Introduction
NOTE: Please be aware that only ONLINE submissions of this application will be accepted.


MaineCare CCTs serve MaineCare members with at least one chronic condition while at risk for one or more chronic conditions. CCTs work with primary care providers, as well as hospitals and community providers, to identify patients at high risk for and/or with high utilization or high cost who need additional support, and will seek to link them to that support within health care practices, and the larger community, as appropriate. In addition to healthcare professionals, the CCT also links to, refers to, and utilizes health promotion, education, prevention and social service assets of the community. CCTs help ensure effective coordination and communication across a patient’s full health care team and community supports.

Before completing this application, please read in full the rules for the CCT Provider model of team-based services found in MaineCare Benefits Manual (MBM), Chapter II and III, Section 91: Health Home Services-Community Care Teams.

Once the final application has been received MaineCare will review and deliver a decision within 30 business days by email.

Within 30 business days of approval, MaineCare will schedule an onsite or webinar training to provide an overview of the billing process and the Maine DHHS Value-Based Purchasing Management System (VMS) portal. The VMS portal allows the provider to, among other things, review and manage their member panel, review recent health care utilization based on MaineCare claims, and complete monthly attestations of service delivery in order to receive payment.

If you have any questions during the application process, please contact HH-BHH-Services.DHHS@maine.gov.

Thank you for your interest.

MaineCare Delivery System Reform Unit
MaineCare Health Home Program CCT Eligibility
Please confirm that your organization meets the eligibility criteria listed below for enrollment as a Community Care Team (CCT). Please note that answering “No” to a required eligibility question means that your organization is ineligible to participate as a CCT until such requirement(s) are met.

Organizations should note that completing this application does not constitute an obligation to enroll as a CCT.

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* 1. Before beginning this application, please confirm that you have read MBM, Chapter II and Chapter III, Section 91: Health Home Services-Community Care Teams rules and understand CCT services and requirements.

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* 2. Please enter the contact information of the individual completing the application:

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* 3. Is your organization enrolled as a MaineCare provider?

If you have chosen no or are unsure of your organization's enrollment status, please contact us at HH-BHH-Services.DHHS@maine.gov to confirm your organization's enrollment status or for information about enrolling as a MaineCare provider.

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* 4. Please enter your organization’s information.

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* 5. Does your organization have an operational Electronic Health Record (EHR) system or software for the systematic and secure collection of electronic health information about individual patients, including MaineCare members with the following capacities:

- a digital format that is capable of being shared across different health care settings including via a Department-designated Health Information Exchange(s) (HIE), a Department-designated, network-connected enterprise-wide information system(s), and other information networks or exchanges; and

- supports clinical EHR functions, such as intake, clinical care, task management, and case management where appropriate, and it has HL7 interoperability capabilities to support the electronic sharing of portions of the patient’s record.

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* 6. Do you currently maintain a Participant Agreement (PA) for data sharing with Maine’s statewide state-designated Health Information Exchange (HIE), HealthInfoNet (HIN), with a minimum dataset including: all patient demographic, encounter, and visit information (including coding) and shared via a Health Level – 7 (HL-7) Admission, Discharge & Transfer (ADT) interface?

**If you are unsure whether your organization meets this requirement, please contact HIN directly at clientengagement@hinfonet.org before submitting this application.

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* 7. CCT Providers deliver services via a team-based model of care that includes a multi-disciplinary team of employed or contracted personnel. Please review all the requirements for team roles found in MaineCare Benefits Manual (MBM), Chapter II, Section 91.02-2 before completing this answer.

For the following required roles, please provide the staff person's name, title, and qualifications:

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* 8. If your organization plans to employ additional staff members for the delivery of CCT services, please provide the name, title, and qualifications for any non-required staff:

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* 9. Does your organization agree to participate in technical assistance and educational opportunities on an annual basis, at a minimum?

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* 10. Does your organization have a documented relationship (e.g., Memorandum of Understanding or practice agreement) with one or more primary care practices to provide CCT services to patients of the practice?

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* 11. Does your agency commit to full implementation of the CCT Provider Core Standards found in MBM, Chapter II, Section 91.02-5 within three months of initial service delivery?

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* 12. Please complete and upload a copy of the CCT Provider Core Standards.

PDF, DOC, DOCX file types only.
Choose File

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* 13. Annually, CCT Providers shall submit a completed assessment of their Behavioral and Physical Health Integration progress and identify an area of focus for the following twelve-(12) month period to improve Behavioral and Physical Health Integration. Please complete that assessment here.

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* 14. Please describe how your team will be structured to ensure eligible members receive CCT covered services: Comprehensive Care Management, Care Coordination, Health Promotion, Comprehensive Transitional Care, Individual and Family Support Services, and Referral to Community and Social Support Services further described in MBM, Chapter II, Section 91.06 (1-6)

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* 15. Are there any technical assistance needs or other questions you have for the DSR team around this application or the CCT program?

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