New York State
Health Homes
Phase I
Implementation
Update
Statewide Webinar
Presented by:
New York State Department of Health
December 9, 2011
1
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
2
Final Phase I counties
 Bronx
 Hamilton
 Brooklyn
 Clinton
 Nassau
 Franklin
 Schenectady
 Warren
 Washington
 Essex
Monroe and Saratoga moved to Phase II
St. Lawrence moved to Phase III
3
Contingently Approved Designated Provider-led Phase I Health Homes
Bronx
Brooklyn
Nassau
Schenectady
Adirondack
Counties
Bronx
Accountable
Health Network
(Joint Venture)
Maimonides
Medical Center
North Shore-LIJ
Health System
Visiting Nurse
Service of
Schenectady
Co.
Adirondack
Health Institute
(AHI)
NYC Health and
Hospitals
Corporation
NYC Health and
Hospitals
Corporation
FEGS Health &
Human Services
System (CBC)
Visiting Nurse
Service of NY
Home Care
Community
Health Care
Network
Bronx Lebanon
(Joint Venture
with CBC, IHealth and
others)
Institute for
Community
Living
(ICL/CBC)
Glens Falls
Hospital
4
Managed Care Plans Health Homes-Phase I
Bronx
Brooklyn
Nassau
Schenectady
Fidelis Care New
York
Fidelis Care
New York
EmblemHealth
Fidelis Care New Fidelis Care New
York
York
United
United
Healthcare
Healthcare
Community Plan Community
Plan
United
Healthcare
Community
Plan
Health First
PHSP, Inc.
Health First
PHSP, Inc.
Health First
PHSP, Inc.
Affinity Health
Plan Inc.
Affinity Health
Plan Inc.
Affinity Health
Plan Inc.
Adirondack
Counties
United
Healthcare
Community
Plan
5
Managed Care Plans Health Homes – Phase I
Bronx (cont)
Brooklyn (cont)
Nassau (cont)
Health Plus PHSP
Health Plus PHSP
Health Plus PHSP
Amerigroup New York, Inc
Amerigroup New York, Inc
NewYork-Presbyterian
System SelectHealth, LLC
NewYork-Presbyterian
System SelectHealth, LLC
Amida Care
Amida Care
EmblemHealth
6
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.

7
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.
8
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
9
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.
10
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)
11
Updated Rates on Website
Projected Average Health Home Payments by Base Health Status and Severity of Illness Excludes LTC and OPWDD Populations
DRAFT FOR REVIEW AND COMMENT ONLY - (November 17, 2011)
Base Health Status1
Single SMI/SED
Upstate
Eligible RecipAverage CRG Average Monthly
ients3
Acuity Score4
Payment5
50,346
6.3406
$148
Eligible RecipAverage CRG Average Monthly
ients3
Acuity Score4
Payment5
25,182
6.3382
$119
Severity of
Illness
Low
State-wide
Average Case
Manager Ratio 2
79:1
Mid
61:1
18,790
8.0873
$189
9,772
8.0239
$150
High
12:1
260
16.5071
$385
60
16.6197
$312
73:1
69,396
6.8704
$160
35,014
6.8419
$128
Low
116:1
276,712
3.1258
$73
89,006
4.0091
$75
Mid
76:1
103,983
6.4740
$151
36,731
7.0456
$132
High
37:1
18,169
10.9285
$255
6,031
11.4136
$214
398,864
4.3631
$102
131,768
5.2032
$98
Single SMI/SED Total
Pairs Chronic
Downstate
Pairs Chronic Total
100:1
Low
89:1
15,593
5.4311
$127
5,155
5.7358
$108
Mid
62:1
21,559
7.9278
$185
7,608
8.2540
$155
High
34:1
7,527
11.3893
$266
2,609
11.8749
$223
65:1
44,679
7.6082
$177
15,372
8.0018
$150
Low
93:1
18,667
5.1243
$120
1,686
5.1243
$96
Mid
51:1
19,157
9.2749
$216
2,215
9.0280
$169
High
12:1
2,069
16.7259
$390
247
16.7148
$313
HIV/AIDS Total
64:1
39,893
7.7507
$181
4,148
7.9328
$149
Grand Total
91:1
552,832
5.1654
$120
186,302
5.7903
$109
Triples Chronic
Triples Chronic Total
HIV/AIDS
12
Projected Health Home Payments
Projected Average Health Home Payments - Sample Populations
Previous
Patient #
Base Health
Status
1
2
3
Pairs Chronic
Pairs Chronic
Triples Chronic
4
Triples Chronic
5
Single SMI/SED
6
Pairs Chronic
7
Pairs Chronic
8
9
Single SMI/SED
Pairs Chronic
10
11
12
HIV/AIDS
Triples Chronic
Triples Chronic
13
Triples Chronic
14
15
16
Triples Chronic
Single SMI/SED
HIV/AIDS
Dx Description
Diabetes and Hypertension
Diabetes and Asthma
Diabetes - Hypertension - Other
Dominant Chronic Disease
Congestive Heart Failure - Diabetes Cerebrovascular Disease
Conduct, Impulse Control, and Other
Disruptive Behavior Disorders
Schizophrenia and Other Chronic
Disease
Asthma and Other Moderate Chronic
Disease
Schizophrenia
Diabetes and Advanced Coronary
Artery Disease
HIV Disease
Cystic Fibrosis
Diabetes - 2 or More Other Dominant
Chronic Diseases
Brain and Central Nervous System
Malignancies
Non-Hodgkin's Lymphoma
Schizophrenia
HIV Disease
Severity Acuity
of Illness Score
Downstate Upstate
Downstate Upstate
Monthly Monthly Acuity
Monthly Monthly
Payment Payment Score Payment Payment
Low
Low
Low
1.6947
4.6947
5.7894
$39
$109
$135
$32
$88
$108
0.8114
4.0729
5.3524
$17
$83
$110
$13
$67
$88
Mid
6.0001
$140
$112
7.4909
$153
$123
Low
6.3574
$148
$119
5.6522
$116
$93
Mid
7.1434
$166
$134
6.9474
$142
$114
Mid
7.1434
$166
$134
8.3686
$171
$138
Mid
High
7.9093
8.818
$184
$205
$148
$165
7.9318
7.0289
$163
$144
$131
$116
Mid
Low
High
10.0992
10.1255
10.8664
$235
$236
$253
$189
$189
$203
10.0992
5.6337
12.3349
$207
$115
$253
$166
$93
$203
High
11.1186
$259
$208
21.1181
$433
$348
High
High
High
11.1186
16.6197
17.7378
$259
$387
$413
$208
$311
$332
11.7499
16.6288
17.7378
$241
$341
$363
$194
$274
$292
13
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.
14
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
15
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).
16
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
17
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
18
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
19
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
20
Plans and Health HomesRoles 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.
21
Plans and Health HomesRoles 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
22
Expected “Wave One” HH Enrollment
Health Hom e Enrollm ent Phasing
Phase
Tier
Phase 1
State Fiscal State
Year
Quarter
SFY '11-'12
FFY & Qrt
-
-
-
-
-
-
-
-
-
Qrt 2
FFY '10-'11 Qrt 4
-
-
-
-
-
-
-
-
-
-
Qrt 3
FFY '11-'12 Qrt 1
-
-
-
-
-
-
-
-
-
-
Qrt 4
FFY '11-'12 Qrt 2
3,715
10,661
16,401
-
-
-
-
-
-
30,778
3,715
10,661
16,401
-
-
-
-
-
-
30,778
9,289
26,652
41,003
3,663
10,510
16,168
-
-
-
107,285
Qrt 1
FFY '11-'12 Qrt 3
Qrt 2
FFY '11-'12 Qrt 4
-
-
-
9,157
26,274
40,421
807
2,314
3,560
82,533
Qrt 3
FFY '12-'13 Qrt 1
5,573
15,991
24,602
-
-
-
2,016
5,785
8,901
62,869
Qrt 4
FFY '12-'13 Qrt 2
3,715
10,661
16,401
5,494
15,764
24,253
-
-
-
76,289
18,577
53,305
82,007
18,313
52,548
80,842
2,823
8,100
12,461
328,976
1,858
5,330
8,201
3,663
10,510
16,168
1,210
3,471
5,340
55,751
Qrt 1
FFY '12-'13 Qrt 3
Qrt 2
FFY '12-'13 Qrt 4
-
-
-
1,831
5,255
8,084
807
2,314
3,560
21,851
Qrt 3
FFY '13-'14 Qrt 1
1,858
5,330
8,201
-
-
-
403
1,157
1,780
18,729
Qrt 4
FFY '13-'14 Qrt 2
1,858
5,330
8,201
1,831
5,255
8,084
-
-
-
30,559
5,573
15,991
24,602
7,325
21,019
32,337
2,420
6,943
10,681
126,891
Qrt 1
FFY '13-'14 Qrt 3
-
-
-
1,831
5,255
8,084
403
1,157
1,780
18,511
Qrt 2
FFY '13-'14 Qrt 4
-
-
-
-
-
-
403
1,157
1,780
3,340
Qrt 3
FFY '14-'15 Qrt 1
-
-
-
-
-
-
-
-
-
-
Qrt 4
FFY '14-'15 Qrt 2
-
-
-
-
-
-
-
-
-
-
SFY '14-'15 Total
Total
High Cost Mid Cost Low Cost High Cost Mid Cost Low Cost High Cost Mid Cost Low Cost
-
SFY '13-'14 Total
SFY '14-'15
Total
FFY '10-'11 Qrt 3
SFY '12-'13 Total
SFY '13-'14
Phase 3
Qrt 1
SFY '11-'12 Total
SFY '12-'13
Phase 2
-
-
27,866
79,957
123,010
1,831
5,255
8,084
807
2,314
3,560
21,851
27,470
78,822
121,263
6,049
17,356
26,702
508,496
* 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.
23
Phase One Population Information by County
Average Amount Paid per Claim/Prescription for Top Ten Categories of Service that Contribute to Overall Spend by County
for Dates of Service 7/1/10 to 6/1/11
Phase 1 County
Drugs
Inpatient
D&TC
OMH
Case
Hospital Rehabilitative Management
Outpatient
Services
Services
Skilled
Nursing
Facility
Home Health
Agency
Physician
Professional
Services Transportation
Services
BRONX
$
5,474 $
6,743 $
125 $
140 $
990 $
160 $
1,599 $
27 $
60 $
107
BROOKLYN
$
4,464 $
6,081 $
112 $
155 $
867 $
175 $
1,494 $
19 $
60 $
124
CLINTON
$
3,462 $
4,098 $
135 $
118 $
495 $
519 $
1,208 $
28 $
69 $
83
ESSEX
$
3,771 $
4,229 $
120 $
120 $
556 $
485 $
370 $
34 $
45 $
87
FRANKLIN
$
3,876 $
5,116 $
151 $
141 $
910 $
391 $
1,359 $
34 $
65 $
115
HAMILTON
$
3,451 $
8,793 $
69 $
86 $
$
1,925 $
25 $
117 $
140
NASSAU
$
3,405 $
5,253 $
128 $
126 $
1,051 $
276 $
1,363 $
19 $
91 $
107
SAINT LAWRENCE $
3,621 $
4,787 $
117 $
354 $
881 $
246 $
892 $
33 $
100 $
96
SARATOGA
$
3,367 $
2,950 $
112 $
88 $
1,085 $
309 $
476 $
21 $
53 $
65
SCHENECTADY
$
3,512 $
3,149 $
86 $
122 $
926 $
170 $
1,072 $
27 $
41 $
65
WARREN
$
2,779 $
4,571 $
81 $
104 $
938 $
336 $
1,287 $
31 $
53 $
86
WASHINGTON
$
3,356 $
3,844 $
84 $
85 $
1,144 $
424 $
1,226 $
25 $
37 $
117
756
NA
24
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.
25
Phase one HH Eligibles by Plan by County*
Type
Name
Bronx
Brooklyn
AMIDA CARE SN
1,025
1,557
AIDS SNP METPLUS SN
1,570
1,517
NY PRESB SYS SELECT HEALTH
2,136SN
1,322
AIDS SNP Total
4,731
4,396
AFFINITY HEALTH PLAN
11,230
4,254
AMERIGROUP NY
600
3,652
CDPHP
EXCELLUS
FIDELIS HC NY
8,567
13,954
GHI HMO SELECT
1
HMO /
GHI PPO
PHSP
HEALTHFIRST
19,488
16,607
HEALTHPLUS
4,096
13,139
HIP
5,136
9,199
METROPLUS
13,465
13,090
NEIGHBORHOOD
3,297
6,604
UNITED HEALTHCARE COMM PLAN
796
17,660
WELLCARE
1,757
3,031
HMO/PHSP Total
68,433
101,190
AFFINITY PROVIDER
22
4
FIDELIS PROVIDER
80
169
GHI HMO SELECT
8
9
HIP ADVANTAGE
124
230
MEDICAID
LIBERTY HEALTH ADVANTAGE 14
14
ADVANTA
MANAGED HEALTH INC PROVIDER
13
17
GE
METROPLUS PROVIDER
17
16
SENIOR WHOLE HEALTH OF NY
TOUCHSTONE/PRESTIGE
27
51
UNITED HEALTHCARE COMM PLAN
1
MEDICAID ADVANTAGE Total
305
511
FFS
Total
24,934
41,462
Grand Total
98,403
147,559
Clinton
Essex
Franklin
Hamilton
Nassau
Saint
Lawrence
Saratoga
Schenect
ady
Warren
Washingt
on
1,618
1
1
826
1
150
376
44
2,304
2
313
1
1,606
1,594
4
334
908
1,213
1
479
539
2,514
2,808
483
873
1
2,279
1,122
3,400
1
2,735
827
376
153
44
13,460
315
11
1
86
1
2,091
2,918
464
840
1,281
1,434
32
76
88
7,631
21,179
3,269
3,584
15
37
17
2
15
1,313
3,842
48
1,677
4,533
17
1,070
1,570
2
664
1,539
Grand
Total
2,582
3,087
3,458
9,127
17,102
4,252
3,539
315
29,361
2
3
38,374
18,357
17,735
26,555
9,902
21,191
4,788
191,476
26
260
18
440
29
30
33
71
78
1
986
85,888
287,477
* 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.
26
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/
27