Health Home Q&As


1. What is the difference between Medical Homes and Health Homes?

The Patient-Centered Medical Home (PCMH) is a model for care, provided by physician-led practices, that seeks to strengthen the physician-patient relationship by replacing episodic care based on illnesses and individual's complaints with coordinated care for all life stages, acute, chronic, preventive, and end of life, and a long-term therapeutic relationship. The physician-led care team is responsible for coordinating all of the individual's health care needs, and arranges for appropriate care with other qualified physicians and support services.

The health home model of service delivery expands on the traditional medical home model to build linkages to other community and social supports, and to enhance coordination of medical and behavioral health care, with the main focus on the needs of persons with multiple chronic illnesses.

The State Medicaid Director's Letter (SMDL#10-024) provides a background and evolution of medical homes and health homes and can be accessed at

Health Home Applications

1. What is the envisioned timeline and activities for this conversation/effort?

Health Homes will be implemented October 1, 2011. Details regarding the timeframe and activities for implementation can be found on the Health Home website at (XLS, 836KB). Search for MRT project #89.

2. When will the Health Home provider application be available?

The Health Home Provider application became available on 8/2/11 and can be accessed on our Health Home website at

3. To what extent is the application for health homes being widely distributed to all qualified entities? Or is it being targeted primarily to convert existing TCM providers?

The availability of the application process was announced via the Health Home listserv which includes a wide variety of stakeholders and interested parties. If you wish to be included on the Health Home listserv, contact us at TCMs are strongly encouraged to apply, but are not the primary target of Health Home applications.

4. Can applications be submitted at any time?

No. Applications can be submitted until September 1, 2011. Additional application dates will be announced in the future based on need.

5. What will the HH application/attestation look like/entail?

The Health Home application includes general demographic questions regarding the applicant, specific questions about the applicants' network, and the ability of the applicant to meet the Health Home Provider Qualification standards. (PDF, 44KB, 6pg.)

6. How many HH applications will be accepted per city? Per region?

  • a. How is this being determined?
  • b. By patient to provider ratio?
  • c. Geographic region?

Currently, there is no restriction on the number of Health Home applications being accepted as long as they are submitted by September 1, 2011. However, applicants are reminded that priority will be given to applications that demonstrate strong and extensive community based organizations and direct service provider networks. In addition, potential Health Home providers will be required to specify their patient enrollment capacity. As determined by the State, additional application dates may be announced in the future.

7. During the transitional period, what kind of technical support will be provided?

The State will provide technical assistance for Health Home providers and interested parties that will include webinars, learning collaboratives, and written guidance documents. The State plans to maintain a highly collaborative working relationship with health home providers through frequent communication and feedback.

8. Is there workforce training funding available to ensure behavioral health case managers are capable of understanding the health care coordination mandates under Health Homes?


9. Is it possible to have a rolling implementation of the model Upstate?

The State determined to implement Statewide to take full advantage of enhanced (90%) federal financial participation.

10. Will community based providers have to link with a single medical provider for an application or will separate applications be required for each partnership?

We expect applications to include multiple direct care providers, community based organizations, and health plans. If a community based provider plans to become a Health Home, they must link with a wide variety of medical, behavioral and social services providers within their network to meet the Health Home Provider Qualification standards. If community based providers wish to be included in a Health Home network, they should contact providers in their community regarding their availability and willingness to become a network provider.

11. Can a local governmental unit as defined in Article 41 of Mental Hygiene Law (e.g., County Mental Health Department) be a health home provider?

Any Medicaid enrolled provider that meets the Health Home Provider Qualification standards can apply to become a Health Home.

12. Is the health home program to be limited to Medicaid HMOs?


13. How prepared are the larger hospitals or managed care companies to respond to the application?

It is expected that larger hospitals and managed care companies that develop strong links with their community providers will likely be prepared to apply.

14. If an FQHC or other provider is otherwise suited to be a health home, but cannot meet the guidelines due to hospitals' inability or unwillingness to share information on ER and admissions to achieve prompt notification of an individual's admission and/or discharge to/from an emergency room, inpatient, or residential/rehabilitation setting, will the hospital be required to share that information?

No. However, the State expects hospitals to partner with community organizations and is interested in hearing from potential applicants about their challenges and obstacles in meeting Health Home requirements and is willing to assist, as feasible, in resolving these issues. In addition, community based organizations should also seek to partner with managed care plans to meet the qualifications and standards.

15. Could certain health homes be designated to enroll children and demonstrate a robust and separate sub-network for children behavioral health services as opposed to each network exhibiting some minimal capacity to serve children with severe emotional disturbances?

No. Health Homes must be able to provide comprehensive, coordinated, and integrated health home services to both adults and children based on their enrollees' medical, behavioral and social needs. Health Homes are expected to seek out and include providers within their network that provide specialty services. However, we expect that some Health Homes may have experience in serving specialized providers.

16. Will there be different implementation expectations/timeline for upstate vs. downstate?


17. Do you have any further information on becoming a Health Home?

The Department's Health Home website is the source of information about New York's Health Home and is frequently updated with new information. We recommend that interested parties visit the website on a regular basis for updated information.

18. How supportive is your department of a health home being in an article 31 vs. article 28?

The Department is very interested in and supportive of receiving applications from a variety of Medicaid enrolled providers including Article 31 providers.

19. What will be the staff qualifications for the Care Managers under this initiative? And what will be the qualifications of the supervisory structure?

The Health Home applicant will determine the supervisory structure and job description of their care manager positions, including professional discipline (if applicable), along with relevant education, training and experience in their Health Home Provider application.

20. Can multiple health care practitioners get together to establish a HH?


21. Can a Health Home have more than one Managed Care Organization in its network?


22. Does the fact that "the NYS Medicaid program plans to certify health homes that build on "current provider partnerships" mean that most or all of the certified health homes will be existing Medicaid or other managed care plans? If not, what other "current provider partnerships" qualify for health home certification?

No. "Current provider partnerships" is a term that the Department uses to recognize he many formal and informal relationships that presently exist in communities that provide medical, behavioral and social services to the Medicaid population. It is expected that potential health home providers will use these existing relationships to develop their health home networks.

23. Do these current provider partnerships include the full range of health home services across primary care, behavioral health care (both substance abuse and mental health) and both adult and pediatric care?

They may. However, all health home applicants will be held to the same Health Home Provider Qualification Standards in terms of demonstrating strong and extensive medical, behavioral health, and social service networks to meet the needs of their Health Home enrollees.

24. Does the requirement for current partnerships preclude the development of new provider partnerships to form health homes?


25. Are the non-TCM providers being required or encouraged (mandated) to utilize the existing network of effective community based providers who can do the care coordination?

The Department is encouraging, but not mandating, potential Health Home applicants to make full use of community resources as they develop their Health Home networks.

26. Will there be room for small providers that typically cannot compete with large healthcare structures but were able to serve a niche population well?

Yes. Health Homes must have a full array of medical, behavioral, and social services providers within their network. Therefore, small providers that cannot meet the Health Home Provider Qualification standards but still wish to serve niche populations are encouraged to contact providers within their community regarding their interest in becoming part of a Health Home network.

27. Could Health Homes contract with LHCSAs, waiver providers, and other entities for Comprehensive Care Management or must this service be provided directly by the Health Home.

Yes. Health Homes can subcontract for the provision of health home services, including comprehensive care management. However, the Health Home provider remains responsible for all health home program requirements, including the services performed by the subcontractor.

28. Can you give us some help with what type of formal agreement/supporting documentation will be needed from the hospitals with us:

  • a. what will the linkage requirements need to state- what is the language
  • b. what specifically will the hospitals need to agree to do/what will we specifically need to do for them.

The Department is not providing specific contract language regarding the relationship between the Health Homes and its network providers. The Health Home is responsible for developing and executing theses contracts. At a minimum, the contracts will need to address the terms of participation, minimum time frames for access to services, provision of crisis intervention and responsibility of each provider.

29. What is the NYS definition of "prompt notification" of an enrollee's admission and discharge?

The Department is not defining prompt notification. The Health Home applicants will define the specific process and time frames they plan to use to assure prompt notification of emergency and inpatient facility admissions/discharges.

30. Where do peer advocates fit in?

Health Homes are encouraged to utilize peers as part of their multidisciplinary team, especially with activities relating to patient and family support and utilization of community and social support services.

Application-Targeted Case Management (TCM)

1. Will all existing children's Blended Case Management, Intensive Case Management and Supportive Case Management providers remain outside the Health Home process initially (first year)?

No. Targeted case management programs can apply to become Health Homes during the first phase of Health Home applications. However, different payment rules will apply for Health Home enrollees that were TCM clients and a new Health Home enrollee.

2. Will children's case management providers have the option to convert to Health Homes?

Yes, contingent on their meeting the Health Home Provider Qualification standards.

3. If some of the kids served by a single provider are enrolled into health homes and some remain in case management services do the services have to be "blind" to the distinction.

A TCM that converts to a Health Home will provide health home services to all of their enrollees, including those that were previously in the TCM prior to conversion.

4. It appears that all TCM slots will be converted to Health Homes. Will only agencies with existing TCM program be allowed to convert to the Health Home or will agencies without a present TCM program be allowed to respond?

Although many TCM programs will convert to Health Homes this year with more to follow next year, agencies without a TCM can partner with other community and direct care providers to apply to become Health Homes.

5. What is the rationale for including targeted case management in the list of providers that are able to convert to health homes?

Targeted case management programs are uniquely positioned to convert to Health Home because they have a wealth of experience in providing comprehensive case management and extensive community supports to help meet the extensive and complex needs of their clients.

6. In order to continue to provide TCM services, we would need to contract or join a health home entity (HH). Can we join a major hospital/mental health psych as well as other chronic illnesses, HIV/AIDS specialties etc? How would this work theoretically and practically?

Yes. TCM providers are encouraged to contact providers within their community regarding their interest in becoming part of a Health Home network. TCMs may also apply to become Health Homes.

Application-Other Experience

1. How will the implementation of health homes take into account the potential to leverage the work that is already being done with the chronically ill population by community behavioral health providers, supportive housing providers, and health care for the homeless providers?

The State has actively sought and used the advice and suggestions from experienced community medical, behavioral, and social services providers in developing Health Home requirements; most important of which is that Health Homes must develop strong community connections to meet the complex needs of health home enrollees. The work that is already being done to serve the needs of chronically ill individuals is a strong foundation for Health Homes, which requires the coordination of medical, behavior, and social services providers and community resources.

In addition, to support existing client/provider relationships and to the extent possible, eligible enrollees will be enrolled in Health Homes based on their existing relationships with a Health Home or the Health Home's network of providers, or if no relationship exists, with a Health Home that provides services within the enrollee's community.

What has DOH learned from the CIDP (Chronic Illness Demonstration Project) process that is relevant to the creation of health homes? What has worked well with CIDP? What has not worked so well?

The Department considered the experience of the CIDP to help develop Health Home requirements. The most significant issues arose with CIDP outreach and active enrollment. For example, the upfront cost of conducting outreach activities was higher than expected. Also, by the time Medicaid enrollees were located, some had lost their eligibility or were enrolled in managed care plans (CIDP enrollees were excluded from managed care). In addition, due to the complexity of the enrollee's needs and their functional status, it was difficult to interest and engage this population regarding the benefits of the CIDP as they struggle with life issues. This highlighted the importance of strong community supports, especially related to housing and peer services, specialty services, and access to timely post discharge services.

The Health Home program requirements address many of these issues. For example, the Health Home payment methodology will acknowledge the costs associated with outreach and engagement activities by providing an outreach rate that provides reimbursement for up to three months of outreach activities. Payment will be made prospectively. Medicaid eligibility will be guaranteed for 6 months and managed care enrollees are included in the Health Home program. Medicaid enrollees will be assigned to a health home provider based, to the extent possible, on existing relationships with health care providers or health care system relationships, geography, and/or qualifying condition. Once assigned, enrollees will be given the option to choose another provider when available, or opt out of health home enrollment. In addition, pending federal approval, enrollment in the Health Home will be mandatory with opt out provisions.

The Department also recognizes the value of peer supports and the need for housing and strongly encourages Health Homes to engage peer supports and housing providers within their networks. As part of the provider qualifications, the Department is requiring Health Homes to address transition issues including timely access to post discharge services and networks that include specialty services. The Department will also develop a shared savings model, a feature in the CIDP, as a means to encourage health home providers toward continuous improvements in reducing avoidable hospital and emergency room costs and improving patient outcomes.

Patient Enrollment

1. What requirements/systems will be in place for notification to health homes when clients present in emergency rooms and inpatient settings, especially in situations where the emergency room/inpatient setting is not part of the Health Home?

The process that will be used to assure notification will be defined by each health home at the time of application.

2. Will there be a unique patient identifier to inform providers about a patient's health home?

Yes, but the identifier may not be available when the program is implemented. Once the identifier is available, the provider will be able to check the enrollee's Medicaid eligibility and their participation in a health home including the identification of their specific health home.


1. Will the State provide real-time access to EMEDNY/MMIS for tracking purposes?

At this time, there are no plans for real-time access to these systems.

Health Information Technology

1. Where can I find more information about the HEAL Projects and the Statewide Policy Guidance?

The information can be found at the NY DOH OHITT website, Health Information Technology.

2. Which domains of HIT will be monitored?

Applicants will need to attest to participation in a RHIO/Qualified Entity, exchange of interoperable clinical information, certified EHRs, clinical decision support, and following statewide policy guidance for interoperable HIE by 18 months of program initiation.

3. Will Health Home reimbursement include administrative overhead to help support the costs associated with interface and building of robust systems?


4. What computerized system will be used to enhance communication amongst our providers and PCP offices and how will that be paid for?

There is no 'common' computerized system in NY. There is the SHIN-NY (Statewide Health Information Network for New York) which is an open source network for sharing information across disparate systems. Projects will be required to fund connectivity and interoperability for patient information.

5. How will the State support more comprehensive integration of the RHIOs into this effort?

The RHIOs are integral to efficient and timely sharing of health information. The DOH has discussed the health home initiative with the RHIOs and the HEAL Projects. We have encouraged the RHIOs and the HEAL projects to reach out to and work collaboratively with potential health home providers in meeting Health Home HIT requirements.

6. What kind of technical support/assistance will be offered in implementing HIT at all levels?

Health home providers should contact one of the two New York Regional Extension Centers for evaluations and support in implementing HIT. The website for the New York City Regional Extension Center is For support outside the NYC boroughs, the website for the NYeC Regional Extension Center is

7. Will the health home providers be given a list of regional health information organizations (RHIOs)/Qualified Entities (QE)?

Regulations are being developed to certify the Qualified Entities. NYS RHIOs are listed on the following website:

8. How might potential health home providers access and analyze timely patient data over the next 18 months if they operate in regions without operational RHIOs?

RHIOs cover every county in NYS. The RHIOs/Qualified Entities will be looking to work with the health home providers and other stakeholders to increase functionality for data exchange.

9. Is it expected that health home providers will link to MCOs?

Yes, and it is expected that health home providers will leverage HIE and abide by state wide policy guidance in sharing information.

10.Will the State invest in off the shelf software analytic systems that can be shared openly and ramp up implementation faster?

The State is working with NYeC and the RHIOs/Qualified Entities to build core statewide services that will enhance connectivity and analytic systems.

11. What is NYeC and what is their website?

NYeC (pronounced "nice") was founded by health care leaders throughout New York State with support from the New York State Department of Health, as a public-private partnership serving as a focal point for key healthcare stakeholders to build consensus on health information technology (HIT) policy priorities and collaborate on national, state and regional HIT adoption, implementation and optimization initiatives. For more information, visit

12. Please clarify what "as feasible" means in Section VI, 6a-6d.

When initially beginning the projects, we understand that the projects may be predominately paper based, or rely on software systems that do not meet interoperability requirements. Rather than slow down the initiatives, we suggest utilizing and leveraging the HIT/HIE infrastructure in New York where 'feasible', knowing that the projects are committing to meeting the final standards 18 months after project inception.

13. The Initial Standards for HIT call for: a health record system which allows the patient health information and plan of care to be accessible to the interdisciplinary team of providers, "as feasible". Providing that a TCM has established, timely, case conferencing, electronically shares the patient's plan of care with a unique identifier and has a system in place to keep each member of the interdisciplinary team up to date – along with a plan to meet the final standards and a letter of support from our local RHIO, will we meet this initial HIT requirement for Health Home?


14. Can Section VI, 6c be interpreted to mean that using faxing or providing copies as an interim measure before full implementation of 6e-6i is allowable to make the plan of care accessible?


15. In consulting with our RHIO, THINC, their Executive Director stated that EHRs are constructed around clinical visits. She questioned whether our agency, even if we're a Health Home, would need a full EHR or whether we would just need some other type of electronic record keeping that could interface with the RHIO's Health Information Exchange. Can you speak to this?

Those providers giving clinical services will need to maintain a certified EHR that is capable of interfacing with the RHIOs. Other providers where a certified EHR is not available will need to have interfaces to the RHIOs for sharing and obtaining the information.

16. The draft NYS Home SPA… (on page 5 of 23) recognizes that many of the potential health home providers my not yet utilize HIT. It states that these providers will be encouraged to utilize RHIOS or other qualified entities to access patient data. It is expected that health home providers must achieve final HIT standards within 18 months.


17. Beyond the 18 month transition period, what will the route to accessing patient data for clients not receiving care in the provider's own system?

It will be up to the health home provider to connect the disparate information sources, working with a HEAL 10 or HEAL 17 project if available in their area, and to continue to leverage the state's HIE infrastructure.

18. Will it be through the data base of either an HMO or BHO?

An HMO or BHO could provide access to encounter data that would help to support this requirement. In addition, clinical information would be available via the RHIOs/Qualified Entities.

19. Is the patient health record required to be certified as an EMR under the Federal program for reimbursing doctors for adoption of EMR's?

Where certification is available, certified EHRs must be utilized as defined under the Federal Program for adoption and for meeting Meaningful Use.

20. We have an inexpensive telemedicine application with a comprehensive electronic health record that could be adjusted to be a perfect adjunct to the health home program. Would you have any contact information for managed care organizations that are expressing interest in this program?

No. It would be the responsibility of the health home to establish connections with the stakeholders involved in the care/services of the patient.

21.On page 10, Section VI (HIT) : we would need to tighten up a process to meet the guidelines of 6b and it may not be available on day one of certification as a health home. Is that acceptable?


22. Where can I find more information about Health Information Technology (HIT)?

Visit the Department's HIT website at or visit the NYeC at