Questions and Answers

Table of Contents


1. What is the difference between a Patient Centered Medical Home and a Health Home?

The Patient-Centered Medical Home (PCMH) is a model for care management 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 Patient Centered Medical Homes and Health Homes and can be accessed at

2. How were Health Homes implemented?

Implementation was phased in. Phase in information can be found at

3. Does the Health Home program include long term care services?

Health Homes are responsible for assuring that their members receive all necessary services, including long term care. However, members needing substantial long term care services, i.e., greater than 120 days may need to be transitioned into other LTC management programs e.g., Managed Long Term Care (MLTC) Plans. Members in need of long term care services greater than 120 days are not being prioritized for enrollment into Health Homes under this State Plan Amendment (SPA), however a process for individuals in MLTC Plans to be enrolled in Health Homes is being developed and guidance will be provided.

4. Will NYS make Health Homes mandatory for Medicaid recipients?

No, not at this time.

5. What is the role of OMH and NYCDOHMH in ensuring that providers, including former OMH TCM providers, have a connection to a health home?

The State (DOH, OMH, and OASAS) along with NYCDOHMH, participated in the review of Health Home Letters of Intent (LOIs) and applications. This review ensured that TCMs are either the lead, or part of, Health Homes.

6. How will DOH adjust members' acuity scores based on members' evolving needs?

Acuity scores will be adjusted periodically based on claims and encounter data. Health Homes can access the member's acuity score through the Health Home Member Tracking System and should be sharing this information with network care management partners. The Department will monitor changes in acuity on an ongoing basis. Determining the care management needs of a member is the responsibility of the care manager working together with the interdisciplinary Health Home team.

7. Will the Health Home be responsible for coordinating all transportation needs?

Yes. For Medicaid fee-for-service Health Home members, Medicaid contracts with transportation vendors in most counties. This is being done on a phase in schedule by county. Please visit the website below to find out if transportation has been phased in using a transportation vendor.

For Medicaid Managed Care Health Home members there is also a phase in schedule. Transportation is being carved out of the managed care benefit package and being covered by Medicaid fee-for-service using a transportation vendor. Please contact the managed care plan to find out if transportation is covered by the plan or covered by fee-for-service.

Eventually all transportation will be covered by Medicaid fee-for-service. Once the phase in schedule is complete the Health Homes will be notified.

8. Will there be any particular identification or process established for linking persons who were previously High Cost as they transition from jail/prison and how will risk issues be assessed and incorporated into prioritizing access to services?

A workgroup has been formed to examine best practices for linking individuals to Health Homes from the criminal justice system. More information can be found at we expect that Health Homes will partner with the corrections systems in their communities to establish smooth transitions.

9. How will the issue of the high costs of homelessness be addressed where there is insufficient housing capacity?

The State is actively taking steps to increase housing capacity through the work of the Medicaid Redesign Team (MRT) Affordable Housing Workgroup. Information about these activities can be found at or It will be important for Health Homes to partner with both shelters and supportive housing providers to help navigate the local challenges, leverage opportunities and be part of local efforts to improve access to housing.

10. What is required for the State to share lists of Health Home candidates with Managed Care Plans and Health Homes?

A Data Exchange Application and Agreement (DEAA) must be approved and access to the Health Commerce System must be obtained before any Medicaid Confidential Data (MCD) can be exchanged. Information on DEAAs can be found at

Caryl Shakshober, MS, Privacy Coordinator
New York State Department of Health
Office of Health Insurance Programs
Division of Program Development & Management
Corning Tower (OCP 720)
Albany, NY 12237

11. Can providers be part of more than one Health Home network?

Yes. It is possible for a provider to join more than one Health Home network.

12. What will be the methodology for care management partners in the Health Home to bill for care management services and will contracts need to be developed between Health Home and partners or subcontractors?

Prior to billing, the Health Home must submit member information to the Health Home Tracking System Portal containing each member's begin date, status, Health Home, and care management agency. The appropriate Health Home biller will bill eMedNY per member, per month (PMPM.) Health Homes must have contracts with any care management partners they will be paying for the delivery of Health Home services.

13. How can I find Medicaid providers in my county?

There is no specific internet resource that identifies Medicaid providers by county. However, to obtain county information, care managers can contact the member's MCO for a list of participating plan providers or access their MCO's website. For Medicaid fee-for-service members, care mangers can utilize the New York State Physician Profile website at Go to the "Click here to search for a physician" icon and then select the "Advanced Search" icon to select by a specific county.

14. Will the designated Health Home provider be responsible for quality reporting?

The expectations outlined in the quality standards is that the designated Health Home will have the capability to share collected information with other partners and collecting and reporting specific quality measures as required by New York State and CMS.

15. Will the State assist in creation of standardized forms?

The Department encourages the development of standardized forms and tools unique to each Health Home, but The Department will not develop them, with the exception of the Consent Form (DOH 5055), Withdrawal of Consent (DOH 5058), Opt Out Form (DOH 5059), and the member welcome letter. The DOH 5055, 5058, and 5059 forms including associated translations are available on the Health Home website at:

16. Will the State provide training for Health Home staff?

The Department is not offering training for staff of Health Homes at this time. Please check under the Partner Resources section of the Health Home Website for training resources, including OHITT sponsored presentations for HIT Adoption Training and a list of organizations that have received funding for workforce retraining. The State has received CMS approval for an enhanced 1115 waiver to provide funds for Health Home Development, which would include additional resources for workforce training and retraining.

17. Do the Health Home eligibility lists provided include the language the client speaks?

The Medicaid tracking system does not have information on the language the member speaks. Health Homes need to work with their partners (who may have a relationship with the member) to help answer some of these questions. Usually it won't be until the care manager is able to locate the member that their language may be identified.

18. Are any resources being developed for the hearing impaired? Are there any DVDs or videos for Deaf individuals, in American Sign Language? They will not be able to understand the written consent.

Not at this time although resources will be available through CMS waiver funds for Health Homes to develop promotional materials.

19. Does the Health Home have a Catalog of Federal Domestic Assistance (CFDA) number?

Medical Assistance Program CDFA # 93.778. The Catalog of Federal Domestic Assistance (CFDA) provides a full listing of all Federal programs available to State and local governments (including the District of Columbia); federally-recognized Indian tribal governments; Territories (and possessions) of the United States; domestic public, quasi- public, and private profit and nonprofit organizations and institutions; specialized groups; and individuals

20. Are the costs the State incurs in administering, overseeing, and assessing/reporting quality measures subject to the enhanced federal share? Are States able to claim the enhanced match for these activities, or the State's regular federal share?

Only costs connected to the provision of Health Home services are eligible for the enhanced federal match.

21. Is there any funding available for Health Home implementation costs?

Over 15 million dollars in Implementations Grants were awarded to Health Homes. More information is available at

The State has received federal approval for an enhanced 1115 waiver to provide additional funds for Health Home Development; details on the process for distribution of these funds will be released in the Fall of 2014.

22. Does the Fee-for-service (FFS) definition exclude all eligibles with managed care coverage or does FFS also include the persons whose services are provided on a FFS basis and not covered by the managed care benefit plan?

The FFS definition excludes all eligible individuals with managed care coverage (even if the Managed Care individual receives carved out services through FFS).

23. Is the State working on developing specific documentation forms beyond the Member Tracking System? Can the MCO's require specific documentation in addition? Is the lead Health Home responsible for developing any additional documentation forms?

Listed on the Health Home website under Forms and Templates ( are various forms, including the Health Home Patient Information Sharing Consent Form (DOH 5055), the Health Home Patient Information Sharing Withdrawal of Consent (DOH 5058) and the Health Home Opt-out Form (DOH 5059), Each Health Home member must have a FACT-GP assessment and Health Home Questionnaire completed upon enrollment, annually and upon discharge. In addition to populating the Member Tracking System, Health Homes must work with their care management partners to submit information on care management services through the Health Home Care Management Assessment and Reporting Tool or HH-CMART. Information on the FACT-GP, Health Home Questionnaire, and the HH-CMART can be found at

24. What role does a TCM case manager representative payee play in the Health Home process?

A representative payee is a person or organization who acts as the receiver of United States Social Security Disability or Supplemental Security Income for a person who is not fully capable of managing their own benefits. Neither the NYS Office of Mental Health nor the AIDS Institute allowed TCM case managers to be a representative payee, and Health Home care managers may not serve in this capacity.

25. What is the relationship between Health Homes, MCO's and Behavioral Health Organizations (BHOs)?

The BHO's were organizations operating under contract to the State on a time-limited basis to monitor Fee-For-Service (FFS) Medicaid admissions for inpatient psychiatric care and detox and review discharge planning. Contracts with BHOs ended in December 2013. The role of the MCOs regarding these services will not change until the transition of behavioral health services into managed care in 2015. If the services are covered by the capitated rate they will continue to be paid by the MCO; if they are "carved out" and paid as FFS they will continue to be paid subject to any applicable limits.

26. Will the lead Health Homes ever have to go through a process of re-applying/recertifying/etc.?

After the initial three year period of designation, the State Implementation partners (DOH, OMH, AI, and OASAS) will collaboratively review each Health Home's performance to determine if the Health Home will be redesignated. State redesignation of Health Homes will be determined based on the needs of the State, compliance with Federal and State program requirements designed to meet Health Home goals of decreased inappropriate inpatient admissions and emergency department visits and improved health outcomes of members. Performance on program benchmarks and quality metrics will be considered, effective engagement and retention rates as well as member satisfaction of enrolled Health Home members.

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Health Home Letter of Intent/Applications/Provider Enrollment/Application Form

1. What was the timeline and associated activities for this conversion/effort?

Health Home implementation was implemented in three geographic phases beginning in January 2012. Details regarding the timeframe and activities for implementation can be found on the Health Home website at Search for MRT project #89.

2. Is the State still accepting Health Home applications?

The State is not currently accepting applications for new Health Homes. Providers of care management or other services that are interested in providing care management and related services can become a network partner of an existing Health Home. Interested providers can contact Health Homes directly ( Service providers must be enrolled in the Medicaid program. Information on becoming an enrolled provider can be found at

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

Requirements for Health Homes to serve children are currently being developed. New York State's goal is to expand Health Home eligibility and network requirements to better serve high needs children. Existing Health Homes and new Health Homes will be eligible to apply through a formal application process. More information can be found at

4. What are the staff qualifications for the Care Managers under this initiative? And what are the qualifications of the supervisory level staff?

Each Health Home will determine the supervisory structure and job qualifications for their care manager positions, including professional discipline (if applicable), along with relevant education, training and experience.

5. Can a Health Home have contracts with more than one Managed Care Organization?

Yes. Health Homes are encouraged to have contracts (known as Administrative Services Agreements or ASAs) with multiple Managed Care Organizations.

6. Does the fact that "the NYS Medicaid program designated Health Homes that built on "current provider partnerships" mean that most or all of the designated Health Homes are existing Medicaid providers or Managed Care Plans?

No. "Current provider partnerships" is a term that the Department uses to recognize the many formal and informal relationships that exist in communities that provide medical, behavioral and social services to the Medicaid population. It is expected that Health Homes continue to build on these relationships to further develop their Health Home partner networks.

7. Do Health Home partner networks cover the full range of Health Home services across primary care, behavioral health care (both substance abuse and mental health)?

Yes. All Health Homes were designated based on their attestation that they would provide the full range of services required as outlined in the Health Home Provider Qualification Standards more information can be found here: Health Homes will be evaluated to ensure they have built strong and extensive medical, behavioral health, and social service networks to meet the needs of their Health Home enrollees and that they are achieving positive outcomes.

8. 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 strongly encouraging Health Home applicants to make full use of community resources. Health Homes were designated based on the extent to which they included these providers in their Health Home networks.

9. Can Health Homes contract with LHCSAs, waiver providers, and other entities for care management or must this service be provided directly by the Health Home?

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.

10. Can you give us some help with language for the contracts or other agreements between Health Homes and their network partners.

The Department is not providing specific contract language regarding the relationship between the Health Homes and its network partners. The Health Home is responsible for developing and executing these 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. ASA templates are provided for the relationships between Health Homes and Managed Care plans, these can be found at

Contractual agreements between the Health Home applicant and their network partners must be developed and in place prior to the first request for reimbursement when partnerships involve a financial arrangement. A business agreement or MOU is suitable only for partnerships that do not involve a financial arrangement. Note that a Data Exchange Application Agreement or DEAA must be in place in order for the Health Home to share information with its network partners prior to member consent, e.g., when providing lists of potential members to agencies for outreach and engagement. Additional information on DEAAs can be found at

11. Where do peer advocates fit in to the Health Home model?

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.

12. Must an individual reside in a county the Health Home has been designated to serve in order to be enrolled in a Health Home?

The member must reside in the county or receive services in the county.

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Targeted Case Management (TCM)

1. Will children's case management providers have the option to become Health Home network partners?

Requirements for Health Homes to serve children are still under development, Children previously served by HIV COBRA case management may continue to be served. Other children's programs will convert to Health Home services once the Health Home network requirements for children have been developed. For additional information see (insert link to Children's HH webpage)

2. What was the rationale for including targeted case management (TCM) programs to become Health Homes?

Targeted case management programs were uniquely positioned to apply to be designated as Health Homes or convert to network partners providing Health Home care management because they have a wealth of experience in providing comprehensive case management and extensive community supports to help meet the complex needs of their clients.

3. Will TCM programs that either become Health Home leads or Health Home network partners be able to keep their TCM slots and bill Medicaid directly for them?

TCM programs that convert to Health Home care management are being allowed to bill directly for both existing slots (known as legacy slots) and new members (also known as expansion slots). TCM slots are billed at a legacy rate established for each provider. Providers must bill for any slots above the legacy cap at the Health Home rates, currently the option to bill legacy rates and to bill directly is in place until December 31, 2014.

4. If a converted OMH TCM provider receives a referral to serve a Medicaid-eligible enrollee that is seriously and persistently mentally ill (SPMI), can the converted TCM provider place the individual in one of their legacy converted TCM slots (if available) and bill Medicaid directly for Health Home services at the legacy TCM rate? Can the provider continue to fill TCM legacy slots with people who are Health Home participants and bill Medicaid directly at the present TCM rates?

Converted OMH TCM programs or COBRA TCM programs can use either legacy or expansion slots for members that meet their legacy diagnostic criteria and can also place new Health Home members into available converted TCM legacy slots. Converting TCM programs and MATS programs can bill eMedNY directly for both legacy and expansion slots. Payment will be at the TCM rate for a specified period. Health Home TCM Legacy Rates Extended for updated information.

5. If a Health Home assigns a member to a TCM provider are services billed at the legacy rate or the Health Home rate?

It depends on whether the legacy provider, who is now part of a Health Home, has a legacy slot available to accept this member. If the provider is below its slot limit, the provider can place the member in a legacy slot and bill for this member directly under the legacy TCM rate. If the TCM provider does not have an available TCM slot, but is still accepting new members, then the member is billed under the Health Home rate. In either case the TCM provider bills directly for a specified period, currently until December 31, 2014.

6. Can you explain more about how the OMH TCM programs transitioned into the Health Home care coordination role?

OMH TCM providers became care management network partners under one or more Health Homes. Once the TCM provider starts billing the Health Home rate codes they are no longer subject to TCM regulations. Health Homes will develop their own policies for the role of care management partners. As part of Health Homes, care coordination will benefit from being connected to a larger service network.

7. Will TCM programs be expected to provide only Health Home care management, or will TCM programs continue to need to meet specified requirements (e.g., OMH required four face-to-face encounters per month per ICM, array of services from regulations, etc.).

Once a TCM program converts to Health Home services (is billing Health Home/OMH/TCM rates) they are no longer subject to TCM rules and regulations. HIV COBRA programs converted to Health Home services once they engaged with a lead Health Home, and accepted Health Home assigned clients.

8. What is to become of those currently served by TCMs who are not Medicaid eligible?

Healthcare for the underinsured and uninsured is a big problem both nationally and statewide. Access to Medicaid and commercial health insurance will improve with the advent of the Health Insurance Exchange. That being said, only Medicaid eligible individuals can participate in Health Homes. OMH has and will continue to provide State Aid funding for non-eligible individuals to receive care management.

9. TCM providers will bill for and receive their provider-specific per-member per month (PMPM) legacy rate. Will legacy providers be required to provide an administrative percentage of this rate to the Health Home and the Managed Care Health Plan?

Health Home, legacy providers and Managed Care Plans will need to negotiate administrative fees as part of their Administrative Services Agreements (ASAs) arrangements. The State has suggested, based on the amount of administrative costs built into the Health Home PMPM that administrative fees be 3% of the PMPM, although some agreements call for a flat fee, which usually ranges from $10-$12 per member per month.

10. What is the role of the County Single Point of Access (SPOA)? Are Health Homes able to assign individuals directly to OMH TCM programs without regard to County SPOA committees?

SPOAs will continue to play a role in assigning patients to TCM programs. Health Homes will need to work with their local SPOA in making some of these determinations.

11. If a Health Home assigns a non-TCM member to a TCM provider can the Health Home bill?

No, TCMs bill for both TCM legacy slots and non-TCM slots (new Health Home or expansion slots).

12. How will TCM providers expand the number of Health Home clients they are eligible to serve and maintain the previous care management relations with their converting TCM clients they currently serve?

It is the State's intention to not disrupt care management relationships that are working; therefore the State is allowing converting TCM programs to keep their members. It will be up to transitioning TCM programs and Health Homes how best to adjust staffing levels and balance their case loads. At least initially many case managers' caseloads will not change until the members who are being served require different levels of services. Ultimately decisions about how to balance case loads and assign members to case managers will be left to the care management agencies and the Health Home, acting in partnership with their local government unit.

13. ACT teams provide case management services as do PROS service providers. Are these service providers included as members of Health Homes provider networks or are their functions being carried out by the Health Home? Is there a potential for duplicate billing for case management services by ACT teams, PROS, and Health Homes? If so, how will this be addressed under the current model?

See the OMH website for guidance,

14. Have OMH Intensive Case Management (ICM) programs been converted to Health Home services?

OMH ICMs are included in Health Home partner networks.

15. There had been some preliminary discussions about granting Health Home access to PSYCKES data, but we haven't heard anything further about it for a while. We hope this is still under consideration because it could be such a valuable tool for Health Home Care Managers. We'd appreciate any information you can provide about the status of this request.

OMH and DOH have finalized a process that will allow Health Home care managers to access PSYCKES. Some of the Health Home network partners such as clinics may already have access to PSYCKES. New users will be added once system updates have been made. See

16. Is it true that services provided to members in legacy slots paid for by OMH TCM legacy rates must meet the current ICM guidelines and the Health Home slots are the only ones exempt from ICM regulations? If that is true then do the care coordinators have to meet current qualifications?

No. Once an OMH TCM program converts to Health Homes (is billing Health Home Service rates/OMH/TCM rates) all slots are no longer subject to OMH TCM rules and regulations. Each Health Home determines and defines the qualifications required for their care managers.

17. How would Medicaid ineligible AOT clients be served in a Health Home?

Medicaid ineligible clients cannot participate in Health Homes. OMH provides funding for ineligible Medicaid clients through State aid.

18. If a member transitions from a Health Home to an Assertive Community Treatment program are they discharged from the Health Home?

Individuals in ACT receive case management services. The Department and OMH have developed a process for integrating the two programs. The guidance can be found on the OMH website

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Chronic Illness Demonstration Project (CIDP)

1. 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 Chronic Illness Demonstration Project authorized the NYS Commissioner of the Department of Health, in consultation with the Office of Mental Health and Office of Alcohol and Substance Abuse Services, to improve care coordination for medically complicated Medicaid Fee for Service beneficiaries across NYS. During the pilot project, it became clear that some of the difficulty associated with this type of program was the ability to locate the individuals that most needed the services. It was also apparent that in order to create the best model that served the complex needs of this population, a broad network of providers across all medical and behavioral health disciplines was needed. These valuable lessons learned from the CIDP have contributed to the creation of the Health Home model. Payment for an outreach was implemented separately from the engagement rate and has provided additional support to providers to ensure the population with the greatest need is located and engaged in the Health Home model. Targeting the correct individuals is essential in obtaining Medicaid Savings. The Department is also seeking permission from CMS to create a Gainsharing model, which tentatively will be structured to provide the greatest shared savings to providers that successfully enroll the most medically complex individuals. Providing access to the correct data and assisting providers with managing the data needs of this program has also been a challenge for the Department. The forthcoming Medicaid Health Home Portal will be geared toward these efforts and provide each program with the data needed to assist them in managing an effective Health Home program. For CIDP information please follow this link:

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Population Assignment/ Eligibility (Patient Tracking System)

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. Hospitals are required under the federal ACA requirement to make referrals to Health Homes.

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

The State has not developed a patient identifier. Health Homes and Managed Care Plans have access to the Health Home Member Tracking System to look up members. Wider access and greater functionality will be incorporated into a Health Home portal currently under development.

3. What happens to behavioral health consumers who opt out of a health home?

It is imperative that the Health Home engage potential members assigned or referred to them. Health Homes and care management agencies should work with individuals so they understand the importance of the Health Home program in assisting them with accessing needed care and services. However, because the Health Home program is voluntary, individuals are given the choice to opt-out of the Health Home program.

4. How does Health home assignment take place?

The State uses a combination of 3M™ Clinical Risk Groups (CRG), which are a 3M product, an algorithm that predicts hospitalizations, and behavioral health indicators to select Medicaid enrollees for Health Homes. Medicaid enrollees will be assigned, to the extent possible, to a Health Home provider based on existing relationships with health care providers or health care system relationships, geography, and/or qualifying condition.

5. Who will be assigning individuals to Health Homes?

The State, and the managed care plans for managed care members, will be assigning patients to Health Homes based on loyalty and attribution data. The initial population group assigned will be individuals who lack any care management or meaningful primary care connection. The State will release lists of members to Health Home providers through the Health Home Tracking System assigned members current demographic information to facilitate outreach and engagement.

OMH Single Point of Access (SPOA) will continue to play a role in assigning patients to TCM programs.

The State has also developed a process for accepting referrals from community providers. This process is described in the Health Homes Provider Manual,

6. How will consumers be notified of their assignment?

Potential Health Home members will be notified of their assignment to the Health Home or Managed Care Plan through a welcome letter provided by the Health Home (fee-for-service Medicaid recipients) or Managed Care Organization. The welcome letter will inform the potential memberabout the Health Home program, how enrollment can benefit him/her, reason for receiving the letter, the care management agency who will be contacting him/her, and options to Opt Out or request another Health Home, if available. It will also include the Medicaid Helpline number for any questions they may have.

As part of this process, the care management agency for the Health Home will send a welcome letter to further engage the potential member in the outreach and engagement process. This letter will reference the Health Home welcome letter, reason for receiving the letter, request contact for further discussion about the benefits of enrollment, and options to Opt Out or request another care management agency. It will also include the Medicaid Helpline number for any questions they may have.

7. How were adults with a serious and persistent mental illness (SPMI) transitioned to Health Homes? There are over 408,000 adults with SPMI.

There are approximately 100,000 Medicaid members with SPMI only; the remaining members identified in the behavioral health group are members with a SPMI and a co-occurring diagnosis.

Members who were receiving care management services from an OMH TCM provider were assigned to Health Homes that included their TCM provider. The goal was not to disrupt existing care management relationships with the exception of TCMs, where these special arrangements were made, Medicaid members enrolled with plans will be assigned into Health Homes by the plan utilizing loyalty and attribution data and a suggested Health Home assignment provided by the State.

8. Will Health Homes be assigned members they have no previous relationship with?

It is possible that some of the assigned members will not have a relationship with the Health Home they are assigned to, however, every effort is made to match recipients to Health Homes based on a loyalty analysis that takes into account the member's utilization of health and behavioral health care services.

9. Will Managed Care Plans that assign Health Home eligible enrollees to Health Homes be following the same NYSDOH algorithm used for the fee-for-service population assignment?

The State will share its suggested Health Home assignment with managed care plans and encourage plans to assign their members to the suggested Health Home, however, managed care plans may have additional data on members. With the exception of managed care enrollees already in TCM programs, managed care plans will be responsible for making their own assignments to Health Homes and may assign additional members based on their own analytics.

10. Will there be a mechanism to cap the number of members assigned to an organization?

At this time, the Department is not able to assign fee for service members based on a Health Home's capacity. However, Managed Care Plans may keep a Health Home's capacity in mind while assigning their plan members to a Health Home.

11. In the future, will all HIV+ Medicaid recipients be assigned a Health Home or is a second diagnosis and high cost claims necessary for eligibility?

All HIV+ individuals are eligible for Health Home services because this diagnosis creates a risk for other conditions. They do not need a second diagnosis to qualify.

12. How will the State assure that consumers not associated with TCM have a connection to a Health Home?

Consumers in need of care coordination services who qualify for Health Home services but are not currently engaged in care management will be among the first assigned to Health Homes.

13. How will the State make Health Home services available to the homeless Medicaid population?

The State will assign a Health Home to homeless Medicaid enrollees that meet Health Home eligibility requirements using provider loyalty information, available information regarding their homeless status, and the enrollee's last known address. In addition the Health Home program is supporting a variety of efforts to assist Health Homes in engaging with the homeless population, more information can be found at

14. Can you provide a brief definition for 'Risk Score'?

Risk scores predict the probability that recipients will experience a negative outcome (e.g. inpatient admission, long term care, death) in the following year. The predictive model used to calculate the risk scores is based on prior year service utilization. Negative outcomes are less likely for recipients with lower risk scores (0) and are more likely for recipients with higher risk scores (100).

15. How is it determined whether a substance use disorder is "chronic" enough to qualify a Medicaid member for Health Home services?

Substance use disorder alone does not qualify a member for Health Home services. In order to be eligible for Health Home services, the member would need to have two chronic conditions, or one single qualifying condition (HIV/AIDS or a serious mental illness). Substance use disorder can qualify as one of the chronic conditions. In order to be considered chronic it needs to have had a significant impact on the member's ability to function.

16. How does an entity refer a Medicaid member for Health Home services?

Guidance for community referrals can be found in the Health Homes Provider Manual ( and was also included in the April 2013 Health Home Special Edition of the Medicaid Update. Health Homes can add Fee-for-Service (FFS) members meeting Health Home criteria to their tracking file as outlined in the Health Home Member Tracking System Specifications. If the member is in Managed Care then the Managed Care Plan should be contacted to make the referral.

17. Can we transition (and get paid for) 18 year olds in our TCM programs to our Adult Health Home?

Age does not preclude membership in a Health Home, however, children are not being prioritized for enrollment in the existing Health Homes while care models tailored specifically to children are being discussed. Any individual formerly served in an adult TCM program can be served in Health Homes. For more information on the development of Health Homes for Children, see

18. May individuals of all ages be served by a Health Home?

There is no age requirement for Health Homes, however, OMH is not transitioning their TCM programs that serve children right now and the State is prioritizing adults for initial assignments. There are several multi-agency State workgroups developing recommendations on how children in Health Home should be served. More information on serving children in Health Homes is available at

19. Are Detention/Correctional facilities and Housing Agencies included under Health Homes?

These entities are encouraged to partner with Health Homes and should reach out to Health Homes they would like to work with. Mechanisms are being explored to provide priority access to Health Homes for homeless individuals and those being released from detention and correctional facilities. Housing providers are being encouraged to network with one or all of the Health Homes in their area.

20. If a Health Home eligible individual is incarcerated when located during Outreach and Engagement, is it possible to enroll the client?

Individuals who are incarcerated have their Medicaid suspended after 30 days and will not qualify for Health Home services until they are no longer incarcerated. However, the Health Home that is assigned that individual may work with county or local jails, prisons, and/or Department of Corrections (DOC)'s transitional services unit to make sure they are aware of the Health Home that will be willing to provide services after the individual's term as the individual may have Medicaid in suspended status until released.

21. How long can Health Home care management services be provided to an active Health Home member who is incarcerated?

As a rule, Medicaid remains active for the first 30 days of incarceration and is then suspended until release. Upon release, Medicaid is restored back to the first day of the month of release so that services can be provided and billed. Depending on the anticipated length of incarceration (e.g., jail or prison), the member can remain enrolled in the Health Home program in an "inactive" status. However, during the period of incarceration when Medicaid is suspended, Health Home care management services cannot be billed.

The Department is developing an inactive status code as part of the move of the Health Home Member Tracking System to the Medicaid Analytics Performance Portal and be working in conjunction with other State agencies on guidance for Health Homes on the length of time an individual can remain on 'inactive' status while incarcerated. At this time, there is no limit on the length of time a Health Home member can remain on 'inactive' status while incarcerated in jail or prison.

It is imperative that Health Homes establish relationships with the criminal justice system to support timely and safe enrollment into the Health Home program upon release of an active Health Home member, or potential member. Health Homes should inform jails and prisons of a member's enrollment in a Health Home and encourage communication to support the Health Homes ability to connect and serve individuals immediately upon release so they can assist in transitioning the individual back into the community.

Guidance on Health Home care coordination for incarcerated members can be found in the Health Homes Provider Billing Manual Section 3.7 at:

22. Will Medicaid Spenddown, Buy-in and individuals in the Special Needs Trust be eligible for Health Home services?

Medicaid spend down individuals can be included in the Health Home program for chronic behavioral and medical conditions. Services can be provided when they are Medicaid eligible. LDSS and OMH regional offices can work with members to ensure they meet any spend down requirements, pursuant to published ADMs. Person's Living with HIV/AIDS (PLWHA's) who have Medicaid spend down can contact ADAP for assistance with their spend-down requirements. Individuals participating in the Medicaid Buy-In program for Working People with Disabilities and those with an Exception Trust (a Supplemental Needs Trust that provides for Medicaid reimbursement upon the death of the recipient) who are fully eligible for Medicaid are eligible for Health Homes. PLWHA's can be served in a grant-funded program. Medicaid cannot reimburse for Health Home services provided to a spend-down member if the member does not meet their spend-down requirement in a given month.

23. Can individuals in a waiver program with care coordination, like the Long Term Home Health Care Program, enroll in a Health Home without jeopardizing their LTHHCP services?

At this point in time individuals enrolled in the LTHHCP are not being prioritized for enrollment in Health Homes. Individuals receiving care management through this or other waiver cannot also receive care management from a Health Home. The care manager needs to work with the member to decide which program provides the best supports and services.

24. In the new Health Home Member Patient Tracking System Guide (06/2013) on Pg. 25; Outreach / Enrollment Code. If both outreach and enrollment occurred in the same month, only the enrollment event should be submitted. Please clarify as we understand this is to be an 'opt-out' program and that members are automatically enrolled. DOH has not described an 'enrollment event'.

When the individual can be considered to be in active care management the segment would be changed from Outreach to Enrollment.

25. Please clarify the following with regard to Outreach:

a) Minimum activity needed in a month to report on tracking sheet/bill

b) Documentation needed to support

c) Is the combination of using data to match list and sending letters to members sufficient to claim Outreach for month one for any member, assuming Outreach continues to be active and progressive going forward?

d) Is documentation required in the clients care management record required to support billing for Outreach and Engagement?

There will be no requirement for minimum face-to-face contacts; however, there must be evidence of activities each month that support billing, including:

  • ~ Active Outreach
  • ~ Contacts (face-to-face, mail, electronic, telephone)
  • ~ Health promotion activities
  • ~ Patient assessment
  • ~ Development of a care management plan; and/or
  • ~ Active work towards achieving care management plan goals

All client contact must be recorded in the case management record. The Health Home monthly PMPM may be billed as long as active outreach is occurring each month and at least one of the given core services (excluding HIT) described on page 13 of the April 2012 Medicaid Update are provided in each billed month, see here:

26. Can a Health Home member also be in a Managed Long Term Care plan?

MLTC plans are for individuals needing more than 120 days of long term care services. If a Health Home member requires more than 120 days of these services, they may be auto-enrolled in a MLTC if available or receive services from a fee-for-service long term care provider if managed long term care plans are not available in their area. In their region a member can be enrolled in both a Health Home and a MLTC but the Health Home and MLTC must enter into an administrative services agreement using a standard template that is under development, so as not to duplicate services.

27. Are we able to close Health Home cases in the event that the client has moved and cannot be located? If so, how do you close a Health Home case?

When sending a tracking file to the Health Home Member Tracking System there is a code in the can be used to close a Health Home case for a member who is lost to follow-up. Details of the Health Home Member Tracking System Specifications Document can be reviewed at:

Further guidance on members who are lost to follow-up can be found in the Health Homes Provider Manual (

28. Are the volume of assignments to lead Health Homes dependent on the NPI numbers (providers) enrolled in the Health Home network?

Yes. The Department is comparing the claims and encounters for eligible Medicaid members to each of the Health Home network providers' NPI numbers. Eligible members will match to a specific Health Home network based on that comparison, so it is possible that a Health Home with more NPI numbers might receive more eligible numbers.

For more information related to Member Assignment, Tracking System, Billing and Rates:

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Billing and Payment

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

At this time, Health Home enrollment information is not available in eMedNY. Health Homes and Managed Care Plans have access to the Health Home Member Tracking System through the Health Commerce System (HCS) portal. A web-based portal that will expand access to member tracking system is being developed.

2. What will be the reimbursement for Health Home services?

Information regarding Health Home reimbursement can be found at

3. Will TCMs that convert to Health Homes be paid the same for their TCM patients?

Yes. TCMs that converted to Health Homes were initially allowed to continue to be paid their TCM rate for up to one year following Health Home implementation based on the SPA approval date; this was subsequently extended to two years. The Department has submitted a State Plan Amendment to CMS to request approval to further extend the TCM rates until December 31, 2014.

4. How will Managed Care Plans pay subcontractors for conducting Health Home care management services?

For non-TCM managed care enrollees, the Managed Care Plan will pay their Health Home providers the Health Home PMPM less a negotiated amount for administrative costs. See also question 10 in this section.

5. What HCPCS code should be used by Health Homes?

HCPCS codes are not required on Health Home claims. In general, Health Homes are responsible for making decision on coding; The Department cannot make billing or coding recommendations.

6. Currently there are limits to providing billable services for clients who are either impatient or incarcerated. In what instances can Health Home services be provided, and billed for, if someone is receiving impatient services or is incarcerated.

Health Homes cannot bill for Health Home services when members are either admitted to an Institute for Mental Disease (IMD) inpatient facility or incarcerated. Inpatient facilities should have discharge planners to assist with transition to a Health Home. Incarcerated individuals will have case management provided through the NYS Department of Corrections. There may be some situations in which care management can be provided.

For further guidance, please refer to questions 20 and 21 above in Q&A section Population Assignment/ Eligibility (Patient Tracking System), and inthe Health Home Provider Manual at:

7. How much of the Health Home PMPM may be retained for administrative services such as HIT?

The state has provided guidance that no more than 6% of the Health Home payment should be retained for administrative purposes, 3% for Managed Care Plans and 3% for the lead Health Home. Health Homes may also be investing in HIT and have other infrastructure costs and the State has not restricted the amount the Health Home may retain but have encouraged as much of the PMPM as possible should be used for direct Health Home services.

8. Is the current Upstate PMPM rate final and does this rate differ between Health Homes within the same county?

The current base rates for Upstate and Downstate have been posted on Health Home website. The base rates are adjusted by member acuity and thus will differ depending on the member.

9. What is the conversion process and methodology regarding rates?

This information can be found on the Health Home website. Please use this link:

10. What is the current average monthly rate for current upstate Health Homes?

There is no calculated average monthly rate. The current base rates for Upstate and Downstate have been posted on Health Home website The base rates are adjusted by member acuity.

11. What is the status of quality withholds and shared savings?

Quality withholds are no longer included in the current Health Home model. An amendment to the Health Home State Plan to characterize a shared savings model has been submitted to the federal Centers for Medicare and Medicaid Services (CMS). The Department is developing a shared savings model based on guidance distributed by CMS.

12. How were former TCM and MATS providers converted to Health Home billing?

Once the State Plan Amendment (SPA) was approved for each phase converting OMH TCM providers were authorized to bill retroactive to the effective date of the SPA. For COBRA TCM programs, all unit billing was to be reconciled back to the effective date of each SPA once all phases were implemented.

13. Will the administrative fees of individual Health Homes be shared?

Sharing of information about administrative fees for individual Health Homes is not a State requirement. If a Health Home wants to share that information they may do so.

14. Are there any issues with continuing to serve current clients who are dual eligible?

You may continue to serve current members who are dual eligible. The Department now includes duals on assignment lists.

15. Billing rates are going to be retroactive for former TCM providers. Will the billing rules also be retroactive? For example if a Medicaid eligible client did not meet the standards for number of visits under the previous standards for billing, will they be included in the retroactive adjustment?

No, reprocessing of claims will only be for those claims that were submitted to the system. Providers cannot go back and submit claims for Health Home services that did not met TCM rules at that time.

For more information about Billing and Rates:

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Health Information Technology

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

The HEAL project ended in November of 2013 but any information can be found at the NY DOH Division of Health Information Technology (DHITT) website: Health Information Technology

Information on the Statewide Policy Guidance can be found at the New York e-Health Collaborative (NYeC) website:

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?

No. However- other sources of revenue will be available to offset HIT costs.

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. As of April, 2014, the SHIN-NY has been designated a “Public Utility” and there are no application costs associated with accessing Health Information. Projects will still be required to fund connectivity and interoperability with their local RHIO.

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 Regional Extension Centers (REC) to reach out to and work collaboratively with potential providers in meeting Health Home HIT requirements.

New York State is also working closely with the Office of the National Coordinator for HIT (ONC) to prepare for the adoption of interoperability standards for care plan applications when those standards are finalized.

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

In addition, for non-technical Health Home HIE support, feel free to visit the New York State Department of Health- Division of Health Information Technology Transformation website at or call (518) 474-4978.

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. Additional information can be found at

Information on the NYS RHIOs can be found at 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 of the Health Home application.

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 may 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, and continue to leverage the state's HIE infrastructure.

18. Will it be through the database 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 of the Health Home application (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:

23. Concerning IT capability, what must a Health Home provider have in place by February 15?

By program implementation or the phase start date, Health Homes in that phase must be able to minimally meet the Health Home Provider Qualification Standards for HIT as described in Section 6a-d. Additionally, any health home applicant who cannot meet the final HIT requirements as described under Section 6e-i in the Provider Qualification Standards must submit a plan for how they will be met within the following 18 months.

24. What will be the nature of Health Home reporting, particularly regarding tracking individuals especially outreach, housing, clubs, etc.? What will be the required reporting frequency?

The SPA outlines quality and tracking information which the State hopes will come primarily from claims and encounters data. Other data under discussion include patient functional status and the use of surveys to collect patient experience.

25. The Health Home SPA states that a single case record will be agreed to and shared by all team professionals. How will this work?

Health Homes must be able to share patient specific information with all members of the health home team for each patient enrolled in the Health Home. Health Homes are responsible for developing their own solutions to functionally meet this requirement so that the entire team can share and discuss information about the patient including changes in patient status and treatment.

26. Is it required to have a working electronic health record by the start of the Health Home program?

No. However, requirements 6a-d of the Provider Qualification standards must be met, if not electronically, then through other means and a plan indicating how the final HIT standards will be met within 18 months must be included in the application.

27. If our agency does not yet have an electronic medical record system (EMR) and is not yet a member of a regional health information organization (RHIO) will we be disqualified from becoming a Health Home network lead agency?

No. An EMR system and RHIO membership is not an initial requirement for submitting an application to become a Health Home. However, the Health Home lead applicant must meet VI.6a-6d requirements as defined in the Health Home Provider Qualifications, if not electronically, then through other means and provide a plan describing how they will achieve the final standards cited in Provider Qualifications VI.6e-6i within 18 months.

28. If another organization/entity within our network already has EMR and RHIO access will this be sufficient?

No. The purpose of the health information technology requirements is to assure the Health Home has a means of sharing patient information with its network. The Health Home lead applicant assures this takes place by meeting Section VI of the Health Home Provider Qualification standards.

29. The requirement that the plan of care exist in a health record system that meets HITECH and meaningful use is difficult and impractical to achieve. Most care management platforms, that have extensive plans of care, will not meet meaningful use standards for some time to come and are often done centrally outside the EHR; however, most certified electronic medical records will. It will not be feasible to have the plan of care exist in a platform that meet all meaningful use provisions, especially if we are linking multiple provider organizations. Possibly one way around this is to work towards putting the plans of care into the RHIO, making the info accessible to all RHIO users but we are not sure if RHIO platform meets all HITECH.

The intent is for the care plan to be accessible to all members of the Health Home member’s care team. Working with the RHIOs to make this information available to the Health Home providers would certainly be an option. Since the RHIO is storing the data or aggregating the data, the 'platform' does not need to meet the HITECH but will need to meet the States policies for sharing electronic health information.

30. Do all individual members of a Health Home network need to purchase a separate membership in a local RHIO?

The only requirement is for the designated Health Home to have a RHIO membership. RHIO membership is encouraged for all other downstream providers but it is not a requirement. RHIOs have different memberships by provider type and or stakeholder. If a hospital is a member of the RHIO, the hospital caregivers can access information under that membership. Individual practitioners, group practices, care organizations or MCOs would need separate membership. As the SHIN-NY is now a public utility, there are no longer any membership fees to join a local RHIO.

31. Can individual members exchange information through the RHIO simply by being a member of the Health Home?

Yes and No.

Personal Health Information can be sent to a RHIO providing that that organization has a participation agreement with that RHIO and the electronic health record system has an interface with the RHIO. Personal Health Information can only be pulled from the RHIO for those patients who have signed a RHIO consent form which contains the name of the organization in question.

32. Regarding the Network, 6F of the Medicaid Health Home Provider Application asks "Health Home provider uses an electronic health record system that qualifies under Meaningful Use provisions of the HITECH Act, which allows the patient's health information and plan of care to be accessible to the interdisciplinary team of providers. If the provider does not currently have such a system, they will provide a plan for when and how they will implement it." Do EHRs meet the meaningful use standards?

Our EHR standard is that providers will use MU certified EHRs. It does not mean that they will have attested to Medicare and Medicaid and be receiving HITEC incentives. RHIOs don't have an MU requirement.

33. Are non-direct care providers required to meet the full New York HIT standards as outlined in the Health Home application? If so, how can they achieve this?

Non-direct care providers can join RHIOs to access and share data but will have their direct providers abide by the SPG and the HIE requirements. While they can utilize a version of their care management system to develop partnerships to maximize the use of HIT across providers, we look for a system that is interoperable among providers and is not a standalone system. This is especially important as Health Home providers cross over different Health Homes.

Any plan to achieve the final HIT standards within 18 mos. of program initiation must include care plan accessibility, certified EHR, SPG and RHISs/QEs evidence based guidelines. It must be able to process, track and follow-up on patient testing, treatment, services, referrals and results.

34. Is funding available under the Health Home initiative for development of Electronic Health Records?

The Health Home initiative does not have direct funds to support Electronic Health Records; however, certain practitioners may qualify for funds available under the federal EHR Incentive Program. The goal of the EHR incentives is to promote the adoption and use of electronic health records by Medicare and Medicaid providers. Total incentives per practitioner can be as much as $63,750 under Medicaid, and $44,000 under Medicare.

The program is administered by the HHS Center for Medicare and Medicaid Services, and more information may be found at For Medicaid specific questions about EHR incentives to be distributed through NY Medicaid, you may submit your questions to

The state is exploring other funding opportunities to support infrastructure including a possible enhancement to the 1115 waiver. For more information, please visit To view the MRT 1115 Waiver Press Release visit

35. In the August 2011 NYS Medicaid Update, the Medicaid Electronic Health Records Incentive Program is showcased on the cover. It appears that the eligibility requirements exclude organizations that are providing Health Home care management services but not direct medical services performed by doctors. Is this true? Has the state considered opening this application process to Health Home care management providers?

Eligibility for the Medicaid Electronic Health Record Incentive Program is defined at the national level. There is currently no additional funding to expand this list. The website for this program is

36. In speaking with EMR vendors and RHIOs most health information technology seems to be designed around the medical practice. Has the state reached out to EMR vendors and RHIOs to discuss developing resources to support the Health Home?

New York has two Regional Extension Centers (REC) to promote adoption and connectivity of electronic health systems. This support aligns with a care coordinated approach such as the Health Home. You should discuss support for these services with the REC or your RHIO.

37. Since the application requires the Health Home provider to use an electronic health record system that qualifies under meaningful use provisions of the HITECH Act, does this refer to the care management and planning record, to the systems utilized by the medical/behavioral health providers, or the information sharing portals provided by the RHIOs?

This is for the EHR utilized by the providers. Where there is an applicable EHR available, eligible providers must use an EHR meeting the qualifications under meaningful use. ONC is determining which vendors and products can meet these qualifications. This is currently applicable for primary care, specialty care and hospital EHRs. As the capabilities and provider types expand, the Health Home providers will be expected to adopt the newer standards for HIE.

The Office of the National Coordinator is working to create interoperability standards for care plan applications. The hope is that within the next several years, these standards will be adopted by HL& as a part of Meaningful Use. At that time, there will be an expectation that care plan applications used by Health Homes will fall under the provision of Meaningful Use.

38. Will software that is ONC Certified for Meaningful Use be accepted without "CCHIT Certification"?

The product, i.e. the EHR or in some cases individual components, will need to be certified. There are many Authorized Testing and Certification Bodies (ACTBs). For additional information, please go to ONC-Authorized Testing and Certification Bodies web link at:

39. From the different HIT networks i.e. BHIX have you chosen one health information exchange?

Where more than one RHIO is an option, you can work with any of the RHIOs or one which will best meet your needs.

40. Are there any funds to aid for profit companies in complying with HIT regulations?

Although we are looking for funding, there are currently no additional funds for HIT adoption and connections.

41. Do you have a specific list of the outcome measures (quality, utilization) that the Lead Health Home will need to report? (more specific than shown in the SPA)

The SPA is the best source for reporting requirements and the State will be providing additional information in the future either through another webinar or learning collaborative.

42. Will the State support HIT implementation for entities that are not currently members of RHIOs or have no electronic medical records/systems?

There are no longer any membership fees associated with becoming a member of a RHIO. Although we are looking for funding, there are currently no additional funds for interface and connectivity costs associated with joining the RHIO.

43. When does the clock start ticking on the 18th months referred to for Phase 2?

The 18 month timeframe for meeting HIT standards for Phase 2 started April 1, 2012 and ended September 30, 2013.

44. All along, Health Homes have been implying that Care Managers would have access to this medical information and that it is essential for us doing our jobs of care management. Is that not the case any longer?

You are required to have an accessible plan of care (not a part of standard 6F). There are a variety of ways to access information such as a portal system or RHIO or it can be integrated into the EHR. The DOH 5055 consent form can also be used to share information within the plan of care between care management and other care plan team members.

45. If the care manager is responsible for assuring everything that's ordered gets done, why are they not required to meet the 6F requirements?

The care manager doesn't have an EHR. Right now there is no certified care manager application. If there were a certified EHR that the care manager would need, they would have to meet the 6F requirements. As per question 37, ONC is working on standards for a certified for meaningful use care plan application but that solution is still several years away.

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Health Home Network

1. How will has the implementation of Health Homes taken 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 enrollee/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.

2. Are Health Homes a temporary phenomenon and will they be replaced by care management for all (e.g., integrated delivery system/SNPs/BHO/MCO)?

No. Health Homes are a care management service operated by a qualified network of providers which will be an integral part of other payment and accountability structures that may evolve from Medicaid Redesign.

3. Can hospitals be part of more than one Health Home network?

Yes, hospitals can operate as a Health Home lead as well as a partner with other leads.

4. If we are an integrated health system with hospital outpatient clinics and community based primary care physicians, are we required to include an FQHC in our Health Home network?

Specific partnerships are not required; however, all lead Health Homes applicants are strongly encouraged to partner with community based organizations that provide complimentary services as well as similar services.

5. Do Health Homes have to provide the coordination of care and care management directly or can that be subcontracted?

Health Home providers can either directly provide, or subcontract for the provision of, Health Home Care services. The Health Home provider remains responsible for all program requirements, including management services performed by the subcontractor – per the NYS Health Home Provider Qualification Standards.

6. Can a provider that is not a Medicaid vendor but is funded by NYS OMH for housing or employment or other services become a subcontractor to a Health Home?

Yes, but the Health Home assumes certain risks for the activities of the subcontractor. See section 2 of the Health Home Provider Manual at:

7. Do you agree that the description below of the three levels of participation in a Health Home is accurate?

Lead Agency – contractually obligated to DOH for Health Home services care management.

Shareholder – member of the network holding a subcontract with the lead agency to provide care management (CM) services for a portion of the health home members. The agency would receive a portion of the PMPM for its CM services and be obligated to the lead agency on performance, etc. This agency also might benefit in any "gain share" arrangement with the lead agency (contingent upon negotiation and contractual arrangements).

Network Member – a member who receives referrals from the health home but is not performing CM services other than normal contacts between providers. While payment is unclear there most likely will not be any "gain share."

Yes. Health Homes can structure their governance models and networks as required to maximize efficiency and service delivery and this is an acceptable arrangement. The Department is open to many kinds of sub contractual relationships but the ultimate accountability and gain sharing will be with the health plan and the State-approved Health Home provider. Downstream movement of dollars will not be directly managed by the State.

8. Can a Health Home member receive substance abuse services (or other services) from a non-networked provider and retain their enrollment in the Health Home, or is the Health Home member restricted to the networked provider, assuming that the service is available in the network?

At this point, the Health Home will not be a closed network and members can receive their services as they typically would (in-network for Managed Care members). However, the Health Home is charged with care coordination and managing the whole person, so Health Home members must get care in an integrated manner that is coordinated their Care Manager, unlike the "siloed" way care management has been provided.

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Health Home Design

1. There are three levels of care described on in the Health Home website; application: low, intermediate and high. Please provide a detailed description of low and intermediate levels of care. Please describe the algorithm that will be used.

It is up to the Health Home to define those levels although the application gives a broad description of what that could mean.

2. Please provide a detailed description of 'service areas/geo-ZIP service areas'.

Service areas can be defined by zip codes, boroughs or counties that a provider serves.

3. Can organizations apply to serve only one of the target populations – for example people with hypertension and diabetes or people with mental illness? Will organizations that serve a narrower population be disadvantaged in the application process?

Health Home providers cannot specialize in specific populations; they must be able to serve all populations.

4. Must a Health Home provide all three levels of care management intensity?


5. Does DOH have guidance on staffing standards for the three levels of care coordination?

No. It is up to each Health Home provider to determine the qualifications and staffing levels for their care managers.

6. All Medicaid participating hospitals will be required to have some sort of procedures for referring patients potentially eligible for Health Home services to Health Home providers. This applies regardless of whether the hospital participates in a Health Home network. Please confirm.

Yes this is a requirement of the federal law authorizing Health Homes.

7. Are there any specific patient ratios that the State is contemplating for low, intermediate and high need patients?

No. It is up to the Health Home to develop caseloads.

8. Are there descriptions of what constitutes a low, intermediate and high need care management service?

Broad definitions were listed in the Health Home application to help define a low, intermediate and high need Health Home member. These definitions were presented as examples but each Health Home must determine the intensity of care management that is required for each category of Health Home members.

9. There is a federal mandate for hospital ER's that treat people with chronic issues to connect individuals to designated Health Homes. Who is educating the hospitals about this requirement?

General guidance on community referrals is included in the Health Home Provider Manual and in the April 2013 Medicaid Update Health Home Special Edition.

10. Why are the Health Home leads so involved in the process of care coordination when they should be focused on an administrative role? Is it true that NYS has stated that Health Home Leads should be focused on outcomes rather than process?

Lead Health Homes are not only responsible for an administrative role, they are also delivering Health Home care management services directly and with network partners while making decisions about how the Health Home should operate. Although the State has posted several required forms and assessments, the State anticipates that Health Homes may have other forms and assessments they will want to use to standardize the provision of care management. The State has stayed away from proscribing process and will be holding Health Homes responsible for meeting quality measures. Health Homes have the flexibility to decide the processes and policies to achieve the best outcomes.

11. Health Home Care Plans will include activities like smoking cessation, wellness groups, peer run services etc. Will those services that are identified on the Care Plan now be approved for Medicaid Transportation?

Currently Medicaid transportation will only cover transportation for medically necessary services such as medical or behavioral health visits. Smoking cessation is a Medicaid covered service so transportation to smoking cessation services would be covered, but not transportation to wellness groups or peer run services, unless these services are part of a medically necessary service, e.g. OMH's Personalized Recovery Oriented Services (PROS).

12. Can Medicaid dollars be used to pay for client travel to and from social service provider's office, PCP, specialist, public assistance office, housing appointment etc.? Due to limited income a number of our clients are unable to attend vital appointments which affect their health. Is there Medicaid transportation reimburses for care plan development and review meetings?

Medicaid transportation will reimburse for medically necessary services such as Health Home care management visits as well as medical and/or behavioral health visits.

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Quality Metrics and Evaluation

1. What is meant by 'clinical risk groups'?

Clinical Risk Groups ™ (CRG) are a 3M product to place patients in clinical and severity levels based on diagnostic acuity. CRG™ is used in development of the Departments suggested Health Home assignments.

2. What data base/metrics will be used to determine the effectiveness of Health Homes? Who will receive this information?

As part of the State's responsibility to CMS we will be collecting data as outlined in the SPA and reporting it to CMS. The State will also be outlining in the SPA the evaluation mechanisms for determining the effectiveness of Health Homes. On April 9, 2014, CMS introduced the Core Set of Quality Measures for Medicaid Health Homes. Health Homes will be apprised of these measures since they are responsible for submitting data on the Core Measures to the Department.

3. What will be the clinical/quality outcomes tracking tool?

The New Core Set of Quality Measures (the comprehensive list of quality measures the State will track) is available on the Health Home website in the SPA: (

4. Will providers be required to adhere to HEDIS standards?

Health Home providers will be required to meet/adhere to the Health Home quality measures, many of which are based on HEDIS standards. Based on provider type and other programs' requirements (e.g., MCO), many providers will be required to meet all HEDIS standards.

5. What is the nature and frequency of required reporting?

Most of the data will be extracted from claims and encounters data. The Health Home Care Management Assessment and Reporting Tool (HH-CMART) is collected on a quarterly basis.

6. Will patients enrolled in a Health Home be excluded from calculation of readmission rates for a hospital if that hospital is not the health home?

All hospitalizations will continue to be factored into the readmission rate calculations but Health Homes can be reported separately for comparison purposes.

7. Will there be regional Health Home advisory committees comprised of stakeholders including consumers and families?

Several Health Homes have implemented regional advisory committees with members who represent providers, plans, peers and members.

As of now, there is a Learning Collaborative series facilitated by the Center for Health Care Strategies in close partnership with DOH and with support from the NYS Health Foundation and will be open to invited representatives from Health Homes. Findings that emerge from this forum will help guide ongoing implementation efforts and inform state policy decisions around this significant delivery system reform effort. The Health Homes Learning Collaborative aims to build from the success of the earlier CIDP Learning Collaborative, which identified critical elements of successful care management programs for high-need beneficiaries, and in doing so, helped shape New York's current Health Home strategy.

Health Homes and Managed Care Organizations have formed a consolidated work group replacing two earlier work groups that were established to address outstanding policy and operational issues related to Health Home Implementation. This Consolidated Workgroup includes representation from Health Homes, (including network partners) and Managed Care Organizations.

8. What will happen to Health Homes that are not meeting the expectation of the consumers?

The State and Managed Care Plans will be closely monitoring the quality of the health homes. The State and Plans have broad latitude in deciding where to assign members and will only assign members to Health Homes meeting quality measures. Plans can also move their members out of Health Homes that are not meeting the needs of members.

9. Will DOH provide a toll-free number and web site in which stakeholders can voice concerns about underperforming Health Homes?

Members can communicate concerns about Health Homes with their Health Home team and their managed care plan and if that does not resolve the concern, contact the Medicaid Helpline at 1-800-541-2831.

10. We understood that the Health Homes were expected to provide a call-center service 24/7. Is that correct or has there been a change in this expectation?

Health Homes are still responsible to establish a 24-hour, 7 days a week call center service to assist their members. The Medicaid Helpline operates only during business hours and will address general questions or concerns. Complaints can be reported to the Medicaid Helpline at 1-800-541-2831. .

11. Is there a proposed standardized risk assessment for Health Homes to use with members upon enrollment into a Health Home? If there is not a standardized risk assessment tool, is there guidance for what Health Homes should include in their assessment?

For a member entering a Health Home, a FACT-GP and HH Functional Assessment must be completed at enrollment, annually and at disenrollment. These will be reported to the State through the HH-CMART tool and used to inform quality measures and outcome reporting. These are limited tools and do not take the place of the comprehensive assessment needed to develop a care management plan for the member. The care manager should use all resources that are available for that member to ensure the most appropriate care management plan is formulated including information from previous care management. We would also expect care managers to use validated assessment tools most appropriate to the member's situation. There are a number of tools such as the DLA Assessment and SBIRT that are available for use.

12. Do we have to use the FACT-GP Assessment posted on the Health Home website?

Yes, all Health Homes must use the FACT-GP functional assessment and the Health Home Questionnaire but are also able to use other additional assessment tools the Health Home finds useful.

13. If someone is already in case management through another mechanism with a Health Home entity, can we use an existing baseline risk assessment or are we required to complete a new Health Home baseline risk assessment?

For a member entering a Health Home, a FACT-GP and HH Functional Assessment must be completed at enrollment, annually and at disenrollment. These will be reported to the State through the HH-CMART tool that will be released shortly. The results of these assessments will be used to adjust the risk scoring for members and, through that, the applicable rates. These are limited tools and do not take the place of the comprehensive assessment needed to develop a care management plan for the member. The care manager should use all resources that are available for that member to ensure the most appropriate care management plan is formulated including information from previous care management. We would also expect care managers to use validated assessment tools most appropriate to the member's situation.

14. Does the assessment have to be conducted only face-to-face or can it be conducted telephonically as well? Face-to-face requirement is a potential obstacle to expeditious enrollment. Also it is unlikely that someone who self disenrolls from a Health Home will be available/willing to complete a functional assessment.

The FACT-GP and HH Functional Assessment as well as the comprehensive assessment must l be conducted face to face. If at disenrollment it is not possible to do these face to face, telephonically could be allowed.

15. The Inpatient Utilization General Hospital Quality Measure Specification includes the rate of utilization of acute inpatient care per 1,000 member months. Data is reported by age for categories: Medicine, Surgery, Maternity (emphasis added) and Total Inpatient" Since Pregnancy is not one of the medical conditions in the Health Home program, how are we to interpret this?

While pregnancy is not a qualifying condition for Health Homes, if members have maternity stays, the stays are included in the inpatient utilization measure. Inpatient utilization is not limited to specific conditions; it is inclusive of all stays just like the HEDIS measure for the Medicaid membership.

16. How do we access the FACT-GP score for the homeless?

Question HH6 is scored on a Yes and No basis. 8 points is scored for NO and 0 is scored for YES. A higher score represents better health, a score of "0" indicates that the member was homeless in the last 7 days; if they are housed, the score is "8". Official scoring guidelines for the FACT-GP and Health Home Functional Questionnaire, which include some reverse scoring methods, can be found on the Health Home website at:

17. Are Care Coordination agencies to enter the FACT-GP data and when should this occur?

The FACT-GP Health Home assessment should be done by the Care Manager or a delegate of the Care Manager. Aggregate scores will be reported to the lead Health Home as part of the Health Home CMART process metrics data collection process.

18. When do we use the required Health Home tools (for example the functional assessment) with Legacy clients?

These should be utilized for existing members as soon as possible, and used upon enrollment for new members. Please use the appropriate language translated forms.

19. What is the purpose of the Health Home Care Management Assessment Reporting Tool?

The Health Home Care Management Assessment Reporting Tool is a database tool developed by the Office of Quality and Patient Safety in conjunction with OHIP Health Home Program to collect process metrics. The tool collects data for the intake and intervention phases of care management services for members involved in Health Homes.

The HH-CMART database tool is used for the collection of standardized care management data for members assigned to Health Homes. The data will provide the NYS Department of Health with information about care management services provided to members, in order to evaluate the volume and type of interventions and the impact care management services have on outcomes for people receiving these services.

The data collected in the HH-CMART will be used in conjunction with Medicaid claims data to evaluate impact to utilization and quality of care for members involved in Health Homes.

20. How can Health Homes contact the Department about questions and updates?

Support webinar/calls regarding the HH-CMART focus on training and discussions around technical issues. Providers are encouraged to ask questions and provide information on situations they encounter so the Department can develop case scenarios in order to assist with consistent data entry into the tool. For questions about the specifications and general reporting guidelines, email the Health Home Team with the subject of Quality Metrics via the Health Home website at: or call the Health Home Provider line at 518-473-5569.

21. Is the HH-CMART reporting data collected by the Health Home rather than the case management provider?

The Health Homes will submit a single file that is a compilation of Health Home CMART data from all care management partners on each Health Home member. The Health Home and Care Management partners must develop a process for the Health Home to collect the Health Home CMART data.

22. Is there a central location with more HH-CMART information?

All information regarding HH-CMART can be found on the Health Home website ( This includes a Technical Specifications Manual, user guide, reporting schedule, and additional frequently asked questions specific to the Health Home Care Management Assessment Reporting Tool.

For information related to Assessment, Process and Quality Metrics:

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Managed Care

1. 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 Managed Care Plans to work with RHIOs. Provider Led Health Homes and their network partners (as specified in the HIT standards) have 18 months to meet final HIT requirements which include working with a RHIO/qualified entity (QE).

2. 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 Managed Care Plans in their area?

There is no requirement that MCOs have ASA's with all Health Homes or vice versa, although this is strongly encouraged. The State is obligated to provide members with a choice of Health Home 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.

3. How can Health Homes obtain contact information for MCOs?

A list of contacts for each of the MCOs is posted on the Health Homes website A list identifying the counties that each MCO offers services in is also posted on the web.

4. In a plan specific agreement with a Managed Care Plan, can performance be included such as documentation, number of services to be delivered, number of contacts, etc.?

No. These requirements cannot be imposed on Health Homes and should not be included in the agreement or any appendices.

For information related to Managed Care:

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Member Forms

Health Home Patient Information Sharing Consent (DOH-5055)

1. Is a special Health Home consent form needed?

Yes. The Health Home Patient Information Sharing Consent (DOH 5055) form is used by the Health Homes to allow for information to be shared between the Health Home and network partners approved by the member.

2. What are the goals of the Health Home consent (DOH-5055)?

The ultimate goal of the Health Home consent form is to get the member into a Health Home, able to receive coordinated services based on a reasonable understanding of the member's health care needs and medical history. The Health Home consent allows partners in the member's Health Home team to share appropriate information to assist the member. The members served by Health Homes are chronically ill, often disenfranchised from even the fragmented system of health care they access and often have hierarchical concerns for food and shelter. They often have low trust of the system and low health literacy, both adding to the concerns of interacting with the health care system. This single consent signed opens the Health Home gateway of care to quickly meet critical care needs, build trust in accessing the system of care, and build self-reliance skills in managing health care conditions.

3. Who is responsible for obtaining consent – lead Health Home or Health Home provider?

The lead Health Home is responsible for ensuring that consent is obtained, but may delegate this responsibility to a care management provider in its network. The Health Home consent can be found at:

4. What will the signed Health Home consent (DOH-5055) allow?

When a member signs the DOH 5055 consent form, s/he gives permission for the Health Home to obtain pertinent information needed to assess the member for services. In addition, the signed consent allows the Health Home care manager to share patient information with network partners and others approved by the member to formulate and maintain an appropriate plan of care.

5. Why was the first original DOH 5055 consent form revised?

The original consent form as a multi-entry consent form was difficult for some Health Homes and RHIOs to operationalize. Additionally, it was tied directly to the RHIO consent so that if a member withdrew their Health Home consent, it impacted the RHIO consent process. The form was modified to accommodate those RHIOs that use a single-entity consent. This separated the Health Home consent from the RHIO consent process except for the lead Health Home which still has its RHIO consent tied to DOH-5055. Health Home partners must still obtain a signed RHIO consent form to allow those partners direct access to the RHIO.

The original consent form was approved by all the appropriate state agencies. Likewise, this consent was reviewed and approved by OMH, OASAS and DOH. It includes the necessary language from the NYeC consent.

6. Will the RHIO consent form automatically allow a Health Home lead or any Health Home partner access to and sharing of Health Home member's medical records/care plan stored in the RHIO?

No. A signed RHIO consent form will only allow access to the RHIO if the organization is a member of that local RHIO.

7. Why was the DOH 5055 consent form revised again in December 2013?

In December 2013, the form was again revised to include language related to PSYCKES (Psychiatric Services and Clinical Knowledge Enhancement System for Medicaid), a HIPAA complain web application developed and overseen by The Office of Mental Health (OMH).

PSYCKES maintains all Medicaid claims and encounter data for clinical decision-making and quality improvement for individuals with any behavioral health service, diagnosis, or psychotropic medication. The New York State Department of Health (DOH) and Office of Mental Health (OMH) have a Memorandum of Understanding (MOU) through which PSYCKES can be accessed to obtain claims data for Medicaid enrollees with a mental health services, diagnosis, or psychotropic medication claim.

PSYCKES data can assist Health Homes to identify, evaluate, plan, coordinate, and manage Health Home members. This sharing of information will support the coordination of care by agencies serving the Health Home member. To support this, PSYCKES language was added to the DOH 5055 consent form. This latest updated version was posted on the DOH Health Home website in English and 7 translated languages in April 2014.

8. Doesn't the PSYCKES consent form automatically allow a Health Home lead or any Health Home partner access to and sharing of Health Home member's information stored in the PSYCKES.

No. A signed OMH PSYCKES consent form will only allow access to PSYCKES for an authorized user who has applied and been given permission by OMH to access PSYCKES. The authorized user cannot share PSYCKES data with any agency or entity that the member has not approved through signing DOH 5055 consent.

9. Will the OMH consent be needed if the member signs the revised DOH 5055 consent (version 12/13)?

No. Once the revised DOH 5055 consent (12/13) is completed and signed by the member, a separate OMH consent form is not needed for the Health Home to share information with its network partners approved by the member.

In order for a network partner to access PSYCKES database directly, they must be an 'authorized user' of PSYCKES, and have the member sign an OMH PSYCKES consent.

10.Do all current Health Home members need to sign the revised DOH 5055 consent?

No. A revised consent (12/13) will only need to be resigned by members for whom access to PSYCKES is appropriate. Otherwise the current version of the DOH 5055 (11/12) consent remains in effect in the member's record.

11.Can the member refuse to grant permission for the Health Home to access and share PSYCKES data?

Yes. The member has the right to refuse access to PSYCKES by the Health Home and others. Some members may not feel comfortable with providing access to all PHI provided through PSYCKES. The consent form must clearly indicate which entities have been declined access by the member.

It is the responsibility of the Health Home and/or care management agency to assure the member understands the benefits of providing consent, what information will be accessed and how information is shared.

12.How do Health Homes access PSYCKES?

All Health Homes are required to be authorized users of PSYCKES. Information on becoming an authorized user can be found on the OMH website at:

13.What if an agency already has access to PSYCKES?

If an agency is already an authorized user of PSYCKES, the agency can continue to access PSYCKES data as long as an OMH PSYCKES consent has been signed by the member.

The current version (11/12) of the DOH 5055 does not allow for the sharing of PSYCKES information, only information from the RHIO. Once the revised DOH 5055 version 12/13 form is posted to replace version 11/12 PSYCKES, data can share between the Health Home and providers on page 3 of the consent approved by the member.

Health Home Patient Information Sharing - Withdrawal of Consent (DOH 5058)

1. What is the purpose of the DOH 5058 Health Home Patient Information Sharing Withdrawal of Consent?

As a voluntary program, an individual who has signed the DOH 5055 Health Home Patient Information Sharing Consent may choose/be disenrolled from the Health Home program. By signing the DOH 5058 form, the member is indicating intent to disenroll from the Health Home program. Also, Health Home and all providers and others approved by the member on page 3 of the signed DOH 5055 may no longer obtain and share PHI about the member. This includes all information obtained from the RHIO and PSYCKES.

2. Why has the 11/12 version of the DOH 5058 Withdrawal of Consent been revised?

The DOH 5058 form was revised (new version 1/14) to correlate with recent revisions to the DOH 5055 consent (12/13) which now includes language allowing Health Homes to access and share data obtained from PSYCKES as well as the RHIO.

PSYCKES language has been added to the DOH 5058 Withdrawal of Consent form supporting a member's right to request disenrollment from the Health Home program and withdrawing his/her permission for Health Homes to continue accessing and sharing PHI from the RHIO and PSYCKES.

3. What happens if the member refuses to sign the DOH 5058 Withdrawal of Consent form?

The reason for signing the DOH 5058 Withdrawal of Consent must be clearly explained to the member. If s/he refuses to sign the DOH 5058, this must be clearly documented in the member's record. The Health Home must comply with the date of notification of disenrollment and end all sharing of PHI.

4. How do providers serving the individual obtain PHI from the RHIO or PSYCKES once the DOH 5058 Withdrawal of Consent has been signed by the member?

If the individual gives permission for providers to obtain PHI from the RHIO after disenrollment from the Health Home program, s/he must sign a separate consent form with the RHIO agencies accessing data from the RHIO and must have permission to access the RHIO.

If the individual gives permission for providers to obtain PHI from PSYCKES, s/he must sign the OMH PSYCKES consent form. The provider wishing to access data from PSYCKES must be an authorized user of PSYCKES.

Health Home Opt-out Form (DOH 5059)

1. What is the purpose of the DOH 5059 Health Home Opt-Out form?

Enrollment into the Health Home program is voluntary. Therefore, if an individual does not wish to enroll in the program, and has not signed the DOH 5055 consent form, the DOH 5059 Opt-Out Form is used. This form notifies the Health Home of the individual's choice not to enroll.

2. What if the assigned/referred individual refuses to sign the DOH 5059?

If the individual expresses their choice not to enroll in the Health Home program but refuses to sign the DOH 5059, the Health Home/care manager must complete the DOH 5059 and document that notification from the individual was received specifically declining enrollment. The date and time of notification should be included.

3. Is the DOH 5059 also used when a member who has signed the DOH 5055 requests/is disenrolled from the Health Home program?

No. In cases where the individual signed the DOH 5055 giving permission for the sharing of PHI, the DOH 5058 Withdrawal of Consent Form must be signed when a member is disenrolled (refer to the DOH 5058 form). The DOH 5058 negates permission for the sharing of PHI effective on the date noted at the time of signing.

The DOH 5059 is used when an individual chooses not to enroll in the Health Home program, and therefore, has not signed the DOH 5055 consent form.

For information on Member Forms:

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1. If a client was disenrolled from the Health Home and then reenrolled do they need to sign a new Health Home Consent? What happens when a client does not sign a Withdrawal of Consent and they are disenrolled? We have a number of clients who are lost to contact or go in and out of the Health Home because they lose their Medicaid or don't meet their spend-down requirements.

Ideally, clients on spend-down should not have to be disenrolled. They should remain on the Health Home enrollment file but the PMPM cannot be billed for a given month unless they have active Medicaid for that month. Disenrollment, withdrawal of consent and subsequent reenrollment of the client would not be required. The Department is exploring the creation of an "inactive" status in the Health Home Member Tracking System to facilitate this process.

2. In planning for enrolling children in Health Homes, the fluctuating Medicaid eligibility will be extremely complex. Children move on and off Medicaid based on their parents' employment and also move between "deemed" Medicaid and community Medicaid (#'s change and gaps in accessing approval occur).

Children currently get 12 months of "continuous coverage" from the date of the eligibility determination, meaning that they're eligible for a year regardless of their income.

3. Can the Health Home bill be used for spend down?

The market value of the Health Home service would be difficult to calculate because Health Home payments are individually calculated based on member acuity. This will be revisited once the Health Home rates are restructured.

4. Where should I send the payment portion in New York City? Are there specific locations to send the pay-in portion in New York City?

Yes, individuals participating in the Pay-In program in New York City should send their payment to the following address: HRA Division of Accounts Receivable and Billing (DARB), 180 Water Street, 9th Floor, New York, NY 10038

5. What does "excess resources verified" mean?

People who are 65 years of age and older, certified blind or certified disabled must have a resource test. If a person has documented their current resources, they are eligible for outpatient long term care services in the community. The term "reference to resources" refers to an individual who in addition to having a resource test has an income test.

6. What if the eligibility file states "no coverage?

There are specific coverage codes for individuals with limited services packages depending on the level of resource documentation they have provided. The "no coverage" code would be assigned to individuals who have had a resource test and documented their resources but who may also have excess income and have not yet provided bills at or above that level. Functionally, they have no coverage at all until they meet their spend-down.

7. If our clients have met their spend downs with other providers, we as a Health Home can bill for those services. Can we use our charges?

See question 4, above.

8. Can spend down clients be sent to a collection agency?


9. If you don't submit bills to reach your spend down are you still enrolled in the Health Home?

If an individual has provisional coverage and has an open Medicaid case but hasn't yet met their spend down, the individual can remain enrolled in the Health Home if they are eligible, but the Health Home cannot bill for services unless the individual has active coverage for the month.

10. Who is the principal provider for the spend-down?

If a person has an excess income and is in a Managed Long Term Care plan they can pay their spend-down to the premium plan and Medicaid will pay the balance of the premium.

11. We are a legacy provider (COBRA) so when we bill, we bill on the first of the month. For the people who are doing the month to month or single month spend-down, will we ever be able to bill for them?

No. The spend down is not based on date of service; it is based on when the bill is presented. .

12. Even though we get the bill in promptly, it can take months for the bill to show up as a "credit" on the account. Is there any policy that says how long a district has to flip the switch from the time they receive the bill?

With the spend down, it is important to understand that whenever that eligibility is met, no matter what date of the month it is, the eligibility goes back to the first of the month. For care management providers who bill, claims are always dated on the first of the month. If care management services were provided for that month and the individual was eligible later in the month, the agency is still able to submit the claim because it goes back to the first of the month.

13. How does spend down work with residents versus non-residents?

If a person does not have acceptable immigration status, the individual is not eligible for full Medicaid. They're eligible for emergency Medicaid only. Spend down follows the same protocol, Individuals who are eligible for emergency coverage only through the spend-down program could only use bills that were for emergency treatment towards their spend down requirement.

14. What entity would be the principal provider for the spend-down if the Health Home member is also serviced by an MLTC?

Spend-down is applied to the MLTC premium. MLTC rates are constructed with that consideration.

15. The February 2014 Medicaid Update has a good explanation of the "cannot bill" policy for Medicaid.

Yes, this publication is a good source. The Medicaid Update is the forum in which the NYS Medicaid Program communicates policy changes, billing procedures and changes in reimbursement, recipient eligibility and the Medicaid payment system. This newsletter is mailed to over 50,000 Medicaid providers throughout NYS.

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