Session 8 -November 19, 2012
1
Program Details and Documentation
Administrative Costs and Rates
Contracting
Billing
Assignment
Data Exchange
Consent
Eligibility
2
MCOs asked when certain elements of the Health Home Program
will be finalized:
◦
◦
◦
◦
Patient Tracking System – Modifications are being considered
Care management matrix or CMART – December 2012
Updated eligibility, loyalty, acuity –December 2012
Benchmarks for performance – Will require assessment of
baseline data and first year performance
◦ Extent to which Phases 2 and Phase 3 will follow the same
rules as Phase 1: 100%,
◦ Timeline for rolling out Phases 2 and 3 –ASAP, once SPAs are
approved.
3
MCOs asked for a compilation of all current program guidance:

A Health Home Provider Manual will be released in January
2013 that will include guidance on:





Billing
Contracting
Member assignment and referral process
Claim submission
Manual will be updated as new policies are developed
4
A new Special Edition of the Medicaid Update regarding Health
Homes was released on November 14, 2012. It features
information on:
Assignment, implementation and billing by phase
Billing rules for converting OMH, COBRA and MATS providers
Use of the tracking system
Increase in Health Home Payments
Community Referrals for Health Home Services
Priority Referrals for Converting Care Management Services
5
MCOs are concerned about the administrative costs of the
program for members receiving Health Home services from
transitioning legacy case management providers:

DOH is exploring ways to increase the MCO rates to support
Health Home administrative activities.

DOH is currently working with its actuary and will bring
options to CMS for discussion.
6
MCOs asked that DOH share Health Home readiness reviews
with MCOs:

Reviews can be shared with MCOs, for Health Homes in
their contracted network.
MCOs asked that DOH reinforce the importance of Health
Homes signing Business Associate Agreements with MCOs, in
order to receive PHI for members:
 DOH
will work to educate Health Homes that BAAs must
be signed with contracted MCOs.
7
MCOs asked that Health Homes be required to report contract
status to DOH:

The Bureau of Managed Care provides updates on
contract negotiations and these are posted on the
Health Home website, updates are provided during
biweekly webinars.
MCOs and Health Homes in Phase 2 and 3 counties should not
wait for SPA approval to begin negotiating contracts.
8
AMIDA CARE
HEALTHFIRST PHSP
METROPLUS
 Institute for Community Living
Community Healthcare Network
Maimonides Medical Center
VNS of NY Home Care
Bronx Lebanon Hospital
NYC Health and Hospitals Corp.
Glens Falls Hospital
 VNS of Schenectady
Bronx Lebanon Hospital Center
Institute for Community Living
Maimonides Medical Center
FEGS Health & Human Services
Community Healthcare Network
Bronx Accountable Healthcare Network
North Shore Long Island Jewish
VNS of NY Home Care
NYC Health and Hospital Corp.
EMBLEM HEALTH
HUDSON HEALTH PLAN
Bronx Accountable Healthcare Network
Maimonides Medical Center
FEGS Health and Human Services
Bronx Lebanon Hospital Center
Institute for Community Living
North Shore Long Island Jewish Center
Hudson Valley Care Coalition
Institute for Family Health
CDPHP
FIDELIS
 VNS Schenectady
Maimonides Medical Center
 FEGS Health and Human Services
Bronx Lebanon Hospital Center
Institute for Community Living
Bronx Accountable Healthcare Network
Adirondack Health Institute
Glens Falls Hospital
VNS of NY Home Care
HEALTHPLUS AMERIGROUP
Bronx Lebanon Hospital Center
FEGS Health and Human Services
Maimonides Medical Center
North Shore Long Island Jewish
NEIGHBORHOOD HEALTH PROVIDERS
UNITED HEALTHCARE OF NEW YORK
Community Healthcare Network
Bronx Lebanon Hospital Center
FEGS Health and Human Services
North Shore Long Island Jewish
Maimonides Medical Center
Hudson Valley Care Coalition
Glens Falls Hospital
VNSNY CHOICE
Bronx Lebanon Hospital Center
Community Healthcare Network
Institute for Community Living
Maimonides Medical Center
VNS of NY Home Care
WELLCARE OF NY
Bronx Lebanon Hospital Center
Institute for Community Living
Bronx Lebanon Hospital Center
Institute for Community Living
Maimonides Medical Center
Community Healthcare Network
Bronx Accountable Healthcare Network
VNS of NY Home Care
Revised November 1, 2012
MCOs requested clarification on the duration of the
billing transition for converting TCM programs:

Just announced-TCMs will now bill legacy rates for two years
from the effective date of the State Plan Amendment (SPA).
MCOs asked if TCM programs will bill DOH directly
indefinitely:

TCM programs are billing DOH directly as part of their
transition to Health Homes; this billing arrangement is not
indefinite.
10

The only difference between Health Home claim and
Capitation claim is the rate code used.

Capitation claims also require a diagnosis code and a
revenue code.

DOH cannot provide coding guidance. MCOs and
Health Homes must be familiar with valid diagnosis
and revenue codes and choose the codes that best
represent the services provided.
11

Append location code to MMIS Provider number

Claim format 837 Institutional or paper UB04

820 Remittance

Use applicable HH Rate Code (1386/1387)

DOS = 1st of the Month in which services are provided

Valid diagnosis code required

Valid revenue code required (see NUBC code set)

Procedure Code not required

For additional information on how to submit a Medicaid
claim, contact eMedNY at 1-800-343-9000
12
MCO’s are requesting updated assignment files:
 Member
assignment files with updated loyalty
information are expected to be released on a quarterly
basis. The next release is anticipated in December
2012

In few weeks, member acuity scores will be available
for download via the HCS portal as a fixed length text
file. Members’ acuity scores will be refreshed
quarterly (DOH will release specifications on this file
shortly).
13
MCOs asked how they should handle assignments of plan
members to Health Homes that they do not contract with (these
are likely members who were assigned when they were FFS):

A member has a right of choice for a MCO and Health Home. If
a member is already assigned to a Health Home when joining
the MCO, the MCO should honor that assignment.

If the Health Home is not contracted with the Plan, the MCO
should advise the care manager who will work with the
member to determine an alternative Health Home or Plan.

DOH expects Health Homes, with partner Care Management
Agencies and MCOs to discuss and agree to appropriate
assignment of Health Home members.
14
MCOs asked if DOH is open to providing Health Home services
to those members with lower and mid range scores:
 The state is prioritizing the members at the highest level of
risk for adverse outcomes at this time.
 In addition to members assigned by the NYSDOH, Health
Homes can accept community referrals. These may include
members identified by the MCO as high risk and in need of
intensive care management. Such members must still have
one of the three basic Health Home diagnoses– 2 chronic,
HIV/AIDS, SPMI.
 The MCO-HH Work Group on Assignment and Quality is
developing further guidance on community referrals.
15
MCOs have found the Health Home Portal very helpful
and are looking forward to future improvements:

DOH is looking at a number of improvements to
smooth data flow and timeliness.
MCOs have requested clarification on the amount of
data that can be shared with the Health Home prior to
member consent:

MCO’s can share the last 5 claims/encounters.
16
Some MCO’s are requesting a specified time period as
an alternative to the last 5 claims/encounters. DOH is
looking into whether that is an option.
Health Home network providers (including contracted
MCOs) must collaborate with the designated lead
Health Home to obtain information necessary to
perform outreach and engagement.
17
MCOs asked about DOH expectations for timeliness of
the member signing the Health Home consent:

DOH anticipates that the care manager will have the consent
form signed to enable the exchange of Personal Health
Information (PHI) in order to deliver quality Health Home
services and care coordination, but a signed consent is not
necessary to start care management services.

If a consent is not signed over an extended time, the MCO and
Health Home may want to discuss the reasons why and together
forge a solution .
18
MCOs asked if a care management provider can advise a
member to change plans if the member’s current plan is not
contracted with the care manager’s lead Health Home:

A member has a right of choice for an MCO and Health
Home. The member and care manager can work together on
the best option for the member. Alternately, the plan can
contract with that Health Home.
MCOs asked if a signed withdrawal of consent form is still
required for members who wish to discontinue participating in
the Health Home:

Yes, a signed withdrawal is required.
19
MCOs asked about a process for active Health Home
members who lose managed care coverage (e.g., due
to loss of eligibility, incarceration) to transition back to
services:
Health Homes will work with members to maintain
eligibility.
A criminal justice workgroup is working on ways to
connect post-release members to Health Homes.
20
21