MaineMOM Services Provider Application 2024

Welcome to the Provider Application for the MaineCare MaineMOM model.

MaineMOM Services provide comprehensive, coordinated care focused on serving pregnant and postpartum MaineCare members with Opioid Use Disorder (OUD) and their infants.

More information on the adopted rule can be found in the MaineCare Benefits Manual, Chapter II, Section 89.

MaineMOM Services Description

MaineMOM Core Services include:

• Care plan development to support individual needs of patients, and identify health-related social needs;
• Transition support between inpatient, outpatient, and other care settings;
• Referrals for community resources;
• Substance use and perinatal care education; and
• Access to recovery-focused services.

MaineMOM Services are provided by an interdisciplinary care team that includes a:

• Clinical lead;
• Medications for Opioid Use Disorder (MOUD) prescriber;
• Perinatal provider;
• Nurse care manager;
• Clinical counselor;
• Patient navigator; and
• Recovery coach.

MaineMOM Service Models

There are three models of MaineMOM Services to accommodate various provider and member situations. The three models are:

• Integrated Model: for members receiving their prenatal and postpartum medical services at the same MaineMOM site location as OUD services;

• Partnership Model: for members who are receiving OUD services onsite from the MaineMOM provider and prenatal and postpartum medical services from a different provider and service location; and

• Perinatal Navigation Model: for members who receive only prenatal and postpartum medical services from the MaineMOM provider and/or are receiving their OUD treatment from a different non-MaineMOM provider and service location.

Please review the adopted MaineMOM rule prior to completing this application: MaineCare Benefits Manual, Chapter II, Section 89.

If you have questions regarding this application, please contact MaineCare at MaineMOM@maine.gov.

To learn more about MaineMOM Services, please visit: www.maine.gov/dhhs/oms/about-us/projects-initiatives/mainemom; www.mainemom.org

Thank you for your interest in becoming a MaineMOM Services provider.

If your care practice would like to apply, please complete the MaineMOM Services Provider Application below. This application period is open with no predicted closure date.

Practices with more than one location MUST complete a separate application for each location. Should additional information be necessary, MaineCare will contact you directly.

Practice Information

The following questions are regarding the practice site location where MaineMOM Services will be offered.

Question Title

* 1. Public-facing practice name (practice name that is known to the general public):

Question Title

* 2. Is this office currently a MaineCare-enrolled provider location? (If "No", please DO NOT CONTINUE with the application and email Gainwell Technologies at MainecareEnroll@gainwelltechnologies.com for information about enrolling as a MaineCare provider.)

Yes

Question Title

* 3. Please provide contact information for the person completing the application:

Name:

Phone:

Email:

Title:

Question Title

* 4. If applicable, please provide an additional contact for MaineCare to use when reaching out regarding MaineMOM Services and/or the application process.

Name:

Phone:

Email:

Title:

Question Title

* 5. Practice site NPI+3: (Note: NPI+3 is the National Provider Identifier plus MaineCare 3-digit site indicator. If you are unsure of your NPI+3, please contact your billing office or your provider enrollment processor.)

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* 6. Practice physical address:

Street:

City/Town:

Zip Code:

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* 7. Practice phone number:

Estimated MaineMOM Panel Size

To receive MaineMOM Services, patients must be enrolled in MaineCare, have an OUD diagnosis, and have or be at risk for a secondary diagnosis of a chronic condition.

More information on member eligibility can be found in the MaineCare Benefits Manual, Chapter II, Section 89.

Question Title

* 8. How many patients at your practice do you expect to engage with MaineMOM Services within the first year of becoming a MaineMOM provider?

1 - 20 patients

20 - 50 patients

50 - 100 patients

100 - 200+ patients

Practice Care Team Roles & Staffing

The questions below pertain to roles and staffing requirements for practices offering MaineMOM Services. These requirements can be found in the MaineCare Benefits Manual, Chapter II, Section 89.

Question Title

* 9. Care providers available at this practice OR that could be recruited after MaineMOM implementation (select all that apply):

Clinical Team Lead: A licensed clinical professional with significant experience treating individuals with substance use disorders, who may be a:
• Physician
• Physician’s assistant
• Psychologist
• Licensed Clinical Social Worker
• Licensed Clinical Professional Counselor
• Licensed Alcohol and Drug Counselor
• Advanced Practice Registered Nurse

Medication for Opioid Use Disorder (MOUD) Prescriber: A licensed healthcare professional with authority to prescribe Medication for Opioid Use Disorder.

Perinatal Provider: A licensed healthcare professional with significant experience caring for people during the prenatal, intrapartum and postpartum periods.

Nurse Case Manager: A licensed healthcare professional who completes the Substance Abuse and Mental Health Services Administration required training within six (6) months of initiating service delivery for members. Professionals appropriate for this role include a:
• Registered nurse or APRN
• Psychiatric nurse licensed as a registered professional nurse and certified as a psychiatric and mental health nurse
• Licensed Practical Nurse

Clinical Counselor: A clinical professional that offers counseling related to opioid dependency and/or individual or group substance use disorder outpatient therapy for members receiving counseling.

Peer Recovery Coach: An individual in long-term recovery, or a recovery ally, who has or is willing to complete the 30-hour Connecticut Community for Addiction Recovery (CCAR) training, or other Department approved Recovery Coach training, within six (6) months of beginning to deliver MaineMOM Services.

Patient Navigator: A certified and/or qualified direct care worker coordinating health care, mental health, and social services and supporting the member in their recovery during the perinatal period.

Question Title

* 10. Please select how the practice plans to coordinate or provide prenatal and postpartum services for pregnant people with OUD.

We have a provider who delivers prenatal and postpartum services within our practice. Patients will be offered OUD treatment and prenatal/postpartum services at the same location.

We have, or plan to establish, a formal relationship with a perinatal and postpartum provider outside of our practice.

We do not have a contractual or formal relationship with a provider who can deliver prenatal and postpartum medical services to individuals with OUD.

Question Title

* 11. Please provide contact information for the perinatal and postpartum provider that has, or will, provide services in partnership with the practice:

Name

Organization/Facility

City

State

Email Address

Phone Number

MaineMOM Provider Requirements

The questions below pertain to MaineMOM covered services and practice characteristics that are required to qualify as a MaineMOM Services provider. These requirements can be found in the MaineCare Benefits Manual, Chapter II, Section 89.

Question Title

* 12. Please indicate your practice team’s current or ability to fulfill the following REQUIRED core standards:

	Yes, the practice currently does this.	Plans to do this activity prior to MaineMOM implementation.	No, the practice does NOT currently meet this requirement.	Does not plan to do this under MaineMOM Services.
Appoint a Clinical Team Lead to implement and oversee the implementation and execution of required Core Standards. The Clinical Team Lead position will be designed to: • Work with providers and staff to build a team-based approach to care • Continually examine processes and structures to improve care • Assist with the review of data on the quality performance of the practice	Appoint a Clinical Team Lead to implement and oversee the implementation and execution of required Core Standards. The Clinical Team Lead position will be designed to: • Work with providers and staff to build a team-based approach to care • Continually examine processes and structures to improve care • Assist with the review of data on the quality performance of the practice Yes, the practice currently does this.	Appoint a Clinical Team Lead to implement and oversee the implementation and execution of required Core Standards. The Clinical Team Lead position will be designed to: • Work with providers and staff to build a team-based approach to care • Continually examine processes and structures to improve care • Assist with the review of data on the quality performance of the practice Plans to do this activity prior to MaineMOM implementation.	Appoint a Clinical Team Lead to implement and oversee the implementation and execution of required Core Standards. The Clinical Team Lead position will be designed to: • Work with providers and staff to build a team-based approach to care • Continually examine processes and structures to improve care • Assist with the review of data on the quality performance of the practice No, the practice does NOT currently meet this requirement.	Appoint a Clinical Team Lead to implement and oversee the implementation and execution of required Core Standards. The Clinical Team Lead position will be designed to: • Work with providers and staff to build a team-based approach to care • Continually examine processes and structures to improve care • Assist with the review of data on the quality performance of the practice Does not plan to do this under MaineMOM Services.
Implement a team-based approach to care delivery that includes expanding the roles of non-physician providers (e.g., APRNs, PAs, nurses, MAs) and non-licensed staff (e.g., recovery coaches, patient navigators) to improve clinical workflows.	Implement a team-based approach to care delivery that includes expanding the roles of non-physician providers (e.g., APRNs, PAs, nurses, MAs) and non-licensed staff (e.g., recovery coaches, patient navigators) to improve clinical workflows. Yes, the practice currently does this.	Implement a team-based approach to care delivery that includes expanding the roles of non-physician providers (e.g., APRNs, PAs, nurses, MAs) and non-licensed staff (e.g., recovery coaches, patient navigators) to improve clinical workflows. Plans to do this activity prior to MaineMOM implementation.	Implement a team-based approach to care delivery that includes expanding the roles of non-physician providers (e.g., APRNs, PAs, nurses, MAs) and non-licensed staff (e.g., recovery coaches, patient navigators) to improve clinical workflows. No, the practice does NOT currently meet this requirement.	Implement a team-based approach to care delivery that includes expanding the roles of non-physician providers (e.g., APRNs, PAs, nurses, MAs) and non-licensed staff (e.g., recovery coaches, patient navigators) to improve clinical workflows. Does not plan to do this under MaineMOM Services.
Adopt processes to identify patients who are at risk for adverse outcomes or are missing critical preventive services and/or other health screenings.	Adopt processes to identify patients who are at risk for adverse outcomes or are missing critical preventive services and/or other health screenings. Yes, the practice currently does this.	Adopt processes to identify patients who are at risk for adverse outcomes or are missing critical preventive services and/or other health screenings. Plans to do this activity prior to MaineMOM implementation.	Adopt processes to identify patients who are at risk for adverse outcomes or are missing critical preventive services and/or other health screenings. No, the practice does NOT currently meet this requirement.	Adopt processes to identify patients who are at risk for adverse outcomes or are missing critical preventive services and/or other health screenings. Does not plan to do this under MaineMOM Services.
Ensure same-day, medication-first substance use treatment is available to members. Please note, same day access can be provided by an external partner (e.g., a buprenorphine induction program at a local hospital), with a documented process to communicate and transition care with the MaineMOM MOUD Prescriber.	Ensure same-day, medication-first substance use treatment is available to members. Please note, same day access can be provided by an external partner (e.g., a buprenorphine induction program at a local hospital), with a documented process to communicate and transition care with the MaineMOM MOUD Prescriber. Yes, the practice currently does this.	Ensure same-day, medication-first substance use treatment is available to members. Please note, same day access can be provided by an external partner (e.g., a buprenorphine induction program at a local hospital), with a documented process to communicate and transition care with the MaineMOM MOUD Prescriber. Plans to do this activity prior to MaineMOM implementation.	Ensure same-day, medication-first substance use treatment is available to members. Please note, same day access can be provided by an external partner (e.g., a buprenorphine induction program at a local hospital), with a documented process to communicate and transition care with the MaineMOM MOUD Prescriber. No, the practice does NOT currently meet this requirement.	Ensure same-day, medication-first substance use treatment is available to members. Please note, same day access can be provided by an external partner (e.g., a buprenorphine induction program at a local hospital), with a documented process to communicate and transition care with the MaineMOM MOUD Prescriber. Does not plan to do this under MaineMOM Services.
Establish processes to identify evidence-based practices for the eligible member population, to train care team members as appropriate, and adapt services to be inclusive and sensitive to culture, ethnicity, sexual orientation, and gender identity. Members of the care team will be in trained in Trauma-Informed Care and stigma-reduction for people living with SUDs.	Establish processes to identify evidence-based practices for the eligible member population, to train care team members as appropriate, and adapt services to be inclusive and sensitive to culture, ethnicity, sexual orientation, and gender identity. Members of the care team will be in trained in Trauma-Informed Care and stigma-reduction for people living with SUDs. Yes, the practice currently does this.	Establish processes to identify evidence-based practices for the eligible member population, to train care team members as appropriate, and adapt services to be inclusive and sensitive to culture, ethnicity, sexual orientation, and gender identity. Members of the care team will be in trained in Trauma-Informed Care and stigma-reduction for people living with SUDs. Plans to do this activity prior to MaineMOM implementation.	Establish processes to identify evidence-based practices for the eligible member population, to train care team members as appropriate, and adapt services to be inclusive and sensitive to culture, ethnicity, sexual orientation, and gender identity. Members of the care team will be in trained in Trauma-Informed Care and stigma-reduction for people living with SUDs. No, the practice does NOT currently meet this requirement.	Establish processes to identify evidence-based practices for the eligible member population, to train care team members as appropriate, and adapt services to be inclusive and sensitive to culture, ethnicity, sexual orientation, and gender identity. Members of the care team will be in trained in Trauma-Informed Care and stigma-reduction for people living with SUDs. Does not plan to do this under MaineMOM Services.
Participate regularly in advisory activities representative of MaineCare and/or MaineMOM members, and family members, where appropriate. Member-informed advisory processes will be established to identify patient-centered needs and solutions for improving care in the practice.	Participate regularly in advisory activities representative of MaineCare and/or MaineMOM members, and family members, where appropriate. Member-informed advisory processes will be established to identify patient-centered needs and solutions for improving care in the practice. Yes, the practice currently does this.	Participate regularly in advisory activities representative of MaineCare and/or MaineMOM members, and family members, where appropriate. Member-informed advisory processes will be established to identify patient-centered needs and solutions for improving care in the practice. Plans to do this activity prior to MaineMOM implementation.	Participate regularly in advisory activities representative of MaineCare and/or MaineMOM members, and family members, where appropriate. Member-informed advisory processes will be established to identify patient-centered needs and solutions for improving care in the practice. No, the practice does NOT currently meet this requirement.	Participate regularly in advisory activities representative of MaineCare and/or MaineMOM members, and family members, where appropriate. Member-informed advisory processes will be established to identify patient-centered needs and solutions for improving care in the practice. Does not plan to do this under MaineMOM Services.
Develop processes to identify local community resources and social support services. Processes will be in place to refer patients and families to local community resources and social support services, including those that provide self-management support to assist members in overcoming barriers to care and meeting health goals.	Develop processes to identify local community resources and social support services. Processes will be in place to refer patients and families to local community resources and social support services, including those that provide self-management support to assist members in overcoming barriers to care and meeting health goals. Yes, the practice currently does this.	Develop processes to identify local community resources and social support services. Processes will be in place to refer patients and families to local community resources and social support services, including those that provide self-management support to assist members in overcoming barriers to care and meeting health goals. Plans to do this activity prior to MaineMOM implementation.	Develop processes to identify local community resources and social support services. Processes will be in place to refer patients and families to local community resources and social support services, including those that provide self-management support to assist members in overcoming barriers to care and meeting health goals. No, the practice does NOT currently meet this requirement.	Develop processes to identify local community resources and social support services. Processes will be in place to refer patients and families to local community resources and social support services, including those that provide self-management support to assist members in overcoming barriers to care and meeting health goals. Does not plan to do this under MaineMOM Services.
Establish processes to reduce wasteful spending of healthcare resources and improve the cost-effective use of healthcare services as evidenced by at least one improvement initiative that targets waste reduction, such as avoidable hospitalizations; reducing avoidable ED visits; or working with the team to develop new processes and procedures that improve patient experience and quality of care, while reducing inappropriate use of services.	Establish processes to reduce wasteful spending of healthcare resources and improve the cost-effective use of healthcare services as evidenced by at least one improvement initiative that targets waste reduction, such as avoidable hospitalizations; reducing avoidable ED visits; or working with the team to develop new processes and procedures that improve patient experience and quality of care, while reducing inappropriate use of services. Yes, the practice currently does this.	Establish processes to reduce wasteful spending of healthcare resources and improve the cost-effective use of healthcare services as evidenced by at least one improvement initiative that targets waste reduction, such as avoidable hospitalizations; reducing avoidable ED visits; or working with the team to develop new processes and procedures that improve patient experience and quality of care, while reducing inappropriate use of services. Plans to do this activity prior to MaineMOM implementation.	Establish processes to reduce wasteful spending of healthcare resources and improve the cost-effective use of healthcare services as evidenced by at least one improvement initiative that targets waste reduction, such as avoidable hospitalizations; reducing avoidable ED visits; or working with the team to develop new processes and procedures that improve patient experience and quality of care, while reducing inappropriate use of services. No, the practice does NOT currently meet this requirement.	Establish processes to reduce wasteful spending of healthcare resources and improve the cost-effective use of healthcare services as evidenced by at least one improvement initiative that targets waste reduction, such as avoidable hospitalizations; reducing avoidable ED visits; or working with the team to develop new processes and procedures that improve patient experience and quality of care, while reducing inappropriate use of services. Does not plan to do this under MaineMOM Services.
Utilize 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.	Utilize 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. Yes, the practice currently does this.	Utilize 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. Plans to do this activity prior to MaineMOM implementation.	Utilize 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. No, the practice does NOT currently meet this requirement.	Utilize 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. Does not plan to do this under MaineMOM Services.

Question Title

* 13. Please explain how the practice develops and maintains competencies to serve pregnant and postpartum people?

For example,

i. Does the practice require specific training about substance use disorders & pregnancy, trauma informed care, harm reduction, motivational interviewing, etc?

ii. Does the practice structurally support ongoing training and competency of the team, such as time dedicated to case conferencing or CME activities?

Question Title

* 14. It is a requirement of MaineMOM providers to participate in an on-site assessment initiated by the Department. This assessment will occur within the first three (3) months of enrollment and is intended to establish baseline assessment of the MaineMOM provider requirements.

Yes, the practice will participate in an on-site assessment.

No, the practice will not participate in an on-site assessment.

Question Title

* 15. It is a requirement that MaineMOM providers submit a Behavioral and Physical Health Integration (BHI) Assessment of the practice. The BHI Assessment will be provided prior to the initial site visit and will guide priorities for the following twelve-month period.

Please note, this will be requested on an annual basis.

Yes, the practice will submit an annual Behavioral and Physical Health Integration Assessment.

No, the practice does not plan to submit an annual Behavioral and Physical Health Integration Assessment.

Question Title

* 16. It is a requirement that MaineMOM enrolled providers share patient data that will be used to assess and report on MaineMOM Quality Measures on a quarterly basis throughout the length of participation.

Yes, the practice will participate in the required reporting.

No, the practice does not plan to participate in the required reporting.

Question Title

* 17. Virtual Q & A Session

To ensure completeness and accuracy of the application, we ask each practice to participate in a learning session with program staff.

Please list up to three (3) date/times (within 30 days) that you are available for a virtual session.

Date / Time

Date

Time

AM/PM

Date / Time

Date

Time

AM/PM

Data / Time

Date

Time

AM/PM

MaineMOM Services Provider Application 2024

Question Title

* 1. Public-facing practice name (practice name that is known to the general public):

Question Title

* 2. Is this office currently a MaineCare-enrolled provider location? (If "No", please DO NOT CONTINUE with the application and email Gainwell Technologies at MainecareEnroll@gainwelltechnologies.com for information about enrolling as a MaineCare provider.)

Question Title

* 3. Please provide contact information for the person completing the application:

Question Title

* 4. If applicable, please provide an additional contact for MaineCare to use when reaching out regarding MaineMOM Services and/or the application process.

Question Title

* 5. Practice site NPI+3: (Note: NPI+3 is the National Provider Identifier plus MaineCare 3-digit site indicator. If you are unsure of your NPI+3, please contact your billing office or your provider enrollment processor.)

Question Title

* 6. Practice physical address:

Question Title

* 7. Practice phone number:

Question Title

* 8. How many patients at your practice do you expect to engage with MaineMOM Services within the first year of becoming a MaineMOM provider?

Question Title

* 9. Care providers available at this practice OR that could be recruited after MaineMOM implementation (select all that apply):

Question Title

* 10. Please select how the practice plans to coordinate or provide prenatal and postpartum services for pregnant people with OUD.

Question Title

* 11. Please provide contact information for the perinatal and postpartum provider that has, or will, provide services in partnership with the practice:

Question Title

* 12. Please indicate your practice team’s current or ability to fulfill the following REQUIRED core standards:

Question Title

Question Title

* 14. It is a requirement of MaineMOM providers to participate in an on-site assessment initiated by the Department. This assessment will occur within the first three (3) months of enrollment and is intended to establish baseline assessment of the MaineMOM provider requirements.

Question Title

Question Title

* 16. It is a requirement that MaineMOM enrolled providers share patient data that will be used to assess and report on MaineMOM Quality Measures on a quarterly basis throughout the length of participation.

Question Title

* 17. Virtual Q & A SessionTo ensure completeness and accuracy of the application, we ask each practice to participate in a learning session with program staff. Please list up to three (3) date/times (within 30 days) that you are available for a virtual session.

Question Title

* 18. Are there any other questions/concerns or additional information you would like to include?

* 17. Virtual Q & A Session

To ensure completeness and accuracy of the application, we ask each practice to participate in a learning session with program staff.

Please list up to three (3) date/times (within 30 days) that you are available for a virtual session.