Session 6
October 10, 2012

Status of Health Home Implementation

Payment updates

Projected Health Home Assignment

Overview of Datamart Portal

Role of LGU and BHOs as Health Home partners

Interim Referral Guidance
2

Bronx: BAHN, HHC,VNS of NY Home
Care, Bronx Lebanon Hospital Ctr.

Brooklyn: Maimonides, Community
Health Care Network, ICL, HHC

Nassau: NS-LIJ, FEGS

Schenectady : VNS of Schenectady
and Saratoga

Northern Region: Adirondack Health
Institute, Inc., Glens Falls Hospital

13 Health Homes designated, HHs,
MCPs and converting CM programs
may bill for Health Home services.

DOH, HH and MCPs developing
operational policies and procedures
and improving the transmission of
Health Home Patient Tracking file
information between NYS DOH and
Health Homes and MCPs through the
DOH OHIP Portal.
3

Monroe : Anthony L. Jordan , Huther Doyle

Erie : Alcohol & Drug Dependency Services, Inc.,
Mental Health Services Erie County -SE Corp V,
Urban Family Practice,

Hudson Valley : Hudson River HealthCare, Inc.,
Open Door Family Medical Ctr. Inc., Institute for
Family Health

Suffolk: FEGS,, Inc, NS-LIJ,
Hudson River HealthCare

Staten Island : Jewish Board of Family &
Children’s Services (JBFCS)

Queens : Community Healthcare Network, HHC,
NS-LIJ with PSCH, JBFCS

Manhattan: Heritage Health & Housing Inc.,
Presbyterian, HHC, St. Luke’s-Roosevelt Hospital
Center, VNS of NY, and JBFCS

21 Health Homes designated, HHs
are in the process of submitting
updated network partner lists,
entering into Data Exchange
Application Agreements (DEAA) with
DOH and executing contracts with
MCPs.

DOH in discussions with CMS re: SPA
approval, HH services cannot be
billed until SPA is approved and rates
are loaded
4

Northern Region : Hudson River HealthCare,
Inc., St. Mary’s Healthcare, Samaritan Hospital,
Adirondack Health Institute, Glens Falls
Hospital, Visiting Nurse Service of Schenectady
& Saratoga Counties,

17 HH designated, DOH is in the final
stages of designating Phase 3 HHs
(pending for Albany, Otsego,
Schoharie, Delaware and Chenango
counties).

Designated Phase 3 HHs are working
on addressing any contingencies
identified in the review of their
applications ,entering into DEAAs and
MCP contracts and formalizing
network partnerships.

DOH in discussions with CMS re: SPA
approval, HH services cannot be
billed until SPA is approved and rates
are loaded .
◦ Central Region: Thomas R. Mitchell,
Onondaga Care Management Services, Inc.,
Upstate Cerebral Palsy, Huther Doyle ,North
Country Children’s Clinic, St. Joseph’s Hospital
Health Center, Catholic Charities of Broome
County, United Health Services Hospitals

Western Region: Mental Health Services Erie
County-Southeast Corp V, Niagara Falls
Memorial Medical Center, Chautauqua County
Dept. of Mental Hygiene
5



The base patient acuity factors are weighted averages
based on total claim costs associated with CRGs for a
Health Home eligible population for a given time
period.
Initial Phase 1 base acuity scores were adjusted
upward for HIV, MHSA and Single SMI illnesses as well
as severity level.
These adjusted acuity scores for Phase 1 HH eligible
individuals have been provided to Phase 1 Health
Homes and Managed Care Plans.
6


In addition to adjusting the acuity scores for Severity
and MHSA/HIV/Single SMI conditions, new weights
include additional upward adjustments for:
 Individuals that are in the Pairs Chronic and Triples
Chronic populations that also have serious mental
illness
 A risk based add-on from the predictive model
(drives dollars to members at higher risk for using
more inpatient services)
The new acuity scores are effective October 1, 2012
and will be made available to health homes and plans
via the OHIP HCS Portal.
7
Revised Payment Rates and Method
 Effective October 1, 2012, Health Home payments will be
based on the new acuity scores and will be member
specific.
 The new acuity scores or “member specific weights” will
be loaded to eMedNY within the next week .
 If an individual does not have an acuity score at the time
a claim is submitted, the claim will go into pend status
for 30 days. A statewide average acuity score (from the
HH assigned population) will be provided to eMedNY so
that the claim will pay.
8
Health Home Base Rates
Rate
Code
Rate Code Description
1386 Health Home Services
1387 Health Home Services - Outreach



Medicaid Rate
Upstate Downstate
$ 18.71 $ 23.27
$ 14.97 $ 18.62
Member Specific Payment Calculation:
member specific acuity x applicable HH base rate
Example: 8.2564 x $23.27 = $192.13
The payment will be automatically calculated when
the claim is submitted to eMedNY by the claims
payment system.
9
Projected Regional Average Health Home Payment Comparison by Base Health Status and Severity of Illness - Pairs Chronic and Triples Chronic
Excludes LTC and OPWDD Populations
Base Health Status
Pairs Chronic
SMI
No
Yes
Pairs Chronic Total
Triples Chronic
No
Yes
Triples Chronic Total
Severity of Eligible
Illness Recipients
Low
39,736
Mid
20,983
High
9,140
Low
12,231
Mid
14,357
High
2,881
99,328
Low
2,562
Mid
7,762
High
6,148
Low
2,519
Mid
4,266
High
1,306
24,563
Average
CRG Acuity
Score (with
Phase I Adj)
2.9200
5.9911
10.4891
5.1901
7.6233
13.0050
5.5171
4.7862
7.2532
11.6339
6.5921
9.1188
13.7219
8.6925
Downstate
Upstate
Ave. Monthly
Average Average Ave. Monthly
Payment Ave. Monthly
CRG
CRG
Payment Ave. Monthly
Average
(based on Paymet (Ave.
Acuity
Acuity
(based on Paymet (Ave.
CRG Acuity Ave. CRG
CRG Acuity
Score
Score
Ave. CRG
CRG Acuity
Score (with Acuity with
with New
%
Eligible
(with
(with
Acuity with
with New
%
NEW Adj) Phase I Adj)
Weights) Increase Recipients Phase I
NEW
Phase I Adj)
Weights) Increase
3.0966
$67.95
$72.06
6.0%
13,270 3.4841 3.6602
$65.19
$68.48
5.1%
7.2789
$139.41
$169.38
21.5%
7,804 6.4872 7.6747
$121.38
$143.59
18.3%
13.8438
$244.08
$322.14
32.0%
3,045 10.8318 13.9366
$202.66
$260.75
28.7%
10.6780
$120.77
$248.48 105.7%
5,244 5.2480 10.5974
$98.19
$198.28
101.9%
15.8052
$177.39
$367.79 107.3%
6,771 7.6472 15.4097
$143.08
$288.32
101.5%
25.4821
$302.63
$592.97
95.9%
1,276 12.8137 24.2513
$239.74
$453.74
89.3%
8.3888
$128.38
$195.21
52.1%
37,410 6.0276 9.1355
$112.78
$170.92
51.6%
4.9587
$111.37
$115.39
3.6%
963 5.2209 5.3808
$97.68
$100.67
3.1%
7.8965
$168.78
$183.75
8.9%
3,053 7.6720 8.2988
$143.54
$155.27
8.2%
13.7811
$270.72
$320.69
18.5%
2,057 12.1024 14.3990
$226.44
$269.40
19.0%
12.5158
$153.40
$291.24
89.9%
747 6.6217 12.4206
$123.89
$232.39
87.6%
17.4123
$212.19
$405.18
90.9%
1,649 9.1996 17.4152
$172.12
$325.84
89.3%
25.2165
$319.31
$586.79
83.8%
530 13.7226 25.0789
$256.75
$469.23
82.8%
12.1102
$202.27
$281.80
39.3%
8,999 8.9715 12.3819
$167.86
$231.66
38.0%
10
Projected Average Health Home Payments by Base Health Status and Severity of Illness
Excludes LTC and OPWDD Populations
Effective October 1, 2012
Base Health Status
Single SMI/SED
SMI
Yes
Single SMI/SED Total
Pairs Chronic
No
Yes
Pairs Chronic Total
Triples Chronic
No
Yes
Triples Chronic Total
HIV/AIDS
No
Yes
HIV/AIDS Total
Grand Total
Severity
of Illness
Low
Mid
High
Low
Mid
High
Low
Mid
High
Low
Mid
High
Low
Mid
High
Low
Mid
High
Low
Mid
High
Eligible
Recipients
15,989
7,261
292
23,542
39,736
20,983
9,140
12,231
14,357
2,881
99,328
2,562
7,762
6,148
2,519
4,266
1,306
24,563
5,997
5,160
1,424
192
3,713
507
16,993
164,426
Downstate
Average
Average
Acuity
Monthly
Eligible
Score
Payment
Recipients
6.6993
$155.89
7,231
9.3623
$217.86
3,621
22.1821
$516.18
68
7.7127
$179.48
10,920
3.0966
$72.06
13,270
7.2789
$169.38
7,804
13.8438
$322.14
3,045
10.6780
$248.48
5,244
15.8052
$367.79
6,771
25.4821
$592.97
1,276
8.3888
$195.21
37,410
4.9587
$115.39
963
7.8965
$183.75
3,053
13.7811
$320.69
2,057
12.5158
$291.24
747
17.4123
$405.18
1,649
25.2165
$586.79
530
12.1102
$281.80
8,999
5.4996
$127.97
752
10.5293
$245.02
815
18.9814
$441.70
160
5.5550
$129.26
36
10.4834
$243.95
450
20.1222
$468.24
65
9.6825
$225.31
2,278
8.9816
$209.00
59,607
Upstate
Average
Acuity
Score
6.6775
9.0329
21.9944
7.5539
3.6602
7.6747
13.9366
10.5974
15.4097
24.2513
9.1355
5.3808
8.2988
14.3990
12.4206
17.4152
25.0789
12.3819
5.4517
9.5101
17.6933
5.5029
9.6692
19.3610
8.9943
9.3305
Average
Monthly
Payment
$124.93
$169.00
$411.52
$141.33
$68.48
$143.59
$260.75
$198.28
$288.32
$453.74
$170.92
$100.67
$155.27
$269.40
$232.39
$325.84
$469.23
$231.66
$102.00
$177.93
$331.04
$102.96
$180.91
$362.24
$168.28
$174.57
11

Additional Phase 1 assignments will include Health
Home eligible individuals with a Composite Score >
125 and individuals with a Predictive Model Risk of >
30%

Additional assignments anticipated to be available late
fall of 2012 via the OHIP HCS Portal instead of
manually.
12

Health Home assignment files will be available once
DEAAs and Portal Functionality is complete.

Assignments will be available via the OHIP HCS Portal

Each Health Home and Managed Care Plan should
have at least one HCS contact to download assignment
files and upload patient tracking files. Test files should
be sent now.
13
Members that are not in converting TCM slots - members with a Composite Score >
125 and members with a Predictive Model Risk > 30%
Phase
FFS *
MMC *
Total
Phase 1
22,781
49,062
71,843
Phase 2
25,790
55,243
81,033
Phase 3
11,639
18,139
29,778
5,404
555
5,959
65,614
122,999
188,613
Unmatched **
sub-total
Members in Converting TCM Slots
Phase
FFS *
MMC *
Total
Phase 1
5,404
7,224
12,628
Phase 2
8,394
7,629
16,023
Phase 3
3,213
2,842
6,055
653
61
714
17,664
17,756
35,420
83,278
140,755
224,033
Unmatched ***
sub-total
Total
* MMC counts are higher as more individuals have moved to MMC.
** Members to be matched to Health Home based on loyalty.
*** Members to be matched to Health Home by Case Management Agency
14
Phase 1 Projected Assignments at Full Implementation (Includes Duals)
Members in Non Converting Slots
COUNTY
FFS
MMC
sub-total
Members in
Converting
TCM Slots
Grand
Total
CLINTON
581
216
797
146
943
ESSEX
147
95
242
47
289
FRANKLIN
315
29
344
122
466
8
12
20
0
20
NASSAU
1,864
4,266
6,130
1,475
7,605
NYC - BRONX
8,836
19,689
28,525
5,221
33,746
10,019
23,255
33,274
5,195
38,469
SCHENECTADY
465
1,141
1,606
254
1,860
WARREN
380
110
490
92
582
WASHINGTON
166
249
415
76
491
Total Phase 1
22,781
49,062
71,843
12,628
84,471
HAMILTON
NYC - BROOKLYN
15
Phase 2 Projected Assignments at Full Implementation (Includes Duals)
COUNTY
DUTCHESS
Members in Non Converting Slots Members in
Converting
FFS
MMC
sub-total TCM Slots
Grand
Total
580
1,076
1,656
834
2,490
ERIE
1,826
5,873
7,699
1,437
9,136
MONROE
1,596
4,302
5,898
1,445
7,343
NYC - MANHATTAN
7,877
11,024
18,901
3,529
22,430
NYC - QUEENS
6,033
15,138
21,171
2,995
24,166
NYC - STATEN ISLAND
1,230
3,281
4,511
803
5,314
ORANGE
891
1,780
2,671
388
3,059
PUTNAM
103
197
300
65
365
ROCKLAND
464
1,121
1,585
313
1,898
2,615
6,055
8,670
2,767
11,437
SULLIVAN
274
616
890
220
1,110
ULSTER
435
974
1,409
125
1,534
WESTCHESTER
1,866
3,806
5,672
1,102
6,774
Total Phase 2
25,790
55,243
81,033
16,023
97,056
SUFFOLK
16
Phase 3 Projected Assignments at Full Implementation (Includes Duals)
Members in Non Converting Slots
COUNTY
FFS
MMC
sub-total
Members in
Converting
TCM Slots
Grand
Total
ALBANY
783
1,973
2,756
397
3,153
ALLEGANY
146
192
338
98
436
BROOME
621
1,082
1,703
324
2,027
CATTARAUGUS
201
537
738
209
947
CAYUGA
312
230
542
98
640
CHAUTAUQUA
339
965
1,304
305
1,609
CHEMUNG
409
439
848
121
969
CHENANGO
309
51
360
58
418
COLUMBIA
165
347
512
78
590
CORTLAND
95
264
359
72
431
DELAWARE
256
48
304
33
337
FULTON
166
450
616
76
692
GENESEE
115
269
384
99
483
GREENE
144
370
514
62
576
HERKIMER
162
289
451
71
522
JEFFERSON
656
36
692
126
818
LEWIS
116
21
137
31
168
LIVINGSTON
109
235
344
70
414
MADISON
195
215
410
85
495
MONTGOMERY
134
429
563
90
653
5,433
8,442
13,875
2,503
16,378
sub-total
17
Phase 3 Projected Assignments at Full Implementation (Includes Duals) (Cont'd)
COUNTY
NIAGARA
ONEIDA
ONONDAGA
ONTARIO
ORLEANS
OSWEGO
OTSEGO
RENSSELAER
SAINT LAWRENCE
SARATOGA
SCHOHARIE
SCHUYLER
SENECA
STEUBEN
TIOGA
TOMPKINS
WAYNE
WYOMING
YATES
Total Phase 3
Members in Non Converting Slots Members in Grand
Converting
FFS
MMC
sub-total TCM Slots
Total
443
1,246
1,689
679
2,368
625
1,444
2,069
565
2,634
1,108
2,436
3,544
695
4,239
163
340
503
161
664
95
240
335
54
389
205
669
874
159
1,033
132
257
389
56
445
383
1,205
1,588
308
1,896
1,004
51
1,055
106
1,161
294
820
1,114
138
1,252
72
77
149
39
188
113
22
135
31
166
72
109
181
57
238
647
90
737
119
856
239
28
267
28
295
198
232
430
148
578
200
297
497
112
609
184
25
209
66
275
29
109
138
31
169
11,639
18,139
29,778
6,055
35,833
18



Currently available to Health Homes and Managed Care Plans
with Health Commerce System Access.
Current Capabilities
o Tracking file submission
o Recipient look-up
 find out member’s HH eligibility, Medicaid eligibility,
HH enrollment, and assigned member’s last 5 claims
o Enrollment record download (“data dump”)
 Creates a file containing all records that a provider
has successfully submitted to the portal
Upcoming Capabilities
o Assignment file download
o Member acuity score file download
o Member claim detail Report
19

Local District Social Services offices (LDSS) and local
government units (LGUs) can be a valuable source of
information to help outreach to and manage care for
assigned members and a referral source for new members.

HH can exchange data with an LDSS or LGU by completing
a DEAA subcontractor packet. The LDSS or LGU should
determine which staff members need to access HH data (in
addition to Medicaid staff who are automatically
permitted access ) These staff members should be listed
on the DEAA, and access to HH member data would be
approved only for these individuals.
20

The State has entered into contracts with five regional
Behavioral Health Organizations (BHOs). The BHOs are
monitoring FFS Medicaid admissions for inpatient
psychiatric care and detox and reviewing discharge
planning.

HHs can execute a Confidentiality Agreement with their
regional BHO and arrange to receive alerts if a member
is admitted for these services. The HH and BHO can
work together on discharge planning and the BHO can
also insure the Health Home is part of the discharge
planning process.
21





Potential members may be referred for Health Home services
Members do not have to be on DOH lists or be approved by DOH
in order to be accepted for Health Home referral. HHs and MCPs
are responsible for determining whether the individual
presumptively meets criteria for referral.
A Health Home and MCP work group is in the process of
developing “rule-in, rule-out” criteria for referrals. Interim
guidance has been developed.
This process will be used to prioritize referrals in the initial phases
of Health Home implementation (to focus initial Health Home
resources to our neediest members). This process will be revisited
when Health Homes are more fully implemented.
There are 3 steps to making a Health Home referral:
22
STEP 1- ASSESS ELIGIBLITY: Must meet eligibility for
Health Home Services as described in the New York State
Health Home State Plan Amendment (claims data should
be used whenever available to verify medical and
psychiatric diagnoses)
◦ Two chronic conditions (e.g., mental health condition, substance
use disorder, asthma, diabetes, heart disease, BMI over 25, or
other chronic conditions, OR
◦ One qualifying chronic condition (HIV/AIDS) and the risk of
developing another, OR
◦ One serious mental illness
23
STEP 2-ASSESS APPROPRIATENESS FOR HEALTH HOME: Has
significant behavioral, medical or social risk factors which can be
modified/ameliorated through care management including any of
the following:
◦ Probable clinical risk for adverse event, e.g., death, disability,
inpatient or nursing home admission
◦ Lack of or inadequate social/family/housing support
◦ Lack of or inadequate connectivity with healthcare system
◦ Non-adherence to treatments or medication(s) or difficulty
managing medications
◦ Recent release from incarceration or psychiatric hospitalization
◦ Deficits in activities of daily living such as dressing, eating, etc
◦ Learning or cognition issues
24
STEP 3 -INITIATE REFERRAL: If member meets criteria described in Steps
1-2, the referral can be made on the basis of this presumptive
assessment.
◦ Referrals for FFS members are made to the lead HH, referrals for plan
members can directly to the MCP or to the lead HH to make the MCP
connection.
◦ HHs and plans have access to assignment information in the HCS
portal and should check an individual’s assignment status prior to
making a referral.
◦ If the individual is already assigned to a Health Home, that Health
Home should be contacted to discuss the appropriate course of action.
(Additional factors which will quantify criteria in Step 2 are under
development by the clinical workgroup-see next slide)
25
Developing Step (coming soon) - QUANTIFY RISK/ACUITY:
Has a history of poor connectivity to care, including but not limited
to:








No primary care practitioner (PCP)
No connection to specialty doctor or other practitioner
Poor compliance (does not keep appointments, etc)
Inappropriate ED use
Repeated recent hospitalization for preventable conditions either
medical or psychiatric
Recent release from incarceration
Cannot be effectively treated in an appropriately resourced
patient centered medical home
Homelessness
26
NOTE

If a comprehensive assessment subsequently reveals that the
individual does not meet Health Home services criteria, the
individual must be transitioned to an appropriate level of care,
such as a Patient Centered Medical Home (PCMH).

Referral process for converting TCM programs may differ, e.g.,
OMH TCM programs and services must be made in consultation
with the LGU Single Point of Access (SPOA).

Detailed instructions on how to use the Health Home Member
Tracking System to make a referral can be found in the Health
Home Member Tracking System specifications document.
27
•
Member Tracking System Specifications Document:
http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/2012-0626_draft_hh_patient_tracking_system.pdf
•
Document explaining Tracking System version updates:
http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/summary_updat
es_hh_patient_tracking_system.pdf
•
•
April Medicaid Update Special Edition (watch for an article in
the October Edition):
Health Home Website:
http://www.health.ny.gov/health_care/medicaid/program/update/2012/april12muspec.pdf
http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/
•
Member Assignment, Tracking System, Billing and Rates
section of Health Home website:
http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/rate_information.htm
28

Discussion with CMS re: SPAs

Final recommendations re: referrals from Plans and
Health Homes clinical workgroup

Working towards assigning children and duals to
Health Homes
29
Questions can also be submitted to the Health Home
mailbox ([email protected]) with the subject
line “Questions Health Home Webinar #6”
30