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TRANSCRIPT
Man
ag
ed
Main
eC
are
In
itia
tive (
MM
I)
Sta
keh
old
er
Ad
vis
ory
an
d S
pecia
lized
Serv
ices C
om
mit
tees
No
vem
ber
19,
2010
Me
eti
ng
Ag
en
da
�Welcome and Introductions
1:00 –1:00 PM
�Discussion: RFP Model Design
1:10 –3:00 PM
�RFP Work Groups (K. Beckendorf)
�Proposed Model Design Presentation (J. Hardy)
�Populations and Services Update (J. Fralich)
1
�Workgroups and Committee Updates
3:00 –3:30 PM
�Member Standing Committee (R. Stroutand R Chaucer)
�Quality Working Group Update (J. Yoe)
�Next Steps (N. Edris)
3:30 –4:00 PM
�Message board for committees
�Wrap Up/Feedback to Design Management Committee
�Next Meeting December 17, 2010
RF
P D
esig
n
2
RF
P D
esig
n
Wo
rk G
rou
ps
RF
P D
es
ign
Wo
rk G
rou
ps
Ex
isti
ng
Wo
rk G
rou
ps
Sp
ecia
l S
erv
ices
Wo
rk G
rou
p
Qu
ali
ty
Wo
rk G
rou
p
New
ly E
sta
blis
he
d W
ork
Gro
up
s
Op
era
tio
ns
Wo
rk G
rou
p
Fin
an
ce
Wo
rk G
rou
p
Reg
ula
tory
/Po
licy
Wo
rk G
rou
p
3
Wo
rk G
rou
pW
ork
Gro
up
Wo
rk G
rou
p
•Answer operations-related
questions for the transition to
managed care
•Focus on coordination
issues with FFS and state
services
•Sampletopics include:
•Pharmacymanagement
•Third-partyliability
coordination
•Non-emergency
transportation coordination
•Develop recommended
approach to financial design
elements of program
•Sampletopics include:
•Rate approach
•Risk corridor/risk sharing
approach
•Financialincentive approach
•Track design against state
and federalrequirements
•Develop required regulatory
documentation for program
•Sampletopics include:
•State Plan Amendment
•Waivers
•Managed Care Rule
RF
P M
od
el D
esig
n
4
RF
P M
od
el D
esig
n
Pro
gra
m C
on
sid
era
tio
ns
Co
nsid
era
tio
nR
eco
mm
en
dati
on
Will any geographies be excluded (e.g.,
rural)?
No, the RFP will cover the entire state.
Co
nsid
era
tio
nR
eco
mm
en
dati
on
Will any state plan benefits be carved out
See Services Matrix for details
Co
ve
red
Po
pu
lati
on
s
Be
ne
fits
5
Will any state plan benefits be carved out
from the contractors?
See Services Matrix for details
Pharmacy:While the administration of the
pharmacy benefit will not be carved out from
the MCOs, the State will maintain a single
PDL/formulary for FFS and the MCOs.
Will contractors be allowed to offer
additional benefits?
Yes, contractors may choose to offer
additional benefits. However, they cannot
reduce or eliminate existing benefits.
Does the Department want to encourage the
contractors to offer specific “in lieu of”
services?
The Department isopen to “in lieu of”
services.
Op
era
tio
na
l M
od
el C
on
sid
era
tio
ns
: G
en
era
l
Co
nsid
era
tio
nR
eco
mm
en
dati
on
How many contractors will the State select?
The State will select twocontractors.
Will the State only contract directly with
MCOs and require ACO involvement, or will
it contract directly with ACOs?
Provider organizationswill be allowed to bid
as long as they meet all RFP requirements,
including the requirement to have a Maine
HMO license.
Will the State deploy a hybrid approach –
contracting with both MCOs and ACOs?
The State will create a market where
provider organizations and MCOs can
6
contracting with both MCOs and ACOs?
provider organizations and MCOs can
partner.
Will the program design vary by geographic
area; i.e., for rural versus urban areas?
No, the design will be consistent across the
state.
Op
era
tio
na
l M
od
el C
on
sid
era
tio
ns
: G
en
era
l
Co
nsid
era
tio
nR
eco
mm
en
dati
on
How will payment reform principles be
incorporated into the model?
The RFP will require MCOs to outline their
approach to payment reform, and the State
will evaluate this in the scoring. A Year 2
incentive payment will be used to reward
MCOs for following through with their
proposals.
How will the initiative relate to payment
reform/medical home pilots?
The State will include a provision in the RFP
that the contractor would be required to
7
reform/medical home pilots?
that the contractor would be required to
participate if Maine signs up for a pilot
project (includes pilots beyond PPACA).
What regulatory requirements will bidders
need to meet from an insurance/licensure
perspective?
An MCO can submit its proposal without a
license, but must be working towards
obtaining one and have one in place when
signing the contract. However, network
robustness will be scored in the RFP
response evaluation.
Op
era
tio
na
l M
od
el C
on
sid
era
tio
ns
: P
aym
en
ts
Co
nsid
era
tio
nR
eco
mm
en
dati
on
What level of risk will the contractors
assume?
•Full risk?
•Downside risk?
•Upside only?
•Depends on the contractor? (MCO versus
ACO)
The contractor will assume full risk.
How will adverse selection be addressed?
A risk adjustment strategy will be employed
8
How will adverse selection be addressed?
•Risk adjustment?
•Stop loss?
•Reinsurance?
A risk adjustment strategy will be employed
that combines demography, geography, and
member-level acuity.
Will the State define provider reimbursement
methodologies or rates?
•Out-of-state provider payment policy
(including Reid providers)?
•Use of FFS fee schedule?
•Use of FFS payment methodology?
MCOs will not be allowed to set
reimbursement rates below Medicaid FFS
rates. MCOs may have different prior
authorization requirements (approved by the
State) than FFS requirements. MCOs may
have to negotiate rates with out-of-state
providers.
•What financial monitoring standards will be
applied?
To be discussed as part of Finance Working
Group.
Op
era
tio
na
l M
od
el C
on
sid
era
tio
ns
:
En
rollm
en
t
Co
nsid
era
tio
nR
eco
mm
en
dati
on
Will eligible members have a choice of
contractors? Will they have a choice in rural
areas?
Eligible members will havea choice of two
contractors across the entire state.
How frequently will members be allowed to
change contractors?
Members can disenrollduring the first 90
days. After the first 90 days members will
have an opportunity to change contractors
annually,with an earlier option based on
cause. The goal will be to align this
9
cause. The goal will be to align this
requirement with the Health Insurance
Exchange.
How will an enrollment broker be used?
Becausethe State can potentially use the
Exchange as an Enrollment Broker in the
long-term, the recommendation is to
contract an Enrollment Broker for two years,
with an option to renew if the Exchange is
not operational.
Op
era
tio
na
l M
od
el C
on
sid
era
tio
ns
:
En
rollm
en
t
Co
nsid
era
tio
nR
eco
mm
en
dati
on
How will members who do not make a
contractor selection be auto assigned?
Auto assignment would occur in tiers:
1.Assign to MCO whosenetworkincludes
the member’s current PCP, if available.
2.If member is not assigned based on
PCP relationship, apply policy algorithm
such as plan size, technical RFP score
(non-cost), quality scores, etc.
3.Migrate to using quality metrics in Year 2
10
3.Migrate to using quality metrics in Year 2
or 3 of the contract.
Members ho are auto-assigned can disenroll
during the first 12 months if it is determined
their doctor is not part of the assigned
network, but part of the other MCO’s.
Will members be guaranteed provider
choice?
This will be a challengein rural areas. The
State will create a standard, but then allow
MCOs to create their “best-effort” network.
When will members be able to go out-of-
network?
The Statewill approve MCO out-of-network
payment policies. Over time –and with
State approval –MCOs will be allowed to
develop closed or tiered networks.
Op
era
tio
na
l M
od
el C
on
sid
era
tio
ns
:
Qu
ality
& D
ata
Co
nsid
era
tio
nR
eco
mm
en
dati
on
How will quality incentives/penalties be
constructed?
The Department will develop a core set of
quality measures for incentives/penalties
from the larger universe of measures.
Measures may change annually.
What performancestandards will be
required? How will compliance be
enforced?
To be determinedby the Quality Working
Group.
What reporting and data submission
To be determinedby the Quality Working
11
What reporting and data submission
requirements will be required?
To be determinedby the Quality Working
Group.
Will NCQA accreditation be required?
NCQA will be required for all MCOs.MCOs
without NCQA accreditation will have a
grace period to achieve accreditation.
RF
P C
on
sid
era
tio
ns
Co
nsid
era
tio
nR
eco
mm
en
dati
on
Will the State contract with a single set of
MCOs for all phasesof enrollment or
reprocure with each phase?
It is the State's intention to have two MCOs
for the entire population. However, if an
MCO fails its readiness review for either
Phase 2 or Phase 3, a new RFP will be
released for the new phase(s) in order to
replace the failing contractor (s).
How will the RFP be scored? What mix of
value will be applied between technical and
If the Stateaccepts the rate-setting proposal
below, scoring will be based solely on
12
value will be applied between technical and
cost?
below, scoring will be based solely on
technical criteria.
Will rates be competitively bid?
Provide bidders with the PMPM price/rate,
which will include assumed savings. The
State will choose its desired actuarially
sound rate range on an annual basis. State
may choose to set rate at the low end of the
rate range, but allow MCOs to earn bonuses
based on criteria such as quality.
RF
P C
on
sid
era
tio
ns
Co
nsid
era
tio
nR
eco
mm
en
dati
on
How much datawill the State provide during
the RFP process?
The State will provide a vendor data book
during the RFPprocess.
If the State allows direct contracting with
ACOs, will there be aseparate RFP for
ACOs?
Therewill not be a separate RFP for ACOs,
but they will be able to bid under the same
requirements as MCOs.
What financialmonitoring standards will be
applied?
To be determined by Finance Working
Group.
13
What performancemetrics will be required?
What will be the penalty structure?
To be determined by Finance Working
Group.
Re
gu
lato
ry a
nd
Po
lic
y C
on
sid
era
tio
ns
Co
nsid
era
tio
nR
eco
mm
en
dati
on
Will the managed care program be
implemented through a State Plan
Amendment (SPA), a waiver, or a
combination?
Year 1 will be implemented through an SPA.
Year 2 may require a waiver. Year 3 will
require a waiver.
Are there legal or regulatory barriers to
include Behavioral Health (BH), substance
abuse (SA), and/or Developmental Disability
(DD) services in the program? (e.g., consent
While Kelly consentdecree still exists,
others have gone away. Confidentiality for
family planning and school-based health
clinics, as well as other Maine statutes and
14
(DD) services in the program? (e.g., consent
decrees, confidentiality laws)?
clinics, as well as other Maine statutes and
regulations. will be addressed in the quality
standards.
How will the managed care program
affect the State's hospital reimbursement
and provider tax?
The hospital supplemental payments will
continue outside the MCOs
and the implementation of DRGs will
continue.
What regulatory requirements will bidders
need to meet from an insurance
perspective?
TheDepartment needs to follow up with the
Bureau of Insurance to discuss possible
licensure requirements.
Lo
ng
er-
Term
Co
ns
ide
rati
on
s
Co
nsid
era
tio
nR
eco
mm
en
dati
on
Will the 2014 expansion population be rolled
intothe program?
ExistingMedicaid-eligible parents over
133% of the FPL will be covered through the
Exchange. Childless adults under 133% of
the FPL will be enrolled in the MCO program
(this includes the childless adult population
on the waiting list).
Will the Statechoose to implement a basic
health plan option in 2014 and enroll those
Under consideration.
15
health plan option in 2014 and enroll those
eligible members into the managed care
program?
Will residents eligible for subsidies in 2014
have access to the MCOs and ACOs?
TheMedicaid MCOs will be required to offer
an individual and small group product on the
Exchange.
Po
pu
lati
on
Ap
pro
ach
16
Po
pu
lati
on
Ap
pro
ach
Gu
idin
g P
rin
cip
les
fo
r P
op
ula
tio
ns
�To manage the whole patient
�To reap the financial benefit of managing the continuum of
services
�To maintain one system of care for family units
17
Po
pu
lati
on
s in
Ma
na
ge
d C
are
Mandatory Enrollment
�Parents and Children
•(except children with special needs)
�People on the non-categorical waiver
�Adults, older adults, and adults with disabilities living in the
community
18
community
•(see list of adults excluded until Year 3)
Vo
lun
tary
En
rollm
en
t
�Children with Special Needs
•Voluntary enrollment in Year 1
•Mandatory enrollment in year 2
oWill need to get a Waiver
�People who change from mandatory to voluntary status
•Ex: children who develop a special need
�People who change from non-dual to dual status
19
�People who change from non-dual to dual status
De
fin
itio
n o
f C
hild
ren
wit
h S
pe
cia
l N
ee
ds
�Children identified using RAC codes
•Children who are eligible based on SSI
•Children who are in state custody, foster care, child protective
custody, and adoptive assistance
�Children identified based on service use
•Children with Serious Emotional Disturbance
o(§65.06-8and §65.06-9)
20
o(§65.06-8and §65.06-9)
•Children with Intellectual Disability/Autism Spectrum Disorder (§28)
•Children with Medical Conditions (§13.03(D); PDN, Levels IV and V)
•Children in residential settings (Therapeutic Foster Care and who
have SED/ID/Autism Spectrum Disorder) (§97 Appendix D)
Gro
up
s E
xc
lud
ed
Un
til Y
ea
r 3
�People who are dually eligible (MaineCare and Medicare)
�People on a home and community based waiver (§19, 21,22, 29 and 32–if approved)
�People on the HIV/AIDS Waiver
�People in nursing homes (more than 90 days)
�People in ICR-MR’s
�People in some of the private non-medical institutions (PNMI’s Appendix C and F)
�Appendix C –Residential Care Facilities
�Appendix F –People with MR/other PNMIS for medical/remedial services (includes people with
21
�Appendix F –People with MR/other PNMIS for medical/remedial services (includes people with
brain injury)
�People in adult family care homes (§2)
�People receiving affordable assisted living services (PDN level IX)
�People receiving private duty nursing –Level V
�People with other health insurance
�Children on Katie Beckett
�People who are medically needy/spend-down
�Members of federally recognized tribes
Ph
as
ed
Ap
pro
ac
h t
o P
op
ula
tio
ns
Ma
nd
ato
ry
Exc
lud
ed
Vo
lun
tary
The Department is proposing a three-year approach to phase populations
into managed care
Po
pu
lati
on
Gro
up
Year
1Y
ear
2Y
ear
3
Du
al-
eli
gib
les
Pe
op
le w
ho
are
du
all
y-e
lig
ible
No
n-D
ua
l-e
lig
ible
s
Pa
ren
ts a
nd
Ch
ild
ren
(in
clu
din
g S
CH
IP;
exc
lud
ing
ch
ild
ren
wit
h s
pe
cia
l ca
re n
ee
ds)
Pe
op
le o
n t
he
No
n-C
ate
go
rica
l Wa
ive
r
Bli
nd
an
d D
isa
ble
d A
du
lts
(no
n-d
ua
ls/n
ot
rece
ivin
g H
CB
S w
aiv
er
or
PD
N le
ve
l V o
r IX
)
22
Bli
nd
an
d D
isa
ble
d A
du
lts
(no
n-d
ua
ls/n
ot
rece
ivin
g H
CB
S w
aiv
er
or
PD
N le
ve
l V o
r IX
)
Old
er
ad
ult
s (n
on
-du
als
/no
t re
ceiv
ing
HC
BS
wa
ive
r o
r P
DN
lev
el V
or
IX)
Pe
op
le r
ece
ivin
g P
DN
lev
el V
Pe
op
le r
ece
ivin
g h
om
e a
nd
co
mm
un
ity
ba
sed
wa
ive
rs (
§1
9 a
nd
21
,22
an
d 2
9)
Pe
op
le o
n t
he
HIV
/AID
S w
aiv
er
Ch
ild
ren
eli
gib
le t
hro
ug
h t
he
Ka
tie
Be
cke
tt p
rog
ram
Pe
op
le in
NF
or
ICF
-MR
Ad
ult
s in
Pri
va
te N
on
-Me
dic
al I
nst
itu
tio
ns
(PN
MIs
)
Ap
pe
nd
ix B
: S
ub
sta
nce
Ab
use
Tre
atm
en
t F
aci
lity
Ap
pe
nd
ix E
: C
om
mu
nit
y R
esi
de
nce
s fo
r P
eo
ple
wit
h M
en
tal I
lln
ess
Ap
pe
nd
ix F
: R
esi
de
nce
fo
r P
eo
ple
wit
h M
en
tal I
lln
ess
Ap
pe
nd
ix C
: R
esi
de
nti
al C
are
Fa
cili
ty
Ap
pe
nd
ix F
: A
ll O
the
r C
om
mu
nit
y R
esi
de
nce
s fo
r P
eo
ple
wit
h M
en
tal R
eta
rda
tio
n /
Re
imb
urs
em
en
t fo
r N
on
-Ca
se M
ixe
d
Me
dic
al a
nd
Re
me
dia
l Fa
cili
tie
s (I
ncl
ud
es
Bra
in I
nju
ry)
Ph
as
ed
Ap
pro
ac
h t
o P
op
ula
tio
ns
(continued)
Ma
nd
ato
ry
Exc
lud
ed
Vo
lun
tary
The Department is proposing a three-year approach to phase populations
into managed care
Po
pu
lati
on
Gro
up
Year
1Y
ear
2Y
ear
3
No
n-D
ua
l-e
lig
ible
s
Ad
ult
s re
ceiv
ing
Pri
va
te D
uty
Nu
rsin
g (
PD
N)
Lev
el I
X (
Ass
iste
d L
ivin
g)
Pe
op
le in
Ad
ult
Fa
mil
y C
are
Ho
me
s (§
2)
Pe
op
le w
ho
Sp
en
d D
ow
n o
r a
re M
ed
ica
lly
Ne
ed
y
Ch
ild
ren
wit
h s
pe
cia
l ca
re n
ee
ds
Ch
ild
ren
wh
o a
re e
lig
ible
ba
sed
on
SS
I b
ase
d o
n R
eci
pie
nt
Aid
Ca
teg
ory
(R
AC
) co
de
23
Ch
ild
ren
wh
o a
re e
lig
ible
ba
sed
on
SS
I b
ase
d o
n R
eci
pie
nt
Aid
Ca
teg
ory
(R
AC
) co
de
Ch
ild
ren
in s
tate
cu
sto
dy
, fo
ste
r ca
re,
chil
d p
rote
ctiv
e c
ust
od
y, a
nd
ad
op
tiv
e a
ssis
tan
ce b
ase
on
RA
C c
od
e
Ch
ild
ren
wit
h S
eri
ou
s E
mo
tio
na
l Dis
turb
an
ce.
Th
is i
ncl
ud
es:
Ch
ild
ren
wh
o a
cce
ss C
hil
dre
n's
Ass
ert
ive
Co
mm
un
ity
Tre
atm
en
t (A
CT
) u
nd
er
§6
5.0
6-8
Ch
ild
ren
wh
o a
cce
ss H
om
e a
nd
Co
mm
un
ity
Ba
se T
rea
tme
nt
(HC
BT
) u
nd
er
§6
5.0
6-9
Ch
ild
ren
wit
h I
nte
lle
ctu
al D
isa
bil
ity
/Au
tism
Sp
ect
rum
Dis
ord
er
§2
8
Ch
ild
ren
wit
h m
ed
ica
l co
nd
itio
ns
Ch
ild
ren
re
ceiv
ing
Ta
rge
ted
Ca
se M
an
ag
em
en
t fo
r ch
ron
ic m
ed
ica
l co
nd
itio
ns
un
de
r §
13
.03
(D
)
Ch
ild
ren
re
ceiv
ing
Pri
va
te D
uty
Nu
rsin
g S
erv
ice
s Le
ve
ls I
V &
V u
nd
er
§9
7
Ch
ild
ren
in P
NM
I u
nd
er
Ap
pe
nd
ix D
of
§9
7.
Th
is in
clu
de
s:
Ch
ild
ren
wh
o a
re in
Th
era
pe
uti
c F
ost
er
Ca
re
Ch
ild
ren
wh
o h
av
e S
ED
/ID
/Au
tism
Sp
ect
rum
Dis
ord
er
Ph
as
ed
Ap
pro
ac
h t
o P
op
ula
tio
ns
(continued)
Ma
nd
ato
ry
Exc
lud
ed
Vo
lun
tary
The Department is proposing a three-year approach to phase populations
into managed care
Po
pu
lati
on
Gro
up
Year
1Y
ear
2Y
ear
3
Gro
up
s o
f S
pe
cia
l In
tere
st (
Co
ve
red
in
No
n-D
ua
l P
op
ula
tio
ns
Ab
ov
e)
Te
rmin
al i
lln
ess
(p
eo
ple
en
roll
ed
in H
osp
ice
are
vo
lun
tary
)
Pe
op
le r
ece
ivin
g h
om
e a
nd
co
mm
un
ity
ba
sed
sta
te p
lan
se
rvic
es
(in
c. c
on
sum
er
dir
ect
ed
an
d P
DN
)
Ad
ult
s w
ith
Se
ve
re a
nd
Pe
rsis
ten
t M
en
tal I
lln
ess
(S
PM
I)*
Pe
op
le w
ith
bra
in i
nju
rie
s w
ho
are
no
t in
PN
MI
Ap
pe
nd
ix F
Pe
op
le w
ith
oth
er
he
alt
h c
are
insu
ran
ce
24
Pe
op
le w
ith
oth
er
he
alt
h c
are
insu
ran
ce
Me
mb
ers
of
Fe
de
rall
y R
eco
gn
ize
d T
rib
es
Pe
op
le w
ho
ch
an
ge
fro
m m
an
da
tory
to
exc
lud
ed
(e
.g.
A p
ers
on
wh
o is
no
t o
n a
wa
ive
r, b
ut
be
com
es
eli
gib
le)
Pe
op
le w
ho
ch
an
ge
fro
m n
on
-du
al t
o d
ua
l sta
tus
Pe
op
le w
ho
ch
an
ge
fro
m m
an
da
tory
to
vo
lun
tary
(e
.g.
Ch
ild
ren
wh
o d
ev
elo
p s
pe
cia
l ne
ed
s)
No
tes
*The status of this group (Adults with SPMI) under managed care is under discussion
Serv
ices A
pp
roach
25
Serv
ices A
pp
roach
Ph
as
ing
of
Se
rvic
es
in
to M
an
ag
ed
Ca
re
�M
os
t s
erv
ice
swill be managed services (i.e. included in the
capitation rate) of the managed care entity in Year 1
�S
om
e s
pe
cia
l s
erv
ice
s will be fee-for service (carved out of the
capitation rate) in Year 1 and managed services in Year 2
Mo
st
ho
me
an
d c
om
mu
nit
y b
as
ed
an
d lo
ng
te
rm c
are
serv
ice
s
26
�M
os
t h
om
e a
nd
co
mm
un
ity b
as
ed
an
d lo
ng
te
rm c
are
serv
ice
s
will be fee for service (carved out of capitation rate) in Years 1 and
2; and managed services in year 3
Se
rvic
es
Ad
de
d t
o C
ap
ita
tio
n R
ate
in
Ye
ar
2
Sp
ecia
l S
erv
ices
�The following services will be fee for service (carved out of
capitation rate) in Year 1 and managed services (included in the
capitation rate) in Year 2
•Rehab and Community Supports for Children (§28)
•Children’s Assertive Treatment Services (§65)
•Children’s Home and Community Based Treatment (§65)
27
•Children’s Home and Community Based Treatment (§65)
•PNMI services for People with Mental Illness (§97; Appendix E)
•Rehabilitation Services (§102)
Se
rvic
es
ad
de
d t
o C
ap
ita
tio
n R
ate
in
Ye
ar
3
Ho
me a
nd
Co
mm
un
ity B
ased
& L
on
g T
erm
Care
Serv
ices
�The following services will be fee for service (carved out of the
capitation rate) in Years 1 and 2 and managed services (included in
the capitation rate) in Year 3
•Adult Family Care Services (§2)
•Consumer Directed Attendant Services (§12)
•Home and Community Based Waiver Services (§19, 21, 22, 29 and
28
•Home and Community Based Waiver Services (§19, 21, 22, 29 and
32 –if approved)
•Day Health (Section 26)
•MaineCare Hospice Services (§43)
•ICF-MR Services (§50)
•Nursing Facility Services --greater than 90 days (§67 )
•Private Duty Nursing Services (§96)
•Private non-medical services (§97 Appendix C and F)
§S
erv
ice
Year
1Y
ear
2Y
ear
3
§2
Ad
ult
Fa
mil
y C
are
Se
rvic
es
FF
SF
FS
MS
§3
Am
bu
lato
ry C
are
Cli
nic
Se
rvic
es
(In
clu
de
s sc
ho
ol-
ba
sed
he
alt
h c
lin
ics)
MS
MS
MS
§4
Am
bu
lato
ry S
urg
ica
l Ce
nte
r S
erv
ice
sM
SM
SM
S
§5
Am
bu
lan
ce S
erv
ice
s M
SM
SM
S
§7
Fre
e-s
tan
din
g D
ialy
sis
Se
rvic
es
MS
MS
MS
§1
2C
on
sum
er
Dir
ect
ed
Att
en
da
nt
Se
rvic
es
FF
SF
FS
MS
§1
3T
arg
ete
d C
ase
Ma
na
ge
me
nt
Se
rvic
es*
MS
MS
MS
Ph
as
ed
Ap
pro
ac
h t
o S
erv
ice
s
The Department is proposing an approach to phase services into managed care over 3 years
MS
Ma
na
ge
d S
erv
ice
s: S
erv
ice
is in
clu
de
d in
th
e c
ap
ita
tio
n r
ate
FF
SF
ee
Fo
r S
erv
ice
: T
he
se
rvic
es
wil
l no
t b
e i
n t
he
ca
pit
ati
on
ra
te a
nd
OM
S w
ill c
on
tin
ue
to
pa
y t
he
pro
vid
er
on
a F
FS
ba
sis.
29
§1
3T
arg
ete
d C
ase
Ma
na
ge
me
nt
Se
rvic
es*
MS
MS
MS
§1
4A
dv
an
ced
Pra
ctic
e R
eg
iste
red
Nu
rsin
g S
erv
ice
sM
SM
SM
S
§1
5C
hir
op
ract
ic S
erv
ice
sM
SM
SM
S
§1
7C
om
mu
nit
y S
up
po
rt S
erv
ice
sM
SM
SM
S
§1
9H
om
e a
nd
Co
mm
un
ity-
Ba
sed
Be
ne
fits
fo
r th
e E
lde
rly
an
d f
or
Ad
ult
s w
ith
Dis
ab
ilit
ies
FF
SF
FS
MS
§2
1H
om
e a
nd
Co
mm
un
ity
Be
ne
fits
fo
r M
em
be
rs w
ith
Me
nta
l Re
tard
ati
on
or
Au
tist
ic D
iso
rde
rF
FS
FF
SM
S
§2
2H
om
e a
nd
Co
mm
un
ity
Be
ne
fits
fo
r th
e P
hy
sica
lly
Dis
ab
led
FF
SF
FS
MS
§2
3D
ev
elo
pm
en
tal a
nd
Be
ha
vio
ral C
lin
ic S
erv
ice
sM
SM
SM
S
§2
5D
en
tal S
erv
ice
s M
SM
SM
S
§2
6D
ay
He
alt
h S
erv
ice
sF
FS
FF
SM
S
§2
8
Re
ha
bil
ita
tiv
e a
nd
Co
mm
un
ity
Su
pp
ort
Se
rvic
es
for
Ch
ild
ren
wit
h C
og
nit
ive
Imp
air
me
nts
an
d F
un
ctio
na
l
Lim
ita
tio
ns
FF
SM
SM
S
§2
9C
om
mu
nit
y S
up
po
rt B
en
efi
ts f
or
Me
mb
ers
wit
h M
en
tal R
eta
rda
tio
n a
nd
Au
tist
ic D
iso
rde
rF
FS
FF
SM
S
§3
0F
am
ily
Pla
nn
ing
Ag
en
cy S
erv
ice
sM
SM
SM
S
§3
1F
ed
era
lly
Qu
ali
fie
d H
ea
lth
Ce
nte
r S
erv
ice
sM
SM
SM
S
No
tes:
* Treatment of targeted case management will be reviewed for each service to identify operational and other considerations
§S
erv
ice
Year
1Y
ear
2Y
ear
3
§3
2
Ch
ild
ren
wit
h I
nte
lle
ctu
al D
isa
bil
itie
s a
nd
Pe
rva
siv
e D
ev
elo
pm
en
tal D
isa
bil
itie
s a
nd
Au
tism
Sp
ect
rum
Dis
ord
er*
*F
FS
FF
SM
S
§3
5H
ea
rin
g A
ids
an
d S
erv
ice
sM
SM
SM
S
§4
0H
om
e H
ea
lth
Se
rvic
es
MS
MS
MS
§4
1D
ay
Tre
atm
en
t S
erv
ice
s**
*F
FS
MS
MS
§4
3H
osp
ice
Se
rvic
es
FF
SF
FS
MS
§4
5H
osp
ita
l Se
rvic
es
MS
MS
MS
Ph
as
ed
Ap
pro
ac
h t
o S
erv
ice
s (continued)
The Department is proposing an approach to phase services into managed care over 3 years
MS
Ma
na
ge
d S
erv
ice
s: S
erv
ice
is in
clu
de
d in
th
e c
ap
ita
tio
n r
ate
FF
SF
ee
Fo
r S
erv
ice
: T
he
se
rvic
es
wil
l no
t b
e i
n t
he
ca
pit
ati
on
ra
te a
nd
OM
S w
ill c
on
tin
ue
to
pa
y t
he
pro
vid
er
on
a F
FS
ba
sis.
30
§4
6P
sych
iatr
ic H
osp
ita
l Se
rvic
es
MS
MS
MS
§5
0IC
F-M
R S
erv
ice
sF
FS
FF
SM
S
§5
5La
bo
rato
ry S
erv
ice
sM
SM
SM
S
§6
0M
ed
ica
l Su
pp
lie
s a
nd
Du
rab
le M
ed
ica
l Eq
uip
me
nt
MS
MS
MS
§6
5O
utp
ati
en
t S
erv
ice
s (m
en
tal h
ea
lth
an
d s
ub
sta
nce
ab
use
tre
atm
en
t)M
SM
SM
S
§6
5M
ed
ica
tio
n M
an
ag
em
en
tM
SM
SM
S
§6
5N
eu
rob
eh
av
iora
l Sta
tus
Exa
m a
nd
Psy
cho
log
ica
l Te
stin
gM
SM
SM
S
§6
5C
risi
s R
eso
luti
on
Se
rvic
es
MS
MS
MS
§6
5C
risi
s R
esi
de
nti
al S
erv
ice
s (e
xce
pt
ad
ult
s w
ith
DD
)M
SM
SM
S
§6
5F
am
ily
Psy
cho
ed
uca
tio
na
lTre
atm
en
tM
SM
SM
S
§6
5In
ten
siv
e O
utp
ati
en
t S
erv
ice
s (s
ub
sta
nce
ab
use
tre
atm
en
t)M
SM
SM
S
§6
5O
pio
idT
rea
tme
nt
(su
bst
an
ce a
bu
se t
rea
tme
nt)
MS
MS
MS
§6
5C
hil
dre
n's
Ass
ert
ive
Co
mm
un
ity
Tre
atm
en
tF
FS
MS
MS
§6
5C
hil
dre
n's
Ho
me
an
d C
om
mu
nit
y B
ase
d T
rea
tme
nt
FF
SM
SM
S
No
tes:
** If waiver is approved ***§41 was repealed and all services are now in §65 (listed here for actuarial purposes)
§S
erv
ice
Year
1Y
ear
2Y
ear
3
§6
7N
urs
ing
Fa
cili
ty S
erv
ice
s (S
ho
rt-s
tay
--3
0 d
ay
s)M
SM
SM
S
§6
7N
urs
ing
Fa
cili
ty S
erv
ice
s (l
on
g-t
erm
se
rvic
es)
FF
SF
FS
MS
§6
8O
ccu
pa
tio
na
l Th
era
py
Se
rvic
es
MS
MS
MS
§7
5V
isio
n S
erv
ice
sM
SM
SM
S
§8
0P
ha
rma
cy S
erv
ice
sM
SM
SM
S
§8
5P
hy
sica
l Th
era
py
Se
rvic
es
MS
MS
MS
§9
0P
hy
sici
an
Se
rvic
es
MS
MS
MS
Ph
as
ed
Ap
pro
ac
h t
o S
erv
ice
s (continued)
The Department is proposing an approach to phase services into managed care over 3 years
MS
Ma
na
ge
d S
erv
ice
s: S
erv
ice
is in
clu
de
d in
th
e c
ap
ita
tio
n r
ate
FF
SF
ee
Fo
r S
erv
ice
: T
he
se
rvic
es
wil
l no
t b
e i
n t
he
ca
pit
ati
on
ra
te a
nd
OM
S w
ill c
on
tin
ue
to
pa
y t
he
pro
vid
er
on
a F
FS
ba
sis.
31
§9
0P
hy
sici
an
Se
rvic
es
MS
MS
MS
§9
4
Pre
ve
nti
on
, He
alt
h P
rom
oti
on
, an
d O
pti
on
al T
rea
tme
nt
Se
rvic
es
(In
clu
de
s b
oth
pe
rio
dic
scr
ee
nin
g,
etc
. fo
r
ge
ne
ral c
hil
d p
op
ula
tio
n &
sp
eci
ali
zed
se
rvic
es
for
chil
dre
n w
ith
sp
eci
al h
ea
lth
ca
re n
ee
ds)
MS
MS
MS
§9
5P
od
iatr
ic S
erv
ice
sM
SM
SM
S
§9
6P
riv
ate
Du
ty N
urs
ing
an
d P
ers
on
al C
are
Se
rvic
es
FF
SF
FS
MS
§9
7P
NM
I Ap
pe
nd
ix B
: S
ub
sta
nce
Ab
use
Tre
atm
en
t F
aci
lity
MS
MS
MS
§9
7P
NM
I Ap
pe
nd
ix C
: R
esi
de
nti
al C
are
Fa
cili
tyF
FS
FF
SM
S
§9
7P
NM
I Ap
pe
nd
ix D
: R
esi
de
nti
al C
hil
d C
are
Fa
cili
ty (
if c
hil
d v
olu
nta
rily
en
roll
s)M
SM
SM
S
§9
7P
NM
I Ap
pe
nd
ix E
: C
om
mu
nit
y R
esi
de
nce
s fo
r P
eo
ple
wit
h M
en
tal I
lln
ess
FF
SM
SM
S
§9
7
PN
MI A
pp
en
dix
F:
Co
mm
un
ity
Re
sid
en
ces
for
Pe
op
le w
ith
Me
nta
l Re
tard
ati
on
/ R
eim
bu
rse
me
nt
for
No
n-
Ca
se M
ixe
d M
ed
ica
l an
d R
em
ed
ial F
aci
liti
es
(In
clu
de
s B
rain
In
jury
)F
FS
FF
SM
S
§1
01
Me
dic
al I
ma
gin
g S
erv
ice
sM
SM
SM
S
§1
02
Re
ha
bil
ita
tiv
e S
erv
ice
sF
FS
MS
MS
§1
03
Ru
ral H
ea
lth
Cli
nic
Se
rvic
es
MS
MS
MS
§1
09
Sp
ee
ch a
nd
He
ari
ng
Se
rvic
es
MS
MS
MS
§1
13
Tra
nsp
ort
ati
on
Se
rvic
es
MS
MS
MS
Qu
ality
Wo
rk G
rou
p
32
Qu
ality
Wo
rk G
rou
p
Up
date
Ma
jor
Ta
sk
s
�Quality Domains
�Quality Standards
�Quality Measures
�State Oversight Responsibilities
33
�External Quality Review Responsibilities
Do
ma
ins
of
Qu
ality
Sta
nd
ard
s(Based on CMS Quality Strategy)
AC
CE
SS
:
�Availability of services
�Network adequacy
�Coordination and continuity of care
�Authorization of service
34
�Authorization of service
Do
ma
ins
of
Qu
ality
Sta
nd
ard
s
ST
RU
CT
UR
E A
ND
OP
ER
AT
ION
S:
�Provider selection
�Enrollee information
�Confidentiality
�Enrollment and disenrollment
�Grievance system
35
�Grievance system
�Sub-contractual relationships and delegation
Do
ma
ins
of
Qu
ality
Sta
nd
ard
s
ME
AS
UR
EM
EN
T A
ND
IM
PR
OV
EM
EN
T:
�Practice guidelines
�Quality assessment and improvement program
�Health information system
36
Up
date
s &
Wra
p U
p
37
Up
date
s &
Wra
p U
p
Sta
ke
ho
lde
r In
pu
t F
ollo
w-U
p
�The MaineCare team has been tracking input from stakeholders
and is actively responding
�Followingtoday’s meeting, a document will be shared with
stakeholders describing how each issue has been addressed
�Tocontinue the discussion on these issues and increase
stakeholder communication with each other and the team, we have
created an on-linediscussion board.
38
created an on-linediscussion board.
Log-in at: www.deloitteonline.com
Co
mm
en
tin
g o
n t
he
Dis
cu
ss
ion
Bo
ard
Discussion Board
for each
Stakeholder
Group
Meeting
Schedule
Calendar
39
Calendar
Start a new topic
Comment on a
previous topic
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pen
dix
40
Ap
pen
dix
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s –
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ga
l a
gre
em
en
t
•You will be required to accept the legal agreement prior to using Deloitte
OnLine.
•The legal agreement will not appear again after you accept it, but you can
read it at any time by clicking the link in the banner.
45
Fir
st
tim
e a
cc
es
s –
3.
Se
cre
t q
ue
sti
on
s
•Secret questions are used to
verify your identity if you forget
your password and/or need to
contact Deloitte Online technical
support.
•You will be prompted to invent
three questions and provide
answers to these questions.
46
answers to these questions.
•Be sure to make your answer to
each question very simple. You
must recall the exactanswer to
each of the questions to verify
your identity.
Fir
st
tim
e a
cc
es
s –
4.
So
ftw
are
op
tio
ns
Software Options page
•Select your time zone.
•Select the “just the web browser”
feature.
47
Lo
gin
pa
ge
You have already become familiar with the loginpage and what happens when you
first access Deloitte OnLine.
However, the loginpage is also where you will find helpful information if you:
•Forget your password
•Need to change your password
•Need to contact Deloitte OnLinetechnical support
48
Lo
gin
pa
ge
–fo
rgo
t yo
ur
pa
ss
wo
rd
If y
ou
fo
rge
t yo
ur
pa
ss
wo
rd:
•Go to the login page.
•Type your user name.
•Click Forgot your password
under the password field.
•Answer the secret questions
that appears to verify your
identity. Note: The answers
49
identity. Note: The answers
must be entered exactly (see:
“secret questions” slide).
•A new password will be
e-mailed to you.
Lo
gin
pa
ge
–c
ha
ng
e y
ou
r p
as
sw
ord
To
ch
an
ge
yo
ur
pa
ss
wo
rd:
•Go to the loginpage.
•Type your user name.
•Click Need to change your
password?Underthe
password field
•The wizard will ask you to:
1.Type your old
password.
50
password.
2.Type your new
password twice.