In Maine:
  • As of July 1, 2011, there were 357,706 beneficiaries enrolled in MaineCare, the state’s Medicaid program. Of these, 176,335 were enrolled in a primary care case management (PCCM) program, including 130,824 children. The PCCM program is mandatory for Medicaid beneficiaries receiving TANF, children, pregnant women, and childless adults below 100% FPL. Medicaid-eligible children under age 19 with special health care needs who meet the criteria for the MaineCare Katie Beckett option are excluded from the PCCM program.
  • Children with Intellectual Disabilities and/or Pervasive Developmental Disorders are eligible to receive benefits through the state’s home and community-based services waiver. The waiver provides an alternative to institutional care for children ages 5-20 who would otherwise require services through an ICF/MR or a psychiatric hospital.

As of 2012, 132,316 individuals were eligible for Maine’s Medicaid benefit for children and adolescents (also known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT). According to 416 data from 2012, Maine achieved an EPSDT screening ratio of 93% and a participation ratio of 53%. 46,961 children received dental services of any kind, with 41,434 receiving preventive dental services.

Last updated January 2014.
Medical Necessity

Maine’s Medicaid Benefits Manual defines “medically necessary services” as those that are:

  1. Provided in an appropriate setting;
  2. Recognized as standard medical care, based on national standards for best practices and safe, effective, quality care;
  3. Required for the diagnosis, prevention and/or treatment of illness, disability, infirmity or impairment and which are necessary to improve, restore or maintain health and well-being;
  4. MaineCare (Medicaid) covered services (subject to age, eligibility, and coverage restrictions as specified in other Sections of this manual as well as Prevention, Health Promotion and Optional Treatment requirements as detailed in Chapter ll, Section 94 of this Manual)’
  5. Performed by enrolled providers within their scope of licensure and/or certification; and
  6. Provided within the regulations of the Manual.
Initiatives to Improve Access
Primary Care Case Management (PCCM)
The state operates a Primary Care Provider Incentive Payment (PCPIP) program which pays additional compensation to providers who delivery high quality healthcare to Medicaid PCCM patients and who rank above the 20th percentile for certain measures compared to other physicians within their specialty. Participating physician specialties include Family Practice, Pediatrics, General Practice, Obstetrics/Gynecology, and Internal Medicine.
The goals of the PCPIP program are to increase access of Medicaid members to providers, reduce unnecessary/inappropriate ER utilizations, and increase utilization of preventive/quality services.
Improving Health Outcomes for Children (IHOC)
In 2010, Maine was awarded a five-year grant from the Centers for Medicare and Medicaid Services (CMS) to improve the quality of children’s health care. Under the grant, the First STEPS (Strengthening Together Early Prevention Services) Learning Initiative was launched to “increase the rate of Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) services for children receiving MaineCare benefits by providing tools and data monitoring, offering comprehensive educational support, and engaging primary care practices in multiple change interventions to build patient centered medical homes for children.”
The First STEPS Learning Initiative was implemented in multiple phases. Phase I (September 2011-April 2012) focused on improving pediatric immunization rates. Overall, immunization rates in participating practices increased by 5.1% after twelve months.
Phase II (May-December 2012) focused on improving developmental, autism, and lead screening rates for children under age three. Participating practices more than doubled the global developmental screening rates in all targeted age groups.
Phase III (April-November 2013) focused on oral health and healthy weight screening. Evaluation results of this phase are not yet completed.
Reporting & Data Collection
Improving Health Outcomes for Children (IHOC)
The Improving Health Outcomes for Children (IHOC) grant works to:
  • Collect and report on the use of evidence-based child health quality measures;
  • Expand Health Information Technology to improve the flow of child health data; and
  • Promote a collaborative child health learning environment.

Under the grant, Maine developed a Master List of Pediatric Measures that builds upon the CHIPRA Initial Core Set of Children’s Health Care Quality Measures. This list includes measures on topics such as well child visits, general development and autism screening, oral health, and behavioral health.


Primary Care Provider Incentive Payment (PCPIP) Program
Maine’s Primary Care Provider Incentive Payment (PCPIP) program includes child-specific quality and access measures on which participating providers are measured, including:

  • Percentage of members 0-20 years of age who had one or more EPSDT procedure(s) during the reporting period;
  • Well-child visits in the first 15 months of life;
  • Follow-up care for children prescribed attention-deficit/hyperactivity disorder medication;
  • Adolescent well care visits; and
  • Children aged 1-3 who had a developmental screening during the measurement year.
Behavioral Health
The focus of the Phase II First STEPS Learning Initiative was to improve developmental, autism, and lead screening rates for children under age three. Twelve pediatric and family practices, including 45 physicians who serve an estimated 20,000 children with MaineCare coverage, participated in the initiative. Practices agreed to track both improvements of specific Improving Health Outcomes for Children (IHOC) measures for developmental, autism and lead/anemia screening rates, and rates of referrals to developmental specialists and Children’s Developmental Services. As part of this phase, MaineCare added modifiers to the developmental screening and assessment CPT codes (96110 and 96111): HI for autism screening and HK for autism testing.
The goal of Phase II was to improve these rates by 50% with the target of achieving rates of 75% for each measure. Information on rates was gathered from chart reviews, MaineCare claims data, administrative data supplied by other programs, self-reported pre/post office surveys, and key informant interviews. The Phase II evaluation found that:
  • Most Phase II providers integrated developmental screening into well child visits; fewer focused on autism and lead screening;
  • Developmental and autism screening rates more than doubled in all age groups and exceeded 75% screening targets in several age groups;
    Increased billing and improved coding of developmental and autism screenings to MaineCare improved claims-based rates; and
  • New screening tools helped identify developmental delays earlier and increased tracking, follow-up and referrals for treatment.

Ultimately, developmental screening rates for practices participating in the initiative rose from the year prior to Phase II to the year after Phase II. The rates rose from:

  • 5.3% to 17.1% for children age one,
  • 1.5% to 13.1% for children age two, and
  • 1.2% to 3.3% for children age three.

2703 Health Homes
Stage B of Maine’s health home initiative seeks to develop Behavioral Health Homes for children and adults with significant behavioral health needs. This new service will be implemented in April 2014 and will provide integrated behavioral and physical health services using a team-based care approach. The Behavioral Health Home Organization (BHHO) will be composed of a primary care provider and a licensed community mental health provider.

Support to Providers and Families
Support to Families
MaineCare, the state Medicaid program, operates the MaineCare Member webpage, which includes a tool to find participating MaineCare providers, a Member Handbook and benefits manual, among other resources.
Support to Providers
The state operates a provider webpage that contains resources on EPSDT, including Maine Well Child Visit forms, schedules and referral forms, fact sheets on dental services, and toolkits.
The primary care case management (PCCM) program website also contains information on how to become a participating provider, and additional information on the incentive payment program.
Providers participating the Patient-Centered Medical home (PCMH) pilot receive a variety of supports, including a learning collaborative, practice coaching, and consultation with experts. Eight community care teams also support primary care providers in implementing the medical homes.

First STEPS Learning Initiative
As part of Maine’s Improving Health Outcomes for Children (IHOC) grant, Maine Quality Counts is leading the First STEPS (Strengthening Together Early Prevention Services) Learning Initiative. In Phase I of the initiative, 24 participating pediatric and family practices received monthly coaching calls, two all-day learning sessions, and tools for practices to track their immunization rates. In Phase II, 12 pediatric and family practices participated in the learning collaborative, which focused on improving developmental, autism, and lead screenings.
Care Coordination
Patient-Centered Medical Home (PCMH)
In 2008, the Maine legislature authorized the development of the Patient-Centered Medical home (PCMH) Pilot. Three collaborators jointly lead the PCMH pilot development, including the Maine Quality Forum, Quality Counts, and the Maine Health Management Coalition. Fifty practices were selected to participate in the pilot, including four pediatric practices.
Practices participating in the PCMH pilot receive per member per month (PMPM) payments from Medicaid, Medicare, and commercial payers. Practices also receive support from a learning collaborative, practice coaching, and consultation with experts. Eight community care teams (CCTs) provide support to providers in operating as medical homes. CCTs coordinate services and connect patients to additional community resources to support their health improvement goals, achieve better health outcomes, and reduce avoidable costs.
Section 2703 Health Homes
In January 2013, CMS approved Maine’s 2703 health home state plan amendment. To be eligible for health home services, adults and children enrolled in Medicaid must have two qualifying chronic conditions, or one qualifying condition and risk of a second. Health home enrollees are linked to a primary care provider who serves as the patient’s medical home, providing acute and preventive care, managing chronic illnesses, coordinating specialty care and referrals to social, community, and long-term services and supports. The roughly 159 health homes across the state are closely tied to the PCMH pilot; practices are required to participate in the PCMH pilot learning collaborative and also receive support from community care teams.
Accountable Communities
Maine is in the process of implementing accountable care organizations through its Accountable Communities Initiative, which seeks to achieve the triple aim by using shared savings based on quality performance, practice-level transformation, coordination across the continuum of care, and community-led innovation. Under this initiative, Medicaid providers will enter into direct contracts with the Maine Department of Health and Human Services using a shared savings model linked to provider attainment of quality benchmarks. These ACOs will be responsible for the coordination of primary, acute, and behavioral health care, as well as long-term services and supports. All MaineCare members who receive the full Medicaid benefit package, including children, will be eligible for accountable community attribution.  
Oral Health
Phase III of the First STEPS (Strengthening Together Early Prevention Services) Learning Initiative, which ran from April-November 2013, is entitled “Encourage Healthy Habits by Improving Oral Health and Healthy Weight Screening, Treatment, and Referral.” Participating practices were provided with training on prevention of early childhood caries, including strategies such as completing an oral health risk assessment, an oral health screening, and fluoride varnish application.