Session 9 – January 17, 2013
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Working Together
HIT Requirements and Funding Opportunities
Sharing Member Information
Member Eligibility for Health Home Services
Outreach and Engagement Work
Health Home Services
Acuity Scores
Billing and Rates
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 The State’s decision to pursue the Health Home (HH)
model in a transformative way was predicated on the
successes and lessons learned in OMH Targeted Case
Management (TCM), HIV COBRA TCM, OASAS Managed
Addiction Treatment Services (MATS), and DOH Chronic
Illness Demonstration Project (CIDP)
 HH providers integrate and coordinate all primary, acute,
behavioral health, and community support services;
treating the whole person with the goal to improve care
and reduce costs.
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 The HH model expands concepts from both converting
case management programs and Patient Centered
Medical Home model by building additional linkages
and enhancing coordination and integration of medical
and behavioral health care to better meet the needs of
people with multiple chronic illnesses
 In other words, the Health Home takes the Medical
Home concept across multiple care disciplines and into
the community for high need Medicaid recipients
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 TCMs were developed to provide community-based case
management to high need Medicaid recipients (HIV+/Mental
Health) often disengaged from medical, mental health, and
social services
 TCMs have years of experience in outreach and engagement of
persons difficult to locate and keep in care:
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unstably housed
mentally ill
history of incarceration
substance using
with multiple chronic illnesses
impacted by stigma
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 HHs networks were approved only if they included
converting case management programs; in many cases
multiple case management programs.
 Lead HHs are expected to be using the value and
expertise of their entire HH network to achieve the
goals of the program.
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 Case management programs operated successfully, but
programs were not anchored into formal comprehensive
networks with medical providers.
• Under HH case management agencies are transitioning as
part of larger networks.
 TCMs are accountable to HH Leads; often multiple leads
with different requirements.
• TCMs work to ensure client outcomes are realized; provide direct
service to locate/engage clients and coordinate member care and
services.
• TCM input into HH policies can help ensure more effective
processes.
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Fiscal Viability
 Converting programs ability to generate revenue to cover
agency administrative and infrastructure costs are dependant
on volume of assignments, and amount and timing of payments
• Concern about future cash flow beyond direct Medicaid billing
• Concern about survival beyond legacy rates
 Administrative costs must be negotiated with multiple HH Leads
and MCOs.
 New infrastructure and HIT costs are not built into
reimbursement; impacting lead HHs and network partners alike.
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Administrative burden
 Tracking enrollee status for multiple HH
 Reporting to multiple MCOs and HH Leads
• Requirements vary - some have added reporting
elements beyond state requirements
 Maintaining databases/EHRs for multiple HH and ensuring
staff are trained to use them
 Building capacity
• Hiring, training, supervising staff
• Oversight and quality assurance
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HH network partners have a joint responsibility to
assure HH outcomes are reached. Establish systems
to ensure:
◦ Clear, regular communication between HH Leads, MCOs,
and converting care management providers
◦ Policy input by all parties
◦ Communication among HH systems in the same region, to
avoid overlap and encourage collaboration (e.g., HUNNY,
CNYHHN)
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 State expects movement of partners as relationships
develop.
 HHs must notify DOH about changes to their network
(changes in name, partners joining or leaving, etc). See
instructions on the Health Home website:
http://www.health.ny.gov/health_care/medicaid/program/medicaid
_health_homes/medicaid_enroll_prov-led_hh_rev.htm
 HHs are responsible to assure they maintain an ability to
meet provider standards and qualifications; much of
which is met through comprehensive network partners
working together.
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Lead Health Home (HH) is responsible for assuring
the HH network meets final HIT standards
 Network care management partners are not required
to join a RHIO but becoming a RHIO member will
enhance the quality and quantity of EHR data shared
 Lead HHs should be working with network partners to
assure partners have any necessary HIT capability;
Work with the partners to fill in gaps
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 Lead Health Home is responsible for a plan to adopt
Certified Meaningful Use (MU) Electronic Health
Records (EHR)
◦ This HIT Standard applies to all Health Homes and is required
for Clinical Partners/Provider Organizations providing clinical
care to Health Home patients (including BHOs).
◦ Care Managers do not necessarily need an EHR, but need an
interoperable Care Plan application.
 A future webinar will address this as well as other HIT
related questions.
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 Partners should work with lead HH to understand
how the HH will share information and meet HIT
standards
 Please contact Office of Health Information
Technology Transformation for specific questions:
E-mail: [email protected]
Phone: 518-474-4987
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 NYS recognizes expense of HIT infrastructure on
Health Homes
 Lead HHs and partner agencies have varying degrees
of HIT infrastructure
 NYS requested funding for HIT infrastructure through
the CMS waiver
• Funding would be prioritized for HH partners that have not
already received funding through other initiatives.
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 NYS OMH is providing one-time HIT funding to assist
former TCM providers to develop electronic care
management system capacity to share information
with their respective HHs.
 HEAL 22 has funding to support technical assistance
for Mental Health/Behavioral Health providers
working with HHs.
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 Access to member information is important to the
entire HH network.
 Currently only HHs and MCPs can access the
Health Home member tracking file through the
Health Commerce System (HCS).
 DOH recognizes that network partners would like
access to the HCS but current system and
resource issues prevent the ability to give all
network partners HCS access.
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 DOH is looking to build a HH portal which would allow
broader access and include additional features, such
the ability to pull claims information.
 In the interim, leads are responsible for sharing
necessary information with the network partners.
 DOH has a proposal to streamline the member tracking
system process and will specify a standardized file
layout to make it easier for network partners to
manage data submission.
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Tracking system calls are held on a regular basis for
Health Homes and MCPs because they currently
submit files directly to NYS.
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Network partners submit files through their HHs and
are encouraged to obtain tracking system
information from the respective HHs.
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Information is also available at:
http://www.health.ny.gov/health_care/medicaid/program/
medicaid_health_homes/docs/2012-0626_draft_hh_patient_tracking_system.pdf
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Health Home Restriction Exception (R/E) codes will
be implemented in mid-2013. These codes will
allow member look-up through eMedNY and other
systems.
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This will be especially valuable to check before
community referrals are made.
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These codes will identify whether a member is
potentially eligible for HH services and, if a
member has been assigned, will identify the name
of the member’s HH.
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 Currently Health Homes and MCPs can only share
the five most recent encounters of HH members.
 Until the portal is developed, DOH will work with
HH and MCPs to see what can be done to improve
the member information provided to network
partners, for both assignments and referrals.
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 New lists will be based on more up-to-date member
eligibility information but eligibility can change.
 Health Homes should verify member eligibility and
assist members on maintaining Medicaid eligibility.
 Often Medicaid coverage is granted retroactively.
However, the decision to provide it retroactively is up
to the county of residence.
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DOH is developing guidance on leveraging existing
strategies for assisting clients with spend down.
• New strategies are being explored, focused on
maintaining eligibility for spend down members.
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Health Homes should work closely with their Local
Government Unit (LGU)
• It will still be necessary to work with members on an
individual basis to maintain eligibility.
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 New lists for Phase 1 and the first set of lists for Phase
2 are being finalized and were just released.
 Members may also be assigned to HHs by network
partners through community referrals.
See Medicaid Update November Special Edition:
http://www.health.ny.gov/health_care/medicaid/program/
update/2012/nov12sped.pdf
 Community referrals can be transmitted to the lead
HH through the member tracking system.
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 TCMs/MATS make assignments for their members
 For members previously enrolled in TCM, MATS
and CIDP programs, the member can choose which
care manager they want as their HH care manager
 For members of a plan that are not contracted
with the TCMs/MATS HH; the lead HH should
contact the member’s plan to initiate contract
discussions
• When a contract cannot be agreed upon, the member can
either choose a different HH or different plan
• The best option is for the HH and Plan to have a contract
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 As part of the States 1115 waiver, the Health Home
development fund requested funds for a public education
campaign to make it easier for outreach partners to engage
with potential HH members.
 Resources to assist with outreach will be made available on
the Partner Resources section of the HH website.
 The State is finalizing a letter HHs can use as part of their
engagement materials that explains the Health Home
program.
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Center for Health Care Strategies (CHCS) with support
from the New York Health Foundation is looking into
launching an online community,
 Designed to build on the Learning Collaborative.
 Will provide a forum for online peer-to-peer exchange,
between in-person Learning Collaborative meetings.
 Will allow HH network care management partners to share
best practices.
 A demonstration of the site’s features and functionality will
occur soon.
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Outreach and Engagement
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HHs have three months to engage members; if
after three months a member is not found or
cannot be engaged in active care management the
member cannot be billed for;
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HHs may decide to continue to try and engage a
member during this non-billable period at their
discretion. Network partners and lead HHs
agencies should discuss process.
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Health Home Services
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All clients who meet HH eligibility criteria can receive HH
services regardless of the level of service intensity.
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HHs are building capacity so members can be prioritized using
acuity scores.
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Health Homes who determine a member no longer needs HH
services should discuss, with the member, the option of having
their care management handled by a PCP and/or PCMH as
appropriate.
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It is the clients choice to opt out or disenroll from a HH. At the
time the client opts out or disenrolls, they should be informed
of options to join other HHs and told they may return to their
original HH at any time.
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Health Home Services
 If a member moves out of a county or borough, HH may
continue to provide HH services to the member, if
practicable.
 If the member’s relocation makes it impractical for the HH to
continue to provide services, the HH is responsible for
transferring the member’s assignment to a HH of the
member’s choice.
 HHs are responsible for linking members to all the physical,
behavioral, and social support services a member may need,
including vocational and housing supports. These resources
should be included in the HH network and made available.
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 Acuity scores will be recalculated quarterly based on
updated claims and encounter data.
 HHs and care management partners may not adjust
acuity scores but the member’s FACT-GP scores, as
well as other factors, will be used to adjust an
individual’s acuity score on a prospective basis.
 HHs will be able to download the acuity scores from
the OHIP Data Portal in the near future to share with
network partners.
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 Claims for members with no established acuity
score will be set to “pend” status.
 DOH will receive notification of the pended claims
and will then submit an average acuity score for
that member to the payment system.
 There will be a delay in payment, but the acuity
score will trigger payment of the pended claim.
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 Converting care management partners can bill up to
the level of their approved legacy slots at the legacy
rate, and bill for additional or expansion slots at the
HH rate.
 New clients can be billed at either the legacy rate or
the HH rate, provided the total number of approved
legacy slots is not exceeded.
 Clients in a MATS legacy slot must have an SUD
diagnosis
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 Legacy rates have been extended another year to
allow converting care management partners time to
transition to HH services by the end of the second
year.
 DOH will monitor funding levels and make an
assessment as to when legacy rates will convert to a
blended or HH rate.
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The HH rates were calculated to allow 6% for
administrative costs, to be split between HHs and
MCPs. A larger percentage is justified only if HHs
and/or MCPs are providing additional support or
services. Network partners should be asking for
justification for any additional amount.
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TCMs/MATS bill directly and some have negotiated an
administrative contribution. DOH is working on ways to
provide administrative support directly to MCPs and
TCMs/MATS and will be conducting a survey to
determine the extent to which these arrangements
have been negotiated.
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Providers that have already have Phase 1 rates loaded
can bill for Phase 2. Phase 2 only providers will have to
wait until rates are loaded to bill for Phase 2.
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It is now anticipated that converting TCM claims will
be reprocessed in early 2013.
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A client can be referred to a HH based on a
presumptive assessment. If the assessment reveals
that the individual does not meet HH criteria,
outreach and assessment can be billed for that month.
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Questions?
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Visit the Health Home website:
http://www.health.ny.gov/health_care/medicaid/program/
medicaid_health_homes/
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Get updates from the Health Homes listserv. To subscribe
send an email to: [email protected].
 In the body of the message, type SUBSCRIBE HHOMES-L YourFirstName
YourLastName
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Email questions or comments: [email protected]
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Call the Health Home Provider Support Line: 518-473-8864
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