Health Home
Statewide
Implementation
Webinar
February 28, 2012
Presented by
The New York
State Department
of Health
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Agenda
• Phase I Implementation Status
• Working with Managed Care Plans
• Health Home Assignments and Enrollment
• Billing and Payment
• Metrics
• Assessment
• Phase II Status Report
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Ready Set Go-State Plan Approval
New York's Medicaid State Plan Amendment (SPA) for
Phase I Health Homes for Medicaid Members with
Behavioral Health and Chronic Conditions was
approved with an effective date of January 1, 2012
• Final version of the SPA posted to the Health Home website
• A detailed Medicaid Update Article will be published
• Provider Manual being written
• Guidance on TCM transition on OMH website
http://www.health.ny.gov/health_care/medicaid/program/medicaid
_health_homes/partner_resources.htm
3
Phase I Implementation Status
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Final Phase I counties
 Bronx
 Hamilton
 Brooklyn
 Clinton
 Nassau
 Franklin
 Schenectady
 Warren
 Washington
 Essex
Note: Albany, Rennselaer and Saratoga have been moved
from Phase II to Phase III to allow more time for network
development
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Health Home Readiness
Provider Enrollment and NPI’s
Lead Health Homes do all billing under one NPI
number (with the exception of old and new TCM slots
which will continue to be billed to eMedNY directly by
case management agencies)
• Health Homes may use an existing NPI number or enroll a
newly structured organization with a new NPI for that
organization, then bill under the NPI of the new organization
• Detailed Medicaid provider enrollment information is
available on the Health Homes website
6
Health Home Readiness
Communication
• Health Homes must maintain current contact
information (updates to [email protected])
• Health Homes must identify contact numbers for
Health Home participants to be directed to, for
assistance and information
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Health Home Readiness
Communication
Plans and Health Homes must develop and prepare to
send out introduction welcome letters
• Plans will send out letters to their Plan members (based on
Plan template approved by DOH)
• Health Homes will send letters to their assigned Fee for
Service list (based on DOH template)
http://www.health.ny.gov/health_care/medicaid/program/
medicaid_health_homes/forms/
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Health Home Readiness
Thinking Ahead
• Health Homes must prepare to meet quality measures
and reporting responsibilities
• Health Homes must develop systems to reimburse
partners, commensurate with the level of Health
Home services delivered
• Health Homes should think through their capacity, i.e.,
how many participants can they serve
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Health Homes and Managed
Care Plans Working Together
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Working with Managed Care Plans
• Managed Care Plans are working on contracts with
Provider-led Health Homes to allow Plans to assign
their members into Health Homes as appropriate
• DOH is working with Health Homes on model
clauses for contracts
http://www.health.ny.gov/health_care/medicaid/program/medi
caid_health_homes/nys_implementation.htm
• Managed Care member assignment into Phase 1
Provider-led health homes will likely commence in
March
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Working with Managed Care Plans
Provider-led Health Homes must work closely with
Managed Care Plans to:
• Coordinate care and services
• Utilize the plan network, for in-plan benefits
• Ensure prior authorization requirements are met
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Working with Managed Care Plans
Managed Care Plans must:
• Contract with provider-led Health Homes
• Assign members using the State algorithm and their own data
(e.g., PCP assignment) to appropriate Health Homes
• Reimburse Health Homes commensurate with the Health Home
services being provided
• Act as State’s partners in monitoring the quality of Health Homes
• Work with Health Homes that are not achieving quality goals
and/or meeting the member’s needs, to help them improve
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Working with Managed Care Plans
• Health Homes need to clearly communicate volume
capacity to Plans
• Plans and Health Homes need to negotiate
participant assignments to ensure a viable case mix
• Contracts need to spell out clear expectations about
assignments
• DOH will work with Plans and Health Homes to
resolve problems
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Working with Managed Care Plans
• Plans may retain a portion of Health Home payments
for administrative services and other support as
necessary
• Contractual agreements should specify the services
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Patient Assignment and
Enrollment
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Health Home Assignments:
Managed Care Workflow
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Health Home Assignments:
Fee-for-Service Workflow
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Health Home Assignment-FFS
• Updated network partner lists were received from all
Health Homes to finalize the algorithm for identifying
and assigning candidates based on loyalty
• Lists of potential participants have been created, with
individuals scoring higher (based on risk for adverse
events and lack of engagement in care) being identified
for assignment first
• Lists will be used to populate member tracking sheets,
which Health Homes will access through the Health
Commerce System (HCS)
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Health Home Assignment-FFS
• Provider-led designated Health Homes have or will
have access to member tracking sheets via HCS for
their assigned members
• Outreach and engagement (or enrollment if
applicable) commencing in February should be
billed in March, using new rates and a February 1
date of service
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Health Home Assignment-MC
• Managed Care Plans have access to their member
tracking sheets via the HCS, for individuals
identified by DOH as potential Health Home
candidates (based on risk and engagement, loyalty,
PCP assignment)
• Managed Care Plans will evaluate potential
candidates and assign them to Health Homes that
best serve their needs
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Health Home Assignment-TCM
• TCMs will identify the Health Homes that best meet
their member’s 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 these
assignments
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Assignment-New Referrals
• New referrals (via HRA, county, SPOA or LGU, 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 the needs of their populations
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Member Tracking Sheet Elements
• Patient Demographic information
• 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)
The information on the member tracking sheet supports the
claim…more on this in the Billing and Payment section
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Member Tracking Sheet Update
 Updated version now available on the website
 DOH will soon schedule a Technical tracking sheet submission
webinar with designated HCS contacts.
 Tracking Sheet Changes:
 The HH Database primary key is the unique combination of Recipient
ID, MC Plan (if applicable), Assigned HH Plan, and Begin Date.
 Must now indicate record type on tracking sheet
 Only Add (new primary key OR move from engagement to enrollment),
Change (changing/updating existing information or disenrolling) or
Remove records (permanent removal – not disenrollment)should be
submitted each month
 Tracking sheet now shows editing logic and required fields
http://www.health.ny.gov/health_care/medicaid/program/medicaid_heal
th_homes/tools_for_imlement.htm
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Outreach and Engagement
• Outreach and engagement-three consecutive months
to find and engage candidate and secure consent. If
not successful, outreach and engagement can
continue but three months must elapse before
another three months of outreach and engagement
can be billed
• If a Health Home candidate definitively opts-out, at
least three months must elapse before the
candidate can be reassigned and no outreach can
occur during this period
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Enrollment and Consent
• Enrollment starts when the candidate has signed the
consent form and becomes a Health Home participant
• The consent form is available on the Health Home
website (currently only in English, translations into
other languages will be available)
http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_h
omes/forms/
• Care managers are expected to help potential Health
Home participants understand that signing includes
consent for Health Home Services as well as allowing
health information to be shared with other Health
Home providers and the RHIO
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Enrollment and Consent
• Personal health information on Health Home members
cannot be shared with network partners until consent is
signed - the date of consent is considered the
enrollment date
• Entry of an enrollment date on the member tracking
sheet and submission of the sheet via HCS will support
claiming through eMedNY for the enrollment rate,
instead of the outreach and engagement rate
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Billing and Payment
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Billing and Payment-Eligibility
• Eligibility will initially be controlled through sharing of member
tracking sheets. Key elements of the tracking sheet (outreach
dates, enrollment dates) will be loaded to member eligibility
files to support claims and appropriate payment edits
• Member tracking sheets will be populated via file transfer for all
Health Home candidates and participants. System changes are
in progress to allow additional functions, e.g., look-up of Health
Home status
Note: Billing and payment, including rates, were covered in detail at the December
9, 2011 Statewide Webinar (presentation is on the Health Homes website)
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Billing and Payment-Rates
• Payment rates will be set based on region and case mix (e.g.
clinical acuity).
• Eventually rates will be further adjusted by member
functional status (e.g. impairment in physical and/or
behavioral functioning, housing status, self management
abilities, etc).
• Except for TCM slots, outreach and engagement will pay at 80%
of the rate, once the candidate is enrolled the rate will be 100%
• CSC will notify managed care plans and Provider-led Health
Homes when they are able to bill new Health Home rate codes.
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Billing and Payment-Rates
Health Home Rate Code Definitions
1386: Health Home Services (Plans and FFS)
1387: Health Home Outreach (Plans and FFS)
1851: Health Home/OMH TCM
1852: Health Home Outreach /OMH TCM
1880: Health Home/AIDS/HIV Case Management
1881: Health Home Outreach/ AIDS/HIV Case Management
1882: Health Home/ MATS
1883: Health Home Outreach/MATS
1885: Health Home/CIDP Case Management
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Billing and Payment-Claims
• Claims are submitted by, and monthly payments made
to, health plans (MC ) Provider-led Health Homes (FFS)
and converting TCM programs (for both MC and FFS)
through eMedNY
• Claims can only be submitted once per month and
must be dated the first of the month; these are
institutional claim types using the electronic 8371
format
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Billing and Payment-TCMs
TCM’s have unique billing rules:
• Existing case management slots, OMH-TCMs, HIV
COBRA, CIDP and the MATS programs will convert to
Health Home rates retroactive to January 1
• TCM’s will bill at 100% of the Per Member Per Month
(PMPM) for outreach and engagement and for
enrollment, for TCM slots
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Billing and Payment-TCMs
TCM’s have unique billing rules:
• TCM programs billing under their existing NPI must bill
eMedNY directly for both MC and FFS participants,
including their legacy TCM capacity and new Health
Home capacity
• Health Homes can negotiate with TCM programs for
upstream payments for administrative services and
other support
35
Billing and Payment-TCMs
• Guidance is under development for case management (i.e.
TCM, COBRA) programs to bill new rates retroactively to
January 1, 2012, for patients they are already serving (may
have option to automatically reprocess these claims)
• No changes to billing until this guidance is released. TCMs
should continue to bill as they are doing now. Once TCMs
have transitioned to new codes, can use the active
enrollment code for continuing care management services,
but health information cannot be shared until Health
Home consent is obtained
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Minimum Billing Requirements
Health Homes must provide at least one of the six core
Health Home services per quarter. There will be no
requirement for minimum face-to-face contacts,
however, there must be 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
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Care Management Metrics
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Metrics
• Care management process metrics will be collected to
assess the level of care management services provided
and the degree to which the six core Health Home
services have been delivered
• Initially, quality metrics will be derived for the most
part from encounter and claims data. State outcome
metrics are included in the SPA, guidance still pending
from CMS (expected Summer 2012) on core measures
and metrics
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Metrics
 State is exploring alignment of Health Home care
management metric reporting with CMART, a case
management reporting utility used by Plans
http://www.health.ny.gov/health_care/medicaid/program/me
dicaid_health_homes/forms/
 Health Homes required to send member-level metrics to
the member’s Managed Care Plan
 Managed Care Plans will report metrics to DOH, for Plan
members, Health Homes will report metrics to DOH for
FFS members
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Metrics
 Goal - uniform platform for reporting that would
satisfy requirements of Plans, Health Homes and DOH
 How often metrics will need to be reported (e.g.,
frequency of contacts, dates) under discussion
(possibly monthly, as part of the process of sharing
member tracking sheets)
 Expect to start the reporting and collecting process
metrics as of April 2012
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Functional Assessment
42
Functional Assessment
• State evaluating a functional self-assessment tool
based on the FACIT-GP to evaluate each Health Home
participant on a range of measures
http://www.health.ny.gov/health_care/medicaid/program/medicaid_health
_homes/forms/
• Validated tool administered face-to-face 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
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Phase II
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Phase II
• Phase II counties are Dutchess, Erie, Manhattan,
Monroe, Orange, Putnam, Queens, Richmond (Staten
Island), Rockland, Suffolk, Sullivan, Ulster, and
Westchester
• 41 applications received for Phase II are under
active review
• Anticipated Start date for Phase II is April 1
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Questions?
Visit the Health Home Website at:
http://www.health.ny.gov/health_care/medicaid/program/
medicaid_health_homes
Attachments for webinar:
http://www.health.ny.gov/health_care/medicaid/program/
medicaid_health_homes/forms/
Send an email to the Health Homes Bureau Mail Log at
[email protected]
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