Rate Information Questions and Answers
December 8, 2011
1. How were the Health Home rates calculated?
A. The Health Home care management rates were calculated using three main variables – 1) caseload variation (scaled from 12 to 1 at highest intensity end and 140 to 1 at lowest intensity end), 2) case management cost and 3) patient specific acuity. Caseload variation (from 12:1 to 140:1) was derived from a combination of sources including existing targeted case management programs, chronic illness demonstration programs and other demonstrations of chronic illness management from other states (e.g., Mass and Washington). Case management cost was derived utilizing cost data reported to the State from existing programs. Patient specific acuity factors were utilized from 3M Clinical Risk Group software. These raw acuity scores were then adjusted for a predicted functional status factor (i.e., Mental Health, Substance Abuse and higher medical acuity groups were "up-weighted" until functional status data become available to more accurately adjust clinical acuity). Patient specific adjusted acuity scores were utilized to "predict" case management need based on a regression formula.
2. How were the base health status groups established?
A. These groups come from the 3M™ Clinical Risk Group software –with some adjustment to collapse some sicker patient groups (Catastrophic and Malignancies) into Pairs and Triples and HIV groups. This software places patients into risk groups based on diagnosis, procedure and pharmacy information.
3. How were the low, medium and high severity groups established?
A. The clinical risk group software puts each patient in each health status group into a severity group from 1 to 6 (level 6 being the highest severity) based on a combination of diagnostic, procedure and pharmacy data from the claims and encounter records. The six groups were collapsed down to low (1-2 severity), medium (3-4) and high (5-6) based on CRG severity ranking.
4. Will these rates be paid statewide or will a regional adjustment factor be used? If a regional adjustment factor is going to be used what is it?
A. The care management rates in the current chart are regional. The current regional factor pays 24.37% more for the downstate region in comparison to the upstate region.
UPDATED 5. How often will the acuity scores be recalculated?
A. Care management rates will be recalculated on a quarterly basis as soon as a reasonable volume of functional status data has been collected and analyzed. The State will carefully measure care management intensity and will make care management rate adjustments as necessary to support efficient care delivery.
6. Are HH providers required to use the caseload ratios that are in this chart?
A. No. HH providers should match patients to the caseload intensity based on the HH program's assessed need for care management.
7. Are the first year enrollment projections set at this point? Will the State consider enrolling more patients than are projected in this chart?
A. These projections are for illustration and planning purposes only. Actual assignment will be based on regional health home capacity, predictive modeling (likelihood of future inpatient admission for a given patient), and primary care/ambulatory care connectivity analysis.
8. This chart includes individuals currently in care management (i.e., COBRA, TCM, MATS, CIDP) can you provide a breakout of those patients in each category since these patients will be paid their existing TCM/Care Management rate for the first year?
A. Yes. We are working on this breakout now and will have it available shortly to post to the HH website.
9. Will this same information (rate chart) be made available for a health home network operating in a given region for the patients likely to be assigned to that network.
A. Yes. We plan to use the attribution and loyalty analysis we are working on right now to feed back specific information about patient acuity and projected rates to each health home network or region.
10. The HIV low intensity rate cell seems to have a low rate and a low intensity staff to patient ratio. This seems out of proportion to some of the other rates. Why is this? Are all HIV Patients in this group on the chart?
A. In the newly revised rate chart, HIV patients have had their acuity scores upweighted. Functional status data when available may be used to further adjust the acuity scores for this group of patients. If patients are in existing HIV COBRA case management then they will be billed at their existing rates for one year. This will give us time to adjust all care management rates including the HIV rates for functional status data. All HIV patients should be in the HIV group on the rate chart. The possible exception is HIV patients that may have be receiving dialysis services – we are checking on this possible exception now.
11. The Single SMI/SED high acuity cell seems to have a very low number of patients in it. Why is that and can it be right?
A. This group is limited to those patients that only have a serious mental illness or serious emotional disturbance and does not include patients with SMI/SED that have another chronic illness (es). Patients with SMI/SED and other chronic conditions are in the pairs, triples or HIV categories and higher acuity SMI/SED patients have another chronic condition placing them in one of these other categories. We will prepare a breakout table that shows the SMI/SED patient counts in the pairs, triples and HIV categories. We will also attempt to show average HH care management rates for the SMI/SED group irrespective of their placement in the other health status groupings.
12. Who can change the severity level for individuals in HHs? What is needed to change it? How quickly can it be changed? And, will the change be "retroactive" to the requested change date?
The severity level for an individual is assigned by DOH and is not subject to appeal. However this severity level will later be adjusted by functional status which will improve the rate specificity. HH providers will be serving many individuals under a rolled up provider-specific rate. Some patients may require more HH services than anticipated, while others may require less. While there will be no patient-specific rate updates, the overall level of the rates for HH services will be revisited regularly (including a review of cost and volume data) with input from the provider community to assure that the reimbursement is adequate to accomplish the goals of the HH initiative.
UPDATED13. Does the State still intend to pay a case finding fee for the first few months? Will it be 80% of the rates on the rate chart?
The State has received approval from CMS to pay case finding (Outreach and Engagement ) rate at 80 percent of the full rate.
UPDATED14. Does the State still intend to do a quality withhold of 20%?
No. There will be no quality withholds for health home services.
15. When will the department provide more detail on the regional adjustment and how the wage equalization (WEF) will be calculated?
The outpatient WEFs for hospital and free-standing services were averaged together. The WEF is 1.2437 and covers all cost components, which means the reimbursement for the same case mix will be 24.37 percent higher downstate as compared to upstate.
16. DOH originally indicated that rates would vary based on volume. Is this no longer the Department's plan?
At present there is no volume adjustment but we may revisit this if we approve a very small rural health home that cannot cover fixed cost at the current fees.
17. Where would the current chronic illness demonstration project (CIDP) population fall in terms of these rate cells? Would they all be high intensity?
Many would be high intensity – each approved health home program will get a rate breakdown of their specific population.
18. Why are the patient to case manager ratios so wide and how can these rates support such a wide range?
The range within each cohort is directly related to the variation in the acuity scores within the cohort. Each patient will receive case management support that is commensurate with their acuity score. In the fee model - low touch patients (with minimal face to face contact) may have patient to case manager ratios as high as 150 to 1 (this would support primarily telephonic/tracking level contract). Actual caseloads will be determined by each health home program and DOH will continue to tailor the payment method to assure it supports the cost of high performing efficient health homes.
19. DOH has indicated that initial enrollment will target those most at risk for hospitalization. Are these cases most likely to be high severity?
Many of these patients are likely to be mid or high severity – those data are being finalized and will be available shortly.
20. There are additional costs associated with Upstate service delivery including significant travel costs and a lack of public transportation infrastructure. Has the State considered adding transportation barriers upstate in the acuity assessment?
Medicaid will pay to transport Medicaid members to Medicaid services including Health home appointments. Transportation cannot be specifically covered by health home dollars.
21. Does the payment rate assume that the HH activities and care coordination will be in-person or telephonic? What percentage of in-person staff time and what category of staff (LCSW, RN, CASAC, etc.) was used to calculate the percentage of the rate allocated to staff time?
In person staff time versus telephonic staff time will vary based on the acuity level and diagnosis of the patient (and eventually functional status). Behavioral Health and higher severity level cases will require more in person staff time. Patients that fall in the low touch group (with patient to manager ratios as high as 140 to 1) were priced as requiring primarily telephonic/tracking staff time.
22. Were costs such as development of care coordination records or HIT factored into the development of the rates?
Amounts were factored into the rates for both personal services and necessary overhead including support and other non-personal service expenses. We are not specifically funding HIT/HIE activities through health home care coordination payments.
23. In the SPA, it is anticipated that HHs that do NOT meet the quality benchmarks will not have access to any of the additional 10% reimbursement. Is the 10% all or nothing? What are the specific quality benchmarks against which HHs will be measured?
These benchmarks will be a subset of the measures included in the State Plan Amendment on the DOH Health Home website but they have not been specifically selected yet.
24. 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.
UPDATED25. 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?
The TCM always bills directly. If the TCM has legacy 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 TCM will bill for the member under the Health Home rate.
UPDATED26. Will OMH and COBRA HIV TCM programs be expected continue to meet TCM 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. (See Regulation Notice for Former Targeted Case Management Providers http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/hh_tcm_reg_chng_ltr.pdf.
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.