Medicaid Health Homes (HH) for Individuals with Chronic Conditions
Health Plan Roles and Responsibilities - Draft 9/29/11
- Health homes will be a new State Plan service that plans must make available to enrolled members that are qualified/identified.
- Plans may operate HH services directly (as a lead applicant) or may provide health home services through contract (not as a lead applicant) or may deliver health homes through a blend of contracted and in house services (as a lead applicant).
- Plans contracting for HH services must utilize state approved HHs in their networks and have signed contracts that establish responsibilities and address payment.
- Plans assign patients to State approved HHs based on HH enrollee lists received from the State and by utilizing State loyalty and attribution data as augmented by the plan's own data.
- Plans will bill HH services thru eMedNY using an NPI and State developed HH rate(s).
- Plans will pay HH contractors proportional to the total HH care management effort provided by the HH.
- Plans will continue to manage all in-plan services for health home members but may contract with health home care managers to assist in carrying out that function under plan direction.
- Plans are responsible for HH outcomes for patients that are assigned to health homes by the plan.
- Plans will, when properly consented, share enrollee PHI with the Health Home that provides services to their enrollees.
- Plans will assist all Health Home providers in their network with coordinating access to data.
- Plans, when operating as a lead HH applicant, will report required care management and patient experience of care data (with State assistance).
- Plans will distribute any gainsharing dollars with Health Homes proportional to total care management effort provided by the Health Home to the enrollee. More gainsharing guidance is forthcoming.
- Plans with enrollees currently in OMH and AIDS/HIV COBRA Targeted Case Management converted Health Homes will follow special rules2 for their TCM enrollees.
- a) Plans do not assign existing TCM patients into Care Management – existing TCM patients and slots will be managed by State and County for two years. (40K out of 715K HH eligibles (6 percent) are in TCM programs)
- b) Plans will work with TCM programs on behalf of members in existing TCM slots to coordinate care and share data but Plans are not held responsible for HH/TCM payment or health home quality outcomes.
- c) Plans may chose to assign new HH patients to TCM programs (under contract) that are converted to HH status if this converted TCM/HH provider has HH capacity above their state approved TCM slots. If a Plan contracts with a converted TCM/HH provider to deliver HH services all of the above requirements apply (except that the converted TCM/HH will bill eMedNY directly for the HH services).
- Plans must obtain an NPI (national provider ID) and enroll in Medicaid to bill for HH services.
- Health Homes must utilize a plan's contracted network of providers for services that are included in the plan's benefit package when arranging care for health home members. Plans may opt to expand provider networks based on health home member need.
- 1. Exceptions to these rules are described in the following charts
- 2. See chart II