This regulation governs Behavioral Health Home (BHH) services under Maine's MaineCare program, establishing provider requirements, staffing qualifications, member eligibility criteria, covered services, and reimbursement methodology for community-based mental health organizations delivering care coordination and wraparound services. BHH providers must be licensed community-based mental health organizations that maintain specific multidisciplinary teams, implement core standards, and serve members with Serious Mental Illness (adults) or Serious Emotional Disturbance (children/youth). Operators must comply with timeliness requirements for intake, maintain electronic health records, establish referral protocols with inpatient and crisis facilities, and adhere to wraparound principles when serving children.
View official sourceTABLE OF CONTENTS PAGE 92.01 PURPOSE1 92.02 DEFINITIONS1 92.02-1 Adult1 92.02-2 Authorized Entity1 92.02-3 Behavioral Health Home (BHH)1 92.02-4 Child1 92.02-5 Child and Family Team1 92.02-6 Diagnostic and Statistical Manual of Mental Health Disorders1 92.02-7 Electronic Health Record1 92.02-8 High-Fidelity Wrap Around BHH Services 2 92.02-9 Planning Process2 92.02-10 Plan of Care or Wraparound Plan of Care2 92.02-11 Serious Emotional Disturbance2 92.02-12 Standard BHH Services2 92.03 PROVIDER REQUIREMENTS3 92.03-1 Behavioral Health Home Provider Requirements3 92.03-2 Protections for Adults with Serious Mental Illness15 92.03-3 Timeliness and Duration of Care16 92.04 MEMBER ELIGIBILITY17 92.04-1 General Eligibility17 92.04-2 Specific Requirements for Standard BHH Services17 92.04-3 Specific Requirements for Wraparound BHH Services18 92.04-4 Eligibility Verification20 92.05 POLICIES AND PROCEDURES FOR MEMBER IDENTIFICATION AND ENROLLMENT20 92.05-1 Member Identification20 92.05-2 Enrollment and Freedom of Choice20 92.06 COVERED SERVICES21 92.06-1 Comprehensive Care Management22 92.06-2 Care Coordination31 92.06-3 Health Promotion32 92.06-4 Comprehensive Transitional Care33 92.06-5 Individual and Family Support Services35 92.06-6 Referral to Community and Social Support Services36 92.07 NON-COVERED SERVICES AND LIMITATIONS37 92.08 REPORTING REQUIREMENTS37 92.09 DOCUMENTATION AND CONFIDENTIALITY 37 92.10 REIMBURSEMENT METHODOLOGY38 92.10-1 BHH Service Rate Methodology38 92.10-2 Pay-for-Performance39 92.11 MINIMUM REQUIREMENTS FOR REIMBURSEMENT41 92.01 PURPOSE The purpose of this service is to implement High-Fidelity Wrap Around Services and other Behavioral Health Home services covered by MaineCare. Members receiving services under this Rule may be covered by the DOJ Settlement Agreement, United States v. State of Maine, No. 1:24-cv-00315-SDN (D. Me. Dec. 20, 2024)(Order on Mot. Dismiss and Retain Jurisdiction, Ex. A, Settlement Agreement Between the United States of America and the State of Maine. Note that the Department has adopted the Children’s Behavioral Health Services Global Rule, MaineCare Benefits Manual, Ch. I, Sec. 7, which contains further requirements of the DOJ Settlement Agreement. 92.02 DEFINITIONS 92.02-1 Adult is a person who is twenty-one (21) years old or older. 92.02-2 Authorized Entity is an organization authorized by the Department of Health and Human Services (DHHS) to perform specified functions pursuant to a signed contract or other approved signed agreement. 92.02-3 Behavioral Health Home (BHH) is a community-based mental health organization that is licensed in the state of Maine, has been approved by MaineCare to provide Section 92 services for members (both Adults and Children) eligible for such services, and that satisfies the additional provider requirements and standards set forth herein. 92.02-4 Child is a person who is under twenty-one (21) years old. 92.02-5 Child and Family Team is a group of people, chosen with the member and the member’s family and connected to them through natural, community, and formal support relationships, that develops and implements the Plan of Care or Wraparound Plan of Care. The Child and Family Team includes the member, family, natural supports chosen by the member and family, service providers, and, as appropriate, representatives of the member’s school and other community contacts. The Child and Family Team is led by a Health Home Care Coordinator. 92.02-6 Diagnostic and Statistical Manual of Mental Health Disorders (DSM) is the current version published by the American Psychiatric Association. The Manual is used to classify mental health disorders and provide standard categories for definition of mental health disorders. 92.02-7 Electronic Health Record (EHR) is a systematic collection of electronic health information about individual MaineCare members. It is a record in digital format that is capable of being shared across different health care settings by a Department-designated Health Information Exchange(s) (HIE) and/or other information networks or exchanges. An EHR supports Clinical EHR functions, such as intake, clinical care, task management, and case management where appropriate, and has HL7 interoperability capabilities to support the electronic sharing of portions of the patient’s record. 92.02-8 High-Fidelity Wrap Around Services (Wraparound BHH Services) are a Department-approved behavioral health service delivery model which is a higher intensity service than Standard BHH Services (as described in the applicable subparts in Section 92.05) and is delivered to members who meet the eligibility criteria in Section 92.03-3. When delivered to a Child, Wraparound BHH Services are “High-Fidelity Wrap Around Services,” a form of “Care Coordination” as contemplated in and when delivered to Children covered by United States v. State of Maine, No. 1:24-cv-00315-SDN (D. Me. Dec. 20, 2024)(Order on Mot. Dismiss and Retain Jurisdiction, Ex. A, Settlement Agreement Between the United States of America and the State of Maine). 92.02-9 Planning Process is a team-based approach that provides individualized, family-driven care through coordinated efforts, which meet the complex needs of Children, youth, and families as defined in this Section. 92.02-10 Plan of Care (POC) and Wraparound Plan of Care (WPOC) are individualized service plans that describe, coordinate, and integrate all of a member’s clinical and non-clinical health care-related needs and services. The POC is person-centered and the WPOC is family-centered. The POC and WPOC include the member’s physical health and behavioral health goals (including recovery-oriented goals), and the services and supports necessary to achieve those goals. BHHs develop a POC for Standard BHH Services and a WPOC for Wraparound BHH Services, and the POC and WPOC are subject to different requirements in Section 92.05-1. When developed for a Child, a POC or WPOC is an Individualized Service Plan as described in United States v. State of Maine, No. 1:24-cv-00315-SDN (D. Me. Dec. 20, 2024)(Order on Mot. Dismiss and Retain Jurisdiction, Ex. A, Settlement Agreement Between the United States of America and the State of Maine). 92.02-11 Serious Emotional Disturbance (SED) is a behavioral health disorder, diagnosed in accordance with the DSM, that a Child has had or is expected to have for at least one (1) year, which has resulted in functional impairment that substantially interferes with or limits the Child’s role or functioning in family, school, or community activities. The diagnosis must not be one of the conditions excluded under section 92.04-2(B)(1) or 92.04-3(A). 92.02-12 Standard BHH Services are the conventional BHH services that are typically lower in intensity than Wraparound BHH Services and delivered to members who meet the eligibility criteria in Section 92.04-2. When delivered to a Child, Standard BHH Services are “Care Coordination” as described in United States v. State of Maine, No. 1:24-cv-00315-SDN (D. Me. Dec. 20, 2024)(Order on Mot. Dismiss and Retain Jurisdiction, Ex. A, Settlement Agreement Between the United States of America and the State of Maine). 92.03 PROVIDER REQUIREMENTS The BHH must meet the following requirements: 92.03-1 Behavioral Health Home (BHH) Provider Requirements A. The BHH must execute a MaineCare Provider Agreement. B. The BHH must be approved as a BHH by MaineCare through the BHH application process. C. The BHH must be a community-based mental health organization, licensed to provide services in the state of Maine, that has a physical location in the state of Maine and delivers mental health and/or behavioral health support services through a team-based model of care that includes at least the following personnel. A BHH delivering multiple BHH service types may assign staff across service populations, provided each staff member meets all applicable qualifications and maintains a caseload at or below the lowest required ratio. If there is a lapse in fulfillment of team member roles of greater than thirty (30) continuous days, the BHH must notify the Department in writing and maintain records of active recruitment to fill the position(s). The direct service staff who deliver Standard BHH Services and Wraparound BHH Services must include the following, based on the type of BHH Service being delivered: Psychiatric Consultant must be a psychiatrist who has current and valid licensure as a physician from the Maine Board of Licensure in Medicine, and who is certified by the American Board of Psychiatry and Neurology Psychiatric medication management or is eligible for examination by that Board as documented by written evidence from the Board, or has completed three (3) years of post-graduate training in psychiatry approved by the Education Council of the American Medical Association and submits written evidence of the training; OR a psychiatric and mental health Advance Practice Registered Nurse (APRN) who is licensed as a nurse practitioner or clinical nurse specialist by the state of Maine, has graduated from a Child and adolescent or Adult psychiatric and mental health nurse practitioner or clinical nurse specialist program, and is certified by the appropriate national certifying body. The Psychiatric Consultant must consult with other BHH and primary care professionals and with the member as necessary, to provide expertise on the development of evidence-based practices and protocols for the BHH organization. Under Section 92, the Psychiatric Consultant must not duplicate any other psychiatric services that may be necessary and provided through other Sections of the MaineCare Benefits Manual. (2) Nurse Care Manager must be a nurse licensed as a registered professional nurse; or an APRN, as defined by the Maine State Board of Nursing. The Nurse Care Manager must provide physical health care consultation, psychiatric care consultation, and work with the BHH, the member’s primary care provider and the member to provide other Section 92 Services as necessary, pursuant to the POC or WPOC. (3) Clinical Team Leader must be a licensed mental health professional, who may be a physician, physician assistant, psychologist, licensed clinical social worker, licensed master social worker- clinical conditional , licensed clinical professional counselor, licensed clinical professional counselor- conditional, licensed marriage and family therapist, APRN, ; OR, for Children’s BHH services, a person who was employed on August 1, 2009 as a case management supervisor under Section 13 of Chapter II of the MaineCare Benefits Manual. Such staff shall be considered qualified to serve as a Clinical Team Leader for purposes of this rule. Clinical Team Leader for Standard BHH Services oversees the development of the POC and direct care management activities across the BHH; supervises, as applicable, Youth Support Specialists, Family Support Specialists, Health Home Care Coordinators, and Certified Intentional Peer Support Specialists (CIPSS); and ensures that the BHH meets its requirements as a whole. Clinical Team Leader for Wraparound BHH Services must have the qualifications of the Clinical Team Leader for Standard BHH Services and successfully complete a Department-approved Wraparound BHH training series and a Department-approved Wraparound BHH supervisor training. The Clinical Team Leader for Wraparound BHH Services oversees the development of the WPOC and provides supervision of Wraparound BHH Coordinators, Wraparound BHH Youth Support Specialists, and Wraparound BHH Family Support Specialists and must ensure fidelity of Wraparound BHH Services. A BHH must maintain staffing equivalent to at least one (1) full-time equivalent (FTE) Clinical Team Leader for Wraparound BHH Services for each FTE Wraparound BHH Coordinator. A Clinical Team Leader for Wraparound BHH Services must not supervise more than six (6) FTE Wraparound BHH Coordinators. (4) Certified Intentional Peer Support Specialist (CIPSS) – (for Adult Standard BHH Services) is an individual who has successfully completed the Maine Office of Behavioral Health (OBH) curriculum for CIPSS and receives and maintains that certification. The CIPSS is an individual who is receiving or has received services and supports related to the diagnosis of a behavioral health condition, is in recovery from that condition, and who is willing to self-identify on this basis with BHH members. Peer support staff may function as a CIPSS without CIPSS certification for the first nine (9) months of functioning as a CIPSS, but may not continue functioning as a CIPSS beyond nine (9) months without: (a) having received provisional certification by completion of the Core training, and (b) continuing pursuit of full certification as a CIPSS and maintaining certification as a CIPSS and maintaining certification as an Intentional Peer Support Specialist according to requirements as defined by OBH. The CIPSS shall coordinate and provide access to Peer Support Services, peer advocacy groups, and other peer-run or peer-centered services, maintain updated information on area peer services, and shall assist the member with identifying and developing natural support systems. A BHH must maintain staffing equivalent to at least one (1) FTE CIPSS for every two hundred (200) members with Serious Mental Illness (SMI) enrolled across the Standard BHH Services program panel. BHH providers may transition to meeting this required CIPPS to member ratio by the addition of one (1) new CIPPS FTE every six (6) months, until full compliance is achieved. (5) Youth Support Specialist (for Child BHH services) is an individual who is between eighteen (18) and thirty (30) years old who is receiving or has received services and supports related to the diagnosis of behavioral health condition, is in recovery from that condition, and who is willing to self-identify on this basis with members receiving services in this Section. Youth Support Specialists engage in team meetings, accept responsibility for parts of the POC or WPOC as directed by the member and family, communicate regularly with the member, and provide one-to-one support when initiated by the member. Youth Support Specialists for Standard BHH Services and Wraparound BHH Services who have not completed provisional certification requirements within nine (9) months of the date of hire are not eligible to perform reimbursable services for any BHH until they have obtained provisional certification. Youth Support Specialists for Standard BHH Services and Wraparound BHH Services who have not completed full certification within twelve (12) months of the date of hire are not eligible to perform reimbursable services for any BHH until they have obtained full certification. a. Youth Support Specialists for Standard BHH Services must successfully complete and continuously maintain certification as a Youth Support Specialist for BHH Services through a Department-approved curriculum. A BHH must maintain staffing equivalent to at least one (1) FTE Youth Support Specialist for Standard BHH Services for every two hundred (200) Child members enrolled across the Standard BHH Services program panel. BHH providers may transition to meeting this required Youth Support Specialist to member ratio by the addition of one (1) new Youth Support Specialist FTE every six (6) months, until full compliance is achieved. b. Youth Support Specialists for Wraparound BHH Services must successfully complete and continuously maintain certification as a Youth Support Specialist for Wraparound BHH Services through a Department-approved Wraparound BHH Youth Support Specialist training program. A BHH must maintain staffing equivalent to at least one (1) FTE Youth Support Specialist for Wraparound BHH Services per twenty (20) families receiving Wraparound BHH Services. A Youth Support Specialist for Wraparound BHH Services must not have a caseload that exceeds twenty (20) families. (6) Family Support Specialist is an individual who has a family member who is receiving or has received services and supports related to the diagnosis of a behavioral health condition and who is willing to self-identify on this basis with members receiving services in this Section. Family Support Specialists engage in team meetings, accept responsibility for parts of the POC or WPOC as directed by the member and family, communicate regularly with the member, and provide one-to-one support when initiated by the member. Family Support Specialists for Standard BHH Services and Wraparound BHH Services who have not completed provisional certification requirements within nine (9) months of the date of hire are not eligible to perform reimbursable services for any BHH until they have obtained provisional certification. Family Support Specialists for Standard BHH Services and Wraparound BHH Services who have not completed full certification within twelve (12) months of the date of hire are not eligible to perform reimbursable services for any BHH until they have obtained full certification. Family Support Specialists for Standard BHH Services must successfully complete and continuously maintain certification as a Family Support Specialist through a Department-approved curriculum. A BHH must maintain staffing equivalent to at least one (1) FTE Family Support Specialists for Standard BHH Services for every two hundred (200) Child members enrolled across the Standard BHH Services program panel. Family Support Specialist for Wraparound BHH Services must successfully complete and continuously maintain certification as a Family Support Specialist through a Department-approved curriculum. A BHH must maintain staffing equivalent to at least one (1) FTE Family Support Specialist for Wraparound BHH Services per twenty (20) families receiving Wraparound BHH Services. A Family Support Specialist for Wraparound BHH Services must not have a caseload that exceeds twenty (20) families. (7) Health Home Care Coordinator for Members with Serious Emotional Disturbance (SED) for Standard BHH Services (SED Health Home Coordinator) must be an individual who has a minimum of a bachelor’s degree from an accredited four (4) year institution of higher learning, with specialization in psychology, mental health and human services, behavioral health, behavioral sciences, social work, human development, special education, counseling, rehabilitation, sociology, nursing, or closely related field; OR who has a bachelor’s degree from an accredited four (4) year educational institution in an unrelated field and at least one (1) year of full-time equivalent relevant human services experience; OR a who has master’s degree in social work, education, psychology, counseling, nursing, or closely related field from an accredited graduate school; OR who has been employed since August 1, 2009 as a case manager providing Services under Chapter II, Section 13 of the MaineCare Benefits Manual. The SED Health Home Coordinator must also enroll in a Department-approved wraparound planning principles training series within thirty (30) days from the date of hire and complete the training series within sixty (60) days from the date of hire. The SED Health Home Coordinator must draft the POC for each member with SED utilizing information from a Child and Adolescent Needs and Strengths assessment (CANS), implement that POC and the coordination of services, and support and encourage members in actively participating in reaching the goals set forth in their POC. Each member must have only one (1) SED Health Home Coordinator and cannot be enrolled in more than one (1) case management program funded by Medicaid. The SED Health Home Coordinator is a “Care Coordinator” as described in United States v. State of Maine, No. 1:24-cv-00315-SDN (D. Me. Dec. 20, 2024)(Order on Mot. Dismiss and Retain Jurisdiction, Ex. A, Settlement Agreement Between the United States of America and the State of Maine). The SED Health Home Coordinator must: Ensure that Children and family members, as applicable, know how to raise issues with existing services or lack of services, including, as applicable, by filing a grievance with the Department; by requesting the SED Health Home Coordinator raise an issue with the provider, with the Department, or with an oversight board; or by requesting the SED Health Home Coordinator make referrals to alternate or additional providers; b. Identify risks that may lead to an out-of-home placement and barriers that prevent a member from living in a family home; c. Meet in places and at times convenient for and preferred by the member and/or their parent/guardian; d. Ensure that members receive timely services, including, if necessary, by seeking services through another agency upon learning that one (1) provider cannot meet the member’s needs, and notify the Department when members do not receive timely services; e. Implement a process to make decisions if the team cannot reach consensus; f. Coordinate with other relevant entities, including school staff, medical providers, juvenile justice staff, and other state service program staff or contractors to ensure those programs support the POC; and g. If the BHH determines that the member needs one (1) or more services that MaineCare only covers in an out-of-home placement, including, but not limited to, inpatient services, psychiatric residential treatment facility services, or children’s residential care facility services, inform the member or parent/guardian of the option to submit an Americans with Disabilities Act (ADA) Title II modification request to the Department to determine whether reasonable modifications can be made so the member can receive services at home or in a community-based setting and, if requested by the parent/guardian or member, submit a request for an ADA modification to the Department’s ADA coordinator. (8) The Health Home Care Coordinator for Wraparound BHH Services (Wraparound BHH Coordinator) must meet the criteria for the SED Health Home Coordinator and enroll in a Department-approved wraparound BHH training series within one (1) month from the date of hire. The Wraparound BHH Coordinator must complete the wraparound BHH training within fifteen (15) months from the date of hire. When serving a Child, a Wraparound BHH Coordinator is a “HFW Care Coordinator” as described in United States v. State of Maine, No. 1:24-cv-00315-SDN (D. Me. Dec. 20, 2024)(Order on Mot. Dismiss and Retain Jurisdiction, Ex. A, Settlement Agreement Between the United States of America and the State of Maine). In addition to the responsibilities of the SED Health Home Coordinator in this Section, except for utilizing information from the CANS and enrolling and completing the wraparound planning principles training series, the Wraparound BHH Coordinator must: Conduct and document the type and content of weekly face-to-face contact with the member’s team; Arrange team meetings at least once each month; In collaboration with the BHH team, ensure that at least ten (10) service hours are provided to the member each month; Perform duties specified in the member’s WPOC; Collect and interpret information about the member’s progress toward goals in accordance with the wraparound principles in Section 92.03-1(L); and Have a caseload that does not exceed ten (10) cases per FTE. Existing Health Home Care Coordinators that transition from providing Standard BHH Services to providing Wraparound BHH Services must adjust their caseloads to meet the 1:10 requirement within thirty (30) days of the date the first Wraparound BHH member is assigned to their caseload. (9) Health Home Care Coordinator for Members with Serious Mental Illness (SMI) for Standard BHH Services (SMI Health Home Coordinator) must be an individual who is certified by the Department as a Mental Health Rehabilitation Technician/Community (MHRT/C). The SMI Health Home Coordinator must draft the POC for each member, oversee that POC and the coordination of services, and support, and encourage members to actively participate in reaching the goals set forth in their POC. The SMI Health Home Coordinator must adhere to the same provider responsibilities that are applicable for Adults as the SED Health Home Coordinator in this Section, except for utilizing information from the CANS. SMI Health Home Coordinators serving Children ages 18 to 21 must enroll in the wraparound planning principles training series within thirty (30) days of their hire date and complete the series within sixty (60) days of their hire date. When serving a Child, a SMI Health Home Coordinator is a “Care Coordinator” as described in United States v. State of Maine, No. 1:24-cv-00315-SDN (D. Me. Dec. 20, 2024)(Order on Mot. Dismiss and Retain Jurisdiction, Ex. A, Settlement Agreement Between the United States of America and the State of Maine). Each member must have only one (1) Health Home Care Coordinator. (10) Medical Consultant must be a physician licensed by the State of Maine to practice medicine or osteopathy, a physician assistant licensed as such by the State of Maine, or a certified nurse practitioner who meets all of the requirements of the licensing authority of the State of Maine. The Medical Consultant must collaborate with other providers of BHH and primary care services or specialty services (at least 4 hours/month per two hundred (200) members or pro-rated for agencies that serve fewer than two hundred (200) clients) to select and implement evidence-based clinical initiatives, lead quality improvement efforts, evaluate progress, and convene provider clinical quality improvement meetings. The BHH must adhere to licensing standards in documentation of all its BHH providers’ qualifications in their personnel files. Pursuant to applicable licensing standards, the BHH must have a review process to ensure that employees providing BHH Services possess the minimum qualifications set forth above. E. The BHH must be co-occurring capable, meaning that the organization is structured to welcome, identify, engage, and serve individuals with co-occurring substance use and mental health disorders and to incorporate attention to these issues into program content. F. The BHH must have an EHR system and an EHR for each member. G. The BHH must have in place processes, and procedures, and member referral protocols with local inpatient facilities, Emergency Departments (ED), Child/Adult residential facilities, crisis services, and corrections for prompt notification of an individual’s admission and/or planned discharge to/from one of these facilities or services. The protocols must include coordination and communication on enrolled or potentially eligible members. The BHH must have systematic follow-up protocols to assure timely access to follow-up care. H. The BHH must ensure that it has policies and procedures in place to ensure that Health Home Care Coordinators can communicate changes in patient condition that may necessitate treatment change with treating clinicians, on an as-needed basis. I. The BHH must participate in BHH technical assistance opportunities, as determined by the Department. At least one (1) member of the care team described in this Section must engage in technical assistance the Department deems necessary. J. Within the first six (6) months following the start of the BHH’s participation, the BHH must obtain a written site assessment from the Department or its authorized entity, to establish a baseline status in meeting the Core Standards defined in Section 92.03-1(N) and identify the BHH’s training and educational needs. K. For the first year of participation, the BHH must submit quarterly reports on progress towards implementing the Core Standards. Within one (1) year of the BHH’s participation, the BHH must fully implement the Core Standards. Once core standards are fully implemented, the BHH may request the Department’s approval to submit the core standard progress report annually instead of quarterly. The Core Standards are: Demonstrated Leadership – The BHH identifies at least one (1) Clinical Team Leader within the BHH who implements and oversees the core standards. The Clinical Team Leader(s) work with other providers and staff in the BHH to build a team-based approach to care, continually examine the processes and structures to improve care, and review data on the performance of the BHH. Team-Based Approach to Care – The BHH has implemented a team-based approach to care delivery that includes expanding the roles of non-licensed team professionals and includes CIPSS and other peer supports as leaders and partners in the provision of care. The BHH utilizes non-licensed staff to improve access, efficiency, and member engagement in specific ways, including one or more of the following: Through clear identification of roles and responsibilities; Training on and integration of CIPSS and other peer supports as meaningful partners in service delivery; and Regular team meetings. (3) Population Risk Stratification and Management – The BHH has adopted processes to identify and stratify members across their population who are at risk of adverse outcomes and adopted procedures that direct resources or care processes to reduce those risks. For purposes of this provision, “adverse outcomes” means hospitalization, institutionalization, involvement with law enforcement, excessive school absenteeism, job loss or home loss, which occur as a result of the member’s SMI or SED. (4) Enhanced Access – The BHH enhances access to services for their members, including: The BHH has a system in place, such as an on call or answering service, for BHH members to reach a member of the organization or an authorized entity twenty-four (24) hours a day, seven (7) days a week to address and triage the members’ needs. The BHH has processes in place to ensure twenty-four (24) hours a day, seven (7) days a week access to BHH member records. The BHH has processes in place to monitor and ensure this enhanced access to care. (5) Comprehensive Consumer/Family Directed Care Planning – The BHH has processes in place to ensure that consumer voice and choice is reflected in development of the POC and WPOC. These processes include: Wraparound principles, as defined in 92.03-1(L), for Children with SED and their families. Practice guidelines for recovery-oriented care. (6) Behavioral and Physical Health Integration – The BHH must submit a completed report of its behavioral and physical health integration progress annually using the Department’s reporting tool. The report must include the previous year’s data and identify an area of focus for the following twelve (12) month period to improve behavioral and physical health integration. (7) Inclusion of Members and Families – The BHH includes members and their family as documented and regular participants at leadership meetings, and/or the BHH has in place a member-driven process to identify needs and solutions for improving services. a. The BHH has processes in place to support members and families to participate in these leadership and/or advisory activities (e.g., on the agency’s Board of Directors, involvement in internal advisory committees that solicit and support the engagement of consumers and families in identifying needs and solutions; b. The BHH has implemented systems to gather member and family input at least annually (through mail surveys, phone surveys, point of care questionnaires, focus groups, or other methods); and The BHH has processes in place to design and implement changes that address needs and gaps in care identified via member and family input. Connection to Community Resources and Social Support Services – The BHH has processes in place to identify and make referrals to local community resources and social support service, including those that provide support in self-management, to assist members in overcoming barriers to care and meeting health and recovery goals. Commitment to Reducing Waste, Unnecessary Healthcare Spending, and Improving Cost-Effective Use of Healthcare Services – The BHH has processes in place to reduce wasteful spending of healthcare resources and improving the cost-effective use of healthcare services, as evidenced by at least one (1) initiative that targets waste reduction, such as: Reducing avoidable hospitalizations; Reducing avoidable ED visits; Reducing out-of-home placements; Working with specialists to develop new models of specialty consultation that improve member experience and quality of care, while reducing unnecessary use of services; and Directing referrals to specialists who consistently demonstrate high quality and cost-efficient use of resources. (10) Integration of Health Information Technology – The BHH uses an electronic data system that includes identifiers and utilization data about members. Member data is used for monitoring, tracking and indicating levels of care complexity for the purpose of improving member care. The system is used to support member care, including one or more of the following: The documentation of need and monitoring clinical care; Supporting implementation and use of evidence-based practice guidelines; Developing plans of care and related coordination; and Determining outcomes (e.g., clinical, functional, recovery, satisfaction, and cost outcomes). L. BHHs must deliver Standard BHH Services and Wraparound BHH Services to Children in accordance with the following wraparound principles: (1) Family voice and choice – Family and member perspectives are gathered and prioritized throughout the POC or WPOC development and care coordination processes. (2) Child and Family Team based – The Child and Family Team consists of individuals agreed upon by the family and member and committed to them through informal, formal, and community support and service relationships. (3) Involvement of natural supports – The Child and Family Team actively seeks out and encourages the full participation of Child and Family Team members drawn from the member’s family and others in the member’s networks of relationships chosen by the member. (4) Collaboration – Child and Family Team members work cooperatively and share responsibility for developing, implementing, monitoring, and evaluating the POC or WPOC. (5) Community-based – The Child and Family Team implements service and support strategies that take place in the most inclusive, most responsive, most accessible, and most integrated settings appropriate for the member’s needs possible, and that safely promote the member and family integration into home and community life. (6) Culturally competent – Service delivery demonstrates respect for and builds on the values, preferences, beliefs, culture, and identity of the member, family, and their community. (7) Individualized – To achieve the goals laid out in the POC or WPOC, the Child and Family Team develops and implements a customized set of strategies, supports, and services. (8) Strengths-based – Identifies, builds on, and enhances the capabilities, knowledge, skills, and assets of the member and family, their community, and other Child and Family Team members. (9) Persistence – Despite challenges, the Child and Family Team persists in working toward the goals included in the POC or WPOC. (10) Outcome-based – The Child and Family Team ties the goals and strategies of the POC or WPOC to observable or measurable indicators of success, monitors progress in terms of these indicators, and revises the plan accordingly. 92.03-2 Protections for Adults with Serious Mental Illness If the member is an Adult with a SMI (i.e., the member meets eligibility criteria in this Section) and is receiving Standard BHH Services reimbursed under Section 92, as identified in the member’s POC, then the provider must: Obtain written approval from the Director of OBH or designee prior to terminating services to that member. Written approval is not required in cases where the terminating provider has successfully facilitated a member’s transfer, with the member’s consent, to a new provider; If approved by OBH, issue a thirty (30) day advanced written termination notice to the member prior to termination of member’s services. In cases where the member poses a threat of imminent harm to persons employed or served by the provider, the Director of OBH or designee may approve a shorter notification for termination of services; Assist the member in obtaining clinically necessary services from another provider prior to discharge or termination; and Accept referrals through the Department-defined referral process within seven (7) calendar days. Only in cases where providers have received written approval of declination from OBH, may a referral be declined. 92.03-3 Timeliness and Duration of Care BHHs must conduct an initial face-to-face intake visit within seven (7) calendar days of referral, regardless of source of referral. In the event a BHH receives a referral and does not have capacity to initiate services, the BHH must offer the option of placing the member on a hold for service. A. Hold for Standard BHH Services and Wraparound BHH Services Members have the option to be placed on hold for Standard BHH Services and Wraparound BHH Services if the BHH, upon receipt of a referral from any source, has determined that it does not have the capacity to conduct an intake within seven (7) calendar days. To be placed on hold for a BHH service, providers must offer the member alternatives to being placed on hold for service, including but not limited to giving information about other service providers within a 25-mile radius servicing the area. This information must be provided in writing. Should members wish to be on hold for service with a BHH, the provider will document the member choice and the offering of alternatives in the member’s referral record. At this time, the seven (7) calendar day face-to-face requirement will be suspended. Agencies must follow up with members no more than thirty (30) calendar days after being placed on hold to reevaluate their desire to remain on hold for service, which will be documented in the member record. BHHs must continue to follow up with members in successive thirty (30) day increments to reevaluate the member’s desire to remain on hold. When the agency has determined it has the capacity to serve the member, it will contact the member immediately and have twenty-four (24) hours to conduct the intake or initial assessment. 92.04 MEMBER ELIGIBILITY Members must meet the eligibility requirements set forth in this Section. 92.04-1 General Eligibility. Members must meet the eligibility criteria as set forth in the MaineCare Eligibility Manual, Chapter 1, Section 1. 92.04-2 Specific Requirements for Standard BHH Services Serious Mental Illness (SMI) — Adult Standard BHH Services. Adult members must meet all of the following criteria. Eligibility must be supported by written diagnosis(es), rendered by a physician, a physician assistant, or a licensed clinician, within the scope of the professional’s license, and the diagnosis(es) must be documented in the member’s record. Members aged eighteen (18) through twenty (20) may choose to receive Adult Standard BHH Services but must meet the criteria below. Members must have a primary mental health diagnosis under the DSM, except that the following diagnoses may not be primary diagnoses for purposes of this eligibility requirement: Delirium, dementia, amnestic, and other cognitive disorders; Mental disorders due to a general medical condition, including neurological conditions and brain injuries; Substance use or dependence; Intellectual disability; Adjustment disorders; Antisocial personality disorder; or ADHD. Members must receive and maintain a LOCUS score, as determined by staff certified for LOCUS assessment by DHHS upon successful completion of prescribed LOCUS training, of seventeen (17) (Level III) or greater. The LOCUS assessment must be administered at least every six (6) months and documented in the member’s record. Serious Emotional Disturbance (SED) — Child Standard BHH Services. Child members must meet all of the following criteria. Members must have a SED, a diagnosed behavioral health disorder included in the DSM, or a diagnosis described in the current version of the Diagnostic Classification of Mental Health and Developmental Disabilities of Infancy and Early Childhood, published by Zero to Three, except that the following diagnoses are not eligible for services in this Section: Learning Disabilities in reading, mathematics, written expression; Motor Skills Disorder; Learning Disabilities Not Otherwise Specified; Communication Disorders (Expressive Language Disorders, Mixed Receptive Expressive Language Disorder, Phonological Disorder, Stuttering, and Communication Disorder Not Otherwise Specified). Members with an excluded diagnosis may still receive Standard BHH Services if they have a qualifying diagnosis. Eligibility must be supported by written diagnosis(es), rendered by a physician, a physician assistant, an APRN, or a licensed clinician, within the scope of the professional’s license, and the diagnosis(es) must be documented in the member’s record. After the initial month of BHH enrollment, members must also have a significant impairment or limitation in adaptive behavior or functioning as evidenced by a CANS score of a two (2) or higher in both of the following Sections: “Child Behavioral/Emotional Needs” and “Life Functioning Domain.” The CANS must be reviewed and updated by the BHH a minimum of every one hundred and eighty (180) days or sooner, when major changes occur. The CANS, including all age relevant domains, must be entered into the Maine ASO database, or approved equivalent data system, for tracking and reporting purposes. Information gathered via the CANS must be used to inform and guide the development of the POC. 92.04-3 Specific Requirements for Wraparound BHH Services Eligibility for Wraparound BHH Services for Children is determined through the Single Assessment described in the Children’s Services Global Rule, MaineCare Benefits Manual, Ch. I, Sec. 7. To receive Wraparound BHH Services, Child members must meet the following criteria: A. Have a SED, a diagnosed behavioral health disorder included in the DSM, or a diagnosis described in the current version of the Diagnostic Classification of Mental Health and Developmental Disabilities of Infancy and Early Childhood, published by Zero to Three, except that the following diagnoses are not eligible for Wraparound BHH Services: Learning Disabilities in reading, mathematics, written expression; Motor Skills Disorder; Learning Disabilities Not Otherwise Specified; Communication Disorders (Expressive Language Disorders, Mixed Receptive Expressive Language Disorder, Phonological Disorder, Stuttering, and Communication Disorder Not Otherwise Specified). Members with an excluded diagnosis may still receive Wraparound BHH Services if they have a qualifying diagnosis. Eligibility must be supported by written diagnosis(es), rendered by a physician, a physician assistant, APRN, or a licensed clinician, within the scope of the professional’s license, and the diagnosis(es) must be documented in the member’s record. Receive and maintain a score of seventeen (17) (Level III) or higher on the age-appropriate Level of Care/Service Intensity tool completed by the Department or its Authorized Entity. The age-appropriate Level of Care/Service Intensity tools are the Early Childhood Service Intensity Instrument (ECSII) for ages zero (0) to five (5), the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII) for ages six (6) to eighteen (18), and the Level of Care Utilization System (LOCUS) for members ages eighteen (18) and over; and Meet at least one (1) of the following criteria: In the past twelve (12) months, having experienced multiple hospitalizations for behavioral health needs or have experienced a combination of hospitalization, crisis stabilization, and emergency department admission for behavioral health needs; or Have past or present experience with two (2) or more of the following: Involvement in the Department’s or another state’s child welfare system. Disruption in the Department’s adoption or placement process because of behavioral needs. Documentation of receiving behavioral health services as a result of a qualifying diagnosis. Risk of homelessness or currently experiencing homelessness. Risk for out of home placement or currently residing in an out of home placement. Involvement in the juvenile justice system, such as an arrest. 92.04-4 Eligibility Verification. Member eligibility is determined by the Department or its Authorized Entity, which must provide prior authorization for services. Eligibility verification must be included in the member’s record. For members receiving Standard BHH Services, the BHH must reassess the members’ eligibility for the services at least every six (6) months. The BHH must conduct reassessments using the CANS or the age-appropriate Level of Care/Service Intensity tool in accordance with Section 92.04-2. Authorizations for Wraparound BHH Services must not exceed fourteen (14) months unless the BHH submits a prior authorization and it is approved by the Department or its Authorized Entity. To ensure ongoing eligibility for Wraparound BHH Services, the BHH must reassess the member at least every thirty (30) days and determine whether the transition readiness factors in Section 92.06-4(B)(2) have been met. 92.05 POLICIES AND PROCEDURES FOR MEMBER IDENTIFICATION AND ENROLLMENT 92.05-1 Member Identification The BHH must identify members who are potentially eligible for Standard BHH Services or Wraparound BHH Services based on the applicable eligibility criteria. The BHH must submit a prior authorization request for Standard BHH Services and a Single Assessment referral for Wraparound BHH Services, in accordance with MBM Chapter I, Section 7. 92.05-2 Enrollment and Freedom of Choice A. Enrollment. Potentially eligible members will be given information about the benefits of participating in a BHH. The member can choose to enroll in Standard BHH Services or Wraparound BHH Services once confirmed eligible. The member can choose to not participate at any time by notifying their BHH or the Department’s Authorized Entity. Requests and Referrals. Members may request Standard BHH Services or Wraparound BHH Services or be referred for BHH services by another MaineCare provider. Selection of a Primary Care Practice. Upon entry of enrollment with a BHH, the BHH will work with the member to identify a primary care provider if the member does not already have one. Duplication and Freedom of Choice. A member may not receive services under this Section at the same time the member is receiving duplicative services, which are identified in Section 92.11(C). If, through the certification process, the member is determined to be receiving a duplicative service, the member must choose which service they want to receive, and such choice must be clearly documented in the member’s record. A member may opt out of BHH Services at any time and may choose to receive services from any qualified BHH, by providing notice to the BHH provider. The choice to switch providers shall be effective on the 21st day of the following month, or the first available date when a duplication of service does not exist. Members who switch providers shall be removed from the member list for that provider. A BHH must transfer all of a member’s clinical documentation to the appropriate BHH within ten (10) business days of notification that a member will transfer. Providers that offer Section 13, Section 17, Section 91, and/or Section 93 Services and also Section 92 Services must be able to demonstrate that members are provided with information regarding choice of Section 13, Section 17, Section 91, Section 93 and Section 92 Services for which the member is eligible and which the provider offers. 92.06 COVERED SERVICES BHH services may be delivered face-to-face, via phone or other media, in any community location where confidentiality can be maintained. Not all aspects of BHH covered services require direct member involvement; however, all covered services require that provider activities are directly related to an individual member’s needs, are member-informed, and pursuant to the member’s POC or WPOC. BHHs must deliver covered services in accordance with the following subsections. The subparts for Standard BHH services and Wraparound BHH services in each subsection contain all the requirements for the respective service model. 92.06-1 Comprehensive Care Management Comprehensive Care Management are services provided to assure that members receive timely and coordinated services and supports that address physical and behavioral health needs, and promote community and home-based recovery. Comprehensive Care Management Services – Standard BHH Services: (1) Comprehensive Assessment. Within the first thirty (30) calendar days following a member’s enrollment for Standard BHH Services, the Health Home Care Coordinator, as necessary in collaboration with the Clinical Team Leader and/or other qualified BHH staff, must provide each member with an in-person meeting and a comprehensive assessment that identifies the medical, behavioral, mental health, social, residential, educational, vocational, and other related needs, strengths, and goals of the member (and the family/caretaker if the member is a minor), including utilization of screening tools for co-occurring disorders. The comprehensive review must include a psychosocial assessment, including history of trauma and abuse, substance use, general health and capabilities, medication needs, member strengths and how they can be optimized to promote goals, available support systems, living situation, employment and/or educational status, behavioral health risk factors, child welfare involvement, and other relevant information. A comprehensive reassessment must occur as changes in the member’s needs warrants, including but not limited to after a crisis event, a hospitalization as a result of the member’s behavioral health needs, the member’s arrest and referral to the Maine Department of Corrections pursuant to 15 M.R.S.A. § 3203-A, an admission for in-patient psychiatric care, a child welfare placement, a placement in an alternative school, or an incident endangering self or others at the member’s school, and at a minimum every twelve (12) months. When serving a Child, a SMI Health Home Coordinator is a “Care Coordinator” as described in United States v. State of Maine, No. 1:24-cv-00315-SDN (D. Me. Dec. 20, 2024)(Order on Mot. Dismiss and Retain Jurisdiction, Ex. A, Settlement Agreement Between the United States of America and the State of Maine). (2) Crisis Plan. The Health Home Care Coordinator must develop an initial crisis plan within seven (7) days of the member’s entry into Standard BHH Services. The crisis plan must include known safety issues; a brief history of crises in the home, school, and community; potential triggers for behavioral crises; successful past strategies for de-escalation; methods for defusing situations, ensuring safety, and debriefing after incidents; and action steps, beginning with the least restrictive supports and ending with the most restrictive supports, including the team member responsible for each support. In crisis or urgent situations, the goal will be to stabilize the member and divert the member whenever possible from receiving services in an out-of-home placement or making an emergency department visit due to a behavioral health need by identifying and furnishing appropriate community-based services. The Health Home Care Coordinator must review the crisis plan and update it as appropriate when the POC is reviewed and following a crisis. (3) Plan of Care Requirements. Based on the comprehensive assessment, within the first thirty (30) calendar days following a member’s enrollment, the Health Home Care Coordinator in partnership with the Child and Family Team must draft a comprehensive, individualized, and member-driven POC that must identify and integrate behavioral and physical health needs and goals. The BHH and the Health Home Care Coordinator in partnership with the Child and Family Team are responsible for the management, oversight, and implementation of the POC, including ensuring active member participation and that measurable progress is being made on the goals identified in the POC. The POC must be consented to by the member and documented in the member’s record, and accessible to the member, the BHH and other providers. The BHH must obtain written consent for the BHH services and the settings in which those services are delivered. The BHH must obtain the member’s authorization for release and sharing of information with the providers of each service identified on the POC. The POC may include, but not be limited to, information on prevention, wellness, peer supports, health promotion and education, and identifying other social, residential, educational, vocational, and community services and supports that enable a member to achieve physical and behavioral health goals. The POC must clearly identify the goals and timeframes for improving the member’s health and the interventions that will produce this effect. If authorized by the member, the BHH must document in the POC the member’s family, guardian(s), or caregiver support systems and preferences. If authorized by the member, the POC must be accessible to the member’s family, guardian(s), or other caregivers. The POC must identify member strengths and how these strengths can be optimized to promote goals and desired outcomes. The POC must clearly identify providers involved in the member’s care, such as the primary care provider, specialist(s), behavioral health care provider(s), Health Home Care Coordinator, and other providers directly involved in the member’s care. The POC must identify all services and the duration, frequency, and intensity of those services needed to address the member’s behavioral health and other healthcare related needs. The POC must also identify the provider who will deliver each service, any barriers that may prevent the member from receiving services and how those barriers will be addressed, whether the member is actually receiving services authorized, whether services are effective, and, if applicable, adjustments to services and justification for any adjustments. The POC must be reviewed and approved in writing by the Clinical Team Leader within the first thirty (30) calendar days following acceptance of the Plan by the member, and every ninety (90) calendar days thereafter, or more frequently if indicated in the POC. The Health Home Care Coordinator with other care team members, as appropriate, must review the POC as changes in the member’s needs occur, or at least every ninety (90) days, to determine the efficacy of the services and supports, and formulate changes in the POC as necessary. For members with SED, POC revisions must occur in consultation with the Child and Family Team. For members with SMI, POC revisions must occur in consultation with the member and, when indicated and consistent with the member’s preferences, the member’s family, guardian, natural supports, and/or service providers. Initially and then every one hundred eighty (180) days, as part of the POC review, the Health Home Care Coordinator must visit the member’s home as appropriate, and, for members with SED, observe family interactions and interview the member, family, and natural supports. For members with SMI, observation of family interactions and interviews with family and natural supports must occur when clinically indicated and consistent with the member’s preferences. The Health Home Care Coordinator must document any updates to the member’s social history related to behavioral health risk factors, child welfare involvement, and developmental trauma in the POC. The BHH must consult with care team members and the member as necessary, and update the POC accordingly to ensure that it remains current. The POC must include a plan to return a member to their home if they are receiving services in an out-of-home placement. The return plan must list the specific steps that will be taken so the member can return from an out-of-home placement and continue to receive necessary services and must include a planned discharge date. The POC must document when the BHH determines that the member needs one (1) or more services that are only offered in an out-of-home placement. The POC must also document when parent/guardians or members choose to receive services in an out-of-home placement. The BHH must address any of the parent’s/guardian’s and/or member’s concerns about receiving services in a family home, including by discussing how to furnish services in a family home other than a parental home, and the POC must document that the BHH addressed these concerns. The POC must document measures taken to afford the member and/or parent/guardian with an informed choice regarding the services they are eligible for. The POC must anticipate and appropriately plan for significant transitions in the member’s life, including a transition to a new school and a transition to Adult services. The POC must reference and coordinate with other written plans relevant to the member’s needs, such as an individualized education plan, a 504 plan, an individualized plan for employment, and a positive behavioral support plan. The POC must include the member’s crisis plan, which must be reviewed as part of each POC review. The member may decline to receive services identified in the POC, in which case the BHH must document such declination in the member’s record. Integration with Primary Care. During the first three (3) months after a member’s enrollment, the BHH must provide individualized outreach, education and support to the member (and family, if the member is a minor) regarding BHH Services and benefits, including information on sharing personal health information, and coordination with primary care services. These services may be provided via in-person meetings, follow up phone calls, development of written materials or presentations, assistance from Peer Support providers, and other strategies to ensure that the BHH’s members are fully educated and engaged with the needs and goals set forth in the POC. Address Gaps in Care. The BHH must scan for gaps in each member’s care by reviewing, at a minimum, utilization reports for data across the following domains, as available, and work with the member and appropriate providers to address any gaps in care: Hospitalizations in the last quarter as well as the last year; ED visits in the last quarter as well as the last year; Patients with total paid claims greater than $10,000; Patients with eleven (11) or more medications; Patients with no PCP visits in the last year; Patients with no HbA1c test (diabetes) in the last quarter; Patients with no LDL panel (diabetes) in the last year; and Patients with no LDL panel in the last year (CVD). Medical Information. The BHH must ensure that current medical information related to a member’s physical health conditions, including lab tests/results and medications, are documented in the member’s record. (7) Clinical Assessments. The BHH must conduct clinical assessments; monitor and follow up on physical and behavioral health care needs; conduct medication review and reconciliation; monitor chronic conditions, tobacco, and other substance use; and communicate regularly with other treatment providers as necessary to identify a member’s emerging care management needs. Specifically, BHHs must have processes to review the results of the member’s screening and assessments that occurred prior to three (3) months before admission. BHHs must also have processes to conduct screenings and assessments for members when clinically indicated. The screenings and assessments include but are not limited to the following: Developmental screening for all Children aged one (1) to six (6), such as the Ages & Stages Questionnaire (ASQ); Parent’s Evaluation of Developmental Status (PEDS); b. For members between ages 16-30 months without a diagnosis of autism spectrum disorder spectrum, at least one administration of the Modified Checklist for Autism in Toddlers (MCHAT 1); c. Depression, anxiety, and substance use screenings as clinically appropriate (e.g. Patient Health Questionnaire (PHQ-9), Alcohol Use Disorder Identification Test (AUDIT), Drug Abuse Screening Test (DAST), CRAFFT for adolescents); and d. Postpartum screening for depression for members who have given birth (e.g. Edinburgh Postpartum Depression Scale (EPDS) at least once in the first six (6) weeks postpartum. B. Comprehensive Care Management Services – Wraparound BHH Services Comprehensive Assessment. The Wraparound BHH Coordinator must: a. Provide each member with an in-person meeting within seven (7) days of entry into Wraparound BHH Services and, in collaboration with the Clinical Team Leader and other qualified BHH staff as necessary, conduct an initial assessment that includes family history and the member’s developmental and educational history, including a detailed social history to identify behavioral health risk factors, child welfare involvement, and developmental trauma. The assessment must identify all necessary services to meet the member’s behavioral health needs and include a visit to the member’s home, as appropriate; interviews with the member, family, and natural supports; and observation of family interactions; b. With the member and member’s family, identify which individuals will be part of the Child and Family Team, and, if applicable, determine the least restrictive setting where the member will reside while receiving services that is appropriate for the member’s needs; c. Identify appropriate assessments to determine the medical, behavioral, mental health, social, residential, vocational, and other related needs, strengths, and goals of the member and member’s family including utilization of screening tools for co-occurring disorders. Future assessments may include but are not limited to a psychosocial assessment, history of trauma and abuse, substance use, general health and capabilities, medication needs, member strengths and how they can be optimized to promote goals, available support systems, living situation, employment and/or educational status, and other relevant information. The written comprehensive assessment must be completed within thirty (30) days of entry into Wraparound BHH Services; d. Repeat the comprehensive assessment as needed and at least every twelve (12) months in partnership with the Child and Family Team. (2) Crisis Plan. The Wraparound BHH Coordinator must develop an initial crisis plan within seven (7) days of the member’s entry into Wraparound BHH Services. The crisis plan must include known safety issues; a brief history of crises in the home, school, and community; potential triggers for behavioral crises; successful past strategies for de-escalation; methods for defusing situations, ensuring safety, and debriefing after incidents; and action steps, beginning with the least restrictive supports and ending with the most restrictive supports, including the team member responsible for each support. In crisis or urgent situations, a goal will be to stabilize the member and divert the member whenever possible from receiving services in an out-of-home placement or making an emergency department visit due to a behavioral health need by identifying and furnishing appropriate community-based services. The Wraparound BHH Coordinator must review the crisis plan and update it as appropriate when the WPOC is reviewed and following a crisis. Wraparound Plan of Care (WPOC). At the initial meeting, the Wraparound BHH Coordinator in partnership with the Child and Family Team must draft a comprehensive, individualized, and member-driven WPOC that identifies and integrates behavioral and physical health needs and goals. The Wraparound BHH Coordinator must develop the WPOC within the first thirty (30) calendar days following a member’s enrollment and update it every thirty (30) days and within seventy-two (72) hours of a reportable event or crisis. The BHH and the Child and Family Team is responsible for the management, oversight, and implementation of the WPOC, including ensuring active member participation and that measurable progress is being made toward identified goals. The WPOC must be consented to by the member and reviewed and approved in writing by the Clinical Team Leader initially and at every update. The WPOC must be documented in the member’s record and distributed to appropriate team members within five (5) to seven (7) business days. The BHH must obtain written consent for services and the settings in which those services will be delivered and authorization for release and sharing of information for each member. The member may decline to receive services identified in the WPOC, in which case the BHH must document such declination in the member’s record. The WPOC must follow Department-approved Wraparound BHH Service recommendations and include, at minimum, the following: Family vision and Child and Family Team mission; The member’s crisis plan, which must be reviewed at each Team meeting and altered as appropriate; Member and family strengths, needs, preferences, goals, desired outcomes, and culture; All services and the duration, frequency, and intensity of those services needed to address the member’s and family’s needs, including informal and community-based options. All services must be approved by a medical or mental health professional working within the scope of his/her license. The WPOC must also identify the provider who will deliver each service, any barriers that may prevent the member from receiving services and how those barriers will be addressed, whether the member is actually receiving services authorized, whether services are effective, and, if applicable, adjustments to services and justification for any adjustments; e. Strategies tied to the member and family’s needs, including the method and frequency of Department-approved Wraparound BHH tools for tracking success; f. Measurable and attainable outcomes; g. A plan for reviewing the WPOC at least monthly and within seventy-two (72) hours following a crisis or significant event involving the member; h. The method and frequency of the Wraparound BHH Coordinator’s communication with the member’s primary care provider and other providers; Documentation of when the BHH determines that the member needs one (1) or more services that are only offered in an out-of-home placement, such as psychiatric residential treatment facility services and children’s residential care facility services. The WPOC must also document when parent/guardians or members choose to receive services in an out-of-home placement; A plan to return a member to their home if they are currently receiving services in an out-of-home placement. The return plan must list the specific steps that will be taken so the member can return from an out-of-home placement and continue to receive necessary services and must include a planned discharge date; A plan for significant transitions in the member’s life, including a transition to a new school and a transition to Adult services; Reference to and coordination with other written plans relevant to the member’s needs, such as an individualized education plan, a 504 plan, an individualized plan for employment, and a positive behavioral support plan; The BHH must address any of the parent’s/guardian’s and/or member’s concerns about receiving services in a family home, including by discussing how to furnish services in a family home other than a parental home, and the WPOC must document that the BHH addressed these concerns; The WPOC must document measures taken to afford the parent/guardian and/or member with an informed choice regarding the services they are eligible for; and Initially and then every one hundred eighty (180) days as part of the WPOC review, the Wraparound BHH Coordinator must visit the member’s home, as appropriate, and observe family interactions, interview the member, family, and natural supports, and document any updates to the member’s social history related to behavioral health risk factors, child welfare involvement, and developmental trauma in the WPOC. (4) Integration with Primary Care. The Wraparound BHH Coordinator must, within the first month of member enrollment, obtain permission from the member to obtain medical information about the member and request the results of the member’s most recent physical evaluation from the member’s primary care provider. The Wraparound BHH Coordinator must ensure that copies of the member’s WPOC is shared with the member’s primary care provider. Gaps in Care. The BHH must scan for gaps in each member’s care and address immediate needs. 92.06-2 Care Coordination Care Coordination is a set of services designed to support the member (and family/guardian if the member is a minor) in the implementation of the POC or WPOC. Care Coordination Services – Standard BHH Services For each member, the BHH must identify specific resources and the amount, duration, and scope of services necessary to achieve the goals identified in the POC. The BHH must provide referrals to other services and supports, as identified in each member’s POC, and must follow up with each member to ensure that the member takes action in regard to each referral. The BHH must have an organizational understanding and provide systematic identification of local medical, community, and social services and resources that may be needed by the member. The BHH must assign to each member a Health Home Care Coordinator, who must be responsible for overall management of the POC, and coordinate and provide access to other providers as set forth in the POC. The BHH must ensure that members have access to crisis intervention and resolution services, coordinate follow up services to ensure that a crisis is resolved, and assist in the development and implementation of crisis plans. Unless other resources are preferred by the member, crisis services are DHHS-funded crisis providers in the community. (5) The BHH must coordinate and facilitate access to psychiatric consultation and/or medication management. (6) For each member, the BHH must monitor physical health and treatment services, including communicating with the member’s primary care provider. The BHH must consult and coordinate with the primary care provider to facilitate successful referral to all necessary services and supports identified in the POC. B. Care Coordination Services – Wraparound BHH Services With support from the Child and Family Team, the Wraparound BHH Coordinator must: Identify the amount, duration, and scope of services necessary to achieve goals identified in the member’s WPOC; Provide referrals to services and supports identified in the WPOC and support the member to take action regarding each referral; In conjunction with the member and member’s family, identify medical, community, and social resources that the member may need, as identified by the member and family, and coordinate access to those resources; and Ensure that members have access to crisis intervention services, coordinate follow-up services to ensure that a crisis is resolved, and assist in the development and implementation of crisis plans. 92.06-3 Health Promotion Health promotion is a set of services that emphasize self-management of physical and behavioral health conditions, in an effort to assist the member in the implementation of the POC or WPOC. A. Health Promotion Services – Standard BHH Services The BHH must provide education, information, training, and assistance to members in developing self-monitoring and management skills, including health promotion services based on each member’s needs set forth in the POC, including chronic physical conditions. The BHH must promote healthy lifestyle and wellness strategies, including but not limited to: substance use prevention, smoking prevention and cessation, nutritional counseling, obesity reduction and prevention, and increasing physical activities. (3) The BHH must coordinate and provide access to self-help/self-management and advocacy groups and must implement population-based strategies that engage members about services necessary for both preventive and chronic care. For members who are minors, the BHH must provide training to the member’s parent/guardian in regard to behavioral management and guidance on at-risk behavior. B. Health Promotion Services – Wraparound BHH Services Within the first ten (10) days after entering Wraparound BHH care, the Wraparound BHH Coordinator must coordinate and provide access to health promotion services and resources to the member and the member’s family, including but not limited to behavioral wellness strategies. The Wraparound BHH Coordinator must ensure the Child and Family Team includes discussion of the member’s physical health goals and objectives. At each Wraparound meeting with the member, the Child and Family Team must ensure the member has access to healthy lifestyle programs and strategies. 92.06-4 Comprehensive Transitional Care Comprehensive Transitional Care services are designed to ensure continuity and coordination of care, and prevent the unnecessary use of the ED, hospitals, and/or out of the home placement of members. In the event Standard or Wraparound BHH Services are terminated because a member voluntarily disengages from services or a member can no longer access services for any reason, the Health Home Care Coordinator must make reasonable efforts to collaborate with the member, their family, and any new provider to help achieve a coordinated, safe transition between the BHH and another provider. The BHH must document these collaborative efforts in the member record. Comprehensive Transitional Care Services – Standard BHH Services The BHH must: Collaborate with facility staff, including admission and discharge planners; the member; and the member’s family or other support system, as appropriate, to ensure a coordinated, safe transition to the home, community, or facility, and to prevent avoidable readmission after discharge. Assist the member with the discharge process, including outreach in order to assist the member with returning to the home/community. Follow up with each member following a hospitalization, use of crisis service, or out of home placement. Assist the member in exploration of less restrictive alternatives to hospitalization/ institutionalization. Provide timely and appropriate follow up communications on behalf of transitioning members, which includes a clinical hand off, timely transmission and receipt of the transition/discharge plan, review of the discharge records, and coordination of medication reconciliation. Facilitate, coordinate, and plan for the transition of members from Children’s services to Adult services. Review any and all discharge plans and conduct timely follow up with the member regarding physical health needs, including medication reconciliation, and update the member’s POC accordingly. Comprehensive Transitional Care Services – Wraparound BHH Services (1) The Wraparound BHH Coordinator must: Collaborate with facility admission and discharge planners, the member, and the member’s family or other support system, as appropriate, to ensure a coordinated, safe transition to the home, community, or facility, and to prevent avoidable readmission after discharge; Assist the member with the discharge process, including outreach in order to assist the member with returning to the home/community; Follow up with each member following a hospitalization, other out of home placement, or use of crisis service; Assist the member in exploration of less restrictive alternatives to hospitalization/institutionalization; Facilitate, coordinate, and plan for the transition of members from Children’s services to the Adult system; Review any and all discharge plans and conduct timely follow up with the member regarding physical health needs, including medication reconciliation, and update the member’s WPOC accordingly. (2) The member may transition out of Wraparound BHH Services after the BHH team members have considered and documented the following transition readiness factors: a. The action steps have resulted in near-completion of outcomes listed in the member’s WPOC; b. The member’s guardian and member can recognize possible responses to behavioral challenges and can respond to potential crises; c. The BHH has presented to the member the transition plan that summarizes family strengths, team accomplishments and interventions; and d. The member and member’s family have identified and understand how to access community services and supports. 92.06-5 Individual and Family Support Services Individual and family support services include assistance and support to the member and/or the member’s family in implementing the POC or WPOC. Individual and Family Support Services – Standard BHH Services The BHH must provide assistance with health-system navigation, including supporting the development of self-advocacy skills by demonstrating and modeling techniques for independent use. In accordance with the members POC the BHH must provide information, consultation, and problem-solving supports, if desired by a member, to the member, and his or her family or other support system, in order to assist the member in managing symptoms or impairments of his or her illness. The CIPSS, Youth Support Specialist, and Family Support Specialist must coordinate and provide access to peer support services, peer advocacy groups, and other peer-run or peer-centered services, and must assist the member with identifying and developing natural supports. The BHH must discuss advance directives with members and their family, guardian(s), or caregivers, as appropriate. (5) The BHH must assist the member in developing communication skills necessary to request assistance or clarification from supervisors and co-workers when needed and in developing skills to enable the individual to maintain employment. (6) The BHH must support the member in accessing medication management and adhering to their treatment plan and must document such efforts in the member’s record. Individual and Family Support Services – Wraparound BHH Services Within the first month and throughout service delivery, the BHH team members must: Assist with health system navigation, including supporting the development of self-advocacy skills by demonstrating and modeling techniques for independent use; Provide initial information, consultation, and problem-solving supports, if desired by the member, to the member and family or other support system in order to assist the member to manage symptoms or impairments of the diagnosis; Assist the member in developing communication skills necessary to manage symptoms or impairments within the home, community, and school; (4) Support the member in accessing medication management and adhering to their treatment plan and must document such efforts in the member’s record. (5) Document the Team’s actions in the member’s record. 92.06-6 Referral to Community and Social Support Services Referral to Community and Social Support Services involves providing assistance to members to obtain and maintain diverse services and supports as identified in their POC or WPOC. Referral to community and social services involves an organizational understanding and systematic identification of area resources, services and supports. Referral to Community and Social Support Services – Standard BHH Services Services may include outreach and coordination by providers, as needed to ensure a successful referral, and may include reminders and scheduling appointments. The BHH will also provide linkages to services, including linkages to long-term care services and home and community supports. Referral to Community and Social Support Services – Wraparound BHH Services The Wraparound BHH Coordinator must provide referrals to community and social supports and monitor those supports. 92.07 NON-COVERED SERVICES AND LIMITATIONS A member may receive Section 92 Services from only one BHH. BHH Services do not preclude a member from receiving other medically necessary services that are not prohibited as duplicative services under this Section. Only the Covered Services set forth herein are reimbursable through Section 92. Only one (1) BHH team is allowed for each member receiving Section 92 services. 92.08 REPORTING REQUIREMENTS In addition to the documentation and reporting requirements of Chapter I, Section I, and other reports that may be required by the Department, the BHH must report in the format designated by the Department, on activities and improvement upon the following. Providers that fail to timely or adequately file reports or satisfy the benchmarks defined by the Department may be terminated from providing Section 92 Services. A. The Core Standards: BHHs must report on the core standards specified in Section 92.02-1(N). B. Health Home Performance Measures: The BHH must submit data necessary to compile and report on the BHH performance measures identified in Section 92.09-2 and posted to the Department’s Value-Based Purchasing webpage at https://www.maine.gov/dhhs/oms/providers/value-based-purchasing. Data sources may include but are not limited to claims, clinical data, the DHHS Enterprise Information System, certification submissions, and surveys. 92.09 DOCUMENTATION AND CONFIDENTIALITY In addition to the requirements, above, and set forth in Chapter I, Section I, the BHH must maintain a specific record and documentation of services for each member receiving covered services. Records. The member’s record must minimally include: Name, address, birthdate, and MaineCare identification number; Diagnosis(es) that support eligibility for services herein, including the most recent documentation of diagnoses that substantiate ongoing eligibility for services; The comprehensive assessment that must be completed within the first thirty (30) days from entry into services and any reassessments that occur; The POC or WPOC; Correspondence to and from other providers; Release of information statements as necessary, signed by or on behalf of the member; (7) Documentation/record entries (i.e. progress notes) for each service provided, including the date of service, the type of service, the place of the service or method of delivery (i.e., phone contact), the goal to which the service relates, the duration of the service, the progress the member has made towards goal attainment, the signature and credentials of the individual performing the service, whether the individual has declined services in the POC or WPOC, and timelines for obtaining needed services. B. Confidentiality and Disclosure of Confidential Documents/Information. Providers must maintain the confidentiality of information regarding these members in accordance with Chapter I, Section I, 42 C.F.R.§§ 431.301-306, 22 M.R.S. §1711-C, and with all other applicable sections of state and federal law and regulation. 92.10 REIMBURSEMENT METHODOLOGY 92.10-1 BHH Service Rate Methodology PMPM Rates The Department reimburses providers of Section 92 Services a monthly Per Member Per Month (PMPM) payment for each Section 92 member. Providers may only receive a PMPM payment if they satisfy the minimum requirements set forth in this Section. There are three PMPM rates. The PMPM rates are determined by the service provided. The three models of service are: Child Standard BHH Services Adult Standard BHH Services Wraparound BHH Services The PMPM rates and annual updates will be posted on the Department’s website at: https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx. Percent Withheld from PMPM Rate Payment Upon setting applicable performance thresholds as described in Section 92.10-2(A), four (4) percent of the PMPM payments are withheld from regular payments and redistributed every three (3) months in accordance with the Performance-Based Adjustment provision. C. Cost of Living Adjustment Each January 1st the Department will apply an annual cost of living adjustment proportional to the percentage increase in the Maine minimum wage, as determined by the Maine Department of Labor, to all Section 92 services which did not receive a rate adjustment within the previous twelve (12) months. The Maine Department of Labor determines the percentage increase, if any, as of August of the previous year over the level as of August of the year preceding that year in the Consumer Price Index for Urban Wage Earners and Clerical Workers (CPI-W) for the Northeast Region, or its successor index, as published by the United States Department of Labor, Bureau of Labor Statistics, or its successor agency, with the amount of the minimum wage increase rounded to the nearest multiple of 5¢. These COLAs will satisfy 22 M.R.S. § 3173-J and will also satisfy the requirements set forth in 22 M.R.S § 7402(1). 92.10-2 Pay-for-Performance Performance Thresholds Upon setting applicable performance thresholds, the Department will withhold four (4) percent of PMPM payments. The remaining four (4) percent of the rate will be paid to BHHs every three (3) months if they satisfy the Minimum Performance Threshold. Subject to the availability of appropriations, the Department will reimburse BHHs that meet the Excellence Performance Threshold an additional 1% of the total PMPM payments every three (3) months. Minimum and Excellence Performance Thresholds are based on a composite score of the performance measures (see Section C below). Performance thresholds are set in advance of performance periods. If the performance threshold(s) change, BHHs will not be scored on an adjusted threshold until six (6) months after the change is implemented. The Department must set the performance thresholds so that no less than 70% of eligible providers are expected to be above the Minimum Performance Threshold and no less than 20% of providers are expected to be above the Excellence Performance Threshold. This means that 30% of eligible providers, at baseline, are not expected to meet the Minimum Performance Threshold and thus will not receive the four (4) percent payment. The Department cannot anticipate the exact percentage of providers that will, during the performance period, satisfy either or neither of the performance thresholds. B. Pay-for-Performance Reporting All BHHs, regardless of performance, will receive a quarterly report with the performance assessment, indicating whether they satisfied the Minimum and/or Excellence Performance Threshold standards and what their reimbursement will be. The report will contain instructions for the BHH to appeal and/or rebut the report’s data if the BHH disagrees with the report and the reimbursement they are set to receive. The Department will provide a thirty (30) day rebuttal period prior to issuing reimbursement. C. Performance Measures The BHH performance measures include the following: Access to Preventive and Ambulatory Care Denominator: MaineCare members assigned to the BHH panel for a minimum of sixty (60) days during the twelve- (12) month assessment period. Numerator: MaineCare members who meet the denominator criteria and who had an ambulatory or preventive care visit during the twelve- (12) month assessment period. Quality of Life / Patient Experience Denominator: MaineCare members assigned to the BHH panel for a minimum of sixty (60) days during the twelve- (12) month assessment period. Numerator: MaineCare members who meet the denominator criteria and completed the most recent questionnaire from an Authorized Entity during the twelve- (12) month assessment period. BHHs are eligible for the pay-for-performance provision if at least 10% of their member panel is eligible for inclusion in the performance measures and if there is a sufficient quality measure-eligible population to allow for appropriate assessment. The sufficient quality measure-eligible population for each quality measure will be listed on: https://www.maine.gov/dhhs/oms/providers/value-based-purchasing. If the BHH does not have the minimum number of required members, it will automatically receive the full rate. 92.11 MINIMUM REQUIREMENTS FOR REIMBURSEMENT Reimbursement for Section 92 Services shall be as follows: Minimum Requirements for Standard BHH Services Reimbursement. In order for the BHH to be eligible for the PMPM payment, for each member each billing month, the BHH shall: Submit cost and utilization reports upon request by the Department, in a format determined by the Department; Scan the utilization data, as identified by MaineCare, for its assigned population; Deliver at least one (1) Section 92.05 Covered Service to an enrolled member within the reporting month, pursuant to the member’s POC. At least one (1) of the services must include a member encounter, which may include encounters with a member’s family, guardian(s), or caregiver, if appropriate and pursuant to the POC. BHHs must take all reasonable steps to deliver the member encounter in-person. If an in-person member encounter is not possible, the BHH may conduct the member encounter via interactive (audio and visual) telehealth only when unforeseen and uncontrollable circumstances prevent in-person service delivery, such as member illness or inclement weather, and must be delivered in accordance with MBM Chapter I, Section 4, Telehealth Services. BHH providers must take all reasonable steps to conduct the minimum monthly encounter in person and must clearly document in the member’s record the unforeseen and uncontrollable circumstance that prevented the encounter from occurring in person. This requirement supersedes anything to the contrary in 10-144 C.M.R. ch. 101, ch. I, § 4, Telehealth Services. The BHH may attest to a member for a single month if a Section 92 service was delivered and a member encounter was attempted, but not achieved, once per twelve- (12) month period; and Adhere to and document the planning process at each ninety (90) day review, involving the member, the member’s family or caregiver, natural supports, and a team of providers who contribute to the planning process as appropriate. Minimum Requirements for Wraparound BHH Services Reimbursement. For each member receiving Wraparound BHH Services for each calendar month, the BHH shall, at a minimum: In collaboration with the Child and Family Team, and in accordance with this Section and Department-approved guidelines for Wraparound BHH Services, develop the WPOC within the first thirty (30) days following enrollment in the service and update it every thirty (30) days and within seventy-two (72) hours of a reportable event or crisis; Provide and document a weekly in-person contact between the Wraparound BHH Coordinator and the member’s team. The minimum weekly in-person contact may be delivered via interactive (audio and visual) telehealth only when unforeseen and uncontrollable circumstances prevent in-person service delivery, such as member illness or inclement weather, and must be delivered in accordance with MBM Chapter I, Section 4, Telehealth Services. BHH providers must take all reasonable steps to conduct the minimum weekly encounter in person and must clearly document in the member’s record the unforeseen and uncontrollable circumstance that prevented the encounter from occurring in person; and Provide and document at least ten (10) service hours per month. All service hours must be delivered by an allowable Wraparound BHH Services provider role and must be provided in accordance with the member’s WPOC. Examples include, but are not limited to, in-person, phone, and video contacts with the member or family, WPOC meetings, safety planning, referrals, and collateral contacts. A collateral contact is a contact on behalf of a member by a BHH provider to seek or share information about the member in order to achieve continuity of care, coordination of services, and the most appropriate mix of services for the member. A BHH delivering Wraparound BHH Services to a member that does not meet these minimum requirements cannot bill for Standard BHH Services instead. Duplication of Services Will Not Be Reimbursed. Payment for services in this Section must not duplicate payments made by public agencies or private agencies under other program authorities for health home, case management, or care coordination services. The Department shall not reimburse BHHs for members receiving Section 92 services if the member is receiving other services that the Department determines are duplicative, including: For Adults: Community Integration Services, Community Rehabilitation Services, and Assertive Community Treatment in Section 17, Community Support Services, and services pursuant to Section 13, Targeted Case Management; Section 89, MaineMOM Services and Reimbursement; Section 91, Health Home Services – Community Care Teams; and Section 93 Opioid Health Home Services. For Children: Children’s Assertive Community Treatment in Section 65, Behavioral Health Services, and services pursuant to Section 13, Targeted Case Management; Section 89, MaineMOM Services and Reimbursement; Section 91, Health Home Services – Community Care Teams; and Section 93, Opioid Health Home Services. The member receives similar services provided through the home and community-based waiver services authorized by Section 1915(c) of the Social Security Act that are described elsewhere in the MaineCare Benefits Manual. BHHs shall review the entirety of each member’s services and ensure that Section 92 services are not duplicative of other services the member is receiving. STATUTORY AUTHORITY: 22 M.R.S. § 42; 22 M.R.S. § 3173-J ESTABLISHED DATE: April 1, 2014 – filing no. 2014-059 RECENT RULEMAKING HISTORY: NONSUBSTANTIVE CORRECTION (drafting error (changed “CALOCUS-CASII” to “LOCUS” at § 92.04-2(A)(2)): May 21, 2026 RULEMAKING EFFECTIVE: April 29, 2026 – filing 2026-099 APAO ACCESSIBILITY CHECK (Word): April 28, 2026 EMERGENCY RULEMAKING EFFECTIVE: January 30, 2026 – filing no. 2026-033 RULEMAKING EFFECTIVE: July 1, 2021 – filing no. 2021-131 RULEMAKING EFFECTIVE: April 21, 2018 – filing no. 2018-061 ESTABLISHED: April 1, 2014