MaineCare, Maine’s Medicaid program, is dedicated to providing healthcare coverage to eligible residents. To enhance the efficiency and quality of this care, Maine has implemented a Managed Care Program. This initiative represents a significant shift towards a patient-centered approach within the state’s healthcare system. But What Is Mainecare Managed Care Program exactly? This article delves into the details of this program, exploring its definition, key components, and how it impacts MaineCare members.
Defining MaineCare Managed Care Program
The MaineCare Managed Care Program is defined as an integrated system of healthcare delivery designed to provide comprehensive services to MaineCare recipients. It operates under the broader umbrella of MaineCare, but introduces a structured approach through “managed care plans.” These plans are essentially entities that contract with the state to deliver a range of healthcare services.
To understand this better, let’s break down some key definitions as outlined in the enacting legislation:
- Managed Care Plan: This refers to an organization that partners with MaineCare to offer healthcare services. These organizations can include health insurers, specialized plans focusing on specific populations, Health Maintenance Organizations (HMOs), or Provider Service Networks. They are authorized by the Department of Health and Human Services to operate within the MaineCare program.
- Managed Care Program: This is the overall system of integrated managed care. It encompasses all covered MaineCare services and is implemented according to specific state regulations.
- Prepaid Plan: A type of managed care plan that is either licensed as a risk-bearing entity or is an approved Provider Service Network. These plans receive a fixed, prospective payment per member each month from MaineCare to deliver the necessary healthcare services. This is a crucial aspect of managed care, shifting from fee-for-service to a more predictable payment model.
- Provider Service Network: This is an entity where the controlling ownership lies with healthcare practitioners or facilities. This could be a single doctor, a group practice, a hospital, or networks of nursing facilities, assisted living facilities, home health agencies, hospice programs, or community care providers for the elderly. This definition highlights the role of provider-led organizations within MaineCare managed care.
- Specialty Plan: These are managed care plans tailored to serve specific segments of the MaineCare population. Eligibility for these plans is based on criteria such as age, specific medical conditions, or diagnoses. This allows for focused care management for populations with unique needs.
In essence, the MaineCare Managed Care Program aims to organize and deliver MaineCare benefits through a network of contracted managed care plans. This structure is intended to improve care coordination, enhance service delivery, and promote better health outcomes for MaineCare members.
Key Features of the MaineCare Managed Care Program
The MaineCare Managed Care Program is built upon several core principles and operational requirements. These are designed to ensure quality, accountability, and efficiency within the system.
Managed Care Plans and Services
A fundamental aspect of the program is the role of managed care plans in service delivery. These plans are responsible for:
- Comprehensive Service Delivery: Managed care plans must be equipped to coordinate and deliver all healthcare services covered under MaineCare to their enrolled members. This integration is key to the “managed” aspect of the program, aiming to avoid fragmented care.
- Selection through Competitive Bidding: MaineCare selects managed care plans through a Request for Proposal (RFP) process. This competitive procurement is designed to maximize value and encourage innovation among potential plan providers. The state seeks to negotiate the best possible terms while allowing flexibility for bidders to propose creative solutions.
- Emphasis on Quality Factors: When selecting managed care plans, MaineCare prioritizes quality. Key factors considered include:
- Accreditation: Accreditation from nationally recognized bodies is a strong indicator of a plan’s commitment to quality standards.
- Fraud and Abuse Prevention: Plans must demonstrate robust policies and procedures to prevent fraud and abuse, ensuring responsible use of MaineCare funds.
- Experience and Quality Standards: Proven experience in serving similar populations and a track record of achieving high quality standards are crucial selection criteria.
- Provider Network Adequacy: The availability and accessibility of primary care and specialist physicians within a plan’s network are rigorously assessed to ensure members have access to necessary care.
- Additional Benefits and Health Initiatives: Plans that offer extra benefits, such as dental care, disease management programs, and other initiatives aimed at improving health outcomes, are favored.
- State Presence and Commitment: Plans with an established presence in Maine or a clear commitment to establishing one are preferred, indicating a long-term dedication to the state’s healthcare landscape.
- Best Value Selection: Ultimately, MaineCare selects plans that are deemed most responsive to the state’s needs and offer the best overall value. Preference is given to plans that have already established strong networks with primary care and specialist physicians, ensuring immediate access for enrollees.
- Budgetary Alignment: Contracts with managed care plans are contingent upon available state funding, ensuring fiscal responsibility and alignment with the biennial or supplemental budget.
Selection and Accountability of Plans
The program outlines specific procedures for selecting managed care plans and ensuring their accountability:
- Procurement Process: MaineCare utilizes a procurement process to select a minimum of three and a maximum of four managed care plans for medical and behavioral health services. This range aims to foster competition while ensuring sufficient choice for MaineCare members.
- Provider Service Network Preference: If at least one Provider Service Network bids and meets the minimum selection criteria, MaineCare is required to select at least one such network. This demonstrates a commitment to incorporating provider-led models within the managed care framework.
- Specialty Plan Enrollment Limits: Participation of specialty plans is also subject to the procurement process, and enrollment in any specialty plan within a region is capped at 5% of the total enrollees in that region. This ensures that specialty plans serve their intended purpose without becoming the dominant model in any area.
- Contract Length and Renewal: MaineCare establishes five-year contracts with selected managed care plans, offering a degree of stability and long-term partnership. These contracts can be renewed for an additional two years, and extensions are possible to accommodate transitions to new plans.
- Contract Requirements for Accountability: To ensure plan accountability, MaineCare contracts include a comprehensive set of requirements. These are designed to promote quality care, transparency, and responsiveness to member needs. Key requirements include:
- Physician Compensation for Care Coordination: Plans must compensate physicians for activities like care coordination, chronic disease management, and preventive care, incentivizing proactive and value-based care.
- Hospital Payment Parity: Hospital compensation must reflect mutually agreed upon rates and payment methods, and should not be lower than similar fee-for-service rates paid by MaineCare, ensuring fair reimbursement for hospital services.
- Access Standards: Contracts mandate specific, population-based standards for the number, type, and geographic distribution of providers within plan networks. These standards are designed to guarantee adequate access to care for both adults and children. Plans are allowed to selectively contract with providers based on credentials, quality, and cost-effectiveness.
- Publicly Accessible Provider Database: Each managed care plan must maintain an accurate and complete electronic database of contracted providers, available on their public website. This database must include information on licensure, location, hours, specialty credentials, and patient feedback mechanisms. This promotes transparency and allows members to assess network adequacy.
- Prescribed Drug Formulary Transparency: Plans must have a publicly accessible and searchable formulary (preferred drug list) on their website. This list must be updated within 24 hours of any changes, and the prior authorization process for medications must be easily accessible to providers, including clear contact information and timely response protocols.
- Encounter Data System: Plans are required to operate an encounter data system to collect, process, store, and report data on all covered services provided to MaineCare members. This data is crucial for program monitoring, quality improvement, and actuarial analysis.
- Performance Standards and Quality Improvement: Contracts include specific performance standards, benchmarks, and timelines for improvement. Plans must establish internal quality improvement systems, including member satisfaction surveys and incentives/disincentives for network providers. They are also required to collect and report Healthcare Effectiveness Data and Information Set (HEDIS) measures, which are published for public comparison. Accreditation by a nationally recognized body is also mandated, or progress towards it within one year of contracting.
- Program Integrity Functions: Plans must implement program integrity measures to combat fraud and abuse. This includes provider credentialing, ongoing monitoring, fraud reporting procedures, and the designation of a program integrity compliance officer.
- Grievance Procedures: Plans must establish internal processes for handling member grievances, with quarterly reporting on grievance numbers, descriptions, and outcomes. These procedures must meet MaineCare’s requirements for member protection and fair resolution.
- Compliance with Enrollment and Data Reporting: Plans must adhere to MaineCare requirements for enrollment management, disenrollment, and encounter data reporting. Non-compliance can result in penalties or contract termination.
- Prompt Payment Requirements: Plans and their fiscal intermediaries must comply with state prompt payment laws, ensuring timely payments to providers.
Payment Structures
The financial aspect of the MaineCare Managed Care Program is structured to incentivize efficiency and quality:
- Risk-Adjusted Capitation Payments: MaineCare pays prepaid plans a per-member, per-month (capitated) payment. These payments are negotiated and risk-adjusted based on historical data, eligibility categories, geographic areas, and the clinical risk profiles of enrolled members. This risk adjustment is critical to ensure plans are adequately compensated for managing diverse populations with varying healthcare needs.
- Incentives for Cost-Effective Chronic Disease Management: Rate negotiations consider adjustments to encourage plans to utilize the most cost-effective treatments for chronic diseases, promoting value-based care and long-term health management.
- Provider Service Network Payment Options: Provider Service Networks can operate as prepaid plans and receive capitated payments. However, for the first two years of their contract, they also have a fee-for-service option. This hybrid approach may help provider networks transition to risk-based payment models. If a Provider Service Network using the fee-for-service option exceeds the risk-adjusted per-member, per-month costs of prepaid plans, they are required to refund half of the case management fee paid by MaineCare during that contract year. This provision encourages cost-consciousness even within the fee-for-service period.
Enrollment and Eligibility
The program outlines specific rules regarding enrollment, choice counseling, and eligibility for managed care plans:
Enrollment Process
- Mandatory Enrollment with Choice: Generally, MaineCare members are required to enroll in a managed care plan during an annual open enrollment period. They are provided with a choice of available plans and can select any plan that is not restricted to a specific population they do not belong to.
- 30-Day Enrollment Window: Members are given 30 days to choose a plan, ensuring sufficient time to make an informed decision.
- Choice Counseling System: MaineCare implements a choice counseling system to provide members with timely and accurate information about available plans. This system includes comparative data on benefits, provider networks, drug formularies, quality measures, and other relevant factors. Counseling is offered through various channels: face-to-face interactions, the MaineCare website, telephone, written materials, and other culturally appropriate media. A competitive bidding process is used to select the choice counseling service provider, and this service cannot be administered by a managed care plan to maintain impartiality.
- 90-Day Disenrollment Period: After enrolling, members have 90 days to voluntarily disenroll and switch to another plan. After this initial period, changes are generally only allowed for “good cause” or during the annual open enrollment.
- Automatic Enrollment: Members who do not actively choose a plan are automatically enrolled into one by MaineCare. The state is prohibited from practices that favor one plan over another in this automatic assignment process, ensuring fairness and neutrality.
- Private Insurance Exception: MaineCare members with access to private health insurance coverage are generally not enrolled in managed care plans. Instead, MaineCare financial assistance is used to help them pay for their share of the cost of their private coverage. The financial assistance is capped at the amount MaineCare would have paid a managed care plan for that member.
- Continued Coverage Option (Premium Payment): Members who become ineligible for MaineCare can choose to continue their MaineCare managed care plan coverage for up to 36 months by paying a monthly premium. This premium is set at the current per-member, per-month rate plus 2%. Members have at least 60 days to elect this option, and plans cannot reject enrollees during this period. However, coverage is terminated for members who are more than 45 days late on premium payments.
Who is Eligible for Managed Care?
While most MaineCare members are required to participate in managed care, certain populations are exempt or may be enrolled in alternative programs:
- Mandatory Managed Care Enrollment (General Rule): Most MaineCare members receive covered services through the managed care program.
- Exempt Populations (Potentially in Capitated Care Management): The following groups may be enrolled in a mandatory capitated care management program instead of the standard managed care program (the legislation specifies “may be enrolled” suggesting flexibility, not mandatory exclusion from all managed care, but potentially a different type of managed care arrangement):
- Individuals eligible for both MaineCare and Medicare (dual eligibles).
- Individuals aged 65 or older.
- Adults 18+ eligible for MaineCare due to disability.
- Individuals requiring residential nursing facility care.
- Children with special needs and those eligible for Supplemental Security Income (SSI).
- Members of Indian tribes (if the program is administered by a tribal health department or clinic).
- Children receiving care in prescribed pediatric extended care facilities.
This list indicates that individuals with complex healthcare needs or those served by specific systems may be handled through different or specialized care management approaches within the broader MaineCare framework.
MaineCare Benefits Under Managed Care Plans
The benefits offered under MaineCare managed care plans are designed to meet the healthcare needs of enrollees while allowing for some flexibility and innovation:
- Minimum Medicaid Benefits: Managed care plans must cover at least the minimum set of Medicaid benefits applicable to each category of eligible member. This ensures a baseline level of coverage for all enrollees.
- Customizable Benefit Packages (Non-Pregnant Adults): With MaineCare approval, plans can customize benefit packages for non-pregnant adults. This may include variations in cost-sharing provisions and the addition of coverage for extra services. MaineCare reviews these proposed packages to ensure they adequately meet enrollee needs and are actuarially equivalent to standard benefit packages.
- Healthy Behavior Incentive Programs: Plans are required to establish programs to encourage and reward healthy behaviors among MaineCare members. Members can earn up to $125 per year for participating in these programs, which can be used to offset other health-related expenses. At a minimum, plans must offer medically approved smoking cessation, weight-loss, and alcohol/substance abuse recovery programs. Plans are also responsible for identifying members who would benefit from these programs and establishing written participation agreements.
Implementation and Stakeholder Involvement
The MaineCare Managed Care Program was implemented with a focus on stakeholder input and a phased rollout:
- Stakeholder Group: The legislation mandated the creation of a patient-centered MaineCare reform stakeholder group. This group, convened by the Department of Health and Human Services, includes providers, patients, managed care providers, and legislators. Its purpose is to provide input on the implementation of the managed care program.
- Federal Approvals: Certain provisions of the program, particularly those related to requiring MaineCare members with access to employer-sponsored insurance to enroll in that coverage, are contingent upon federal approval from the Centers for Medicare and Medicaid Services (CMS).
- Implementation Timeline: The Department was required to issue a Request for Proposals for managed care plans by October 1, 2013. Implementation of the statewide managed care program began by January 1, 2014, with full implementation across all regions and populations by July 1, 2014. By July 1, 2015, at least two managed care plans were required to include long-term care and home and community-based services for eligible MaineCare populations.
Conclusion
The MaineCare Managed Care Program represents a significant shift in how Maine delivers healthcare services to its Medicaid population. By contracting with managed care plans, the state aims to create a more coordinated, efficient, and quality-focused healthcare system. The program emphasizes accountability, transparency, and patient-centered care through its plan selection process, contract requirements, and focus on quality improvement and member choice. Understanding the key features of this program is crucial for MaineCare members, providers, and stakeholders alike to navigate and contribute to the ongoing evolution of healthcare in Maine.
This comprehensive guide provides a detailed answer to the question “what is mainecare managed care program,” drawing directly from the enacting legislation to offer a clear and informative overview.
