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Managed Care

Managed Care Organization (MCO) Roles & Responsibilities

  1. MCO's contracting with NYSDOH designated Health Homes to provide Health Home services must utilize and sign a contract (Administrative Health Home Services Agreement) with the Health Home.
  2. MCO's assign members to NYSDOH designated Health Homes based on Health Home eligibility lists received from NYSDOH utilizing loyalty and attribution data as augmented by MCO data.
  3. MCOs will bill Health Home services through eMedNY using the MCO's MMIS identification number using Health Home rates
  4. MCOs can retain up to three percent (not to exceed amount established in the Administrative Health Home Services Agreement) of the Health Home fee and pass the rest through to the Health Home unless additional services have been negotiated.
  5. MCO's will continue to provide all in-plan services for Health Home members but will contract with Health Homes to coordinate services including in-plan and Medicaid fee-for-service benefits.
  6. MCO's and Health Homes share responsibility for outcomes for patients that are assigned to Health Homes
  7. MCO's will share member PHI with the Health Home that provides services. Guidance for sharing information prior to member consent can be found here.
  8. MCO's with members currently in OMH and AIDS/HIV COBRA, MATS and CIDP targeted case management (TCM) converting programs will follow special guidance below for these individuals.
    • MCO's do not assign existing TCM patients to Health Homes, converting TCM programs assign their members to the Health Home that will best meet the member's needs and preserve the care management relationship.
    • MCO's will work with Health Homes on behalf of members in existing TCM slots to coordinate care and share data.
  9. Health Homes must utilize the MCOs contracted provider network for services that are included in the MCO's benefit package when arranging/coordinating care for Health Home members. MCOs may opt to expand provider networks based on Health Home member needs.

Health Home and Managed Care Organization Contracting

There are three options available for Health Homes to enter into Administrative Health Home Services Agreements with Managed Care Organizations (MCOs):

  1. MCOs may develop plan-specific agreements with Health Homes for Health Home services. Plan specific agreements must include the Key Contract Provisions that were developed collaboratively between the MCOs, Health Homes and NYSDOH. The MCO must submit the plan specific agreement to the NYSDOH Division of Health Plan Contracting and Oversight, Bureau of Managed Care Certification and Surveillance for review and approval. Once the MCO has an Approved Agreement for Health Home services on file with the Bureau of Managed Care Certification and Surveillance, the MCO and Health Home can use that as a template to negotiate mutually acceptable agreements/contracts. Changes may be made to the Approved Agreement, but the amended agreement must be submitted once again by the MCO to the Bureau of Managed Care Certification and Surveillance for final approval.
  2. If the MCO does not have a plan specific Approved Agreement on file with the Bureau of Managed Care Certification and Surveillance, or if the Health Home and MCO are unable to negotiate a mutually acceptable agreement/contract using the Approved Agreement, the Standard Health Home Administrative Services Agreement can be used. The signed agreement must be submitted by the MCO to the Bureau of Managed Care Certification and Surveillance for review and approval.
  3. If the MCO and Health Home modify the Standard Agreement, the modified Standard Agreement must be submitted by the MCO to the Bureau of Managed Care Certification and Surveillance for review and approval. When approved it becomes a plan specific Approved Agreement on file for that MCO.

    NOTE:

    • When submitting agreements for review and approval the MCO must include a completed and signed Health Home Statement and Certification form (DOH-5060).
    • The Standard Agreement may not be modified to include care manager requirements, credentialing requirements, the reporting of data beyond what is required by the Health Home or other similar additions.
    • The MCO agreement/contract that is being agreed upon with the Health Home (using any of the three methods outlined above) is NOT considered a Provider Agreement. It is an Administrative Health Home Services Agreement.

Managed Care Information

Health Home and Managed Long Term Care (MLTC) Plan Administrative Services Agreements

An Administrative Services Agreement (ASA) template has been developed for Health Homes and MLTC Plans to delineate their respective care management roles when both are serving recipients, to ensure that services are not duplicated. The Department has released this ASA template for Statewide use along with additional guidance and a suggested care planning tool that can be used to more clearly define the roles of the Health Home care manager and the MLTC Plan care coordinator.

Revised Managed Care Questions and Answers for Health Home

Revised 1. Is there managed care related eligibility information available, similar to the information provided by county for FFS Health Home eligible recipients?

Currently, there is no Managed Care Health Home recipient eligibility information available, but this information may be posted in the future.

Revised 2. Is it still the expectation that MCOs participating in the Health Home program align themselves (contract with) a RHIO as a condition of the Health Home program within the next 18 months? Or, is it the requirement for the Provider Lead Health Homes to obtain a contract with a RHIO?

There has never been a requirement for MCO's to work with RHIOs. Provider Led Health Homes and their partners have 18 months to meet final HIT requirements which include working with a RHIO/qualified entity (QE).

Revised 3. If individuals are to have choice of both Health Homes and MCOs in their area, are Health Homes required to be a network provider with ALL Medicaid Managed Care Providers in their community?

There is no requirement that MCOs contract with all Health Homes or vice versa. The State is obligated to provide members with a choice of Health Homes as practicable which is being accomplished by designating more than one Health Home in each region. In addition, members have a choice of care managers in their Health Home.

Revised 4. Will the Health Homes be receiving contact information on who we should be reaching out to at the MCO plans, once we are ready to begin receiving rosters? OR is the expectation that the plans have to initiate outreach to us?

Health Homes should contact Plans when ready to pursue contracts to work with their members. A list of contacts for each of the MCOs is posted on the Health Home website. A list identifying the counties that each MCO offers services in is also posted on the web.

Revised 5. Is NYS revising some of the financing structures for Health Homes? Are the following accurate?

  • a. MCO's will get a separate payment so no money will be taken from the Health Home rate.
  • b. There will be an additional Health Home administrative rate added, intended for Lead Health Home payment with a 3% cap, with the result that 100% of the initial rates DOH has published for Health Home services will go to the Care Management Agency.

As of now there is no change in how MCOs will receive support for administrative services. DOH is in discussions with CMS to add administrative support to the Plan capitation rate for the support of Health Homes. If that is approved our billing guidelines and instructions will be revised.

Questions or comments: medicaid@health.ny.gov

Revised: February 2014