New York State
Health Homes
Implementation and
Billing Update
Statewide Webinar
Presented by:
New York State Department of Health
January 12, 2012
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Issues Covered on Today’s Webinar
 Timeline
 Applications
 Payment Policy and Billing
 Patient Assignment and Enrollment
 Patient Consent
 Disenrollment Process
 Patient Rosters
 …and more
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Health Home - Updated Timeline
 State Plan Amendment under review by CMS:
approval expected shortly
 January 1, 2012: Existing Case Management (COBRA,
MATS, TCMs) providers begin billing using HH rates
 Working on policy on patient consent timing
 February 1, 2012: List Assignment begins for Health
Plans and FFS
 February 15, 2012: New Application Deadline for
Phase II
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Health Home Web Based
Application
 The Health Home Application is being updated
 The updates primarily impact tables which list the partners
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and providers
Completed updates expected by February 1, 2012
New Phase 2 application deadline February 15, 2012
Obtain link to import information from Phase 1 application
into Phase 2 by emailing [email protected]
Subject: Import Phase 1 application
Applications can be worked on before updates are
completed but expect to submit Tables in a NEW
FORMAT starting the beginning of February
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Outreach and Engagement
Payments
 Existing case management slots (i.e., OMH TCM,
COBRA, MATS) will bill at 100% of the approved
PMPM rate for Outreach and Engagement
 For new Health Home members, case management
fee will be paid in two increments: outreach and
engagement or active case management
 Outreach and engagement for new members will be
paid at a reduced percentage (80%) of the active care
management PMPM
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Outreach and Engagement
Payments and Time Period
 The outreach and engagement PMPM will be available
for the three (3)months. If outreach and engagement is
unsuccessful, the provider may not bill again for three
(3)months from the conclusion of the outreach and
engagement period
 All Health Home outreach and engagement activities are
billable under the monthly PMPM as long as one of the
six (6) core services are provided in the billed quarter
 Once a patient has been assigned a care manager and
has consented, the full active case management PMPM
may be billed on the first day of that month
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Health Home Payments
 Rates will be set based on region and case mix (clinical
acuity). Eventually rates will be further adjusted by
member functional status
 Providers should submit one claim per month
using the first of the month as the date of service
 Monthly payments to health plans (MC patients),
provider-led Health Homes (FFS patients) and
converting TCM programs (both MC and FFS patients)
will be made through eMedNY
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Health Home Payments – Provider
Enrollment
 Providers already enrolled in Medicaid must add
Category of Service (COS) 0265
 New Health Home Providers that are not yet enrolled
in NYS Medicaid must enroll
 Enrollment instructions are posted on the eMedNY
website (https://www.emedny.org/ )
 New entities will need to obtain an NPI number before
enrolling in the Medicaid program
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Patient Rosters/Health Home
Member Tracking Sheet
 Billing and member flow will be controlled through a sharing of
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member rosters between the State, Health Plans, Health Homes
and Care Management agencies
Rosters of eligible Health Home members will be shared with
Phase 1 Health Homes and Health Plans via NYS Health
Commerce System (HCS) – formerly known as the HPN – on or
before February 1
Health Homes and Plans must populate member rosters on the
HCS with required information to receive payment
Two options to populate rosters are being explored – data entry
application and/or file transfer
Eventual amendments to WMS and eMedNY will be made to
report out certain roster fields and to implement Health Home
eligibility editing
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Roster Sharing/Health Home
Member Tracking Sheet
 All Provider-Led Health Homes must complete a Data
Exchange Agreement Application (DEAA) to obtain
rosters for initial member assignment
 Health Homes must have the ability to access the HCS
to receive rosters
 Identify the HCS Coordinator in your organization to
obtain an HCS account
 If unable to locate your HCS Coordinator contact your
administration for assistance
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Member Assignment & Enrollment
 Managed Care Plans will assign plan members who
qualify for Health Home services to Provider-led
Health Home
 DOH will assign FFS members to Provider-led Health
Homes
 Plans will send enrollment letters to their members
 Health Homes will send enrollment letters to their
assigned FFS members
 The Plans and the assigned Provider-led Health
Homes are the member contacts
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Patient Consent Process
 The assigned Health Home is required to secure patient
consent forms to officially enroll all Health Home members
in a Health Home program
 The signed consent form allows their patient information
to be shared with Health Home partners, including a
Regional Health Information Organization (RHIO), if
applicable
 The signed consent form documents patient enrollment in
the program and the active case management fee may be
billed for that month
 Final consent form will be posted on the Health Home
website
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Disenrollment or Changing
Health Homes
 Members who decide to disenroll from Health Homes must
sign a disenrollment form
 Members should request a disenrollment form from their
Plan or Provider-led Health Home
 Members who choose to be in a different Health Home
should notify their Plan or assigned Provider-led Health
Home
 Members who either cannot be located or refuse to sign the
patient consent or disenrollment form must be disenrolled
either immediately or after the three (3) month Outreach
and Engagement period as appropriate
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Chronic Illness Demonstration
Program (CIDP) Issues
 CIDP contracts will end on March 29, 2012
 By March 29 all CIDPs must be in a Health Home
partnership to continue to provide care management
services
 For one year as of effective date of SPA, CIDPs bill
eMedNY directly for existing CIDP members
converting to Health Homes
 CIDPs must use new Health Home rate codes for new
Health Home members
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Members in Multiple Counties
 NYS has proposed to CMS that Health Home rates for
case management providers serving existing members
in multiple counties enrolled during different
implementation Phases, be based either on county of
residence or county of service
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Care Management Process Metrics
 Health Home Core Services
 Comprehensive care management
 Coordination and health promotion
 Transitional care from inpatient to other settings
 Individual and family supports
 Referral to community and social support services
 Must provide documentation demonstrating how requirements
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are being met
Reporting period
Case Management Data Elements
Includes data elements from managed care plan
Functional Assessment elements
Metrics will be on web shortly
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Health Home Payments to Plans
 The plan is paid for Health Home services outside of their
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regional premium using a monthly care management fee paid
under a rate code
The Plan will bill eMedNY for Health Home payments using the
rate codes 1386 and 1387 as appropriate
The Health Home payment is made to the Plan after the member
is assigned to a Health Home
The Plan and the Health Home must have a contract prior to
making payments to the Health Home
The Health Home is paid by the Plan after Health Home services
are provided
The date of service is the first day of the month
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Data Exchange Agreement
Application (DEAA)
 Health Homes must submit a completed Data
Exchange Agreement Application (DEAA) to the
Medicaid Privacy Officer
 Information sent to all Provider–led Health Homes on
DEAAs also must be signed by all Health Home
partners providing case management
 DEAA process being customized for Health Homes
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Health Commerce System (HCS)
Access
 Health Homes must have access to the Health
Commerce System (HCS) to receive member
rosters/Health Home member tracking sheets
 Identify the HCS coordinator within the organization
to obtain HCS accounts for appropriate staff
 DOH Health Home staff are reaching out to Health
Homes to verify and assist with HCS access
 If there is a problem, contact DOH at
[email protected] using subject line ‘HCS’
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Billing Codes
REVISED 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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How to Submit a Claim for Health
Home Services
 Managed Care Plans & Provider-led Health Homes
will receive a letter from CSC that they are able to bill
new Health Home rate codes
 Health Home claims must be submitted/dated the
first of the month
 Claims can only be submitted once per month for
assigned members
 These are institutional type claims
Bill electronically using 8371 format
If paper, use UB-04
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Health Home Lead Applicant
Readiness Checklist
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Must be enrolled in Medicaid
Must resolve any approval contingency
Must have DEAA
Must have HCS access
Must have contracts with plans & downstream care managers
Secure Health Home partners
Confirm ability to bill rate codes for FFS & TCM
Confirm ability to share roster information (two way
communication) with downstream Health Home providers
 Confirm ability to pay downstream Health Home providers
 Develop procedures to collect and report monthly care
management process metrics & functional assessment for each
enrolled member
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Next Steps for DOH Implementation Team
 Secure SPA approval from CMS
 Continue implementation work with the Health Plans
 Post detailed billing guidelines to Health Home
website and publish in Medicaid Update
 Complete FFS loyalty matching to Health Homes
 Share final rosters with plans and Health Homes
 Regional meetings with Health Plans and Provider-led
Health Homes
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