Draft Managed Care Enrollee in Need of HH – Plan Roles and Responsibilities
Year One Targeted Case Management Conversion Logic
Chart II
September 29, 2011
| TCM Agency (A) Targeted Case Management (TCM) Provider Converts to Health Home as Lead or Partner (Total HH Capacity X+Y) |
Health Home (HH)Topic | TCM Agency (B Targeted Case Management (TCM) Provider Does Not Convert to Health Home (Total TCM Capacity Z) |
|
|---|---|---|---|
| Agency A: Current Number of (TCM Slots: X) |
Agency A: (New HH Capacity: Y) (under contract with Health Plan for MC enrollees) |
Agency B: Current Number of TCM Slots: Z |
|
| Yes | Yes | Health Home Standards | No |
| TCM Rate | Health Home Rate | Payment Amount | TCM Rate |
| Agency A1 | Health Plan | Slot Management1/Patient Assignment | Agency B2 |
| 90% | 90% | Percentage of Federal Financial Participation | 50% |
| Agency A will report to State and to health plan. | Agency A will report to State (if lead applicant) and to health plan. | Quality Reporting Measures and Evaluation | N/A (subject to existing TCM standards) |
| Agency A | Responsibility shared by Agency A and the health plan. | Outcome Accountability | N/A (subject to existing TCM standards) |
| Agency A bills eMedNY3,4 | Agency A bills eMedNY with plan approval3,4 | Claiming | Agency B bills eMedNY |
Footnotes
- 1. With County input for OMH and with HH network input as appropriate for both COBRA and OMH.
- 2. With County input for OMH.
- 3. Fee-For-Service and Managed Care patients
- 4. Agency A must track slots and bill the appropriate rate - in the case of patient health home assignment from a plan, Agency A must retain approval from the plan in order to support the fee for service claim.
