New York State Health Homes Phase I Implementation UpdateStatewide Webinar Presented by: New York State Department of Health December 9, 2011
Health Homes Phase I • Applications reviewed for: • Meeting Provider Qualifications and Standards and providing adequate choice within Health Home partnerships • Care Management “Bandwidth” ability to meet needs of all facets of complex populations (e.g., Mental Health, Housing, Substance Use Disorder, etc.) • Promoting the State vision to minimize silos and concentrate volume over a few rather than many Health Home networks/systems thereby assuring a more limited accountability structure and more financially viable Health Homes. • Creating choices where applicable between institutional lead and community based lead Health Homes
Final Phase I counties • Bronx • Brooklyn • Nassau • Schenectady • Washington Monroe and Saratoga moved to Phase II St. Lawrence moved to Phase III Hamilton Clinton Franklin Warren Essex
Health Plans and Health Home Contracting • DOH will approve health plan health home applications so plans may assist with arranging for health home services. This approval is contingent on the following: • Contracting with State Designated Provider-led Health Homes is required in areas with sufficient approved State Designated Provider-led Health Homes capacity. • In instances where the plan is contracting with State Designated Provider Based Health Homes the plan may: • choose which State Designated Provider Based Health home(s) to contract with. • assist with the provision of certain health home services (e.g., data management) as contractually agreed to by the State Designated Provider-led Health Home and the Health Plan - in this any case dollars retained by the plan shall be proportional to effort. • Plans should only directly provide health home services in areas where such approved capacity is insufficient as agreed upon by the State and the Health Plan.
Continued Opportunities for Partnerships • The Contingent Designated Provider-led Health Homes are still finalizing joint governance arrangements and contracts • The State is still suggesting additional providers and provider types to designated Health Homes to include in their partnership – some of this is necessary to address approval contingencies.
What if my application was not designated as a Health Home? • Many high-quality providers submitted Health Home applications • The State could not approve all of the applicants as Health Homes • Applicants who were not designated as Health Homes and are not currently partnering with an approved Health Home provider should reach out to designated provider-led Health Homes and discuss possible partnerships
HH Rosters and Sharing of lists • State has started to share lists with Plans about their members who qualify for Health Home services • Lead Health Homes will be required to submit a Data Exchange Agreement Application (DEAA) to share lists with their health home network providers • Lead Health Homes are responsible for securing member consent at enrollment to allow full access to member data.
Monthly Roster Elements • Patient Demographic information • Health Plan • Assigned Health Home • Health Home Direct Care Management Provider • TCM, MATS, CIDP • MCO, CBO • Enrollment/Disenrollment Status • Various Dates • Consent • Enrollment/disenrollment • Patient Profile (e.g., Risk Score, Acuity Score, Ambulatory Connectivity and Loyalty)
Billing Principles • Prior to billing, the HH roster must be completed including identification of each member’s: • Designated health home (MCO/FFS provider) • Contracted provider • Care management agency • MCO/FFS HH Lead Care Manager/TCM • MCO can only bill for non-TCM members • The roster supports the claim path.
Assignment and Billing For Fee-for-Service Members • State will assign members into Health Homes • State Designated Health Homes will bill eMedNY PMPM Rate Codes: • 1386- Health Home Services • 1387- Outreach & Engagement – for up to 3 months initially, additional 3 months allowed, 3 months after last claim • Subcontractors bill the State Designated Health Home
Assignments and Billing (cont’d.) For Managed Care Members, Managed Care Plans: • Assign members to State Designated Provider-led Health Homes based on the information provided by the State and information the Plan has such as Primary Care Provider assignment • State Designated Provider-led Health Homes bill Managed Care Plans for delivering Health Home services to the Plans’ members (not including members assigned to TCM programs).
Assignments and Billing (cont’d.) For Plans that are NOT State Designated Health Homes: • Plans will receive a ‘kick’ payment to pay the Health Homes the plan assigned members • Plans will bill the state the Rate Codes: • 1386- Health Home Services • 1387- Outreach & Engagement
Assignments and Billing (cont’d.) For Plans that ARE Health Homes • Plans need to register for a NPI number and enroll in the Medicaid program as a case management provider • Plans that are Health Homes will bill the state the Rate Codes: • 1386- Health Home Services • 1387- Outreach & Engagement
Billing for Existing Case Management Providers • Bill eMedNY for BOTH their current slots and additional members assigned to them through Health Homes • Current slots –working on consolidating rates for average PMPM • New rate codes: • COBRA–1880 • MATS- 1386 • OMH- (still working on OMH billing and rate code consolidation) • CIDP- receive current PMPM – new rate code- 1885
Billing for Existing Case Management Providers (cont’d.) • Case Management programs that add slots through Health Homes • Bill eMedNY for the additional slots the average PMPM using: • Health Home Rate codes 1386 & 1387
Plans and Health Homes-Roles and Responsibilities Plans: • State’s partners in assigning members and monitoring the quality of Health Homes • Assign members using the state algorithm and their own data to appropriate Health Homes • Contract with provider-led Health Homes in areas with sufficient provider-led Health Home capacity • Reimburse health homes commensurate with the Health Home services being provided • Monitor quality, assist Health Homes with Health Home care management network development/maintenance and move members out of Health Homes that are not achieving quality goals and/or meeting the member’s needs.
Plans and Health Homes-Roles and Responsibilities (cont’d.) Provider – Lead Health Homes • Continually meet provider qualification standards • Meet Quality Measures and reporting responsibilities • Develop their Health Information Plans • Utilize all of their partners appropriately in the delivering of Health Home services • Reimburse partners commensurate with level of Health Home services delivered • Work closely with health plans to coordinate care management and service access
Expected “Wave One” HH Enrollment * Low Cost Members are not slated for Health Home enrollment under the current plan but this could change as the project progresses and as high and mid- cost members are assigned in a given region.
HH Eligibles by County and Age with Spending * Updated HH Attribution from June 1, 2010 through May 31, 2011 – County as of last date of Medicaid Eligibility. Saratoga and St. Lawrence have been moved out of phase one.
Phase one HH Eligibles by Plan by County* * Updated HH Attribution from June 1, 2010 through May 31, 2011 – Plan enrollment as of last date of Medicaid Eligibility Saratoga and St. Lawrence have been moved out of phase one.
Health Home – Open Issues • WMS Flag to identify Health Home • Care Management Metrics • Functional Status Tool • Timing of State Plan and Start Date • OMH TCM Rate Collapsing • MATS Rates • Next Webinar Date and Time TBD-Focus on Billing Health Home Website: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/