Questions and Answers
February 25, 2013
- Note: Any questions which have been added will have the word NEW preceding them and any answers that have been revised will have the word UPDATED preceding them.
Table of Contents
- NEW General
- Health Home Letter of Intent/Applications/Provider Enrollment/Application Form
- Targeted Case Management (TCM)
- Chronic Illness Demonstration Project (CIDP)
- NEW Population Assignment/ Eligibility (Patient Tracking System)
- NEW Billing and Payment
- NEW Health Information Technology
- Health Home Network
- Health Home Design
- Quality Metrics and Evaluation (CMART)
- NEW Member Consent
- Revised Managed Care
1. What is the difference between Medical Homes and Health Homes?
The Patient-Centered Medical Home (PCMH) is a model for care, provided by physician-led practices, that seeks to strengthen the physician-patient relationship by replacing episodic care based on illnesses and individual's complaints with coordinated care for all life stages, acute, chronic, preventive, and end of life, and a long-term therapeutic relationship. The physician-led care team is responsible for coordinating all of the individual's health care needs, and arranges for appropriate care with other qualified physicians and support services.
The health home model of service delivery expands on the traditional medical home model to build linkages to other community and social supports, and to enhance coordination of medical and behavioral health care, with the main focus on the needs of persons with multiple chronic illnesses.
The State Medicaid Director's Letter (SMDL#10-024) provides a background and evolution of medical homes and Health Homes and can be accessed at https://www.cms.gov/smdl/downloads/SMD10024.pdf.
2.When will Health Homes be implemented?
Implementation will be phased in. Phase in information can be found at http://health.ny.gov/health_care/medicaid/program/medicaid_health_homes/.
3. Does the Health Home program include long term care?
Yes, on a short term basis. 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, will need to be transitioned into other LTC management programs. The process for conducting this transition is under discussion by State staff. Members in need of long term care services greater than 120 days are excluded from being enrolled into health homes under this State Plan Amendment (SPA).
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 TCM providers, have a connection to a health home?
The State (DOH, OMH, and OASAS) is working with NYCDOHMH, who will assist in the review of Health Home Letters of Intent (LOIs) and applications. The review will be one means of assuring that TCMs are either the lead, or part of, Health Homes. Based on these reviews, applications that do not include TCMs will be asked to find these partners.
6. Is a special Health Home consent form needed?
The State is developing a patient consent form for use by the Health Homes which will allow for patient information to be shared between the Health Home partners, including RHIOs and address HIV/AIDS, mental health and substance abuse information.
7. Who is responsible for obtaining consent – lead Health Home or Health Home provider?
The lead Health Home is responsible for securing the consent from Medicaid members.
8. How will DOH know that patients are more stable and can be moved from "high" to "mid"? Or, once a high, would they stay a high because of their clinical score?
Determining the change in acuity will be the responsibility of the care manager working together with the interdisciplinary Health Home team. Through claims data, the DOH will learn of changes.
9. Will the Health Home be responsible for coordinating all transportation needs?
Yes, but actual costs cannot be covered by Health Home dollars.
10. 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?
The DOH and NYCDOHMH are discussing processes to support the transition from jails to Health Homes. We expect that Health Homes will partner with the corrections systems in their communities to establish smooth transitions. NYCDOHMH is looking to work with the Health Homes on these transitions.
11. How will the management/barrier issues that relate to high costs (homelessness) be addressed where there is insufficient capacity?
The State recognizes that there is inadequate housing capacity. It will be important for Health Homes to partner with both shelters and supportive housing providers to help navigate the local challenges and be part of the work to improve access to housing.
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13. When will the State be sharing roster detail with plans and provider-led Health Homes?
The DOH has already begun to share the exchange of data with some Health Homes. However, a Data Exchange Application and Agreement (DEAA) must be approved and access to the Health Commerce System must be obtained before any confidential data can be exchanged. The sooner the provider-led Health Homes complete the DEAAs the sooner lists can be shared.
14. Will Managed Care Organizations (Plans) be designated as Health Homes in NYC?
Under Phase I, plans must contract with provider-led Health Homes.
15. Will you be sending a draft Data Exchange Application and Agreement (DEAA) that we can begin working with?
The DEAA was forwarded to designated Health Homes electronically.
16. Should providers be doing outreach to consumers they currently serve to inform them of these changes?
Members serviced by existing care management programs, such as Targeted Case Management (TCM) programs that are converting to Health Homes can start to discuss the switch to Health Home. For members that are not in care management programs already, Health Home partners should wait to get their lists so as not to confuse a member who may not make the initial assignment rosters.
17. Is it possible to join more than one network and what is the time frame to join?
It is possible for a provider to join more than one Health Home partnership. Discussions about timing is between the existing organization and the Health Home partnerships.
18. What will be the methodology for partners in the Health Home to bill for case management services and will contracts need to be developed between Health Home and partners or subcontractors?
Prior to billing, the Health Home roster must be completed including identification of each member's designated Health Home, consent forms, contracted provider and care management agency. The State designated Health Home will bill eMedNY per member, per month (PMPM.) Health Homes must have contracts with any partner they will be paying for the delivery of Health Home services.
19. Is there a difference between provider-based and provider-led Health Homes?
There is no difference between a provider-based and a provider-led Health Home; just two different terms.
20. What does "start date" mean? Will enrollment be expected on that date?
This is the date that program implementation will cThere is no specific internet resource that identifies Medicaid providers by county. However, to obtain county information Managed Care members should contact their MCO for a list of participating plan providers or access their MCO's website. Medicaid fee-for-service members can utilize the New York State Physician Profile website at http://www.nydoctorprofile.com/. Go to the "Click here to search for a physician" icon and then select the "Advanced Search" icon to select by a specific county.ommence including enrollment.Health Homes will start getting their lists from the State and Plans, can enroll members that are currently in care management programs and begin outreach and engagement.
21. 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 of sharing collected information with other partners and collecting and reporting specific quality measures as required by New York State and CMS.
22. Will the state assist in creation of standardized forms?
Standardized forms and tools unique to each Health Home are supported by DOH, but, DOH will not develop them. Consent forms and metrics will be standardized and some templates will be developed as enrollment and declination tools.
23. Please elaborate on the low need individuals not being part of the initial phase of Health Home?
The initial phase will focus on members who are at risk of hospitalization and/or have low ambulatory connectivity. Members targeted are those who have high cost and complex chronic conditions that drive a high volume of high cost inpatient episodes. The low need members tend to have meaningful ambulatory care connections and are currently well managed.
24. The implementation date for Phase 2 is listed on the website as April 1. Has the date been revised since it is past that date?
The implementation date for Phase 2 is April 1. This date corresponds to the effective date of the Phase 2 State Plan Amendment (SPA), which is still under review by CMS. OMH (and COBRA) converting case management programs for Phase 2 may bill retroactive to April 1, for members already engaged in targeted case management. Guidance will be issued for OASAS MATS programs as to the effective date for Phase 2 billing. Converting case management programs will receive additional guidance on billing the Health Home rate codes for legacy slots and information on the retroactive reprocessing that will adjust post-April 1 date of service claims from the pre-Health Home rate code to the new Health Home rate code.
25. When will the decision be made on applications for the Phase 3 Health Homes and what is the expected start date?
Phase 3 begins July 1st which is aligned with the effective date of Phase 3 State Plan Amendment (SPA). SPA's for Phases 2 and 3 are still under review by CMS. Contingently designated Health Homes in Phase 3 will be announced starting in late July-August. Once the SPA for Phase 3 is approved, converting case management programs may bill retroactive to July 1, for members already engaged in targeted case management.
26. Will DOH provide training for Health Home staff?
DOH 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 is pursuing an enhanced 1115 waiver to provide funds for Health Home Development, which would include additional resources for workforce training and retraining.
27. 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
28. 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 the Health Home program is exploring resources that could be developed, including an ASL video.
29. 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
30. What is the FMAP rate for costs NYS incurs in administering, overseeing, and assessing/reporting quality measures? Would states be able to claim the enhanced match for these activities, or the state's regular FMAP?
Only costs connected to the provision of Health Home services are eligible for the enhanced match.
31. Health Homes will bill NYS Medicaid for their care/case management services once operational, is there any funding available for implementation?
At this point in time there is no source for implementation funding. The State is pursuing an enhanced 1115 waiver to provide funds for Health Home Development.
32. 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 eligibles with managed care coverage (even if the Managed Care individual receives carved out services through FFS).
33. Is the state working on developing specific documentation forms beyond the Matrix and Tracking forms? 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, the Health Home Patient Information Sharing Withdrawal of Consent and the Health Home Opt-out Form. It is at the discretion of the Health Home to develop any additional forms they may need.
34. Is there any guidance on state Intensive Case Management progams (ICM) "embedded" with various county programs? How do I know which Phase 2 counties ICM's are embedded? How this will impact OMH ICM's?
Guidance for State ICM's, whether embedded or facility based, will be issued shortly. The OMH central office currently bills the TCM rate codes, so services should be provided under the current TCM regulations.
NEW 35. Will you be holding any webinars for health care recipients/members?
None are scheduled at this time. However, we are developing member specific Health Home information and resources for the Health Home website.
NEW 36. 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 allow TCM case managers to be a representative payee.
NEW 37. Is there an internet resource to identify Medicaid providers by county?
There is no specific internet resource that identifies Medicaid providers by county. However, to obtain county information Managed Care members should contact their MCO for a list of participating plan providers or access their MCO's website. Medicaid fee-for-service members can utilize the New York State Physician Profile website at http://www.nydoctorprofile.com/. Go to the "Click here to search for a physician" icon and then select the "Advanced Search" icon to select by a specific county.
NEW 39. What is the relationship between Health Homes, MCO's and Behavioral Health Organizations?
The BHO monitors Fee-For-Service (FFS) Medicaid admissions for inpatient psychiatric care and detox and reviews discharge planning. Health Homes may want to work with their legal counsel to execute a Confidentiality Agreement with their regional BHO that would allow the Health Home to receive alerts if one of their members was admitted for these services. DOH would then request a copy of such agreement be sent to the DEAA office enabling the BHO to review the discharge plan with the Health Home. The role of the MCOs regarding these services has not changed. 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.
NEW 40. Will the lead Health Homes ever have to go through a process of re-applying/recertifying/etc.?
No, after the initial three year period of designation, the DOH, OMH and OASAS will collaboratively review each Health Home's performance to determine if the program 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 process and quality metrics will be considered, effective engagement and retention rates and member satisfaction of enrolled Health Home members.
Health Home Letter of Intent/Applications/Provider Enrollment/Application Form
1. What is the envisioned timeline and activities for this conversion/effort?
Health Home implementation will be phased in starting January 1, 2012. Details regarding the timeframe and activities for implementation can be found on the Health Home website at http://health.ny.gov/health_care/medicaid/redesign/docs/2011-07-12_medicaid_redesign_plan_workbook.xls. Search for MRT project #89.
2. When will the Health Home provider application be available?
The Health Home Provider application became available on 8/2/11 and can be accessed on our Health Home website at http://health.ny.gov/health_care/medicaid/program/medicaid_health_homes
3. To what extent is the application for Health Homes being widely distributed to all qualified entities? Or is it being targeted primarily to convert existing TCM providers?
The availability of the application process was announced via the Health Home listserv which includes a wide variety of stakeholders and interested parties. If you wish to be included on the Health Home listserv, contact us at email@example.com. TCMs are strongly encouraged to apply, but are not the primary target of Health Home applications.
4. Can applications be submitted at any time?
No. Applications for phase 1 counties that submitted LOIs in September can be submitted through November 1, 2011. Application due dates for phase 2 and 3 have not yet been determined.
5. What will the HH application/attestation look like/entail?
The Health Home application includes general demographic questions regarding the applicant, specific questions about the applicants' network, and the ability of the applicant to meet the Health Home Provider Qualification standards. http://health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/inter_health_home.pdf (PDF, 44KB, 6pg.)
6. How many HH applications will be accepted per city? Per region?
a. How is this being determined?
b. By patient to provider ratio?
c. Geographic region?
Currently, there is no restriction on the number of Health Home applications being accepted as long as a LOI was received by the State in September from the lead Health Home applicant. Applicants are reminded that priority will be given to applications that demonstrate strong and extensive community based organizations and direct service provider networks.
7. During the transitional period, what kind of technical support will be provided?
The State will provide technical assistance for Health Home providers and interested parties that will include webinars, learning collaboratives, and written guidance documents. The State plans to maintain a highly collaborative working relationship with health home providers through frequent communication and feedback.
8. Is there workforce training funding available to ensure behavioral health case managers are capable of understanding the health care coordination mandates under Health Homes?
9. Is it possible to have a rolling implementation of the model Upstate?
The State will be phasing in implementation of Health Homes by county. Implementation phase in information can be found at http://health.ny.gov/health_care/medicaid/program/medicaid_health_homes/.
10. Will community based providers have to link with a single medical provider for an application or will separate applications be required for each partnership?
We expect applications to include multiple direct care providers, community based organizations, and health plans. If a community based provider plans to become a Health Home, they must link with a wide variety of medical, behavioral and social services providers within their network to meet the Health Home Provider Qualification standards. If community based providers wish to be included in a Health Home network, they should contact providers in their community regarding their availability and willingness to become a network provider.
11. Can a local governmental unit as defined in Article 41 of Mental Hygiene Law (e.g., County Mental Health Department) be a health home provider?
Any Medicaid enrolled provider that meets the Health Home Provider Qualification standards can apply to become a Health Home.
12. Is the health home program to be limited to Medicaid HMOs?
13. How prepared are the larger hospitals or managed care companies to respond to the application?
It is expected that larger hospitals and managed care companies that develop strong links with their community providers will likely be prepared to apply.
14. If an FQHC or other provider is otherwise suited to be a health home, but cannot meet the guidelines due to hospitals' inability or unwillingness to share information on ER and admissions to achieve prompt notification of an individual's admission and/or discharge to/from an emergency room, inpatient, or residential/rehabilitation setting, will the hospital be required to share that information?
No. However, the State expects hospitals to partner with community organizations and is interested in hearing from potential applicants about their challenges and obstacles in meeting Health Home requirements and is willing to assist, as feasible, in resolving these issues. In addition, community based organizations should also seek to partner with managed care plans to meet the qualifications and standards.
15. Could certain Health Homes be designated to enroll children and demonstrate a robust and separate sub-network for children behavioral health services as opposed to each network exhibiting some minimal capacity to serve children with severe emotional disturbances?
No. Health Homes must be able to provide comprehensive, coordinated, and integrated health home services to both adults and children based on their enrollees' medical, behavioral and social needs. Health Homes are expected to seek out and include providers within their network that provide specialty services. However, we expect that some Health Homes may have experience in serving specialized providers.
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17. Do you have any further information on becoming a Health Home?
The Department's Health Home website is the source of information about New York's Health Home and is frequently updated with new information. We recommend that interested parties visit the website on a regular basis for updated information.
18. How supportive is your department of a health home being in an article 31 vs. article 28?
The Department is very interested in and supportive of receiving applications from a variety of Medicaid enrolled providers including Article 31 providers.
19. What will be the staff qualifications for the Care Managers under this initiative? And what will be the qualifications of the supervisory structure?
The Health Home applicant will determine the supervisory structure and job description of their care manager positions, including professional discipline (if applicable), along with relevant education, training and experience in their Health Home Provider application.
20. Can multiple health care practitioners get together to establish a HH?
21. Can a Health Home have more than one Managed Care Organization in its network?
22. Does the fact that "the NYS Medicaid program plans to certify Health Homes that build on "current provider partnerships" mean that most or all of the certified Health Homes will be existing Medicaid or other managed care plans? If not, what other "current provider partnerships" qualify for health home certification?
No. "Current provider partnerships" is a term that the Department uses to recognize he many formal and informal relationships that presently exist in communities that provide medical, behavioral and social services to the Medicaid population. It is expected that potential health home providers will use these existing relationships to develop their health home networks.
23. Do these current provider partnerships include the full range of health home services across primary care, behavioral health care (both substance abuse and mental health) and both adult and pediatric care?
They may. However, all health home applicants will be held to the same Health Home Provider Qualification Standards in terms of demonstrating strong and extensive medical, behavioral health, and social service networks to meet the needs of their Health Home enrollees.
24. Does the requirement for current partnerships preclude the development of new provider partnerships to form Health Homes?
25. Are the non-TCM providers being required or encouraged (mandated) to utilize the existing network of effective community based providers who can do the care coordination?
The Department is encouraging, but not mandating, potential Health Home applicants to make full use of community resources as they develop their Health Home networks.
26. Will there be room for small providers that typically cannot compete with large healthcare structures but were able to serve a niche population well?
Yes. Health Homes must have a full array of medical, behavioral, and social services providers within their network. Therefore, small providers that cannot meet the Health Home Provider Qualification standards but still wish to serve niche populations are encouraged to contact providers within their community regarding their interest in becoming part of a Health Home network.
27. Could Health Homes contract with LHCSAs, waiver providers, and other entities for Comprehensive Care Management or must this service be provided directly by the Health Home.
Yes. Health Homes can subcontract for the provision of health home services, including comprehensive care management. However, the Health Home provider remains responsible for all health home program requirements, including the services performed by the subcontractor.
28. Can you give us some help with what type of formal agreement/supporting documentation will be needed from the hospitals with us:
- a. what will the linkage requirements need to state- what is the language
- b. what specifically will the hospitals need to agree to do/what will we specifically need to do for them.
The Department is not providing specific contract language regarding the relationship between the Health Homes and its network providers. The Health Home is responsible for developing and executing theses contracts. At a minimum, the contracts will need to address the terms of participation, minimum time frames for access to services, provision of crisis intervention and responsibility of each provider.
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.
29. What is the NYS definition of "prompt notification" of an enrollee's admission and discharge?
The Department is not defining prompt notification. The Health Home applicants will define the specific process and time frames they plan to use to assure prompt notification of emergency and inpatient facility admissions/discharges.
30. Where do peer advocates fit in?
Health Homes are encouraged to utilize peers as part of their multidisciplinary team, especially with activities relating to patient and family support and utilization of community and social support services.
31. Can organizations submit one comprehensive application to provide health home services for both people with multiple chronic illness and people with behavioral health conditions?
32. In response to Section A question 2, are we supposed to include actual people or just types of positions?
Types of positions.
33. If two separate entities are applying for two separate Health Homes (both as the their own lead) but plan to work together in some instances (could be health plans, hospitals, etc) , should they be listed as network participants in the separate LOI's?
34. For Section C, Attestation, is all that is required to "attest" to all the different statements is a signature on the Health Home Provider Attestation Form or is a separate attestation required for each individual statement (1-4 under C and Section B, CMS Health Home Provider Functional Requirements)?
Only one signature is required.
35. Can an applicant co-apply with another organization?
No. An applicant cannot co-apply. There can only be one lead entity on each application.
36. What is meant by "full program maturity" for Table 2.2?
Full program maturity refers to the time the Health Home reaches its full capacity in terms of the number of patients it can manage effectively.
37. Who can be the Health Home lead applicant?
Any enrolled Medicaid provider can be the lead applicant.
38. What should providers do if they intend to be a HH lead or network member but are unable to find hospitals or MCO's willing to partner with them?
Once we receive and review LOIs, the State reserves the right to ask applicants serving the same service area to work together to submit one application.
39. In regard to the submissions requirements, the application states you must indicate licensure type and certification requirements in table 1.1. Can you clarify or define what these two fields actually mean?
Licensure type- specify the field the applicant is licensed (facility license-Article 16, 28, 31, 32, or professional practice license-MD, RPh, etc.).
Certification Type- specify any special designation a provider has, for example, *NCQA PCMH, Center of Excellence, etc.. For practitioners, please indicate specialty (if any) or any special professional designation or qualification provider has earned: Internal medicine, psychiatry, etc.
40. With respect to the creation of Table1:1 for inclusion in the Letter of Intent, what information should be included?
For the Letter of Intent, we only need the organizations. Table 1.1 in the Application will be used to assign patients and, therefore, we are requesting the NPI numbers for all the providers in the network. Some of the providers in your network also may practice at other locations and those locations may be in another Health Home. Therefore, for patient assignments we need to match as much as possible the claims data we have on the billing physician and location so we can assign the patient to the appropriate Health Home. Thus, the better this chart is the more accurate the patient assignments can be.
41. Should specialists be included in Table 1:1?
Yes. The more information that is provided the better for the matches; which while they may not be perfect, the detail may help us get close.
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43. Do you want an applicant to submit attachments with contracts, MOUs, and additional information we think would be helpful?
No additional information, including attachments, should be submitted with the application unless specifically requested by the State.
44. What factors did the State consider when choosing counties for the three phase-ins?
Based on the Health Home applicants' LOIs received in September, counties were chosen based on the strength of Health Home networks within the county, minimal or lack of cross network issues that needed to be addressed, minimal or lack of gaps in the variety of providers within their networks (mental health, substance abuse, social services, specialty services), and geographic mix (NYC, suburban, rural).
45. Must the enrollee reside in the county being implemented to be enrolled in a Health Home?
46. As the lead applicant planning to provide services in one of the Phase 1 counties, can I also serve enrollees in Phase 2 and 3 counties during Phase 1 implementation?
No. As Phase 2 and 3 are implemented, Health Homes already approved to provide HH services under Phase 1 will need to resubmit their application with updated information for Phase 2 and 3 if they plan to provide Health Home services to Medicaid enrollees in these counties.
47. What if the HH network provider has more than one service location?
Each service location should be entered on a separate line in Table 1.1.
48. Should all licensed and funded medical, behavioral, residential, homeless and social service network providers be listed on the application or just licensed treatment providers (e.g. medical, MH, SA clinics, ACT, PROS)?
Any provider that is part of the Health Home network should be listed.
49. Should every licensed clinician providing services at a site be listed on the application or just the clinic?
List all HH network providers (medical, behavioral, and social service) in the Health Home network. For medical and behavioral health facilities and practitioners, include their NPI. This information helps us determine loyalty and attribution for patient assignment. Non-health related network providers (housing, etc.) will not have NPIs.
50. On Table 2.1, what is meant by "Not Currently in Care Management" as opposed to "Initiation" and "Maturity"?
"Not currently in Care Management" refers to the enrollee population that is not currently in a TCM, CIDP, or MATS, or managed care program. Initiation refers to the number of enrollees (capacity) that the Health Home can effectively provide HH services to upon implementation. Maturity refers to the number of enrollees (capacity) that the Health Home expects to serve once it grows to its desired size.
51. Please clarify what the attestation statement "contractual agreements are in place" means?
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. All agreements (including contracts) should describe the roles and responsibilities of each party to the agreement.
Targeted Case Management (TCM)
1. Will all existing children's Blended Case Management, Intensive Case Management and Supportive Case Management providers remain outside the Health Home process initially (first year)?
No. Targeted case management programs can apply to become Health Homes during the first phase of Health Home applications. However, different payment rules will apply for Health Home enrollees that were TCM clients and a new Health Home enrollee.
2. Will children's case management providers have the option to convert to Health Homes?
Yes, contingent on their meeting the Health Home Provider Qualification standards.
3. If some of the kids served by a single provider are enrolled into Health Homes and some remain in case management services do the services have to be "blind" to the distinction.
A TCM that converts to a Health Home will provide health home services to all of their enrollees, including those that were previously in the TCM prior to conversion.
4. It appears that all TCM slots will be converted to Health Homes. Will only agencies with existing TCM program be allowed to convert to the Health Home or will agencies without a present TCM program be allowed to respond?
Although many TCM programs will convert to Health Homes this year with more to follow next year, agencies without a TCM can partner with other community and direct care providers to apply to become Health Homes.
5. What is the rationale for including targeted case management in the list of providers that are able to convert to Health Homes?
Targeted case management programs are uniquely positioned to convert to Health Home because they have a wealth of experience in providing comprehensive case management and extensive community supports to help meet the extensive and complex needs of their clients.
6. In order to continue to provide TCM services, we would need to contract or join a health home entity (HH). Can we join a major hospital/mental health psych as well as other chronic illnesses, HIV/AIDS specialties etc? How would this work theoretically and practically?
While the Department strongly encourages TCMs to convert to Health Homes which assure greater access to medical, behavioral, and social services providers, TCMs are not required to do so at this time. TCMs that plan to convert are encouraged to contact providers within their community regarding their interest in becoming part of a Health Home network. TCMs may also apply to become Health Homes.
7. What happens to existing TCM enrollees when Health Homes are implemented?
Existing TCM enrollees will remain with their TCMs so as not to disrupt existing relationships.
8. How will this work?
TCMs converting to Health Homes keep their TCM enrollees but will be held to Health Home standards. TCMs that do not convert will continue with their enrollees under their existing standards. However, TCMs that do not convert should be aware that TCMs will be phased out over the next two years.
9. Will TCM programs that either become Health Home lead entities or HH network providers keep their TCM slots for two years and bill Medicaid directly for them?
TCM converted HHs will keep their TCM slots for two years from the date the State receives federal approval to implement Health Homes in their counties.
10. During at least the 1st year, if a converted TCM/HH receives a referral to serve a Medicaid-eligible enrollee that is seriously and persistently mentally ill (SPMI), can the converted TCM/HH place the individual in one of their converted TCM/HH slots (if available) and bill Medicaid directly for HH services at the TCM rate? Can we continue to fill our TCM converted Health Home slots with people who are Health Home participants and bill Medicaid directly at the present TCM rates for one year or two years?
Yes, converted TCM/HHs can place Health Home members into available converted TCM/HH slots and bill eMedNY directly. Payment will be at the TCM rate for up to one year (based on the SPA approval date) and at a blended TCM/HH rate in year two. See Health Home TCM Legacy Rates Extended for updated information.
11. For currently existing TCM providers, who provides services under the current Deficit Reduction Act definition of TCM services, will the new definition of Health Home services supersede those existing regulations?
The Deficit Reduction Act (DRA) will not apply under a Health Home scenario. However, if a TCM provider is not in a Health Home, the DRA regulations apply.
12. If a Health Home assigns a non- TCM member to a TCM provider can the Health Home bill for non-TCM services at the Health Home rate?
It depends on whether the TCM provider, who is now part of a Health Home, has a slot available to accept this member under the TCM slot or a Health Home slot. If the TCM has slots available then the TCM will bill for this member under the TCM rate, if the TCM does not have an available TCM slot, but is still accepting new members, then the member is billed under the Health Home rate. See Health Home TCM Legacy Rates Extended for updated information.
13. Can you explain more about how OMH TCM will transition into the DOH care coordination role?
Policies are still under development. However, OMH TCM providers have dedicated some or all of their slots to Health Homes. The current TCMs will become care coordinators under the Health Home and will no longer be subject to TCM regulations, past or present. Health Homes will develop their own policies for the role of care coordination, but it is expected that as part of Health Homes, care coordination will benefit from being connected to care delivery directly.
14. Will OMH TCM programs be expected to provide only Health Home care management, or will OMH TCM programs continue to need to meet OMH requirements (e.g., four face-to-face encounters per month per ICM, array of services from regulations, etc.).
Once an OMH TCM program converts to Health Home services (is billing Health Home/OMH/TCM rates) they are no longer subject to TCM rules and regulations. COBRA programs converted to Health Home services once they engaged with a lead Health Home and signed DEAA's and accepted Health Home assigned clients. This conversion is taking place by Phases in each county. Phase 3 counties are just beginning the conversion. The unit billing will be retroactively reconciled with the PMPM legacy rates once all Phases are implemented. See Health Home TCM Legacy Rates Extended for updated information.
15. 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. It is expected that over the next few years, access to health insurance will improve. That being said, only Medicaid eligible individuals can participate in Health Homes. TCMs are going to claim their current TCM rate for a transition period so the services the Medicaid rate has supported can remain intact temporarily while decisions can be made about transitioning non-Medicaid members into appropriate coverage. OMH also is working on guidance for serving non-Medicaid clients.
16. If Health Home cannot bill for TCM enrolled participants how does that encourage referrals for HIV specific services?
Under Health Homes TCM programs will bill for both their TCM slots and Health Home members directly; which includes HIV-specific services, the TCM program. Participating partners will accept referrals.
17. TCM providers will receive the PMPM rate specific to that provider. Will we be required to provide an administrative percentage of this rate to the health plan?
The Health Home and the Health Plan will need to collaborate and decide on any administrative fee.
18. How will backfilling of vacant TCM slots be determined and authorized?
For the first year, any unutilized slots may be used and payment will be at the current TCM rate. Slots may be filled either through assignments made by the lead Health Home entity, through the SPOA, or community referral. See Health Home TCM Legacy Rates Extended for updated information.
19. Will Health Homes be able to assign individuals directly to OMH TCM slots 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 SPOA in making some of these determinations. The State is discussing the role of the SPOAs in assigning enrollees to TCM converted Health Homes and will announce that process once it is completed.
20. 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 slots).
21. How will TCM provider 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 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.
22. 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?
OMH is developing guidance which will be provided once it is completed.
23. Are OMH Intensive Case Management (ICM) programs being carved into Health Homes?
OMH ICMs are included in Health Homes.
24. 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 is currently working with Health Home care managers to allow them to access PSYKES. Some of the Health Home network providers such as clinics may already have access to PSYKES.
25. Who establishes acuity for legacy slots?
DOH calculates acuity based on an algorithm that looks at member claim data. Legacy rates are based on the converting provider's pre-Health Home payments, not on member's acuity scores.
26. Is it true that services provided to consumers in legacy slots paid for by OMH/TCM 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?
Once an OMH TCM program converts to Health Homes (is billing Health Home Service rates/OMH/TCM rates) they are no longer subject to OMH TCM rules and regulations. Each Health Home determines and defines the qualifications required for their care managers.
27. As a converting TCM can billing be done retroactively for outreach and engagement for referred individuals we currently are receiving from SPOA?
DOH will provide guidance shortly.
NEW 28. How would Medicaid ineligible AOT clients be served in a Health Home?
Medicaid ineligible clients cannot participate in Health Homes. There is an Assisted Outpatient Treatment program for ineligible Medicaid clients that is funded through State aid.
NEW 29. How does the Health Home interface with the PSYCKES system?
This PSYCKES system collects Medicaid data to identify what resources and services have been paid for a specific individual whether in a Health Home or BHO. This interface is under review to allow Health Homes to utilize the information.
NEW 30. If TCM programs have clients in Phase 1 and Phase 2, how should billing proceed until Phase 2 is implemented?
TCM programs in Phase 1 may start billing for Health Home services. Billing for Phase 2 members must wait until the State Plan Amendment is approved.
NEW 31. Clarify when the OMH and COBRA TCM regulations no longer apply to TCM services.
Once a TCM program bills for Health Home services using the legacy rates they are no longer subject to TCM regulations.
NEW 32. 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. DOH and OMH are currently developing guidance on integrating the two programs.
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 Department considered the experience of the CIDP to help develop Health Home requirements. The most significant issues arose with CIDP outreach and active enrollment. For example, the upfront cost of conducting outreach activities was higher than expected. Also, by the time Medicaid enrollees were located, some had lost their eligibility or were enrolled in managed care plans (CIDP enrollees were excluded from managed care). In addition, due to the complexity of the enrollee's needs and their functional status, it was difficult to interest and engage this population regarding the benefits of the CIDP as they struggle with life issues. This highlighted the importance of strong community supports, especially related to housing and peer services, specialty services, and access to timely post discharge services.
The Health Home program requirements address many of these issues. For example, the Health Home payment methodology will acknowledge the costs associated with outreach and engagement activities by providing an outreach rate that provides reimbursement for up to three months of outreach activities. Payment will be made prospectively. Medicaid eligibility will be guaranteed for 6 months and managed care enrollees are included in the Health Home program. Medicaid enrollees will be assigned to a health home provider based, to the extent possible, on existing relationships with health care providers or health care system relationships, geography, and/or qualifying condition. Once assigned, enrollees will be given the option to choose another provider when available, or opt out of health home enrollment. In addition, pending federal approval, enrollment in the Health Home will be mandatory with opt out provisions.
The Department also recognizes the value of peer supports and the need for housing and strongly encourages Health Homes to engage peer supports and housing providers within their networks. As part of the provider qualifications, the Department is requiring Health Homes to address transition issues including timely access to post discharge services and networks that include specialty services. The Department will also develop a shared savings model, a feature in the CIDP, as ameans to encourage health home providers toward continuous improvements in reducing avoidable hospital and emergency room costs and improving patient outcomes.
2. If a CIDP covers areas of two boroughs, can it transition into 2 discrete HHs--one for each borough?
The State would prefer to see one application, but if a CIDP can develop two distinct comprehensive Health Home applications that cover each borough and it makes sense for them to operate two Health Homes then they may submit two applications. The State may ask them to combine into one application.
3. Can a provider that is transitioning a CIDP serving two boroughs into a Health Home expand its target area in each borough beyond the CIDP catchment area? The CIDP provider and its network also have both TCM and licensed health/behavioral health programs serving people throughout the boroughs.
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 at the time of application.
2. Will there be a unique patient identifier to inform providers about a patient's health home?
Yes, but the identifier may not be available when the program is implemented. Once the identifier is available, the provider will be able to check the enrollee's Medicaid eligibility and their participation in a health home including the identification of their specific health home.
3. What happens to behavioral health consumers who opt out of a health home?
It is imperative on the health home to engage their enrollees. Initially beneficiaries will be given the option to opt-out and will continue to receive their services as they always did, but if they receive TCM services from a TCM that is converting to health home and wish to continue to receive those serves they must consent to health home services. NY is pursuing an amendment to the current 1115 waiver to make Health Homes mandatory.
4. How will beneficiary health home assignment take place?
The State will use 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 consumers?
The State, and the health plans for non-TCM managed care, 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 provide Health Home providers a roster of assigned enrollees and current demographic information to facilitate outreach and engagement.
SPOAs will continue to play a role in assigning patients to TCM programs. The State is discussing the role of the SPOAs in assigning enrollees to TCM converted HHs and will announce that process once it is developed.
The State also plans to develop a process for accepting referrals from community providers in the future.
6. How will consumers be notified of their assignment?
Members will receive a letter describing Health Homes, their assignment and options to choose another provider, when available, or opt out of health home enrollment.
7. What mechanisms will be employed, and in what time frame, to enroll 408,000 SPMI adults?
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 currently in TCM or other care management will be assigned to Health Homes that include their TCM provider. The goal is not to move TCM patients. With the exception of TCMs, where special arrangements may be made, Medicaid members enrolled with plans will be assigned into Health Homes by the plan utilizing loyalty and attribution data provided by the State.
8. Will the State provide data on the targeted population?
Yes. Information is available at http://health.ny.gov/health_care/medicaid/program/medicaid_health_homes/population_information.htm.
9. Will Health Homes be assigned beneficiaries they have no previous relationship with?
It's possible and likely that some of the assigned beneficiaries will not have a relationship with the HH they are assigned to.
10. Will health 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 algorithm with managed care plans and encourage plans to use this as a means of assigning patients into Health Homes. With the exception of managed care enrollees already in TCMs, managed care plans will actually be responsible for making their own patient assignments to Health Homes.
11. Will there be a mechanism to cap the number of clients assigned to an organization?
The number of clients assigned to a Health Home will be based on the capacity entered on the application and the patient selection algorithm.
12. 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.
13. 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.
See question #20 under Population Assignment/Eligibility (Patient Tracking System) section.
15. How will the State make HH 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.
16. 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).
17. 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. The member would need to have two chronic conditions, HIV/AIDS or a mental health condition. An assigned care manager would then be responsible for coordinating all of the member's care including any substance use disorder treatments the member may need as determined through a care plan.
18. Can you give us an idea as to when the Phase 2 counties will be receiving the list of eligible Members?
Several items must be completed before Phase 2 Health Homes can get their member lists. Phase 2 Lead Health Homes must provide their latest partnership lists to the Health Home program. Lead Health Homes must complete their DEAA (Data Exchange Application and Agreement) and their partners must complete the DEAA subcontractor packet. The DEAA allows DOH to release to the Lead Health Home the Medicaid confidential data and protected health information that is on the patient tracking sheets and the subcontractor packet allows Lead Health Homes to share this information with their network partners. Once the DEAA is approved by DOH, a loyalty analysis will be run to appropriately match Medicaid members who are eligible for Health Home services to the appropriate Health Home. Once this is completed the Health Homes will receive their FFS lists. Phase 2 Health Homes that have completed the steps outlined above can expect to get FFS lists when the SPA is approved. Managed Care Plans can share lists of Managed Care members with Health Homes once they have a contract.
19. How does an entity refer a Medicaid member for Health Home services?
Community referral guidance is still under development. In the interim lead 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.
20 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, the State is considering the option of excluding children diagnosed with a serious emotional disturbance (SED) and children with a substance use disorder (SUD) from Health Homes while other care models are being discussed that target the special needs of these children. Any individual being served in a current adult TCM program can be served in Health Homes.
21. May individuals of all ages be served by a Health Home?
Yes, 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 two multi-agency State workgroups developing recommendations on how children in Health Home should be served. More information on serving children in Health Homes will be forthcoming.
22. 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 designated 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. OMH is encouraging all funded housing providers to network with one or all of the Health Homes in their area.
23. 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 may 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 city jail and/or DOCs 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.
24. Will Medicaid Spenddown, Buy-in and individuals in the Special Needs Trust be eligible for Health Home services?
Medicaid spenddown individuals can be included in the Health Home program for chronic behavioral and medical conditions, provided their Medicaid eligibility can be sustained. LDSS and OMH regional offices can work with members to ensure they meet any spenddown requirements, pursuant to published ADMs. Person's Living With HIV/AIDS (PLWHA's) who have Medicaid spenddown can contact ADAP for assistance with their spenddown 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.
25. 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 eligible for Health Home services. These individuals may be included in future Health Home waves.
26. In the newest Health Home Member Patient Tracking System Guide (6-26-12) on Pg 18; 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. See also Q and A #2 under Member Consent on the Health Home website
27 What information will be used to inform the acuity adjustment and how frequently will the individual's acuity be adjusted? Is there a mechanism for a care manager to request an acuity adjustment?
Claims data will be used to adjust acuity. In the future, the functional assessment information may also impact acuity. During the implementation phase, acuity will be adjusted on a quarterly basis. As rates stabilize acuity may be adjusted less frequently (semi-annually or annually). There is no mechanism for the care manager to request an acuity adjustment.
28. Please clarify the following with regard to Outreach:
1) Minimum activity needed in a month to report on tracking sheet / bill
2) Documentation needed to support
3) 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?
4) Is documentation required in the clients care management record required to support billing for Outreach and Engagement?
1) 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
2)-4) All client contact must be recorded in the case management record. All Health Home Outreach and Engagement activities are billable under the monthly PMPM as long as active outreach is occurring each month and at least one of the five core services (excluding HIT) described on page 13 of the Medicaid Update are provided in each billed month.
NEW 30. How long can care coordination be provided to an incarcerated individual or a resident of a state hospital?
As a rule, Medicaid is active for 30 days for incarcerated individuals and can be restored upon release so that services can be provided and billed. Guidance on Health Home care coordination for inpatients is under development.
NEW 31. Can a Health Home member also be in a Managed Long Term Care plan?
Managed Long Term Care 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 would have the option to enroll in a Managed Long Term Care Plan if available or receive services from a fee-for-service long term care provider. The member would no longer be eligible to be enrolled in a Health Home.
NEW 32. 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 there is a code in the tracking system 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: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/2012-06-26_draft_hh_patient_tracking_system.pdf. Further guidance on members who are lost to follow-up is under development.
NEW 33. Are the volume of assignments to lead health homes dependent on the NPI numbers (providers) enrolled in the HEALTH HOME network?
Yes. DOH is running the number of 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 members.
Billing and Payment
1. Will the State provide real-time access to EMEDNY/MMIS for tracking purposes?
At this time, there are no plans for real-time access to these systems.
2. What will be the reimbursement for Health Home services?
Information regarding Health Home reimbursement can be found at http://health.ny.gov/health_care/medicaid/program/medicaid_health_homes/rate_information.htm.
3. Will TCMs that convert to Health Homes be paid the same for their TCM patients?
Yes. TCMs that convert to Health Homes will continue to be paid their TCM rate for up to one year following Health Home implementation based on the SPA approval date. During year 2, converted TCMs will be paid a blended TCM/HH rate. In year 3, converted TCMs will be paid the Health Home rate. Non-converted TCMs will continue with their existing rate for up to two years post Health Home implementation, after which time, Medicaid payment for non-converted TCM will end.
4. Regarding TCM rates (current/year1, blended/year 2, totally integrated/year 3), on what dates will the rates be effective? How will the cost analysis for these rates be configured?
The year one period begins on the effective date of the SPA. Health Home rates will be based on a review of instate and out-of-state care management payments based on actual provider cost experience.
5. If a managed care plan elects not to participate in Health Homes, will DOH consider paying the Health Home directly for Health Home services provided to that plan's enrollees?
Other than for converted TCM/Health Homes, which will bill eMedNY directly for Health Home services, payment for Health Home services provided to enrollees in MCOs will be billed by and paid to the MCOs whether they participate in a Health Home or not. If the MCO is not the lead entity, or the MCO does not participate in a Health Home network, the MCO will distribute the Health Home payment to the Home provider proportional to the total Health Home care management provided.
6. How will health plans pay subcontractors for conducting health home care management services?
For non-TCM managed care enrollees, the health plan will reimburse their sub-contracted providers a portion of the PMPM proportionate to the care management effort of the sub-contractor.
7. 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 decisions on coding; DOH cannot make billing or coding recommendations.
8. Currently there are limits to providing billable services for clients who are either inpatients or incarcerated. In what instances can Health Home services be provided, and billed for, if someone is receiving inpatient 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 transitions 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 subject to Olmsted Laws, further guidance will be provided when the applicability of these laws to Health Home services has been determined.
9. If the payment made by the Lead Health Home to the downstream provider happens to go to an Article 28 provider, is the payment subject to the HCRA surcharge?
We are consulting with our HCRA program leads on this issue and will post an answer shortly.
10. 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 some of which may go to Managed Care Plans. 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.
NEW 11. 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.
NEW 12. What is the conversion process and methodology regarding rates?
This information can be found on the Health Home website. Please use this link: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/rate_information.htm
NEW 13. 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.
NEW 14. How do we bill for dual eligible members who may have coinsurance or a copay?
You would submit the claim as you typically would and Medicare would cross-over the claim to Medicaid. There would not be member coinsurance or copay responsibility, for Medicaid, once member-level Health Home Restriction Exemption (R/E) codes are in effect.
NEW 15. 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 gain sharing process has been submitted to the federal Centers for Medicare and Medicaid Services (CMS). DOH recently responded to questions and is awaiting a response from CMS.
16. Will Health Homes for subsequent phases have to wait for SPA approval before we can implement services?
Yes, for new members. Existing TCM members may continue to be served, once SPAs are approved OMH TCM providers may bill retroactive to the effective date of the SPA. SPAs for Phases 2 and 3 have been submitted to CMS for approval. TCM providers will continue to bill with the current TCM rate codes and once SPAs are approved TCM providers will be notified of the new Health Home rate codes and amounts. Guidance will be issued to OASAS MATS providers as to the effective date for Phase 2 billing and whether billing will be adjusted back retroactively to a particular date. For COBRA TCM programs, all unit billing will be reconciled back to the effective date of each SPA once all Phases have been implemented. COBRA TCM programs will continue to serve all existing clients and will continue to take "bottom up" referrals during this time. Additional guidance on the reprocessing of claims to adjust the TCM rate code to the new HH rate code will be provided after SPA approval.
NEW 17. Will the administrative fees of individual Health Homes be shared?
Sharing of information about administrative fees for individual Health Home is not a State requirement. If a Health Home wants to share that information they may do so.
NEW 18. Are there any issues with continuing to serve current clients who are dual eligibles?
You may continue to serve current members who are dual eligible. In addition, DOH has included duals on the recent assignment lists. The State is also in the process of negotiating a demonstration opportunity with CMS to serve dual eligibles. More information will follow.
NEW 19. 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 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.
Health Information Technology
1. Where can I find more information about the HEAL Projects and the Statewide Policy Guidance?
The information can be found at the NY DOH OHITT website, Health Information Technology.
2. Which domains of HIT will be monitored?
Applicants will need to attest to participation in a RHIO/Qualified Entity, exchange of interoperable clinical information, certified EHRs, clinical decision support, and following statewide policy guidance for interoperable HIE by 18 months of program initiation.
3. Will Health Home reimbursement include administrative overhead to help support the costs associated with interface and building of robust systems?
4. What computerized system will be used to enhance communication amongst our providers and PCP offices and how will that be paid for?
There is no 'common' computerized system in NY. There is the SHIN-NY (Statewide Health Information Network for New York) which is an open source network for sharing information across disparate systems. Projects will be required to fund connectivity and interoperability for patient information.
5. How will the State support more comprehensive integration of the RHIOs into this effort?
The RHIOs are integral to efficient and timely sharing of health information. The DOH has discussed the health home initiative with the RHIOs and the HEAL Projects. We have encouraged the RHIOs and the HEAL projects to reach out to and work collaboratively with potential health home providers in meeting Health Home HIT requirements.
6. What kind of technical support/assistance will be offered in implementing HIT at all levels?
Health home providers should contact one of the two New York Regional Extension Centers for evaluations and support in implementing HIT. The website for the New York City Regional Extension Center is http://nycreach.org/news. For support outside the NYC boroughs, the website for the NYeC Regional Extension Center is http://www.nyehealth.org/rec/.
In addition, for non-technical health home HIE support, feel free to visit the New York State Department of Health – Office of Health Information Technology Transformation website at http://www.health.ny.gov/technology/ or call (518) 474-4987.
7. Will the health home providers be given a list of regional health information organizations (RHIOs)/Qualified Entities (QE)?
Regulations are being developed to certify the Qualified Entities. NYS RHIOs are listed on the following website: http://www.nyehealth.org/index.php/resources/rhios.
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 http://www.nyehealth.org.
12. Please clarify what "as feasible" means in Section VI, 6a-6d.
When initially beginning the projects, we understand that the projects may be predominately paper based, or rely on software systems that do not meet interoperability requirements. Rather than slow down the initiatives, we suggest utilizing and leveraging the HIT/HIE infrastructure in New York where 'feasible', knowing that the projects are committing to meeting the final standards 18 months after project inception.
13. The Initial Standards for HIT call for: a health record system which allows the patient health information and plan of care to be accessible to the interdisciplinary team of providers, "as feasible". Providing that a TCM has established, timely, case conferencing, electronically shares the patient's plan of care with a unique identifier and has a system in place to keep each member of the interdisciplinary team up to date – along with a plan to meet the final standards and a letter of support from our local RHIO, will we meet this initial HIT requirement for Health Home?
14. Can Section VI, 6c be interpreted to mean that using faxing or providing copies as an interim measure before full implementation of 6e-6i is allowable to make the plan of care accessible?
15. In consulting with our RHIO, THINC, their Executive Director stated that EHRs are constructed around clinical visits. She questioned whether our agency, even if we're a Health Home, would need a full EHR or whether we would just need some other type of electronic record keeping that could interface with the RHIO's Health Information Exchange. Can you speak to this?
Those providers giving clinical services will need to maintain a certified EHR that is capable of interfacing with the RHIOs. Other providers where a certified EHR is not available will need to have interfaces to the RHIOs for sharing and obtaining the information.
16. The draft NYS Home SPA… (on page 5 of 23) recognizes that many of the potential health home providers 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, working with a HEAL 10 or HEAL 17 project if available in their area, and to continue to leverage the state's HIE infrastructure.
18. Will it be through the data base of either an HMO or BHO?
An HMO or BHO could provide access to encounter data that would help to support this requirement. In addition, clinical information would be available via the RHIOs/Qualified Entities.
19. Is the patient health record required to be certified as an EMR under the Federal program for reimbursing doctors for adoption of EMR's?
Where certification is available, certified EHRs must be utilized as defined under the Federal Program for adoption and for meeting Meaningful Use.
20. We have an inexpensive telemedicine application with a comprehensive electronic health record that could be adjusted to be a perfect adjunct to the health home program. Would you have any contact information for managed care organizations that are expressing interest in this program?
No. It would be the responsibility of the health home to establish connections with the stakeholders involved in the care/services of the patient.
21.On page 10, Section VI (HIT) : we would need to tighten up a process to meet the guidelines of 6b and it may not be available on day one of certification as a health home. Is that acceptable?
22. Where can I find more information about Health Information Technology (HIT)?
REVISED 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 interoperable with HITECH MU certified EHRs for the purpose of exchanging information amongst multiple providers and provider organizations. Working with the RHIOs to make this information available to the HH 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?
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 need to be able to have separate membership. RHIOs are working with health home members on member fees and services for health home applicants. Since RHIOs have differing organizational structures, we suggest contacting your local RHIO for more specifics.
31. Can individual members exchange information through the RHIO simply by being a member of the health home?
No. See above.
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 interoperability, certified HER, 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 http://www.cms.gov/EHRIncentivePrograms/. For Medicaid specific questions about EHR incentives to be distributed through NY Medicaid, you may submit your questions to HIT@health.state.ny.us.
The state is exploring other funding opportunities to support infrastructure including a possible enhancement to the 1115 waiver. For more information, please visit http://www.health.ny.gov/health_care/medicaid/redesign/mrt_waiver.htm. To view the MRT 1115 Waiver Press Release visit http://www.governor.ny.gov/press/06042012-new-federal-waiver-to-request
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 http://www.cms.gov/EHRIncentivePrograms/.
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.
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). Please go to ONC-Authorized Testing and Certification Bodies weblink: http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3120 for additional information.
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?
Although we are looking for funding, there are currently no additional funds for HIT adoption and connections.
NEW 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 will end September30, 2013. The standard will be met if 90% of the required partners are using a certified EHR.
NEW 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 interoperable care plan which isn't a part of the 6F standard. There are a variety of ways to access the information such as a portal system or RHIO or it can be integrated into the EHR. Consent form 5055 can also be used to share information within the care management plan to their shareholders.
NEW 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.
Health Home Network
1. How will the implementation of Health Homes take into account the potential to leverage the work that is already being done with the chronically ill population by community behavioral health providers, supportive housing providers, and health care for the homeless providers?
The State has actively sought and used the advice and suggestions from experienced community medical, behavioral, and social services providers in developing Health Home requirements; most important of which is that Health Homes must develop strong community connections to meet the complex needs of health home enrollees. The work that is already being done to serve the needs of chronically ill individuals is a strong foundation for Health Homes, which requires the coordination of medical, behavior, and social services providers and community resources.
In addition, to support existing client/provider relationships and to the extent possible, eligible enrollees will be enrolled in Health Homes based on their existing relationships with a Health Home or the Health Home's network of providers, or if no relationship exists, with a Health Home that provides services within the enrollee's community.
2. Are HH's 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 survive any payment and accountability structure that may evolve from Medicaid Redesign.
3. What happens if a health home demands an exclusive contract with a provider? In these cases, what happens when a health home folds?
The State does not expect exclusive contract demands. The State will be working with Health Home providers to help them be successful.
4. Can hospitals be part of more than one health home network?
Yes, hospitals can submit a health home application as a lead or host as well as partner in other applications with a different host. Although the State's preference is for one host application, if it makes sense from a regional perspective for a hospital system to submit more than one Health Home application then they may do so.
5. Please confirm that a provider must affirmatively agree to be part of a health home network. If a hospital operates its own health home, must it participate in any other health home network?
A provider must consent to, by contract or agreement with a Health Home, to participate in their network. It is not mandatory for any provider to participate in any other HH network, although hospitals are strongly encouraged to act as partners in other health home applications.
6. 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 applicants are strongly encouraged to partner with community based organizations that provide complimentary services as well as similar services.
7. Does the applicant 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 services. The health home provider remains responsible for all health home program requirements, including services performed by the subcontractor – per the NYS Health Home Provider Qualification Standards.
8. 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?
9. 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 of its network
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. Every agency can anticipate some level of effort from this initiative as CMS will be contacting them for status in treatment reports and potential case conferences for individuals enrolled in a health home. DOH is open to many kinds of subcontractural 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.
10. Can a Health Home enrollee 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 enrollee 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 their care in a manner that is tied with their Care Manager, unlike the "siloed" way it is today.
11. Can a Health Home enrollee 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 enrollee 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 their care in a manner that is tied with their Care Manager, unlike the "siloed" way it is today.
Substance use disorder providers should partner with the lead Health Homes so that the Health Home can assure appropriate coordination and that the Case Manager effectively can engage all providers. Partners will need to work out with the lead applicant the kind of linkage agreement that is needed (e.g. contract, MOU) as that will determine what services are being provided and whether money will be exchanged between the Health Home and the partner(s).
Health Home Design
1. There are three levels of care described in the health home 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; rather they must be able to serve all populations except those who are excluded from the HH program (SED children, those in need of LTC or those with intellectual disabilities.) That being said a disease specific focus could be part of a more comprehensive health home application.
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 HH provider to determine the qualifications of 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?
8. Are there descriptions of what constitutes a Low, Intermediate and High Need CM Service?
Broad definitions were listed in the application to help define a Low, Intermediate and High need health home member. These definitions were presented as examples but each health home will be able, and should, determine the intensity of CM that is required for each category of health home members.
NEW 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?
Referral guidance is under development for use by hospitals and other providers. Once guidance is developed we will be working with the Hospital Associations for input and assistance in communicating this requirement to hospitals.
NEW 10. Question: 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 services directly and with network partners 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 better the provision of care. 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 the Health Home may or may not need to meet quality measures.
NEW 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).
NEW 12. Can Medicaid dollars be use to pay for client travel to and from social service providers 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 reimburse for care plan development and review meetings?
Medicaid transportation will only reimburse for transportation to medically necessary services such as medical or behavioral health visits.
Quality Metrics and Evaluation (CMART)
1. What is meant by 'clinical risk groups'?
Clinical Risk Groups ™ are a 3M product to place patients in clinical and severity levels based on diagnostic acuity.
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 Health Homes effectiveness.
3. What will be the clinical/quality outcomes tracking tool?
The comprehensive list of quality measures the State will track is available on the 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 (i.e.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 is available through claims and encounters data, other frequency for other measures will be determined later.
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?
The State is working with a broad based statewide advisory committee with members who represent providers, plans, peers, and members.
There will also be learning collaboratives to support the designated Health Homes and regional advisory committees are under discussion.
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 bring resolution with the Medicaid call center.
10. The answer to Question 9 under Quality Metrics and Evaluation in the Q&A's posted on the Health Home website refers to a Medicaid Call Center being available for members. We understood that the Health Home was 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 Call Center operates only during business hours and will address general questions or concerns. A process for handling complaints about Health Homes through the Medicaid Call Center is under development. .
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 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. There are a number of tools such as the DLA Assessment and SBIRT that are available for use.
12. Is the FACT- GP functional assessment final? Page 3 still indicates draft.
The FACT-GP and HH Functional Assessment with scoring guidelines in their final form were posted on the Health Home website on July 18, 2012.
13. Question: Do we have to use the FACT-GP Assessment posted on the HH Site?
Yes, all Health Homes must use the FACT-GP functional assessment but are also able to use other additional assessment tools the Health Home finds useful.
14. 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.
15. 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.
It is our expectation that the FACT-GP and HH Functional Assessment as well as the comprehensive assessment will be conducted face to face. If at disenrollment it is not possible to do these face to face, telephonically could be allowed.
16. 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 HH 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.
NEW 17. How do we access the FACT-GP score for the homeless?
In the FACT-GP Health Home functional assessment, question number 6 addresses homelessness. This can be found on the Health Home website at the following link: FACT - GP and Health Home Questionnaire Scoring Sheet. Information on what is homelessness is can be found in the document at the following link: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/assessment_quality_measures/docs/scoring_guidelines_hh_func_assessment.pdf
NEW 18. 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. Please refer to question 11 in this section for reporting guidelines.
NEW 19. When do we use the required Health Home tools (for example the functional assessment) with Legacy clients?
These should be utilized for Phase 1 Health Homes for existing members as soon as possible, and used upon enrollment for new members. Please use the appropriate language translated forms.
NEW 1. How did Health Homes get permission to share HIV/AIDS information when this has always been restricted/protected medical information? HIV/AIDS data was always redacted from medical Record before data was shared. If shared was a HIPAA violation.
The Health Home patient consent allows HIV/AIDS information to be shared with core providers that the patient included on the consent . The Health Home consent form was approved by DOH, specifically the AIDS Institute, OMH and OASAS. Once the Health Home member signs the consent form you may share health information with the members core Health Home service p
- See: Member Consent
1. Is there managed care related eligibility information available, similar to the information provided by county for FFS Health Home eligible recipients?
Currently, there is no Managed Care Health Home recipient eligibility information available, but this information may be posted in the future.
2. Is it still the expectation that MCOs participating in the Health Home program align themselves (contract with) a RHIO as a condition of the Health Home program within the next 18 months? Or, is it the requirement for the Provider Lead Health Homes to obtain a contract with a RHIO?
There has never been a requirement for Managed Care Plans to work with RHIOs. Provider Led Health Home and their partners have 18 months to meet final HIT requirements which include working with a RHIO/qualified entity (QE).
3. If individuals are to have choice of both Health Homes and MCOs in their area, are Health Homes required to be a network provider with ALL Managed Medicaid Providers in their community?
There is no requirement that MCOs contract with all Health Homes or vice versa. The State is obligated to provide members with a choice of Health 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.
4. Will the Health Homes be receiving contact information on who we should be reaching out to at the MCO plans, once we are ready to begin receiving rosters? OR is the expectation that the plans have to initiate outreach to us?
Health Homes should contact Plans when ready to pursue contracts to work with their members. A list of contacts for each of the MCOs is posted on the Health Home website. A list identifying the counties that each MCO offers services in is also posted on the web.
5. Is NYS revising some of the financing structures for Health Homes? Are the following accurate?
a. MCO's will get a separate payment so no money will be taken from the Health Home rate.
b. There will be an additional Health Home administrative rate added, intended for Lead Health Home payment with a 3% cap, with the result that 100% of the initial rates DOH has published for Health Home services will go to the Care Management Agency.
As of now there is no change in how MCOs will receive support for administrative services. DOH is in discussions with CMS to add administrative support to the Plan capitation rate for the support of Health Homes. If that is approved our billing guidelines and instructions will be revised.
NEW6. 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.