Statewide Webinar-June 6,2012
Tentative Dates
Downstate Town Hall Meeting-June 19, 2012
Upstate Town Hall Meeting-June 22, 2012

Address Health Home concerns
◦ List assignments
◦ Reporting requirements
◦ Contracting
◦ Billing and payment

Provide a progress report on Health Home
implementation
2
New Implementation Timeline
Jan 1,
2012
Phase I Implementation (10 Counties) Bronx, Brooklyn, Nassau,
Schenectady, Clinton, Essex, Franklin, Hamilton, Warren, Washington.
Existing case management (COBRA and TCMs) providers begin billing using
Health Home rates.
Feb 1,
2012
List assignment begins
Feb 15,
2012
Application deadline for Phase II (13 Counties) Dutchess, Erie, Manhattan,
Monroe, Orange, Putnam, Queens, Richmond (Staten Island), Rockland,
Suffolk, Sullivan, Ulster, Westchester
April 1,
2012
Phase II implementation (retro billing back to 4/1 for CIDP programs)
Existing CIDP providers begin billing using Health Home rates. MATS begin
billing using Health Home rates TBD.
June 1,
2012
Application deadline for Phase III (39 counties) Albany, Alleghany, Broome,
Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Columbia,
Cortland, Delaware, Fulton, Genesee, Greene, Herkimer, Jefferson, Lewis,
Livingston, Madison, Montgomery, Niagara, Ontario, Oneida, Onondaga,
Orleans, Oswego, Otsego, Rensselaer, Saratoga, Schoharie, Schuyler,
Seneca, St. Lawrence, Steuben, Tioga, Tompkins, Wayne, Wyoming, Yates
July 1,
2012
Phase III implementation (tentatively)
3
High Risk Health Home Population
Chronic Episode Diagnostic Categories
Health Home Eligibles Adults 21+ Years
With a Predictive Risk Score 75% or Higher (n=27,752)
Percent of Adult Recipients with Co-Occurring Condition
Condition
Total
43.5
Severe Mental Illness
46.2
Mental Illness
54.4
Substance Abuse
37.6
Hypertension
29.8
Hyperlipidemia
27.8
Diabetes
28.3
Asthma
13.4
Congestive Heart Failure
12.2
Angina & Ischemic HD
8.3
HIV
12.7
Obesity
22.1
Osteoarthritis
15.5
COPD & Bronchiectasis
13.5
Epilepsy
41.9
CVD
18.8
Kidney Disease
Total 100.0
Severe
Mental
Illness
Mental
Illness
100.0
70.4
61.9
39.1
41.0
36.3
52.4
22.1
30.5
50.2
50.5
45.7
38.8
65.1
33.2
25.2
43.5
74.7
100.0
60.3
51.6
52.2
46.5
58.5
37.9
47.8
48.4
61.4
62.7
53.0
66.6
45.3
40.4
46.2
Angina
& IscheSubstHyperCongestmic
ance Hyper- lipidemi
ive Heart
Heart
Abuse tension
a Diabetes Asthma Failure Disease
77.2
70.9
100.0
51.1
47.1
41.8
62.9
30.6
41.8
73.5
45.8
56.8
50.6
66.3
44.6
32.4
54.4
33.8
42.0
35.4
100.0
59.8
56.0
40.8
79.5
68.2
25.2
52.6
49.9
54.7
38.8
55.9
61.5
37.6
28.1
33.7
25.9
47.4
100.0
58.8
39.7
61.9
81.5
20.0
55.4
41.8
48.1
33.2
50.2
49.9
29.8
23.2
28.0
21.4
41.4
54.9
100.0
34.8
53.5
57.6
18.1
53.1
35.5
40.7
27.2
43.1
50.6
27.8
34.1
35.8
32.8
30.7
37.7
35.4
100.0
32.3
40.3
41.9
49.0
44.0
60.1
35.1
32.3
27.6
28.3
6.8
11.0
7.5
28.2
27.8
25.7
15.3
100.0
45.1
6.7
22.2
15.8
29.2
8.9
32.0
35.8
13.4
8.5
12.6
9.4
22.1
33.4
25.3
17.4
41.2
100.0
6.8
23.1
18.7
24.8
10.6
29.2
27.2
12.2
COPD &
Osteo- BronchHIV Obesity arthritis iectasis Epilepsy
9.6
8.7
11.2
5.6
5.6
5.4
12.3
4.1
4.6
100.0
3.2
10.0
8.7
8.1
6.2
7.9
8.3
14.8
16.9
10.7
17.8
23.6
24.3
22.0
21.1
24.1
4.9
100.0
22.7
21.0
15.6
18.3
18.3
12.7
23.2
29.9
23.1
29.3
30.9
28.1
34.3
26.1
33.8
26.6
39.3
100.0
36.1
24.8
27.4
29.1
22.1
Health Home High Risk
13.9
17.8
14.5
22.6
25.1
22.8
33.0
33.9
31.5
16.4
25.7
25.5
100.0
16.2
25.0
22.3
15.5
20.1
19.4
16.4
13.9
15.0
13.2
16.7
8.9
11.7
13.2
16.5
15.1
14.0
100.0
13.2
11.7
13.5
Kidney
CVD Disease
31.9
41.0
34.4
62.2
70.4
64.9
47.7
100.0
100.0
31.1
60.1
52.0
67.2
41.1
100.0
78.6
41.9
10.9
16.4
11.2
30.8
31.5
34.3
18.4
50.3
41.9
17.9
27.2
24.9
27.0
16.3
35.4
100.0
18.8
Note: Diagnosis History During Period of July 1, 2010 through June 30, 2011.
4
New York State Health Home Analytical
Products
◦ CRG Based Attribution – For Cohort Selection
◦ CRG Based Acuity – For Payment Tiers
◦ Predictive Model - Predicts future negative events
(Inpatient, Nursing Home Death) using claims and
encounters – For Assignment Priority
◦ Ambulatory Connectivity Measure – For Assignment
Priority
◦ Provider Loyalty Model – Establishes Patient Connectivity
to Existing Care Management, Ambulatory (including
BH), ED and Inpatient – For Matching to Appropriate HH
and to Guide Outreach activity.
5


Loyalty analysis goal – keep members with
meaningful (ambulatory) provider
connections
State reviewed where eligible Health Home
members seek care:
◦ Current Case Management services
◦ Ambulatory care
◦ Emergency or inpatient use

Members assigned to Health Homes where
they have the most connectivity
6
Eligible for Health Home services with either two or more chronic
conditions, HIV/AIDS or serious persistent mental illness;
members given a risk score and an ambulatory connectivity score
 Risk Score
◦ Scale of 0-100
◦ High score means a higher chance the member would have an
adverse event (inpatient or nursing home admission, death)
◦ Based on John Billings algorithm at NYU
 Ambulatory connectivity
◦ Scale of 0-100
◦ The fewer ambulatory care visits the higher the score
 Risk and Ambulatory score added together = DOH Composite
Score-members with scores 125 and above (for initial launch)
assigned to Health Homes based on loyalty
7





Will explore assigning members with higher risk
scores but higher ambulatory connectivity.
Converting TCM members will be included on May
rosters (due to DOH in June)
Dual eligibles will be assigned
Contracts are being expedited to facilitate
assignment of Managed Care members
Guidance on accepting community referrals is
being developed
8
Health Home FFS Assignments To Date
9
Potential Assignments from
Managed Care Plans-Phase 1
10



New referrals (via HRA, county, SPOA, care management
agency, practitioners, hospital, prisons, BHO, etc) meeting
Health Home criteria must be assigned to Health Homes to
ensure access to care management
For Managed Care Members, the referring entity will contact
the Plan to actuate the Health Home assignment
For FFS members, the referring entity will contact DOH
(contact information to be provided shortly) to actuate an
appropriate Health Home assignment. Process will include
collaboration with OMH, AIDS Institute, and OASAS to
ensure these assignments best serve member needs
11



State assigned FFS members to Health Homes based on
their score and loyalty analysis
Managed Care Plans will assign MC members to Health
Homes based on similar information
Tracking file lists are not perfect
◦ State ‘cleaned up’ lists but challenges remain
◦ Medicaid eligibility and MC enrollment status changes
daily
◦ List Generation is in the process of being more automated

Health Homes identify the members for outreach and
enrollment through the Member Tracking System
12









Initial lists went out to Managed Care Plans and Lead Health
Homes 2/21 – 2/22
Updated lists of members w/ composite scores >125 sent
Health Homes 3/28
Loyalty files sent to Health Homes 4/9
Addresses and last 5 claims sent to Health Homes 4/12
Health Homes were sent members enrolled in converting case
management programs 5/9
Managed Care Plans were sent members currently enrolled in
converting case management programs 5/15 – 5/16
May lists from HH for FFS due in June 5th.
Next Submission Date for Managed Care and FFS – July 3rd.
Working on capacity to give recent claims and encounters to
HHs for assigned members.
13




Weekly calls to provide technical assistance
with Member Tracking System logistics
Development of an OHIP Datamart Portal for
Member Tracking
Restriction codes to identify potential
candidates for Health Home services and to
indicate Health Home assignments
Design of portals to allow real-time access
to member-level Medicaid data
14



TCMs identify the Health Homes that best
meet their members’ needs
DOH will make assignments to Health
Homes based on these recommendations
Managed Care Plans and Health Homes will
receive member tracking sheets that reflect
assignments
15



TCMs identify the Health Homes that best
meet their members’ needs
TCMs make Health Home assignment and
sends assignment information DIRECTLY to
Health Homes
Health Homes send member tracking file
collected from downstream providers to
DOH for FFS members and to Managed Care
Plans for MC members
16




Transitioning TCMs bill Medicaid directly for all
Health Home services provided
Transitioning TCMs can bill for members
enrolled in Managed Care prior to signed MC
contracts
Health Homes can negotiate upstream
payments to cover administrative costs
Transitioning TCMs only submit tracking file
information to Health Homes, not DOH directly
17



Guidance on retroactive billing will be
provided
DOH (with OMH, OASAS, and the AIDS
Institute) are scheduling conference calls
with the TCM provider community to discuss
Health Home tracking system and billing
issues
Ground rules for referrals, transitions from
shelters and criminal justice system are
being developed
18




Key provisions for Plans to use in executing
Health Home contracts were approved by
DOH
Several plans submitted contracts that went
beyond the key provisions
Plans have been directed to limit contracts
with Health Homes to the key provisions
Once contracts are in place Plans can assign
Managed Care members to Health Homes
19


Health Homes must provide at least one of the
five core Health Home services per month
There will be no requirement for minimum faceto-face contacts, however, there must be active
outreach or active care management and evidence
of activities that support billing, including:
◦
◦
◦
◦
Contacts (face-to-face, mail, electronic, telephone)
Patient assessment
Development of a care management plan
Active progress towards achieving goals
20

Detailed billing guidance provided in the
Health Home Special Edition of the Medicaid
Update (April 2012) for billing guidance
http://www.health.ny.gov/health_care/medicaid/program/
update/2012/april12muspec.pdf

Provider enrollment assistance is available
◦ TCM providers-automatically enrolled for Health Home
Category of Service 0265
◦ Lead Health Homes can contact the Health Home team for
assistance with provider enrollment

Provider manual in development
21


Process metrics will be collected to assess
the level of case management services
provided and the degree to which the core
Health Home services have been delivered
as required
Outcome metrics will be derived in part
from claims data and other variables. State
outcome metrics are included in the SPA,
guidance still pending from CMS on
specifications for additional measures
22



Statewide Health Home and Managed Care Plan
workgroups are being established to develop
recommendations for a standardized set of
process and outcome measures
DOH is developing a customized reporting
module based on CMART, an case management
reporting utility for reporting to Managed Care
Plans, as the framework for all Health Home
process metrics
Goal is to have a uniform platform and a
standard set of metrics in place by Fall 2012
23



State is finalizing instructions and scoring
criteria for a functional self-assessment tool
based on the FACT-GP to evaluate each Health
Home participant on a range of measures. See:
http://www.health.ny.gov/health_care/medicaid
/program/medicaid_health_homes/forms/
Validated tool administered upon enrollment,
annually thereafter and at discharge; results
reported to the State
Results of assessments used to adjust initial
rates, which were based on calculated acuity
and risk scores
24



Adding a Health Home administrative
payment to Plan capitation rate
Ensuring equitable distribution of
members and payments
Adjusting payment rates for homelessness
and predictive risk of negative event

Medicare and Medicaid gainsharing

Assignment of duals
25




Updating partner lists to refine loyalty
analysis
Medicaid eligibility (uninsured, spend
downs)
Separating Health Homes from TCM
rules and regulations
Having biweekly calls with the larger
Health Home community to hear
concerns and answer questions
26
Discussion
27