCare Benefits Manual.

1.07-2Exclusions from Participation

The following MaineCare members are excluded from participation in Primary Care Case Management:

a. Members who are eligible for both MaineCare and Medicare;

b. Members with other forms of comprehensive health insurance;

c. Members under age nineteen (19) with special health care needs who meet the eligibility criteria for the MaineCare Katie Beckett eligibility option, as described in Section 1902(e)(3) of the Social Security Act;

d. Members residing in a nursing facility or intermediate care facility for the mentally retarded (ICF-MR);

e. Alaskan Natives or Native Americans who are members of federally recognized tribes and who have requested to be excluded from program participation; and

f. Members receiving Home and Community Benefits.

1.07-3Exemptions from Participation

Certain MaineCare members may request an exemption from participation in Primary Care Case Management on the basis of individual conditions. Exemptions may also occur when the Office of MaineCare Services determines enrollment is not in the best interest of the State. The Office of MaineCare Services will retain final responsibility for all exemption decisions. Conditions supporting an exemption are listed below. A member is eligible to request an exemption if she/he:

a.Administrative Exemptions

i. has to travel more than thirty (30) minutes to a participating PCP (if not in an established relationship with a participating PCP);

ii. is homeless;

iii. is a migrant or a family member accompanying a migrant;

iv. has specific language barriers or cultural needs that may not be addressed by an available PCP. Culturally appropriate care is care that is provided with sensitivity, understanding and respect for the member's culture. Each of these cases will be reviewed by the OMS for cultural sensitivity/medical necessity for exemption;

v. is required to follow member restriction provisions;

vi. is residing out of state;

vii. does not have an updated address;

viii. is residing in a jail or State or private mental institution; or ix. is an inpatient of a hospital on the date of enrollment. Such individuals will have an automatic enrollment after the hospital discharge.

b.Clinical Exemptions

i. has a terminal illness and has an established relationship with a qualified health care provider who is not a qualified MaineCare Primary Care Case Management PCP. Each of these cases will be reviewed by the MaineCare Medical Director for medical necessity for exemption;

ii. has a chronic and debilitating condition which requires managed services from a qualified primary care health provider who is not a MaineCare Primary Care Case Management PCP. Each of these cases will be reviewed by the MaineCare Medical Director for medical necessity for exemption; or iii. is receiving hospice care.

MaineCare members identified as exempt, but otherwise eligible for participation in Primary Care Case Management, may voluntarily choose to participate in Primary Care Case Management.

1.07-4Voluntary Participation

The following members may not be required to participate in PCCM, but may voluntarily choose to participate in Primary Care Case Management:

a. Children under age nineteen (19):

i. with Adoption Assistance; or

ii. under the age of nineteen (19) with special health care needs who meet all other eligibility criteria; or

iii. in DHHS foster care; or other out-of home placement;

iv. under age nineteen (19) years of age and eligible for SSI who do not otherwise meet exclusion criteria under Section 1.07-2;

b. Members who are Alaskan native or Native American or part of a federally recognized tribe;

c. Non-English speaking members who had been granted exemptions; or

d. Eligible for Supplemental Security Income (SSI) who do not meet exclusion criteria under Section 1.07-2.

1.07-5Enrollment

MaineCare members who must participate in Primary Care Case Management will be notified by mail within three (3) business days of the date they appear in MECAPS.

Opportunities for face-to-face sessions to enroll in the benefit will be provided on the basis of, among other things, the following:

(1) a specific request by a member;

(2) a determination by MaineCare Member Services that there is a significant probability that the member will not complete and return the enrollment application and make an informed choice without face-to-face intervention; or

(3) a meeting arranged by MaineCare Member Services, in conjunction with, and at the request of a member, advocacy group or community service agency. Upon request, MaineCare Member Services will provide interpreter services for face-to-face sessions for members who are non-English and limited English speaking and/or deaf/hard of hearing, provided the request is received by MaineCare Member Services in advance of the session. The member will have twenty-eight (28) calendar days to complete the enrollment process. Prior to the end of the twenty-eight (28) calendar days, the member must complete and return the provider choice form by mail or call MaineCare Member Services to enroll by phone. The member must also, as a part of the enrollment process, provide the names of three providers (in order of preference) as choices for a PCP. In the event a member does not elect a provider, a Primary Care Case Management PCP will be selected for the member.

1.07-6Selection of a Primary Care Provider (PCP) and/or a PCP Site

In order to assist members in selecting a PCP, MaineCare Member Services will have available a list of participating PCPs within thirty (30) minutes travel time of the member's town of residence. The member may choose to enroll with a PCP who is further than a travel distance of thirty (30) minutes. Members may request a PCP not on the list or not currently enrolled as a PCP. If the member has requested a PCP who does not want to enroll in Primary Care Case Management, the member must select another Primary Care Case Management PCP.

In cases where a PCP has more than one PCP site, the member must choose one PCP site where the member will get PCCM services. If the member does not choose, the Department will choose for the member. A member can receive PCCM services at only one PCP site.

1.07-7Assignment

When a member is unable or unwilling to select a MaineCare Primary Care Case Management PCP within twenty-eight (28) calendar days of the date in which the enrollment packet was mailed, the member will be assigned to a PCP who has an opening on his/her PCP panel. Members will be assigned to a PCP based on age and gender-appropriateness and in accordance with the travel time standard established in Section 1.07-3. To the extent possible, members will be assigned in consideration of the following:

(a) members (including members within family units) will be assigned to their existing participating PCPs; (b) family units will be assigned to the same participating PCP or to a PCP the enrolled member has selected, if that PCP is appropriate based on age and gender parameters.

1.07 -8Effective Date of Primary Care Case Management Enrollment and PCP Selection

Enrollment in Primary Care Case Management will be prospective only. The PCP selection or assignment is effective on the 1^stor 15^th of the month following the date the assignment is entered into MECAPS.

1.07 -9Member Initiated PCP Change or PCP Site Change Emergency Change

Members enrolled in Primary Care Case Management may change their PCP or PCP site within ninety (90) calendar days of a PCP selection without cause and at any time for good cause. Good cause means a documented situation where there is an inability, after making a reasonable effort, to establish or maintain a satisfactory member/PCP relationship.

a.Member Initiated PCP Change: Members enrolled in Primary Care Case Management must contact MaineCare Member Services if they want to change from their current PCP to a different PCP or a different PCP site.

If approved, selection of a different PCP will take place on the first day of the following month or five (5) calendar days from the date of the request for the PCP change, whichever comes later or as determined by the OMS The OMS notifies PCP sites of changes with Enroll/Disenroll patient panel reports. These reports are sent to the PCP sites on a monthly basis.

Members are notified through a letter by MaineCare Member Services with the PCP site change information.

b. Emergency reassignments will be made within five (5) business days. Emergency means a situation where an expedited change in the PCP is necessary to prevent serious and irreparable harm to the member, PCP and/or staff. If the emergency reassignment cannot be implemented within the five (5) day time frame, MaineCare Member Services must provide the member with written notification that s/he may see any participating MaineCare provider for the provision of all Managed Primary Care Case Management Services until the reassignment process is completed.

1.07-10Department Initiated PCP Reassignment

In addition to member or PCP requests, the OMS will disenroll a member from a PCP or a PCP site for the following reasons:

a. the contract with the PCP is terminated;

b. a PCP dies, retires, closes his/her practice or leaves the area;

c. the member loses MaineCare eligibility;

d. the member moves to an area where Primary Care Case Management is not operational;

e. the member's eligibility changes to a category of assistance that is excluded from participation;

f. the member's status changes such that he or she meets the criteria for exclusion in Section 1.07; or

g. other situations as determined appropriate by the OMS.

h. Emergency reassignments will be made within five (5) business days. Emergency means a situation where an expedited reassignment in the PCP is necessary to prevent serious and irreparable harm to the member, PCP and/or staff. If the emergency reassignments cannot be implemented within the five (5) day time frame, MaineCare Member Services must provide the member with written notification that s/he may see any participating MaineCare provider for the provision of all Managed Primary Care Case Management Services until the reassignment process is completed.

1.07-11Re-Enrollment Provisions

A member enrolled in Primary Care Case Management whose MaineCare eligibility ends and who is again determined eligible for MaineCare within sixty (60) calendar days of the termination date will be assigned to his/her last PCP. Members who have been ineligible for MaineCare for more than sixty (60) calendar days and are subsequently determined to be eligible for MaineCare will be contacted, as set forth in Section 1.07, to select a PCP.

When a PCP or a PCP site has been, or will be, closed (because of termination of contract or if a PCP dies, retires, closes his/her practice or leaves the area, or is otherwise unable or unwilling to continue the PCP practice), the Department will immediately notify the PCP's members, in writing, of the closing. OMS must complete the reassignment process within sixty (60) calendar days from the date of the written notice.

1.07-12Member Restriction Provisions

A member enrolled in Primary Care Case Management may be required to follow member restriction provisions in order to receive care (as defined in the MaineCare Benefits Manual, Chapter IV) if a pattern of abuse or non-compliance is identified. Members who are required to follow restriction provisions will be disenrolled from Primary Care Case Management.

C.M.R. 10, 144, ch. 101, ch. VI, 144-101-VI-01, subsec. 144-101-VI-01.07